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Anatomic landmarks for arthroscopic suprapectoral biceps tenodesis: a cadaveric study
ARTICLE IN PRESS J Shoulder Elbow Surg (2018) ■■, ■■–■■
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ORIGINAL ARTICLE
Anatomic landmarks for arthroscopic suprapectoral biceps tenodesis: a cadaveric study Andrew S. Neviaser, MDa, Diana C. Patterson, MDb,*, Paul J. Cagle, MDb, Bradford O. Parsons, MDb, Evan L. Flatow, MDb a
Department of Orthopaedic Surgery, Ohio State University, Columbus, OH, USA Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
b
Background: Biceps tenodesis reduces the incidence of Popeye deformity occurring with tenotomy, but pain may occur with tenodesis superior to or within the bicipital groove. Arthroscopic suprapectoral tenodesis is an attractive alternative. The purpose of this study was to establish landmarks for arthroscopic suprapectoral tenodesis and determine the appropriate fixation point to optimize muscle tension. Methods: Twelve fresh cadaveric shoulders were dissected. Urethane polymer was injected into the axillary artery. The position of the anterior branch of the axillary nerve was marked. The transverse humeral ligament was split, exposing the biceps (long head of the biceps [LHB]) from its origin to the pectoralis major tendon (PMT). The intra-articular portion was released. Measurements were taken from the proximal tendon to described landmarks. Results: The mean length of the intra-articular LHB was 2.53 cm (range, 1.72-3.55 cm). The mean distance from the LHB origin to the inferior lesser tuberosity (LT) was 5.58 cm (range, 4.02-6.87 cm), and that to the superior border of the PMT was 8.46 cm (range, 6.46-10.78 cm). The suprapectoral tenodesis zone (inferior LT to superior PMT) was 2.96 cm (range, 1.54-4.40 cm). In all specimens, a branch of the anterior humeral circumflex arose medial to the LHB and distal to the LT and crossed the suprapectoral zone from medial to lateral at 1.49 ± 0.42 cm proximal to the PMT, approximately at the level of the axillary nerve. The musculocutaneous nerve was on average 3.06 cm (range, 1.86-3.76 cm) from the tenodesis zone. Conclusion: A branch of the anterior humeral circumflex is a reliable landmark for identifying the midsuprapectoral zone. The distance from the proximal LHB tendon to this crossing vessel averaged 6.32 cm in female specimens and 8.28 cm in male specimens. These findings allow appropriate tensioning of the LHB during arthroscopic suprapectoral tenodesis. Level of evidence: Anatomy Study; Cadaveric Dissection © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Biceps tenodesis; arthroscopic tenodesis; suprapectoral tenodesis; axillary nerve; musculocutaneous nerve; anterior circumflex vessels; landmarks; cadaveric study
*Reprint requests: Diana C. Patterson, MD, Department of Orthopaedic Surgery, Mount Sinai Health System, 5 E 98th St, Ninth Floor, Box 1188, New York, NY 10029, USA. E-mail address: [email protected] (D.C. Patterson).
The long head of the biceps (LHB) tendon is increasingly recognized as a common source of shoulder pain.18,19,33 Surgical treatment for recalcitrant pain of the LHB or superior labrum injury can be tenotomy or tenodesis.3,8,9,11,18,27,28,32
1058-2746/$ - see front matter © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. https://doi.org/10.1016/j.jse.2018.01.007
ARTICLE IN PRESS 2 Tenotomy produces reliable pain relief, but muscle retraction can result in a cosmetic deformity and muscle cramping.4,11,13,27-29,32 Tenodesis reduces the incidence of this Popeye deformity and pain and is preferred in younger, more active patients. Tenodesis can be performed via an open or arthroscopic approach, with a variety of fixation methods.1,2,5,7,17,34 Residual postoperative anterior shoulder pain and bicipital groove tenderness have been observed following arthroscopic tenodesis proximal to, or within, the bicipital groove.24 This pain has been attributed to persistent tenosynovitis extending into the bicipital groove following tenodesis at the proximal aspect.6,26 Bicipital groove pain has been observed with increased frequency when the transverse humeral ligament is not released.26 Several studies have suggested that tenodesis distal to the bicipital groove may eliminate this pain.22-26 Prior studies have examined the anatomy of the proximal humerus, particularly the relationship of the LHB tendon and the insertion of the pectoralis major.14,15,20,35 LaFrance et al20 evaluated the relationship of the musculotendinous junction of the biceps and the longitudinal width of the pectoralis major tendon at its humeral insertion. They identified the most distal aspect of the musculotendinous junction as the optimal tenodesis site for tensioning in a subpectoral tenodesis. Johannsen et al15 demonstrated that it was possible to consistently perform tenodesis of the biceps tendon distal to the bicipital groove in an arthroscopic technique and demonstrated reliable measurements of bony landmarks from the superior lip of the humeral tenodesis tunnel. We identified only 1 study, by Jarrett et al,14 that examined anatomic landmarks of the proximal humerus that would be visible during a standard arthroscopic approach, however. Lo and Burkhart21 described a technique for arthroscopic suprapectoral tenodesis distal to the inferior tuberosity and the bicipital groove but proximal to the insertion of the pectoralis major tendon. This was later modified by Flatow and colleagues.22 Multiple studies have shown low rates of revision and a reduced incidence of postoperative pain using this technique.21,22 Appropriate soft tissue tensioning remains a concern, however. Over-tensioning can lead to tenodesis failure, while under-tensioning of the biceps can produce a pseudoPopeye deformity.15,34,35 The purpose of this study was to identify reliable landmarks and anatomic relationships to aid in establishing physiological muscle tension during arthroscopic suprapectoral tenodesis.
A.S. Neviaser et al. scribed by Hettrich et al.12 The brachial artery was ligated distal to the insertion of the pectoralis major tendon. Dissections were completed 12 to 24 hours following the injections to allow the polymer to solidify. Surgical exposure of the proximal humerus was performed via a standard deltopectoral approach. The anterior motor branch of the axillary nerve was isolated on the undersurface of the deltoid muscle belly, and its craniocaudal position was marked on the humeral shaft. The anterior deltoid was then reflected off the clavicle and acromion. The transverse humeral ligament was split in line with the bicipital groove and into the rotator interval superiorly, exposing the LHB tendon. The biceps was exposed from its intra-articular origin at the superior labrum to the superior margin of the pectoralis major tendon. One kilogram of tension was placed on the biceps muscle to most accurately represent anatomic measurements and relationships of the biceps with surrounding structures. The location of the musculotendinous junction was confirmed to be physiological and fixed with a suture, per the technique used by Jarrett et al.14 The intraarticular portion of the tendon was measured, and the LHB tendon was then released from the labrum. Measurements of distances to identifiable anatomic landmarks were made with digital calipers (Absolute Digimatic Caliper Series 500; Mitutoyo, Aurora, IL, USA) (Fig. 1).
Results The mean age of the 11 specimens was 65.5 years. There were 7 female and 4 male specimens for analysis, and there were 5 right and 6 left shoulders. The mean age of the female cadavers was 66.4 years, and that of the male cadavers was 64 years. The mean length of the intra-articular segment of the tendon was 2.53 cm (range, 1.72-3.55 cm). The mean distance
Methods Cadaveric study Twelve fresh cadaveric shoulders were available for the study. One was found to have a large rotator cuff and tear and prior rupture of the LHB tendon; this specimen was excluded from the analysis. A urethane polymer (PMC-780; Smooth-On, Easton, PA, USA), injected into the axillary artery proximal to the branching of the thoracoacromial trunk, was used to define vascular structures as de-
Figure 1 resected.
Intraoperative measurement of exteriorized tendon to be
ARTICLE IN PRESS Landmarks for arthroscopic suprapectoral tenodesis
Figure 2 The mean distance from the proximal end of the detached long head of the biceps tendon to the inferior edge of the lesser tuberosity was 5.58 ± 0.51 cm. The digital caliper used to perform measurements in the study is shown.
from the proximal end of the detached LHB tendon to the inferior edge of the lesser tuberosity was 5.58 cm (range, 4.026.87 cm) (Fig. 2). The overall average distance from the proximal tendon edge to the proximal aspect of the insertion of the pectoralis major tendon was 8.46 cm (range, 6.4610.78 cm); there was variation between sexes, measuring a mean of 7.69 cm in female shoulders and 9.86 cm in male shoulders. The mean length of the suprapectoral tenodesis zone, extending from the inferior border of the lesser tuberosity to the superior margin of the pectoralis major tendon, was 2.96 cm. Other neurovascular structures that may be identified during arthroscopic biceps tenodesis were found to have consistent anatomic relationships to the mid-suprapectoral zone. The musculocutaneous nerve passed a mean of 3.06 cm (range, 1.863.76 cm) medial to the suprapectoral tenodesis site. The axillary nerve was 0.96 cm (range, 0.24-1.83 cm) lateral to the tenodesis site. A vascular branch from the anterior humeral circumflex vessels crossing the suprapectoral zone was identified in all specimens. It was predictably found medial to the LHB and distal to the inferior aspect of the lesser tuberosity. It crossed the suprapectoral zone from medial to lateral, deep to the biceps tendon, at a mean of 1.49 ± 0.42 cm proximal to the superior edge of the pectoralis major tendon (Fig. 3). In all shoulders, this vessel was found at approximately the same craniocaudal level as the axillary nerve (Fig. 4). The distance from the proximal origin of the LHB tendon to this crossing vessel averaged 6.89 ± 0.18 cm; the mean distance was 6.32 cm in female specimens and 8.28 cm in male specimens. This difference in distance was statistically significant (P = .01).
3
Figure 3 A vascular branch off the anterior humeral circumflex vessels (narrow arrow) was predictably found distal to the inferior aspect of the lesser tuberosity. It crossed from medial to lateral, deep to the biceps tendon, at a mean of 1.49 cm proximal to the superior edge of the pectoralis major tendon (wide arrow).
Figure 4 The axillary nerve (narrow arrow) was always located at the same superior-inferior level as the crossing vessels (wide arrow). The circle indicates the tenodesis site.
Discussion The purpose of this anatomic study was to identify reliable landmarks for arthroscopic suprapectoral tenodesis that would aid in establishing optimal muscle tension. Our results demonstrate that the proximal LHB tendon can be divided into 3 anatomic segments: approximately 2.5 cm intra-articularly, 3 cm in the bicipital groove, and 3 cm suprapectorally. We have identified a consistent blood vessel that crosses near the midpoint of the suprapectoral zone that can serve as a reliable reference to estimate the distance from the biceps origin.
ARTICLE IN PRESS 4 This vessel can be used to determine how much of the LHB tendon should be resected to maintain the appropriate resting length-tension relationship during arthroscopic tenodesis. There is evidence that the location of tenodesis may be a significant factor affecting outcomes. Lutton et al22 presented a series of 17 patients who underwent proximal versus distal arthroscopic tenodesis; 5 received a proximal tenodesis, and in 12, a more distal location was used. Of the 5 patients with proximal reattachment, 2 had persistent pain at the tenodesis site and bicipital groove, and both required further débridement surgery for resolution. In the group that underwent suprapectoral tenodesis, no patients had bicipital groove pain at 1 year of follow-up. In a larger series including 188 patients, Sanders et al26 showed a higher revision rate for proximal arthroscopic tenodesis than for distal (35.7% vs 2.7%). In addition, patients in whom proximal tenodesis was performed with release of the biceps sheath had a lower revision rate than patients in whom the sheath was not released (2.4% vs 13.4%). Gombera et al10 found that patients undergoing an arthroscopic suprapectoral tenodesis in the distal aspect of the bicipital groove or distal to the groove showed similar pain relief and clinical outcomes to patients undergoing open subpectoral tenodesis. There were no complications or failures in the arthroscopic group but 2 complications in the open cohort. Other studies have also noted the reported loss of motion following arthroscopic tenodesis with more superior tenodesis locations.36 Knowledge of the arthroscopic location of critical neurovascular structures and the ability to safely place the biceps tendon at this distal location via an arthroscopic approach allow patients to avoid the morbidity of an open approach. There are several prior anatomic studies addressing the proximal humerus anatomy and relationship of the biceps tendon to surrounding structures. However, many of these discuss relationships that are only pertinent during an open approach. LaFrance et al20 investigated the relationship between the longitudinal width of the pectoralis tendon at its humeral insertion and the musculotendinous junction of the biceps tendon. They found that the final resting spot of the most distal aspect of the musculotendinous junction of the LHB tendon after tenodesis should be approximately 3 cm distal to the inferior edge of the pectoralis major tendon. These landmarks are not, however, relevant to the standard arthroscopic techniques because the distal aspect of the LHB musculotendinous junction or the inferior edge of the pectoralis major is not commonly visualized. The findings of our study are consistent with those of a study performed by Jarrett et al.14 In their study of a similar number of cadaveric specimens, the musculocutaneous nerve was a mean of 3.47 cm medial to the LHB at the superior border of the pectoralis tendon. The anterior humeral circumflex vessels were 4.63 cm proximal to the musculotendinous junction of the LHB, and the distance from the lesser tuberosity to the musculotendinous junction of the biceps was 5.37 cm.14 Several cadaver studies have also shown a trend that more superior placement of arthroscopic biceps tenodesis, com-
A.S. Neviaser et al. pared to an open subpectoral biceps tenodesis, has an association with overtensioning. In a cadaveric comparison of arthroscopic tenodesis and open subpectoral tenodesis techniques, Johannsen et al15 showed that while both techniques enabled placement of the tenodesis tunnel distal to the inferior border of the bicipital groove, with an average distance of 9.8 mm in the arthroscopic specimens, the open subpectoral approach placed the tunnel a mean of 2.2 cm farther distal than the arthroscopic approach. In a biomechanical cadaveric comparison study, Werner et al 35 showed that the arthroscopic suprapectoral technique resulted in a mean of 2.15 cm of biceps over-tensioning versus 0.78 cm in an open subpectoral tenodesis group. In a clinical examination of increased postoperative stiffness following arthroscopic suprapectoral tenodesis, Werner et al noted that the tenodesis site in patients with stiffness was significantly more proximal than in those without stiffness. Of 106 patients in this group, 17.9% reported postoperative stiffness at 9 months postoperatively, in comparison with 5.6% in 143 patients following open subpectoral tenodesis. Tenodesis sites in those reporting stiffness were a mean of 32.4 mm from the top of the humeral head versus 50.34 mm in patients without stiffness.36 These studies demonstrate the importance of consistently placing the biceps tenodesis site at the proper anatomic location to re-create the appropriate biceps tension. Recognizing the anatomic differences between our male and female specimens is also critical to appropriate tensioning. Demographic studies have shown that men undergo bicep tenodesis more frequently than women, at a ratio of nearly 2:1.16,30,31 Female patients have been shown to be more likely to experience postoperative stiffness.36 In our study the distance from the proximal tendon edge to the proximal insertion of the pectoralis major tendon was a mean of 2.17 cm greater in the male specimens than in the female specimens. Indiscriminant resection of a uniform length of tendon without awareness of any sex-specific differences may lead to overtensioning and complications in female patients. There are a few limitations to our study. First, only 11 specimens were available for analysis. We did show statistically significant differences between male and female specimens, but more specimens would enable us to further confirm these differences. In future anatomic studies, examining the biceps tendon arthroscopically could help confirm whether the neurovascular structures appreciated in this study are readily visible intraoperatively.
Conclusion These findings provide reliable landmarks for accurate placement and fixation of the LHB tendon when performing an arthroscopic suprapectoral tenodesis. The proximal LHB tendon can be divided into 3 broad anatomic segments: 2.5 cm intra-articularly, 3 cm in the bicipital groove, and 3 cm suprapectorally. Crossing vessels are reliably
ARTICLE IN PRESS Landmarks for arthroscopic suprapectoral tenodesis identified during arthroscopy to bisect the suprapectoral humeral segment and ensure safe placement of the tenodesis distal to the biceps groove and in the midsuprapectoral zone.
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Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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ARTICLE IN PRESS 6 J Shoulder Elbow Surg 2005;14:238-46. http://dx.doi.org/10.1016/ j.jse.2004.07.008 33. Warner JJ, McMahon PJ. The role of the long head of the biceps brachii in superior stability of the glenohumeral joint. J Bone Joint Surg Am 1995;77:366-72. 34. Werner BC, Evans CL, Holzgrefe RE, Tuman JM, Hart JM, Carson EW, et al. Arthroscopic suprapectoral and open subpectoral biceps tenodesis. A comparison of minimum 2-year clinical outcomes. Am J Sports Med 2014;42:2583-90. http://dx.doi.org/10.1177/0363546514547226
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ORIGINAL ARTICLE
Anatomic landmarks for arthroscopic suprapectoral biceps tenodesis: a cadaveric study Andrew S. Neviaser, MDa, Diana C. Patterson, MDb,*, Paul J. Cagle, MDb, Bradford O. Parsons, MDb, Evan L. Flatow, MDb a
Department of Orthopaedic Surgery, Ohio State University, Columbus, OH, USA Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai Health System, New York, NY, USA
b
Background: Biceps tenodesis reduces the incidence of Popeye deformity occurring with tenotomy, but pain may occur with tenodesis superior to or within the bicipital groove. Arthroscopic suprapectoral tenodesis is an attractive alternative. The purpose of this study was to establish landmarks for arthroscopic suprapectoral tenodesis and determine the appropriate fixation point to optimize muscle tension. Methods: Twelve fresh cadaveric shoulders were dissected. Urethane polymer was injected into the axillary artery. The position of the anterior branch of the axillary nerve was marked. The transverse humeral ligament was split, exposing the biceps (long head of the biceps [LHB]) from its origin to the pectoralis major tendon (PMT). The intra-articular portion was released. Measurements were taken from the proximal tendon to described landmarks. Results: The mean length of the intra-articular LHB was 2.53 cm (range, 1.72-3.55 cm). The mean distance from the LHB origin to the inferior lesser tuberosity (LT) was 5.58 cm (range, 4.02-6.87 cm), and that to the superior border of the PMT was 8.46 cm (range, 6.46-10.78 cm). The suprapectoral tenodesis zone (inferior LT to superior PMT) was 2.96 cm (range, 1.54-4.40 cm). In all specimens, a branch of the anterior humeral circumflex arose medial to the LHB and distal to the LT and crossed the suprapectoral zone from medial to lateral at 1.49 ± 0.42 cm proximal to the PMT, approximately at the level of the axillary nerve. The musculocutaneous nerve was on average 3.06 cm (range, 1.86-3.76 cm) from the tenodesis zone. Conclusion: A branch of the anterior humeral circumflex is a reliable landmark for identifying the midsuprapectoral zone. The distance from the proximal LHB tendon to this crossing vessel averaged 6.32 cm in female specimens and 8.28 cm in male specimens. These findings allow appropriate tensioning of the LHB during arthroscopic suprapectoral tenodesis. Level of evidence: Anatomy Study; Cadaveric Dissection © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. Keywords: Biceps tenodesis; arthroscopic tenodesis; suprapectoral tenodesis; axillary nerve; musculocutaneous nerve; anterior circumflex vessels; landmarks; cadaveric study
*Reprint requests: Diana C. Patterson, MD, Department of Orthopaedic Surgery, Mount Sinai Health System, 5 E 98th St, Ninth Floor, Box 1188, New York, NY 10029, USA. E-mail address: [email protected] (D.C. Patterson).
The long head of the biceps (LHB) tendon is increasingly recognized as a common source of shoulder pain.18,19,33 Surgical treatment for recalcitrant pain of the LHB or superior labrum injury can be tenotomy or tenodesis.3,8,9,11,18,27,28,32
1058-2746/$ - see front matter © 2018 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved. https://doi.org/10.1016/j.jse.2018.01.007
ARTICLE IN PRESS 2 Tenotomy produces reliable pain relief, but muscle retraction can result in a cosmetic deformity and muscle cramping.4,11,13,27-29,32 Tenodesis reduces the incidence of this Popeye deformity and pain and is preferred in younger, more active patients. Tenodesis can be performed via an open or arthroscopic approach, with a variety of fixation methods.1,2,5,7,17,34 Residual postoperative anterior shoulder pain and bicipital groove tenderness have been observed following arthroscopic tenodesis proximal to, or within, the bicipital groove.24 This pain has been attributed to persistent tenosynovitis extending into the bicipital groove following tenodesis at the proximal aspect.6,26 Bicipital groove pain has been observed with increased frequency when the transverse humeral ligament is not released.26 Several studies have suggested that tenodesis distal to the bicipital groove may eliminate this pain.22-26 Prior studies have examined the anatomy of the proximal humerus, particularly the relationship of the LHB tendon and the insertion of the pectoralis major.14,15,20,35 LaFrance et al20 evaluated the relationship of the musculotendinous junction of the biceps and the longitudinal width of the pectoralis major tendon at its humeral insertion. They identified the most distal aspect of the musculotendinous junction as the optimal tenodesis site for tensioning in a subpectoral tenodesis. Johannsen et al15 demonstrated that it was possible to consistently perform tenodesis of the biceps tendon distal to the bicipital groove in an arthroscopic technique and demonstrated reliable measurements of bony landmarks from the superior lip of the humeral tenodesis tunnel. We identified only 1 study, by Jarrett et al,14 that examined anatomic landmarks of the proximal humerus that would be visible during a standard arthroscopic approach, however. Lo and Burkhart21 described a technique for arthroscopic suprapectoral tenodesis distal to the inferior tuberosity and the bicipital groove but proximal to the insertion of the pectoralis major tendon. This was later modified by Flatow and colleagues.22 Multiple studies have shown low rates of revision and a reduced incidence of postoperative pain using this technique.21,22 Appropriate soft tissue tensioning remains a concern, however. Over-tensioning can lead to tenodesis failure, while under-tensioning of the biceps can produce a pseudoPopeye deformity.15,34,35 The purpose of this study was to identify reliable landmarks and anatomic relationships to aid in establishing physiological muscle tension during arthroscopic suprapectoral tenodesis.
A.S. Neviaser et al. scribed by Hettrich et al.12 The brachial artery was ligated distal to the insertion of the pectoralis major tendon. Dissections were completed 12 to 24 hours following the injections to allow the polymer to solidify. Surgical exposure of the proximal humerus was performed via a standard deltopectoral approach. The anterior motor branch of the axillary nerve was isolated on the undersurface of the deltoid muscle belly, and its craniocaudal position was marked on the humeral shaft. The anterior deltoid was then reflected off the clavicle and acromion. The transverse humeral ligament was split in line with the bicipital groove and into the rotator interval superiorly, exposing the LHB tendon. The biceps was exposed from its intra-articular origin at the superior labrum to the superior margin of the pectoralis major tendon. One kilogram of tension was placed on the biceps muscle to most accurately represent anatomic measurements and relationships of the biceps with surrounding structures. The location of the musculotendinous junction was confirmed to be physiological and fixed with a suture, per the technique used by Jarrett et al.14 The intraarticular portion of the tendon was measured, and the LHB tendon was then released from the labrum. Measurements of distances to identifiable anatomic landmarks were made with digital calipers (Absolute Digimatic Caliper Series 500; Mitutoyo, Aurora, IL, USA) (Fig. 1).
Results The mean age of the 11 specimens was 65.5 years. There were 7 female and 4 male specimens for analysis, and there were 5 right and 6 left shoulders. The mean age of the female cadavers was 66.4 years, and that of the male cadavers was 64 years. The mean length of the intra-articular segment of the tendon was 2.53 cm (range, 1.72-3.55 cm). The mean distance
Methods Cadaveric study Twelve fresh cadaveric shoulders were available for the study. One was found to have a large rotator cuff and tear and prior rupture of the LHB tendon; this specimen was excluded from the analysis. A urethane polymer (PMC-780; Smooth-On, Easton, PA, USA), injected into the axillary artery proximal to the branching of the thoracoacromial trunk, was used to define vascular structures as de-
Figure 1 resected.
Intraoperative measurement of exteriorized tendon to be
ARTICLE IN PRESS Landmarks for arthroscopic suprapectoral tenodesis
Figure 2 The mean distance from the proximal end of the detached long head of the biceps tendon to the inferior edge of the lesser tuberosity was 5.58 ± 0.51 cm. The digital caliper used to perform measurements in the study is shown.
from the proximal end of the detached LHB tendon to the inferior edge of the lesser tuberosity was 5.58 cm (range, 4.026.87 cm) (Fig. 2). The overall average distance from the proximal tendon edge to the proximal aspect of the insertion of the pectoralis major tendon was 8.46 cm (range, 6.4610.78 cm); there was variation between sexes, measuring a mean of 7.69 cm in female shoulders and 9.86 cm in male shoulders. The mean length of the suprapectoral tenodesis zone, extending from the inferior border of the lesser tuberosity to the superior margin of the pectoralis major tendon, was 2.96 cm. Other neurovascular structures that may be identified during arthroscopic biceps tenodesis were found to have consistent anatomic relationships to the mid-suprapectoral zone. The musculocutaneous nerve passed a mean of 3.06 cm (range, 1.863.76 cm) medial to the suprapectoral tenodesis site. The axillary nerve was 0.96 cm (range, 0.24-1.83 cm) lateral to the tenodesis site. A vascular branch from the anterior humeral circumflex vessels crossing the suprapectoral zone was identified in all specimens. It was predictably found medial to the LHB and distal to the inferior aspect of the lesser tuberosity. It crossed the suprapectoral zone from medial to lateral, deep to the biceps tendon, at a mean of 1.49 ± 0.42 cm proximal to the superior edge of the pectoralis major tendon (Fig. 3). In all shoulders, this vessel was found at approximately the same craniocaudal level as the axillary nerve (Fig. 4). The distance from the proximal origin of the LHB tendon to this crossing vessel averaged 6.89 ± 0.18 cm; the mean distance was 6.32 cm in female specimens and 8.28 cm in male specimens. This difference in distance was statistically significant (P = .01).
3
Figure 3 A vascular branch off the anterior humeral circumflex vessels (narrow arrow) was predictably found distal to the inferior aspect of the lesser tuberosity. It crossed from medial to lateral, deep to the biceps tendon, at a mean of 1.49 cm proximal to the superior edge of the pectoralis major tendon (wide arrow).
Figure 4 The axillary nerve (narrow arrow) was always located at the same superior-inferior level as the crossing vessels (wide arrow). The circle indicates the tenodesis site.
Discussion The purpose of this anatomic study was to identify reliable landmarks for arthroscopic suprapectoral tenodesis that would aid in establishing optimal muscle tension. Our results demonstrate that the proximal LHB tendon can be divided into 3 anatomic segments: approximately 2.5 cm intra-articularly, 3 cm in the bicipital groove, and 3 cm suprapectorally. We have identified a consistent blood vessel that crosses near the midpoint of the suprapectoral zone that can serve as a reliable reference to estimate the distance from the biceps origin.
ARTICLE IN PRESS 4 This vessel can be used to determine how much of the LHB tendon should be resected to maintain the appropriate resting length-tension relationship during arthroscopic tenodesis. There is evidence that the location of tenodesis may be a significant factor affecting outcomes. Lutton et al22 presented a series of 17 patients who underwent proximal versus distal arthroscopic tenodesis; 5 received a proximal tenodesis, and in 12, a more distal location was used. Of the 5 patients with proximal reattachment, 2 had persistent pain at the tenodesis site and bicipital groove, and both required further débridement surgery for resolution. In the group that underwent suprapectoral tenodesis, no patients had bicipital groove pain at 1 year of follow-up. In a larger series including 188 patients, Sanders et al26 showed a higher revision rate for proximal arthroscopic tenodesis than for distal (35.7% vs 2.7%). In addition, patients in whom proximal tenodesis was performed with release of the biceps sheath had a lower revision rate than patients in whom the sheath was not released (2.4% vs 13.4%). Gombera et al10 found that patients undergoing an arthroscopic suprapectoral tenodesis in the distal aspect of the bicipital groove or distal to the groove showed similar pain relief and clinical outcomes to patients undergoing open subpectoral tenodesis. There were no complications or failures in the arthroscopic group but 2 complications in the open cohort. Other studies have also noted the reported loss of motion following arthroscopic tenodesis with more superior tenodesis locations.36 Knowledge of the arthroscopic location of critical neurovascular structures and the ability to safely place the biceps tendon at this distal location via an arthroscopic approach allow patients to avoid the morbidity of an open approach. There are several prior anatomic studies addressing the proximal humerus anatomy and relationship of the biceps tendon to surrounding structures. However, many of these discuss relationships that are only pertinent during an open approach. LaFrance et al20 investigated the relationship between the longitudinal width of the pectoralis tendon at its humeral insertion and the musculotendinous junction of the biceps tendon. They found that the final resting spot of the most distal aspect of the musculotendinous junction of the LHB tendon after tenodesis should be approximately 3 cm distal to the inferior edge of the pectoralis major tendon. These landmarks are not, however, relevant to the standard arthroscopic techniques because the distal aspect of the LHB musculotendinous junction or the inferior edge of the pectoralis major is not commonly visualized. The findings of our study are consistent with those of a study performed by Jarrett et al.14 In their study of a similar number of cadaveric specimens, the musculocutaneous nerve was a mean of 3.47 cm medial to the LHB at the superior border of the pectoralis tendon. The anterior humeral circumflex vessels were 4.63 cm proximal to the musculotendinous junction of the LHB, and the distance from the lesser tuberosity to the musculotendinous junction of the biceps was 5.37 cm.14 Several cadaver studies have also shown a trend that more superior placement of arthroscopic biceps tenodesis, com-
A.S. Neviaser et al. pared to an open subpectoral biceps tenodesis, has an association with overtensioning. In a cadaveric comparison of arthroscopic tenodesis and open subpectoral tenodesis techniques, Johannsen et al15 showed that while both techniques enabled placement of the tenodesis tunnel distal to the inferior border of the bicipital groove, with an average distance of 9.8 mm in the arthroscopic specimens, the open subpectoral approach placed the tunnel a mean of 2.2 cm farther distal than the arthroscopic approach. In a biomechanical cadaveric comparison study, Werner et al 35 showed that the arthroscopic suprapectoral technique resulted in a mean of 2.15 cm of biceps over-tensioning versus 0.78 cm in an open subpectoral tenodesis group. In a clinical examination of increased postoperative stiffness following arthroscopic suprapectoral tenodesis, Werner et al noted that the tenodesis site in patients with stiffness was significantly more proximal than in those without stiffness. Of 106 patients in this group, 17.9% reported postoperative stiffness at 9 months postoperatively, in comparison with 5.6% in 143 patients following open subpectoral tenodesis. Tenodesis sites in those reporting stiffness were a mean of 32.4 mm from the top of the humeral head versus 50.34 mm in patients without stiffness.36 These studies demonstrate the importance of consistently placing the biceps tenodesis site at the proper anatomic location to re-create the appropriate biceps tension. Recognizing the anatomic differences between our male and female specimens is also critical to appropriate tensioning. Demographic studies have shown that men undergo bicep tenodesis more frequently than women, at a ratio of nearly 2:1.16,30,31 Female patients have been shown to be more likely to experience postoperative stiffness.36 In our study the distance from the proximal tendon edge to the proximal insertion of the pectoralis major tendon was a mean of 2.17 cm greater in the male specimens than in the female specimens. Indiscriminant resection of a uniform length of tendon without awareness of any sex-specific differences may lead to overtensioning and complications in female patients. There are a few limitations to our study. First, only 11 specimens were available for analysis. We did show statistically significant differences between male and female specimens, but more specimens would enable us to further confirm these differences. In future anatomic studies, examining the biceps tendon arthroscopically could help confirm whether the neurovascular structures appreciated in this study are readily visible intraoperatively.
Conclusion These findings provide reliable landmarks for accurate placement and fixation of the LHB tendon when performing an arthroscopic suprapectoral tenodesis. The proximal LHB tendon can be divided into 3 broad anatomic segments: 2.5 cm intra-articularly, 3 cm in the bicipital groove, and 3 cm suprapectorally. Crossing vessels are reliably
ARTICLE IN PRESS Landmarks for arthroscopic suprapectoral tenodesis identified during arthroscopy to bisect the suprapectoral humeral segment and ensure safe placement of the tenodesis distal to the biceps groove and in the midsuprapectoral zone.
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Disclaimer The authors, their immediate families, and any research foundations with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.
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