Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients

Comparison of Bone Tunnel and Cortical Surface Tendon-to-Bone Healing in a Rabbit Model of Biceps Tenodesis

BACKGROUND

Many orthopaedic surgical procedures involve reattachment of a single tendon to bone. Whether tendon-to-bone healing is better facilitated by tendon fixation within a bone tunnel or on a cortical surface is unknown. The purpose of this study was to evaluate tendon-healing within a bone tunnel compared with that on the cortical surface in a rabbit model of biceps tenodesis.

METHODS

Thirty-two rabbits (24 weeks of age) underwent unilateral proximal biceps tenodesis with tendon fixation within a bone tunnel (BT group) or on the cortical surface (SA [surface attachment] group). Postoperatively, rabbits were allowed free-cage activity without immobilization. All rabbits were killed 8 weeks after surgery. Healing was assessed by biomechanical testing, microcomputed tomography (micro-CT), and histomorphometric analysis.

RESULTS

Biomechanical testing demonstrated no significant difference between the groups in mean failure loads (BT: 56.8 ± 28.8 N, SA: 55.8 ± 14.9 N; p = 0.92) or stiffness (BT: 26.3 ± 16.6 N/mm, SA: 32.3 ± 9.6 N/mm; p = 0.34). Micro-CT analysis demonstrated no significant difference between the groups in mean volume of newly formed bone (BT: 69.3 ± 13.9 mm, SA: 65.5 ± 21.9 mm; p = 0.70) or tissue mineral density of newly formed bone (BT: 721.4 ± 10.9 mg/cm, SA: 698.6 ± 26.2 mg/cm; p = 0.07). On average, newly formed bone within the tunnel represented only 5% of the total new bone formed in the BT specimens. Histological analysis demonstrated tendon-bone interdigitation and early fibrocartilaginous zone formation on the outer cortical surface in both groups. In contrast, minimal tendon-bone bonding was observed within the tunnel in the BT specimens.

CONCLUSIONS

Tendon fixation in a bone tunnel and on the cortical surface resulted in similar healing profiles. For tendons placed within a bone tunnel, intratunnel healing was minimal compared with the healing outside the tunnel on the cortical surface.

CLINICAL RELEVANCE

The creation of large bone tunnels, which can lead to stress risers and increase the risk of fracture, may not be necessary for biceps tenodesis procedures.

Surgical technique for arthroscopic onlay suprapectoral biceps tenodesis with an all-suture anchor

The long head of the biceps is a frequent pain generator in the shoulder. Tendinopathy of the long head of the biceps may be treated with biceps tenodesis. There has been great debate about the optimal technique for biceps tenodesis, without a clear distinction between different techniques. Biceps tenodesis fixation may include interference fixation, suspensory fixation, all-suture anchors, and soft tissue fixation. In this technical note, we describe an all-arthroscopic onlay suprapectoral biceps tenodesis with an all-suture anchor.

Subpectoral Biceps Tenodesis With PEEK Interference Screw: A Biomechanical Analysis of Humeral Fracture Risk

PURPOSE

To quantify the torsional load to fracture for subpectoral biceps tenodesis with interference screw fixation.

METHODS

We randomized 28 specimens from 14 matched-pair full-length humeri (mean age, 55.3 years) into 3 groups: (1) empty ream group (ERG), (2) screw-only group (SOG), and (3) screw-plus-biceps tendon group (SBG). In each group, 1 humerus of each matched pair was prepared according to group allocation and the contralateral humerus remained intact as a control. In the ERG, an 8-mm unicortical hole was reamed 1 cm proximal to the inferior border of the pectoralis major tendon insertion; in the SOG, the humerus was filled with an 8-mm × 12-mm PEEK (polyether ether ketone) screw; and in the SBG, the humerus was filled with a PEEK screw and the cadaveric long head of the biceps tendon. Humeri were tested under torsional displacement at a rate of 1°/s until fracture. Maximum torque, energy to maximum torque, and linear stiffness were used to assess humerus strength.

RESULTS

Compared with contralateral intact specimens, the maximum torque to fracture was reduced by 28% in the ERG (P = .005), 30% in the SOG (P = .014), and 20% in the SBG (P = .046). Energy to maximum torque was similarly reduced in the ERG (P = .007), SOG (P = .023), and SBG (P = .049). Stiffness was increased by 4% in the ERG (P = .498), 9% in the SOG (P = .030), and 4% in the SBG (P = .439).

CONCLUSIONS

Drilling an 8-mm unicortical hole in zone 3 of the bicipital tunnel for open subpectoral biceps tenodesis reduces the torsional load to humeral fracture up to 28% at time 0. The addition of a PEEK tenodesis screw alone reduced the maximum torque by 30%, and the addition of a screw with the long head of the biceps tendon reduced the maximum torque by 20%. The total load to fracture was reduced in all settings. Stiffness was not significantly different for the ERG and SBG, but stiffness was significantly higher for the SOG compared with the intact matched humeri at time 0.

CLINICAL RELEVANCE

When performing a biceps tenodesis, humeral fracture susceptibility is increased with an applied torsional load at time 0. Thus providers must be aware of this reduced integrity when a subpectoral biceps tenodesis is used.

Editorial Commentary: Shoulder Subpectoral Biceps Tenodesis Significantly Increases the Humeral Fracture Risk-Is This a Reason to Look for Alternatives?

Subpectoral tenodesis is performed at the surgical neck of the humerus. In a cadaveric study, the insertion of a unicortical PEEK (polyether ether ketone) screw decreased the torsional load to failure (fracture) by 30% compared with intact control specimens but was similar to unicortical reaming without screw insertion. Placing the biceps tendon into the tunnel and securing it with a unicortical screw reduced the torsional load to failure by 20%. Whether these facts are significant is currently unknown, but the creation of a stress riser is a concern and may possibly result in surgical neck fractures.

Clinical and sonographic evaluation of subpectoral biceps tenodesis with a dual suture anchor technique demonstrates improved outcomes and a low failure rate at a minimum 2-year follow-up

INTRODUCTION

The purpose of this study was to evaluate the clinical outcomes and integrity of an open subpectoral biceps tenodesis using a dual suture anchor construct.

MATERIALS AND METHODS

Patients with at least 2 years of follow-up were retrospectively evaluated for simple shoulder test (SST), American Shoulder and Elbow Surgeons (ASES) score, and visual analog scales (VAS) for pain, function and satisfaction. A physical exam assessed shoulder range of motion and elbow strength. Ultrasonography visualized construct integrity.

RESULTS

Of 43 eligible patients, 36 completed questionnaire evaluation and 22 completed an additional physical examination. Indications included superior labral anterior-posterior (SLAP) lesions (4), partial thickness tears (6), instability (6), and tenosynovitis of the biceps tendon (20). Eighteen patients (50%) had an associated rotator cuff tear. Patient-reported outcomes improved pre- vs postoperatively: ASES score (45.4 vs 78.6, P < 0.001), SST (5.1 vs 9.6, P < 0.001), pain-VAS (4.8 vs 2.0, P < 0.001), and function-VAS (4.9 vs 2.3, P < 0.001). Satisfaction-VAS was 8.3 postoperatively. Patient-reported outcomes did not differ for patients with an associated rotator cuff tear compared to those without (P ≥ 0.427). None of the physical exam measures were lower on the operative side compared to the healthy side (P ≥ 0.516). Sonographic evaluation revealed preserved integrity of the tenodesis construct in all cases. No complications were noted.

CONCLUSIONS

Subpectoral biceps tenodesis utilizing a dual suture anchor technique is a treatment option for SLAP lesions, partial thickness tears, subluxation, and tenosynovitis of the long head of the biceps with high rates of postoperative patient satisfaction, a low failure rate, and improved outcome scores. The presence of a concomitant rotator cuff tear did not influence clinical outcomes.

Open subpectoral biceps tenodesis in patients over 65 does not result in an increased rate of complications

Background

Long head biceps tendon pathology is a common cause of anterior shoulder pain and is often associated with other shoulder conditions, such as rotator cuff tears and osteoarthritis. It is well accepted that older patients are at increased risk for major and minor peri- and postoperative complications.

The purpose of this study is to investigate patients over 65 years old who underwent subpectoral biceps tenodesis and compare the complication rates of this group to those of patients younger than 65 years old. The hypothesis is, that there would be no difference in complication rates and that clinical outcome scores for patients over 65 were satisfying and showed improvements over time.

Methods

There were 337 patients who underwent open subpectoral biceps tenodesis, between January 2005 and June 2015, 23 were identified as being over the age of 65 with a minimum follow up of 12 months. All patients over the age of 65 were evaluated pre- and postoperatively using Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), Constant-Murley (CM) and Single Assessment Numeric Evaluation (SANE). Intraoperative and postoperative adverse events (fracture, infection, wound opening, rupture/failure and neurovascular injuries) related to the tenodesis procedure and to the surgery itself were collected from all 337 patients in a routine postoperative follow-up.

Results

The under 65 group (range 27–64 years) at an average follow up (FU) of 30 months (range 12–91 months) showed a 5.4% (17 out of 314) post-operative complication rate related to the subpectoral tenodesis, whereas the group over 65 (range 65–77 years) at an average follow up of 33 months (range 12–79 months) showed an 8.7% (2 out of 23) complication rate.

Conclusion

This study demonstrates that in patients over the age of 65, biceps tenodesis is a successful procedure when performed for biceps tendinopathy and concomitantly with other surgical procedures of the shoulder, and does not result in an increased rate of complications when compared to a group of patients under the age of 65.

In Vivo Analysis of Biceps Tendon Characteristics in Subpectoral Tenodesis

PURPOSE

To report the in vivo characteristics of the long head of the biceps tendon (LHBT); to evaluate the relation of age, gender, height, weight, and body mass index to the length and sutured and tubularized diameter of the LHBT; and to determine the smallest possible tunnel diameter for a subpectoral biceps tenodesis (SPBT) that can accommodate most patients.

METHODS

The study included 66 patients (33 men and 33 women) with an average age of 54 years (range, 29-73 years) undergoing SPBT. After tenotomy, the length from the biceps musculotendinous junction to the released end was measured. The tendon was transected 3 cm proximal to the musculotendinous junction and sutured, and the diameter was measured. The depth of the reamed tunnel was recorded.

RESULTS

The average tendon length was 84.0 mm, measuring 91.9 mm in men and 76.2 mm in women (P < .001), and the average tendon diameter was 4.4 mm, varying slightly between men (4.5 mm) and women (4.3 mm) (P < .001). Mean bone tunnel depth was 17.5 mm, with 19 mm in men and 16.1 mm in women (P < .001). Patient height showed a significant relation to both tendon length and tendon diameter. Weight was not correlated with tendon diameter but did show a significant relation to tendon length.

CONCLUSIONS

We have characterized the in vivo length and diameter of the LHBT at the time of an SPBT. Our findings have shown that there was a statistically significant gender difference in tendon length and diameter, but the diameter of the sutured tendon, which was placed into the tunnel, averaged 4.4 mm and ranged from 3.5 to 5 mm for all ages, both genders, all heights, and all weights. This finding is clinically relevant in that a small tunnel measuring 5.5 mm or less is sufficient to perform an SPBT.

LEVEL OF EVIDENCE

Level IV, case series, anatomic study.

Long Biceps Subpectoral Tenodesis With Suspensory Button and Bicortical Fixation

Tenodesis of the long head of the biceps (LHB) tendon has long been recognized as a valid alternative to address pathologic conditions of this tendon. However, the location and type of fixation is still a matter of discussion, because common complications associated with this procedure include failure of the repair, persistent pain, reaction to the fixation device, cosmetic deformity, and fracture. The authors describe a method of subpectoral LHB tenodesis that aims to preserve bone stock and allows a strong, easy, and reproducible type of fixation with a minimal approach. LHB tenotomy is performed arthroscopically in a standard fashion, and the tenodesis is completed with bicortical fixation in the humerus using a knotless suspensory button with an appropriate pusher originally developed for another purpose. Magnetic resonance imaging showed a safe distance between the implant and important vasculonervous structures. In the cases where subpectoral fixation is chosen, this method seems to offer additional safety as a result of the minimal amount of bone removed and the very small size of the implant.

Low incidence of failure after proximal biceps tenodesis with unicortical suture button

PURPOSE

Recent interest in suture button fixation has developed with regard to proximal biceps tenodesis fixation. Biomechanical studies have demonstrated viability of a unicortical suture button technique in vitro. Despite this, no clinical data has been reported to validate the biomechanical data. The purpose of this study is to report on complication and failure rates in the early postoperative period after bicep tenodesis with a unicortical suture button.

METHODS

A retrospective review was performed of all biceps tenodesis performed at our institution over a 36-month period using a unicortical suture button for fixation. All included patients had a minimum 12 weeks follow up. Failures were defined as complete loss of fixation, change in biceps contour during the early postoperative period, acute pain at the tenodesis site, or acute loss of supination strength.

RESULTS

145 of 166 biceps tenodesis procedures performed by the 4 surgeons at our institution met inclusion criteria. 80.1% of the patients were active duty military at the time of surgery. The average age was 38.2 years. There were 7 total complications (4.8%), including one failure (0.7%) requiring revision.

CONCLUSION

Failure and complication rates in the early postoperative period using a unicortical suture button for biceps tenodesis fixation are consistent with other reported techniques. This study adds clinical data to the existing biomechanical reports that this technique is strong enough to provide stable fixation of the biceps tendon to allow healing of the tendon to the humerus.

Patient Satisfaction After Biceps Tenotomy

Background:

Biceps tenotomy and tenodesis are frequently performed for proximal biceps lesions; however, there continues to be debate as to which method is superior. This study examined patient-reported outcomes after biceps tenotomy.

Hypothesis:

Biceps tenotomy in the setting of concomitant shoulder pathology is a reasonable option with high satisfaction rates and a low incidence of pain and cramping in middle-aged to older individuals.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 104 patients (mean age, 63.5 years; range, 40-81 years) were evaluated at the time of surgery and at a mean follow-up of 38.4 months (range, 22-57 months). Biceps tenotomy was performed as a component of more extensive shoulder surgery in all patients. Patient satisfaction, frequency of cramping and spasms, biceps pain, weakness, and cosmetic deformity were evaluated at over 1-year follow-up.

Results:

Ninety-one percent of patients were satisfied or very satisfied with their surgical outcome, and 95% would have their surgery again. Three patients who reported being unsatisfied or very unsatisfied had either advanced glenohumeral arthritis or an irreparable rotator cuff tear. Cosmetic deformity occurred in 13% of patients. Twenty percent reported spasms and cramping in their biceps, and 19% reported some biceps pain; however, frequency of spasms and cramping was typically once weekly, and biceps pain was reported as severe or very severe in only 2 patients. Subjective biceps weakness was reported in 17% of patients. Age had no effect on outcome measures, and female sex was associated with less limitation and greater satisfaction after tenotomy compared with men.

Conclusion:

Our results indicate that patient-reported downsides to biceps tenotomy were usually mild and/or infrequent and did not affect patient satisfaction. We conclude that biceps tenotomy is a viable option that can lead to a high rate of patient satisfaction and outcomes in middle-aged to older individuals undergoing shoulder surgery with biceps pathology.

A Simple, All-Arthroscopic, Knotless Suture Lasso Loop Technique for Suprapectoral Biceps Tenodesis

A variety of pathology of the long head of the biceps tendon can contribute to anterior shoulder pain in adults that can be managed with either arthroscopic tenotomy or tenodesis when conservative treatment fails. Biceps deformity or the Popeye sign is a major concern in patients after tenotomy. Biceps tenodesis can be performed in a variety of ways with different sized anchors and at different locations (suprapectoral or subpectoral). Several studies have shown that patient outcomes and complication rates are similar between all-arthroscopic suprapectoral biceps tenodesis and open subpectoral biceps tenodesis. We describe a simple, knotless, arthroscopic intra-articular biceps tenodesis technique using a 1.5-mm LabralTape lasso loop technique and a 2.9-mm PushLock anchor.

No-holes transpectoral tenodesis technique vs tenotomy of the long head of the biceps brachii

BACKGROUND

There is no univocal consensus regarding Long Head of the Biceps (LHB) best treatment between tenotomy and tenodesis. There is no consensus regarding the best location to perform the tenodesis. The LHB tenodesis performed by the proximal tendon excision as first step can miss the proper tension to the muscle belly. Fixations proximal to the pectoralis major can lead to groove pain. This study aims to test the efficacy of a new LHB tenodesis technique by comparing its results with the tenotomy.

METHODS

We retrospectively evaluated patients who underwent surgery between May 2014 and May 2015. The mean follow up was 14.7 months. Sixteen patients underwent mini-open tenodesis to the Pectoralis Major tendon by the use of a resorbable suture (TD group); sixteen underwent tenotomy (TT group). The mean age of the TD group was 54 years; the mean age of the TT group was 56 years. We evaluated pain, subjective perception of the patient of possible aesthetic and strength differences between the two biceps, "Popeye sign", and tests to stimulate the LHB. We administered three evaluation questionnaires: the ASES score, the SPADI score, and the SST.

RESULTS

32 consecutive patients were evaluated. The clinical scores did not record statistically significant differences: the mean ASES score was 92.9 (TD) and 90.8 (TT); the mean SPADI score was 92.5 (TD), and 89.7 (TT); the mean SST was 8.9 (TD), and 8.4 (TT). Compared to the TD group, in the TT group we registered with greater frequency the "Popeye sign" with a P value < 0.05 (9 cases vs 1), and spasms in the biceps muscle belly (5 cases vs 1). All other signs or symptoms evaluated were more frequent in the TT group, except the strength difference perceived by the patient (3 patients in the TT group, and 2 in the TD group). No complications were recorded.

CONCLUSIONS

This new Long Head of the Biceps (LHB) tenodesis technique is valuable and reliable, and provided better results than tenotomy.

LEVEL OF EVIDENCE

IV.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: Radiographic Characteristics

PURPOSE

To provide a detailed account of the location of the long head of the biceps (LHB) tenodesis tunnels using an all-arthroscopic suprapectoral technique in a prospective group of patients. These patients were then compared with a retrospective group of open subpectoral tenodesis patients of similar characteristics.

METHODS

Postoperative radiographs from a prospective group of all-arthroscopic suprapectoral LHB tenodeses were compared with a retrospective group of open subpectoral tenodeses. Digital anteroposterior images were used to measure distances from clinically pertinent radiographic landmarks to tenodesis tunnel sites.

RESULTS

Forty patients (20 all-arthroscopic, 20 open) met the inclusion criteria. The inferior border of the bicipital groove was located a mean distance of 33.7 ± 6.9 mm from the top of the humeral head. The mean distance measured in the open group was approximately 28 mm (P < .001) distal compared with the arthroscopic group. The humeral diameter was 7.5 ± 5.4 mm narrower at the subpectoral tenodesis site (P < .001). All 20 patients in the open subpectoral group had tenodesis tunnels placed distal to the bicipital groove compared with 17 of 20 patients (85%) in the all-arthroscopic group. There were 2 cases of lateral wall cortical reaming during subpectoral tenodesis but no periprosthetic humeral fractures. There were 2 cases of bicortical reaming during the all-arthroscopic tenodesis with no known complications.

CONCLUSIONS

The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques, and the open subpectoral method achieves fixation in a significantly narrower region of the humerus.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Outcomes following long head of biceps tendon tenodesis

Lesions of the proximal long head of the biceps tendon (LHB) have been considered as a major cause of shoulder pain and dysfunction. The role of the LHB in causing pain has been a source of controversy for many years, and extensive literature is available discussing anatomy, function, pathology, and most importantly appropriate treatment. Despite this, there is a lack of consensus in the literature regarding the management of biceps-related pathology. Biceps tenotomy and tenodesis are common surgical treatment options when dealing with LHB-related pathology. In this review, a brief discussion on surgical options is provided while focusing on the different options for biceps tenodesis including outcomes and complications.

Combined arthroscopic tenodesis of the long head of biceps and rotator cuff repair in antero-superior cuff tears

PURPOSE AND HYPOTHESIS

This study evaluates the functional and cosmetic results following fixation of the long head of the biceps (LHB) tendon at the antero-medial footprint anchor of a rotator cuff reconstruction, using the "lasso-loop" technique.

METHODS

39 patients with a mean age of 62 years with a rotator cuff tear and associated lesion of the LHB tendon were included in this study. Besides rotator cuff repair in an arthroscopic anchor technique, all patients received additional LHB tenodeses using the lasso-loop technique. Clinical follow-up consisted of the Constant score (CS), LHB score, DASH score, and WORC index. Relevant sub-items, such as elbow flexion strength and cosmesis, were compared to the contralateral arm.

RESULTS

At an average follow-up of 22 months (11-39 months), the CS resulted in an average of 81 points. The biceps-specific LHB score showed a mean value of 89 points. The analysis of the DASH score showed an average of 16.9 points and the analysis of the WORC index showed an average result of 79.7 %. Distalization of the biceps muscle was objectively in three cases (7.7 %) (as observed by the examiner) and subjectively in one of those cases (as noted by the patient). There was a loss in elbow flexion strength compared to the contralateral side; however, this loss was not statistically significant and not associated with clinical apparent re-tear or insufficiency of the tenodesis.

DISCUSSION

The arthroscopic lasso-loop tenodesis of the LHB tendon is a time and cost-efficient technique. No additional anchor is needed when included in the rotator cuff repair. Functional and cosmetical results as well as results from the biceps-specific LHB score were good to excellent. The loss in elbow flexion strength is most likely associated with concomitant rotator cuff lesion.

CONCLUSION

The lasso-loop fixation technique of the LHB tendon using the antero-medial footprint anchor in rotator cuff tears is a reliable and cost-efficient procedure.

LEVEL OF EVIDENCE

III.

Proximal versus distal screw placement for biceps tenodesis: a biomechanical study

PURPOSE

To assess the maximum and end torque of a fourth-generation composite humerus model with no screw inserted or with a screw inserted in the distal (subpectoral) position or proximal (suprapectoral) position.

METHODS

24 large-size, fourth-generation composite humeri were randomised to the control (n=8), proximal (n=8), or distal (n=8) group. For the latter 2 groups, an 8-mm-head interference screw (7x25 mm) was inserted at 1 cm proximal and 1 cm distal to the superior aspect of the insertion of the pectoralis major tendon, respectively. The maximum and end torque of each humerus was assessed.

RESULTS

Respectively for the control, proximal, and distal groups, the maximum torque was 81.8, 78.7, and 74.3 Nm, and the end torque was 80.7, 78.6, and 71.8 Nm; only the difference between control and distal groups was significant (p=0.005 for maximum torque and p=0.033 for end torque). All fractures in both control and proximal groups involved the distal 1/3 humerus. In the distal group, the fractures involved either the distal 1/3 humerus (n=6) or the screw-hole (n=2); the difference between the 2 types of fracture was not significant in terms of maximum torque (75.7 vs. 70.0, p=0.086) or end torque (75.3 vs. 61.4, p=0.40).

CONCLUSION

Compared with proximal placement of an interference screw, distal placement decreased the maximum torque (though not significantly) and may increase the risk of proximal humeral fracture.

Biomechanical Comparison of All-Suture Anchor Fixation and Interference Screw Technique for Subpectoral Biceps Tenodesis

PURPOSE

To compare the biomechanical characteristics of the subpectoral Y-knot all-suture anchor fixation with those of the interference screw technique.

METHODS

Sixteen fresh-frozen human cadaveric shoulders with a mean age of 67.6 ± 5.8 years (range, 52 to 74 years) were studied. The specimens were randomly grouped into 2 experimental biceps tenodesis groups (n = 8): Y-knot all-suture anchor or interference screw. The specimens were cyclically tested to failure by applying tensile forces parallel to the longitudinal axis of the humerus. A preload of 5 N was applied for 2 minutes prior to cyclic loading for 500 cycles from 5 to 70 N at 1 Hz; subsequently, a load-to-failure test at 1 mm/s was performed. The ultimate failure load, stiffness, displacement at cyclic and failure loading, and mode of failure were recorded.

RESULTS

The all-suture anchor technique displayed values of ultimate failure load and stiffness comparable to that of the interference screw technique. The displacement at cyclic and failure loading of the all-suture anchor trials were significantly greater than the interference screw (P = .0002). The all-suture anchor specimens experienced anchor pullout and tendon tear equally during the trials, whereas the interference screw group experienced tendon tear in most of the cases and screw pullout in 2 trials.

CONCLUSIONS

The Y-knot all-suture anchor fixation provides equivalent ultimate failure load and stiffness when compared with the interference screw technique in tenodesis of the proximal biceps tendon from a subpectoral approach. However, the interference screw technique demonstrates significantly less displacement in response to cyclic and failure loading.

CLINICAL RELEVANCE

The all-suture anchor fixation is an alternative technique for subpectoral biceps tenodesis even at greater displacement when compared with the interference screw fixation during cyclic and failure loading.

Qualitative Assessment and Quantitative Analysis of the Long Head of the Biceps Tendon in Relation to the Pectoralis Major Tendon Humeral Insertion: An Anatomic Study

PURPOSE

To qualitatively assess and to quantitatively analyze the long head of the biceps tendon (LHBT) in the region of the pectoralis major (PM).

METHODS

From 11 fresh cadaveric donors, 20 cadaveric shoulders without operative scars were dissected-mean age, 76.9 years (range, 61 to 93 years); male, 75%; left-sided, 55%; mean height, 67.8 inches (range, 61 to 71 inches); mean weight, 148.1 pounds (range, 106 to 176 pounds). Two specimens with discovered ruptures were excluded. The LHBT circumference was measured at the anterior edge of supraspinatus, suprapectorally, midpectorally, and subpectorally. The muscle was then removed from the LHBT and the circumference was again measured at the supra-, mid-, and subpectoral levels. These data were used to calculate the area of the tendon. All measurements were performed by 2 independent observers. Statistical analysis was performed to assess reliability of data and the difference between serial measurements.

RESULTS

The mean calculated percentage tendon decreased from 86.7% at the superior edge of the PM to 49.8% at the midpoint of the PM and to 17.5% at the inferior edge of the PM.

CONCLUSIONS

Distal to the PM, the LHBT was composed of a small percentage of tendon to muscle, which may have implications for the mechanical strength of fixation of tenodesis. The anatomic location of the musculotendinous junction of the LHBT began proximal to the superior edge of the PM tendon, which implies that restoration of anatomic tensioning may require a more proximal docking site than previously described. Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may not be optimal.

CLINICAL RELEVANCE

Tenodesis performed between the midpoint of the PM insertion and more distal points involves a significant portion of muscle, which may affect the mechanical strength or optimal choice of fixation location.

Biomechanics of a novel technique for suprapectoral intraosseous biceps tenodesis

BACKGROUND

The Caspari-Weber (C.W.) tenodesis is a standard miniopen intraosseous technique to fix the long head of the biceps tendon. The suprapectoral intraosseous biceps tenodesis (SPIBiT) is a novel arthroscopic, intraosseous, tendon-sparing alternative using a cortical button. No biomechanical data exist comparing the time-zero performance of the SPIBiT and C.W. constructs.

METHODS

Nine pairs of human cadaver shoulders were tested. The SPIBiT used a finger-trap suture pattern holding the tendon inside a humeral tunnel above the pectoralis tendon, anchored with a cortical button on the anterior humerus distal to the bicipital groove. The subpectoral C.W. used a Krackow suture technique. Specimens underwent 500 cycles of uniaxial loading, followed by ultimate failure testing.

RESULTS

The SPIBiT was placed in 5 left and 4 right humeri (5 female, 4 male; 59 ± 6 years). The C.W. was initially stiffer (P = .003), whereas the SPIBiT exhibited higher energy dissipation (hysteresis; P = .006). Metrics decreased for both constructs over 500 cycles (P ≤ .050). Constructs failed through suture bunching and tendon tearing within the main suture bundle. The SPIBiT exhibited a novel failure in 2 specimens, with the cortical button pulling distally and suture cutting through cortical bone. Failure occurred at 272.0 ± 114.3 N and 282.3 ± 59.4 N for the SPIBiT and C.W., respectively (P = .766). The C.W. was stiffer (P < .001).

CONCLUSION

The SPIBiT is an arthroscopic suprapectoral intraosseous alternative to the C.W. biceps tenodesis, but in light of the novel failure mode, clinical use is not recommended. Future investigations should quantify the impact of construct compliance on healing, and future constructs should avoid suture point loading on thin cortical bone.

Torsional Fracture of the Humerus after Subpectoral Biceps Tenodesis with an Interference Screw: A Biomechanical Cadaveric Study

BACKGROUND

Humeral fracture following subpectoral biceps tenodesis has been previously reported; however, there are no published biomechanical studies reporting the resulting torsional strength of the humerus. Our purpose was to determine if there is an increased risk of humerus fracture after subpectoral biceps tenodesis with an interference screw and to determine if screw size is also a factor. We hypothesized that limbs receiving the procedure would have reduced failure torque and rotation under external rotation compared to untreated controls and that the larger screw size would result in inferior mechanical properties compared to the smaller.

METHODS

Twenty matched pairs of embalmed cadaveric humeri were subjected to subpectoral biceps tenodesis using either a 6.25 or 8.0mm interference screw, with the untreated contralateral limb serving as a control. Each humerus was mechanically tested in torsional external rotation to failure.

FINDINGS

Maximum torque and rotation to failure were reduced in the tenodesis group compared to controls; however, there was no difference between screw sizes. When both screw sizes were combined into a single group, paired t-tests also showed similar differences.

INTERPRETATION

Based on our experiment, there is an increased risk for humerus spiral fracture when subjected to torsional external rotation after subpectoral biceps tenodesis with an interference screw compared to an intact humerus; however, there is not a significant difference between a 6.25mm and 8.0mm screw. Surgeons may elect to use alternative fixation methods in patients at high risk (e.g., overhead throwing athletes, etc.) for torsional loads and fracture.

Biceps tenodesis (long head): arthroscopic keyhole technique versus arthroscopic interference screw: a prospective comparative clinical and radiographic marker study

PURPOSE

The long head biceps tenodesis (LHBT) is an alternative to tenotomy in order to prevent Popeye sign.Biomechanical studies showed that interference screw(IFS) was the strongest fixation but there might be complications and cost. What's more, the analyses of tenodesis failures are undervalued because they only take visible deformations of the arm into account. The purpose of this study was to compare a modified arthroscopic "keyhole" LHBT (modified @KH) with an arthroscopic IFS LHBT(@IFS) using an objective method. We hypothesized that modified @KH gave similar clinical outcomes as @IFS without its hassles or drawbacks.

METHODS

We present a 12-month prospective comparative study (modified @KH versus @IFS) performed by two experienced orthopedic surgeons. Modified @KH was performed on one hundred and nine patients versus @IFS that was performed on one hundred and two. A radiopaque marker was placed into the tendon. The review was conducted in the sixth month with clinical examination and plain standard X-ray to objectify the potential migration of the marker.

RESULTS

Modified @KH showed 2.4 % visible deformity without any Popeye sign but 3.4 % radiographic metallic marker migrations. No complications were noted. @IFS showed 5.8 % visible deformity with 2.9 % Popeye sign and with 10.3 % radiographic metallic marker migrations;pain at tenodesis location was noted in 2 %. P value (0.13) indicates that there were no statistically significant differences.

CONCLUSION

We confirm the hypothesis that the modified@KH gives clinical and radiographic outcomes at least similar to @IFS without any complications and cost. The establishment of the radiopaque marker allows us to know the exact number of failures.Level of evidence Consecutive prospective comparative clinical, Level II-1 studies.

Open Subpectoral Tenodesis of the Proximal Biceps

This article summarizes both the various techniques for an open subpectoral biceps tenodesis as well as the biomechanics associated with these procedures. It provides information regarding the indications and contraindications to support the surgeon's decision. Furthermore, a postoperative protocol as well as an outcome overview is presented to address postoperative care. A short summary of the recent literature regarding potential complications is included to provide further insight on this technique. The open subpectoral tenodesis of the long head of the biceps is a safe and reproducible technique with a low complication rate for patients with pathologies of the proximal biceps.

Biomechanical characterization of unicortical button fixation: a novel technique for proximal subpectoral biceps tenodesis

PURPOSE

Proximal biceps tenodesis is one method for treating biceps-related pain. Tenodesis protects the length-tension relationship of the biceps muscle, maintains strength, and provides a better cosmetic appearance than tenotomy. The purpose of this investigation was to compare the mechanical properties of a unicortical metal button and an interference screw in proximal biceps tenodesis.

METHODS

Six pairs of fresh-frozen shoulders were dissected, leaving the proximal biceps tendon as a free graft. On each pair of shoulders, a biceps tenodesis was performed using an interference screw or a unicortical metal button. The specimens were mounted and a cyclic load (10-60 N) was applied at 1 Hz for 200 cycles, followed by an axial load to failure. The displacement, ultimate load to failure, and mode of failure were recorded.

RESULTS

Displacement in response to cyclic loading was 3.7 ± 2.2 mm for the interference screw and 1.9 ± 1.0 mm for the cortical button (P = 0.03). Load at failure for the interference screw was 191 ± 64 N (stiffness: 24 ± 11 N/mm) and 183 ± 61 N (stiffness: 24 ± 7. N/mm) for the unicortical button (P = n.s. for both cases).

CONCLUSIONS

As a novel technique for subpectoral biceps tenodesis, a unicortical button demonstrated significantly less displacement in response to cyclic loading than the interference screw. The ultimate load to failure and stiffness for the two methods were not different. In this way, a unicortical button may provide a reliable alternative method of fixation with a potentially lower risk of post-operative humeral fracture and a construct that permits early mobilization following biceps tenodesis.

Arthroscopic proximal biceps tenodesis at the articular margin: evaluation of outcomes, complications, and revision rate

PURPOSE

The purpose of this study was to evaluate the incidence of residual pain, outcomes, and the revision rate of arthroscopic proximal biceps tenodesis high in the groove at the articular margin of the humeral head by interference screw fixation.

METHODS

Seven surgeons pooled data on patients who underwent an arthroscopic biceps tenodesis at the articular margin by interference screw fixation. All patients had a minimum of 50 weeks' follow-up. Preoperative and postoperative patient data including visual analog scale scores (obtained by all surgeons), objective shoulder scores (Simple Shoulder Test and University of California, Los Angeles scores obtained by 2 and 4 surgeons, respectively), and need for revision surgery (obtained by all surgeons) were retrospectively analyzed, the results are reported, and statistical analysis was performed.

RESULTS

After the application of our exclusion criteria, 1,083 patients were included in the analysis. The mean follow-up period was 136 weeks. The overall revision surgery rate for this group was 4.1% (44 of 1,083). Revision for biceps tenodesis-related issues was needed in only 4 cases (for a biceps tenodesis-related revision rate of 0.4%). Pain scores improved from 6.47 preoperatively to 1.08 postoperatively (P < .0001). University of California, Los Angeles scores improved from 14.9 preoperatively to 30.1 postoperatively (P < .0001), and Simple Shoulder Test scores improved from 2.7 preoperatively to 10.2 postoperatively (P < .0001).

CONCLUSIONS

Arthroscopic biceps tenodesis performed at the articular margin results in a low surgical revision rate, a low rate of residual pain, and significant improvement in objective shoulder outcome scores.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Suprapectoral biceps tenodesis: a biomechanical comparison of a new "soft anchor" tenodesis technique versus interference screw biceps tendon fixation

BACKGROUND

The interference screw technique is commonly used in tenodesis of the long head of the biceps for its well-documented robust fixation strength. Some complications may occur after tenodesis with interference screw such as persistent pain, bone fracture and cyst formation. A new technique using a small "soft anchor" has been proposed to avoid the risk of occurrence of the above-mentioned complications associated with the use of the interference screw. However, the proposed technique must provide adequate fixation strength. This study investigated the mechanical performance of the new technique and compared it with interference screw fixation.

METHODS

Fourteen human humeri and proximal biceps were tested after tenodesis using the two techniques. The fixation constructs were cycled 500 times between 20N and 100N at 1Hz to simulate some level of post-operative physical activity. Then, a tensile test to failure was performed to determine the strength of the two tenodesis constructs.

FINDINGS

The ultimate strength was 238N (SD 96N) and 172N (SD 58N) for the "soft anchor" and the interference screw, respectively (P=0.14). In two out of seven repetitions in both groups, failure occurred at low load level due to inaccuracies in performing tenodesis. Considering these cases as outliers, the strength values increased up to 290N (SD 40N) and 202N (SD 32N) for the "soft anchor" and the interference screw, respectively (P=0.02).

INTERPRETATION

The "soft anchor" technique provides a fixation strength comparable with the interference screw, but without using a screw. It could be considered as an alternative for suprapectoral biceps tenodesis.

Subpectoral biceps tenodesis: a new technique using an all-suture anchor fixation

There are several options for LHB tenodesis; yet, there is no standard of care. This technical note describes an extramedullary all-suture anchor technique for LHB tenodesis that is similar to the extramedullary cortical button technique. The LHB tenodesis is performed by using the Y-Knot (1.3-mm; ConMed Linvatec, Largo, FL).The biceps tenotomy is completed arthroscopically, and a standard subpectoral approach is used for the tenodesis. A reamer is first used to drill through the anterior cortex of the humerus; subsequently, a 1.3-mm drill bit is used to drill through the posterior cortex. The Y-Knot anchor is passed through the bone tunnel and secured on the posterior cortical bone. A modified rolling hitch suture is placed 10 mm distal to the end of the LHB tendon by using one suture limb of the Y-Knot anchor. The other suture limb is pulled to shuttle the LHB tendon into the humerus, and the construct is fixed by tying down one limb to the other. This technical note describes an alternative method for subpectoral biceps tenodesis and uses a small drill hole, conserves bone, and minimizes trauma to the tendon.

LEVEL OF EVIDENCE

V.

Biomechanical analysis of subpectoral biceps tenodesis: effect of screw malpositioning on proximal humeral strength

BACKGROUND

Humeral fracture after subpectoral tenodesis of the long head of biceps tendon (LHB) is a rare but devastating complication.

PURPOSE

To determine whether malpositioned (laterally eccentric) tenodesis screw placement has an influence on humerus strength reduction compared with central placement.

STUDY DESIGN

Controlled laboratory study.

METHODS

Two groups, each consisting of 10 matched pairs of human humeri, were used for this study. Biceps tendons were fixed subpectorally with 8-mm screws in unicortical 8-mm sockets. In the first group, the socket was placed concentrically in the bicipital groove and the tendon was fixed with an interference screw. In the second group, the socket was malpositioned 30% eccentrically to the lateral (tension) side of the humerus. Contralateral humeri remained intact as positive controls. Specimens were aligned in 40° of abduction, and a uniaxial compressive force was applied to the humeral head until failure. Strength reduction was reported as percentage reduction in ultimate failure load between paired humeri. Relative defect size was calculated as a percentage of the total humeral width at the height of the tenodesis.

RESULTS

Laterally eccentric malpositioned biceps tenodeses significantly decreased humeral strength compared with intact (mean change, -25%; SD, 23%; P=.017), while concentrically placed biceps tenodeses did not (mean change, -10%; SD, 15%; P=.059). A linear regression between relative defect size and strength reduction in the malpositioned group showed a significant negative linear correlation (beta=-2.577; R2=0.423; P=.042).

CONCLUSION

Humeral fracture after subpectoral tenodesis of the LHB is a complication that may be minimized with careful surgical technique. Laterally eccentric malpositioned biceps tenodesis caused significant reduction (25%) in humeral strength, which might be clinically relevant and contribute to postsurgical humeral shaft fracture. Strength reduction was also significantly correlated with relative defect size. Surgeons using this technique should ensure central and orthogonal placement of the socket, especially in smaller individuals. This study lends biomechanical evidence to support the clinical procedure of a correctly, concentrically placed tenodesis screw.

CLINICAL RELEVANCE

These biomechanical results indicate that in a clinical setting, special attention should be drawn to patient selection for LHB tenodesis. This study reveals that central screw positioning is critical, particularly in high-impact and overhead athletes, as well as for patients with small humeral widths or osteoporotic bone quality. Alternative surgical options such as smaller screws or other fixation methods might be considered to diminish the postoperative risk of humeral fracture.

Midterm clinical outcomes for arthroscopic subdeltoid transfer of the long head of the biceps tendon to the conjoint tendon

PURPOSE

The aim of this study was to assess the midterm functional outcomes for arthroscopic subdeltoid transfer of the long head of the biceps tendon (LHBT) to the conjoint tendon.

METHODS

Fifty-six shoulders in 54 patients (46 men, 8 women; mean age, 42 years) who underwent isolated arthroscopic subdeltoid LHBT transfer to the conjoint tendon by a single surgeon with a minimum of 4 years follow-up were evaluated with American Society of Shoulder and Elbow Surgeons (ASES) and L'Insalata scores. A subset of patients was available for physical examination.

RESULTS

At an average of 6.4 years postoperatively, ASES and L'Insalata scores were 86 and 85, respectively, corresponding to 88% of patients rated good to excellent. Twelve shoulders (10 from men patients, 2 from women patients; mean age 41 years; average follow-up, 6.3 years) underwent physical examination. Mean University of California, Los Angeles (UCLA) score was 31, and there were no significant differences in side-to-side elbow flexion strength or endurance using a 10-pound weight. One patient had a Popeye sign. There were no major complications reported in this cohort.

CONCLUSIONS

Arthroscopic transfer of the LHBT to the conjoint tendon is a safe and durable intervention for chronic refractory biceps tendinitis. LEVEL OF 

EVIDENCE

Level IV, therapeutic case series.

Biomechanical comparison of two techniques for arthroscopic suprapectoral biceps tenodesis: interference screw versus implant-free intraosseous tendon fixation

BACKGROUND

A novel arthroscopic technique allows for intraosseous tendon placement in biceps tenodesis using bone tunnels and suture while avoiding the expense of an implant. No biomechanical characterization exists for this construct.

METHODS

Tensile tests were used to compare a suture-only biceps tenodesis technique (arthroscopic biceps intraosseous tenodesis [ABIT]) with interference screws in 7 pairs of cadaveric shoulders. The ABIT used a modified finger-trap suture method to secure the tendon to itself through an intraosseous bone tunnel. Interference screw placement followed the manufacturer's protocol for implantation. An open technique was used to provide consistency during laboratory preparation.

RESULTS

During cyclic loading, the screws were significantly stiffer (P = .040) but dissipated more energy (P = .002). During failure loading, suture-only specimens showed significantly greater failure loads (P < .001) and deformation (P = .046). The failure mechanism for the ABIT method was tendon elongation with progressive tensioning and slippage of the tendon through the suture mass. No complete tendon failure occurred for the ABIT. Gross tendon failure occurred in all interference screw tests at the bone-tendon-screw interface. No screw or suture failed in any biceps tendon test.

CONCLUSION

The ABIT construct showed significantly higher failure loads and deformation compared with interference screws. The comparable stiffness after cycling of both constructs suggests that micromotion at the bone-tendon interface is similar, which-in addition to the intraosseous fixation-may be important in promoting healing. The ABIT construct was found to absorb and restore more energy (hysteresis), suggesting potential for greater tendon preservation, which may translate into improved construct longevity. The suture-only method can eliminate the expense of an implant.

Arthroscopic tenodesis of the long head of the biceps

The long head of the biceps (LHB) is commonly implicated in shoulder pathology due to its anatomic course and intimacy with the rotator cuff and superior labrum of the glenoid. Treatment of tendinosis of the LHB may be required secondary to partial thickness tears, instability/subluxation, associated rotator cuff tears, or SLAP (superior labrum, anterior to posterior) lesions. Treatment options include open or arthroscopic techniques for tenodesis vs tenotomy. Controversy exists in the orthopedic literature regarding the preferred procedure. The all-arthroscopic biceps tenodesis technique is a viable and reproducible option for treatment. This article provides a review of the all-arthroscopic biceps tenodesis technique using proximal interference screw fixation and its subsequent postoperative regimen. All-arthroscopic biceps tenodesis maintains elbow flexion and supination power, minimizes cosmetic deformities, and leads to less fatigue soreness after active flexion. Thus, arthroscopic biceps tenodesis should be offered and encouraged as a treatment option for younger, active patients.

Complications after subpectoral biceps tenodesis using a dual suture anchor technique

Purpose:

A variety of fixation techniques for subpectoral biceps tenodeses have been described including interference screw and suture anchor fixation. Biomechanical data suggests that dual suture anchor fixation has equivalent strength compared to interference screw fixation. The purpose of the study is to determine the early complication rate after subpectoral biceps tenodesis utilizing a dual suture anchor technique.

Materials and Methods:

A total of 103 open subpectoral biceps tenodeses were performed over a 3-year period using a dual suture anchor technique. There were 72 male and 31 female shoulders. The average age at the time of tenodesis was 45.5 years. 41 patients had a minimum of 6 months clinical follow-up (range, 6 to 45 months). The tenodesis was performed for biceps tendonitis, superior labral tears, biceps tendon subluxation, biceps tendon partial tears, and revisions of prior tenodeses.

Results:

There were a total of 7 complications (7%) in the entire group. There were 4 superficial wound infections (4%). There were 2 temporary nerve palsies (2%) resulting from the interscalene block. One patient had persistent numbness of the ear and a second patient had a temporary phrenic nerve palsy resulting in respiratory dysfunction and hospital admission. One patient developed a pulmonary embolism requiring hospital admission and anticoagulation. There were no hematomas, wound dehiscences, peripheral nerve injuries, or ruptures. In the sub-group of patients with a minimum of 6 months clinical follow-up, the only complication was a single wound infection treated with oral antibiotics.

Conclusions:

Subpectoral biceps tenodesis utilizing a dual suture anchor technique has a low early complication rate with no ruptures or deep infections. The complication rate is comparable to those previously reported for interference screw subpectoral tenodesis and should be considered as a reasonable alternative to interference screw fixation.

Level of Evidence:

Level IV-Retrospective Case Series

Nerve proximity during bicortical drilling for subpectoral biceps tenodesis: a cadaveric study

PURPOSE

The long head of the biceps can develop tendonitis and tendinosis, which can lead to pain in the bicipital groove. The use of bicortical button fixation allows for a smaller defect in the humerus compared with tenodesis screws, reducing the risk of fracture. Our objective is to evaluate the exit location of our bicortical button and its relation to relevant posterior nervous structures.

METHODS

We performed anatomic dissection of 6 fresh-frozen cadaveric upper extremities. At the level of the inferior border of the pectoralis major tendon, the musculotendinous junction of the long head of the biceps was identified. At the base of the bicipital groove, a 3.2-mm guidewire was advanced perpendicularly through both the anterior and posterior cortex. Posteriorly, the radial and axillary nerves were carefully dissected. For each dissection, we recorded the closest distance from the posterior cortical hole created by our drill to both the axillary and radial nerves using digital calipers.

RESULTS

The mean distance from the axillary nerve to the posterior drill hole was 25.1 mm (95% confidence interval, 21.6 to 28.6 mm). The mean distance from the radial nerve to the posterior drill hole was 30.3 mm (95% confidence interval, 27.2 to 33.4 mm).

CONCLUSIONS

With placement of the tenodesis at the inferior aspect of the bicipital groove in conjunction with the musculotendinous junction, open subpectoral tenodesis of the long head of the biceps can be performed using bicortical button fixation without risk to the posterior nervous structures.

CLINICAL RELEVANCE

This cadaveric study suggests that posterior proximal humerus nervous structures can be avoided with proper tenodesis placement.

Anatomic and radiographic comparison of arthroscopic suprapectoral and open subpectoral biceps tenodesis sites

BACKGROUND

Arthroscopic suprapectoral and open subpectoral surgical techniques are both commonly utilized approaches for proximal biceps tenodesis of the long head of the biceps brachii. A central limitation to the widespread use of an arthroscopic approach for biceps tenodesis is that the tendon may be tenodesed too proximally in the bicipital groove, leading to persistent pain and tendinopathy. Purpose/

HYPOTHESIS

The purpose of this study was to determine the in vivo tenodesis location using arthroscopic suprapectoral and open subpectoral techniques for proximal biceps tenodesis in relation to clinically pertinent anatomic and radiographic landmarks. The null hypothesis was that arthroscopic suprapectoral biceps tenodesis would not be significantly different in terms of the location from open subpectoral biceps tenodesis.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 20 matched pairs of cadaveric shoulder specimens were randomized such that within each pair, 1 shoulder underwent a standard open subpectoral biceps tenodesis and the other underwent an arthroscopic suprapectoral tenodesis. Limited dissection and exposure of the surgical tunnel site and reference landmarks were subsequently performed, and anteroposterior and lateral radiographs were obtained. Direct measurements were performed anatomically using a digital caliper and radiographically using picture archiving and communication system (PACS) software from the proximal lip of the humeral tunnel to regional landmarks.

RESULTS

Both techniques were able to place the humeral tunnel distal to the bicipital groove in all specimens. On average, the open subpectoral approach placed the tunnel 2.2 cm distal to the arthroscopic suprapectoral approach.

CONCLUSION

The arthroscopic suprapectoral biceps tenodesis technique used in this study consistently placed the tenodesis tunnel distal to the bicipital groove, which may allay concerns about the bicipital groove as a pain source after this procedure.

CLINICAL RELEVANCE

This anatomic study provides new information on tunnel placement in 2 biceps tenodesis techniques. In addition, it provides clinically relevant anatomic and radiographic guidelines using clinically pertinent landmarks. This information may be useful in preoperative planning, intraoperative technique, and postoperative assessment of both open subpectoral and arthroscopic suprapectoral biceps tenodesis.

Biomechanical evaluation of subpectoral biceps tenodesis: dual suture anchor versus interference screw fixation

BACKGROUND

Subpectoral biceps tenodesis has been reliably used to treat a variety of biceps tendon pathologies. Interference screws have been shown to have superior biomechanical properties compared to suture anchors; although, only single anchor constructs have been evaluated in the subpectoral region. The purpose of this study was to compare interference screw fixation with a suture anchor construct, using 2 anchors for a subpectoral tenodesis.

METHODS

A subpectoral biceps tenodesis was performed using either an interference screw (8 × 12 mm; Arthrex) or 2 suture anchors (Mitek G4) with #2 FiberWire (Arthrex) in a Krackow and Bunnell configuration in seven pairs of human cadavers. The humerus was inverted in an Instron and the biceps tendon was loaded vertically. Displacement driven cyclic loading was performed followed by failure loading.

RESULTS

Suture anchor constructs had lower stiffness upon initial loading (P = .013). After 100 cycles, the stiffness of the suture anchor construct "softened" (decreased 9%, P < .001), whereas the screw construct was unchanged (0.4%, P = .078). Suture anchors had significantly higher ultimate failure strain than the screws (P = .003), but ultimate failure loads were similar between constructs: 280 ± 95 N (screw) vs 310 ± 91 N (anchors) (P = .438).

CONCLUSION

The interference screw was significantly stiffer than the suture anchor construct. Ultimate failure loads were similar between constructs, unlike previous reports indicating interference screws had higher ultimate failure loads compared to suture anchors. Neither construct was superior with regards to stress; although, suture anchors could withstand greater elongation prior to failure.

Biomechanical comparison of long head of biceps tenodesis with interference screw and biceps sling soft tissue techniques

PURPOSE

The purpose of our study was to compare biomechanically a long head biceps tenodesis using an all soft tissue biceps sling technique versus an interference screw technique.

METHODS

Six paired fresh frozen shoulder specimens were separated into 2 groups. One group used an all soft tissue biceps sling technique for tenodesis. The other group used the interference screw technique for subpectoral tenodesis of the long head biceps tendon. Specimens in both groups were sequentially loaded for 200 cycles, and the difference between the initial and final displacements were recorded. Specimens were then loaded to failure. Load and mode of failure were recorded.

RESULTS

The mean displacement of all specimens undergoing the sling technique was significantly less than that of the interference technique at 3.0 mm (±0.80) versus 5.0 mm (±1.08) (P < .05). The biceps sling technique had a higher mean ultimate failure load (UFL) than did the interference screw tenodesis (216.9 N ± 91.6 v 171.7 N ± 101.4), although this was not statistically significant (P = .63). In the interference screw technique, 4 specimens failed at the tenodesis site by either tearing or complete pullout, whereas 2 failed at the biceps myotendinous junction. In the sling technique, 4 specimens failed at the biceps myotendinous junction, whereas one specimen tore at the tenodesis site and one detached the pectoralis tendon insertion from the humerus. One specimen in the biceps sling technique and 2 specimens in the interference screw technique failed before completing all 200 cycles.

CONCLUSIONS

The results of this biomechanical study show that the biceps sling technique has construct stability similar to that of the interference screw technique.

CLINICAL RELEVANCE

The biceps sling may be a reasonable alternative for treating symptomatic pathologic conditions of the long head biceps tendon.

Biomechanical comparison of intramedullary cortical button fixation and interference screw technique for subpectoral biceps tenodesis

PURPOSE

The purpose of this study was to biomechanically evaluate a new technique of intramedullary cortical button fixation for subpectoral biceps tenodesis and to compare it with the interference screw technique.

METHODS

We compared intramedullary unicortical button fixation (BicepsButton; Arthrex, Naples, FL) with interference screw fixation (Bio-Tenodesis screw; Arthrex) for subpectoral biceps tenodesis using 10 pairs of human cadaveric shoulders and ovine superficial digital flexor tendons. After computed tomography analysis, the specimens were mounted in a testing machine. Cyclic loading was performed (preload, 5 N; 5 to 70 N at 1.5 Hz for 500 cycles), recording the displacement of the tendon. Load to failure and stiffness were subsequently evaluated with a load-to-failure test (1 mm/s).

RESULTS

Cyclic loading showed a displacement of 11.3 ± 2.8 mm for intramedullary cortical button fixation and 9 ± 1.7 mm for interference screw fixation (P = .112). All specimens within the cortical button group passed the cyclic loading test, whereas 3 of 10 specimens within the interference screw group failed by tendon slippage at the screw-tendon-bone interface after a mean of 252 cycles (P = .221). Load-to-failure testing showed a mean load to failure of 218.8 ± 40 N and stiffness of 27.2 ± 7.2 N/mm for the intramedullary cortical button technique. For the interference screw, the mean load to failure was 212.1 ± 28.3 N (P = .625) and stiffness was 40.4 ± 13 N/mm (P = .056).

CONCLUSIONS

We could not find any major differences in load to failure when comparing the tested techniques for subpectoral biceps tenodesis. Intramedullary cortical button fixation showed no failure during cyclic testing. However, we found a 30% failure rate (3 of 10) for the interference screw fixation.

CLINICAL RELEVANCE

Intramedullary cortical button fixation provides an alternative technique for subpectoral biceps tenodesis with comparable and, during cyclic loading, even superior biomechanical properties to interference screw fixation.

Biomechanical evaluation of a unicortical button versus interference screw for subpectoral biceps tenodesis

PURPOSE

The purpose of this study was to evaluate and compare the biomechanical properties of a unicortical button with an interference screw used for subpectoral biceps tenodesis. We also describe the anatomic dangers of bicortical button use in the subpectoral location.

METHODS

Twenty-eight fresh-frozen human cadaveric shoulders with a mean age of 52 years were studied. The specimens were randomly divided into 4 experimental biceps tenodesis groups (n = 7): unicortical button, interference screw, bicortical suspensory button, and bicortical suspensory with interference screw (Arthrex, Naples, FL). Each tenodesis specimen was mounted on a mechanical testing machine, preloaded for 2 minutes at 5 N, cycled from 5 to 70 N for 500 cycles (1 Hz), and loaded to failure (1 mm/s). We determined the mode of failure and computed the ultimate load to failure, yield load, pullout stiffness, and displacement at peak load. Calculations of the distance between the axillary and radial nerves with respect to the bicortical buttons were also calculated in 6 specimens.

RESULTS

There was no statistically significant difference (P > .05) among groups in terms of age, ultimate load to failure, pullout stiffness, or displacement at peak load. Suture-tendon interface failure was the most commonly observed mode of failure. The axillary nerve was on average 7.8 mm from the bicortical button; however, in 6 specimens the nerve was less than 3 mm away.

CONCLUSIONS

The use of a unicortical button for subpectoral biceps tenodesis provides biomechanical properties similar to the use of an interference screw. In addition, the use of a bicortical button in this area of the proximal humerus puts the axillary nerve at risk.

CLINICAL RELEVANCE

Using a unicortical button subpectoral biceps method may provide a surgeon with a safe and technically easy and reproducible technique while providing similar biomechanical properties to a known standard implant.

Symptomatic chronic long head of biceps rupture: Surgical results

Purpose:

Chronic rupture of the long head of biceps (LHB) tendon is usually asymptomatic. However, some active patients suffer with long-term cramping pain associated with repetitive biceps use. The aim of this study is to review the outcomes of biceps tenodesis performed for chronic LHB ruptures.

Materials and Methods:

We performed a retrospective review of 11 consecutive patients who underwent biceps tenodesis for symptomatic chronic LHB ruptures over a 4-year period.

Results:

There were 10 men and one woman with an average age at surgery of 41 years (range 23-65). The mean follow-up was 29 months (range 6-60). In five cases a tendon was still identifiable and suitable for repair with an ‘in-bone’ interference screw. However, in six cases the tendon was not possible to tenodese with an interference screw. In these cases we used an ‘on-bone’ technique with suture anchors. All, except one, patients reported improvement in their arm pain (78%), strength (74%) and appearance. All, except one, were glad to have had the surgery.

Conclusions:

Symptomatic chronic LHB ruptures improve with a biceps tenodesis procedure. Due to the chronicity of the injury and possible degeneration of the tendon, a suitable tendon for ‘in-bone’ tenodesis may not be possible. In these cases an ‘on-bone’ footprint repair with suture anchors achieves good results.

Level of Evidence:

IV (retrospective case series).

Long head of the biceps pathology combined with rotator cuff tears

The long head of the biceps tendon (LHBT) is an anatomic structure commonly involved in painful shoulder conditions as a result of trauma, degeneration, or overuse. Recent studies have pointed out the close correlation between LHBT lesions and rotator cuff (RCT) tears. Clinicians need to take into account the importance of the LHBT in the presence of other shoulder pathologies. This paper provides an up-to-date overview of recent publications on anatomy, pathophysiology, diagnosis, classification, and current treatment strategies.

Surgical correction of the "Popeye biceps" deformity: dual-window approach for combined subpectoral and deltopectoral access and proximal biceps tenodesis

"Popeye biceps" deformity represents the appearance of a distally retracted biceps muscle resulting from either a traumatic long biceps tendon (LBT) rupture or an iatrogenic LBT tenotomy. Cosmetic and functional problems associated with the deformity may necessitate surgical correction, and surgical exposure using multiple incisions is recommended. The technique presented here describes a novel mini-open approach using a single 1-in incision that provides access to 3 peripectoral anatomical zones. Preoperative sonographic localization of the ruptured and retracted LBT is used to guide incision placement, and facilitates intraoperative tendon retrieval via a limited incision and minimal dissection. Inferolateral retraction of the mini-incision window permits infrapectoral and subpectoral LBT mobilization and dissection. Deltopectoral access via superomedial retraction of the same skin window is used to expose the suprapectoral zone and is employed for LBT retrieval and proximal tenodesis. Technical tips for safe dissection via a mini-incision, and methods for biological LBT augmentation are discussed.