Changing practice in shoulder surgery: a nationwide population-based analysis of rotator cuff repair and biceps tenodesis in Germany, 2010–2024
This nationwide German study from 2010 to 2024 reveals a coordinated shift in shoulder surgery characterized by the replacement of open rotator cuff repairs with arthroscopic techniques, a post-2019 decline in overall repair volumes, and a marked increase in the routine integration of biceps tenodesis, reflecting evolving surgical decision-making.
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The human shoulder is a marvel of engineering, a ball-and-socket joint that allows for a vast range of motion, from reaching a high shelf to throwing a ball. Yet, this freedom comes with a cost: the tendons that stabilize the joint, known as the rotator cuff, are prone to wear and tear. When these tendons tear, they cause significant pain and weakness, often requiring surgical repair. For decades, the standard approach involved making a large incision to access the joint directly. Over time, however, surgeons began using smaller tools and cameras to perform the same repairs through tiny keyholes, a method called arthroscopy. Alongside the rotator cuff sits another structure, the long head of the biceps tendon, which often becomes damaged at the same time as the cuff. While surgeons have long debated whether to simply cut this tendon loose or reattach it to the bone, the trend in recent years has shifted toward reattaching it, a procedure known as tenodesis. Understanding how these surgical choices have evolved across an entire nation offers a clear window into how medical practice changes, balancing new techniques with the actual needs of patients.
A team of researchers in Germany set out to map these changes over a fifteen-year period, from 2010 to 2024. They did not rely on a small group of hospitals or a specific type of patient; instead, they examined the complete records of every shoulder surgery performed in every hospital inpatient ward across the country. By analyzing millions of data points, they tracked three specific actions: repairing the rotator cuff through a keyhole, repairing it with a traditional open incision, and reattaching the biceps tendon. Their goal was to see if the rise in biceps reattachment was simply because more people were getting shoulder surgery, or if doctors were genuinely changing their minds about how to treat the biceps tendon itself.
The data revealed a story of three distinct movements happening at once. First, the method of repair changed dramatically. In 2010, open surgery was still the most common way to fix a torn rotator cuff. By 2024, the tables had turned completely. The number of open repairs fell steadily every year, while the number of arthroscopic repairs rose sharply, peaking in 2019 before settling at a lower level. By the end of the study, nearly two out of every three repairs were being done arthroscopically. Second, the total volume of shoulder repairs did not just keep climbing forever. The number of all rotator cuff repairs combined reached its highest point in 2019, with nearly 58,000 procedures performed that year. After that peak, the total number of repairs began to decline, dropping to about 47,000 by 2024. This drop happened even after the initial disruptions of the global pandemic had passed, suggesting that the decline was part of a longer-term shift in how these surgeries were being performed or scheduled, rather than just a temporary pause.
The most striking finding concerned the biceps tendon. While the total number of shoulder repairs began to fall after 2019, the number of times surgeons chose to reattach the biceps tendon continued to climb. In 2011, surgeons performed just under 3,700 of these reattachments. By 2024, that number had more than tripled to over 12,000. This growth was so rapid that the ratio of biceps reattachments to rotator cuff repairs more than doubled over the study period. In the 2010s, for every ten rotator cuff repairs, surgeons reattached the biceps tendon roughly twice. By the end of the study, that number had risen to nearly four times for every ten repairs. This shift was most pronounced in patients between the ages of 40 and 49, where the practice of reattaching the tendon became the norm rather than the exception.
The researchers noted that this surge in biceps reattachment was not merely a side effect of more people getting shoulder surgery. Even as the total number of rotator cuff repairs started to decrease, the number of biceps reattachments kept rising until it plateaued around 2021. This suggests a genuine change in surgical philosophy. Doctors appear to be increasingly viewing the biceps tendon as a routine part of the repair process, rather than an optional step to be taken only in specific cases. The data also showed that men were more likely to undergo these procedures than women, and that the peak age for surgery was between 55 and 64 years old. While the study could not determine the exact reasons for the decline in total surgery volume or the specific outcomes for individual patients, the numbers clearly show a coordinated evolution in German shoulder care. The field has moved decisively toward minimally invasive techniques, and the management of the biceps tendon has transformed from a selective choice into a standard component of shoulder reconstruction.
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