Gilles Walch and the French School Heritage: Who kills the Biceps when repairing a distal isolated supraspinatus tear? An international survey from the SFA biceps study group

Abstract

Background: Important cultural differences exist among surgeons worldwide regarding managing the long head of the biceps (LHB) during distal supraspinatus repair. French surgeons are well-known for their aggressive approach to managing LHB, often involving sacrifice. The concept of the biceps box was adopted depicting 5 intrinsic and 5 extrinsic lesions based on arthroscopic patterns.

Aim: This study conducts an international survey that assesses how surgeons worldwide choose to preserve, sacrifice, or "it depends" for ten LHB pathologies (biceps box, SFA classification) during isolated distal supraspinatus repair and whether geographic origin influences these decisions.

Hypothesis: there is greater agreement for intrinsic than extrinsic lesions.

Materials and methods: Ten video records reporting the different scenarios were used to investigate surgeons' practices regarding the management of the LHB. For intrinsic abnormalities, the biceps may show delamination or fraying, fissures, an hourglass shape, medial instability, or lateral instability. For extrinsic abnormalities, the biceps may be exposed, or linked to the presence of a chondral imprint. This may also be associated with an isolated medial pulley lesion, show an abnormal superior labral insertion such as SLAP I and II lesions, and exhibit signs of biceps inflammation.

Results: Nine hundred ninety-five surgeons answered the questionnaire: 56% from Europe, including 23% from France, 23% from Asia, 10% from North America, 5% from Australia-New Zealand, 4% from South America, and 2% from Africa. Forty percent of French surgeons chose to perform a systematic biceps tenotomy/tenodesis when repairing a distal supraspinatus tear. In Europe and Africa, 20% of surgeons opted for this biceps sacrifice. North American and Asian surgeons were more conservative in their approach, with only 9% and 8% respectively choosing systematic biceps sacrifice. Regarding the tear pattern of the biceps, there was a strong consensus on some intrinsic lesions, such as delamination and medial instability, with 87% (PABAK-3 = 0.639; Pₒ = 0.759, substantial agreement) and 79% (PABAK3 = 0.455; moderate) of respondents, respectively, agreeing with the need for sacrifice. For the other lesions, there was no consensus on the approach. Compared to the rest of the world, French surgeons are much more likely to choose section in all scenarios; in practice, for a similar situation, the chance of selecting section is about 2-6 times higher in France than in the rest of the world.

Conclusion: The concept of the biceps box indicated a difference in the management of LHB, with a tendency to sacrifice intrinsic lesions while preserving extrinsic lesions. A strong consensus in favor of sacrifice was found only for delaminated biceps and medial instability. French surgeons remained the greatest "biceps killers".

Level of evidence: V; Expert Opinion.

Keywords: Rotator cuff; Rotator cuff repair; Rotator cuff tears; Tenodesis; Tenotomy.