Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients

No clinical difference in outcomes between inlay and onlay arthroscopic biceps tenodesis techniques during rotator cuff repair

BACKGROUND

Both inlay and onlay arthroscopic biceps tenodesis (ABT) are common procedures performed during rotator cuff repair. The inlay method involves creating a bone socket in the bicipital groove to secure the long head of the biceps tendon using an interference screw. The onlay method utilizes a suture anchor to secure the long head of the biceps tendon on the surface of the bicipital groove. Little is known on the long-term differences in patient-reported outcomes between these 2 techniques. The primary purpose of this study was to compare patient-reported outcomes of inlay vs. onlay ABT with a minimum follow-up of 2 years. Secondary aims were to evaluate the impact of rotator cuff tear size on outcomes and compare rates of complications between the 2 techniques.

METHODS

A retrospective chart review was performed to identify patients who had an ABT during a full-thickness rotator cuff repair. Any symptom specific to the biceps were noted, including pain and cramping, Popeye deformity, or revision surgery. Complication rates were compared between groups. The visual analog scale pain score, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation, and Veteran's RAND-12 score (VR-12) scores were compared at 2 years. The impact of rotator cuff tear size was analyzed by categorizing into small/medium or large/massive based on operative reports and arthroscopic images.

RESULTS

There were 165 patients identified (106 in the inlay group and 59 in the onlay group). No revision surgeries were performed secondary to the biceps tendon in either group. Eleven patients (10%) in the inlay group complained of biceps pain or cramping compared to 2 patients (3%) in the onlay group (P = .11). One Popeye deformity was noted in each group (P = .67). No significant differences were found between groups for visual analog scale (P = .41), ASES functional (P = .61), ASES index (P = .91), Single Assessment Numeric Evaluation (P = .09), VR-12 Physical Component Score (P = .77), or VR-12 Mental Component Score (P = .09). Rotator cuff tear size within the groups also did not demonstrate statistical significance.

CONCLUSION

No clinical differences or complications were found at minimum 2-year follow-up between inlay and onlay ABT in patients undergoing rotator cuff repair when controlling for tear size. The clinical relevance suggests either technique is effective and can be based on surgeon preference.

Arthroscopic biceps tenodesis using press-fit bony plug: a case series study

PURPOSE

To assess the feasibility, operative time, clinical outcomes, possible complications, and failure rates of all-through arthroscopic biceps tenodesis using press-fit bony plug technique.

METHODS

This prospective case series study involved 30 skeletally mature patients with long head of biceps pathology (tendinitis after failure of conservative treatment, subluxation, dislocation, or tendon tears). All patients were followed up for 24 months at least.

RESULTS

Twenty-nine patients regained full shoulder and elbow range of motion; one case suffered from reflex sympathetic dystrophy. There was a significant improvement in the constant, ASES, and VAS scores when comparing the pre-operative and post-operative values. The average biceps strength was 96% compared to the opposite healthy side. No cases were complicated by neuro-vascular deficits or failure of the tenodesis.

CONCLUSION

Press-fit biceps tenodesis is safe and accessible with low economic demands. We recommend this technique to be used more often when addressing patients with long head of biceps pathologies.

REGISTRATION DATA

Registration number: N-1562023. Registration date: June 2022 "Retrospectively registered".

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.

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.

Subpectoral Biceps Tenodesis Using an All-Suture Knotless Anchor

The long head of the biceps tendon is a common pain generator in the anterior shoulder and is concomitantly seen with other shoulder pathology including subacromial impingement, as well as rotator cuff and labral tears. This Technical Note describes a mini-open onlay biceps tenodesis technique using all-suture knotless anchor fixation. This technique is easily reproducible, is efficient, and offers the unique benefits of providing a consistent length-tension relation and mitigating the risk of peri-implant reaction and fracture without sacrificing strength of fixation.

Bi-Cortical transhumeral drilling for biceps tenodesis - Is it safe?

Background

Biceps tenodesis is an effective procedure performed to treat shoulder pain originating from the long head biceps tendon. In arthroscopic biceps tenodesis unicortical drilling of the humerus is more commonly practiced as it is considered safe to the vital structures lying posterior to the proximal humerus. Many surgeons are wary of the bi-cortical approach as it poses a risk to these vital structures. The aim of this study was to establish whether bi-cortical drilling in proximal humerus is safe or not. Our second purpose was to find a safe zone (if any) for bi-cortical drilling if bi-cortical drilling is safe.

Methods

This study is a descriptive study conducted on cadaveric shoulders. Bilateral shoulders and arms of ten fresh-frozen cadavers (mean age 77.7 y) were dissected. Four landmarks in the dissected humerus were identified. They were superior margin of the bicipital groove, center of the bicipital groove, upper and lower border of pectoralis major insertion. Bi-cortical trans-humeral pinning was done in the humerus at all these points so that the pin exited through the posterior cortex of the humerus. The shortest distance between the pin and the nearest vital structure namely axillary nerve, radial nerve, articular surface of the humeral head, and cephalic vein was calculated from each fixed landmark.

Results

We established that bi-cortical drilling in proximal humerus was safe. The safe zone established for bi-cortical biceps tenodesis is at the middle of bicipital groove, which is 18.00 ± 4.02 mm inferior to the groove's upper border. The boundaries of the safe zone lie 9.39 mm superiorly and 9.40 mm inferiorly to the middle of the bicipital groove.

Conclusion

The center of the established safe zone for bi-cortical trans-humeral pinning was 18 mm inferior to the bicipital groove's upper border.

High Rate of Return to Sporting Activity Among Overhead Athletes With Subpectoral Biceps Tenodesis for Type II SLAP Tear

PURPOSE

To evaluate the functional and athletic outcomes after primary subpectoral biceps tenodesis for type II SLAP tear in overhead athletes.

METHODS

All competitive elite athletes with type II SLAP tears undergoing biceps tenodesis by a single surgeon were isolated between 2007 and 2015. Exclusion criteria were applied to individuals not involved in overhead athletics, clinical follow-up <24 months, adjacent rotator cuff or labral repair, concomitant SLAP repair, and/or previous arthroscopic shoulder surgery. Patient-reported outcome measures included visual analog scale (VAS), Kerlan Jobe Orthopaedic Clinic shoulder score, and Single Assessment Numerical Assessment. Clinical and sporting outcomes were recorded using a sports-specific questionnaire.

RESULTS

Of 22 identified patients, 16 competitive overhead athletes (72.7%; 11 men, 5 women) with a mean age of 21.0 years were available at mean 4.5-year follow-up. Baseball or softball comprised the majority of patients (n = 9; 56.3%), followed by gymnastics (n = 2), swimming (n = 2), and other sports (n = 3). At mean 4.1 months postoperatively, 13 patients (81.3%) returned to previous level of athletic activity, whereas 2 patients (12.5%) failed to return to sporting activity and 1 (6.3%) returned at a lower level of competition. VAS pain significantly decreased from an average of 4.4 preoperatively to 1.7 postoperatively (P = .002), and mean Single Assessment Numerical Assessment scores also demonstrated significant improvement (55.4-76.7; P = .008). Final mean Kerlan Jobe Orthopaedic Clinic score was 74.0 (standard deviation 25.9), including 2 patients with suboptimal outcomes due to persistent pain. There were no significant differences in mean forward flexion or rotation in either the adducted or throwing position (P > .05), although small, significant decreases in postoperative active abduction were noted (165° vs 155°; P = .003).

CONCLUSIONS

In the current series of competitive overhead athletes, 81% of patients returned to previous level of play at an average of 4.1 months postoperatively after subpectoral biceps tenodesis for symptomatic SLAP tear. Athletes reliably experienced significant decreased activity-related pain with athletic function.

LEVEL OF EVIDENCE

IV, case series.

Onlay Versus Inlay Biceps Tenodesis for Long Head of Biceps Tendinopathy: A Systematic Review and Meta-analysis

INTRODUCTION

Proximal biceps tenodesis is a common surgical treatment of tendinosis of the long head of the biceps tendon. Two of the most common techniques incorporate onlay and inlay fixation methods, which can be done arthroscopically or open and in a variety of anatomic locations. The purpose of this meta-analysis was to compare the clinical outcomes between onlay versus inlay humeral fixation for biceps tenodesis for long head of the biceps tendon pathology.

METHODS

A literature search was conducted using PubMed, EMBASE, and Cochrane Library. Only studies reporting outcomes and complications after onlay and inlay biceps tenodeses were included.

RESULTS

Six studies with a total of 418 patients (252 onlay, 166 inlay) with a mean age of 56.84 years were included. Visual analog pain scale scores, Constant score, and American Shoulder and Elbow Surgeons shoulder score did not differ. "Popeye" deformity was found in 17 patients (7.80%) in the onlay group and in 15 patients (11.28%) in the inlay group (odds ratio, 0.28; P = 0.07). No difference in postoperative cramping or failure rates was found.

CONCLUSION

Both onlay and inlay biceps tenodeses result in improved clinical outcomes and are at low risk of Popeye deformities, with no statistically significant differences between either method. Additional studies are required to assess the clinical significance of these differences.

Open Subpectoral Tenodesis for Isolated Traumatic Long Head of Biceps Tendon Rupture Provides Excellent Functional Outcomes in Active Male Patients

Background: For many years the long head of biceps tendon (LHBT) rupture has been described and is commonly identified by weakness, cramping, and the so-called "Popeye" sign. Traditionally, this was treated non-operatively, likely reflecting patient factors and the technical difficulty in reattaching a degenerative and shortened tendon. In contrast, traumatic distal biceps rupture is now commonly repaired despite historically being managed non-operatively. The advent of a convenient and reproducible surgical technique led to an increase in the rate of fixation, thereby improving the cramping and weakness associated with non-operative treatment. Given recent surgical advances within this field, many techniques are now present for LHBT pathology. We describe results from a cohort of patients suffering traumatic LHBT rupture who sought a surgical solution to improve their symptoms.

Methods: Over four years, 18 male patients underwent surgical intervention for isolated traumatic LHBT rupture. The technique used involved an open subpectoral tenodesis with fixation of the LHBT into the bicipital groove. Postoperative immobilization using a sling was recommended for six weeks prior to a progressive rehabilitation program. Patients were assessed with pre- and postoperative visual analog scores (VAS) for pain and American Shoulder and Elbow Society (ASES) scores.

Results: The mean patient age at the time of surgery was 49 years (range: 26-65 years). The mean time to surgery was nine weeks (range: 2-24 weeks). All patients showed an improvement following surgery with a mean pre-op ASES score of 33 (range: 10-60) compared to a post-op score of 92.6 (range: 85-100). All patients were able to return to work and sport, with all but one returning to the same functional demand level of work. The mean pre-op pain VAS was 6.3 (out of 10) compared to 0.2 post-op. All patients had a requirement for analgesia pre-operatively and none had postoperatively. No surgical complications were observed. No correlation was observed between the time to surgery and the outcome.

Discussion: LHBT rupture is often treated non-operatively as few studies within the literature describe the surgical technique and outcomes from surgical intervention. When treated non-operatively, patients complain of pain, cramping, and cosmetic deformity known as the "Popeye" sign. Following a traumatic rupture of the LHBT, we have demonstrated excellent outcomes using a standard approach and common fixation technique that has the potential to improve the functional outcome for symptomatic patients.

Conclusion: Open subpectoral biceps tenodesis is associated with excellent outcomes in symptomatic patients following isolated LHBT rupture.

All-Suture Suspensory Button Has Similar Biomechanical Performance to Metal Suspensory Button for Onlay Subpectoral Biceps Tenodesis

Purpose

To evaluate the maximal load at failure, cyclic displacement, and stiffness of onlay subpectoral biceps tenodesis (BT) with an intramedullary unicortical metal button (MB) versus a unicortical all-suture button (ASB).

Methods

Eighteen matched paired human cadaveric proximal humeri were randomly allocated for subpectoral BT with either ASB or MB using a high-strength suture. Specimens were tested on a servohydraulic mechanical testing apparatus under cyclic load for 1,000 cycles and then loaded to failure. The clamp was then adjusted to isolate the suture-anchor point interface and loaded to failure. Maximal load to failure, displacement, and stiffness were compared.

Results

There was no significant difference between groups in stiffness, displacement, or yield load. The maximal load to failure for the MB was greater than the ASB (347.6 ± 74.1N vs 266.5 ± 69.3N, P = .047). Eight specimens in each group failed by suture pull-through on the tendon. When the suture-anchor point interface was isolated, there was no significant difference in maximal load at failure (MB 586.5 ± 215.8N vs ASB 579.6 ± 255.9N, P = .957).

Conclusions

This study demonstrates that the MB and ASB have similar biomechanical performance when used in subpectoral BT. Although the MB showed statistically significant greater maximal load to failure, there was no difference between the MB and ASB when the suture-tendon interface was eliminated. Suture pull-through was the most common mode of failure for both implants, underscoring the importance of the suture-tendon interface.

Clinical Relevance

Fixation techniques for the treatment of long head of the biceps brachii tenodesis continue to evolve. The use of an all-suture suspensory button has advantages, but it is important to understand if this implant is a biomechanically suitable alternative to a metal suspensory button.

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.

Current Controversies and Decision-Making in the Management of Biceps Pathologies

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Biceps tendon pathologies include a spectrum of injuries that range from mild tendinosis to complete tendon rupture.

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Tendinosis, the most common pathology, occurs more frequently with age and is likely related to chronic degeneration. On the other side of the spectrum of severity lies a rupture of the long head of the biceps tendon (LHBT), which may be accompanied by injury to the glenoid labrum.

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Superior labral anterior-posterior (SLAP) tears are frequently associated with biceps pathology. Surgical management for injuries of the bicipital-labral complex includes biceps tenodesis or tenotomy and SLAP repair. A consensus as to which of these procedures is the optimal choice has not been reached, and management may ultimately depend on patient-specific characteristics.

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Due to the relatively low incidence of distal biceps tendon rupture, agreement on the optimal management strategy has not been reached. Surgical repair, or reconstruction in the case of a chronic rupture, is often chosen. However, nonoperative management has also been utilized in older, less-active patients.

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.

Increased Load to Failure in Biceps Tenodesis With All-Suture Suture Anchor Compared With Interference Screw: A Cadaveric Biomechanical Study

PURPOSE

To compare the biomechanical characteristics of a single radially expanding all-suture anchor with an interference screw for open subpectoral long head of biceps tendon (LHBT) tenodesis.

METHODS

Eighteen fresh-frozen matched-pair human cadaveric humeri were used for this biomechanical study. The matched pair humeri were randomly assigned into 2 experimental biceps tenodesis groups: conventional interference screw (CIS) or all-suture suture anchor (ASSA). Open subpectoral LHBT tenodesis was then performed and biomechanical testing was performed using a servohydraulic test frame. A preload of 5 N was applied for 2 minutes before cyclic loading. Displacement was recorded at cycle 300 (D300) and cycle 500 (D500) and at ultimate failure. Data recorded included displacement, load to failure, displacement at failure. Paired t test was used for analysis.

RESULTS

Decreased displacement was observed for the CIS group at D300 (1.67 ± 0.57 mm vs 3.35 ± 2.24 mm; P = .04), D500 (2.00 ± 0.76 mm vs 3.87 ± 2.20 mm; P = .04), and at failure (5.17 ± 3.05 mm vs 10.76 ± 2.66 mm; P < .001). Load to failure was lower in CIS specimens (170 ± 24.5 N vs 217.8 ± 51.54 N; P = .02). Failure in each case was tendon pullout for all CIS specimens; in ASSA 6 specimens failed as the suture pulled through the tendon, 2 specimens failed by suture breakage. No difference in stiffness was observed between the 2 groups (CIS = 98.33 ± 22.98 N/m vs ASSA = 75.94 ± 44.83 N/m; P = .20).

CONCLUSIONS

Our study found that open subpectoral biceps tenodesis performed with an ASSA construct results in increased load to failure as compared with CIS. However, the CIS did demonstrate decreased displacement as compared to ASSA in this cadaveric biomechanical study.

CLINICAL RELEVANCE

ASSA and CIS at time zero provide fixation as indicated by the provider intraoperatively for LHBT tenodesis. ASSA, however, does remove less cortical bone than does CIS and therefore produces a smaller stress riser in the proximal humerus. Further testing as to the integrity of ASSA is warranted to determine the integrity of the tenodesis with cyclical loading.

[Acute rupture of the pectoralis major muscle at the musculotendinous junction : Case report of a rare injury and literature review]

Die Pectoralis-major-Ruptur (PMR) ist eine seltene Verletzung, die v. a. beim Kraftsport aufritt. Vorgestellt wird der Fall eines 31-jährigen Profibasketballspielers, der sich beim Bankdrücken eine Komplettruptur am muskulotendinösen Übergang des M. pectoralis major (PM) zugezogen hatte. Drei Wochen nach dem erlittenen Trauma erfolgte bei persistierenden Schmerzen und Kraftdefizit die Refixation des PM. Drei Monate postoperativ konnte der Patient bei vollem Bewegungsumfang schmerzfrei in den Basketballsport zurückkehren. Die Verletzungsentität wird vor dem Hintergrund der aktuellen Literatur diskutiert und das operative Vorgehen im Detail dargestellt.

Arthroscopic Biceps to Subscapularis Tenodesis: A Surgical Technique

A wide variety of techniques are available for tenodesis of the long head of the biceps tendon, and current literature does not favor any one in particular. We present a simple method for arthroscopic soft tissue biceps tenodesis that uses the subscapularis tendon as the anchor. This 5-step technique is time-efficient, technically simple, cost effective, and does not require powered instruments or specialized implants.

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.

[Injuries of the biceps-labrum complex : Principles, pathologies and treatment concepts]

BACKGROUND

The biceps-labrum complex is prone to acute lesions and degenerative changes due to its anatomical structure and the high load it has to endure. Pathological changes of these structures are common pain generators and can significantly impair shoulder function. Anatomically, the biceps-labrum complex can be divided into three zones: inside, junction and bicipital tunnel.

DIAGNOSTIC PROCEDURE

Despite the focused physical examination and advancements in imaging techniques, the exact localization of pathologies remains challenging. Arthroscopy can be used to accurately diagnose inside and junctional pathologies but extra-articular changes in the region of the bicipital tunnel can only be partially visualized.

TREATMENT

In cases of unsuccessful conservative treatment and correct indications, a high level of patient satisfaction can be surgically achieved. In young patients an anatomical reconstruction of inside lesions or tenodesis of the long head of the biceps tendon is performed; however, even tenotomy is a valuable option and can achieve equally satisfactory results. Unaddressed pathological changes of the bicipital tunnel can lead to persistence of pain. In clinical procedures performing tenodesis, both the different techniques and the implants used have been found to show similar results. This article describes the anatomical principles, pathological changes, the focused clinical instrumental diagnostics and discusses the different treatment philosophies as well as the outcome according to the recent literature.

Conversion of Failed Proximal Long Head of the Biceps Tenodesis to Distal Subpectoral Tenodesis: Outcomes in an Active Population

PURPOSE

To assess failure rates and patient reported outcomes following revision of failed proximal long head of the biceps (LHB) tenodesis.

METHODS

Patients from an active-military population who underwent revision proximal (suprapectoral) to distal (subpectoral) LHB tenodesis were prospectively enrolled. Patients were included if they were between the ages of 16 and 60 years presenting after a previous biceps tenodesis with mechanical failure and clinical failure, defined as Single Assessment Numeric Evaluation (SANE) or American Shoulder and Elbow Surgeons (ASES) <70. Exclusion criteria were concomitant rotator cuff repair or debridement, full-thickness rotator cuff tear, extensive labral tears, or any evidence of glenohumeral arthritis. Pre- and postoperative SANE and ASES were documented and analyzed.

RESULTS

From 2004 to 2010, a total of 12 patients (all male) with a mean age of 39.9 years (range, 30-54 years) were assessed at a mean follow-up time of 29 months (range, 24-38 months). Nine patients presented with a failed tenodesis construct located at the top of the bicipital groove and 9 patients had LHB tendons originally affixed with an interference screw. Diagnostic arthroscopy revealed that the majority of patients (10/12) had excessive scarring at the site of previous fixation. Mean preoperative assessments of SANE (70.4) and ASES (59.9) improved postoperatively to SANE (90.3; P < .01) and ASES (89.8; P < .01). No patients were lost due to follow-up, and there were no reported complications or failures. All patients returned to full active duty and were able to perform all required physical tests before returning to their vocation.

CONCLUSIONS

Patients presenting with symptoms following a proximal LHB tenodesis can be successfully converted to a distal (subpectoral) LHB tenodesis with favorable outcomes. Although in a small sample, there was excessive scarring and synovitis in a majority, which improved significantly when treated with a revision subpectoral tenodesis with minimal complication risk and no reported failures.

LEVEL OF EVIDENCE

IV (Therapeutic case series).

Clinical Outcomes of an All-Arthroscopic Biceps Tenodesis Using the Anterolateral Anchor During Concomitant Double-Row Rotator Cuff Repair

Background:

Pathology of the long head of the biceps tendon frequently occurs concomitantly with rotator cuff tears, necessitating a surgical treatment, often in the form of a tenodesis procedure. Many techniques for a tenodesis exist; however, they often require additional implants or a separate incision.

Purpose:

To report an average of 2-year outcomes of an all-arthroscopic biceps tenodesis employing the stay sutures from the anterolateral anchor during concomitant double-row rotator cuff repair (RCR).

Study Design:

Case series; Level of evidence, 4.

Methods:

Data were prospectively collected and retrospectively reviewed for all patients who underwent an all-arthroscopic biceps tenodesis during concomitant double-row RCR by the senior author between January 2014 and May 2018. Patients were included if they underwent this procedure and had baseline preoperative patient-reported outcomes (PROs) with a minimum of 1 year of postoperative PROs for the American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS) for pain score. Additionally, patient data, surgical history, postoperative complications, and satisfaction were reported.

Results:

Fifteen patients were eligible for the study. There were 12 (80%) men and 3 (20%) women with a mean age of 50.0 years (range, 35-64 years). The mean follow-up time was 25.2 months (range, 13-63 months). Six of 15 (40%) patients also had an arthroscopic subscapularis repair performed. ASES shoulder scores improved from 37.1 preoperatively to 94.1 postoperatively (P < .001), and VAS scores improved from 6.4 preoperatively to 0.5 postoperatively (P < .001). One patient who underwent concomitant subscapularis repair reported continued anterior groove pain. No patients experienced biceps cramping, developed a deformity, or required a repeat operation at the final follow-up. Overall, 93.3% of the patients reported being highly satisfied with their surgery.

Conclusion:

This study presents the clinical results of an all-arthroscopic technique for concomitant double-row RCR and biceps tenodesis, which resulted in high rates of patient satisfaction and significant improvement in reported shoulder outcome and pain scores. Additionally, this technique offers the potential benefits of avoiding a secondary incision, which may decrease surgical morbidity while also decreasing cost by eliminating the need for an extra, tenodesis-specific implant.

Arthroscopic Biceps Tenodesis Outcomes: A Comparison of Inlay and Onlay Techniques

BACKGROUND

Arthroscopic biceps tenodesis (ABT) high in the groove can be achieved using an inlay or an onlay technique. However, there is little information comparing outcomes between the 2.

PURPOSE

To compare postoperative healing and functional outcomes of ABT high in the groove performed using either an onlay or an inlay technique.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective study was performed on patients undergoing ABT at the articular margin (high in the groove) at a single center over a 2-year period. An inlay technique using an interference screw was performed during the first year, followed by an onlay technique using a knotless suture anchor during the second. Tendon healing, elbow flexion strength, functional outcome, and complications were evaluated at a postoperative minimum of 1 year.

RESULTS

A total of 37 patients with inlay and 53 with onlay ABTs were available for follow-up. There was no difference in range of motion, functional outcome scores, or elbow flexion strength between the groups. A postoperative popeye deformity was noted in 27% of patients in the inlay group as compared with 9.4% of the onlay group (P = .028). Four patients (10.8%) in the inlay group required revision surgery (2 of which were biceps tenodesis related) as compared with 0% in the onlay group (P = .015).

CONCLUSION

An onlay technique using a knotless suture anchor for ABT at the top of the articular margin is an acceptable alternative to an inlay technique using an interference screw. The onlay technique was associated with lower rates of postoperative popeye deformity and revision surgery as compared with the inlay technique.

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.

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.

Using Interconnected Knotless Anchor for Suprapectoral Biceps Tenodesis Could Offer Improved Biomechanical Properties in a Cadaveric Model

PURPOSE

To compare the biomechanical characteristics of the interconnected knotless anchor (IKA) fixation with the double knotless anchor (DKA) and interference screw (IS) fixation in the suprapectoral biceps tenodesis.

METHODS

In total, 24 fresh-frozen human cadaveric shoulders (mean age, 67.3 ± 6 years) were used for the study. All the specimens were randomly divided into 3 experimental biceps tenodesis groups (n = 8): IKA, DKA, and IS. After tenodesis, each specimen was preloaded at 5 N for 2 minutes, followed by a cyclic loading test from 5 to 70 N for 500 load cycles. Finally, a destructive axial load to failure test (1 mm/s) was performed. All the values, including ultimate failure load, stiffness, cyclic displacement, and mode of failure were evaluated.

RESULTS

The IKA provided the highest construct stiffness (38.9 ± 7.7 N/mm) and ultimate failure load (288.3 ± 47.6 N), the results for which were statistically better than the corresponding results in the IS and DKA groups. In terms of cyclic displacement, there were no statistical differences among the 3 fixation constructs. The most common failure mode was biceps tendon tearing in IS group (7/8) and IKA group (8/8). In the contrast, suture slippage accounted for the most common failure mode in DKA.

CONCLUSIONS

In suprapectoral bicep tenodesis, IKA fixation appears to offer improved construct stiffness and ultimate failure load while maintaining comparable suture slippage as compared with IS fixation or DKA fixation in the current biomechanical study.

CLINICAL RELEVANCE

The IKA fixation compares favorably with other techniques and could be an alternative clinical option for suprapectoral biceps tenodesis.

Clinical relevance of the anatomy of the long head bicipital groove, an evidence-based review

Pathology in the bicipital groove can be a source of anterior shoulder pain. Many studies have compared treatment techniques for the long head biceps tendon (LHBT) without showing any clinically significant differences. As the LHBT is closely related to the bicipital groove, anatomical aspects of this groove could also be implicated in surgical outcomes. The aim of this review is to contribute to developing the optimal surgical treatment of LHBT pathology based on clinically relevant aspects of the bicipital groove. Medline/PubMed was systematically searched using key words "bicipital" and "groove" and combinations of their synonyms. Studies reporting on evolution, embryonic development, morphometry, vascularization, innervation, and surgical treatment of the LHBT and the bicipital groove were included. The length of the bicipital groove reported in the included studies ranged from 81.00 mm to 87.33 mm, width from 7.74 mm to 11.60 mm, and depth from 3.70 mm to 6.00 mm. The anatomy of the bicipital groove shows a bottleneck narrowing approximately two-thirds from superior. The transverse humeral ligament can constrain the bicipital groove and could be involved in anterior shoulder pain. When either LHBT tenotomy or tenodesis is performed, routinely releasing the transverse ligament could decrease postoperative anterior shoulder pain, which has frequently been reported in the literature. To avoid the bottle neck narrowing, a location below the bicipital groove may be preferred for biceps tenodesis over a more proximal tenodesis site. Level of evidence: IV.

Suprapectoral versus subpectoral tenodesis for Long Head Biceps Brachii tendinopathy: A systematic review and meta-analysis

BACKGROUND

Suprapectoral long head biceps (LHB) tenodesis and subpectoral LHB tenodesis are both commonly performed surgical procedures. Due to the more proximal position of the suprapectoral tenodesis site this technique may be accompanied with more postoperative pain in the bicipital groove and cramping pain in the biceps muscle. We hypothesized that subpectoral tenodesis is associated with a better clinical outcome than suprapectoral tenodesis.

METHODS

A literature search was conducted in PubMed and Embase from January 2000 to July 2019 with the terms "biceps" and "tenodesis". Only comparing studies reporting on American Shoulder Elbow Score (ASES), VAS for anterior shoulder pain, Constant Murley Score (CMS), pain in the bicipital groove and Popeye deformity following suprapectoral and subpectoral tenodesis were included. Quality assessment of included articles was performed using the Coleman score.

RESULTS

Seven comparative studies with 409 patients reporting the results of LHB suprapectoral and subpectoral tenodesis were included. A significant, but clinically irrelevant difference in ASES (mean difference 2.15) p=0.01 was observed. No significant difference in CMS (mean difference 0.09), VAS for anterior shoulder pain (mean difference 0.01), Popeye deformity (odds ratio 3.19) and persistent bicipital pain (odds ratio 2.66). The Coleman score ranged between 53 and 87.

CONCLUSION

Based on this meta-analysis we found a significantly, though not clinically relevant difference in ASES in favour of subpectoral LHB tenodesis when compared with suprapectoral LHB tenodesis. Comparable results were found with regard to outcome scores, pain in the bicipital groove and avoiding a Popeye deformity.

Biomechanical Evaluation of Humerus Fracture After Subpectoral Biceps Tenodesis With Interference Screw Versus Unicortical Button

PURPOSE

To compare the torsional failure strength of the humerus after subpectoral biceps tenodesis with an interference screw versus a unicortical button in a human cadaveric model.

METHODS

Thirteen matched pairs of fresh-frozen human cadaveric upper extremities were randomized to receive either 2.6 × 12 mm unicortical button or 6.25-mm interference screw subpectoral biceps tenodesis. After the procedure, the humeri were loaded into a materials testing machine. The humeri were loaded in external rotation with respect to the elbow at 1.0°/s until failure. Rotation angle to failure, failure torque, energy absorbed, and stiffness were compared by paired t-tests with alpha set at 0.05.

RESULTS

Humeri that were fixed with unicortical buttons showed statistically significant higher rotation to failure (26.87 ± 5.83 vs 19.04 ± 3.86°, P < .001), failure torque (54.11 ± 22.01 vs 44.95 ± 17.47 Nm, P < .001), and energy absorbed (883.93 ± 582.28 vs 451.40 ± 216.19 Nm-Deg, P = .002) than humeri fixed with interference screws.

CONCLUSIONS

In a cadaveric biomechanical model, at time 0, the use of a 2.7 × 12-mm unicortical button fixation in biceps tenodesis resulted in higher loads required to fracture the humerus when compared with a 6.25-mm interference screw fixation in a torsion model.

CLINICAL RELEVANCE

This study demonstrates a significant biomechanical difference with regards to fracture of the humerus, between 2 commonly used fixations methods and implant sizes, interference screw, and unicortical button. The results of this study can aid surgeons in implant selection as well as help to improve patient education prior to surgery.

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.

Subpectoral Biceps Tenodesis: All-Suture Anchor Onlay Technique

Surgical management for biceps pathologies has advanced to provide stronger fixation and to be less invasive. The long head of the biceps tendon has been recognized as a common contributor to anterior shoulder pain and is often associated with other glenohumeral pathologies such as SLAP lesions, rotator cuff tears, and subacromial impingement. Both tenotomy and tenodesis have shown to be effective in ameliorating pain associated with the long head of the biceps tendon. However, decreased muscle function and cosmetic concerns are seen at higher rates after tenotomy compared with tenodesis. One option for the treatment of biceps tendon pathology includes mini-open subpectoral biceps tenodesis. Lower reoperation rates are observed after subpectoral biceps tenodesis than after suprapectoral biceps tenodesis, with thoughts that releasing the tendon from its sheath and the bicipital groove relieves the patient of most associated pain. The purpose of this Technical Note is to describe in detail our preferred operative technique for mini-open subpectoral biceps tenodesis using an onlay technique with all-suture anchor fixation.

Mini-open Subpectoral Biceps Tenodesis Using All-Suture Anchor

The proximal biceps tendon is a common source of shoulder pain and dysfunction. When patients continue to have pain after exhaustive nonoperative treatment, the long head of the biceps tendon can be effectively treated with a tenotomy or tenodesis. Although biceps tenotomy is a less complex and highly reliable treatment, there is the potential for suboptimal outcomes including muscle cramping, fatigue, cosmetic deformity, and supination weakness. Biceps tenodesis eliminates the source of shoulder pain while securing the tendon proximally. Currently, there are multiple techniques for performing a biceps tenodesis (arthroscopic, open suprapectoral, open subpectoral) and myriad fixation methods (bio-tenodesis screw, bone bridge, cortical button, all-suture anchor). Our article presents a technique for a mini-open subpectoral biceps tenodesis using an onlay technique with an all-suture anchor preloaded with needles. This technique allows efficient and proper tendon fixation while minimizing potential complications.

Biceps tenotomy versus tenodesis: patient-reported outcomes and satisfaction

Background

Biceps tenotomy and tenodesis are surgical treatments for pathology of the proximal tendon of the long head of the biceps. There is debate over which procedure provides better patient outcomes.

Purpose

Compare patient-reported outcomes and satisfaction between biceps tenotomy and tenodesis.

Methods

This retrospective cohort study including all patients undergoing arthroscopic biceps tenodesis or tenotomy as part of more extensive shoulder surgery with a single surgeon. Concomitant procedures included rotator cuff repair, subacromial decompression, acromioclavicular joint resection, and debridement. Patients 36–81 years old were contacted by phone at > 2-year post-operatively to complete a biceps-specific outcome questionnaire. Subject decision not to participate was the sole exclusion criterion. Satisfaction scores and frequencies of potential biceps-related downsides (biceps cramping/spasms, biceps pain, shoulder pain, weakness, cosmetic deformity) were analyzed for the effects of procedure, sex, and age.

Results

Satisfaction score distributions were similar between patients with tenodesis and patients with tenotomy (χ² = 8.34, P = 0.08), although slightly more patients with tenodesis than patients with tenotomy reported being satisfied or very satisfied (96% versus 91%). Perceived downsides occurred more frequently among patients with tenotomy than in patients with tenodesis: 59% of patients with tenotomy reported ≥ 1 downside, versus 37% of patients with tenodesis (P < 0.01). In patients reporting ≥ 1 downside, distributions of total downsides differed between procedures (χ² = 10.04, P = 0.04): patients with tenotomy were more likely to report multiple concurrent downsides than were patients with tenodesis (31% versus 16%). Each individual downside tended to be reported as present by a greater proportion of patients with tenotomy than patients with tenodesis. Sex had no effect on satisfaction or downsides, but there was a trend for older patients to report higher satisfaction and fewer downsides.

Conclusions

Biceps tenotomy and tenodesis are both viable treatments for proximal biceps tendon pathology, yielding high patient satisfaction. There were trends toward greater satisfaction and fewer problems in patients with tenodesis. Still, younger patients with tenodesis did report perceived downsides. Alternatively, older patients tended to be more satisfied with both procedures overall. Regardless of procedure, most patients receiving either tenotomy or tenodesis would undergo their respective surgery again.

Level of Evidence

Level III evidence, retrospective comparative cohort study

Rupture of the long head of the biceps brachii tendon near the musculotendinous junction in a young patient: A case report

We report an unusual case of the long head of the biceps brachii tendon rupture near the musculotendinous junction in a young patient. The injury occurred in a young athlete during sports competition. The clinical presentation, surgical treatment, and technique with tenodesis using a unicortical button of the ruptured tendon were presented. The post-surgical recovery was uneventful, and the patient returned to sports in 6 mo. The treatment approach and surgical technique of the long head of biceps brachii rupture was reviewed and discussed. In conclusion, surgical treatment of the long head of the biceps brachii tendon rupture with unicortical button tenodesis resulted in a favorable outcome in a young athlete.

Trends in Open and Arthroscopic Long Head of Biceps Tenodesis

BACKGROUND

In young and active patients, long head of biceps (LHB) tenodesis has become a common procedure for managing LHB pathology, but it remains unclear whether it is performed in isolation or along with other shoulder procedures and whether open and arthroscopic techniques produce different complications.

QUESTIONS/PURPOSES

We sought to determine and compare open and arthroscopic LHB tenodesis in terms of (a) trends in overall use, (b) trends in use in isolation and in association with rotator cuff repair (RCR) and superior labral tear from anterior-to-posterior (SLAP) debridement/repair, and (c) the rates of post-operative complications.

METHODS

We performed a retrospective analysis of data from an insurance database to identify LHB tenodesis procedures performed from 2011 to 2014. The overall annual rates of open and arthroscopic LHB tenodesis were determined and then stratified according to concurrent RCR and SLAP repair/debridement. A multivariate logistic regression analysis that controlled for patient demographics (age, sex, comorbidity) was performed.

RESULTS

Overall, 8547 patients underwent LHB tenodesis, of which 43.5% were open and 56.5% were arthroscopic procedures. There was a significant increase in the utilization of LHB tenodesis from 2011 to 2014. In isolation, open LHB tenodesis was the more common technique overall and by year. Arthroscopic LHB tenodesis was the most common tenodesis technique performed in conjunction with RCR and SLAP repair/debridement. The overall complication rate was 2.9%; only wound dehiscence demonstrated a difference between techniques.

CONCLUSIONS

The rates of open and arthroscopic LHB tenodesis procedures increased significantly from 2011 to 2014, with open techniques more common when LHB tenodesis is performed in isolation and arthroscopic techniques more common when performed as a concomitant procedure. Our use of a population database did not allow us to evaluate biomechanical or cost-related phenomena, and future research should examine these and other relevant differences between these two LHB tenodesis techniques.

Complications of Arthroscopic Versus Open Biceps Tenodesis in the Setting of Arthroscopic Rotator Cuff Repairs: An Analysis of the American Board of Orthopaedic Surgery Database

INTRODUCTION

The purpose of this study was to compare complication rates between arthroscopic versus open biceps tenodesis in the setting of arthroscopic rotator cuff repair and to determine the effect of fellowship training on complication rates.

METHODS

The American Board of Orthopaedic Surgery database was used to identify cases of arthroscopic and open biceps tenodesis in the setting of rotator cuff repair between 2012 and 2016. Surgical, medical, and anesthetic complications, location, fellowship training, surgery year, and patient demographic data were recorded. Overall and specific complication rates were calculated and analyzed. Chi-square or Fisher exact tests were used to determine statistical significance.

RESULTS

Altogether, 1,725 cases of arthroscopic biceps tenodesis and 1,637 cases of open biceps tenodesis with arthroscopic rotator cuff repair were analyzed. No significant difference was found between overall complication rates between arthroscopic (11.4%) versus open (13.1%) biceps tenodesis (P = 0.14). Although open tenodesis had statistically significant higher rates of wound healing issues (0.7% versus 0.2%, P = 0.02), hematoma/seroma formation (0.5% versus 0.1%, P = 0.02), nerve injury (1.5% versus 0.4%, P < 0.01), deep vein thrombosis (0.49% versus 0.12%, P ≤ 0.05), and general anesthetic complications (0.75% versus 0.06%, P = 0.03), these rates remain comparably low. Shoulder arthroscopy fellowship-trained surgeons were more likely to use arthroscopic techniques than non-fellowship-trained surgeons (P < 0.01) but had a higher complication rate (P = 0.01).

DISCUSSION

No differences were found in overall complication rates between open and arthroscopic biceps tenodesis in the setting of rotator cuff repairs. Although open techniques had statistically significant higher rates of nerve injury, wound complications, and hematoma/seroma formation, this may not reflect clinical significance because these complication rates remained <2% in both techniques. Higher complication rates were seen among fellowship-trained surgeons, which may reflect greater case complexity. Both open and arthroscopic biceps tenodesis in the setting of rotator cuff repair show low complication rates, and the technique should be based on surgeon preference and patient factors.

LEVEL OF EVIDENCE

Level IV, case series.

Double on-lay fixation using all suture-type anchor for subpectoral biceps tenodesis has favorable functional outcomes and leads to less cosmetic deformities than single on-lay fixation

PURPOSE

This study aimed to compare the clinical outcomes between single on-lay and double on-lay subpectoral biceps tenodesis (SPBT) using all-suture type anchor in patients with concomitant long head of the biceps tendon (LHBT) lesions and rotator cuff tears.

METHODS

The study included 130 patients who underwent SPBT using all-suture type anchor and arthroscopic rotator cuff repair. Single and double anchor on-lay fixations were performed in 69 patients (group A) and 61 patients (group B), respectively. In 16 patients of group A and 36 patients of group B, a metallic wire was embedded at tenodesis site and difference of wire location pre-and postoperatively was measured using simple radiography.

RESULTS

In both groups, the mean visual analogue scale (VAS) score during motion, the mean UCLA and constant scores significantly improved at the last follow-up (all p < 0.001). These scores were not significantly different between two groups. However, postoperatively, a significant difference was observed in the incidence of cosmetic deformity between two groups (p = 0.019). The cosmetic deformity was noted in 9 (13.0%) patients (Popeye deformity 7.2% and biceps softening 5.8%) in group A and 1 (1.6%) patient (Popeye deformity) in group B. In the subgroup analysis on biceps migration after the surgery, the mean migration distance of metal wire was 2.5 ± 3.0 mm in group A and 1.9 ± 2.6 mm in group B (n.s.). No patient had migration of > 10 mm.

CONCLUSIONS

SPBT using all-suture type anchor was a favorable treatment option for lesions of the LHBT with rotator cuff tear. The clinical relevance of this study is the finding that double on-lay fixation with all-suture type anchor would result less cosmetic deformity than the single on-lay fixation for those who need subpectoral biceps tenodesis.

LEVEL OF EVIDENCE

III.

Biomechanical Comparison of Subpectoral Biceps Tenodesis Onlay Techniques

Background:

Subpectoral biceps tenodesis can be performed with cortical fixation using different repair techniques. The goal of this technique is to obtain a strong and stable reduction of biceps tendon in an anatomic position.

Purpose/Hypothesis:

The purpose of this study was to compare (1) displacement during cyclic loading, (2) ultimate load, (3) construct stiffness, and (4) failure mode of the biceps tenodesis fixation methods using onlay techniques with an all-suture anchor versus an intramedullary unicortical button. It was hypothesized that fixation with all-suture anchors using a Krackow stitch would exhibit biomechanical characteristics similar to those exhibited by fixation with unicortical buttons.

Study Design:

Controlled laboratory study.

Methods:

Ten pairs of fresh-frozen cadaveric shoulders (N = 20) were dissected to the humerus, leaving the biceps tendon-muscle unit intact for testing. A standardized subpectoral biceps cortical (onlay) tenodesis was performed using either an all-suture anchor or a unicortical button. The biceps tendon was initially cycled from 5 to 70 N at a frequency of 1.5 Hz. The force on the tendon was then returned to 5 N, and the tendon was pulled until ultimate failure of the construct. Displacement during cyclic loading, ultimate failure load, stiffness, and failure modes were assessed.

Results:

Cyclic loading resulted in a mean displacement of 12.5 ± 2.5 mm for all-suture anchor fixation and 29.2 ± 9.4 mm for unicortical button fixation (P = .005). One all-suture anchor fixation and 2 unicortical button fixations failed during cyclic loading. The mean ultimate failure load was 170.4 ± 68.8 N for the all-suture anchor group and 125.4 ± 44.6 N for the unicortical button group (P = .074), with stiffness 59.3 ± 11.6 N/mm and 48.6 ± 6.8 N/mm (P = .091), respectively. For the unicortical button, failure occurred by suture tearing through tendon in 100% of the specimens. For the all-suture anchor, failure occurred by suture tearing through tendon in 56% and knot failure in 44% of the specimens.

Conclusion:

The all-suture anchor fixation using a Krackow stitch for subpectoral biceps tenodesis provided ultimate load and stiffness similar to unicortical button fixation using a nonlocking whipstitch. The all-suture anchor fixation technique was shown to be superior in terms of displacement during cyclic loading when compared with the unicortical button fixation technique. However, the results of this study help to show that the fixation method used on the humeral side is less implicative of the overall construct strength than stitch location and technique, as the biceps tendon tissue and stitch configuration seem to be the limiting factor in subpectoral onlay tenodesis techniques.

Clinical Relevance:

All-suture anchors have a smaller diameter than traditional suture anchors, can be inserted through curved guides, and preserve humeral bone stock without compromising postoperative imaging. This study supports use of the all-suture anchor fixation technique for subpectoral biceps tenodesis, with high biomechanical fixation strength and low displacement, as an alternative to the subpectoral onlay biceps tenodesis technique.

Arthroscopic Tenodesis of the Long Head Biceps Tendon Using a Double Lasso-Loop Suture Anchor Configuration

Multiple different techniques exist for performing a biceps tenodesis, and the literature has yet to define a particular technique as superior with respect to outcomes. Factors as the center of various clinical and biomechanical studies include analyzing arthroscopic versus open techniques, optimal fixation sites, and the use specific fixation devices (i.e., anchor, screw). This article details an all-arthroscopic approach for proximal tenodesis of the long head of the biceps tendon (LHBT) using a 2-portal method in a minimally invasive manner. Optimal biomechanical fixation of the LHBT is achieve by using 2 suture anchors in the creation of a dual lasso-loop configuration at the level of the bicipital groove. Technical pearls with respect to optimal arthroscopic viewing, efficient identification of the LHBT and subsequent release from the bicipital groove, and appropriate use of suture anchors for lasso-loop creation are presented for review. Two specific technical advantages of this technique include 2 fixation points for the LHBT to minimize failure risk, and smaller drill holes when compared with commonly performed tenodesis screw techniques to theoretically limit humeral fracture risk.

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.

[Modern treatment strategies for the long head of the biceps tendon]

The long head of the biceps and the biceps pulley sling are prone to acute or degenerative injury. As they both were identified as major pain generators, adequate diagnosis and treatment is vital for successful treatment of shoulder pain. Although the basic principles to address either pathology have not changed over the last decades, new trends have evolved to simplify surgical options. SLAP (superior labral tear from anterior to posterior) repair is seen more restrictive and is mostly performed in young individuals, whereas tenotomy or tenodesis are more often used in patients over 30. The long head of the biceps and pulley lesions are treated with either tenotomy or tenodesis. Surgical techniques for tenodesis are especially less invasive using current implants. Tenodesis is performed either intraarticular, supra- or subpectoral with tenodesis screws or suture anchors. Soft tissue tenodesis has become unpopular over the last decade. Surgical treatment of the long head of the biceps pathologies allows highly satisfying results if the indication is chosen thoroughly.

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.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The "Double Lasso-Loop" Technique Used for Arthroscopic Proximal Biceps Tenodesis

Disorders of the long head biceps tendon are among the most challenging of shoulder problems to diagnose and manage. In this Technical Note, we introduce an arthroscopic technique for proximal biceps tenodesis high in the groove at the articular margin of the humeral head using a single anchor and 2 self-cinching loops followed by 5 alternating half-hitches to secure the construct. This method is simple and enables stable fixation of the biceps tendon.

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.

Biceps tenodesis versus biceps tenotomy for biceps tendinitis without rotator cuff tears

Disorders of the long head of the biceps tendon (LHB) are a well-recognised cause of shoulder pain despite the function of the long head of the biceps remaining poorly understood. There has been a dramatic rise in the number of biceps tenodesis procedures being performed in the last decade. This may partly be attributed to concerns regarding residual cosmetic deformity and pain after biceps tenotomy though there is little evidence to suggest that functional outcomes of tenodesis are superior to biceps tenotomy. Current literature focuses on LHB disorders with concomitant rotator cuff tears. The aim of this review is to discuss the anatomy of the LHB, the pathogenesis of tendinopathy of the LHB, indications of biceps tenodesis and tenotomy and compare the current literature on the functional outcomes of these procedures for LHB disorders in the absence of rotator cuff tears.

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.