Arthroscopic evaluation and treatment of biceps brachii long head tendon injuries: A survey of the MOON shoulder group

Injuries to the biceps brachii long head tendon commonly occur in conjunction with tears in the rotator cuff and glenoid labrum. Consensus on treatment of varying levels of severity is undetermined. We surveyed members of the Multicenter Orthopedic Outcomes Network (MOON) Shoulder Group, to determine a consensus on arthroscopic grading and treatment. We hypothesized that the Lafosse classification system would show a high level of inter- and intraobserver agreement regarding grading/treatment. Arthroscopic videos of 30 patients determined to have biceps brachii long head tendon injuries were viewed by 13 surgeons. The surgeons graded the severity of the injury macrostructure based on the Lafosse classification system and chose from a list of treatment options. Four months later the same surgeons viewed the same videos and repeated the survey. Analysis with weighted and non-weighted Kappa values was performed to determine intra- and interobserver reliability for severity grading and to determine the preferred treatments for each level of severity. Intraobserver reliability testing for the Lafosse system showed substantial agreement after two rounds (81.28%, K=0.7006). Interobserver testing demonstrated substantial agreement for Grade 0 (K=0.7152), fair agreement for Grade 1 (K=0.3803), and moderate agreement for Grade 2 (K=0.5156). Combined responses recommended no surgical treatment for 95.4% of the lesions classified as grade 0 (62/65). No surgical treatment was recommended for Grade 1 lesions in 24.1% of the cases (35/145), debridement in 38.6% (56/145), and tenotomy or tenodesis in 37.2% (54/145). Evaluators preferred tenotomy or tenodesis for 98.3% of the Grade 2 lesions (177/180). Analysis of the Lafosse system indicated substantial intraobserver reliability for all grades. As Grades 1 and 2 showed only fair and moderate agreement, a need for a reliable grading system still exists. Grade 2 lesions should be treated with tenotomy or tenodesis. A preferred treatment for Grade 1 lesions could not be determined given the high variability of responses. Higher-powered surveys may help determine the ideal treatment of Grade 1 injuries.