Open Versus Arthroscopic Biceps Tenodesis: A Comparison of Functional Outcomes

Abstract

Background

The proximal aspect of the long head of the biceps brachii (LHB) is a frequent source of anterior shoulder pain. Multiple techniques for LHB tenodesis have been described. However, comparative outcomes are lacking. The present study aims to compare functional results, patient reported outcomes, complications, and clinical failures for patients undergoing open versus arthroscopic LHB tenodesis.

Methods

All patients who underwent open or arthroscopic LHB tenodesis from 2009-2012 at a single institution were identified. Patient demographics, comorbidities, and operative variables of interest, including concomitant procedures, were recorded. Minimum 1-year follow-up was required for inclusion. Outcomes, including patient reported outcomes, physical exam findings, and complications were compared between open and arthroscopic LHB tenodesis patients.

Results

Overall, 45 patients (25 open, 20 arthroscopic) were available for analysis. In total, there was a single clinical failure in a patient who underwent arthroscopic LHB tenodesis. No other complications or failures were noted. Active shoulder forward elevation was increased in the open tenodesis group as compared to the arthroscopic tenodesis group (177.8 ± 9.3° vs. 171.3 ± 11.7°; p = 0.049). Otherwise, there was no difference in range of motion or strength. For both groups, both the SF-36 and ASES scores improved significantly from preoperative values.

Conclusion

Both open and arthroscopic LHB tenodesis provide good to excellent outcomes with few complications. Given the recent increased utilization of LHB tenodesis, future studies should use randomization and prospective data collection in order to determine if discrete patient populations are better served by either open or arthroscopic LHB tenodesis techniques

Introduction

The proximal aspect of the long head of the biceps brachii (LHB) is a common source of anterior shoulder pain. With failure of conservative treatment options, proximal LHB tenodesis has been described as a viable surgical treatment option for a variety of LHB pathologies, including LHB tendonitis, tendinopathy, instability, and superior labrum anterior-posterior lesions (SLAP)¹-³. While previous studies have failed to provide a definitive advantage for LHB tenodesis compared with tenotomy⁴-⁸, tenodesis provides the reported advantage of improved strength and decreased cramping pain through maintenance of the LHB length-tension relationship as well as more consistent cosmetic results⁹. Clinically, many patients under the age of 40 prefer tenodesis to tenotomy due to the more consistent cosmetic results and concerns with weakness and cramping associated with tenotomy in this young, active population.

Multiple techniques for LHB tenodesis have been described10-15. Technical considerations include open versus arthroscopic approach, fixation technique, and tenodesis location, which are generally described as suprapectoral or subpectoral. In some cases, the approach utilized for LHB tenodesis may be dictated by concomitant pathology, including rotator cuff or labral pathology, but this is ultimately at the discretion of the treating surgeon. While comparative studies are limited to Level III and IV evidence¹⁶-¹⁹, satisfactory results have consistently been reported regardless of approach and fixation technique²⁰-²². However, there is limited evidence to suggest that LHB tenodesis location, specifically with-in the bicipital groove, may result in inferior outcomes as compared to a more distal tenodesis location¹⁸,²³.

Few studies have previously compared outcomes following arthroscopic and open LHB tenodesis techniques¹⁶- ¹⁸. Given the increasing incidence of biceps tenodesis²⁴,²⁵, particularly arthroscopic biceps tenodesis, further study is warranted. The goal of the present study was to compare function, patient reported outcomes, complications, and clinical failures following arthroscopic and open LHB tenodesis.

Methods

Institutional Review Board Approval

This study received approval from the University of Iowa Institutional Review Board.

Data Collection

All patients undergoing LHB tenodesis from January 1, 2009 to December 31, 2012 at a single institution were identified using Common Procedural Terminology (CPT) codes 23430 (tenodesis of long tendon of biceps) and 29828 (arthroscopy, shoulder, surgical; biceps tenodesis). A total of 93 patients were identified. In all cases, operative reports were reviewed to confirm that tenodesis was performed and to determine surgical technique (open versus arthroscopic). Study inclusion criteria included patient age ≥ 18 years, proximal biceps tendon pathology including biceps tendonitis, tendinopathy, instability, or SLAP tears, diagnosed preoperatively with physical exam and/or imaging and confirmed during diagnostic arthroscopy, and minimum 1-year follow-up with a documented physical exam at the time of followup. Exclusion criteria included absence of a documented physical exam despite >1-year follow-up or follow-up <1 year. Using these criteria, a total of 45 patients (25 open, 20 arthroscopic) were identified for analysis from the original 93 patients who underwent arthroscopic or open LHB tenodesis during the time period of the study (48.4% inclusion). All procedures were performed by one of two fellowship-trained sports medicine surgeons.

Patient demographics, comorbidities, and operative variables of interest were recoreded. Patient demographic characteristics included age at the time of surgery, sex, race, surgery on the dominant arm, and history of prior ipsilateral shoulder surgery. All relevant comorbidities required to calculate the Age-Adjusted Charlson Comorbidity index (AACI)²⁶,²⁷ were obtained. Additionally, the American Society of Anesthesiologists (ASA) classification and smoking status, which was further categorized as “non-smoker” for patients with no smoking history, “former smoker” for patients with a history of smoking but did not smoke within four weeks of surgery, and “current smoker” for patients with a history of smoking within four weeks of surgery were documented. Operative variables of interest included open versus arthroscopic approach, concomitant procedures at the time of LHB tenodesis, including rotator cuff repair, labral repair, cartilage procedures, subacromial decompression, and distal clavicle resection, and method of fixation, including interference screw or suture anchor fixation.

Surgical Technique

Open subpectoral LHB tenodesis is typically performed following completion of any concomitant procedures. With pathology identified at the time of diagnostic arthroscopy, a biceps tenotomy is performed at the biceps-labral junction with an arthroscopic scissors or basket. A 3-4 cm incision is then made in the axilla centered over the inferior border of the pectoralis major tendon. The inferior border of the pectoralis major tendon is then bluntly retracted superiorly and the arm internally rotated to allow palpation of the bicipital groove and biceps tendon. The biceps tendon is then delivered from the wound and a #2 braided suture placed in a locked fashion 15-20 mm proximal to the myotendinous junction and excess proximal tendon excised. An 8 mm unicortical bone tunnel is then drilled just distal to the inferior border of the pectoralis major tendon insertion and an 8 mm bioabsorbable interference screw placed while attached to the tendon until the screw sits flat along the anterior cortical surface of the humerus. The tag ends of the locked suture are then tied and cut to complete the procedure.

Arthroscopic suprapectoral LHB tenodesis procedures were performed using the technique described by Romeo et al²⁸. Briefly, the biceps tendon is tagged using #2 braided suture placed through the tendon after diagnostic arthroscopy. With the suture in place, a biceps tenotomy is performed at the level of the biceps-labral junction. Posterolateral and anterolateral portals were then established, and depending on concomitant pathology, a limited subacromial bursectomy was performed to visualize the transverse ligaments overlying the biceps tendon within the bicipital groove. The bicipital groove and biceps tendon are then exposed using electrocautery. The tagged biceps tendon is then pulled out the anterolateral portal and the transverse ligaments overlying the biceps tendon is further released while pulling gentle traction on the tendon. Approximately 15-20 mm of the most proximal aspect of the tendon is excised and a locking #2 braided suture placed. A guidewire is then placed in the bicipital groove and unicortical bone tunnel drilled over the guidewire. The tendon is then fixed into the proximal humerus with a 7.0 or 8.0 mm bioabsorbable tenodesis screw.

Outcomes

Outcome measures of interest were broadly categorized into patient reported outcome measures, including general health and general shoulder measures, physical exam findings, and complications. The short form-36 (SF-36) physical component score (PCS) and mental component score (MCS) provided assessment of general health-related quality of life²⁸,²⁹. General shoulder measures included the American Shoulder and Elbow Surgeons (ASES) score³⁰, the Disabilities of the Arm, Shoulder, and Hand (DASH) score³¹, the Single Assessment Numeric Evaluation (SANE)³², the Simple Shoulder Test (SST)³³, and the Constant-Murley score (CMS)³⁴. Additionally, during the postoperative assessment, all patients were asked “would you suggest your surgery to friends or family in the future?” warranting a simple “yes” or “no” response. Questionnaires were completed by all patients at their minimum 1-year follow-up. However, due to changes in data collection methods at the institution during the course of the study, not all measures were collected or available preoperatively.

Physical examination included an assessment of shoulder range of motion, strength, and special shoulder and biceps tests. All range of motion measurements were made on both the operative and contralateral extremity. Active shoulder forward elevation and abduction were measured with a goniometer in degrees. Active shoulder internal and external rotation were graded according to the criteria established by Constant and Murley for use with the CMS³⁴. Using these criteria for internal and external rotation, any decrease in motion between the operative and contralateral extremity was considered an internal rotation or external rotation deficit, respectively. Strength assessment included evaluation of elbow flexion and shoulder abduction strength using the MicroFet2 handheld dynamometer (Hoggan Scientific, L.L.C., Salt Lake City, UT, USA). Forearm supination strength was similarly measured using a Cybex dynamometer (Cybex International, Medway, MA, USA). All strength measurements were made in pounds (lbs) on both the operative and contralateral arm. Special tests and observations relevant to biceps pathology were also performed. All patients were observed for presence of a “Popeye” deformity, indicating failure of proximal fixation. Bicipital groove tenderness was assessed by palpation of the bicipital groove through the subpectoral triangle, as described by Mazzocca et al.²¹. The Speed’s test ³⁵ and Yergason supination test³⁶ were also performed as previously described. The presence of pain with palpation of the bicipital groove, Speed’s test, or Yergason supination test was considered positive and dichotomously coded as “yes” or “no”. The biceps apex distance was measured on both arms and the difference between the two values referred to as the biceps apex difference. The method of measurement was modified from the original description by Mazzocca et al.²¹, using the medial epicondyle as a reference point for measurement as this was found to be a more consistently reliable landmark than the inferior border of the pectoralis major tendon. Additionally, the biceps circumference at the apex of the biceps was measured on both arms and the difference between the two values referred to as the biceps circumference difference. All assessments were made at minimum 1-year follow-up by a single member of the research team to maintain consistent measurement technique.

Evaluated complications included wound infections requiring either antibiotic treatment or return to the operating room for irrigation and debridement, reoperation within the follow-up period, and loss of proximal fixation. The primary outcome of interest was clinical failure, defined as loss of proximal fixation with presence of the “Popeye” deformity at minimum 1-year follow-up.

Statistical Analysis

Comparison of outcomes between the arthroscopic and open tenodesis groups were performed using Student’s t-test and chi-square or Fisher’s exact test for continuous and categorical variables, respectively. Similarly, preoperative and postoperative outcomes were compared when there was >60% chart completion of both preoperative and postoperative measures. Several continuous variables were also categorically defined and reported to allow further comparison between arthroscopic and open tenodesis groups as well as preoperative and postoperative measures. All statistical analysis was performed with SPSS Statistics (IBM Corp., Armonk, NY, USA). A p-value of >0.05 was considered statistically significant.

Results

Overall, there were 45/95 patients available for analysis (48.4%) between 2009 and 2012 that underwent proximal LHB tenodesis with mean follow-up of 3.2 ± 1.1 years. Of these, 25 (55.6%) underwent open tenodesis and 20 (44.4%) underwent arthroscopic tenodesis procedures. The was 43.8 ± 12.5 years, and the majority of patients were male (82.2%). Patients undergoing arthroscopic tenodesis were significantly older than those undergoing open tenodesis (49.9 ± 11.8 years vs. 38.9 ± 11.0 years; p = 0.003) (Table I). Concomitant procedures were performed in 41/45 (91.1%) of patients. Rotator cuff repair was the most commonly performed concomitant procedure (66.7%), and was performed more frequently in patients undergoing arthroscopic tenodesis as compared to open tenodesis (85.0% vs. 52.0%; p = 0.027). There were no other significant differences in demographic characteristics, comorbidities, and operative variables between the two cohorts.

Table I.

Demographic Characteristics, Comorbidities, and Operative Variables of Open and Arthroscopic Biceps Tenodesis Patients

	All (n=45)	Open(n=25)	Arthroscopic(n=20)	pvalue*
Demographic Characteristics
Age†	43.8 ± 12.5	38.9 ± 11.0	49.9 ± 11.8	0.003
Sex (%)				0.435
Male	82.2	88.0	75.0
Female	17.8	12.0	25.0
Race (%)				0.332
White	88.9	88.0	90.0
Black	4.4	8.0	0.0
Other	6.7	2.2	4.4
DominantArm(%)	66.7	76.0	55.0	0.205
Prior ipsilateral shoulder surgery (%)	13.3	12.0	15.0	1.000
Follow-up (yrs)†	3.2 ± 1.1	3.1 ± 0.9	3.4 ± 1.3	0.428
Comorbidities
Charlson Comorbidity Index†	0.9 ± 1.7	0.6 ± 1.8	1.2 ± 0.5	0.274
ASA†	1.7 ± 0.6	1.6 ± 0.5	1.8 ± 0.6	0.395
Smoking Status (%)				0.879
Nonsmoker	64.4	65.0	64.0
Former smoker	17.8	20.0	16.0
Current smoker	17.8	15.0	20.0
Operative Variables
Fixation (%)				1.000
Screw	88.9	88.0	90.0
Suture Anchor	11.1	12.0	10.0
Concomitant Procedures (%)
Rotator Cuff Repair	66.7	52.0	85.0	0.027
Rotator Cuff Debridement	4.4	8.0	0.0	0.495
Labral Repair	8.9	16.0	0.0	0.117
Cartilage Procedure	2.2	4.0	0.0	1.000
Subacromial Decompression	80.0	72.0	90.0	0.260
Distal Clavicle Resection	11.1	8.0	15.0	0.642

^*Open versus arthroscopic comparison.

^†Listed as mean ± standard deviation.

In total, there was a single clinical failure identified at 9 weeks postoperatively in a patient who underwent arthroscopic tenodesis with interference screw fixation, leading to an overall failure rate of 2.2%. There was no significant difference in clinical failures between the arthroscopic and open tenodesis cohorts (5.0% vs. 0.0%, p = 0.444). The single clinical failure was the only identified complication, as there were no wound infections or reoperations reported during the follow-up period.

Active shoulder forward elevation was significantly decreased in the arthroscopic tenodesis group as compared with the open tenodesis group (171.3 ± 11.7° vs. 177.8 ± 9.3°; p = 0.049) (Table II). Otherwise, there were no differences in active range of motion between the two groups. Similarly, there were no differences in elbow flexion, shoulder abduction, or forearm supination strength between the two groups. Average biceps apex difference for the entire cohort was 0.6 ± 0.8 cm and was equivalent for open and arthroscopic groups (0.5 ± 0.5 cm vs. 0.9 ± 1.0 cm; p = 0.112). The percentage of patients who had a biceps apex difference of 0, or equal to the contralateral arm, was 44.0% and 30.0% for the open and arthroscopic tenodesis groups, respectively (p = 0.336). Persistent bicipital groove tenderness was noted in 15.6% of patients after LHB tenodesis, with no significant difference in the frequency of bicipital groove tenderness between the open and arthroscopic tenodesis groups (20.0% vs. 10.0%, p = 0.437).

Table II.

Outcomes Following Open and Arthroscopic Biceps Tenodesis^*

	All (n=45)	Open (n=25)	Arthroscopic (n=20)	p value‡
Patient Reported Outcome Measures
SF-36 PCS	46.4 ± 11.5	48.2 ± 10.0	44.1 ± 13.0	0.272
SF-36 MCS	52.4 ± 9.3	53.0 ± 7.4	51.7 ± 11.4	0.675
ASES	81.1 ± 21.1	82.3 ± 20.4	79.6 ± 22.3	0.681
DASH	12.3 ± 14.4	11.3 ± 14.5	13.7 ± 14.8	0.649
SANE	88.9 ± 16.9	88.9 ± 18.0	88.8 ± 16.1	0.981
SST	10.9 ± 1.9	10.8 ± 2.2	11.1 ± 1.4	0.701
Constant-Murley Score	87.4 ± 16.3	88.0 ± 19.7	86.7 ± 11.1	0.774
Would recommend surgery again (%)	97.8	96.0	100.0	1.000
Physical Exam Findings
Bicipital groove tenderness (%)	15.6	20.0	10.0	0.437
Positive Speed’s test (%)	2.2	4.0	0.0	1.000
Positive Yergason’s test (%)	4.4	4.0	5.0	1.000
Biceps apex difference (cm)†	0.6 ± 0.8	0.5 ± 0.5	0.9 ± 1.0	0.112
Biceps circumference difference (cm)†	-0.2 ± 1.3	-0.1 ± 1.2	-0.3 ± 1.4	0.609
Strength (lbs)†
Elbow Flexion	-1.7 ± 8.9	-0.4 ± 7.4	-3.3 ± 10.6	0.307
Forearm Supination	-0.4 ± 2.3	-0.2 ± 1.5	-0.6 ± 2.9	0.654
Shoulder Abduction	-2.5 ± 5.1	-3.8 ± 5.3	-1.0 ± 4.6	0.057
Range of motion
Shoulder forward elevation (degrees)	174.9 ± 10.7	177.8 ± 9.3	171.3 ± 11.7	0.049
Shoulder abduction (degrees)	174.9 ± 10.5	177.4 ± 9.3	171.8 ± 11.4	0.081
Internal rotation deficit†	6.7	4	10	0.577
External rotation deficit†	2.2	0	5	0.444
Complications (%)
Wound Infection	0.0	0.0	0.0	1.000
Reoperation	0.0	0.0	0.0	1.000
Loss of proximal fixation	2.2	0.0	5.0	0.444

^*Listed as mean ± standard deviation except where noted.†Compared to contralateral arm.

^‡Open versus arthroscopic comparison.

Table III.

Pre- and Postoperative Outcome Measures Following Biceps Tenodesis

Outcome Measure	Percent Available (%)	Preoperative	Postoperative	Difference	p value
SF-36 PCS	77.8	41.6 ± 8.3	46.2 ± 11.2	4.6 ± 8.7	0.004
SF-36 MCS	77.8	51.6 ± 9.4	52.8 ± 9.7	1.3 ± 8.3	0.379
ASES	64.4	14.7 ± 6.3	81.6 ± 20.8	66.9 ± 19.6	<0.001

When comparing postoperative patient reported outcome measures, there were no significant differences between the groups. Only a single patient who underwent open tenodesis stated that they would not recommend surgery again. Due to changes in institutional data collection methods during the time period of the study, adequate chart completion for comparison of preoperative and postoperative outcomes was only available for SF-36 and ASES measures, which had 77.8% and 66.4% chart completion, respectively. For the entire cohort, both SF-36 PCS (41.6 ± 8.3 vs. 46.2 ± 11.2; p = 0.004) and ASES (14.7 ± 6.3 vs. 81.6 ± 20.8; p < 0.001) scores improved significantly compared to preoperative values (Table III). Using established minimal clinically important differences (MCID) for the ASES score³⁷, all patients showed improvement postoperatively, regardless of open or arthroscopic surgical technique. While the MCID for the SF-36 PCS has been established previously for other joints³⁸-⁴⁰, it has not been established for the shoulder. Using a conservative MCID of 10 points for the SF-36 PCS, 25.7% of patients improved postoperatively, with equivalent results for open and arthroscopic tenodesis (26.3% vs. 25.0%; p = 1.000). Further stratification of patients by those who did and did not undergo concomitant rotator cuff repair revealed no significant difference in any outcome measure (Table IV).

Table IV.

Patient Characteristics and Outcomes following Biceps Tenodesis with and without Rotator Cuff Repair^*

	No Rotator Cuff Repair (n=15)	Rotator Cuff Repair (n=30)	p value
Patient Reported Outcome Measures
SF-36 PCS	46.6 ± 12.3	46.2 ± 11.2	0.935
SF-36 MCS	52.0 ± 6.8	52.6 ± 10.6	0.843
ASES	77.4 ± 25.1	83.1 ± 18.6	0.455
DASH	19.2 ± 18.7	8.8 ± 10.7	0.112
SANE	85.7 ± 22.3	90.4 ± 13.7	0.463
SST	10.6 ± 2.6	11.1 ± 1.4	0.500
Constant-Murley Score	88.8 ± 14.8	86.7 ± 17.2	0.674
Would recommend surgery again (%)	93.3	100.0	0.333
Physical Exam Findings
Popeye deformity (%)	6.7	0.0	0.333
Bicipital groove tenderness (%)	20.0	13.3	0.670
Positive Speed’s test (%)	6.7	0.0	0.333
Positive Yergason’s test (%)	13.3	0.0	0.106
Biceps apex difference (cm)†	0.9 ± 0.9	0.5 ± 0.7	0.178
Biceps circumference difference (cm)†	-0.3 ± 1.0	-0.2 ± 1.4	0.819
Strength (lbs)†
Elbow Flexion	-4.4 ± 9.5	-0.3 ± 8.5	0.169
Forearm Supination	0.3 ± 2.0	-0.7 ± 2.3	0.146
Shoulder Abduction	-2.0 ± 5.1	-2.8 ± 5.2	0.597
Range of motion
Shoulder forward elevation (degrees)	175.0 ± 12.4	174.8 ± 10.0	0.957
Shoulder abduction (degrees)	175.0 ± 12.4	174.8 ± 9.7	0.964
Internal rotation deficit†	6.7	6.7	1.000
External rotation deficit†	0.0	3.3	1.000
Complications (%)
Wound Infection	0.0	0.0	1.000
Reoperation	0.0	0.0	1.000
Loss of proximal fixation	6.7	0.0	0.333

^*Listed as mean ± standard deviation except where noted.

^†Compared to contralateral arm.

Discussion

Proximal LHB pathology is a common source of anterior shoulder pain. LHB tenodesis has been shown to be an effective procedure for management of anterior shoulder pain associated with biceps tendinitis, tendinopathy, and SLAP tears, with increasing utilization within the last decade²⁴,²⁵. While LHB tenodesis is a common procedure with consistent outcomes²⁰,²¹, multiple technique variations, including open and arthroscopic approaches, have been described with few comparative clinical studies¹⁶-¹⁸. The present study compared open and arthroscopic LHB tenodesis procedures with similar clinical results and only a single clinical failure at mean 3.2 year follow-up. These findings suggest that both arthroscopic and open tenodesis provide a safe and effective method for treatment of anterior shoulder pain related to proximal biceps tendon pathology. Several of these findings warrant further discussion.

The primary outcome of the present study was clinical failure, defined as loss of proximal fixation with development of the so-called “Popeye” deformity. We identified a single clinical failure in a patient who underwent arthroscopic biceps tenodesis. Despite the cosmetic deformity, the patient was asymptomatic and would recommend the surgery again. Additionally, no other significant complications were noted following either open or arthroscopic biceps tenodesis. In a comparison of open versus arthroscopic biceps tenodesis, Werner and colleagues noted no tenodesis failures and rare complications¹⁶. Similarly, Mazzocca and colleagues identified only a single clinical failure in their open tenodesis case series with minimum 1-year follow-up²¹. In a systematic review that included nearly 500 patients undergoing arthroscopic or open tenodesis, only 3 failures of fixation were noted following arthroscopic tenodesis and 2 failures following open tenodesis¹⁹. In concordance withour findings, clinical failures and complications following LHB tenodesis are rare¹⁹,⁴¹. In the appropriately indicated patient who has failed conservative management, LHB tenodesis remains a safe and effective treatment option for proximal LHB pathology.

Additionally, subjective and objective outcomes following open and arthroscopic tenodesis were evaluated. When comparing the two cohorts, we found no difference in patient reported outcomes, biceps apex difference, bicipital groove tenderness, or strength at minimum 1-year follow-up. Similar to previous studies, we noted a significant improvement in patient reported outcomes postoperatively as compared to preoperative values²¹. Additionally, the postoperative ASES scores following open and arthroscopic tenodesis studies in the present study compare favorably with previous reports, suggesting a good or excellent clinical outcome¹⁶,¹⁹. With respect to range of motion, patients undergoing arthroscopic tenodesis had decreased shoulder forward elevation compared to patients who underwent open tenodesis. All other range of motion parameters were equivalent. It should be noted that patients undergoing arthroscopic biceps tenodesis were significantly older than those who underwent open tenodesis procedures and were also more likely to have underwent concomitant rotator cuff repair, which may provide an explanation for this finding. However, stratified analysis based on the presence or absence of concomitant rotator cuff repair failed to similarly identify a difference in range of motion between the two cohorts. In a comparative study of open and arthroscopic biceps tenodesis, Werner and colleagues noted an increased incidence of postoperative stiffness following arthroscopic tenodesis¹⁸. While acknowledging that prior research on this subject is limited, the authors speculated that extensive bursectomy, excessive fluid extravasation, and more proximal tenodesis location following arthroscopic tenodesis may contribute to this finding. Given that the use of open or arthroscopic technique is largely based on individual surgeon preference in addition to the fact that biceps tenodesis in the present study, as well as previous studies, is frequently performed in conjunction with other procedures¹⁶,²¹, a well-designed, randomized, prospective study may improve interpretation of these results by eliminating several sources of bias.

As previously mentioned, a stratified analysis of patients who did and did not undergo concomitant rotator cuff repair at the time of LHB tenodesis was performed based on previous findings which suggested patients undergoing concomitant rotator cuff repair have lower patient reported outcomes²¹. Interestingly, we did not find that concomitant rotator cuff repair significantly affected postoperative patient reported outcomes. Additionally, we found no difference in strength or range of motion between the two cohorts. While concomitant rotator cuff repair undoubtedly changes several aspects of postoperative management, in the present study, there was no apparent effect on outcomes at minimum 1-year follow-up. Additionally, as LHB tenodesis is often performed in conjunction with other procedures, it should be noted that the success of the procedure overall, as measured by patient reported outcomes, should not be solely attributed to the tenodesis procedure itself.

The present study does have several limitations, including those inherent to a retrospective review of a single institution’s data. Limiting study inclusion to those patients with a minimum 1-year follow-up resulted in inclusion of only 48% of the patients undergoing the procedure during the study period. However, post hoc analysis of included patients and those excluded based on inclusion/exclusion criteria revealed no differences in demographic characteristics, comorbidities, previous ipsilateral surgery, and concomitant procedures at the time of LHB tenodesis. Due to changes in data collection methods at the institution during the time frame of the study, comparison of preoperative and postoperative patient reported outcome measures was limited. While the MCID for the ASES has been previously established, the MCID for the SF-36 for patients undergoing shoulder surgery has not been well-established, and as such, an arbitrary MCID was selected based primarily on data available following lower extremity arthroplasty procedures³⁸,⁴⁰. Despite these shortcomings, the present study adds to the limited body of current evidence and further justifies the necessity of large, prospective, randomized trials to help clarify the appropriate indications and techniques LHB tenodesis.

In conclusion, we found that both open and arthroscopic LHB tenodesis consistently provide good to excellent clinical results with few complications. These results are consistent with previously reported outcomes which have failed to identify superior results with either open or arthroscopic LHB tenodesis techniques, leaving the choice of technique largely to the discretion of the treating surgeon. Given the recent increased utilization of LHB tenodesis, future studies should use randomization and prospective data collection in order to determine if discrete patient populations are better served by either open or arthroscopic LHB tenodesis techniques.