Arthroscopic biceps tendon tenodesis: the anchorage technical note

Surgical Treatment of Shoulder Pathologies in Professional Gymnasts: Findings, Treatment, and Clinical Outcomes

Background: This study aims to investigate the impact of shoulder surgery on professional gymnasts through a case series, analyzing the mechanisms of injury and the shoulder lesion patterns, and reporting the clinical outcomes and return to sport. Methods: Twenty-nine surgically treated shoulders in twenty-seven professional gymnasts were retrospectively analyzed. Patients were stratified based on predominant symptoms and anatomical lesions in painful or unstable shoulders. Demographic and injury data, pathological findings, surgical procedure information, and data on time and level of return to sport were collected. Results: The average age of participants was 20.2 ± 3.8 years. Acute traumatic onset was reported in 51.8% of cases. Shoulders were categorized as painful in 13 cases and unstable in 16 cases. The most common pathologies were capsulolabral injuries (72%), biceps injuries (48%), and rotator cuff injuries (40%). All of the athletes returned to training within an average of 7.3 months, while the return to competition rate was 56%, achieved in an average of 10.3 months. The sport-specific subjective shoulder value was 84.8% ± 16.6%. Half of the patients who stopped competition reported reasons related to symptom persistence, while the other half reported personal reasons. No significant difference in the return to sport was reported in the cases of painful or unstable shoulder. Conclusions: Professional gymnasts requiring shoulder surgery commonly present multiple and complex lesions. Returning to training was possible in all cases; however, the possibility of persisting symptoms and other personal factors which may compromise the return to competition should be discussed with the athlete to give them insights into the possible outcomes.

Elite professional goalkeepers report high rate of sport resumption after shoulder surgery

PURPOSE

The aim of this study is to evaluate the return to sport after surgical treatment of shoulder injuries in professional goalkeepers in relationship with the mechanism of injury and the pattern of related shoulder lesions.

METHODS

Twenty-six shoulders in nineteen elite male professional soccer goalkeepers were retrospectively analyzed considering multiple diseases (instability, rotator cuff, biceps or other tendon injuries). Data was collected for injury modality and context, pathological findings, surgical procedures, time, level of return to sport, and complications.

RESULTS

The mechanism of injury was "mild trauma without contact" in 46% of the cases and 54% of injuries happened during training. 11 patients (42%) reported multiple pattern lesions and 9 patients (35%) classic anterior instability lesions. The mean time for return to differentiated training and unrestricted sport activity was 14 and 20.2 weeks, respectively. 15 athletes (62.5%) reported 100% return to sport, 4 (16.7%) to 90%, 1 (4.2%) to 85%, 3 (12.5%) to 80% and 1 athlete to 50%, stopping professional activity. 21% of the cases reported the persistence of some shoulder symptoms. 3 cases experienced a new injury. Patients with classic anterior instability had significantly lower age (30.7 vs 19.8 years, P = 0.001), experienced injury in different context and reported symptoms more frequently compared to multiple lesion patients (4/8 vs 0/10, P = 0.011).

CONCLUSION

Professional elite goalkeepers which required shoulder surgery for different causes demonstrated high-rate level of return to play despite the persistence of mild symptoms. The high frequency of multiple lesions, patients' characteristics, injury context and mechanism, increase the concern for injuries in overstressed shoulder for this category of sport.

LEVEL OF EVIDENCE

IV.

Arthroscopic Suprapectoral Biceps Tenodesis: The "Double Secure Loop Technique" Using an All-Suture Anchor and an Arthroscopic Suture Passer

Although the long head of the biceps tendon is known to resist superior movement of the humeral head in the shoulder joint and assist flexion and supination of the elbow joint, its exact function remains unclear. Moreover, the ideal treatment of lesions of the long head of the biceps tendon such as tendinitis, subluxation, dislocation, and partial or complete rupture remains controversial. Various tenodesis methods have been introduced by many authors. This technique-based article aims to discuss tenodesis as an option for biceps tendon fixation.

Patient-determined outcomes after arthroscopic rotator cuff repair with and without biceps tenodesis utilizing the PITT technique

HYPOTHESIS AND BACKGROUND

The percutaneous intra-articular transtendon technique (PITT) is a simple, rapid, and low-cost method of performing a biceps tenodesis. Few studies exist that examine the patient-determined outcomes of this technique in general or in patients undergoing arthroscopic rotator cuff repair (RCR) with and without biceps tenodesis. We hypothesized that patients undergoing an isolated arthroscopic RCR would have equivalent outcomes to those undergoing RCRs with PITT biceps tenodesis.

METHODS

We compared preoperative, patient-determined outcomes scores on patients undergoing primary arthroscopic RCR with and without a PITT biceps tenodesis with postoperative scores at a minimum of 2 years. These scores included the Western Ontario Rotator Cuff score (WORC), American Shoulder and Elbow Surgeons score (ASES), Single Assessment Numeric Evaluation (SANE), Simple Shoulder Test (SST), and Shoulder Activity Level (SAL). Indication for a concomitant biceps tenodesis was a partial long head biceps tendon tear or biceps instability/subluxation.

RESULTS

A total of 153 patients underwent an isolated RCR and 131 patients underwent RCR with biceps tenodesis (RCRBT). Both groups had improvements in WORC, ASES, SANE, and SST (P < .0001) and deteriorations in the SAL (P ≤ .005). There was no difference in the change in outcome scores between the groups (RCRBT vs. RCR, respectively) for WORC (46 vs. 47; P = .85), ASES (46 vs. 47; P = .82), SANE (53 vs. 51; P = .35), SST (5.8 vs. 5.8; P = .93), and SAL (-0.9 vs. -1.4; P = .46). There was no difference between the groups in complications that required revision surgery (1.5% vs. 1.3%; P = .91).

CONCLUSIONS

Arthroscopic PITT RCRBT is safe and effective with equivalent patient-determined outcomes compared with patients undergoing RCR without biceps tenodesis.

Arthroscopic extra-articular suprapectoral biceps tenodesis with knotless suture anchor

Tenodesis of the long head of the biceps tendon is a frequently performed procedure during shoulder arthroscopy. Various open and arthroscopic techniques have been described with comparable outcomes and complication rates. We describe a simple, knotless, arthroscopic extra-articular biceps tenodesis technique using a 4.5-mm knotless anchor. This technique avoids the complications associated with open tenodesis surgery while still removing the diseased biceps tendon from the bicipital groove. The benefits from knotless suture anchor include no requirement of arthroscopic knot tying and no risk of the knot irritation under the coracoid and coracoacromial ligament.

Arthroscopic proximal versus open subpectoral biceps tenodesis with arthroscopic repair of small- or medium-sized rotator cuff tears

PURPOSE

The study was aimed to compare arthroscopic proximal biceps tenodesis and open subpectoral biceps tenodesis in repair of small or medium rotator cuff tears.

METHODS

Eighty-five patients underwent biceps tenodesis with arthroscopic repair of a rotator cuff tear, and 66 patients were followed for median of 26.8 (18-42) months with ultrasonography were reviewed. The arthroscopic biceps tenodesis group included 34 cases, and the open subpectoral biceps group included 32 cases. Patients were evaluated using visual analogue scale (VAS), American Shoulder and Elbow Surgeons (ASES), and constant scores. Rotator cuff repair and fixation of the biceps tendon were assessed by ultrasonography. Fixation failure and degree of deformity were evaluated by the pain in the bicipital groove and biceps apex distance (BAD).

RESULTS

VAS score and tenderness at the bicipital groove decreased significantly in the open subpectoral group at 3 months postoperative. In both groups, the range of motion, ASES score, and constant score increased significantly (P < 0.05). Rotator cuff retear occurred in three cases (8.8 %) in the arthroscopic group and two cases in the open subpectoral group (6.2 %). There was no significant difference in BAD between the two groups.

CONCLUSION

There was no difference between open subpectoral tenodesis and arthroscopic proximal tenodesis at the time of the final follow-up; however, open subpectoral tenodesis showed encouraging results at 3-month follow-up. This early result of subpectoral tenodesis was related to removing most part of biceps tendinitis and using intra-bicipital groove tenodesis technique.

LEVEL OF EVIDENCE

III.

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.

[New arthroscopic portal for performing tenotomy/tenodesis procedures on the long head of the biceps brachii tendon]

BACKGROUND

Shoulder arthroscopy is the standard technique for performing procedures involving the intertubercular groove. Current techniques continue to produce excessive soft tissue manipulation and neurovascular injury.

MATERIALS AND METHODS

A cross-sectional, observational and descriptive study was conducted on a cohort of 24 shoulders following the standard surgical protocol and using punch dissection. The neurovascular structures with risk of damage by the standard lateral portal were evaluated during the study to establish a secure area for a new arthroscopic portal. Finally, the safety of the new proposed site was evaluated.

RESULTS

The presence of 24 venous structures, with a mean diameter was 1.05mm (SD: 0.71) was documented. A tendency was observed in locating these structures in the lower half of the dissecting field for the left shoulders and a hypovascular area between the 7 and 10hours circle dissected relative to the right shoulder. The new site was determined at a point 1.5 cm anterolateral to the anterolateral border of the acromion at an angle of 60° degrees to the horizontal axis of the acromion and towards the intertubercular groove of the humerus.

CONCLUSIONS

The methodology used in this study is innovative, reproducible and applicable for the study of all existing shoulder arthroscopic portals procedures, as well as any joint. The results provided by this study will be helpful for clinicians to improve tenotomy/tendon tenodesis procedures of the long head of the biceps brachii tendon.

Demographic trends in arthroscopic and open biceps tenodesis across the United States

BACKGROUND

The purpose of this study was to evaluate trends in procedures and to report on demographic data of patients undergoing arthroscopic vs. open biceps tenodesis.

METHODS

A retrospective review of a commercially available database (PearlDiver) was conducted to identify cases of arthroscopic and open biceps tenodesis performed between 2007 and 2011 with concurrent diagnoses of commonly associated shoulder disorders. Each record provided the patient's age, gender, and region within the United States, and statistical significance was determined with respect to each of these demographics.

RESULTS

There were 9011 patients who underwent arthroscopic biceps tenodesis and 11,678 patients who underwent open biceps tenodesis between 2007 and 2011. The number of biceps tenodesis cases increased from 2007 to 2011 (2047 to 5832; P = .015). Both arthroscopic and open biceps tenodesis procedures were performed most commonly in the 30- to 59-year-old age group (76.3% and 76.1%; P < .00001). Men underwent arthroscopic or open biceps tenodesis more commonly than women did (66.1% and 71.9%; P < .00001). Rates of both open and arthroscopic biceps tenodesis varied significantly among the Midwest, South, Northeast, and West regions (P = .009; P = .007); 49.8% of arthroscopic and 44.6% of open biceps tenodesis cases were associated with rotator cuff tears, whereas 14.4% of arthroscopic and 16.2% of open cases were associated with biceps tendon disorders.

CONCLUSION

Both arthroscopic and open biceps tenodesis cases increased annually from 2007 to 2011. The majority of biceps tenodesis cases were performed in men aged 30 to 59 years, and the South had the highest overall number of cases. Further studies are required to evaluate the efficacy of these procedures with and without concomitant pathologic processes.

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.

Long head biceps tenodesis with a knotless cinch suture anchor: a biomechanical analysis

PURPOSE

The purpose of this study was to evaluate the initial fixation strength of 3 techniques of arthroscopic tenodesis of the long head of the biceps (LHB).

METHODS

Eighteen human cadaveric shoulders were randomly assigned to one of 3 simulated arthroscopic biceps tenodesis techniques-simple suture (SS), Krakow stitch (KS), or lasso loop (LL)-combined with a knotless fixation implant (3.5-mm Piton Anchor; Tornier, Minneapolis, MN). Biomechanical parameters were evaluated by cyclic loading and load to failure.

RESULTS

The mean failure load (P = .007) was 158.3 ± 32.2 N, 109.8 ± 41.1 N, and 46.6 ± 3.8 N for the KS, SS, and LL techniques, respectively. Mean stiffness was greater (statistically significant) in the KS (21.4 ± 3.0 N/mm) and SS (20.7 ± 7.9 N/mm) treatment groups compared with the LL group (4.5 ± 1.5 N/mm) (P = .011).

CONCLUSIONS

Biceps tenodesis performed with a more secure tendon suturing technique, such as the Krakow technique, provides superior ultimate and fatigue strength and thus may be more secure in clinical application and yield better clinical results. The mechanical properties of the LL technique were especially poor in comparison.

CLINICAL RELEVANCE

Although more complex suturing techniques for arthroscopic biceps tenodesis can be technically challenging, more secure tendon fixation may improve clinical outcomes.

Trends in long head biceps tenodesis

BACKGROUND

Tenodesis of the long head of the biceps tendon has become a popular surgical treatment option for patients with pain or instability attributed to a diseased or unstable biceps tendon. No previous studies have characterized the practice patterns of surgeons performing biceps tenodesis in the United States.

PURPOSE

To investigate current trends in both arthroscopic and open biceps tenodesis across time, sex, age, and region of the United States as well as associated charges.

STUDY DESIGN

Descriptive epidemiology study.

METHODS

Patients who underwent biceps tenodesis (Current Procedural Terminology [CPT] codes 23430 and 29828) for the years 2008 through 2011 were identified using the PearlDiver Patient Record Database, including both private-payer and Medicare data. These cohorts were then assessed for associated diagnoses using International Classification of Diseases, 9th Revision, codes and concomitant procedures using CPT codes. These searches yielded procedural volumes, sex and age distribution, regional volumes, and average per-patient charges. A χ(2) linear-by-linear association analysis, Student t test, and linear regression were used for comparisons, with P < .05 considered significant.

RESULTS

A total of 44,932 biceps tenodesis procedures were identified from 2008-2011. The incidence of biceps tenodesis procedures per 100,000 database patients increased 1.7-fold over the study period, from 8178 in 2008 to 14,014 in 2011 (P < .0001). An increase in the overall percentage volume was noted in patients aged 60-69 years (P = .039) and 20-29 years (P = .016). The overall charges for arthroscopic tenodesis increased at a rate significantly greater than that of open tenodesis (P < .0001). Rotator cuff tear or sprain, bicipital tenosynovitis, biceps tendon rupture, superior labral lesion, and osteoarthritis were the most common diagnoses associated with biceps tenodesis procedures. A significant increase in isolated biceps tenodesis was also observed over the study period, from 1967 patients in 2008 to 3565 patients in 2011, representing a 1.8-fold increase.

CONCLUSION

The incidence of biceps tenodesis has increased yearly from 2008-2011. Arthroscopic tenodesis has emerged as a more popular technique. Charges associated with the procedure have increased significantly. Significant regional variations in procedural incidences exist.

Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of minimum 2-year clinical outcomes

BACKGROUND

While a vast body of literature exists describing biceps tenodesis techniques and evaluating the biomechanical aspects of tenodesis locations or various implants, little literature presents useful clinical outcomes to guide surgeons in their decision to perform a particular method of tenodesis.

PURPOSE/HYPOTHESIS

To compare the clinical outcomes of open subpectoral biceps tenodesis (OSPBT) and arthroscopic suprapectoral biceps tenodesis (ASPBT). Our null hypothesis was that both methods would yield satisfactory results with regard to shoulder and biceps function, postoperative shoulder scores, pain relief, and complications.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent either ASPBT or OSPBT for isolated superior labrum or long head of the biceps lesions with a minimum follow-up of 2 years were evaluated with several validated clinical outcome measures and physical examinations including range of motion and strength.

RESULTS

Between 2007 and 2011, a total of 82 patients met all inclusion and exclusion criteria, which included 32 patients with ASPBT and 50 patients with OSPBT; 27 of 32 (84.4%) patients with ASPBT and 35 of 50 (70.0%) patients with OSPBT completed clinical follow-up. Overall outcomes for both procedures were satisfactory. No significant differences were noted in postoperative Constant-Murley (ASPBT: 90.7; OSPBT: 91.8; P = .755), American Shoulder and Elbow Surgeons (ASPBT: 90.1; OSPBT: 88.4; P = .735), Single Assessment Numeric Evaluation (ASPBT: 87.4; OSPBT: 86.8; P = .901), Simple Shoulder Test (ASPBT: 10.4; OSPBT: 10.6; P = .762), long head of the biceps (ASPBT: 91.6; OSPBT: 93.6; P = .481), or Veterans RAND 36-Item Health Survey (ASPBT: 81.0; OSPBT: 80.1; P = .789) scores. No significant range of motion or strength differences was noted between the procedures.

CONCLUSION

Both ASPBT and OSPBT yield excellent clinical and functional results for the management of isolated superior labrum or long head of the biceps lesions. No significant differences in clinical outcomes as determined by several validated outcome measures were found between the 2 tenodesis methods, nor were any significant range of motion or strength deficits noted at a minimum 2 years postoperatively.

Increased incidence of postoperative stiffness after arthroscopic compared with open biceps tenodesis

PURPOSE

To determine the incidence of postoperative stiffness after open and arthroscopic biceps tenodesis, compare the incidence between each method, and determine relevant risk factors for its occurrence.

METHODS

A consecutive series of patients who underwent biceps tenodesis during a 3-year period were retrospectively reviewed.

RESULTS

We evaluated 249 patients, which included 143 who underwent open subpectoral tenodesis and 106 who underwent arthroscopic suprapectoral tenodesis. The mean overall follow-up period for the arthroscopic group was 9.9 months (range, 5.1 to 33.5 months). The mean overall follow-up period for the open group was 9.5 months (range, 4.7 to 49.2 months). There was no significant difference in overall follow-up duration between groups (P = .627). A significantly increased incidence of postoperative stiffness was found in the arthroscopic group compared with the open group (17.9% v 5.6%, P = .002). Within the arthroscopic group, patients with postoperative stiffness were more frequently female patients than those without stiffness (63.2% v 33.3%, P = .016) and were more likely to be smokers than those without stiffness (36.8% v 16.1%, P = .040). The tenodesis site was located significantly more proximal in the arthroscopic group of patients with postoperative stiffness compared with patients without postoperative stiffness (32.44 ± 7.8 mm from the top of the humeral head v 50.34 ± 7.8 mm, P < .0001).

CONCLUSIONS

Our results show a notably increased incidence of postoperative stiffness after arthroscopic suprapectoral biceps tenodesis compared with open subpectoral biceps tenodesis. This appears to occur more commonly in female patients and smokers and may have a relation to the position of the tenodesis, with a more superiorly placed tenodesis site being a potential influencing factor. On the basis of this series, this complication most commonly will improve over time and with symptom-based management.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Reliability of the posterolateral corner of the acromion as a landmark for the posterior arthroscopic portal of the shoulder

HYPOTHESIS

The present study aimed to evaluate the variability of the posterolateral corner of the acromion (PCA) position in relation to the glenohumeral joint, in a craniocaudal direction, to assess whether the universal use of a certain distance from that point will always lead to a consistent placement of the posterior arthroscopic portal of the shoulder.

METHODS

The study used 140 dried scapulae (36 women and 34 men). Measurements included the glenoid height and the perpendicular distance between the PCA and the most superior point of the glenoid. The percentage of coverage of the glenoid by the acromion was defined as the ratio between the 2 measurements. The Student t test was used to examine for significant differences between the sexes and the Student paired t test between sides (P < .05).

RESULTS

The average glenoid height was 3.37 ± 0.29 cm (range, 2.69-4.00 cm). The perpendicular distance between the PCA and the most superior point of the glenoid was 0.82 ± 0.69 cm (range, -0.35 to 2.27 cm). The percentage of coverage of the glenoid by the acromion was 24% ± 20% (range, -10% to 64%).

CONCLUSIONS

The position of the PCA in relation to the glenohumeral joint is quite variable. Therefore, the use of a universal distance from the PCA will not always lead to a consistent placement of the posterior arthroscopic portal of the shoulder. Future research is needed in this area to develop techniques to individualize placement of the posterior portal.

Modified subpectoral biceps tenodesis

PURPOSE

The proximal part of the long head of the biceps muscle has become a recognized cause of significant shoulder pain. Tenodesis of the long head of the biceps has been advocated as a treatment for pain resulting from biceps tendonopathy, biceps instability, and biceps tendon tears. All of these pathologies may be encountered during rotator cuff, SLAP or Bankart surgery, or in isolation. Several techniques have been described for this tenodesis, including various arthroscopic and subpectoral methods.

METHODS

We present a modified bone bridge technique of Mazzocca et al., for subpectoral biceps tenodesis. In this technique we tenodese the tendon through two bone tunnels back over the muscle itself without implants.

RESULTS

Application of this technique on 30 patients (ages 25-48 years) with short-term follow-up of 12-18 months showed statistically significant improvement (P value < 0.05) of the mean Constant and Oxford shoulder scores (pre-operative mean scores were 39.03 and 21.3, respectively, while postoperative mean scores were 76.43 and 44.8, respectively).

CONCLUSION

This technique has potential advantages as it allows the possibility of adjusting the tension of the biceps tendon before final suturing, in addition to quicker soft tissue healing.

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.

Anatomy of the biceps tendon: implications for restoring physiological length-tension relation during biceps tenodesis with interference screw fixation

PURPOSE

The purpose of this study was to characterize the normal length and diameter of the long head of the biceps tendon (BT) to provide guidelines for interference screw tenodesis.

METHODS

Twenty-one cadaveric shoulders were dissected. The BT length was measured from its origin to the humeral head articular margin (AM), lower subscapularis, upper pectoralis major, musculotendinous junction of the biceps (MTJ), and lower pectoralis major (LPM). Tendon diameter was measured at levels corresponding to tenodesis: (1) at the AM, (2) suprapectorally, and (3) subpectorally.

RESULTS

The mean tendon length was 24.9 mm from the origin to the AM, 56.1 mm to the lower subscapularis, 73.8 mm to the upper pectoralis major, 98.5 mm to the MTJ, and 118.4 mm to the LPM. The mean tendon diameter was 6.6 mm for tenodesis at the AM, 5.1 mm for suprapectoral tenodesis, and 5.3 mm for subpectoral tenodesis. During biceps tenodesis with interference screw fixation, restoring the normal length-tension relation of the BT depends on the site of tenodesis and the depth of the bone socket. At the AM, a 25-mm bone socket on average will maintain the length-tension relation. For tenodesis more distally, the length of tendon resection varies with bone socket length. Because the MTJ is above the LPM, subpectoral tenodesis should be performed proximal to the LPM.

CONCLUSIONS

This study provides guidelines for restoring the normal length-tension relation during biceps tenodesis with interference screw fixation. The simplest way to restore this relation is with tenodesis adjacent to the humeral head AM and a bone socket of 25 mm in depth. For tenodesis at more distal locations, both the length of the BT and the depth of the bone socket must be considered.

CLINICAL RELEVANCE

Information about the normal BT may be useful in preserving the physiological length-tension relation during biceps tenodesis.

Arthroscopic suprapectoral tenodesis of the long head biceps: reproducing an anatomic length-tension relationship

Tenodesis is an accepted treatment option in the management of pathology involving the long head of the biceps (LHB). Among the common causes for revision surgery after tenodesis are residual pain within the bicipital groove, cramping, early biceps fatigue, and biceps deformity. Most technical descriptions of arthroscopic biceps tenodesis involve fixation of the LHB tendon within or proximal to the intertubercular sulcus and thus fail to address the described sources of pain within this proximal anatomic location. Suprapectoral tenodesis offers the surgeon the ability to remove the LHB from within the bicipital groove by fixating the biceps more distally. Cramping, early fatigue, and biceps deformity have been described when the appropriate length-tension relation of the biceps tendon has not been restored after LHB tenodesis. Our described procedure allows for a more consistent restoration of the anatomic length-tension relation of the LHB, therefore reducing the symptoms associated with this variable. This all-arthroscopic, suprapectoral biceps tenodesis with interference fixation addresses the most common causes for revision surgery and offers a comprehensive solution for LHB pathology.

The long head of biceps as a source of pain in active population: tenotomy or tenodesis? A comparison of 2 case series with isolated lesions

The tendon of the long head of the biceps (LHB) is a common source of pain in the shoulder, and the surgical treatments proposed are tenotomy or tenodesis performed in different ways. The purpose of this study is to compare the clinical results (objective and subjective) of tenotomy versus soft tissue tenodesis. One-hundred and four patients with an isolated LHB pathology, arthroscopically treated between 2004 and 2007, were observed retrospectively. Forty-eight of these patients were treated with tenotomy and 56 with a soft tissue tenodesis technique. All the patients were evaluated by an independent observer with a minimum follow-up of 2 years which included VAS, DASH questionnaire, Constant score and ROM evaluation with a goniometer. All these evaluations were performed pre- and post-operatively. An independent expert radiologist then performed an ultrasound examination only in the post-operative evaluation of the tenodesis group looking to confirm the effectiveness of the procedure. In both groups, the scores were significantly improved. In the tenotomy group, 16.6 % of the patients had bicipital cramps for a mean post-operative time of 1 month. Constant score improved in both groups: 46.6 to 86.1 in tenotomy group and 48.9-84.9 in tenodesis group; VAS improved from 8.4 to 1.5 in tenotomy group and from 8.8 to 1.4 in tenodesis group; DASH scores changed from 42.5 to 13.6 in tenotomy group and from 55.8 to 11.4 in tenodesis group. Popeye sign was present in 37.5 % in the tenotomy group and in 5.3 % in tenodesis group. In 3 patients of the tenodesis group, ultrasound revealed complete failure of the tenodesis. In conclusion, both procedures are effective in terms of treatment of LHB pathologies. Tenotomy does not require specific post-operative treatment and is easy to perform, but cramp and Popeye sign may occur after surgery. The soft tissue tenodesis technique is an easy and cost-effective way to perform tenodesis with good results, especially in preventing the Popeye sign, but requires a longer rehabilitation time. Level of evidence IV.

Full thickness tears: retaining the cuff

Repair of rotator cuff tears is technically challenging. Full thickness rotator cuff tears have no potential for spontaneous healing, no reliable tendons substitutes are available, and their management is only partially understood. Many factors seem to contribute to the final outcome, and considerable variations in the decision-making process exist. For these reasons, decisions are often taken on the basis of surgeon's clinical experience. Accurate and prompt diagnosis is fundamental to guide correct management, and the tear pattern should be carefully evaluated to planning the most appropriate repair.

Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon

Lesions of the long head biceps tendon (LHB) are frequent causes of shoulder pain and disability. Biceps tenotomy and tenodesis have gained widespread acceptance as effective procedures to manage both isolated LHB pathology and combined lesions of the rotator cuff and biceps-labral complex. The function of the LHB tendon and its role in glenohumeral kinematics presently remain only partially understood because of the difficulty of cadaveric and in vivo biomechanical studies. The purpose of this article is to offer an up-to-date review of the anatomy and biomechanical properties of the LHB and to provide an evidence-based approach to current treatment strategies for LHB disorders.

Management of failed biceps tenodesis or tenotomy: causation and treatment

The purpose of this paper is to review the management of long head biceps tendon pathology, with a particular emphasis on a prior failed biceps tenotomy or tenodesis. Failed biceps tenotomy generally results from a lack of thorough preoperative discussion of potential outcomes rather than from technical problems. Patients with unsatisfactory results can be treated with conversion to a biceps tenodesis. Failed biceps tenodesis is usually recognized with persistent pain in the area of the bicipital groove, often caused by either the mechanical failure of the tenodesis or associated shoulder pathology that is not addressed at the time of the primary surgery. Operative treatment options include revision tenodesis or biceps tenotomy. The subpectoral approach provides excellent versatility and ability to meet technical objectives when performing revision tenodesis, by removing the tendon completely from the groove and preserving biceps function.

A new operative treatment for chronic biceps femoris tendon avulsion

In this report, an original technique for augmentation of chronic biceps femoris tendon avulsion is described. The procedure is developed using a reverse fascia flap of biceps femoris to be a single-tailed graft. Then, a suture anchor is inserted on the fibular head to approximate and fix the retracted the biceps femoris. Finally, a tunnel is drilled at the proximal fibula to let the graft pass through, and the end of the graft loop is sutured to itself. This technique confers effective, firm fixation of chronic biceps femoris tendon avulsion.

Biomechanical evaluation of 2 arthroscopic biceps tenodeses: double-anchor versus percutaneous intra-articular transtendon (PITT) techniques

BACKGROUND

Recently, there is increasing interest in different arthroscopic biceps tenodesis techniques. However, little data have been published about the biomechanical properties of soft tissue tenodesis.

PURPOSE

This study was undertaken to evaluate the biomechanical properties of 2 different arthroscopic biceps tenodeses: the percutaneous intra-articular transtendon (PITT) technique and the suture-anchor technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Fifteen fresh-frozen cadaveric specimens were randomly allocated to the 2 different biceps tenodesis techniques. The humerus with biceps tenodesis was mounted on a materials testing machine to perform a load to failure test. The structural properties including ultimate load (N) and stiffness (N/mm) were derived from the load-displacement curve. The mode of failure was also recorded. Ultimate load and stiffness were compared with the parametric Student t test.

RESULTS

Both repairs showed typical load-displacement curves followed by a constant increase in load and displacement until failure occurred. Suture-anchor and PITT techniques had ultimate loads of 175.4 +/- 40.4 N and 142.7 +/- 30.9 N (P = .10) and stiffness of 15.9 +/- 8.4 N/mm and 13.3 +/- 3 N/mm (P = .36), respectively, with no significant differences between them. All of the surgical constructs failed in the tendon site by pulling out with the sutures through the substance of the tendon.

CONCLUSION

The suture-anchor and PITT techniques exhibited satisfactory initial strength with no statistical difference between the 2 groups. These findings, along with the consistent pullout of the suture through the tendon during failure, suggest that the most important factor for initial strength is not the attachment site but the quality of the biceps tendon.

CLINICAL RELEVANCE

The quality of the tendon should be taken into account when deciding the surgical technique and the rehabilitation program. The PITT technique has the benefit of avoiding hardware complications and cost.

Long head of biceps tendon pathology: management alternatives

The role of biceps tendon as a source of shoulder pain and pathology has been well documented in orthopedic literature. Recently, interest in the long head of the biceps tendon has been renewed as its association with subscapularis lesions, superior labral anterior to posterior (SLAP) lesions, rotator cuff pathology, impingement, and pulley or "hidden" lesions of the rotator interval are demonstrated. Advances in imaging and arthroscopy have increased our breadth of knowledge about the anatomy, pathology, and role of the biceps tendon. Management and treatment methods have evolved with improved patient selection and proper diagnosis of long head biceps pathology.

Soft tissue tenodesis of the long head of the biceps tendon associated to the Roman Bridge repair

Background

Rotator cuff tears are frequently associated with pathologies of the long head of the biceps tendon (LHBT). Tenotomy and tenodesis of the LHBT are commonly used to manage disorders of the LHBT.

Methods

We present an arthroscopic soft tissue LHBT tenodesis associated with a Roman Bridge (double pulley – suture bridges) repair

Results

Two medial row 5.5-mm Bio-Corkscrew suture anchors (Arthrex, Naples, FL), double-loaded with No. 2 FiberWire sutures (Arthrex, Naples, FL), are placed in the medial aspect of the footprint. A shuttle is passed through an anterior point of the rotator cuff and through the LHBT by means of a Penetrator or a BirdBeak suture passer (Arthrex, Naples, FL). A tenotomy of the LHBT is performed. All the sutures from the anteromedial anchor are passed through a single anterior point in the rotator cuff using a shuttle technique. All the sutures from the posteromedial anchor are passed through a single posterior point in the rotator cuff. The sutures in the medial row are tied using the double pulley technique. A suture limb is retrieved from each of the medial anchors and manually tied as a six-throw surgeon's knot over a metal rod. The two free suture limbs are pulled to transport the knot over the top of the tendon bridge. The two free suture limbs are then used to produce suture bridges over the tendon, using a Pushlock (Arthrex, Naples, FL), placed 1 cm distal to the lateral edge of the footprint. The same double pulley – suture bridges technique is repeated for the other two suture limbs from the two medial anchors.

Conclusion

This technique allows to perform a double pulley – suture bridges repair for a rotator cuff tear, associated with a soft tissue tenodesis for the management of LHBT pathology. The tenodesis of the LHBT is performed just with the passage of a shuttle inside the LHBT, after passing it through the anterior portion of the rotator cuff, with successive detachment of the LHBT from the glenoid. It is a technically easy procedure which can be performed relatively quickly, and does not require additional fixation.

Arthroscopic biceps tenodesis incorporated into rotator cuff repair using suture anchors

A simple and effective technique is described for incorporating arthroscopic biceps tenodesis into arthroscopic suture anchor rotator cuff repair.

Chondral print on humeral head: an indirect sign of long head biceps tendon instability

Long head biceps (LHB) tendon pathologies are becoming increasingly recognized causes of shoulder pain in the published literature. Instability of LHB presenting as dislocation or subluxation has been recently recognized as a possible cause of disabling pain or discomfort of the shoulder. A clinical diagnosis of LHB instability is very difficult and often confounding because of association with other shoulder pathologies. However, an early diagnosis of LHB instability is important in order to prevent the evolution of lesions of the biceps pulley until an internal anterosuperior impingement of the shoulder (ASI) and subscapular tear occur. The advent of arthroscopy contributed to enhance understandings. The goal of this article is to describe an arthroscopic sign, the chondral print on the humeral head, associated with a LHB instability, that when present can be very useful to help the surgeon to make the diagnosis of unstable LHB tendon.