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

Subpectoral proximal humeral anatomy: Guidance to decrease risk of fracture following subpectoral biceps tenodesis

Background

Biceps tenodesis is used for a variety of shoulder and biceps pathologies. Humeral fracture is a significant complication of this procedure. This cadaveric anatomy study sought to determine the cortical thickness of the humeral proximal shaft to identify the optimal technique to decrease unicortical drilling and reduce the risk of fracture.

Methods

A computed tomography (CT) of eight cadaveric humeral specimens was obtained with a metallic marker placed at the site of subpectoral tenodesis. These scans were examined to define the cortical thickness of the subpectoral region of the humerus and determine angular safe zones for reaming.

Results

At the standard point of a subpectoral tenodesis, a mean angle relative to the coronal plane of 29.2° medially and 21.6° laterally from the deepest portion of the bicipital groove avoided unicortical drilling with a 7 mm reamer. These values varied slightly 1 cm proximal and distal to this level. The thickest regions of cortex in the subpectoral humerus correspond to the ridges of the bicipital groove.

Discussion

To avoid unicortical tunnels, surgeons should limit deviation from the perpendicular approach to no more than 23° relative to the coronal plane medially and 11° relative to the coronal plane laterally.

A Radiostereometric Analysis of Tendon Migration After Arthroscopic and Mini-Open Biceps Tenodesis: Interference Screw Versus Single Suture Anchor Fixation

BACKGROUND

Studies suggest that similar clinical results are achieved via arthroscopic and open biceps tenodesis (BT) techniques.

PURPOSE

To quantify the postoperative migration of the BT construct between arthroscopic suprapectoral BT (ASPBT) and open subpectoral BT (OSPBT) techniques via interference screw (IS) or single-suture suture anchor (SSSA) fixation using radiostereometric analysis.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Distal migration of the biceps tendon after OSPBT with a polyetheretherketone IS, OSPBT with 1 SSSA, ASPBT with polyetheretherketone IS, and ASPBT with 2 SSSAs was measured prospectively. Patients with symptomatic biceps tendinopathy and preoperative patient-reported outcome measures (PROMs) including Constant-Murley subjective, Single Assessment Numeric Evaluation, or Patient-Reported Outcomes Measurement Information System-Upper Extremity scores were included. A tantalum bead was sutured on the proximal end of the long head of the biceps tendon before fixation of tendon tissue. Anteroposterior radiographs were performed immediately postoperatively, at 1 week, and at 3 months. Bead migration was measured, and preoperative PROMs were compared with those at latest follow-up.

RESULTS

Of 115 patients, 94 (82%) were available for final follow-up. IS fixation yielded the least tendon migration with no difference between the open and arthroscopic approaches (4.31 vs 5.04 mm; P = .70). Fixation with 1 suture anchor demonstrated significantly greater migration than that achieved with an IS at both 1 week (6.47 vs 0.1 mm, 6.47 vs 1.75 mm, P < .001;) and 3 months (14.76 vs 4.31 mm, 14.76 vs 5.04 mm, P < .001) postoperatively. Two-suture anchor fixation yielded significantly greater migration than IS fixation at 1 week (7.02 vs 0.1 mm, P < .001; 7.02 vs 1.75 mm, P = .003) but not 3 months postoperatively (8.06 vs 4.31 mm, P = .10; 8.06 vs 5.04 mm, P = .07). Four patients with suture anchor fixation (3 patients in the OSPBT 1 SSSA group, 9.4%, and 1 patient in the ASPBT 2 SSSAs group, 3.8%) developed a Popeye deformity, whereas no Popeye deformities occurred in the IS groups. Mean 3-month bead migration in patients with and without a Popeye deformity was 60.8 and 11.2 mm, respectively (P < .0001). PROMs did not differ among groups at final follow-up.

CONCLUSION

Interference screw fixation yielded the least tendon migration whether achieved arthroscopically or open. The available data indicated that fixation with 1 SSSA but not 2 SSSAs resulted in significantly greater migration than that achieved with an IS. Despite variations in tendon migration, PROMs were similar among all groups. When SSSAs are used, tendon migration may be minimized by using ≥2 anchors.

The high resistance loop (H-loop) technique used for all-inside arthroscopic knotless suprapectoral biceps tenodesis: A case series

Introduction

Suprapectoral tenodesis is a common technique for the treatment of long head biceps tendon lesions. However, so far, there is no gold standard treatment in all-inside arthroscopy. The purpose of the present study was to introduce and evaluate the functional outcomes of an innovative, all-inside arthroscopic high resistance loop (H-loop, high resistance to tissue cutout and 360° grasping of the tendon) technique for long head of biceps (LHB) tenodesis.

Method

From September 2020 to March 2022, a series of cases of 32 consecutive patients (28 rotator cuff tear with LHBT pathology and 4 superior labrum anterior-posterior (SLAP) tears which including 2 type II and 2 type IV) who received LHB tenodesis using all-inside arthroscopic high resistance loop technique were included in this study. The American Shoulder and Elbow Surgeon Score (ASES), Visual Analog Scale (VAS), Simple Shoulder Test Score (SST), Constant–Murley scores, and University of California at Los Angeles Scoring System (UCLA) were used to evaluate the clinical outcomes of patients in preoperative and final follow-up. Meanwhile, postoperative complications were also observed.

Result

32 patients (14 women and 18 men, average age was 55.7 years) underwent all-inside arthroscopic knotless suprapectoral biceps tenodesis using the H-Loop stitch technique. The mean time of follow-up was 16.2 ± 2.6 months. The ASES, VAS, Constant–Murley, SST, and UCLA scores improved from 51.5 ± 15.8, 5.5 ± 1.6, 57.8 ± 14.7, 5.0 ± 2.8, and 16.1 ± 3.8 preoperatively, to 89.1 ± 7.5, 1.0 ± 0.8, 87.3 ± 5.5, 10.4 ± 1.5, and 31.3 ± 2.6 in the last follow-up, respectively (p < 0.001). During the follow-up, no patients in this study experienced postoperative complications such as infection of the wound, injury of nerves, and hardware failure; no patients required revision after their operation. In addition, none of the patients had cramping or a “Popeye” deformity during follow-up.

Conclusion

This article presents an innovative, all-arthroscopic H-loop technique for LHB tenodesis. This technique for LHB tenodesis showed favorable functional and cosmetic outcomes, as well as high satisfaction rates. Due to its simplicity of operation and satisfactory preliminary clinical outcomes, H-loop technique is perhaps another option to choose in all-inside arthroscopic LHB tenodesis.

Reliable Clinical and Sonographic Outcomes of Subpectoral Biceps Tenodesis Using an All-Suture Anchor Onlay Technique

PURPOSE

To evaluate the clinical outcomes and structural integrity of primary subpectoral biceps tenodesis using an all-suture anchor onlay technique for long head of the biceps (LHB) tendon pathology.

METHODS

We conducted a retrospective case series with prospectively collected data of patients who underwent primary, isolated subpectoral biceps tenodesis with a single all-suture anchor onlay fixation between March 2017 and March 2019. Outcomes were recorded at a minimum follow-up of 12 months based on assessments of the American Shoulder and Elbow Surgeons (ASES) score, LHB score, and elbow flexion strength and supination strength measurements. The integrity of the tenodesis construct was evaluated using ultrasound.

RESULTS

Thirty-four patients were available for clinical and ultrasound examination at a mean follow-up of 18 ± 5 months. The mean ASES score significantly improved from 51.0 ± 14.2 points preoperatively to 89.8 ± 10.5 points postoperatively (P < .001). The minimal clinically important difference for the ASES score was 8.7 points, which was exceeded by 31 patients (91.2%). The mean postoperative LHB score was 92.2 ± 8.3 points. Regarding subcategories, an average of 47.2 ± 6.3 points was reached for "pain/cramps"; 26.4 ± 6.1 points, "cosmesis"; and 18.6 ± 2.6 points, "elbow flexion strength." Both elbow flexion strength and supination strength were similar compared with the nonoperated side (P = .169 and P = .210, respectively). In 32 patients, ultrasound examination showed an intact tenodesis construct, whereas 2 patients (5.9%) sustained failure of the all-suture anchor fixation requiring revision.

CONCLUSIONS

Primary subpectoral biceps tenodesis using an all-suture anchor onlay technique for pathology of the LHB tendon provides reliable clinical results and a relatively low failure rate (5.9%).

LEVEL OF EVIDENCE

Level IV, case series.

Management of proximal biceps tendon pathology

The long head of the biceps tendon is widely recognized as an important pain generator, especially in anterior shoulder pain and dysfunction with athletes and working individuals. The purpose of this review is to provide a current understanding of the long head of the biceps tendon anatomy and its surrounding structures, function, and relevant clinical information such as evaluation, treatment options, and complications in hopes of helping orthopaedic surgeons counsel their patients. An understanding of the long head of the biceps tendon anatomy and its surrounding structures is helpful to determine normal function as well as pathologic injuries that stem proximally. The biceps-labral complex has been identified and broken down into different regions that can further enhance a physician’s knowledge of common anterior shoulder pain etiologies. Although various physical examination maneuvers exist meant to localize the anterior shoulder pain, the lack of specificity requires orthopaedic surgeons to rely on patient history, advanced imaging, and diagnostic injections in order to determine the patient’s next steps. Nonsurgical treatment options such as anti-inflammatory medications, physical therapy, and ultrasound-guided corticosteroid injections should be utilized before entertaining surgical treatment options. If surgery is needed, the three options include biceps tenotomy, biceps tenodesis, or superior labrum anterior to posterior repair. Specifically for biceps tenodesis, recent studies have analyzed open vs arthroscopic techniques, the ideal location of tenodesis with intra-articular, suprapectoral, subpectoral, extra-articular top of groove, and extra-articular bottom of groove approaches, and the best method of fixation using interference screws, suture anchors, or cortical buttons. Orthopaedic surgeons should be aware of the complications of each procedure and respond accordingly for each patient. Once treated, patients often have good to excellent clinical outcomes and low rates of complications.

The rate and reporting of fracture after biceps tenodesis: A systematic review

BACKGROUND

The purpose of this systematic review was to (1) define the cumulative humerus fracture rate after BT and (2) compare how often fracture rate was reported compared to other complications.

METHODS

A systematic review was performed using the PRISMA guidelines.

RESULTS

39 studies reported complications and 30 reported no complications. Of the 39 studies that reported complications, 5 studies reported fracture after BT (n = 669, cumulative incidence of 0.53%). The overall non-fracture complication rate was 12.9%.

DISCUSSION

Due to the relatively high incidence of fracture, surgeons should ensure that this complication is disclosed to patients undergoing BT.

Long Head of the Biceps Tendon Ruptures: Biomechanics, Clinical Ramifications, and Management

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Pathology of the long head of the biceps tendon is a common source of shoulder pain and often occurs in combination with other shoulder disorders.

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Nonsurgical management, including rest and activity modification, use of nonsteroidal anti-inflammatory drugs, physical therapy, and corticosteroid injections, is usually the first line of treatment.

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Patients with symptoms that are refractory to nonsurgical management are indicated for biceps tenotomy or various tenodesis procedures.

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Although several studies have reported a higher incidence of "Popeye" deformity, muscle cramping, and pain in the bicipital groove postoperatively with tenotomy compared with tenodesis, there are no substantial differences in functional scores or patient satisfaction between the 2 techniques.

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To date, both tenotomy and tenodesis have been shown to be effective options in the management of long head of the biceps tendinopathy, and there are advantages to each procedure.

Establishing Clinically Significant Outcomes for Patient-Reported Outcomes Measurement Information System After Biceps Tenodesis

PURPOSE

To establish thresholds for improvement in patient-reported outcome scores that correspond with clinically significant outcomes (CSOs) including the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) computer adaptive testing (CAT) and pain interference (PIF) CAT after biceps tenodesis (BT) and to assess patient variables that are associated with achieving these outcomes.

METHODS

After institutional review board approval was obtained, a prospectively maintained institutional database was queried for patients undergoing BT between December 2017 and August 2019. Patients undergoing BT in isolation or BT in conjunction with rotator cuff debridement, SLAP repair, subacromial decompression, or distal clavicle excision were included in the analysis. Anchor- and distribution-based methods were used to calculate the MCID whereas an anchor-based method was used to calculate SCB and the PASS for PROMIS UE CAT and PIF CAT.

RESULTS

A total of 112 patients (86.8% follow-up) who underwent BT were included for analysis. The MCID, net SCB, absolute SCB, and PASS for PROMIS UE CAT were 4.02, 9.25, 43.4, and 41.1, respectively. The MCID, net SCB, absolute SCB, and PASS for PROMIS PIF CAT were -4.12, -10.7, 52.4, and 52.4, respectively. Higher preoperative UE CAT and PIF CAT scores, preoperative opioid use, depression, and living alone were negative predictors of CSO achievement. Male sex and regular participation in exercise were positive predictors of CSO achievement.

CONCLUSIONS

Patients with higher preoperative UE scores were less likely to achieve the MCID (odds ratio [OR], 0.84), whereas patients with higher preoperative PIF scores were less likely to achieve absolute SCB and the PASS (OR, 0.83-0.89). Most patients achieved the MCID for PIF CAT (70.5%) and UE CAT (62.5%) at final follow-up. Male sex (OR, 4.38-9.15) and regular exercise participation (OR, 6.45-18.94) positively predicted CSO achievement, whereas preoperative opioid use (OR, 0.06), depression (OR, 0.23), and living alone (OR, 0.90) were negative predictors of CSO achievement.

LEVEL OF EVIDENCE

Level IV, case series.

Technique of Arthroscopic Suprapectoral Tenodesis of the Long Head of the Biceps With Interference Screw

Tenodesis and tenotomy are the main surgical options to treat different pathologies of the long head of the biceps tendon. Maintaining the functionality of the tendon during tenodesis makes it more preferable surgical option. The consensus on the most advanced tenodesis technique has not been reached. The article presents the arthroscopic all-inside technique of suprapectoral tenodesis of the biceps tendon using the technique of "zone marking" with 2 spinal needles or pins.

Double Tension Slide Technique as a Novel Repair for Distal Biceps Tendon Tear: A Biomechanical Evaluation

Background

A comparative biomechanical analysis of two distal biceps tendon repair techniques was performed: a single suture tension slide technique (TST) and two suture double tension slide (DTS) technique.

Methodology

Ten matched pairs of fresh frozen human cadaveric elbows (20 elbows) were randomly separated into two cohorts for distal biceps tendon repair. One cohort underwent the TST, and the other underwent the DTS technique. The tendon was preconditioned with cyclic loading from 0° to 90° at 0.5 Hz for 3,600 cycles with a 50 N load. The specimens were then loaded to failure at a rate of 1 mm/s. The difference in the load to failure between the groups was analyzed using the Student’s t test. The mode of failure was compared between groups using the chi-square test. All p-values were reported with significance set at p < 0.05.

Results

Overall, 77.8% of the included matched pairs demonstrated greater load to failure in the DTS group. The mean load to failure in the DTS group was 383.3 ± 149.3 N compared to 275.8 ± 98.1 N in the TST group (p = 0.13). The DTS specimens failed at the tendon (5/9), suture (3/9), and bone (1/9). The TST specimens failed at the tendon (4/9) and suture (5/9) only. There was no significant difference in failure type between groups (p = 0.76).

Conclusions

DTS demonstrates a similar to greater load to failure compared to TST with a trend towards statistical significance. The redundancy provided by the second suture has an inherent advantage without compromising the biomechanical testing.

Implant-Free Subpectoral Biceps Tenodesis Is Biomechanically at Higher Risk of Spiral Fracture of the Humerus Compared With Implant-Free Suprapectoral Biceps Tenodesis

Purpose

To compare the likelihood of spiral fracture of the humerus using torsional load to failure after intraosseous biceps tenodesis at the position of the arthroscopic suprapectoral tenodesis versus the subpectoral meta-diaphyseal location.

Methods

Eight matched pairs of humeri were dissected. Unicortical tenodesis holes were drilled, either at the bottom of the bicipital groove (group 1) or just below the pectoralis major tendon insertion (subpectoral) in the humeral diaphysis (group 2). Tenodesis was performed in a 7-mm bone tunnel, with suture fixation distal to this site using 2 separate 2-mm holes, secured with No. 2 polyester suture. Each humerus was potted in plaster and mounted to a hydraulic torsional load frame, consistent with previously validated models for creating humeral spiral fractures. External rotation torque was applied to each humerus distally until fracture occurred. The paired t test was used to compare the 2 groups.

Results

Fracture occurred at the subpectoral cortical drill hole in all 8 specimens in group 2. In group 1, only 2 fractures occurred through the tenodesis hole, with spiral fracture resulting in the diaphysis of the humerus in 6 of 8 specimens. Average torque to failure measured 31.35 Nm in group 1 and 25.08 Nm in group 2; the difference was statistically significant (P < .0001).

Conclusions

Subpectoral cortical drill holes for biceps tenodesis were shown to be a stress riser for humeral spiral fracture. Suprapectoral cortical drill holes were shown to be significantly less of a stress riser. The amount of torque required to fracture the humerus through the subpectoral drill holes was less than with the suprapectoral drill holes. Only 2 fractures occurred through the suprapectoral tenodesis holes, and significantly more torque was required to create these fractures.

Clinical Relevance

Clinically, the difference between suprapectoral and subpectoral tenodesis fracture potential should be considered when selecting a tenodesis location.

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.

KAToB: Knotless All-Arthroscopic Intraarticular Tenodesis of the Biceps, An Efficient, Simple, Reproducible Technique

Biceps tenodesis is a commonly performed procedure. It can be done using a multitude of fixation methods, at multiple locations, and either open or arthroscopic, with little if any clinical differences in the literature. Yet, many techniques have drawbacks in the risk of complications or in the technical ease. Here we present what we have found to be an efficient, simple, reproducible technique: KAToB, Knotless All-arthroscopic intraarticular Tenodesis of the Biceps using a knotless anchor at the articular margin. This technique minimizes the risk of nerve injury, infection, and fracture; has good clinical outcomes; and has a low rate of failure.

All-suture anchor and unicortical button show comparable biomechanical properties for onlay subpectoral biceps tenodesis

Hypothesis

The purpose of this study was to biomechanically evaluate onlay subpectoral long head of the biceps (LHB) tenodesis with all-suture anchors and unicortical buttons in cadaveric specimens.

Methods

After evaluation of bone mineral density, 18 fresh-frozen, unpaired human cadaveric shoulders were randomly assigned to 2 groups: One group received an onlay subpectoral LHB tenodesis with 1 all-suture anchor, whereas the other group received a tenodesis with 1 unicortical button. The specimens were mounted in a servo-hydraulic material testing system. Tendons were initially loaded from 5 N to 100 N for 5000 cycles at 1 Hz. Displacement of the repair constructs was observed with optical tracking. After cyclic loading, each specimen was loaded to failure at a rate of 1 mm/s.

Results

The mean displacement after cyclic loading was 6.77 ± 3.15 mm in the all-suture anchor group and 8.41 ± 3.17 mm in the unicortical button group (P = not significant). The mean load to failure was 278.05 ± 38.77 N for all-suture anchor repairs and 291.36 ± 49.69 N for unicortical button repairs (P = not significant). The most common mode of failure in both groups was LHB tendon tearing. There were no significant differences between the 2 groups regarding specimen age (58.33 ± 4.37 years vs. 58.78 ± 5.33 years) and bone mineral density (0.50 ± 0.17 g/cm² vs. 0.44 ± 0.19 g/cm²).

Conclusion

All-suture anchors and unicortical buttons are biomechanically equivalent in displacement and load-to-failure testing for LHB tenodesis. All-suture anchors can be considered a validated alternative for onlay subpectoral LHB tenodesis.

Fracture Epidemiology in Professional Baseball From 2011 to 2017

Background:

Fractures are a significant cause of missed time in Major League Baseball (MLB) and Minor League Baseball (MiLB). MLB and the MLB Players Association recently instituted rule changes to limit collisions at home plate and second base.

Purpose:

To evaluate the epidemiologic characteristics of fractures in professional baseball and to assess the change in acute fracture incidence secondary to traumatic collisions at home plate and second base after the recently instituted rule changes.

Study Design:

Descriptive epidemiology study.

Methods:

The MLB Health and Injury Tracking System (HITS) database was used to access injury information on MLB and MiLB players to analyze fracture data from 2011 to 2017. Injuries were included if the primary diagnosis was classified as a fracture in the HITS system in its International Classification of Diseases, Ninth Revision, codes; injuries were excluded if they were not work related, if they occurred in the offseason, or if they were sustained by a nonplayer. The proportion of fractures occurring due to contact with the ground or another person in the relevant area of the field—home plate or second base—in the years before rule implementation was compared with the years after.

Results:

A total of 1798 fractures were identified: 342 among MLB players and 1456 among MiLB players. Mean time missed per fracture was 56.6 ± 48.4 days, with significantly less time missed in MLB (46.8 ± 47.7 days) compared with MiLB (59.0 ± 48.3 days) (P < .0001). A 1-way analysis of variance with post hoc Bonferroni correction demonstrated that starting pitchers missed significantly more time due to fractures per injury than all other position groups (P < .0001). Acute fractures due to contact with the ground or with another athlete were significantly decreased after rule implementation at home plate in 2014 (22 [3.0%] vs 14 [1.3%]; P = .015) and at second base in 2016 (90 [7.0%] vs 23 [4.5%]; P = .045).

Conclusion:

The recently instituted rule changes to reduce collisions between players at home plate and at second base are associated with reductions in the proportion of acute fractures in those areas on the field.

Increased Risk of Humeral Fracture With Open Versus Arthroscopic Tenodesis of the Long Head of the Biceps Brachii

Purpose

To determine the risk of postoperative humeral fracture following tenotomy, open tenodesis and arthroscopic tenodesis of the long head of the biceps brachii.

Methods

A retrospective review of deidentified patient data from the Medicare Standard Analytic File using the PearlDiver software was conducted to identify procedures performed between 2005 and 2014. Groups were matched by age, gender, region, and medical comorbidities.

Results

We evaluated 157,163 patients who had undergone arthroscopic or open tenodesis or tenotomy of the long head of the biceps brachii over a 10-year period (2005-2014), and we identified 2,196 postoperative humeral fractures (1.4%). Matched subgroup analysis consisting of 44,292 patients demonstrated a statistically significant increase in humeral fracture risk in open (280; 1.26%) compared to arthroscopic tenodesis (232; 1.04%) with a P value of 0.03 and an odds ratio of 1.21. The majority of fractures were sustained by patients 65-74 years of age.

Conclusion

In this study, an increased risk of postoperative humeral fracture was associated with open tenodesis of the LHB.

Level of Evidence

III, Retrospective Comparative Trial.

Subpectoral Biceps Tenodesis of the Shoulder: Indications and Technique Options

Subpectoral biceps tenodesis of the shoulder may be a useful tool that can address a wide range of disorders in the setting of pathology of the long head of the biceps tendon. Primary indications include (1) zone 2 or zone 3 tendon pathology and (2) failed previous proximal tendon tenodesis. Secondary indications include (1) an overhead athlete or thrower, (2) chronic tendinopathy, and (3) surgeon preference. A subpectoral technique allows tendon fixation directly posterior (deep) to the pectoralis tendon high in the bicipital fossa or in the mid fossa or fixation low in the fossa inferior to the pectoralis tendon (infrapectoral). Fixation technique options include an onlay suture anchor, onlay unicortical button, inlay bicortical button, or inlay interference screw. Potential surgical complications include humeral fracture, loss of fixation, tendon pullout or rupture, and neurovascular injury. Regardless of the specific location or technique used, subpectoral tenodesis is a valuable tool for the treatment of proximal biceps tendon pathology.

Editorial Commentary: Shoulder Biceps Tenodesis Implant Selection Requires Consideration of Complications and Cost

The long head of biceps tendon (LHB) has been evaluated as one of the most important pain generators of the shoulder. In addition, an unstable LHB can cause cartilage lesions of the humerus. For the treatment of LHB lesions, tenodesis or tenotomy has been shown to be appropriate. A well-performed biceps tenodesis provides a lower rate of Popeye-sign deformities compared with tenotomy but must result in low implant complication rates and costs.

Editorial Commentary: Biceps Tenodesis Fixation: Screw, Button, or None of the Above?

Clinical outcomes following shoulder subpectoral biceps tenodesis are generally favorable, with a very low complication rate (2%). One of the most devastating complications following this procedure is the occurrence of a proximal humerus fracture. Although all constructs have their unique advantages and disadvantages, creating a smaller bone hole while achieving good biomechanical outcomes is worth considering. This may be most advantageous in overhead-throwing athletes, tennis players, and/or volleyball athletes, who subject their shoulders to more torsional load due to the requirements of their sport. Thus, in addition to screws and buttons, smaller-diameter suture anchors could also be thoughtfully considered as a biceps tenodesis fixation option.

Distal Biceps Tendon Repair Using a Double Tension Slide Technique

Distal biceps tendon ruptures are thought to be secondary to an acute forceful eccentric load on a degenerative tendon. Nonoperative treatment following rupture leads to significantly decreased forearm supination and elbow flexion strength. There are several techniques described in the literature for repair. This article describes, with video illustration, distal biceps tendon repair using a double tension slide technique with 2 No. 2 high-tension nonabsorbable composite sutures.

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.

A biomechanical comparison of two arthroscopic suture techniques in biceps tenodesis: whip-stitch vs. simple suture techniques

BACKGROUND

The aim of this study was to compare the biomechanical performance of whip-stitch (WS) and simple suture techniques (SST) of the long head of the biceps tendon in suprapectoral intraosseous tenodesis with interference screw fixation.

METHODS

A total of 10 paired cadavers (61.1 ± 4.6 years) were randomized to receive WS or SST biceps tenodesis beginning at the musculotendinous junction. Both groups implemented a No. 2 FiberLoop wire and underwent suprapectoral fixation with a polyetheretherketone interference screw at the bicipital grove. A Materials Testing System performed cyclic testing (500 cycles), followed by load to failure at 1 mm/s. Load, displacement, and time were recorded during cyclic and failure testing. A 2-tailed Student's t-test and χ² analysis were performed for failure load and mode of failure, respectively.

RESULTS

Two SST specimens and 1 WS specimen failed during cyclic loading via tendon rupture at the screw-tendon interface. There was no significant statistical difference in the cyclic displacement after 500 cycles between the WS (12.9 mm ± 4.4 mm) and SST groups (14.0 mm ± 3.8 mm, P = .2); cyclic strain, defined as the peak displacement at the 500th cycle divided by the initial gauge length, between the WS (0.4 ± 0.2) and SST groups (0.7 ± 0.7, P = .3); maximal load (162.7 N ± 56.8 N vs. 153.1 N ± 39.3 N, respectively, P = .6); and stiffness (50.5 N/mm ± 17.7 N/mm vs. 43.3 N/mm ± 10.9 N/mm, respectively, P = .3). All specimens ruptured at the screw-tendon interface.

CONCLUSION

The WS technique can provide equivalent biomechanical performance to the SST in suprapectoral intraosseous biceps tenodesis with interference screw fixation.

Editorial Commentary: Size Matters: Biomechanical Analysis of All-Suture Suture-Anchor Fixation Compared to Conventional Suture Anchors and Interference Screws for Biceps Tenodesis

Anchors and screws demonstrate similar fixation properties for shoulder biceps tenodesis allowing healing, but anchors requiring smaller drill holes reduce the risk of postoperative fractures under torsional stress. Clinicians could create the smallest possible holes in the humerus, especially in throwing athletes who create large torsional stresses.

Editorial Commentary: Silly Biceps, Tenodesis Is for Kids!

There is now a strong consensus that the best surgical treatment of a SLAP lesion is often something different from a primary direct repair, especially in older patients in whom postoperative stiffness and persistent pain have led most of us to perform a biceps tenodesis instead. However, treatment of younger patients and especially the overhead athlete group is more problematic and thus controversial. This study demonstrates that biceps tenodesis in these patients can be more successful and have a higher return to sport than SLAP repair alone. There may also be a role for biceps tenodesis AND a SLAP repair but the numbers presented in this paper preclude an analysis of exactly who that group is. When it comes to the treatment of patients with SLAP lesions for whom a very well executed rehabilitation program has failed, understanding the symptoms and demographics of your patients is critical to surgical decision making. The pendulum may swing toward tenodesis, but beware: The correct answer is usually near the center of the arc!

Incidence and Characteristics of Humeral Shaft Fractures After Subpectoral Biceps Tenodesis

Background:

Biceps tenodesis is a procedure that can address biceps and labral pathology. While there is an increased risk of humeral fracture after biceps tenodesis, it has been described only in case reports.

Purpose:

To identify the incidence, demographics, and characteristics of humeral shaft fractures after biceps tenodesis.

Study Design:

Case series; Level of evidence, 4.

Methods:

The US Military Health System Data Repository was searched for patients with a Current Procedural Terminology code for biceps tenodesis between January 2013 and December 2016. The cohort of identified patients was then searched for those assigned a code for humeral fracture per the International Classification of Diseases, 9th Revision and 10th Revision. The electronic health records and radiographs of patients who were diagnosed with a humeral fracture were then evaluated to confirm that the fracture was related to the biceps tenodesis. Records were then reviewed for patient demographics, radiographs, operative reports, and clinical notes.

Results:

A total of 15,085 biceps tenodeses were performed between January 2013 and December 2016. There were 11 postoperative and 1 intraoperative humeral fractures. The incidence of fracture was <0.1%. All fractures were extra-articular spiral fractures that propagated through the tenodesis site. Eight patients were treated with functional bracing, 3 with open reduction and internal fixation, and 1 with a soft tissue biceps tenodesis revision. Of 8 patients successfully treated nonoperatively, 6 regained full range of shoulder motion. Only 2 of the 4 patients who required operative treatment regained full range of shoulder motion.

Conclusion:

Humeral shaft fracture after biceps tenodesis is a rare complication that occurs in 7.9 out of 10,000 cases. Fractures occurred after various methods of fixation, including suture anchor, cortical button, and interference screw. Most patients were initially treated nonoperatively, and those who healed usually achieved full range of motion; however, those who required operative intervention often had restricted range of motion on final follow-up. Future studies should determine risk factors for fracture after biceps tenodesis.

The X-Pulley Technique for Subpectoral Long Head of the Biceps Tenodesis Using All-Suture Anchors

Subpectoral long head of the biceps tenodesis is gaining popularity as a technique for treating patients with various pathologies of the tendon or its anchor to the superior labrum. It has the added advantage of addressing bicipital groove pathologies. Various techniques for performing it have been described, but none is without problems. We present a modification of the previously described techniques that involves 2 all-suture anchors and offers the added advantage of a reduced risk of fracture without sacrificing the biomechanical strength of the construct. We also believe that it may potentiate healing by providing an adequate surface contact area between the tendon and bone with a minimal risk of damage to the tendon and neurovascular structures.

Editorial Commentary: How Can I Tenodese the Biceps Tendon of the Shoulder? Let Me Count the Ways

The debate regarding the management of long head of the biceps tendon pathology continues to evolve. Previous literature has compared tenotomy and tenodesis, tenodesis above or below the pectoralis major tendon, tenodesis to bony or soft tissue sites, and a host of fixation methods. Recent research compares biomechanical fixation between an all-suture anchor and interference screw for arthroscopic tenodesis. Although the methods have similar biomechanical properties, time-zero cadaveric data has inherent limitations, and importantly, there is a substantial cost differential between these and other implants that surgeons should also consider when choosing a tenodesis method.

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

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