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http://ajs.sagepub.com/content/early/2014/12/12/0363546514560155The online version of this article can be found at:

 DOI: 10.1177/0363546514560155

published online December 12, 2014Am J Sports MedBrian C. Werner, Stephen F. Brockmeier and F. Winston Gwathmey

Trends in Long Head Biceps Tenodesis  

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Trends in Long Head Biceps Tenodesis

Brian C. Werner,* MD, Stephen F. Brockmeier,* MD, and F. Winston Gwathmey,*y MDInvestigation performed at the Department of Orthopaedic Surgery,University of Virginia Health System, Charlottesville, Virginia, USA

Background: Tenodesis of the long head of the biceps tendon has become a popular surgical treatment option for patients withpain or instability attributed to a diseased or unstable biceps tendon. No previous studies have characterized the practice pat-terns of surgeons performing biceps tenodesis in the United States.

Purpose: To investigate current trends in both arthroscopic and open biceps tenodesis across time, sex, age, and region of theUnited States as well as associated charges.

Study Design: Descriptive epidemiology study.

Methods: Patients who underwent biceps tenodesis (Current Procedural Terminology [CPT] codes 23430 and 29828) for theyears 2008 through 2011 were identified using the PearlDiver Patient Record Database, including both private-payer and Medi-care data. These cohorts were then assessed for associated diagnoses using International Classification of Diseases, 9th Revi-sion, codes and concomitant procedures using CPT codes. These searches yielded procedural volumes, sex and agedistribution, regional volumes, and average per-patient charges. A x2 linear-by-linear association analysis, Student t test, and lin-ear regression were used for comparisons, with P \ .05 considered significant.

Results: A total of 44,932 biceps tenodesis procedures were identified from 2008-2011. The incidence of biceps tenodesis pro-cedures per 100,000 database patients increased 1.7-fold over the study period, from 8178 in 2008 to 14,014 in 2011 (P \.0001). An increase in the overall percentage volume was noted in patients aged 60-69 years (P = .039) and 20-29 years (P= .016). The overall charges for arthroscopic tenodesis increased at a rate significantly greater than that of open tenodesis(P \ .0001). Rotator cuff tear or sprain, bicipital tenosynovitis, biceps tendon rupture, superior labral lesion, and osteoarthritiswere the most common diagnoses associated with biceps tenodesis procedures. A significant increase in isolated biceps te-nodesis was also observed over the study period, from 1967 patients in 2008 to 3565 patients in 2011, representing a 1.8-foldincrease.

Conclusion: The incidence of biceps tenodesis has increased yearly from 2008-2011. Arthroscopic tenodesis has emerged asa more popular technique. Charges associated with the procedure have increased significantly. Significant regional variationsin procedural incidences exist.

Keywords: long head biceps; tenodesis; arthroscopic tenodesis; open tenodesis; procedure charge; regional analysis

Tenodesis of the long head of the biceps tendon is a surgicaltreatment option for patients with pain or instabilityattributed to a diseased or unstable biceps tendon whohave failed nonoperative measures.6,25,26,33,34,36 Surgeonswho advocate for biceps tenodesis favor the procedure inactive patients, laborers, and those concerned with cos-metic results, as alternative procedures such as tenotomy

have been associated with increased rates of postoperativecosmetic deformity and cramping.z

Numerous techniques for biceps tenodesis have beendescribed, which can be generally classified into arthro-scopic§ and open|| approaches. Historically, open bicepstenodesis procedures were performed for clear cases ofbiceps tendinopathy. Recently, indications for bicepstenodesis have expanded to include the management ofshoulder lesions including primary and revision superiorlabrum anterior-posterior (SLAP) tears that were previ-ously treated with repair or revision repair.9,38,56 As tenod-esis has increased in popularity, numerous fixation optionshave been described as well. Regardless of technique, indi-cation, or concomitant procedures, clinical outcomes afterbiceps tenodesis demonstrate generally favorable results,

yAddress correspondence to F. Winston Gwathmey, MD, Departmentof Orthopaedic Surgery, University of Virginia Health System, 400 Ray C.Hunt Drive, Suite 330, Charlottesville, VA 22903, USA (e-mail:fwg7d@virginia.edu).

*Department of Orthopaedic Surgery, University of Virginia HealthSystem, Charlottesville, Virginia, USA.

The authors declared that they have no conflicts of interest in theauthorship and publication of this contribution.

The American Journal of Sports Medicine, Vol. XX, No. XDOI: 10.1177/0363546514560155� 2014 The Author(s)

zReferences 6, 19, 21, 24, 43, 52, 54, 57, 58.

§References 2, 7, 8, 10, 13, 17, 20, 26-28, 30, 32, 42, 47, 50, 51, 55.

||References 4, 5, 14, 15, 18, 22, 23, 26, 34, 35, 37-39, 41, 44-46, 48.

1

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with excellent relief of pain, return to function, and returnto work.{

A detailed literature search yielded no other studiescharacterizing the current trends in practice patterns oforthopaedic surgeons in performing biceps tenodesis inthe United States. An analysis of these trends is importantnot only to patients but also to the broader orthopaedic andhealth care community.61 The purpose of this study was toinvestigate current trends in biceps tenodesis across time,sex, age, and region of the United States as well as chargesassociated with the procedure. We hypothesized that therehas been a significant increase in the overall number oftenodeses being performed and in the number of arthro-scopic tenodeses being performed and that associatedcharges have similarly increased with time.

MATERIALS AND METHODS

All data for this study were derived from a for-fee databaseof patients, the PearlDiver Patient Records Database(www.pearldiverinc.com; PearlDiver Inc). This databasecontains procedure volumes, demographics, and averagecharge information for patients with International Classi-fication of Diseases, 9th Revision (ICD-9), diagnoses andprocedures or Current Procedural Terminology (CPT)codes. All data are deidentified and anonymous and werethus exempt from institutional review board approval.Data for the present study were derived from 2 sectionswithin the PearlDiver database: a private-payer databaseand a Medicare-based database. The private-payer data-base has its largest contribution from UnitedHealth Group(Decatur, Illinois), with more than 30 million individualpatient records. The Medicare database has more than100 million individual patient records from 2008-2011.

To prevent overlap of patients between the 2 databases orcounting patients who used both private and Medicare insur-ances for a single procedure, all patients from the private-payer database were restricted to those aged \65 years,and all patients from the Medicare database were restrictedto those aged �65 years. Access to the database was grantedby PearlDiver Technologies for the purpose of academicresearch. The database was stored on a password-protectedserver maintained by PearlDiver. The CPT and ICD-9 codescan be searched in isolation or in combination with oneanother. The search results yielded the number of patientswith the searched code or combination of codes in eachyear, 5-year age group, and region of the United States.

For the purposes of this study, the database was queriedfor biceps tenodesis using CPT codes 23430 (open bicepstenodesis) and 29828 (arthroscopic biceps tenodesis). Thesesearches yielded procedural volumes, sex distribution, agedistribution, regional volumes, and average per-patientcharges for the CPT code. As code 29828 was first introducedin 2008, we began our search query in 2008 for both proce-dures. The database was then queried for diagnoses associ-ated with the tenodesis CPT codes using ICD-9 codes,including rotator cuff tear or sprain, bicipital tenosynovitis,

biceps rupture, superior labral lesion, osteoarthritis or adhe-sive capsulitis, and stiffness. The database was then queriedfor concomitant procedures performed at the same time asbiceps tenodesis using CPT codes including arthroscopic rota-tor cuff repair, arthroscopic subacromial decompression,arthroscopic distal clavicle resection, arthroscopic SLAPrepair, arthroscopic capsulorrhaphy, arthroscopy debride-ment or lysis of adhesions, open rotator cuff repair, open dis-tal clavicle resection, and open acromioplasty.

Finally, the database was queried for patients who under-went isolated arthroscopic or open biceps tenodesis proce-dures using CPT codes. Isolated biceps tenodesis wasdefined as occurring in patients who underwent biceps tenod-esis but did not undergo concomitant reconstructive proce-dures, including rotator cuff repair (arthroscopic or open),SLAP repair, or capsulorrhaphy (open or arthroscopic).Patients were still considered to have an isolated tenodesisif a concomitant subacromial decompression or distal clavicleexcision was performed. In addition to querying for demo-graphic data of the cohorts who underwent isolated bicepstenodesis, we also queried for associated diagnoses in thesame fashion as the overall tenodesis cohorts.

Procedural charge data were obtained for patients whounderwent isolated biceps tenodesis. Charge data were fil-tered to include only facility-related charge data. No physi-cian charge data were included. Patients with concomitantprocedures were excluded from the charge analysis toallow a true comparison of charges for the tenodesis proce-dure alone, as opposed to equipment, operating room time,and facility fees for any concomitant procedures. Chargedata are provided as average overall charge as well asaverage procedural charges provided by the Medicareand private-payer insurance databases.

Overall procedural volume data are reported as thenumber of patients with the given CPT(s) in the databaseoutput as well as an incidence, which is calculated as thenumber of patients with the CPT of interest normalizedto the total number of patients in the database for that par-ticular year. Age group and sex analysis are reported asthe number of patients reported in the database outputand as a percentage of patients who underwent the CPTof interest in that year. As UnitedHealth Care is the larg-est contributor to the private-payer portion of the databaseand is represented most prominently in the Southernregion of the United States, data for the regional analysiswere presented only as an incidence. This incidence is cal-culated as the number of patients in a particular regionand year normalized to the total number of patients inthe database for that particular region or year. Regionswere defined as Midwest, Northeast, South, and West.i

A x2 linear-by-linear association analysis was used todetermine statistical significance with regard to trendsover time in procedural volumes, sex, age group, andregion. The Student t test and linear regression modelingwere used to compare average charge and trends in aver-age charges between groups and subgroups. The databaseprovides standard deviations of average charge in additionto the charge itself, allowing this calculation to be made.For all statistical comparisons, P \ .05 was consideredsignificant.{References 9, 23, 31, 35, 38, 41, 49, 53, 56.

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RESULTS

In total, 44,932 biceps tenodesis procedures (CPT 23430 or29828) were identified in the database from 2008-2011.Over the 4-year study period, there was a significant increasein the overall number of biceps tenodeses being performed,from 8178 in 2008 to 14,014 in 2011 (P \ .0001). The overallincidence of biceps tenodesis procedures per 100,000 data-base patients increased 1.7-fold over the study period, from25.2 in 2008 to 42.1 in 2011 (P\ .0001). Significant increasesin both arthroscopic biceps tenodesis (1.8-fold increase from2008-2011) and open biceps tenodesis (1.5-fold increase

from 2008-2011) were observed, with arthroscopic bicepstenodesis increasing at a significantly more rapid rate thanopen biceps tenodesis (P \ .0001) (Table 1 and Figure 1).

A comparison of overall, arthroscopic, and open bicepstenodesis procedural volumes by age group is provided inTable 1. Overall, a significant increase in percentage vol-ume was noted in patients aged 60-69 years (P = .039)and 20-29 years (P = .016). For arthroscopic tenodesis,a significant increase in percentage volume was notedpatients aged 20-29 years (P = .019). Among the opentenodesis patients, no significant changes in percentagevolume were noted by age group.

TABLE 1Biceps Tenodesis: 2008-2011a

2008 2009 2010 2011 P

Biceps tenodesis proceduresTotal 8178 10,768 11,972 14,014 \.0001Open tenodesis 3636 (44.5) 4230 (39.3) 4748 (39.7) 5719 (40.8) \.0001b

Arthroscopic tenodesis 4542 (55.5) 6538 (60.7) 7224 (60.3) 8295 (59.2)Sex

Female .626c

Total 3140 (38.4) 4156 (38.6) 4615 (38.5) 5431 (38.8)Open tenodesis 1234 (39.3) 1457 (35.1) 1672 (36.2) 1956 (36.0)Arthroscopic tenodesis 1906 (60.7) 2699 (64.9) 2943 (63.8) 3475 (64.0)

MaleTotal 5038 (61.6) 6612 (61.4) 7357 (61.5) 8583 (61.2)Open tenodesis 2402 (47.7) 2773 (41.9) 3076 (41.8) 3763 (43.8)Arthroscopic tenodesis 2636 (52.3) 3839 (58.1) 4281 (58.2) 4820 (56.2)

Age, yOverall

\19 26 (0.3) 21 (0.2) 32 (0.3) 40 (0.3) .88520-29 35 (0.4) 80 (0.7) 82 (0.7) 107 (0.8) .01630-39 240 (2.9) 318 (3.0) 338 (2.8) 426 (3.0) .72640-49 857 (10.5) 1033 (9.6) 1194 (10.0) 1367 (9.8) .24050-59 1567 (19.2) 1813 (16.8) 2068 (17.3) 2574 (18.4) .71560-69 2725 (33.3) 3746 (34.8) 4134 (34.5) 4873 (34.8) .03970-79 2329 (28.5) 3210 (29.8) 3502 (29.3) 3992 (28.5) .486801 399 (4.9) 547 (5.1) 622 (5.2) 635 (4.5) .179

Arthroscopic tenodesis\19 11 (0.2) 0 (0.0) 14 (0.2) 16 (0.2) .44320-29 14 (0.3) 36 (0.6) 37 (0.5) 55 (0.7) .01930-39 94 (2.1) 155 (2.4) 148 (2.0) 188 (2.3) .81240-49 408 (9.0) 531 (8.1) 610 (8.4) 679 (8.2) .26650-59 781 (17.2) 989 (15.1) 1120 (15.5) 1374 (16.6) .97060-69 1572 (34.6) 2298 (35.1) 2580 (35.7) 2951 (35.6) .24170-79 1422 (31.3) 2176 (33.3) 2303 (31.9) 2616 (31.5) .481801 240 (5.3) 353 (5.4) 412 (5.7) 416 (5.0) .518

Open tenodesis\19 15 (0.4) 21 (0.5) 18 (0.4) 24 (0.4) .80720-29 21 (0.6) 44 (1.0) 45 (0.9) 52 (0.9) .22530-39 146 (4.0) 163 (3.9) 190 (4.0) 238 (4.2) .60140-49 449 (12.3) 502 (11.9) 584 (12.3) 688 (12.0) .82750-59 786 (21.6) 824 (19.5) 948 (20.0) 1200 (21.0) .86260-69 1153 (31.7) 1448 (34.2) 1554 (32.7) 1922 (33.6) .23170-79 907 (24.9) 1034 (24.4) 1199 (25.3) 1376 (24.1) .464801 159 (4.4) 194 (4.6) 210 (4.4) 219 (3.8) .128

aValues in parentheses are percentages. Bolded values indicate statistical significance (P \ .05).bSignificantly more rapid rate of increase for arthroscopic tenodesis compared with open tenodesis.cIncrease in female tenodesis patients compared with male tenodesis patients.

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Analysis of overall procedural incidence by region dem-onstrated significant increases (compared with the overallincrease in volume) in both the Western (P = .001) andSouthern (P \ .0001) regions. Although the incidence ofbiceps tenodesis increased in all regions over the studyperiod, the increase in the Midwest was significantly out-paced by the overall increase in procedural incidence (P =.001) (Figure 2; see also the Appendix, available online athttp://ajsm.sagepub.com/supplemental). Procedural inci-dences of arthroscopic biceps tenodesis increased in allregions over the study period. The increase in proceduralincidence outpaced the overall arthroscopic proceduralincrease in the South (P \ .0001). The increase in the Mid-west (P = .007) and West (P = .003) was outpaced by theoverall increase. Procedural incidences of open bicepstenodesis also increased in all regions over the studyperiod. The rate of increase in the South (P = .029) out-paced the overall rate of increase (see the Appendix, avail-able online).

The overall average charge for isolated biceps tenodesisincreased from US$3298 per patient in 2008 to US$4209per patient in 2011 (P \ .0001). The overall charges forarthroscopic tenodesis increased from $3252 in 2008 to$4300 in 2011, while the charges for open tenodesis increasedfrom $3355 in 2008 to $4077 in 2011 (Figure 3). The overallcharges for arthroscopic tenodesis increased at a rate signif-icantly greater than that of open tenodesis (P\ .0001). Of the44,932 tenodesis patients included, 27,189 had Medicareinsurance and 17,743 had private-payer insurance. Thecharges in the private insurance database were significantlyhigher than those in the Medicare database at all timepoints. The charges for arthroscopic tenodesis increased ata rate significantly greater than that of open tenodesis inthe private insurance database (P \ .0001); this trend wasnot observed in the Medicare database (P = .206).

A summary of associated diagnoses for arthroscopic andopen biceps tenodesis is provided in Table 2. Rotator cufftear or sprain, bicipital tenosynovitis, biceps tendon rup-ture, superior labral lesion, and osteoarthritis were the

most common diagnoses associated with biceps tenodesisprocedures. For both arthroscopic and open biceps tenode-sis, the percentage of patients with bicipital tenosynovitisand superior labral lesions increased significantly through-out the study period, while the percentage of patients withrotator cuff tears and adhesive capsulitis decreasedthroughout the study period.

A summary of concomitant procedures for arthroscopicand open biceps tenodesis is also provided in Table 2. Sig-nificant increases throughout the study period were seenin the percentage of arthroscopic tenodesis patients whounderwent concomitant arthroscopic rotator cuff repair(68.9% to 72.8%; P \ .0001), arthroscopic subacromialdecompression (83.4% to 86.7%; P \ .0001), arthroscopicdistal clavicle resection (33.4% to 37.4%; P \ .0001), andarthroscopic debridement (31.5% to 34.0%; P = .002). Thepercentage of patients who underwent open rotator cuffrepair decreased significantly (10.0% to 6.8%; P \ .0001).Also increasing significantly throughout the study period

3636 4230 47485719

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2008 2009 2010 2011

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Figure 1. Trends in biceps tenodesis from 2008-2011. Therewas a 1.7-fold increase in biceps tenodesis procedures overthe study period.

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Figure 2. Overall regional analysis of biceps tenodesis from2008-2011.

$3200

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2008 2009 2010 2011

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Figure 3. Average charges per patient for isolated bicepstenodesis from 2008-2011. The rate of increase in chargesincreased more rapidly for arthroscopic tenodesis comparedwith open tenodesis.

4 Werner et al The American Journal of Sports Medicine

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were the percentage of open tenodesis patients who under-went concomitant arthroscopic rotator cuff repair (19.3% to22.0%; P \ .0001), arthroscopic subacromial decompres-sion (50.4% to 54.5%; P \ .0001), and arthroscopic debride-ment (35.2% to 39.8%; P \ .0001). The percentage ofpatients who underwent concomitant open rotator cuffrepair (41.4% to 30.1%; P \ .0001), open distal clavicleresection (9.6% to 7.4%; P = .021), and open acromioplasty(4.5% to 2.8%; P \ .0001) all decreased significantly.

A total of 11,125 patients underwent isolated arthro-scopic (5340 patients) or open (5785 patients) biceps tenod-esis from 2008-2011. A significant increase in isolated bicepstenodesis was observed over the study period, from 1967patients in 2008 to 3565 patients in 2011, representinga 1.8-fold increase (95% CI, 1.7-1.9). The rate of increasewas similar for both arthroscopic (1.8-fold increase; 95%CI, 1.6-1.9) and open (1.9-fold increase; 95% CI, 1.7-2.0)procedures. A summary of patient demographics and

associated diagnoses for isolated biceps tenodesis is pro-vided in Table 3. The most notable trends were observedin the isolated arthroscopic tenodesis cohort. The percent-age of patients younger than 30 years who underwentarthroscopic tenodesis increased significantly during thestudy period (P \ .0001). The percentage of isolated arthro-scopic tenodesis patients with an associated diagnosis ofbicipital tenosynovitis or superior labral lesion alsoincreased significantly over the study period (P \ .0001).

DISCUSSION

The purpose of this study was to report current US trendsin biceps tenodesis as well as procedural charges anddemographics including sex, age, and region. Our datademonstrated a significant increase in the number ofbiceps tenodesis procedures from 2008-2011. This biceps

TABLE 2Biceps Tenodesis: Associated Diagnoses and Concomitant Proceduresa

2008 2009 2010 2011 P

Arthroscopic tenodesis 4542 6538 7224 8295Associated diagnoses

Rotator cuff tear/sprain 4225 (93.0) 6097 (93.3) 6670 (92.3) 7649 (92.2) .016b

Bicipital tenosynovitis 999 (22.0) 1502 (23.0) 1702 (23.6) 2134 (25.7) \.0001Biceps tendon rupture 941 (20.7) 1346 (20.6) 1524 (21.1) 1669 (20.1) .487Superior labral lesion 708 (15.6) 1089 (16.7) 1251 (17.3) 1481 (17.9) .001Osteoarthritis 1712 (37.7) 2595 (39.7) 2603 (36.0) 2994 (36.1) \.0001b

Adhesive capsulitis or stiffness 459 (10.1) 679 (10.4) 482 (6.7) 447 (5.4) \.0001b

Concomitant proceduresArthroscopic rotator cuff repair 3128 (68.9) 4600 (70.4) 5130 (71.0) 6040 (72.8) \.0001Arthroscopic subacromial decompression 3787 (83.4) 5588 (85.5) 6239 (86.4) 7191 (86.7) \.0001Arthroscopic distal clavicle resection 1515 (33.4) 2447 (37.4) 2682 (37.1) 3105 (37.4) \.0001Arthroscopic SLAP repair 286 (6.3) 421 (6.4) 498 (6.9) 490 (5.9) .401Arthroscopic capsulorrhaphy 120 (2.6) 141 (2.2) 236 (3.3) 197 (2.4) .798Arthroscopic debridement/LOA 1429 (31.5) 2118 (32.4) 2374 (32.9) 2824 (34.0) .002Open rotator cuff repair 455 (10.0) 533 (8.2) 533 (7.4) 566 (6.8) \.0001b

Open distal clavicle resection 99 (2.2) 107 (1.6) 114 (1.6) 140 (1.7) .095Open acromioplasty 30 (0.7) 33 (0.5) 27 (0.4) 38 (0.5) .105

Open tenodesis 3636 4230 4748 5719Associated diagnoses

Rotator cuff tear/sprain 3102 (85.3) 3621 (85.6) 3954 (83.3) 4693 (82.1) \.0001b

Bicipital tenosynovitis 883 (24.3) 1158 (27.4) 1334 (28.1) 1761 (30.8) \.0001Biceps tendon rupture 1056 (29.0) 1161 (27.4) 1208 (25.4) 1409 (24.6) \.0001b

Superior labral lesion 546 (15.0) 716 (16.9) 780 (16.4) 1003 (17.5) .006Osteoarthritis 1427 (39.2) 1743 (41.2) 1918 (40.4) 2309 (40.4) .539Adhesive capsulitis or stiffness 305 (8.4) 358 (8.5) 202 (4.3) 276 (4.8) \.0001b

Concomitant proceduresArthroscopic rotator cuff repair 701 (19.3) 772 (18.3) 936 (19.7) 1258 (22.0) \.0001Arthroscopic subacromial decompression 1832 (50.4) 2196 (51.9) 2458 (51.8) 3118 (54.5) \.0001Arthroscopic distal clavicle resection 778 (21.4) 929 (22.0) 1050 (22.1) 1287 (22.5) .214Arthroscopic SLAP repair 184 (5.1) 235 (5.6) 248 (5.2) 278 (4.9) .419Arthroscopic capsulorrhaphy 73 (2.0) 87 (2.1) 107 (2.3) 114 (2.0) .956Arthroscopic debridement/LOA 1281 (35.2) 1568 (37.1) 1815 (38.2) 2274 (39.8) \.0001Open rotator cuff repair 1879 (41.4) 2160 (33.0) 2282 (31.6) 2498 (30.1) \.0001b

Open distal clavicle resection 435 (9.6) 545 (8.3) 597 (8.3) 612 (7.4) .021b

Open acromioplasty 204 (4.5) 235 (3.6) 239 (3.3) 234 (2.8) \.0001b

aValues in parentheses are percentages. Bolded values indicate statistical significance (P \ .05). LOA, lysis of adhesions.bStatistically significant decrease from 2008-2011.

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tenodesis trend is similar to trends reported for other com-mon shoulder procedures noted in database studies,including a 105% increase in SLAP repairs from 2004-2009 and a 147% increase in arthroscopic rotator cuffrepairs from 2004-2009.61,62 We found that the increasein the incidence of arthroscopic biceps tenodesis signifi-cantly outpaced the increase in open tenodesis over thestudy period, which is consistent with other database stud-ies that noted an increased preference for arthroscopic pro-cedures in the shoulder and hip.40,62 No previous studies,however, have confirmed this trend specifically for bicepstenodesis.

Biceps tenodesis is often advocated over tenotomy inactive patients, laborers, patients younger than 60 years,and those patients, particularly female, who wish to avoidthe potential for cosmetic deformity.# No unique CPT codeexists for tenotomy, preventing an accurate comparison oftenotomy to tenodesis in the present database study.Although tenodesis has traditionally been recommendedin younger patients, the results of the present studyshow that a large proportion of patients who have

undergone biceps tenodesis are older than 60 years. Fur-thermore, a significant increase in the subgroup of patientsaged 60-69 years was noted compared with other agegroups. Interestingly, utilization of arthroscopic tenodesishas increased significantly over the study period inpatients aged 20-29 years, which could potentially repre-sent patients with failed SLAP repairs or surgeons whoprefer biceps tenodesis as a primary procedure for SLAPlesions based on several recent studies.9,23,38,56

Charges and cost are infrequently discussed metricsrelated to orthopaedic procedures that are of increasingimportance when considering the likelihood of bundledpayments and minimizing procedural expenses. Chargesin the present study encompass hospital and facility fees,including operating room time, equipment, implants, andother related expenses. The amount actually reimbursedby the insurer is not recorded in the database. The averagecharge for isolated tenodesis procedures overall increasedsignificantly over the time period, from $3298 per patientin 2008 to $4209 per patient in 2011. Charges for arthro-scopic tenodesis increased significantly more rapidly thanopen tenodesis. Without any direct comparative clinicalevidence available in the literature proving superiority ofarthroscopic tenodesis over open tenodesis, associated#References 9, 23, 31, 35, 38, 41, 49, 53, 56.

TABLE 3Isolated Biceps Tenodesis: Demographics and Associated Diagnosesa

2008 2009 2010 2011 P

Isolated arthroscopic tenodesis 923 1309 1481 1627Demographics

Female 361 (39.1) 488 (37.3) 563 (38.0) 613 (37.7) .646Male 562 (60.9) 821 (62.7) 918 (62.0) 1014 (62.3)Age \30 y 0 (0.0) 13 (1.0) 13 (0.9) 46 (2.8) \.0001Age 30-49 y 190 (20.6) 236 (18.0) 299 (20.2) 367 (22.6) .046Age 50-70 y 462 (50.1) 642 (49.0) 759 (51.2) 777 (47.8) .393Age 701 y 271 (29.4) 418 (31.9) 410 (27.7) 438 (26.9) .021b

Associated diagnosesRotator cuff tear/sprain 674 (73.0) 968 (73.9) 1040 (70.2) 1143 (70.3) .027b

Bicipital tenosynovitis 259 (28.1) 385 (29.4) 436 (29.4) 565 (34.7) \.0001Biceps tendon rupture 200 (21.7) 309 (23.6) 352 (23.8) 361 (22.2) .960Superior labral lesion 153 (16.6) 242 (18.5) 280 (18.9) 376 (23.1) \.0001Osteoarthritis 413 (44.7) 624 (47.7) 662 (44.7) 698 (42.9) .091Adhesive capsulitis or stiffness 132 (14.3) 169 (12.9) 154 (10.4) 155 (9.5) \.0001b

Isolated open tenodesis 1044 1288 1515 1938Demographics

Female 334 (32.0) 415 (32.2) 536 (35.4) 658 (34.0) .144Male 710 (68.0) 873 (67.8) 979 (64.6) 1280 (66.0)Age \30 y 12 (1.1) 34 (2.6) 43 (2.8) 56 (2.9) .009Age 30-49 y 282 (27.0) 340 (26.4) 385 (25.4) 480 (24.8) .138Age 50-70 y 531 (50.9) 598 (46.4) 737 (48.6) 975 (50.3) .613Age 701 y 219 (21.0) 316 (24.5) 350 (23.1) 427 (22.0) .980

Associated diagnosesRotator cuff tear/sprain 573 (54.9) 755 (58.6) 797 (52.6) 1025 (52.9) .026b

Bicipital tenosynovitis 311 (29.8) 429 (33.3) 509 (33.6) 726 (37.5) \.0001Biceps tendon rupture 346 (33.1) 374 (29.0) 410 (27.1) 515 (26.6) \.0001b

Superior labral lesion 153 (14.7) 234 (18.2) 245 (16.2) 342 (17.6) .160Osteoarthritis 422 (40.4) 551 (42.8) 677 (44.7) 896 (46.2) .001Adhesive capsulitis or stiffness 100 (9.6) 148 (11.5) 86 (5.7) 121 (6.2) \.0001b

aValues in parentheses are percentages. Bolded values indicate statistical significance (P \ .05).bStatistically significant decrease from 2008-2011.

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charges and costs should be a consideration when selectinga method of tenodesis for a given patient. The reason forthese charge discrepancies and trends is likely multifacto-rial, including difference in cost of implants, variability inoperating room time, and inflation of hospital and surgicalcenter fees among others.

Numerous indications for biceps tenodesis exist, includingboth superior labral and biceps injury.3,9,16,29 We assesseddiagnoses associated with biceps tenodesis procedures andfound that a diagnosis of rotator cuff tear or sprain was pres-ent in more than three-quarters of all tenodesis patients,regardless of tenodesis method. Specific to biceps and supe-rior labral pathologic conditions, bicipital tenosynovitis andsuperior labral lesions were commonly associated diagnoses,both of which increased in percentage throughout the studyperiod. An associated diagnosis of proximal biceps tendonrupture decreased throughout the study period. Thesechanges could reflect recent literature that advocates theuse of biceps tenodesis as a primary treatment for SLAPtears as well as evidence that tenodesis is an effective man-agement of failed SLAP repairs.9,16,23,38,56

Biceps tenodesis is often performed in combination withother shoulder procedures, most commonly rotator cuffrepair.11,31,35,41 This study found that arthroscopic bicepstenodesis was more frequently associated with concomi-tant procedures compared with open tenodesis, most com-monly arthroscopic rotator cuff repair and arthroscopicsubacromial decompression. The rate of concomitantarthroscopic rotator cuff repair with arthroscopic or openbiceps tenodesis increased throughout the study period,although more significantly with arthroscopic tenodesis.Some of this effect may be due to an increase in the numberof isolated biceps tenodesis procedures being performed.Our data indicate a significant increase in both isolatedarthroscopic and open biceps tenodesis.

This national database study of both private-payer andMedicare patients included a very large number of patientswith a biceps tenodesis procedure but has a number of lim-itations, many of which are inherent to database studies ofthis nature.1,12,40,59-63 First, as with any retrospective data-base investigation, the results of the study rely on the accu-racy of coding within the database. Second, while weattempted to accurately represent a population of interestby including both private payer (age \65 years) and Medi-care (age �65 years) patients, we cannot assure that thedatabase represents a true cross-section of the UnitedStates. Third, the PearlDiver database currently indexesonly a 5-year increment of data for the populations of inter-est, and we were able to use only 4 years’ worth of datagiven that the CPT code for arthroscopic tenodesis wasnot introduced until 2008. While the study period was largeenough to find significant trends, some changes may not beaccurately characterized in a given 4-year time period.Fourth, there is no specific CPT code for biceps tenotomy,leaving us unable to compare the trend in biceps tenodesisto tenotomy. Finally, because of the very large sample sizein this study, a statistically significant finding in the resultsmay not correlate with clinical significance.

There are several strengths to this national databasestudy. The inclusion of both private-payer and Medicare

data allows a more accurate representation of the US pop-ulation undergoing biceps tenodesis. Data acquisition andcompilation are blinded, which increases the validity anddecreases potential sources of bias with regard to datareporting.

CONCLUSION

The incidence of biceps tenodesis has increased yearly from2008-2011. Arthroscopic biceps tenodesis has emerged asa more popular technique. While a large proportion ofpatients who have a biceps tenodesis are older than60 years, there is a notable increase in the number ofpatients aged 20-29 years who have an arthroscopic tenod-esis. Charges associated with the procedure have increasedsignificantly overall and more rapidly for arthroscopictenodesis. Future studies evaluating the natural historyand clinical outcomes after both open and arthroscopicbiceps tenodesis are needed to better elucidate the clinicaleffects of the demographic trends identified in this study.

Note

i. Regions were defined as Midwest (Illinois, Indiana, Iowa, Kan-sas, Michigan, Minnesota, Missouri, Nebraska, North Dakota,Ohio, South Dakota, Wisconsin), Northeast (Connecticut, Mas-sachusetts, Maine, New Hampshire, New Jersey, New York,Pennsylvania, Rhode Island, Vermont), South (Alabama,Arkansas, Washington, DC, Delaware, Florida, Georgia, Ken-tucky, Louisiana, Maryland, Mississippi, North Carolina, Okla-homa, South Carolina, Tennessee, Texas, Virginia, WestVirginia) and West (Alaska, Arizona, California, Colorado,Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah,Washington, Wyoming).

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