Effect of age, gender, and body mass index on incidence and satisfaction of a Popeye deformity following biceps tenotomy or tenodesis: secondary analysis of a randomized clinical trial.

BACKGROUND: The purpose of this study was to determine the incidence of Popeye deformity following biceps tenotomy vs. tenodesis and evaluate risk factors and subjective and objective outcomes. METHODS: Data for this study were collected as part of a randomized clinical trial in which patients aged ≥18 years undergoing arthroscopic shoulder surgery for a long head of the biceps tendon lesion were allocated to undergo tenotomy or tenodesis. The primary outcome measure for this secondary analysis was rate of Popeye deformity at 24 months postoperation as determined by an evaluator blinded to group allocation. Those with a deformity indicated their satisfaction with the appearance of their arm on a 10-cm visual analog scale, rated their pain and cramping, and completed the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form and the Western Ontario Rotator Cuff index. Isometric elbow flexion and supination strength were also measured. Cohen kappa was calculated to measure inter-rater reliability between patient and evaluator on the presence of a deformity. Logistic regression was performed to identify predictors of presence or absence of a Popeye deformity. RESULTS: One hundred fourteen patients were randomly assigned to 2 groups, of which 42 to the tenodesis group and 45 to the tenotomy group completed a 24-month follow-up. Based on clinical observation, the odds of a Popeye in the tenotomy group were 4.3 times greater than in the tenodesis group (P = .018) with incidence of 33% (15/45) and 9.5% (4/42), respectively. Surgical technique was the only significant predictor of perceived deformity, with male gender trending toward significance (odds ratio 7.33, 95% confidence interval 0.867-61.906, P = .067). Mean (standard deviation) satisfaction score of those with a deformity regarding appearance of their arm was 7.3 (2.6). Increasing satisfaction was correlated with increasing age (r = 0.640, P = .025), but there was no association with gender (r = -0.155, P = .527) or body mass index (r = -0.221, P = .057). Differences in subjective outcomes were dependent on whether the Popeye was clinician- or self-assessed. CONCLUSION: The odds of developing a perceived Popeye deformity was 4.3 higher after tenotomy compared to tenodesis based on clinician observation. Male gender was trending toward being predictive of having a deformity. Pain and cramping were increased in those with a self-reported Popeye. Younger patients were significantly less satisfied with a deformity despite no difference in functional outcomes at 24 months. Thus, biceps tenodesis may be favored in younger male patients to minimize the risk of Popeye and the risk of dissatisfaction in the appearance of their arm following surgery.

Biceps Tenodesis Versus Tenotomy in the Treatment of Lesions of the Long Head of the Biceps Tendon in Patients Undergoing Arthroscopic Shoulder Surgery: A Prospective Double-Blinded Randomized Controlled Trial.

BACKGROUND: The biceps tendon is a known source of shoulder pain. Few high-level studies have attempted to determine whether biceps tenotomy or tenodesis is the optimal approach in the treatment of biceps pathology. Most available literature is of lesser scientific quality and shows varying results in the comparison of tenotomy and tenodesis. PURPOSE: To compare patient-reported and objective clinical results between tenotomy and tenodesis for the treatment of lesions of the long head of the biceps brachii. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients aged ≥18 years undergoing arthroscopic surgery with intraoperative confirmation of a lesion of the long head of the biceps tendon were randomized. The primary outcome measure was the American Shoulder and Elbow Surgeons (ASES) score, while secondary outcomes included the Western Ontario Rotator Cuff Index (WORC) score, elbow and shoulder strength, operative time, complications, and the incidence of revision surgery with each procedure. Magnetic resonance imaging was performed at postoperative 1 year to evaluate the integrity of the procedure in the tenodesis group. RESULTS: A total of 114 participants with a mean age of 57.7 years (range, 34 years to 86 years) were randomized to undergo either biceps tenodesis or tenotomy. ASES and WORC scores improved significantly from pre- to postoperative time points, with a mean difference of 32.3% (P < .001) and 37.3% (P < .001), respectively, with no difference between groups in either outcome from presurgery to postoperative 24 months. The relative risk of cosmetic deformity in the tenotomy group relative to the tenodesis group at 24 months was 3.5 (95% CI, 1.26-9.70; P = .016), with 4 (10%) occurrences in the tenodesis group and 15 (33%) in the tenotomy group. Pain improved from 3 to 24 months postoperatively (P < .001) with no difference between groups. Cramping was not different between groups, nor was any improvement in cramping seen over time. There were no differences between groups in elbow flexion strength or supination strength. Follow-up magnetic resonance imaging at postoperative 12 months showed that the tenodesis was intact for all patients. CONCLUSION: Tenotomy and tenodesis as treatment for lesions of the long head of biceps tendon both result in good subjective outcomes but there is a higher rate of Popeye deformity in the tenotomy group. REGISTRATION: NCT01747902 ( ClinicalTrials.gov identifier).

Diagnosing PCL Injuries: History, Physical Examination, Imaging Studies, Arthroscopic Evaluation.

Isolated posterior cruciate ligament (PCL) injuries are uncommon and can be easily missed with physical examination. The purpose of this article is to give an overview of the clinical, diagnostic and arthroscopic evaluation of a PCL injured knee. There are some specific injury mechanisms that can cause a PCL including the dashboard direct anterior blow and hyperflexion mechanisms. During the diagnostic process it is important to distinguish between an isolated or multiligament injury and whether the problem is acute or chronic. Physical examination can be difficult in an acutely injured knee because of pain and swelling, but there are specific functional tests that can indicate a PCL tear. Standard x-ray's and stress views are very useful imaging modalities but magnetic resonance imaging remains the gold standard imaging study for detecting ligament injuries. Every knee scope should be preceded by an examination under anesthesia. Specific arthroscopic findings are indicative of a PCL tear such as the "floppy ACL sign" and the posteromedial drive through sign. History, physical examination and imaging should all be combined to make an accurate diagnosis and initiate appropriate treatment.

Patellar height measurements: Insall-Salvati ratio is most reliable method.

PURPOSE: Patella alta is a risk factor for patellofemoral pain and instability. Several measurement methods and imaging modalities are in use to measure patellar height. The first aim of this study was to determine the intra- and interrater reliability of different patellar height measurement methods on conventional radiography (CR), CT and MRI. The second aim was to examine the applicability of patellar height measurement methods originally designed for CR on CT and MRI. METHODS: Forty-eight patients who were treated for patellar instability were included. All patients had undergone a pre-operative conventional radiograph, CT scan and MRI. Five methods for measuring patellar height were performed on radiographs, CT and MRI by four observers. For each measurement, the intra- and interrater reliability was determined by calculating the intra-class correlation coefficient (ICC). A Bland-Altman analysis was performed for measurements with an ICC ≥ 0.70. RESULTS: The Insall-Salvati (IS) ratio was the only measurement that showed good intra- and inter-observer reliability on CR, CT and MRI. The intra- and inter-observer reliability of the patellotrochlear index (PTI) for MRI was good to excellent for all observers. The IS ratio showed a moderate to good reliability for comparison of all three imaging modalities with the best agreement between radiography and MRI. The other patellar height measurements showed only poor to moderate inter-method agreement. CONCLUSION: In this study, the Insall-Salvati ratio shows better intra- and inter-observer reliability than the Blackburne-Peel ratio, the Caton-Deschamps ratio and the modified Insall-Salvati ratio on all imaging modalities. Radiography and CT seem to have better reliability than MRI. The patellotrochlear index, however, shows good inter- and intra-observer reliability on MRI. Only for the IS method was there acceptable agreement between CR and MRI. This means that the established Insall-Salvati normal values could be used for MRI as well. This study shows that the most reliable method to measure patella height is the Insall-Salvati ratio measured on conventional radiographs or the patellotrochlear index on MRI. LEVEL OF EVIDENCE: Level II diagnostic.