Biomechanical strain characteristics of soft tissue biceps tenodesis and bony tenodesis

Humerus Fractures After Open Subpectoral Biceps Tenodesis: Three Cases with 2-year Functional Outcome Data and Review of the Literature

CASE

The authors present 3 cases of humerus fracture after biceps tenodesis performed by 3 different surgeons with radiographs and outcome scores with a minimum of 30 months follow-up. Fractures occurred between 7 days and 4 months postoperatively and include 2 fractures where tenodesis had been performed with interference screw fixation and one fracture where tenodesis had been performed with a bicortical endobutton technique.

CONCLUSIONS

These case reports highlight the risk of this complication in biceps tenodesis with bony fixation. The authors review the previously reported cases and relevant biomechanical studies that elucidate risk factors for humerus fracture and discuss alternative means to treat biceps tendon pathology.

A Systematic Review and Meta-analysis of Biceps Tenodesis Fixation Strengths: Fixation Type and Location Are Biomechanically Equivalent

PURPOSE

The purpose of this meta-analysis and systematic review was to critically evaluate the biomechanical outcomes of different fixation constructs for a variety of biceps tenodesis techniques in cadaveric models based on both type of fixation and location.

METHODS

A PROSPERO-registered systematic review (CCRD42018109243) of the current literature was conducted with the terms "long head of biceps" AND "tenodesis" AND "biomechanics" and numerous variations thereof in the PubMed, Embase, and Cochrane databases, yielding 1,460 abstracts. After screening by eligibility criteria, 18 full-text articles were included. The individual biomechanical factors evaluated included ultimate load to failure (in newtons), stiffness (in newtons per millimeter), and cyclic displacement (in millimeters). After reviewing the included literature, we performed a quality analysis of the studies (Quality Appraisal for Cadaveric Studies scale score) and a meta-analysis comparing raw mean differences in data between the suprapectoral and subpectoral fixation location groups, as well as between the fixation construct groups.

RESULTS

Among the 18 included studies, 347 cadaveric specimens were evaluated for ultimate load to failure, stiffness, and cyclic displacement when comparing both location (suprapectoral vs subpectoral) and tenodesis fixation type (interference screw vs cortical button, suture anchor, or all-soft-tissue techniques). Interference screw fixation showed significantly greater mean stiffness by 8.0 N/mm (P = .013) compared with the other grouped techniques but did not show significant differences when evaluated for ultimate load to failure and cyclic displacement (P = .28 and P = .18, respectively). Additionally, no difference in construct strength was seen when comparing the fixation strength of suprapectoral versus subpectoral techniques for stiffness, ultimate load to failure, and cyclic loading (P = .47, P = .053, and P = .13, respectively).

CONCLUSIONS

In this meta-analysis, no significant biomechanical differences were found when the results were stratified by specific surgical technique (interference screw vs other tenodesis techniques) and location (suprapectoral vs subpectoral biceps tenodesis).

CLINICAL RELEVANCE

As a result of this study, when biomechanically evaluating specific tenodesis constructs, the individual clinician has the liberty of choosing the fixation technique based on his or her preference and knowledge of shortcomings of each type of fixation construct.

Intra-articular arthroscopic biceps tenodesis with interference screw: clinical and isokinetic evaluation

Background

Although biceps tenodesis has been widely used to treat its pathologies, few studies looked at the objective evaluation of elbow strength after this procedure. The purpose of this study is to clinically evaluate patients submitted to long head of the biceps (LHB) tenodesis with interference screws through an intra-articular approach and analyze the results of an isokinetic test to measure elbow flexion and forearm supination strengths.

Methods

Patients who had biceps tenodesis were included in the study if they had a minimum follow-up of 24 months. Patients were excluded if they had concomitant irreparable cuff tears or previous or current contralateral shoulder pain or weakness. Postoperative evaluation was based on University of California-Los Angeles (UCLA) shoulder score and on measurements of elbow flexion and supination strength, using an isokinetic dynamometer. Tests were conducted in both arms, with velocity set at 60º/s with 5 concentric-concentric repetitions.

Results

Thirty-three patients were included and the most common concomitant diagnosis were rotator cuff tear (69%) and superior labrum anterior to posterior (SLAP) lesions (28%). The average UCLA score improved from 15.1 preoperatively to 31.9 in the final follow-up (P < .001). Isokinetic tests showed no difference in peak torque between the upper limbs. One patient had residual pain in the biceps groove. None of the patients had Popeye deformity. UCLA score and follow-up length did not demonstrate correlation with peak torque.

Conclusion

Arthroscopic proximal biceps tenodesis with interference screw, close to the articular margin, yielded good clinical results. Isokinetic tests revealed no difference to the contralateral side in peak torque for both supination and elbow flexion.

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.

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.

Editorial Commentary: To Screw or to Sew--Which Is Better for Arthroscopic Biceps Tenodesis?

As the popularity of arthroscopic biceps tenodesis continues to grow, surgeons must choose between performing a soft-tissue tenodesis and performing a bony tenodesis. Although there is no difference in visual analog scale, Constant, or American Shoulder and Elbow Surgeons scores at greater than 2 years' follow-up, elbow flexion strength index and fixation failure rates favor bony tenodesis, important factors to consider when deciding which procedure to perform.

Which Is Better for Arthroscopic Tenodesis of the Long Head of the Biceps: Soft Tissue or Bony Interference Fixation?

PURPOSE

To compare the outcome between arthroscopic soft tissue tenodesis (STT) at the rotator interval and bony interference fixation tenodesis (BIFT) at the distal bicipital groove for the long head of the biceps (LHB).

METHODS

Twenty-five shoulders that underwent arthroscopic STT of the LHB were compared with 28 shoulders that underwent arthroscopic BIFT using a 5.5-mm Bio-Tenodesis screw (Arthrex, Naples, FL). American Shoulder and Elbow Surgeons scores, Constant score, and elbow flexion strength index (EFSI) were checked preoperatively, postoperative 1 year and 2 years. Ultrasound imaging evaluation took place at 1 year and 2 years postoperatively as well.

RESULTS

The overall functional outcomes improved after surgery in both groups. The BIFT group showed a significant increase in EFSI (preop: 0.54, postoperative 2 years: 0.94) compared with that of the STT group (preop: 0.52, postoperative 2 years: 0.74) at postoperative 2 years (P = .006). However, no significant difference was seen in the increase of American Shoulder and Elbow Surgeons scores and Constant scores between the two groups. At postoperative 2 years, ultrasound showed seven empty grooves in the STT group, but only two empty grooves in the BIFT group (P = .046).

CONCLUSIONS

Arthroscopic BIFT for the LHB showed better improvement in EFSI than arthroscopic STT. In addition, the STT group showed a higher failure rate than the BIFT group.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.