Outcomes of Biceps Tenodesis Variations With Concomitant Rotator Cuff Repair: A Multicenter Database Analysis

Background

Studies to date comparing biceps tenodesis methods in the setting of concomitant rotator cuff repair (RCR) have demonstrated relatively equivalent pain and functional outcomes.

Purpose

To compare biceps tenodesis constructs, locations, and techniques in patients who underwent RCR using a large multicenter database.

Study Design

Cohort study; Level of evidence, 3.

Methods

A global outcome database was queried for patients with medium- and large-sized tears who underwent biceps tenodesis with RCR between 2015 and 2021. Patients ≥18 years of age with a minimum follow-up of 1 year were included. The American Shoulder and Elbow Surgeons, Single Assessment Numeric Evaluation, visual analog scale for pain, and Veterans RAND 12-Item Health Survey (VR-12) scores were compared at 1 and 2 years of follow-up based on construct (anchor, screw, or suture), location (subpectoral, suprapectoral, or top of groove), and technique (inlay or onlay). Nonparametric hypothesis testing was used to compare continuous outcomes at each time point. The proportion of patients achieving the minimal clinically important difference (MCID) at the 1- and 2-year follow-ups were compared between groups using chi-square tests.

Results

A total of 1903 unique shoulder entries were analyzed. Improvement in VR-12 Mental score favored anchor and suture fixations at 1 year of follow-up (P = .042) and the onlay tenodesis technique at 2 years of follow-up (P = .029). No additional tenodesis comparisons demonstrated statistical significance. The proportion of patients with improvement exceeding the MCID did not differ based on tenodesis methods for any outcome score assessed at the 1- or 2-year follow-up.

Conclusion

Biceps tenodesis with concomitant RCR led to improved outcomes regardless of tenodesis fixation construct, location, or technique. A clear optimal tenodesis method with RCR remains to be determined. Surgeon preference and experience with various tenodesis methods as well as patient clinical presentation should continue to guide surgical decision-making.

Advances in Prepectoral Breast Reconstruction

Breast reconstruction can be divided into prepectoral breast reconstruction (PPBR) and subpectoral breast reconstruction (SPBR) according to the implant plane. The original prepectoral breast reconstruction was abandoned for a long time due to the frequent and severe complications. Now, advances in materials technology and improved methods of mastectomy have made safe prepectoral breast reconstruction possible. Moreover, a number of studies have gradually demonstrated the advantages of prepectoral breast reconstruction. As prepectoral breast reconstruction becomes more and more attractive, it is time to review the current advances in prepectoral breast reconstruction.

Comparison of Outcomes Following Prepectoral and Subpectoral Implants for Breast Reconstruction: Systematic Review and Meta-Analysis

(1) Background: Implant-based breast reconstruction following mastectomy helps to restore quality of life while aiming at providing optimal cosmetic outcomes. Both prepectoral (PP) and subpectoral (SP) breast implants are widely used to fulfill these objectives. It is, however, unclear which approach offers stronger postoperative benefits. (2) Methods: We performed a systematic review of the literature through PubMed, Cochrane Library, and ResearchGate, following the PRISMA guidelines. Quantitative analysis for postoperative pain as the primary outcome was conducted. Secondary outcomes included patient satisfaction and postoperative complications such as seroma, implant loss, skin necrosis, wound infection, and hematoma. (3) Results: Nine articles involving 1119 patients were retrieved. Our results suggested increased postoperative pain after SP implants and significantly higher rates of seroma following PP implants (p < 0.05). Patient satisfaction was found to be similar between the two groups; however, the heterogeneity of measurement tools did not allow us to pool these results. The rates of implant loss, skin necrosis, wound infection, and hematoma showed no significant differences between the two cohorts. (4) Conclusion: Our data suggest that both implant placements are safe and effective methods for breast reconstruction following mastectomy. However, homogeneity in outcome measurements would allow one to provide stronger statistical results.

Clinical outcome comparison of suprapectoral and subpectoral tenodesis of the long head of the biceps with concomitant rotator cuff repair: A systematic review

BACKGROUND

Simultaneous repairs of rotator cuff and biceps tenodesis can be managed by tenodesis of long head of biceps tendon to a subpectoral or suprapectoral area. This review investigated long head of biceps tendon tenodesis with concomitant rotator cuff repair and evaluated the clinical outcomes and incidences of complications based on tenodesis location.

METHODS

Medline, Cochrane, and Embase databases were searched for published, randomized or nonrandomized controlled studies and prospective or retrospective case series with the phrases "suprapectoral," "subpectoral," "tenodesis," and "long head of biceps tendon". Those with a clinical evidence Level IV or higher were included. Non-English manuscripts, review articles, commentaries, letters, case reports, and sole long head of biceps tendon tenodesis articles were excluded.

RESULTS

From 481 studies, 13 were chosen. In total, 1194 subpectoral and 2520 suprapectoral tenodesis cases were investigated. Postoperative Constant-Murley and American Shoulder and Elbow Surgeons mean scores showed similar good results. In terms of complication incidences, while transient nerve injuries were more commonly seen in patients with subpectoral tenodesis, persistent bicipital pain and Popeye deformity are mostly seen in patients with suprapectoral tenodesis.

DISCUSSION

Biceps tenodesis to suprapectoral or subpectoral area with concomitant rotator cuff repair demonstrated similar outcomes. Popeye deformity and persistent bicipital pain were higher in suprapectoral area and transient neuropraxia was found to be higher in subpectoral area.Level of evidence: IV.

Early Versus Delayed Active Range of Motion After Open Subpectoral Biceps Tenodesis

Background

Little is known regarding the effect of early active elbow range of motion (ROM) protocols on failure rates and outcomes after open subpectoral biceps tenodesis.

Hypothesis

We hypothesized that patients managed using an early active ROM protocol after open subpectoral biceps tenodesis would demonstrate similar failure rates and functional outcomes compared to patients managed using a traditional delayed active ROM protocol.

Study Design

Cohort study; Level of evidence, 3.

Methods

We evaluated 63 patients who underwent open subpectoral biceps tenodesis with unicortical suture button fixation. Based on surgeon preference, 22 patients were managed using an early active motion protocol consisting of no restrictions on elbow flexion or forearm supination, while 41 patients were managed using a delayed motion protocol postoperatively. Primary outcome measures included failure of biceps tenodesis and American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores. Secondary outcomes included shoulder and elbow ROM at 6 months postoperatively.

Results

The mean follow-up for the 63 patients was 24.2 months postoperatively. One patient (2.4%) in the delayed active motion cohort and no patients in the early active motion cohort experienced failure. Final outcome scores as well as 6-month shoulder and elbow ROM indicated excellent functional outcomes, with no significant difference between motion cohorts. The median postoperative ASES scores were 97.99 in the early active motion cohort (mean ± standard deviation [SD], 95.49 ± 7.68) and 95.42 in the delayed motion cohort (mean ± SD, 90.93 ± 16.08), while median postoperative SANE scores were 96 in the early motion cohort (mean ± SD, 94.23 ± 6.68) and 95 in the delayed motion cohort (mean ± SD, 88.39 ± 17.98). Subgroup analysis demonstrated no significant difference in outcome scores based on the performance of concomitant rotator cuff repair or hand dominance.

Conclusion

Early active ROM after open subpectoral biceps tenodesis with unicortical suture button fixation resulted in low failure rates and excellent clinical outcomes, comparable to the results of patients managed using delayed active ROM protocols. This suggests that patients undergoing open subpectoral biceps tenodesis may be managed using either early or delayed active motion protocols without compromising functional outcome.

Patient Quality of Life After Subpectoral Implant-based Breast Reconstruction With Synthetic or Biological Materials

AIM

Quality of life and patient satisfaction after subpectoral breast reconstruction with meshes or acellular dermal matrices (ADM) and implants were assessed using the BreastQ questionnaire to investigate a potential influence of the materials on these parameters.

PATIENTS AND METHODS

The BreastQ questionnaire was completed by 121 patients, who had received material-assisted, heterologous, subpectoral breast reconstruction between 2010 and 2018.

RESULTS

Answers were similar independent of the reconstruction materials used. After prophylactic mastectomy, the physical wellbeing (chest) improved significantly with all materials (p=0.04). Postoperative radiotherapy significantly reduced satisfaction with outcome (p=0.005). Patients under 50 years old had significantly better postoperative sexual wellbeing than older patients (p=0.03).

CONCLUSION

No influence was detected of the materials on the postoperative quality of life and patient satisfaction. An overall better quality of life was reported by younger and normal-weight patients with prophylactic or nipple-sparing mastectomy without radiotherapy.

A Comparative Analysis between Subpectoral versus Prepectoral Single Stage Direct-to-Implant Breast Reconstruction

Background and objectives: Until now subpectoral breast reconstruction (SBR) has been the predominant form; however, it can present with pectoralis muscle contraction and animation deformity. To avoid these complications, surgeons have begun placing breast implants in the same anatomic space as the breast tissue that was removed. We report a comparative analysis of prepectoral breast reconstruction (PBR) versus subpectoral breast reconstruction to analyze their differences. Materials and Methods: Direct-to-implant (DTI) reconstruction using acellular dermal matrix (ADM) performed from February 2015 to February 2020 were retrospectively reviewed. We then compared the clinical course and postoperative outcomes of the two groups (prepectoral vs. subpectoral) based on the overall incidence of complications, pain scale, and the duration of drainage. Results: A total of 167 patients underwent unilateral DTI, with SBR 114 (68.3%) and PBR 53 (31.7%). Patient demographics were similar between the two groups. There was no statistically significant difference in rates of seroma, infection (requiring intravenous antibiotics), hematoma, and skin necrosis. Implant loss rates in the SBR 6.1% (n = 7) and PBR 9.4% (n = 5) were also not statistically significant (p = 0.99). The hemovac duration period was significantly longer in the SBR (14.93 ± 5.57 days) group than in the PBR group (11.09 ± 4.82 days) (p < 0.01). However, post-operative pain scores are similar between two groups, although it is not clear whether this was due to the effect of postoperative patient-controlled analgesia. Conclusions: A SBR is a commonly used procedure with various advantages, but there are many problems due to damage to the normal pectoralis major muscle. According to the results of our study, the PBR group had a shorter hemovac duration period compared to the SBR group, although there was no significant difference in complication rate. A PBR is a simple and safe technique allowing early discharge without increasing the incidence of long-term complications.

Giant Phyllodes Tumor in Ectopic Breast Tissue

Breast masses are uncommon in children and adolescents. Ectopic breast tissue is further uncommon and may be present in locations such as the face, back, and thigh. A 12-year-old female child presented with a hard, nonmobile lump in the right breast. On exploration by submammary incision, the lump was found to be below the pectoralis major muscle and had no communication with the overlying orthotopic breast tissue. Histopathological examination revealed a well-encapsulated biphasic lesion, with features characteristic of a phyllodes tumor. We report a hitherto unreported case of aberrant breast tissue lying under the pectoralis muscle and containing phyllodes tumor.

Superior Labral Anterior Posterior Repair and Biceps Tenodesis Surgery: Trends of the American Board of Orthopaedic Surgery Database

BACKGROUND

Recent evidence has specified indications for performing superior labral anterior posterior (SLAP) repair and biceps tenodesis (BT) for the treatment of bicipital-labral lesions in the shoulder. Trends in performance of these procedures are expected to reflect the growing body of research regarding this topic.

PURPOSE

To report practice trends for the surgical treatment of SLAP lesions utilizing the American Board of Orthopaedic Surgery (ABOS) database, particularly in older patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The ABOS database was retrospectively queried between 2012 and 2017 by Current Procedural Terminology (CPT) codes for SLAP repair (29807), open BT (23430), and arthroscopic BT (29828). The patient population was excluded if any concomitant open shoulder procedure was performed. Trends over time were evaluated with respect to case volume, patient age, surgeon subspecialty, and whether a concomitant arthroscopic rotator cuff repair (RCR) was performed (CPT 29827).

RESULTS

A total of 9908 cases met inclusion/exclusion criteria: 4632 performed with RCR and 5276 performed without. The mean age of patients without RCR was 40.8 ± 13.8 years, while for those receiving RCR it was 55.0 ± 9.9 years (P < .001). In patients without RCR, there was a significant decline in rate of SLAP repairs performed over this period (P < .001). A significantly greater proportion of patients receiving open and arthroscopic BT were older than 35 years of age, compared with those receiving SLAP repair (P < .001). Within the RCR cohort, there was also a significant decline in concomitant SLAP repairs performed (P < .001) over the study period. With respect to BT, open BT was performed more frequently in the cohort without RCR (74.5%) than in the cohort with RCR (52.1%) (P < .001). Similarly, arthroscopic BT was performed more commonly in the cohort with RCR (47.9%) than in the cohort without RCR (25.5%) (P < .001).

CONCLUSION

The ABOS database revealed significantly reduced rates of SLAP repairs performed in recent times. Trends with age remained consistent over time, in that SLAP repairs were predominantly performed in younger patients. Open BT was performed more frequently overall, but with an increased proportion of arthroscopic BT occurring with RCR. Arthroscopic BT was performed much more frequently with RCR than without.

Management of Failed Proximal Biceps Surgery: Clinical Outcomes After Revision to Subpectoral Biceps Tenodesis

BACKGROUND

The preferred surgical technique to manage biceps-superior labral pathology is often debated, and rates of revision and persistence of pain vary widely according to surgical technique and patient characteristics.

PURPOSE

To evaluate the clinical and functional outcomes of patients undergoing revision subpectoral tenodesis after failed primary tenodesis or tenotomy of the long head of the biceps.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

All patients undergoing revision biceps management by the senior surgeon between 2006 and 2016 and with a minimum 24-month follow-up were retrospectively identified. Patients being treated with concomitant rotator cuff repair or capsular release were excluded. Patient characteristic variables were recorded. Patient-reported outcomes including the functional score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons were obtained, and range of motion, strength, and complications were quantified.

RESULTS

In total, 25 patients with revision biceps tenodesis were identified at a mean follow-up of 76.5 ± 31.5 months. The average age was 44.4 ± 14.3 years, and the surgical indications included failure of index suprapectoral biceps tenodesis (56%), subpectoral biceps tenodesis (36%), and patient dissatisfaction after tenotomy (8%). There was a significant improvement in the VAS score (P < .001), SANE (P = .001), SST (P = .035), functional score (P < .001), and forward elevation (P = .028), whereas postoperative strength (P = .440), abduction (P = .100), and external rotation (P = .745) improvement failed to achieve statistical significance after revision surgery. There was no difference in postoperative outcome measures between modes of failures, concomitant procedures, and sex. Twenty-two (88%) patients reported high satisfaction and stated they would have this revision surgery again. The overall complication rate was 48%, with half of these reporting pain of >3 on a scale of 10 and 4% of patients requiring additional surgeries.

CONCLUSION

The current study demonstrates high patient satisfaction (88%) and significant improvement in functional outcomes with revision biceps tenodesis, a mini-open subpectoral technique, after previous failed tenodesis or tenotomy. Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. Patients should be counseled on the high complication rate (48%), with persistent pain being the most common complaint.

Latest Trends in Subpectoral Breast Reconstruction

There has been a shift in recent years toward a growing popularity of implant-based breast reconstruction, especially in the setting of increased frequency of concurrent contralateral prophylactic mastectomy. Advancements in implant safety and technology have also allowed for an expanding implant reconstruction practice across the country. The traditional approach is immediate two-stage implant reconstruction with placement of a tissue expander within a subpectoral pocket. The introduction of acellular dermal matrix has revolutionized implant-based breast reconstruction, allowing surgeons the opportunity to minimize morbidity while maximizing aesthetic outcomes. There have also been advances in the management of postoperative pain control as well as secondary revision surgery.

Complications of biceps tenodesis based on location, fixation, and indication: a review of 1526 shoulders

BACKGROUND

Long head of the biceps tendon (LHBT) tenodesis is predominantly performed for 2 reasons: anterior shoulder pain (ASP) or structural reasons (partial tear, dislocation).

METHODS

Between 2006 and 2014, all cases of primary LHBT tenodesis performed at an integrated health care system were retrospectively reviewed. Complications were analyzed by tenodesis location (below or out of the groove [OOG] vs leaving tendon in the groove [ITG]), fixation method (soft tissue vs implant), and indication (preoperative ASP vs structural).

RESULTS

Among 1526 shoulders, persistent ASP did not differ by fixation method (11.0% for implant vs 12.8% for soft tissue, P = .550) or location (10.8% for OOG vs 12.9% for ITG, P = .472). Soft-tissue tenodesis cases had more frequent new-onset ASP (11.9% vs 2.6%, P < .001) and subjective weakness (8.50% vs 3.92%, P < .001) but less frequent revisions (0% vs 1.19%, P = .03) than implant tenodesis cases. No difference was found between ITG and OOG for persistent ASP (12.9% vs 10.8%, P = .550), new-onset ASP (6.5% vs 2.8%, P = .339), cramping (1.70% vs 2.31%, P = .737), deformity (4.72% vs 4.62%, P = .532), or subjective weakness (6.23% vs 4.32%, P = .334), but ITG cases had more revisions (1.51% vs 0.60%, P = .001). Among implant tenodesis cases, 1 shoulder (0.085%) sustained a fracture.

CONCLUSION

The overall complication rate of LHBT tenodesis was low. Of the shoulders, 10.8% to 12.9% continued to have ASP, regardless of whether the LHBT was left ITG. Soft-tissue tenodesis cases had higher rates of new-onset ASP and subjective weakness. No significant difference for tenodesis ITG or OOG was found in biceps-related complications.

The role of fat grafting in prepectoral breast reconstruction

Prepectoral breast reconstruction has reemerged as a promising alternative to submuscular implants, as they place the patient at lower risk for pain, muscular impairment, and animation deformity. However, the thinner amount of overlying tissue in prepectoral reconstruction presents its own unique set of challenges. A "rippling" deformity is seen in some prepectoral patients, which is typically corrected with fat grafting. This report details our recommended technique for fat grafting in the prepectorally implanted patient.

Immediate physical therapy without postoperative restrictions following open subpectoral biceps tenodesis: low failure rates and improved outcomes at a minimum 2-year follow-up

HYPOTHESIS

We aimed to determine patient-reported outcomes in patients undergoing open subpectoral biceps tenodesis with a dual-fixation construct who had no postoperative range-of-motion or weight-bearing restrictions. Our hypothesis was that patients without postoperative restrictions would have low failure rates with improved patient-reported outcomes. We further hypothesized that this technique would allow an earlier return to activity and similar functional outcomes when compared with those reported in the literature.

METHODS

In this institutional review board-approved retrospective outcome study, we evaluated 105 patients who underwent primary open subpectoral biceps tenodesis with a bicortical suture button and interference screw construct without postoperative restrictions. The primary outcome measure was failure of the biceps tenodesis. Postoperative outcome scores included the Short Form 12 (SF-12) Physical Component Score; SF-12 Mental Component Score; American Shoulder and Elbow Surgeons total score and subscales; and Disabilities of the Arm, Shoulder and Hand score.

RESULTS

A total of 98 patients (85%) were available for final follow-up at an average of 3.5 years. There were 2 failures (2.2%), at 5 weeks and 9 weeks postoperatively. Four patients underwent additional surgery unrelated to the previous tenodesis procedure. Final outcome scores indicated high levels of function, including the SF-12 Physical Component Score (mean, 51.5; SD, 7.8), SF-12 Mental Component Score (mean, 54.7; SD, 6.7), American Shoulder and Elbow Surgeons total score (mean, 89.4; SD, 14.2), and Disabilities of the Arm, Shoulder and Hand score (mean, 11.3; SD, 13.4).

CONCLUSION

Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure.

Subpectoral biceps tenodesis using a novel anterior cortical button technique

BACKGROUND

Various surgical treatments are described in the literature for biceps pathology.

METHOD

The techniques currently described for subpectoral tenodesis involve the use of suture anchors, interference screws, bicortical suture buttons or unicortical suture buttons.

RESULTS

A review of 31 patients with a subpectoral biceps tenodesis using the anterior cortical button technique is presented.

CONCLUSIONS

We describe a novel technique, which provides an opportunity to obtain a robust cortical and intramedullary tenodesis, performed under direct vision without the risk of drilling the far cortex and therefore avoiding any potential for neurological injury. There is no cortical implant, which may lead to a diaphyseal stress riser and subsequent fracture risk.

A simple technique for relocating chronic CIED leads to a subpectoral position for relief of erosion and pain

BACKGROUND

Methodology specific for moving superficial chronically implanted transvenous pacing leads to a subpectoral pocket is not described in the literature. Relocation of prepectoral leads and generator to a submuscular pocket for relief of erosion and pain with minimal pectoral trauma is possible by applying a variant of a previously described submammary tunneling technique.

METHODS

All patients presenting for device follow-up, elective battery replacement, or system upgrade over an 8-month period were considered for relocation if experiencing significant thinning or pain over their prepectoral implant. Those selected for relocation then had their system moved subpectorally via the tunneling technique. Patients were followed for 6 months postoperatively for procedurally related complications and resolution of preprocedure symptoms.

RESULTS

Thirty-two leads in 14 patients were all successfully relocated. Of the relocated leads, five (16%) were a three-pin connector implantable cardioverter defibrillator lead. Three patients (21%) in the group required short-term prescription analgesia in the immediate postdischarge period. Pain and erosion concerns abated in the study group by the 3-month follow-up.

CONCLUSIONS

Relocation of superficial pacing leads with CIED generator to a subpectoral pocket facilitated by this tunneling method is successful, safe, and can accommodate single and multipin leads with minimal pectoral trauma and no nerve damage.

A retrospective study of primary breast augmentation: recovery period, complications and patient satisfaction

BACKGROUND

The most critical thing in breast augmentation surgery is to determine the location for implant placement. However, few researches on this were carried out in China. We therefore conducted this retrospective study to compare the recovery period, complications and patient satisfaction at two different implant placement locations-the subglandular plane and the subpectoral plane.

METHODS

A total of 144 patients were included. All of them have undergone primary aesthetic breast augmentation with cohesive silicone gel implant. Then they were divided into two groups according to the implant location: group A (in the subglandular plane) and group B (in the subpectoral plane). Data collected were patient data, surgery-related indicators, recovery, complications and patient satisfaction.

RESULTS

Thirty-nine patients were assigned to group A, and 105 patients to group B. In terms of patient data, no significant difference was found in age, follow-up time and the size of prosthesis between the two groups, but there existed statistically significant difference in body mass index (BMI) and the preoperative mammary tissue thickness (P < 0.05). For surgery-related indicators and recovery, group A was better than group B in surgical blood loss, duration of pain and indwelling drainage tube, with statistical significance (P < 0.05). But regarding the complications, significant difference was found only in the nipple-areola numbness (P < 0.05). Overall, 76% of the patients reported they were "satisfied" with the outcome or the outcome was "perfect".

CONCLUSION

Implant placement in the subglandular plane has a shorter recovery period than that in the subpectoral plane. The occurrence of complications and degree of patient satisfaction are similar in the two groups.

All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii

BACKGROUND

Pathologic changes of the long head of the biceps tendon are a recognized source of shoulder pain in adults that can be treated with tenotomy or tenodesis when nonoperative measures are not effective. It is not clear whether arthroscopic or open biceps tenodesis has a clinical advantage.

HYPOTHESIS

Pain relief and shoulder function after all-arthroscopic suprapectoral biceps tenodesis are similar to outcomes after an open subpectoral tenodesis.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A prospective database was reviewed for patients undergoing an all-arthroscopic suprapectoral or open subpectoral biceps tenodesis. Adult patients with a minimum 18-month follow-up were included. Patients undergoing a concomitant rotator cuff or labral repair were excluded. The groups were matched to age within 3 years, sex, and time to follow-up within 3 months. Pain improvement, development of a "Popeye" deformity, muscle cramping, postoperative American Shoulder and Elbow Surgeons scores, satisfaction scores, and complications were evaluated.

RESULTS

Forty-six patients (23 all-arthroscopic, 23 open) with an average age of 57.2 years (range, 45-70 years) were evaluated at a mean follow-up of 30.1 months (range, 21.1-44.9 months). No patients in either group developed a Popeye deformity or complained of arm cramping. There was no significant difference in mean American Shoulder and Elbow Surgeons scores between the open and all-arthroscopic groups (92.3 vs 88.9; P=.42); similarly, there was no significant difference in patient satisfaction scores between the groups (8.9 vs 9.1; P=.73). Eighteen patients (78.3%) in the arthroscopic cohort and 16 (69.6%) in the open cohort fully returned to athletic activity (P=.50). Eight patients (34.8%) in the arthroscopic group and 10 (39.1%) in the open group reported pain at night or with heavy activities. There were no complications in the all-arthroscopic group. There were 2 complications in the open group that resolved by final follow-up.

CONCLUSION

Biceps tenodesis remains a reliable treatment for pathologic abnormality of the long head of the biceps. Patients undergoing an all-arthroscopic suprapectoral tenodesis in the distal aspect or distal to the bicipital groove showed similar pain relief and clinical outcomes as compared with patients undergoing open subpectoral tenodesis. Open subpectoral biceps tenodesis may carry a higher complication risk secondary to a more invasive technique.

Safety of open suprapectoral and subpectoral biceps tenodesis: an anatomic assessment of risk for neurologic injury

BACKGROUND

Surgical techniques for proximal biceps tenodesis that include penetration of the posterior humeral cortex for fixation may pose risk to the surrounding neurovascular structures.

HYPOTHESIS

The risk of neurologic injury with techniques that involve penetration of the posterior humeral cortex for fixation in proximal biceps tenodesis will increase as the tenodesis site moves proximally from the subpectoral to the suprapectoral location.

METHODS

Proximal biceps tenodesis was performed on 10 cadaveric upper extremities with 3 separate techniques. The proximity of the hardware to the relevant neurovascular structures was measured. The distances between the tenodesis site and the relevant neurovascular structures were measured.

RESULTS

The guide pin was in direct contact with the axillary nerve in 20% of the suprapectoral tenodeses. The distance between the axillary nerve and the tenodesis site was 10.5 ± 5.5 mm for the suprapectoral location, 36.7 ± 11.2 mm in the subpectoral scenario, and 24.1 ± 11.2 mm in the 30° cephalad scenario (P = .003). The distance between the radial nerve and the anterior tenodesis site was 41.3 ± 9.3 mm for the suprapectoral location and 48.0 ± 10.7 mm for the subpectoral location. The distance of the musculocutaneous nerve from the tenodesis site was 28.4 ± 9.2 mm for the suprapectoral location and 37.4 ± 11.2 mm for the subpectoral location.

CONCLUSION

In a cadaveric model of open biceps tenodesis, penetration of the posterior humeral cortex at the suprapectoral location results in proximity to the axillary nerve and should be avoided. Subpectoral bicortical button fixation drilled perpendicular to the axis of the humerus was a uniformly safe location with respect to the axillary nerve.

Analysis of "hidden lesions" of the extra-articular biceps after subpectoral biceps tenodesis: the subpectoral portion as the optimal tenodesis site

BACKGROUND

In biceps tenodesis for intra-articular tears, determining the distal extension of the lesions through the biceps groove is important in choosing the optimal tenodesis site.

PURPOSE

To determine the optimal tenodesis site by analyzing the extension and delamination of an extra-articular lesion, or a "hidden lesion," in the retrieved biceps after subpectoral biceps tenodesis.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 36 subpectoral tenodeses were performed, and the retrieved biceps were analyzed. The biceps lesions were divided into zones according to their location as follows: the proximal intra-articular (zone A), middle intragroove (zone B), and distal extra-articular portions (zone C); the lesions in zones B and C were called "hidden lesions." The length and delamination depth of the biceps tears were examined, and the severity of the accompanying tenosynovitis and degeneration was assessed.

RESULTS

Tears invaded zone B in all the cases and extended to zone C in 28 cases (77.8%). Tenosynovitis was observed along the tear in 28 cases (77.8%) and extended to zone C in 26 cases (72.2%). The mean tear length in the hidden lesions, including the tear and tenosynovitis, was 34.2 mm. Degenerative changes in the proximal intra-articular and middle intragroove portions were observed in all the cases and up to the distal extra-articular portion in 29 cases (80.6%).

CONCLUSION

In approximately 80% of the intra-articular biceps tears evaluated in this study, a "hidden lesion" was observed going beyond the bicipital groove and extending to the distal extra-articular portion. Therefore, the subpectoral portion may be considered the optimal tenodesis site for the complete removal of all hidden biceps lesions.

Anatomy of the sternal origin of the pectoralis major: implications for subpectoral augmentation

BACKGROUND

The pectoralis major typically is manipulated for implant coverage and pocket design in subpectoral breast augmentation. An understanding of its anatomy can guide successful creation of the implant pocket.

OBJECTIVES

The authors evaluated the anatomy of the sternal origin of the pectoralis major to inform surgical planning, help establish a technique for subpectoral augmentation mammaplasty, and identify the most common locations of perforators.

METHODS

The sternal origins of 24 pectoralis major muscles were dissected and examined in 15 female cadavers to determine the structure and width of the pectoralis major sternal origin and its relationship to the locations of internal mammary perforators.

RESULTS

The average width of the sternal origin of the pectoralis major was 7.1 mm (range, 3 mm-1.8 cm). This width decreased slightly from the second rib to the second intercostal space and then increased progressively in the caudal direction toward the fifth rib. The sternal origin terminated an average of 5.4 mm (range, 1-16 mm) from the midline, with the greatest distance at the fifth rib and large variability throughout. A row of perforators from the internal mammary artery traversed the subpectoral space an average of 2.7 cm from the midline (range, 1-3.7 cm).

CONCLUSIONS

The sternal origin of the pectoralis major was thin and highly variable, suggesting that its partial release for implant medialization during subpectoral augmentation is unsafe.

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

Anatomic relationship of the pectoralis major and minor muscles: a cadaveric study

BACKGROUND

Although the anatomy of the individual pectoralis major and minor muscles has been described previously, never before has the anatomic relationship between these muscles been investigated.

OBJECTIVE

The authors identify the anatomic relationship of the costal origins of the pectoralis major and minor muscles.

METHODS

Bilateral thoracic wall dissection was completed in 102 cadavers. In each dissection, the chest wall soft tissue was removed, and the distance between costal origins of the pectoralis major and the pectoralis minor muscles was measured.

RESULTS

In 49 female and 53 male cadavers, 202 pectoralis major muscles were lifted to expose the costal origins of the pectoralis major and minor muscles. Distances between pectoralis major and pectoralis minor muscles were separated into 3 categories: less than 1 cm, between 1 and 3 cm, and greater than 3 cm. Forty-nine (24%) pectoralis muscle dissections displayed a distance of less than 1 cm between costal muscle origins. Eighty-three dissections (41%) showed an intermediate distance of between 1 and 3 cm, while the remaining 70 (35%) were over 3 cm. No significant difference was observed in these percentages with regard to sex. Ten cadavers displayed asymmetry in pectoralis muscle origin distance. Eight specimens displayed shared fibers between pectoralis major and minor muscles.

CONCLUSIONS

The anatomic relationship between the costal origin of the pectoralis major and minor muscles is highly variable. Understanding this spatial relationship has important implications for cosmetic and reconstructive breast surgery.

Recurrent breast cancer in the subpectoral space after implant reconstruction

Breast reconstruction after mastectomy is most commonly performed with a prosthetic implant placed beneath the pectoralis major. Recurrence may rarely be identified in the subpectoral space where the implant was placed. We report a case of recurrent breast cancer after implant-based reconstruction with isolated subpectoral recurrence discovered 5 years later during secondary revision of her reconstructed breast.

Clinical outcomes of revision biceps tenodesis

Purpose:

Biceps tenotomy and tenodesis are effective treatment options for biceps pathology, but outcomes of revision surgery are not known. This study examines the clinical outcomes of patients who have undergone a revision biceps tenodesis.

Materials and Methods:

A retrospective review of all patients since 2004 (N = 21) who had undergone a revision biceps tenodesis with greater than 6-month follow-up was completed. A follow-up survey was carried out, and the visual analog scale (VAS), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and University of California – Los Angeles (UCLA) scores were obtained, along with SF-12 Mental (MCS-12) and Physical Component Summaries (PCS-12).

Results:

Indications for revision surgery were continued pain (14) and ruptured biceps (7). Complete follow-up examinations were performed in 15 of 21 patients (71.4%). Average follow-up was 33.4 ± 23.5 months. The mean postoperative scores were 1.9 out of 10, VAS; 79 out of 100, SANE; 10.2 out of 12, SST; 83 out of 100, ASES; 29 out of 35, UCLA; 44, PCS- 12; and 47.1, MCS- 12. Five patients were considered failures with a UCLA score below 27. Seventeen of twenty-one patient underwent concomitant procedures. Complete preoperative and postoperative data were collected for 14 patients. All scores demonstrated highly significant improvement from preoperative levels (P < 0.005), except for the MCS-12. There was no statistically significant difference in the outcomes of revision due to rupture and revision due to persistent pain.

Conclusions:

The results suggest that revision subpectoral biceps tenodesis provides significant pain relief and improvement in functional outcomes at a mean follow-up of 33.4 months.

Level of Evidence:

Case Series, Level 4.