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Failed Superior Labrum Anterior Posterior and Proximal Biceps Surgery
Failed Superior Labrum Anterior Posterior and Proximal Biceps Surgery Robert C. Grumet, MDa,b, Scott P. Fischer, MDa,b, and Benjamin D. Rubin, MDa,b The accurate diagnosis of proximal biceps and superior labral pathology remains a challenge to many orthopedic surgeons. Moreover, the appropriate management of this elusive diagnosis remains controversial. Although “failure” of the treatment of proximal biceps is a relatively uncommon occurrence, recognition and management options available are largely anecdotal. The goal of this article is to attempt to define “failure” and outline examination findings, imaging studies, and treatment options available for patients who have failed previous surgical intervention. Oper Tech Sports Med 20:253-258 © 2012 Elsevier Inc. All rights reserved. KEYWORDS superior labrum anterior posterior, proximal biceps, tenodesis
W
ith the relatively rapid rise in the understanding and surgical management of proximal biceps disorders, there has been an, unfortunate, commensurate rise in diagnosis and management of presumed management failures. Just as there is much inconsistency in the definition, diagnosis, indications, and management of these lesions primarily, there is much debate about the appropriate management of the patients who continue to be symptomatic. However, defining “failure” in this somewhat elusive diagnosis is likely the most challenging aspect of the treatment algorithm. How do we know if the management of the proximal biceps pathology is indeed the source of the symptom(s), or is this an expected or acceptable outcome of the intervention? Many would define failure as incomplete relief of symptoms after the index operation. However, the “art of medicine” is determining whether that is a technical failure of the operation, a failure to identify or recognize the pathology, or a failure of communication before surgery and the resultant disappointment regarding patient expectations. In some cases, without careful attention to the patient expectations and desired outcome, additional surgery may be equally or even more unsatisfactory than the first. The patient’s simplest measure of surgical success is improvement of pain. As such, patients will often define “failure” of the procedure as persistent pain despite surgical intervenaOrthopaedic
Specialty Institute, Orange, CA. Orthopaedic Institute, Department of Orthopaedic Surgery, Irvine, CA. Address reprint requests to Robert C. Grumet, MD, Orthopaedic Specialty Institute, 280 South Main Street, Suite 200, Orange, CA 92868. E-mail: [email protected] bHoag
1060-1872/12/$-see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.otsm.2012.09.002
tion. However, the source of the pain is often multifactorial, and careful preoperative evaluation is necessary. Persistent pain may be because of mechanical failure, incomplete healing, unrecognized concomitant pathology, or surgical complications. Humeral head abrasion from superior labrum anterior posterior (SLAP) repairs has been described.1 Complications from tenodesis procedures have also been described with infection, failure of fixation, musculocutaneous neuropathy, and reflex sympathetic dystrophy.2 Stiffness is also a known common complication after SLAP repair with an incidence reported between 8% and 13%.3,4 In some cases, inadequate or incomplete rehabilitation is a contributor to ongoing symptoms.
History and Examination The history of the symptoms is a critical component in attempting to define the cause, as well as the source, of the failure. Many patients may state that the symptoms after surgery are the same as the symptoms they described to their surgeon before surgery, thus potentially a failure to accurately identify the pathology preoperatively. The diagnosis of SLAP or proximal biceps pathology can, in many cases, be challenging and often clouded by concomitant pathology. A thorough history regarding the mechanism of injury, palliative and provocative maneuvers, and previous relief with injections and/or physical therapy may help guide the examiner to a specific source of the symptoms. Furthermore, patients should be asked about their expectations of a proposed surgery. Patients should understand the difficulty of 253
254 Table 1 Differential Diagnosis of Anterior Shoulder Pain Impingement syndrome Rotator cuff tendinopathy Rotator cuff tear Acromioclavicular joint arthropathy Subacromial bursitis Adhesive capsulitis Glenohumeral arthritis Long head of biceps tendinopathy Long head of biceps instability Coracoid impingement Cervical spine degenerative disk disease Glenohumeral instability Acromioclavicular joint instability Superior labrum anterior–posterior tears Scapular dyskinesis and pectoralis minor contracture
making the diagnosis accurately and, even in cases of an accurate diagnosis, the proposed outcome of the surgical intervention. Pain is by far the most nonspecific symptom with which a patient can present. However, as is the case with almost all orthopedic diagnoses, the chief complaint in combination with the patient’s history and examination findings may aid physicians in focusing the diagnosis to the previous biceps surgery. Similar to the initial presenting sign, patients may define the pain as anterior with associated overhead activities. Occasionally, the pain will radiate down the anterior biceps muscle belly. Care must be taken to differentiate other common sources of shoulder pain from proximal biceps pain, including acromioclavicular joint pathology, rotator cuff tendinopathy or tears, adhesive capsulitis, glenohumeral arthritis, and many others (Table 1). Patients will often describe pain and spasm radiating into the anterior biceps muscle after a biceps tenotomy. Similarly, however, patients having undergone a previous biceps tenodesis often describe pain at the tenodesis site.5 Thus, it is important to understand whether the pain is a known and acceptable side effect of the procedure or whether the pain is considered a “failure.” This fine line is often best defined by the physician–patient relationship and the patient’s expectations of the surgery. Subjectively, patients may also describe mechanical symptoms, weakness, and stiffness. Mechanical symptoms may occur because of a variety of factors, including prominent hardware or sutures and the resultant abrasion of the humeral head articular cartilage. Instability of the proximal biceps can be described and result from an unrecognized concomitant subscapularis or biceps pulley tearing (Fig. 1). Similarly, patients may describe the sensation of a “pop” or a cosmetic change in the contour of the biceps if previous hardware used to tenodese the long head of the biceps has suddenly failed postoperatively.6 Weakness and stiffness postoperatively can be challenging to differentiate between inadequate rehabilitation and surgical complications, such as neurologic injury,2 or unrecognized concomitant pathology, such as a rotator cuff tear or adhesive capsulitis.
R.C. Grumet, S.P. Fischer, and B.D. Rubin Physical examination findings should always start with observation of the patient and the affected shoulder. Care must be taken to evaluate the patient’s previous surgical incisions to help clarify the type of previous procedures performed and for potential preoperative planning if necessary. Atrophy of the supraspinatus, infraspinatus, or biceps may indicate a previously unrecognized neurologic injury or concomitant pathology, such as suprascapular neuropathy, spinoglenoid cyst, or rotator cuff tears. The biceps should be compared with the contralateral shoulder for contour differences or “popeye” deformity, indicating proximal biceps rupture, previous tenotomy, or failure of a previous biceps tenodesis.5 Observation of the scapula position and scapular movement patterns should be a part of a thorough evaluation of a patient with a failed proximal biceps surgery. A poorly positioned or dyskinetic scapula may significantly contribute to distal pathology, including biceps and rotator cuff inflammation, and thus significant shoulder pain, loss of function, and strength. Differentiating between these functional abnormalities, because of poor scapular mechanics, versus classic structural abnormalities may aid in deciding whether further surgical intervention is warranted. Structural abnormalities are more likely to be treated surgically, whereas functional abnormalities, for example, scapular dyskinesis secondary to sensorimotor dysfunction, are not likely to benefit from surgical intervention. Palpation of the joint is done to attempt to isolate the source of the patient’s discomfort. Pain to palpation or crepitation of the acromioclavicular joint suggests concomitant pathology in that location. Patients with a previous tenotomy or tenodesis may continue to have persistent biceps groove pain or tenderness over the tenodesis site.5 Tenderness specifically within the bicipital groove should appropriately migrate laterally with external rotation of the humerus. An unstable biceps within the groove may subluxate into and out of the bicipital groove with a palpable click or clunk. Rotator cuff and periscapular muscle strength is assessed to evaluate for possible concomitant pathology. Patients with a previous tenotomy may describe diminished supination strength.7 A restriction of the patient’s range of motion may suggest postoperative arthrofibrosis, unrecognized glenohumeral ar-
Figure 1 Subscapularis tendon tear (red arrow) with medial subluxation of the biceps tendon (blue arrow) from the bicipital groove.
Failed SLAP and proximal biceps surgery
255
Management The appropriate management of the failed proximal biceps surgery will depend on the presumptive source and the mechanism of the failure. Previously unrecognized concomitant pathology may be addressed conservatively through a combination of injection therapies, physical therapy, or nonsteroidal anti-inflammatories. In some cases, these pain sources may require further surgical intervention, such as repair of rotator cuff tears (Fig. 3), capsulotomy for adhesive capsulitis, or treatment of extra-articular pathology involving the long head biceps tendon and/or sheath. Figure 2 Magnetic resonance arthrography showing evidence of extravasation of gadolinium under the superior labrum (red arrow) suggesting a superior labral anterior–posterior tear.
throsis or adhesive capsulitis, or surgical technical error in repair of a Buford complex or sublabral foramen. There are a series of special tests that have been designed to attempt to clinically evaluate for proximal biceps pathology with varying degrees of specificity and sensitivity. Many clinicians have found a battery of 2 to 3 tests, which in their own hands, are the most sensitive for the evaluation of proximal biceps pathology, such as superior labral tears anteroposterior, bicep tendinitis, and instability.8-10
Stiffness Postoperative stiffness after previous proximal biceps surgery or superior labral repair is a known complication.3,4 In many cases, mild cases of stiffness will resolve with an appropriate course of physical therapy, including soft tissue release and
Imaging Standard radiographs of the shoulder are done to primarily evaluate for concomitant pathology, such as rotator cuff tear arthropathy, calcific tendinitis, and acromioclavicular or glenohumeral arthrosis. Additionally, x-rays may be of some value in evaluating for failed hardware and loose bodies within the joint. In office, ultrasonography can be extremely helpful in evaluating postoperative biceps pain, especially when there is a question of long head biceps tendon instability, detachment from fixation, prominent fixation devices, which are not radiopaque on standard radiographs, or postoperative hematoma. Ultrasonography can also be used to evaluate for rotator cuff disease as a source of concomitant pathology and continued pain. In addition to traditional magnetic resonance imaging, magnetic resonance arthrography is often used to evaluate the intra-articular structures, specifically the labrum and biceps anchor (Fig. 2). Arthrography may be helpful in revision cases as well to evaluate for new labral tears or incomplete healing of a previous attempted repair. Previous arthroscopic images may be helpful to not only evaluate the previous surgical technique but also to evaluate the state of the supporting structures at the time of the index procedure. This may help to differentiate between previously unrecognized concomitant pathology versus new changes in the rotator cuff, or cartilage integrity, since the previous surgery.
Figure 3 Arthroscopic image revealing a high-grade partial-thickness articular-sided rotator cuff tear. After preparation of the humeral head footprint (A) the rotator cuff was repaired (B).
R.C. Grumet, S.P. Fischer, and B.D. Rubin
256
Figure 4 Patient who underwent repair of superior labral anterior–posterior tear with persistent pain after surgery. Repeat arthroscopy reveals prominent nonabsorbable suture (A) with associated chondral abrasion of the humeral head (B). Anteroposterior and axillary radiographs showing evidence of prominent suture anchors after previous superior labrum anterior–posterior tear (C, D).
joint mobilization. However, refractory cases because of either unrecognized concomitant pathology or the surgical technique may benefit from selective capsular release and/or manipulation under anesthesia. This procedure may be followed by early and frequent physical therapy or use of a home continuous passive motion chair to maintain the intraoperative range of motion.
Mechanical Symptoms and Chondral Injury Other, less common, sources of failure include pain from prominent sutures or prominent or failed hardware. Patients may describe mechanical symptoms, squeaking, or popping. In cases of interval healing of the previous surgery, patients may consider removal of the failed hardware. However, hardware failure in light of a failed surgery and lack of interval healing may benefit from management of the failure as outlined later in the text. Chondrolysis or chondral injury, although a rare complication associated with proximal biceps surgery, can be quite devastating. In some cases, prominent
suture or hardware has been thought to iatrogenically contribute to chondral injury (Fig. 4). In some cases, however, as in the case of global chondrolysis, the cause is largely idiopathic. Management of chondral injury in the shoulder in a young patient population is difficult.11 Isolated chondral lesions may be managed with cartilage restorative procedures, such as microfracture, autologous chondrocyte implantation, or osteochondral allografts. Larger areas of chondral loss and chondrolysis may only be salvaged by attempted biological resurfacing techniques or arthroplasty. Patients with recognized failed index management of proximal biceps pathology who fail to improve with conservative management and have a recognized surgically correctable pathology may be managed with an additional surgery.
Failed SLAP Cases of presumed failure because of incomplete healing or retear of previous repaired superior labral tears may be ad-
Failed SLAP and proximal biceps surgery
257 to identify and protect the musculocutaneous nerve. Failure of fixation of a previous soft tissue or bony tenodesis and effective resultant tenotomy may benefit from revision tenodesis if patients are unhappy with the cosmetic result or symptoms of such failure.
Failed Tenodesis
Figure 5 Biceps tendon tearing revealed after the tendon was retracted intra-articularly.
dressed differently depending on the patient’s age, activity level, and desired outcome. Younger patients with obvious retear or incomplete healing may benefit from revision arthroscopy with either debridement or rerepair of the labral tear in an effort to restore normal anatomy and therefore function. However, this set of circumstances is likely the rare exception to the patient with failed SLAP repair. In many cases, patients may have interval healing of the labral repair with persistent pain defining their “failure.” Frequently the source of the persistent pain is the proximal biceps either intra-articular or within the bicipital groove (Fig. 5). A simple injection of corticosteroid within the bicipital groove12 may be not only diagnostic but also therapeutic in relieving proximal biceps irritation. However, persistent pain within the groove may require further intervention with either biceps anchor debridement, tenotomy, or tenodesis. Tenotomy is generally better tolerated in older lower demand patients. However, patients must be counseled about the possibility of cosmetic deformity, loss of supination strength, and biceps spasm (often temporary). Tenodesis is effective to remove the diseased biceps tendon from the presumed inciting bicipital groove. Tenodesis of the proximal biceps has been shown to be quite effective management even in younger patient population13,14 for persistent pain believed to be because of proximal biceps pathology. Tenodesis is generally reserved for younger patients, heavy laborers, or patient’s concerned about cosmetic or functional deficit of tenotomy.
Failed Tenotomy Patients with failed previous proximal biceps surgery, such as continued pain and spasm after tenotomy, despite attempts to relieve these symptoms with a skilled manual therapist, may benefit from attempted conversion to biceps tenodesis. Depending on the chronicity of the tenotomy care must be taken in identifying the long head of the biceps and appropriately mobilizing the tendon for tenodesis. Excessive tension on the tenodesis may result in failure of fixation or stiffness. Extreme care must be taken
Patients with a previous history of biceps tenodesis may define failure of the surgery by having continued pain at the location of the tenodesis or failure of fixation. Revision tenodesis may be considered to address this persistent pain.15 Arthroscopic techniques, which place the biceps tendon within the groove, are technically more demanding but perhaps more esthetically pleasing in keeping with an all-arthroscopic technique.16 However, arguments against the technique suggest that patients can have continued pain because of the persistent pain generator of the biceps tenosynovium within the groove. Alternatively, open techniques have been described to place the biceps in a subpectoral location.17 By removing the biceps from the groove this technique may potentially eliminate this common source of pain. Nevertheless, this technique is often performed in an open fashion with associated morbidity and complications from the open technique.17 The ideal location and fixation method of tenodesis of the long head of the biceps is not yet established.
Conclusions Failure of proximal biceps surgery is an uncommon occurrence. However, the ability to recognize common sources of “failure” is important to counsel patients on the causes and treatment options. Pain as well as failure to recognize concomitant pathology and biological and mechanical failure are all recognized sources of “failed” surgery. Recognition of the source or sources of failure is important to guide management. Preoperative patient counseling regarding the expected outcomes as well as the known incidences of pain, cosmetic deformity, and other complications may lead to a lower incidence of defined “failure” after management of this complex shoulder pathology.
References 1. Byram IR, Dunn WR, Kuhn JE: Humeral head abrasion: An association with failed superior labrum anterior posterior repairs. J Shoulder Elbow Surg 20:92-97, 2011 2. Nho SJ, Reiff SN, Verma NN, et al: Complications associated with subpectoral biceps tenodesis: Low rates of incidence following surgery. J Shoulder Elbow Surg 19:764-768, 2010 3. Schrøder CP, Skare O, Gjengedal E, et al: Long-term results after SLAP repair: A 5-year follow-up study of 107 patients with comparison of patients aged over and under 40 years. Arthroscopy (in press) 4. Brockmeier SF, Voos JE, Williams RJ 3rd, et al: Outcomes after arthroscopic repair of type-II SLAP lesions. J Bone Joint Surg Am 91: 1595-1603, 2009 5. Slenker NR, Lawson K, Ciccotti MG, et al: Biceps tenotomy versus tenodesis: Clinical outcomes. Arthroscopy 28:576-582, 2012
258 6. Koch BS, Burks RT: Failure of biceps tenodesis with interference screw fixation. Arthroscopy 28:735-740, 2012 7. Wittstein JR, Queen R, Abbey A, et al: Isokinetic strength, endurance, and subjective outcomes after biceps tenotomy versus tenodesis: A postoperative study. Am J Sports Med 39:857-865, 2011 8. Cook C, Beaty S, Kissenberth MJ, et al: Diagnostic accuracy of five orthopedic clinical tests for diagnosis of superior labrum anterior posterior (SLAP) lesions. J Shoulder Elbow Surg 21:13-22, 2012 9. Ben Kibler W, Sciascia AD, Hester P, et al: Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med 37:1840-1847, 2009 10. Schlechter JA, Summa S, Rubin BD: The passive distraction test: A new diagnostic aid for clinically significant superior labral pathology. Arthroscopy 25:1374-1379, 2009
R.C. Grumet, S.P. Fischer, and B.D. Rubin 11. Provencher MT, Barker JU, Strauss EJ, et al: Glenohumeral arthritis in the young adult. Instr Course Lect 60:137-153, 2011 12. Grumet RC, Rubin BD: Injection therapies in the management of shoulder injuries. Oper Tech Sports Med 20:114-123, 2012 13. Weber SC: Surgical management of the failed SLAP repair (Review). Sports Med Arthrosc 18:162-166, 2010 14. Boileau P, Parratte S, Chuinard C, et al: Arthroscopic treatment of isolated type II SLAP lesions: Biceps tenodesis as an alternative to reinsertion. Am J Sports Med 37:929-936, 2009 15. Gregory JM, Harwood DP, Gochanour E, et al: Clinical outcomes of revision biceps tenodesis. Int J Shoulder Surg 6:45-50, 2012 16. Verma NN, Drakos M, O’Brien SJ: Arthroscopic transfer of the long head biceps to the conjoint tendon. Arthroscopy 21:764, 2005 17. Provencher MT, LeClere LE, Romeo AA: Subpectoral biceps tenodesis (Review). Sports Med Arthrosc 16:170-176, 2008
W
ith the relatively rapid rise in the understanding and surgical management of proximal biceps disorders, there has been an, unfortunate, commensurate rise in diagnosis and management of presumed management failures. Just as there is much inconsistency in the definition, diagnosis, indications, and management of these lesions primarily, there is much debate about the appropriate management of the patients who continue to be symptomatic. However, defining “failure” in this somewhat elusive diagnosis is likely the most challenging aspect of the treatment algorithm. How do we know if the management of the proximal biceps pathology is indeed the source of the symptom(s), or is this an expected or acceptable outcome of the intervention? Many would define failure as incomplete relief of symptoms after the index operation. However, the “art of medicine” is determining whether that is a technical failure of the operation, a failure to identify or recognize the pathology, or a failure of communication before surgery and the resultant disappointment regarding patient expectations. In some cases, without careful attention to the patient expectations and desired outcome, additional surgery may be equally or even more unsatisfactory than the first. The patient’s simplest measure of surgical success is improvement of pain. As such, patients will often define “failure” of the procedure as persistent pain despite surgical intervenaOrthopaedic
Specialty Institute, Orange, CA. Orthopaedic Institute, Department of Orthopaedic Surgery, Irvine, CA. Address reprint requests to Robert C. Grumet, MD, Orthopaedic Specialty Institute, 280 South Main Street, Suite 200, Orange, CA 92868. E-mail: [email protected] bHoag
1060-1872/12/$-see front matter © 2012 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.otsm.2012.09.002
tion. However, the source of the pain is often multifactorial, and careful preoperative evaluation is necessary. Persistent pain may be because of mechanical failure, incomplete healing, unrecognized concomitant pathology, or surgical complications. Humeral head abrasion from superior labrum anterior posterior (SLAP) repairs has been described.1 Complications from tenodesis procedures have also been described with infection, failure of fixation, musculocutaneous neuropathy, and reflex sympathetic dystrophy.2 Stiffness is also a known common complication after SLAP repair with an incidence reported between 8% and 13%.3,4 In some cases, inadequate or incomplete rehabilitation is a contributor to ongoing symptoms.
History and Examination The history of the symptoms is a critical component in attempting to define the cause, as well as the source, of the failure. Many patients may state that the symptoms after surgery are the same as the symptoms they described to their surgeon before surgery, thus potentially a failure to accurately identify the pathology preoperatively. The diagnosis of SLAP or proximal biceps pathology can, in many cases, be challenging and often clouded by concomitant pathology. A thorough history regarding the mechanism of injury, palliative and provocative maneuvers, and previous relief with injections and/or physical therapy may help guide the examiner to a specific source of the symptoms. Furthermore, patients should be asked about their expectations of a proposed surgery. Patients should understand the difficulty of 253
254 Table 1 Differential Diagnosis of Anterior Shoulder Pain Impingement syndrome Rotator cuff tendinopathy Rotator cuff tear Acromioclavicular joint arthropathy Subacromial bursitis Adhesive capsulitis Glenohumeral arthritis Long head of biceps tendinopathy Long head of biceps instability Coracoid impingement Cervical spine degenerative disk disease Glenohumeral instability Acromioclavicular joint instability Superior labrum anterior–posterior tears Scapular dyskinesis and pectoralis minor contracture
making the diagnosis accurately and, even in cases of an accurate diagnosis, the proposed outcome of the surgical intervention. Pain is by far the most nonspecific symptom with which a patient can present. However, as is the case with almost all orthopedic diagnoses, the chief complaint in combination with the patient’s history and examination findings may aid physicians in focusing the diagnosis to the previous biceps surgery. Similar to the initial presenting sign, patients may define the pain as anterior with associated overhead activities. Occasionally, the pain will radiate down the anterior biceps muscle belly. Care must be taken to differentiate other common sources of shoulder pain from proximal biceps pain, including acromioclavicular joint pathology, rotator cuff tendinopathy or tears, adhesive capsulitis, glenohumeral arthritis, and many others (Table 1). Patients will often describe pain and spasm radiating into the anterior biceps muscle after a biceps tenotomy. Similarly, however, patients having undergone a previous biceps tenodesis often describe pain at the tenodesis site.5 Thus, it is important to understand whether the pain is a known and acceptable side effect of the procedure or whether the pain is considered a “failure.” This fine line is often best defined by the physician–patient relationship and the patient’s expectations of the surgery. Subjectively, patients may also describe mechanical symptoms, weakness, and stiffness. Mechanical symptoms may occur because of a variety of factors, including prominent hardware or sutures and the resultant abrasion of the humeral head articular cartilage. Instability of the proximal biceps can be described and result from an unrecognized concomitant subscapularis or biceps pulley tearing (Fig. 1). Similarly, patients may describe the sensation of a “pop” or a cosmetic change in the contour of the biceps if previous hardware used to tenodese the long head of the biceps has suddenly failed postoperatively.6 Weakness and stiffness postoperatively can be challenging to differentiate between inadequate rehabilitation and surgical complications, such as neurologic injury,2 or unrecognized concomitant pathology, such as a rotator cuff tear or adhesive capsulitis.
R.C. Grumet, S.P. Fischer, and B.D. Rubin Physical examination findings should always start with observation of the patient and the affected shoulder. Care must be taken to evaluate the patient’s previous surgical incisions to help clarify the type of previous procedures performed and for potential preoperative planning if necessary. Atrophy of the supraspinatus, infraspinatus, or biceps may indicate a previously unrecognized neurologic injury or concomitant pathology, such as suprascapular neuropathy, spinoglenoid cyst, or rotator cuff tears. The biceps should be compared with the contralateral shoulder for contour differences or “popeye” deformity, indicating proximal biceps rupture, previous tenotomy, or failure of a previous biceps tenodesis.5 Observation of the scapula position and scapular movement patterns should be a part of a thorough evaluation of a patient with a failed proximal biceps surgery. A poorly positioned or dyskinetic scapula may significantly contribute to distal pathology, including biceps and rotator cuff inflammation, and thus significant shoulder pain, loss of function, and strength. Differentiating between these functional abnormalities, because of poor scapular mechanics, versus classic structural abnormalities may aid in deciding whether further surgical intervention is warranted. Structural abnormalities are more likely to be treated surgically, whereas functional abnormalities, for example, scapular dyskinesis secondary to sensorimotor dysfunction, are not likely to benefit from surgical intervention. Palpation of the joint is done to attempt to isolate the source of the patient’s discomfort. Pain to palpation or crepitation of the acromioclavicular joint suggests concomitant pathology in that location. Patients with a previous tenotomy or tenodesis may continue to have persistent biceps groove pain or tenderness over the tenodesis site.5 Tenderness specifically within the bicipital groove should appropriately migrate laterally with external rotation of the humerus. An unstable biceps within the groove may subluxate into and out of the bicipital groove with a palpable click or clunk. Rotator cuff and periscapular muscle strength is assessed to evaluate for possible concomitant pathology. Patients with a previous tenotomy may describe diminished supination strength.7 A restriction of the patient’s range of motion may suggest postoperative arthrofibrosis, unrecognized glenohumeral ar-
Figure 1 Subscapularis tendon tear (red arrow) with medial subluxation of the biceps tendon (blue arrow) from the bicipital groove.
Failed SLAP and proximal biceps surgery
255
Management The appropriate management of the failed proximal biceps surgery will depend on the presumptive source and the mechanism of the failure. Previously unrecognized concomitant pathology may be addressed conservatively through a combination of injection therapies, physical therapy, or nonsteroidal anti-inflammatories. In some cases, these pain sources may require further surgical intervention, such as repair of rotator cuff tears (Fig. 3), capsulotomy for adhesive capsulitis, or treatment of extra-articular pathology involving the long head biceps tendon and/or sheath. Figure 2 Magnetic resonance arthrography showing evidence of extravasation of gadolinium under the superior labrum (red arrow) suggesting a superior labral anterior–posterior tear.
throsis or adhesive capsulitis, or surgical technical error in repair of a Buford complex or sublabral foramen. There are a series of special tests that have been designed to attempt to clinically evaluate for proximal biceps pathology with varying degrees of specificity and sensitivity. Many clinicians have found a battery of 2 to 3 tests, which in their own hands, are the most sensitive for the evaluation of proximal biceps pathology, such as superior labral tears anteroposterior, bicep tendinitis, and instability.8-10
Stiffness Postoperative stiffness after previous proximal biceps surgery or superior labral repair is a known complication.3,4 In many cases, mild cases of stiffness will resolve with an appropriate course of physical therapy, including soft tissue release and
Imaging Standard radiographs of the shoulder are done to primarily evaluate for concomitant pathology, such as rotator cuff tear arthropathy, calcific tendinitis, and acromioclavicular or glenohumeral arthrosis. Additionally, x-rays may be of some value in evaluating for failed hardware and loose bodies within the joint. In office, ultrasonography can be extremely helpful in evaluating postoperative biceps pain, especially when there is a question of long head biceps tendon instability, detachment from fixation, prominent fixation devices, which are not radiopaque on standard radiographs, or postoperative hematoma. Ultrasonography can also be used to evaluate for rotator cuff disease as a source of concomitant pathology and continued pain. In addition to traditional magnetic resonance imaging, magnetic resonance arthrography is often used to evaluate the intra-articular structures, specifically the labrum and biceps anchor (Fig. 2). Arthrography may be helpful in revision cases as well to evaluate for new labral tears or incomplete healing of a previous attempted repair. Previous arthroscopic images may be helpful to not only evaluate the previous surgical technique but also to evaluate the state of the supporting structures at the time of the index procedure. This may help to differentiate between previously unrecognized concomitant pathology versus new changes in the rotator cuff, or cartilage integrity, since the previous surgery.
Figure 3 Arthroscopic image revealing a high-grade partial-thickness articular-sided rotator cuff tear. After preparation of the humeral head footprint (A) the rotator cuff was repaired (B).
R.C. Grumet, S.P. Fischer, and B.D. Rubin
256
Figure 4 Patient who underwent repair of superior labral anterior–posterior tear with persistent pain after surgery. Repeat arthroscopy reveals prominent nonabsorbable suture (A) with associated chondral abrasion of the humeral head (B). Anteroposterior and axillary radiographs showing evidence of prominent suture anchors after previous superior labrum anterior–posterior tear (C, D).
joint mobilization. However, refractory cases because of either unrecognized concomitant pathology or the surgical technique may benefit from selective capsular release and/or manipulation under anesthesia. This procedure may be followed by early and frequent physical therapy or use of a home continuous passive motion chair to maintain the intraoperative range of motion.
Mechanical Symptoms and Chondral Injury Other, less common, sources of failure include pain from prominent sutures or prominent or failed hardware. Patients may describe mechanical symptoms, squeaking, or popping. In cases of interval healing of the previous surgery, patients may consider removal of the failed hardware. However, hardware failure in light of a failed surgery and lack of interval healing may benefit from management of the failure as outlined later in the text. Chondrolysis or chondral injury, although a rare complication associated with proximal biceps surgery, can be quite devastating. In some cases, prominent
suture or hardware has been thought to iatrogenically contribute to chondral injury (Fig. 4). In some cases, however, as in the case of global chondrolysis, the cause is largely idiopathic. Management of chondral injury in the shoulder in a young patient population is difficult.11 Isolated chondral lesions may be managed with cartilage restorative procedures, such as microfracture, autologous chondrocyte implantation, or osteochondral allografts. Larger areas of chondral loss and chondrolysis may only be salvaged by attempted biological resurfacing techniques or arthroplasty. Patients with recognized failed index management of proximal biceps pathology who fail to improve with conservative management and have a recognized surgically correctable pathology may be managed with an additional surgery.
Failed SLAP Cases of presumed failure because of incomplete healing or retear of previous repaired superior labral tears may be ad-
Failed SLAP and proximal biceps surgery
257 to identify and protect the musculocutaneous nerve. Failure of fixation of a previous soft tissue or bony tenodesis and effective resultant tenotomy may benefit from revision tenodesis if patients are unhappy with the cosmetic result or symptoms of such failure.
Failed Tenodesis
Figure 5 Biceps tendon tearing revealed after the tendon was retracted intra-articularly.
dressed differently depending on the patient’s age, activity level, and desired outcome. Younger patients with obvious retear or incomplete healing may benefit from revision arthroscopy with either debridement or rerepair of the labral tear in an effort to restore normal anatomy and therefore function. However, this set of circumstances is likely the rare exception to the patient with failed SLAP repair. In many cases, patients may have interval healing of the labral repair with persistent pain defining their “failure.” Frequently the source of the persistent pain is the proximal biceps either intra-articular or within the bicipital groove (Fig. 5). A simple injection of corticosteroid within the bicipital groove12 may be not only diagnostic but also therapeutic in relieving proximal biceps irritation. However, persistent pain within the groove may require further intervention with either biceps anchor debridement, tenotomy, or tenodesis. Tenotomy is generally better tolerated in older lower demand patients. However, patients must be counseled about the possibility of cosmetic deformity, loss of supination strength, and biceps spasm (often temporary). Tenodesis is effective to remove the diseased biceps tendon from the presumed inciting bicipital groove. Tenodesis of the proximal biceps has been shown to be quite effective management even in younger patient population13,14 for persistent pain believed to be because of proximal biceps pathology. Tenodesis is generally reserved for younger patients, heavy laborers, or patient’s concerned about cosmetic or functional deficit of tenotomy.
Failed Tenotomy Patients with failed previous proximal biceps surgery, such as continued pain and spasm after tenotomy, despite attempts to relieve these symptoms with a skilled manual therapist, may benefit from attempted conversion to biceps tenodesis. Depending on the chronicity of the tenotomy care must be taken in identifying the long head of the biceps and appropriately mobilizing the tendon for tenodesis. Excessive tension on the tenodesis may result in failure of fixation or stiffness. Extreme care must be taken
Patients with a previous history of biceps tenodesis may define failure of the surgery by having continued pain at the location of the tenodesis or failure of fixation. Revision tenodesis may be considered to address this persistent pain.15 Arthroscopic techniques, which place the biceps tendon within the groove, are technically more demanding but perhaps more esthetically pleasing in keeping with an all-arthroscopic technique.16 However, arguments against the technique suggest that patients can have continued pain because of the persistent pain generator of the biceps tenosynovium within the groove. Alternatively, open techniques have been described to place the biceps in a subpectoral location.17 By removing the biceps from the groove this technique may potentially eliminate this common source of pain. Nevertheless, this technique is often performed in an open fashion with associated morbidity and complications from the open technique.17 The ideal location and fixation method of tenodesis of the long head of the biceps is not yet established.
Conclusions Failure of proximal biceps surgery is an uncommon occurrence. However, the ability to recognize common sources of “failure” is important to counsel patients on the causes and treatment options. Pain as well as failure to recognize concomitant pathology and biological and mechanical failure are all recognized sources of “failed” surgery. Recognition of the source or sources of failure is important to guide management. Preoperative patient counseling regarding the expected outcomes as well as the known incidences of pain, cosmetic deformity, and other complications may lead to a lower incidence of defined “failure” after management of this complex shoulder pathology.
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