Arthroscopic Biceps Tenodesis Using Interference Screw Fixation in the Bicipital Groove

Biomechanical properties of suprapectoral biceps tenodesis with double-anchor knotless luggage tag sutures vs. subpectoral biceps tenodesis with single-anchor whipstitch suture using all-suture anchors

Background

As the use of all-suture anchors continues to increase, limited biomechanical data on the use of these anchors in various configurations for tenodesis of the long head biceps tendon (LHBT) exists. The aim of this study was to compare the biomechanical properties of a 2-anchor luggage tag suprapectoral biceps tenodesis (Sup-BT) vs. a single-anchor whipstitch subpectoral biceps tenodesis (Sub-BT) using all-suture anchors. The hypothesis was that the Sub-BT will have a higher ultimate load to failure and less creep relative to the Sup-BT construct.

Methods

Eighteen fresh frozen cadaveric humeri were used. The specimens were randomly divided into 2 groups of 9; i) The Sup-BT were performed with 2 1.8 mm knotless all-suture anchors using a luggage-tag fixation configuration, ii) The Sub-BT were performed using a single 1.9 mm all-suture anchor and a whipstitch suture configuration with a tied knot. The humeri were tested on a hydraulic MTS machine where the specimens were preloaded at 5 N for 2 minutes and then cyclically loaded from 5 to 50 N for 1000 cycles at 1 Hz while maximum displacement was recorded with a motion system and markers attached to the bone and bicep tendon. The tendon was then tensioned at a rate of 1 mm/s to obtain the ultimate load to failure. CT scans of the specimens were used to calculate the bone mineral density at the site of the anchor/bone interface and video recordings were captured during load to failure to document all modes of failure.

Results

There was no significant difference in the average load to failure of the Sup-BT and Sub-BT groups (197 N ± 45 N (SD), 164 N ± 68 N (SD) respectively; P = .122) or creep under fatigue between the Sup-BT vs. Sub-BT specimens (3.1 mm, SD = 1.5 vs. 2.2 mm, SD = 0.9; P = .162). The bone mineral density was statistically different between the 2 groups (P < .001); however, there were no observed failures at the anchor/bone interface and no correlation between failure load and bone mineral density.

Conclusion

The ultimate load to failure and creep between a Sup-BT with 2 knotless all-suture anchors using a luggage tag suture configuration was equivalent to a Sub-BT with 1 all-suture anchor using a whipstitched suture configuration and a tied knot. Surgeons can perform either technique confidently knowing that they are biomechanically equivalent in a cadaver model at time zero, and they offer similar strength to other fixation methods cited in the literature.

The Digitation Sign Facilitates Diagnosis of Shoulder Subscapularis Lesions on Preoperative Magnetic Resonance Imaging

Purpose

The purposes of this study were to investigate a radiographic sign found on coronal magnetic resonance imaging (MRI) sequences in subscapularis (SSC) pathology, reporting interobserver reliability data and sensitivity and specificity; and to correlate the preoperative assessment of SSC pathology with intraoperative assessment of the SSc during shoulder arthroscopy.

Methods

A consecutive series of patients undergoing arthroscopic rotator cuff repair from January 2020 to December 2020 were examined. The positive diagnosis of a subscapularis tendon tear was prospectively determined and confirmed by arthroscopy. The “digitation sign” was assessed by 3 independent shoulder-trained fellows when evaluating the SSC in the coronal plane on T2-weighted images.

Results

Of the 132 patients included, 74 (56%) had SSC tendon tears confirmed during arthroscopy. Interobserver agreement for digitation sign was substantial (k= 0.640). Sensitivity for digitation sign only was 74.3%; for criteria of Adams et al. (Accuracy of preoperative magnetic resonance imaging in predicting a subscapularis tendon tear based on arthroscopy; Arthroscopy 2010;26:1427-1433) only, 83.8%; and for the combination of the 2 methods, 89.2%. Specificity was 84.5% for digitation sign only, 77.6% for Adams et al. criteria only, and 67.2% for the combination of the 2 methods. Sensitivity is statistically better when the digitation sign is added to the Adams et al. criteria for detection of SSC lesions. As expected, specificity is statistically lower. SSC tears are significantly associated with biceps lesions.

Conclusion

Preoperative systematic MRI evaluation by shoulder surgeons can diagnose subscapularis lesions by using the digitation sign in the coronal plane along with Adams et al. criteria, leading to good sensitivity. This easy-to-apply sign can be helpful in the initial MRI evaluation in the coronal plane, with improved sensitivity when combined with a systematic approach.

Level of Evidence

II, study of diagnostic test.

The "Sandwich Tenodesis": An Arthroscopic Technic for Combined Soft-Tissue and Bony Fixation of the Long Head of the Biceps

Pathology of the long head of the biceps can contribute to substantial shoulder pain. After nonoperative treatment has failed, either open or arthroscopic tenotomy or tenodesis can be recommended depending on age, occupation, function, and cosmetic preference. While classic tenodesis techniques rely on tendon-to-bone fixation, multiple studies have shown superior healing results for fixation between similar types of tissue, such as tendon-to-tendon. In this technique, we present the "sandwich technique," performed entirely arthroscopically. A single 4-strand anchor with bioabsorbable screw is used to provide 2 types of fixation. Two strands are first used to lasso-loop the long head of the biceps to the bicipital groove, providing bone-to-tendon fixation. The other strands are then used to anchor rotator interval tissue to the tendon, providing a similar tissue or tendon-to-tendon patch augmentation.

Diagnostic value of the hourglass biceps test for the detection of intra-articular long head of the biceps hypertrophy

Background

Shoulder surgeons performing tenodesis note a great variability in morphology of the proximal biceps. The hourglass biceps test measures the integrity of the intra-articular biceps tendon. The hourglass maneuver (HM) is positive when there is a passive flexion deficit compared to the contralateral shoulder in a relaxed patient in the supine position.

Hypothesis

Preoperative HM is correlated with an increased width of the biceps portion resected during tenodesis.

Methods

This prospective study evaluated all patients (N = 58) who underwent biceps tenodesis between January and September 2019. Two groups of patients were compared: group 1 (n = 20) had a positive HM and group 2 had a negative HM (n = 38). The smallest (s) and largest (L) width of the tendon were measured intraoperatively, and the L/s ratio was calculated. The HM was then evaluated as a diagnostic test by creating a contingency table and determining the sensitivity and specificity of the test for different L/s ratios. A receiver operating characteristic curve was created and the area under the curve (AUC) was calculated.

Results

A nonsignificant difference was found between the mean largest biceps width in group 1 compared to group 2 (11.65 mm [range: 5-21] vs. 9.71 mm [range: 6-20], respectively; P < .05). The AUC was 0.81; the sensitivity was 68.9% and specificity, 80.8%.

Conclusion

Preoperative positivity of the HM is linked to the increased width of the biceps portion resected during tenodesis. The hourglass biceps test should be predictive of intraoperative hourglass biceps according to our definition.

Magnetic resonance arthrography is insufficiently accurate to diagnose biceps lesions prior to rotator cuff repair

PURPOSE

To evaluate the diagnostic accuracy between magnetic resonance arthrography (MRA) and arthroscopic examination for the assessment of pathologies of the long head of the biceps (LHB) prior to rotator cuff (RC) repair. The hypothesis was that MRA is suitable to identify biceps instabilities, due to improved visibility of the biceps pulley.

METHODS

Sixty-six patients aged 58.5 ± 17.6 (range, 46-71) scheduled to have RC repair between 2016 and 2017 were prospectively enrolled. MRA images of the LHB were interpreted by one radiologist and two surgeons, then compared to arthroscopic findings. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated by comparing MRA axial readings to arthroscopic assessment in the neutral position (static instability), MRA sagittal readings to arthroscopic assessment in external rotation (dynamic s instability), MRA coronal and axial readings to arthroscopic assessment in the neutral position (tendinopathy).

RESULTS

Among the three observers, the radiologist obtained the highest sensitivity and specificity for MRA, which were respectively: (1) for static instability, 62% (C.I. 35-85) and 77% (C.I. 63-88); (2) for dynamic instability, 50% (C.I. 29-71) and 62% (C.I. 46-77), and (3) for tendinopathy, 49% (C.I. 36-62) and 100% (C.I. 3-100).

CONCLUSIONS

MRA is not suitable for the diagnosis of LHB lesions prior to arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Diagnostic study, Level I.