Abstract:

Background

Anterior shoulder pain （anterior shoulder pain） is the most common form around the shoulder， occurring in up to 30% of patients and lasting for a year or more in 40%.Causes of pain include rotator cuff injury， shoulder impingement syndrome， glenolabial injury， and injury of the biceps long tendon（long head tendon）.As a receptor of shoulder joint pain and pressure， the long head tendon is an important cause of shoulder joint motor dysfunction， manifesting as inflammation， edema， dislocation， tear， etc.The injury can occur alone and is often accompanied by other structural injuries， such as supraspinatus and subscapular tendon injuries.Previous literature has confirmed a high correlation between biceps long tendon injury and rotator cuffinjury.Singaraju et al.showed that the correlation between supraspinatus tendon tear and biceps long tendon injury was as high as 78.5%， and with every 1 cm increase in supraspinatus tendon injury， the incidence of biceps long tendon lesions increased by 1.7 times.Tendinopathy combined with rotator cuff repair is the most commonly used technique for treating anterior shoulder pain caused by rotator cuff injury combined with a long head tendon injury.Tendinopathy can be performed using various surgical techniques， and tendon fixation locations are often selected according to the doctor's surgical preference， the patient's age， and functional requirements.Proximal fixation of intertubercular sulcus has the advantages of being a simple technique， having fast speed and few incisions， but the postoperative pain relief may be incomplete due to residual pathological tendon tissue.Some studies have suggested no significant difference in functional outcome between the intertubercular sulcus's proximal fixation and the pectoralis major's upper margin.However， researchers who support the fixation of the upper margin of the pectoralis major believe that the slide of the long head tendon in the sheath formed by the transverse humeral ligament is the primary source of pain.Hence， the removal of this lesion is particularly important， but this method of fixation is complicated and carries the risk of humeral fracture and neurovascular damage.In recent years， a large number of studies have compared tenodesis.However，due to confounding factors such as the difference between endoscopic and open surgery， long head tendon injury combined with different follow-ups， there is no consensus on the optimal fixation position for long head tendon surgery.Therefore， this study only included patients with typical clinical injuries of long head tendon combined with rotator cuff injury to make the study closer to clinical practice and give full play to the clinical guiding role of the study.At the same time， the type of rotator cuff injury was limited to Ellmann type I supraspinatus tendon degenerative tear to reduce the impact of accompanying injury and its severity on pain and mobility in the study results.Reduce potential bias from other subtypes.

Objective

To compare and analyze the initial clinical efficacy of arthroscopic anterior clearance， proximal intertubercular sulcus fixation， and upper margin pectoralis major fixation combined with rotator cuff repair in the treatment of Ellmann Type I supraspinatus tendon tear complicated with longhead tendon injury.

Methods

The clinical data of 36 patients with Ellmann type I supraspinatus tendon tear and long head tendon injury resulting in anterior shoulder pain were retrospectively analyzed.They were divided into anterior clearance + rotator cuffrepair group （AR group， n=15）， proximal intertubercular sulcus fixation + rotator cuff repair group （IR group， n=10）， fixed upper border of pectoralis major + rotator cuff repair group （SR group， n=11）.VAS，ASES， CMS， UCLA， and SST scores， the incidence of intertubercular sulci tenderness， and the improvement of shoulder active/passive motion were compared before and at least 3 to 6 months after surgery.MRI and physical examination measured the incidence of complications and rotator cuff healing at 3 and 6 months after surgery.

Results

All 36 patients were observed and followed up for at least 3 - 6 months.MRI showed that the rotator cuff healed well in all patients， and no complications such as Popeye deformity occurred.Postoperative shoulder joint scores of patients in the three groups were significantly improved compared with those before surgery； postoperative ASES scores in the AR group were significantly increased compared with those before surgery （P＜0.01）； preoperative UCLA scores in the IR and SR groups were significantly increased compared with those before surgery （P＜ 0.01）； postoperative VAS and SST scores in the SR group were significantly decreased compared with those before surgery （P=0.02， P=0.04）； The active forward flexion activity of IR group was significantly improved after operation （P=0.01）， and the active forward flexion， passive forward flexion and passive abduction activity of IR group were significantly greater than those of AR group （P=0.01， P＜0.01， P=0.05）； The positive rate of internodal groove tenderness after operation was significantly lower than that before operation （P=0.01， P=0.03， P＜ 0.01）， IR and SR groups were significantly better than AR group （P=0.02，P=0.04）.

Conclusion

The three operations combined with rotator cuff repair for Ellmann Type I supraspinatus tendon degeneration tear combined with long head tendon injury can effectively relieve shoulder pain and improve shoulder joint function 3 to 6 months after surgery.The pain improvement is more evident after the upper margin of pectoralis major muscle fixation， and the mobility is better after the proximal intertubercular sulci fixation.

Key words: Anterior shoulder pain, Rotator cuff repair, Biceps humerus long head tendinopathy