Abstract
Purpose
To evaluate the 1-year clinical outcomes of patients treated with combined proximal biceps tenodesis and repair of type II to III subscapularis tendon (SST) injuries according to Lafosse et al., using the Loop ‘N’ Tack (LNT) technique.
Methods
All patients undergoing proximal biceps tenodesis and rotator cuff repair between March 1, 2020, and January 30, 2022, were retrospectively identified. Only patients undergoing combined proximal biceps tenodesis and repair of grade II or III SST injuries with a minimum follow-up of 1 year were included. All patients underwent combined single-anchor proximal biceps tenodesis and SST repair using the LNT technique. The following outcome scores were recorded at a final follow-up of 1 year postoperatively and compared with baseline, preoperative values: American Shoulder and Elbow Score (ASES), Single Assessment Numerical Evaluation (SANE), Veterans Rand 12 Item Health Survey (VR-12), and visual analog scale (VAS). The minimal clinically important difference (MCID) for all outcome indices was determined with a distribution-based method.
Results
A total of 41 consecutive patients were included. The MCID values for VAS pain, ASES, SANE, and VR-12 mental scores were 0.97, 8.5, 10.9, and 6.0 respectively. At 1-year final follow-up, approximately 95% (39/41) of patients exceeded the MCID for VAS pain scores, 90% (37/41) of patients for ASES scores, 85.4% (34/41) of patients for SANE scores, and 75.6% (31/41) of patients for VR-12 mental health scores. On average, ASES and SANE scores improved by 37 (preoperatively: 45.2, 1 year: 82.4, P < .001) and 38 points (preoperatively: 38.0, 1 year: 75.7, P < .001), respectively, while VAS scores decreased by 4 points (preoperatively: 5.49, 1 year: 1.48, P < .001). Approximately 88% (36/41) of patients were satisfied at 1 year postoperatively. Treatment failure was observed in 1 patient (2.4%).
Conclusions
Patients treated with combined, single-anchor SST repair and LNT proximal biceps tenodesis achieved significant improvements in function, high satisfaction, and low rates of reoperation at 1 year postoperatively. Additionally, 76% to 95% of patients met the MCID for VAS pain, ASES, SANE, and VR-12 mental health scores.
Level of Evidence
Level IV, retrospective case series.
Pathology of the long head of the biceps tendon (LHBT) is commonly associated with injuries involving the subscapularis tendon (SST) and together comprise a prevalent source of anterior shoulder dysfunction.1, 2, 3 The upper third or “border” of the SST is important biomechanically by providing stability to the biceps pulley complex through force-coupling.1,4, 5, 6, 7 Although isolated tears of the SST only account for 3% to 5% of all arthroscopically repaired rotator cuff tendons (RCTs), they may be identified in up to 50% of all arthroscopic rotator cuff surgeries.8, 9, 10 Given its critical role in overall shoulder function, it has been suggested that some of these lesions should be repaired and not simply debrided.6
As literature rarely delineates upper-third tears from larger patterns, determining the utility of different treatment strategies remains a challenge in treating these SST injuries.6,11,12 In addition, for patients undergoing rotator cuff repair (RCR) with coexisting biceps-labral pathology, the optimal approach to treatment is debated in comparative studies.13, 14, 15, 16 Currently, there are few combined single-anchor techniques reported in literature to address both pathologies.4,5,17,18 The Loop ‘N’ Tack (LNT) tenodesis has been reported as an effective treatment for isolated proximal biceps disease across recent biomechanical and clinical studies.19, 20, 21, 22 Additionally, as outlined by Kim et al.,17 this simple, knotless, all-arthroscopic procedure can also accommodate repairs of the anterior RCT. However, the clinical outcomes of patients undergoing combined biceps tenodesis and SST repair using this technique are not well understood.
Therefore, the purpose of this study was to evaluate the 1-year clinical outcomes of patients treated with combined proximal biceps tenodesis and repair of type II to III SST tears according to Lafosse et al.,8 using the LNT technique. It was hypothesized that combined, single-anchor repair of upper-third SST injuries and proximal biceps tenodesis would result in excellent outcomes, improved patient function, and low rates of reoperation.
Methods
After receiving institutional review board approval, all consecutive patients undergoing proximal biceps tenodesis and RCR were retrospectively identified between March 1, 2020, and January 30, 2022. Only patients undergoing combined proximal biceps tenodesis and repair of grade II or III SST injuries8 with a minimum follow-up of 1 year were included. Patients were excluded if they lacked complete outcome reporting at 1 year postoperatively; had more than 2 RCTs torn at the time of surgery; had grade I, IV, or V SST injuries; or underwent proximal biceps tenodesis and RCR that did not include the SST. All SST lesions and additional pathologies were identified preoperatively on magnetic resonance imaging (MRI) by a blinded musculoskeletal radiologist who was not involved in this study. Subscapularis lesions were then graded intraoperatively by the senior author (J.P.) in accordance with the Lafosse classification.8
Surgical Technique
All procedures were performed by a single sports medicine–trained orthopaedic surgeon (J.M.P.) at a single ambulatory surgical center. Each patient, regardless of additional procedures performed, underwent arthroscopic combined single-anchor repair of SST tears and proximal biceps tenodesis using the LNT technique.17,19
Initial Setup and Diagnostic Arthroscopy
The patient can be placed in the lateral decubitus (or beach-chair) position. After sterile preparation and draping, a diagnostic arthroscopy is performed through a standard posterior viewing portal using a 30° arthroscope. With an 18-gauge spinal needle, an anterior portal is established within the rotator interval. If a significant tear of the subscapularis tendon is identified and a repair is planned, the LHBT and superior labral complex are carefully evaluated for fraying, macroscopic inflammation, and subluxation out of the bicipital groove using an arthroscopic probe. For patients meeting procedural criteria for proximal biceps tenodesis, careful attention is paid to ensure instruments placed through the anterior cannula easily pass above and below the proximal biceps tendon while maintaining access to the distal intra-articular portion of the bicipital groove and the lesser tuberosity.
Proximal Biceps Tenodesis
The proximal biceps is then sewn and tenotomized according to Hammarstedt et al.19 With the use of a suture passer (SP), the looped end of a 1.3-mm flat braided suture is loaded around the passer to set up a cinch stitch while the free end is loaded into the grasping tip. This is performed by shuttling the free end of the suture through the anterior portal superior to the biceps tendon and then retrieving this same free end inferior to the biceps tendon. After withdrawing the free end of the suture through the anterior cannula, it is drawn through the loop, creating a looped hitch or “luggage-tag” knot. The free end is pulled to cinch the “luggage tag” firmly around the biceps. The free end of the suture is advanced through the anterior cannula with a SP and is advanced through the central aspect of the biceps tendon just distal to the secured loop. With the SP tissue penetrator, the free end of the suture is grasped and pulled back through the anterior cannula completing the LNT knot. Biceps tensioning can be adjusted by moving the loop proximal or distal along the tendon. Placing the “luggage-tag” stitch a few millimeters distal to its insertion on the superior labrum will allow the biceps to be taken slightly off tension, thus limiting biceps motion and rendering any associated groove pathology irrelevant. Should the surgeon choose to keep the native tension of the biceps, the biceps can be cinched closer to its exit from the intra-articular shoulder, further from its insertion on the superior labrum.
SST Repair
After completing the LNT knot and LHBT tenotomy, the SST tear is visualized from the posterior viewing portal. The eventual tenodesis location along the superior border of the SST at the most distal visualized portion of the intra-articular groove and lesser tuberosity is gently debrided until osseous abrasion is achieved. Subcoracoid decompression with soft tissue release is performed as warranted to mobilize the torn SST. Using a SP, the looped end of a 1.7-mm flat braided suture is secured around the device while the free end is passed through the midportion of the exposed SST (Fig 1A). The suture is then released and retrieved around the superior margin of the SST within the glenohumeral joint (Fig 1B). The free end of the suture is withdrawn through the anterior cannula and a looped hitch knot is created by passing the free end of the suture through the loop and pulling to secure around the SST (Fig 1C). Tensioning can be augmented by the placement of the luggage-tag stitch, medial to lateral. The chosen anchor position is prepared using the corresponding awl. The free ends from both the proximal biceps and SST luggage stitches are fed through a 4.75-mm knotless anchor. The anchor is seated in the aforementioned location with all slack removed from the suture (Fig 1 D and E). This permits the tenotomized LHBT to translate into a “tacked” onlay position within the bicipital groove while restoring the SST to its anatomic footprint. Radiofrequency ablation is then used to mushroom cap the remaining LHBT to further prevent suture pullout (Fig 1E). Any concomitant pathology may then be addressed arthroscopically. Arthroscopy portals are finally closed in a standard fashion.
Fig 1.
Demonstration of the luggage-tag arthroscopic surgical knot for subscapularis tears in a left shoulder as viewed from the posterior portal with the patient in the lateral decubitus position using a 30° scope. Passing of the looped end of suture through the subscapularis tendon (A). Retrieval of the looped suture through anterior cannula, over the superior border of the tendon (B). Cinching of the suture onto the tendon after externally passing the free end through the looped suture (C). Anchor placement at the most distally visualized portion of the intra-articular biceps groove, along the superior border of the subscapularis tendon (including biceps FiberLink suture) (D, E). Debridement of residual long head of the biceps tendon stump after anchor seating and tensioning (F). (BT, biceps tendon; H, humeral head; ST, subscapularis tendon.)
Rehabilitation
In the immediate postoperative phase, patients wear a shoulder immobilizer for comfort and/or sleep for the first 2 to 4 weeks. Patients are permitted to begin passive and active assist (forward flexion only) range of motion (ROM) after 48 hours. Forward shoulder flexion is limited to 90° (week 1) and 100° (week 2) while no external rotation (ER) beyond 0° is permitted through the first 2 weeks. There is strict biceps avoidance for the first 2 weeks while internal rotation (IR) isometric exercises are withheld during the first 3 weeks. Between weeks 3 and 4, ROM is gradually increased to 120° to 140° of forward flexion and IR/ER at 45° of shoulder abduction in the scapular plane. External rotation beyond 0° is still not permitted. Isotonic strengthening exercises are initiated. Between weeks 5 and 6, shoulder forward flexion is advanced as tolerated with full IR permitted at 45° of shoulder abduction and ER to 35° to 40°. Passive and active assist IR at 90° of abduction is initiated along with continued isotonic and now gentle dynamic strengthening. Between weeks 7 and 8, ER is advanced at 90° of shoulder abduction to 45° to 50° and then 75° to 80° beginning in postoperative week 8.
Data Collection and Analysis
A variety of information, including patient demographics, procedural characteristics, and patient outcomes, was retrieved from the Surgical Outcomes System (SOS) database (Arthrex). Clinical outcomes were recorded at a final follow-up of 1 year and compared with preoperative, baseline evaluations for all indices. Pain and mental health outcomes were assessed using the visual analog scale (VAS) and Veterans Rand 12 Item Health Survey (VR-12), whereas the Single Assessment Numerical Evaluation (SANE) and American Shoulder and Elbow Score (ASES) were selected to score patient function. Patient satisfaction was measured using Patient-Reported Outcomes Measurement Information System (PROMIS) scores. To assess treatment failure, all clinical documentation was reviewed between the procedure date and 1 year postoperatively (L.B., B.K.). Treatment failure was defined by the following end points: reoperation for revision RCR or biceps tenodesis, manipulation under anesthesia, and reverse total shoulder arthroplasty. Postoperative imaging was not routinely obtained as part of the study; however, those with radiographic evidence of RCT retear or LHBT rerupture when present were also considered a treatment failure.
Statistical analysis was performed using standard statistical software (SPSS, version 21; IBM). The minimal clinically important difference (MCID) for all outcome indices was determined with a distribution-based method,23 using half of the standard deviation for the overall change in each outcome score across the entire cohort.24 Patients were classified as meeting the MCID if their improvement in the outcome score succeeded the calculated MCID value. All sets of data were tested for a normal distribution using the Kolmogorov-Smirnov test. To compare preoperative and postoperative continuous variables, a paired t test was performed. A P value less than .05 was considered statistically significant for all tests.
Results
A total of 76 consecutive patients were initially identified. Approximately 46% (35/76) of patients were excluded overall. A total of 12 patients had more than 2 RCTs torn at the time of surgery, 10 patients underwent proximal biceps tenodesis and RCR that did not include the SST, and 5 patients had grade I, IV, or V SST injuries. Of patients meeting procedural criteria (48/76), 7 patients lacked clinical follow-up at 1 year (7/48, 14.5%). Of the 41 patients available for evaluation, 63% (26/41) were males and collectively averaged 55 years of age (SD 7.27) at the time of surgery (Table 1). Approximately 17% (7/41) of patients were treated for isolated SST injuries, whereas 83% (34/41) underwent additional repair of the supraspinatus tendon (63%) or posterosuperior RTC (20%) (Table 1). In this particular subset of patients, approximately 62% (21/34) of supraspinatus injuries were classified as full thickness, whereas 38% (13/34) of repairs were performed on partial-thickness injuries. Of the SST tears identified, 90% (37/41) were classified as Lafosse grade II injuries. All patients underwent proximal biceps tenodesis for superior labral complex instability. An average of 1.22 procedures were performed on each patient in addition to proximal biceps tenodesis and RCR.
Table 1.
Patient Demographics
| Characteristic | Value |
|---|---|
| Overall (n) | 41 |
| Male, n (%) | 26 (63) |
| Female, n (%) | 15 (37) |
| Age, mean (SD), y | 54.97 (7.27) |
| Body mass index, mean (SD) | 29.6 (6.21) |
| Tobacco use, n (%) | 0 (0) |
| Diabetes, n (%) | 0 (0) |
| Dominant arm involved, n (%) | 20 (49) |
| Subscapularis tear grade, n (%) | |
| II | 37 (90) |
| III | 4 (10) |
| Combined rotator cuff repair, n (%) | |
| Isolated subscapularis | 7 (17) |
| Subscapularis and supraspinatus | 26 (63) |
| Subscapularis and infraspinatus | 8 (20) |
| SLAP grade, n (%) | |
| Type I | 1 (2) |
| Type II | 40 (98) |
| Additional procedures, n (%) | |
| Acromioplasty/SAD | 40 (98) |
| Distal clavicle excision | 7 (17) |
| Chondroplasty | 3 (7) |
SAD, subacromial decompression.
Compared with baseline evaluations, patients achieved significant improvements in all outcome scoring indices at 1 year postoperatively, including ASES (preoperatively: 45.2 [SD 17.0], 1 year: 82.4 [SD 19.8], P < .001), SANE (preoperatively: 38.0 [SD 21.9], 1 year: 75.7 [SD 24.5], P < .001), and VAS (preoperatively: 5.49 [SD 1.93], 1 year: 1.48 [SD 1.87], P < .001) (Table 2). The MCID values for VAS pain, ASES, SANE, and VR-12 mental scores were 0.97, 8.5, 10.9, and 6.0 respectively. Approximately 95% (39/41) of patients exceeded the MCID for VAS pain scores, 90% (37/41) of patients for ASES scores, 85.4% (34/41) of patients for SANE scores, and 75.6% (31/41) of patients for VR-12 mental health scores. Upon subgroup analysis, there were no significant differences in 1-year outcome indices between isolated SST and additional RCR groups (Table 3). In addition, approximately 88% (36/41) of patients were satisfied at 1 year postoperatively. A total of 3 patients were dissatisfied (7.3%), whereas 1 patient (2.4%) met treatment failure criteria. The latter occurred in a 59-year-old male patient with loss of motion related to degenerative changes that subsequently required a capsular release and revision proximal biceps tenodesis (open subpectoral).
Table 2.
Clinical Outcome Scoring at 1 Year Postoperatively
| Clinical Outcome | Preoperative | 1 Year | AD | P Value |
|---|---|---|---|---|
| VAS | 5.49 (2.94) | 1.48 (1.88) | 4.01 | .001 |
| ASES | 45.15 (7.02) | 82.42 (9.8) | 37.27 | .001 |
| SANE | 37.95 (21.91) | 75.68 (12.23) | 37.73 | .001 |
| VR-12 Mental | 47.99 (11.99) | 51.88 (9.24) | 3.89 | .005 |
NOTE. Mean (SD) outcome reporting for all included patients, compared between a standardized preoperative assessment and at 1 year postoperatively.
AD, absolute difference; ASES, American Shoulder and Elbow Score; SANE, Single Assessment Numerical Evaluation; VAS, visual analog scale; VR-12, Veterans Rand 12 Item Health Survey.
Table 3.
Clinical Outcome Scoring at 1 Year Postoperatively, Stratified by Rotator Cuff Repair Groups
| Clinical Outcome | Isolated SST | Isolated SST + RCR | P Value |
|---|---|---|---|
| VAS | 1.71 (1.70) | 1.44 (1.97) | .37 |
| ASES index | 77.19 (16.88) | 83.50 (21.0) | .23 |
| SANE | 67 (33.15) | 77.47 (23.74) | .15 |
| VR-12 Mental | 52.54 (12.02) | 51.87 (7.89) | .65 |
NOTE. Comparison of mean (SD) outcome scoring at 1 year postoperatively for patients undergoing SST repair and proximal biceps tenodesis with and without additional RCR. Preoperative scores were also compared between the groups and no statistically significant differences were found for all outcomes indices.
ASES, American Shoulder and Elbow Score; RCR, rotator cuff repair; SANE, Single Assessment Numerical Evaluation; SST, subscapularis tendon; VAS, visual analog scale; VR-12, Veterans Rand 12 Item Health Survey.
Discussion
At 1 year postoperatively, patients undergoing combined arthroscopic proximal biceps tenodesis and repair of type II to III SST injuries using the LNT technique achieved significant improvements in shoulder function, high rates of patient satisfaction, and low rates of reoperation. Additionally, the results of the study defined the MCID for the VAS pain, ASES, SANE, and VR-12 mental component scores, which were met by most patients undergoing this procedure.
Although arthroscopic SST repair is generally supported,25, 26, 27 the clinical evaluation of specific or isolated tear patterns has become more relevant.4, 5, 6,11,12,17,18,28 Injuries to the upper-third SST are of particular interest given its biomechanical importance and role in difficult-to-treat anterior shoulder dysfunction.4,5,17,18 The use of single-anchor fixation is supported for isolated, complete SST tears containing up to 50% footprint disruption (Lafosse II-III).12,29 Biomechanical studies have recommended that upper-third SST tears should be anchored superolateral from the native footprint, near the entrance of the bicipital groove, to preserve the “leading edge” and function of the superior aspect of the subscapularis.30 This is appealing for treating proximal biceps disease, which often accompanies SST tears.2, 3, 4, 5 However, the utility of single-anchor constructs for combined SST repair and proximal biceps tenodesis is limited to a few technical reports that lack any clinical evaluation.4,17,18
At 1-year follow-up, significant improvements in all scoring indices were noted among our cohort of patients. Similar to available literature, patients achieved substantial increases in shoulder function scores. For example, Katthagen et al.5 reported the outcomes of 28 patients who underwent single-anchor fixation of upper-third SST tears with open subpectoral tenodesis. Of those with complete (type II) tears (n = 17), the mean (SD) ASES score improved to 93.7 (10.8) from a mean (SD) preoperative score of 54.1 (19.7). To substantiate our findings, at least 85% of patients met the MCID for shoulder function scores, whereas 95% of patients met the MCID for VAS pain scores in our study. However, for RCR in general, the MCID for ASES scores ranges from 11.1 to 27.1, whereas those reported for SANE and VAS pain scores range from 13.0 to 16.9 and 1.5 to 2.4, respectively.31, 32, 33 Comparatively, the MCID values reported from our study were considerably lower. Furthermore, despite the rate of treatment success among our cohort of patients, the heterogeneity of rotator cuff pathology and concomitant procedures makes attributing these findings solely to the LNT technique difficult.
One of the challenges to arthroscopic SST repair compared with superior RCR is working within the subcoracoid space. The LNT technique has been described for treating isolated proximal biceps disease19, 20, 21, 22 and, recently, with combined repair of upper border SST injuries.17 According to Kim et al.,17 this all-arthroscopic technique negates the need for additional portal incisions or subacromial access, can be successfully performed with knotless anchors, and is cost-saving relative to independently performed procedures. However, this technique is limited to intra-articular biceps pathology and can be technically challenging in the setting of subpar visualization. Although the biomechanical strength and durability of knotless anchors is supported in literature,34,35 an additional disadvantage reported by Kim et al.17 is that loading 3 sets of suture into a single anchor may lead to increased tension and failure. However, this may be less of a concern with our described technique, which loads 2 sets of suture instead of 3. Furthermore, the LNT technique for isolated proximal biceps tenodesis has been supported both biomechanically21 and clinically.22 Duerr et al.22 reported the clinical outcomes of 59 patients undergoing isolated LNT proximal biceps tenodesis, which included no reoperations for biceps-related pathology at 2-year follow-up.
Although 4 patients with type III injuries were treated using this technique, the procedure’s utility for type III patterns with footprint disruption beyond 50% is less understood clinically.12,29 Similarly, the management of partial, upper border tears (type I) remains debated, as some reports have identified suboptimal outcomes with repair compared with debridement.5,36 As such, the biomechanical properties of this technique and repair should be further investigated.
Limitations
This study has several limitations that should be considered while interpreting our results. First, our study design did not include a control group that validates the benefits of this particular treatment. Additionally, clinical outcomes were reported at 1 year, which may overestimate treatment success compared with longer follow-up studies. Second, isolated SST tears only comprised 17% of our patient cohort. As such, the heterogeneity of RTC tear morphology and concomitant procedures performed introduces significant variability. Although no statistically significant differences were demonstrated between the clinical outcomes of different treatment groups, it is plausible this is related to type II (β) error. Lastly, our definition of treatment failure did not include any radiographic follow-up to confirm the structural integrity of RCR, which likely underestimates the percentage of patients meeting this criteria.
Conclusions
Patients treated with combined, single-anchor SST repair and LNT proximal biceps tenodesis achieved significant improvements in function, high satisfaction, and low rates of reoperation at 1 year postoperatively. Additionally, 76% to 95% of patients met the MCID for VAS pain, ASES, SANE, and VR-12 mental health scores.
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: S.A. reports a relationship with Arthrex that includes consulting or advisory. J.M.P. reports a relationship with Arthrex that includes consulting or advisory. All other authors (L.B., B.K., C.B.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
References
- 1.Arai R., Mochizuki T., Yamaguchi K., et al. Functional anatomy of the superior glenohumeral and coracohumeral ligaments and the subscapularis tendon in view of stabilization of the long head of the biceps tendon. J Shoulder Elbow Surg. 2010;19:58–64. doi: 10.1016/j.jse.2009.04.001. [DOI] [PubMed] [Google Scholar]
- 2.Chen C.H., Hsu K.Y., Chen W.J., Shih C.H. Incidence and severity of biceps long head tendon lesion in patients with complete rotator cuff tears. J Trauma. 2005;58:1189–1193. doi: 10.1097/01.ta.0000170052.84544.34. [DOI] [PubMed] [Google Scholar]
- 3.Urita A., Funakoshi T., Amano T., et al. Predictive factors of long head of the biceps tendon disorders—the bicipital groove morphology and subscapularis tendon tear. J Shoulder Elbow Surg. 2016;25:384–389. doi: 10.1016/j.jse.2015.12.015. [DOI] [PubMed] [Google Scholar]
- 4.Fleck K.E., Field L.D. Consolidated proximal biceps tenodesis and subscapularis repair. Arthrosc Tech. 2017;6:e1967–e1971. doi: 10.1016/j.eats.2017.07.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Katthagen J.C., Vap A.R., Tahal D.S., Horan M.P., Millett P.J. Arthroscopic repair of isolated partial- and full-thickness upper third subscapularis tendon tears: Minimum 2-year outcomes after single-anchor repair and biceps tenodesis. Arthroscopy. 2017;33:1286–1293. doi: 10.1016/j.arthro.2017.01.027. [DOI] [PubMed] [Google Scholar]
- 6.Burkhart S.S., Brady P.C. Arthroscopic subscapularis repair: Surgical tips and pearls A to Z. Arthroscopy. 2006;22:1014–1027. doi: 10.1016/j.arthro.2006.07.020. [DOI] [PubMed] [Google Scholar]
- 7.Koh K.H., Ahn J.H., Kim S.M., Yoo J.C. Treatment of biceps tendon lesions in the setting of rotator cuff tears: Prospective cohort study of tenotomy versus tenodesis. Am J Sports Med. 2010;38:1584–1590. doi: 10.1177/0363546510364053. [DOI] [PubMed] [Google Scholar]
- 8.Lafosse L., Jost B., Reiland Y., Audebert S., Toussaint B., Gobezie R. Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears. J Bone Joint Surg Am. 2007;89:1184–1193. doi: 10.2106/JBJS.F.00007. [DOI] [PubMed] [Google Scholar]
- 9.Nové-Josserand L., Hardy M.B., Leandro Nunes Ogassawara R., Carrillon Y., Godenèche A. Clinical and structural results of arthroscopic repair of isolated subscapularis tear. J Bone Joint Surg Am. 2012;94:e125. doi: 10.2106/JBJS.K.00008. [DOI] [PubMed] [Google Scholar]
- 10.Naimark M., Zhang A.L., Leon I., Trivellas A., Feeley B.T., Ma C.B. Clinical, radiographic, and surgical presentation of subscapularis tendon tears: A retrospective analysis of 139 patients. Arthroscopy. 2016;32:747–752. doi: 10.1016/j.arthro.2015.11.019. [DOI] [PubMed] [Google Scholar]
- 11.Denard P.J., Burkhart S.S. A new method for knotless fixation of an upper subscapularis tear. Arthroscopy. 2011;27:861–866. doi: 10.1016/j.arthro.2010.11.010. [DOI] [PubMed] [Google Scholar]
- 12.Lorbach O., Trennheuser C., Kieb M., Efe T., Kohn D., Anagnostakos K. Reconstruction of 25 and 50 % subscapularis tears: A single anchor with a double-mattress suture is sufficient for the reconstruction. Knee Surg Sports Traumatol Arthrosc. 2016;24:3855–3862. doi: 10.1007/s00167-015-3767-5. [DOI] [PubMed] [Google Scholar]
- 13.Lee H.J., Jeong J.Y., Kim C.K., Kim Y.S. Surgical treatment of lesions of the long head of the biceps brachii tendon with rotator cuff tear: A prospective randomized clinical trial comparing the clinical results of tenotomy and tenodesis. J Shoulder Elbow Surg. 2016;25:1107–1114. doi: 10.1016/j.jse.2016.02.006. [DOI] [PubMed] [Google Scholar]
- 14.Oh J.H., Lee H.Y., Kim S.H., et al. Comparison of treatments for superior labrum-biceps complex lesions with concomitant rotator cuff repair: A prospective, randomized, comparative analysis of debridement, biceps tenotomy, and biceps tenodesis. Arthroscopy. 2016;32:958–967. doi: 10.1016/j.arthro.2015.11.036. [DOI] [PubMed] [Google Scholar]
- 15.Zhang Q., Zhou J., Ge H., Cheng B. Tenotomy or tenodesis for long head biceps lesions in shoulders with reparable rotator cuff tears: A prospective andomized trial. Knee Surg Sports Traumatol Arthrosc. 2015;23:464–469. doi: 10.1007/s00167-013-2587-8. [DOI] [PubMed] [Google Scholar]
- 16.De Carli A., Vadalà A., Zanzotto E., et al. Reparable rotator cuff tears with concomitant long-head biceps lesions: Tenotomy or tenotomy/tenodesis? Knee Surg Sports Traumatol Arthrosc. 2012;20:2553–2558. doi: 10.1007/s00167-012-1918-5. [DOI] [PubMed] [Google Scholar]
- 17.Kim J.Y., Park H.Y., Del Sol S.R., et al. Arthroscopic single portal, single anchor knotless subscapularis repair with concomitant tenodesis of the long head of the biceps tendon. Arthrosc Tech. 2021;10:e1117–e1123. doi: 10.1016/j.eats.2021.01.002. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Rayos Del Sol S., Guzman A., Shin Yin S.S., et al. Single-portal, single-anchor repair of a superior third subscapularis tear using a self-punching knotless soft suture anchor. Arthrosc Tech. 2021;10:e2079–e2085. doi: 10.1016/j.eats.2021.05.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Hammarstedt J.E., Rinaldi J., Guth J.J., Akhavan S. The Loop ‘N’ Tack biceps tenodesis: An all-arthroscopic, intra-articular technique. Arthrosc Tech. 2020;9:e1899–e1902. doi: 10.1016/j.eats.2020.08.017. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Schillhammer C.K. Tack-and-loop biceps tenodesis of the shoulder: Description of technique. Arthrosc Tech. 2022;11:e1709–e1713. doi: 10.1016/j.eats.2022.06.005. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Acosta J., Rinaldi J.M., Guth J.J., Akhavan S. The Loop ‘n’ Tack knot: Biomechanical analysis of a novel suture technique for proximal biceps tenodesis. Orthop J Sports Med. 2020;8 doi: 10.1177/2325967120952315. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Duerr R.A., Nye D., Paci J.M., Akhavan S. Clinical evaluation of an arthroscopic knotless suprapectoral biceps tenodesis technique: Loop ‘n’ Tack tenodesis. Orthop J Sports Med. 2018;6 doi: 10.1177/2325967118779786. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Sedaghat A.R. Understanding the minimal clinically important difference (MCID) of patient-reported outcome measures. Otolaryngol Head Neck Surg. 2019;161:551–560. doi: 10.1177/0194599819852604. [DOI] [PubMed] [Google Scholar]
- 24.Scanaliato J.P., Green C.K., Sandler A.B., Hurley E.T., Hettrich C.M., Parnes N. Establishing the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after arthroscopic posterior labral repair for posterior glenohumeral instability. Am J Sports Med. 2024;52:207–214. doi: 10.1177/03635465231210289. [DOI] [PubMed] [Google Scholar]
- 25.Nové-Josserand L., Collin P., Godenèche A., et al. Ten-year clinical and anatomic follow-up after repair of anterosuperior rotator cuff tears: Influence of the subscapularis. J Shoulder Elbow Surg. 2017;26:1826–1833. doi: 10.1016/j.jse.2017.03.037. [DOI] [PubMed] [Google Scholar]
- 26.Seppel G., Plath J.E., Völk C., et al. Long-term results after arthroscopic repair of isolated subscapularis tears. Am J Sports Med. 2017;45:759–766. doi: 10.1177/0363546516676261. [DOI] [PubMed] [Google Scholar]
- 27.Hasler A., Boyce G., Schallberger A., Jost B., Catanzaro S., Gerber C. Arthroscopic repair of isolated subscapularis tears: clinical outcome and structural integrity with a minimum follow-up of 4.6 years. J Shoulder Elbow Surg. 2019;28:2171–2180. doi: 10.1016/j.jse.2019.03.024. [DOI] [PubMed] [Google Scholar]
- 28.Kim S.-H., Oh I., Park J.-S., Shin S.-K., Jeong W.-K. Intra-articular repair of an isolated partial articular-surface tear of the subscapularis tendon. Am J Sports Med. 2005;33:1825–1830. doi: 10.1177/0363546505278259. [DOI] [PubMed] [Google Scholar]
- 29.Borbas P., Cammarata S., Loucas R., et al. Arthroscopic single anchor repair techniques for upper third subscapularis tears provide sufficient biomechanical stability. Knee Surg Sports Traumatol Arthrosc. 2022;30:2105–2112. doi: 10.1007/s00167-021-06808-0. [DOI] [PubMed] [Google Scholar]
- 30.Dyrna F., Beitzel K., Pauzenberger L., et al. A superolaterally placed anchor for subscapularis “leading-edge” refixation: A biomechanical study. Arthroscopy. 2019;35:1306–1313.e1. doi: 10.1016/j.arthro.2018.11.060. [DOI] [PubMed] [Google Scholar]
- 31.Kim D.M., Kim T.H., Kholinne E., et al. Minimal clinically important difference, substantial clinical benefit, and patient acceptable symptomatic state after arthroscopic rotator cuff repair. Am J Sports Med. 2020;48:2650–2659. doi: 10.1177/0363546520943862. [DOI] [PubMed] [Google Scholar]
- 32.Tashjian R.Z., Shin J., Broschinsky K., et al. Minimal clinically important differences in the American Shoulder and Elbow Surgeons, Simple Shoulder Test, and visual analog scale pain scores after arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2020;29:1406–1411. doi: 10.1016/j.jse.2019.11.018. [DOI] [PubMed] [Google Scholar]
- 33.Cvetanovich G.L., Gowd A.K., Liu J.N., et al. Establishing clinically significant outcome after arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2019;28:939–948. doi: 10.1016/j.jse.2018.10.013. [DOI] [PubMed] [Google Scholar]
- 34.Barber F.A., Bava E.D., Spenciner D.B., Piccirillo J. Cyclic biomechanical testing of biocomposite lateral row knotless anchors in a human cadaveric model. Arthroscopy. 2013;29:1012–1018. doi: 10.1016/j.arthro.2013.02.006. [DOI] [PubMed] [Google Scholar]
- 35.Nolte P.C., Midtgaard K.S., Ciccotti M., et al. Biomechanical comparison of knotless all-suture anchors and knotted all-suture anchors in type II SLAP lesions: A cadaveric study. Arthroscopy. 2020;36:2094–2102. doi: 10.1016/j.arthro.2020.04.026. [DOI] [PubMed] [Google Scholar]
- 36.Randelli P., Arrigoni P., Aliprandi A., et al. Repair versus shaving of partial-thickness articular-sided tears of the upper subscapularis tendon. A prospective randomized controlled trial. Joints. 2016;3:109–115. doi: 10.11138/jts/2015.3.3.109. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.