Arthroscopic Suprapectoral Biceps Tenodesis Research Articles

Randomized Prospective Analysis of Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: 1 Year Follow-up

Objectives:Biceps pathology typically includes pain in the anterior shoulder that is reproduced with provocative maneuvers. However, optimal treatment of patient with this diagnosis is not clear and can include tenotomy or various forms of tenodesis. As tenotomy can lead to cosmetic deformity and anterior humeral discomfort from spasms, many surgeons perform tenodesis. Technique for tenodesis includes intra-articular soft tissue fixation or osseous fixation, suprapectoral osseous fixation, and subpectoral osseous fixation. Focusing on the later two, it is unclear if there is a clinical or surgical benefit of performing an open subpectoral biceps tenodesis (OBT) versus arthroscopic suprapectoral biceps tenodesis (ABT). We therefore designed this randomized clinical trial to assess these two techniques.Methods:Patients diagnosed with biceps tendinopathy meeting the inclusion and exclusion criteria were randomized into the arthroscopic and mini-open biceps tenodesis groups. Prior to surgery, patients were asked a series of questions regarding their anterior shoulder pain and underwent a subsequent shoulder exam. Follow-up was d at 3 months, 6 months, and 1 year time points, during which the shoulder exam and patient questionnaires were also d.Results:A total of 38 patients were enrolled with a mean age of 43.5 ± 10.5 years and a mean BMI of 28.3 ± 5.4. All patients had arthroscopic evidence of biceps pathology and underwent either an ABT (18) or an OBT (20). All patients underwent a concomitant arthroscopic subacromial decompression. The surgical time for the ABT group, 17.2 ± 3.7 minutes, was significantly greater than the OBT group, 11.7 ± 6.1 (p<0.01). One patient was converted from the ABT group to the OBT group due to sheering of a severely attenuated tendon preventing an ABT. One patient in the OBT group required a revision tenodesis. No significant difference (p > 0.05) was found in strength or anterior shoulder pain at 3 months, 6 months, and 1 year. Additionally, no significant difference (p > 0.05) was found in clinical outcome scores (ASES, Constant subjective, WORC, KJOC) between the two groups.Conclusion:This randomized clinical trial suggests there is no clinical difference between the two techniques. Additionally, while the arthroscopic procedure requires more surgical time, the revision rates are not different. Besides the cosmetic concern for an additional scar, we recommend decisions to be made based on surgeon preference and experience.

Clinical Evaluation of an Arthroscopic, Knotless, Suprapectoral Biceps Tenodesis Technique

Objectives:Pathology of the long of head of the biceps tendon (LHB) is a well-known cause of shoulder pain that is commonly managed with arthroscopic suprapectoral biceps tenodesis when conservative treatment fails. The purpose of this study is to present an arthroscopic, knotless, suprapectoral biceps tenodesis technique known as the Loop ‘N’ Tack and report the clinical outcomes in patients with a minimum of 2 years follow-up.Methods:The technique grasps the LHB proximally at the superior labrum and fixes it to the most distally visualized portion of the intra-articular bicipital groove. A retrospective review of all patients who had undergone the Loop ‘N’ Tack biceps tenodesis by the senior author between January 2009 and May 2014 was completed. Patients were excluded if any portion of the surgery was performed open, or if they had less than 2 years of follow-up. Charts were reviewed and patients were contacted for demographic data, time from surgery, concomitant procedures, worker’s compensation (WC) status, visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and University of California, Los Angeles (UCLA) scores. Statistical analysis was performed using Mann-Whitney U test for comparing non-parametric data sets.Results:follow-up evaluations were performed in 59 of 68 patients (87%). Average follow-up was 43 months. 88% of patients had at least 1 additional procedure performed at the time of biceps tenodesis. The mean ASES scores improved from 42.5 preoperatively to 90.1 postoperatively (p < 0.001). Fifty-four of fifty-nine patients (91.5%) had a good/excellent outcome with UCLA score > 27 and ASES > 70. Three patients (5%) reported biceps cramping pain with overuse. Two patients (3.3%) reported intermittent anterior shoulder pain similar to preoperative symptoms. No patients had developed a “Popeye” deformity at final clinical examination. 97% of patients reported that they were satisfied overall with the procedure. Comparing patients who had a rotator cuff repair or labrum repair at the time of biceps tenodesis with patients who did not have either, there were no significant differences in preoperative VAS or ASES, or postoperative outcomes scores. There were 10 WC patients who had worse postoperative VAS (p = 0.02), ASES (p = 0.03), SANE (p = 0.03), and UCLA scores (p = 0.02) compared to non-WC patients.Conclusion:The Loop ‘N’ Tack biceps tenodesis technique provides a high rate of patient satisfaction and high outcomes scores with a low rate of postoperative pain and no reported incidence of ‘Popeye’ deformity. We believe these good clinical results are due to the secure fixation of the LHB while relieving tension and minimizing motion of the tendon within the bicipital groove. Figure 1.Right shoulder, beach chair position, posterior viewing portal. (A) Suture loop around BT and tissue penetrator through BT to secure loop. (B) BT cut at insertion. BT = Biceps Tendon, G = Glenoid, HH = Humeral Head

Arthroscopic Transtendinous Biceps Tenodesis With All-Suture Anchor

There are several methods for long head of the biceps (LHB) tenodesis, yet the optimal option is still debatable. Here we introduce a technique for arthroscopic suprapectoral biceps tenodesis with an all-suture anchor, the transtendinous biceps tenodesis technique. The LHB tenodesis is performed by using the Y-Knot anchor (1.3-mm). A standard suprapectoral approach is used for the tenodesis. A 1.3-mm drill bit is used to drill through the midportion of the biceps tendon and underlying bone to make a pilot hole. Next, the Y-Knot anchor is passed through the tendon and anchored on the underlying bone. A wrapping suture technique is then used to wrap around, tension, and secure the LHB tendon with the aid of a shuttling polydioxanone suture. The construct is fixed by tying down both suture limbs in a nonsliding fashion. This Technical Note describes an alternative method for all-arthroscopic suprapectoral biceps tenodesis using an all-suture anchor with a small diameter to minimize trauma to the tendon.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: A Comparison of Restoration of Length-Tension and Mechanical Strength Between Techniques

This study aimed to (1) evaluate the exvivo restoration of the long head biceps length-tension for both arthroscopic suprapectoral biceps tenodesis (ASPBT) and open subpectoral biceps tenodesis (OSPBT) techniques and (2) assess how location in the proximal humerus affects pullout strength for tenodesis using an interference screw implant. Eighteen matched cadaveric shoulders were randomized to OSPBT or ASPBT groups (9 each). Tenodesis was performed using clinical techniques. Preoperatively, a metallic bead was placed in the biceps tendon and a fluoroscopic image was obtained. Postoperatively, an image was obtained to evaluate the location of the tenodesis and the metallic bead and determine tensioning. Biomechanical load-to-failure testing was then performed. The ASPBT technique resulted in an average of 2.15 ± 0.62 cm of biceps overtensioning compared with 0.78 ± 0.35 cm (P < .001) in the OSPBT group. The average load to failure in the ASPBT group was 138.8 ± 29.1 N compared with 197 ± 38.6 N (P= .002) in the OSPBT group. Failure caused by implant pullout was significantly more frequent in the ASPBT group (7 of 9) than in the OSPBT group (1 of 9). The described ASPBT technique using an interference screw implant has the tendency to overtension the biceps and has a significantly decreased ultimate load to failure compared with an open subpectoral technique in matched cadaveric specimens. This study shows differences in the biomechanical properties of OSPBT and ASPBT. Modification of currently published ASPBT techniques may be necessary to improve restoration of the physiological length-tension relationship of the biceps. Clinical studies may need to clarify if the lower ultimate load to failure for the ASPBT technique is clinically significant.

Clinical Outcomes Similar Using Open or Arthroscopic Biceps Tenodesis Techniques

This article discusses a study conducted to compare the clinical outcomes of open subpectoral biceps tenodesis (OSPBT) and arthroscopic suprapectoral biceps tenodesis (ASPBT). The results showed that OSPBT and ASPBT both produce excellent clinical and functional results for the management of isolated SLAP (superior labral tear from anterior to posterior) or long head of the biceps injury.

Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis

Background: While a vast body of literature exists describing biceps tenodesis techniques and evaluating the biomechanical aspects of tenodesis locations or various implants, little literature presents useful clinical outcomes to guide surgeons in their decision to perform a particular method of tenodesis. Purpose/Hypothesis: To compare the clinical outcomes of open subpectoral biceps tenodesis (OSPBT) and arthroscopic suprapectoral biceps tenodesis (ASPBT). Our null hypothesis was that both methods would yield satisfactory results with regard to shoulder and biceps function, postoperative shoulder scores, pain relief, and complications. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent either ASPBT or OSPBT for isolated superior labrum or long head of the biceps lesions with a minimum follow-up of 2 years were evaluated with several validated clinical outcome measures and physical examinations including range of motion and strength. Results: Between 2007 and 2011, a total of 82 patients met all inclusion and exclusion criteria, which included 32 patients with ASPBT and 50 patients with OSPBT; 27 of 32 (84.4%) patients with ASPBT and 35 of 50 (70.0%) patients with OSPBT completed clinical follow-up. Overall outcomes for both procedures were satisfactory. No significant differences were noted in postoperative Constant-Murley (ASPBT: 90.7; OSPBT: 91.8; P = .755), American Shoulder and Elbow Surgeons (ASPBT: 90.1; OSPBT: 88.4; P = .735), Single Assessment Numeric Evaluation (ASPBT: 87.4; OSPBT: 86.8; P = .901), Simple Shoulder Test (ASPBT: 10.4; OSPBT: 10.6; P = .762), long head of the biceps (ASPBT: 91.6; OSPBT: 93.6; P = .481), or Veterans RAND 36-Item Health Survey (ASPBT: 81.0; OSPBT: 80.1; P = .789) scores. No significant range of motion or strength differences was noted between the procedures. Conclusion: Both ASPBT and OSPBT yield excellent clinical and functional results for the management of isolated superior labrum or long head of the biceps lesions. No significant differences in clinical outcomes as determined by several validated outcome measures were found between the 2 tenodesis methods, nor were any significant range of motion or strength deficits noted at a minimum 2 years postoperatively.

Increased Incidence of Postoperative Stiffness After Arthroscopic Compared With Open Biceps Tenodesis

To determine the incidence of postoperative stiffness after open and arthroscopic biceps tenodesis, compare the incidence between each method, and determine relevant risk factors for its occurrence. A consecutive series of patients who underwent biceps tenodesis during a 3-year period were retrospectively reviewed. We evaluated 249 patients, which included 143 who underwent open subpectoral tenodesis and 106 who underwent arthroscopic suprapectoral tenodesis. The mean overall follow-up period for the arthroscopic group was 9.9 months (range, 5.1 to 33.5 months). The mean overall follow-up period for the open group was 9.5 months (range, 4.7 to 49.2 months). There was no significant difference in overall follow-up duration between groups (P = .627). A significantly increased incidence of postoperative stiffness was found in the arthroscopic group compared with the open group (17.9% v 5.6%, P = .002). Within the arthroscopic group, patients with postoperative stiffness were more frequently female patients than those without stiffness (63.2% v 33.3%, P = .016) and were more likely to be smokers than those without stiffness (36.8% v 16.1%, P = .040). The tenodesis site was located significantly more proximal in the arthroscopic group of patients with postoperative stiffness compared with patients without postoperative stiffness (32.44 ± 7.8 mm from the top of the humeral head v 50.34 ± 7.8 mm, P < .0001). Our results show a notably increased incidence of postoperative stiffness after arthroscopic suprapectoral biceps tenodesis compared with open subpectoral biceps tenodesis. This appears to occur more commonly in female patients and smokers and may have a relation to the position of the tenodesis, with a more superiorly placed tenodesis site being a potential influencing factor. On the basis of this series, this complication most commonly will improve over time and with symptom-based management. Level III, therapeutic case-control study.

Increased Post-Operative Stiffness after Arthroscopic Suprapectoral Biceps Tenodesis

Objectives:Biceps tenodesis can be performed open or arthroscopically and can be positioned in a suprapectoral or subpectoral position. Suprapectoral tenodesis can be carried out arthroscopically, whereas the subpectoral tenodesis is performed as an open procedure. The goal of this study is to compare the incidence of postoperative stiffness between arthroscopic suprapectoral and open subpectoral biceps tenodesis and evaluate risk factors for its occurrence.Methods:Study Design: The charts of all patients who underwent arthroscopic or open biceps tenodesis who were a minimum of two years post-procedure were reviewed. Patients with preoperative frozen shoulder, prior shoulder surgery, or massive rotator cuff tears which required longer post-operative immobilization were excluded. Post-operative stiffness was defined as persistent range of motion deficit (<100oof forward flexion and abduction; <40o of internal or external rotation) and pain resulting in a diagnosis of post-operative frozen shoulder and requiring either an injection, lysis of adhesions/manipulation, or both.Analysis:Means were calculated for continuous variables and compared using Students t test. Frequencies for categorical variables were compared using chi square tests.Results:We identified 249 consecutive biceps tenodeses from 2008-11 (106 arthroscopic, 143 open) that met inclusion and exclusion criteria. A significantly increased incidence of post-operative stiffness was found in the arthroscopic tenodesis cohort as compared to the open cohort (17.9% vs. 5.6%, p=0.002). The groups were otherwise well matched. (Table I). Further analysis was performed comparing patients with and without post-operative stiffness within the arthroscopic cohort. (Table II) Female gender (63.2% vs 33.3%, p = 0.016) and smoking (36.8% vs 16.1%, p = 0.040) were independent risk factors for post-operative stiffness after arthroscopic tenodesis. Location of the tenodesis from the top of the humeral head as measured on x-ray was 32.4 mm (stiff cohort) versus 50.3 mm (non-stiff cohort) (p < 0.0001). BMI, workmans compensation status and concomitant procedures did not significantly increase the risk of post-operative stiffness. Auto-immune diagnoses such as diabetes mellitus and thyroid disease were also not significant predictors for post-operative stiffness. Of the 19 arthroscopic tenodesis patients who developed post-operative stiffness, 18 had normal range of motion and were pain free by final follow up. In 16 patients, symptoms resolved with one or more injections; two patients did require reoperation, undergoing arthroscopic lysis of adhesions and manipulation.Conclusion:Our results demonstrate a notable incidence of post-operative stiffness after arthroscopic suprapectoral tenodesis. This occurs more commonly in females and smokers. A more proximal location of the tenodesis is noted in patients who develop post-operative stiffness. The relationship between this issue and the arthroscopic suprapectoral tenodesis technique may be multifactorial, with potential etiologies including increased soft-tissue manipulation, fluid extravasation, bursal resection in the sub-deltoid space, increased risk of bleeding in the region of the bicipital sheath, or possibly an effect related to over-tensioning of the biceps with a presentation mimicking post-operative capsulitis, that improves over time and with symptom-based management.

Anatomic and Radiographic Comparison of Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis Sites

Background: Arthroscopic suprapectoral and open subpectoral surgical techniques are both commonly utilized approaches for proximal biceps tenodesis of the long head of the biceps brachii. A central limitation to the widespread use of an arthroscopic approach for biceps tenodesis is that the tendon may be tenodesed too proximally in the bicipital groove, leading to persistent pain and tendinopathy. Purpose/Hypothesis: The purpose of this study was to determine the in vivo tenodesis location using arthroscopic suprapectoral and open subpectoral techniques for proximal biceps tenodesis in relation to clinically pertinent anatomic and radiographic landmarks. The null hypothesis was that arthroscopic suprapectoral biceps tenodesis would not be significantly different in terms of the location from open subpectoral biceps tenodesis. Study Design: Controlled laboratory study. Methods: A total of 20 matched pairs of cadaveric shoulder specimens were randomized such that within each pair, 1 shoulder underwent a standard open subpectoral biceps tenodesis and the other underwent an arthroscopic suprapectoral tenodesis. Limited dissection and exposure of the surgical tunnel site and reference landmarks were subsequently performed, and anteroposterior and lateral radiographs were obtained. Direct measurements were performed anatomically using a digital caliper and radiographically using picture archiving and communication system (PACS) software from the proximal lip of the humeral tunnel to regional landmarks. Results: Both techniques were able to place the humeral tunnel distal to the bicipital groove in all specimens. On average, the open subpectoral approach placed the tunnel 2.2 cm distal to the arthroscopic suprapectoral approach. Conclusion: The arthroscopic suprapectoral biceps tenodesis technique used in this study consistently placed the tenodesis tunnel distal to the bicipital groove, which may allay concerns about the bicipital groove as a pain source after this procedure. Clinical Relevance: This anatomic study provides new information on tunnel placement in 2 biceps tenodesis techniques. In addition, it provides clinically relevant anatomic and radiographic guidelines using clinically pertinent landmarks. This information may be useful in preoperative planning, intraoperative technique, and postoperative assessment of both open subpectoral and arthroscopic suprapectoral biceps tenodesis.

Where to tenodese the biceps: proximal or distal?

The best location for biceps tenodesis is controversial as surgeons have begun to question whether tenodesis location affects the incidence of residual bicipital postoperative pain. An open distal tenodesis technique has been previously proposed to eliminate remaining symptoms at the bicipital groove. We asked the following questions: (1) Does a higher tenodesis in the biceps groove result in postoperative pain? And (2) can the tenodesis location be successfully moved more distally ("suprapectoral tenodesis") by an arthroscopic technique? We retrospectively reviewed 17 patients undergoing arthroscopic biceps tenodesis and evaluated their tenodesis location, either within the upper half of the groove (five) or in the lower half of the groove or shaft (12). Patient outcomes were assessed with visual analog scale scores for pain, American Shoulder and Elbow Surgeons scores, and Constant-Murley scores. Minimum followup was 12 months (mean, 28 months; range, 12-69 months). Two patients had persistent pain at 12 months; both had a tenodesis in the upper half of the groove. The overall American Shoulder and Elbow Surgeons and Constant-Murley scores were improved at latest followup. Arthroscopic suprapectoral biceps tenodesis represents a new technique for distal tenodesis. Our preliminary observations suggest a more distal tenodesis location may decrease the incidence of persistent postoperative pain at the bicipital groove, although additional research is needed to definitively state whether the proximal location is in fact more painful. Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.