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Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: Radiographic Characteristics
Arthroscopic Suprapectoral and Open Subpectoral Biceps Tenodesis: Radiographic Characteristics Justin L. Hodgins, M.D., David Kovacevic, M.D., Stephen Purcell, B.S., Charles M. Jobin, M.D., William N. Levine, M.D., and Christopher S. Ahmad, M.D.
Purpose: To provide a detailed account of the location of the long head of the biceps (LHB) tenodesis tunnels using an all-arthroscopic suprapectoral technique in a prospective group of patients. These patients were then compared with a retrospective group of open subpectoral tenodesis patients of similar characteristics. Methods: Postoperative radiographs from a prospective group of all-arthroscopic suprapectoral LHB tenodeses were compared with a retrospective group of open subpectoral tenodeses. Digital anteroposterior images were used to measure distances from clinically pertinent radiographic landmarks to tenodesis tunnel sites. Results: Forty patients (20 all-arthroscopic, 20 open) met the inclusion criteria. The inferior border of the bicipital groove was located a mean distance of 33.7 6.9 mm from the top of the humeral head. The mean distance measured in the open group was approximately 28 mm (P < .001) distal compared with the arthroscopic group. The humeral diameter was 7.5 5.4 mm narrower at the subpectoral tenodesis site (P < .001). All 20 patients in the open subpectoral group had tenodesis tunnels placed distal to the bicipital groove compared with 17 of 20 patients (85%) in the all-arthroscopic group. There were 2 cases of lateral wall cortical reaming during subpectoral tenodesis but no periprosthetic humeral fractures. There were 2 cases of bicortical reaming during the all-arthroscopic tenodesis with no known complications. Conclusions: The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques, and the open subpectoral method achieves fixation in a significantly narrower region of the humerus. Level of Evidence: Level III, retrospective comparative study.
P
athological lesions of the long head of the biceps (LHB) tendon are a common source of persistent anterior shoulder pain.1,2 Treatment strategies continue
From the Center for Shoulder, Elbow and Sports Medicine, Columbia University, New York, New York, U.S.A. The authors report the following potential conflicts of interest or sources of funding: C.M.J. receives support from the Journal of Bone and Joint Surgery, American; Highlights; Shoulder and Elbow; Journal of Shoulder and Elbow Surgery; Accumed; and Toriner. C.S.A receives support from Arthrex, Major League Baseball, and Stryker. W.N.L. receives support from American Board of Orthopaedic Surgery, American Orthopaedic Association, Journal of the American Academy of Orthopaedic Surgeons, and Zimmer. This study was reviewed and approved by the Columbia University Medical Center Institutional Review Board, protocol no. IRB-AAAP3050. Received October 6, 2015; accepted March 24, 2016. Address correspondence to Christopher S. Ahmad, M.D., Chief, Sports Medicine Service, Co-Director, Center for Shoulder, Elbow, and Sports Medicine, Director, Pediatric and Adolescent Sports Medicine, Biomechanics Research, Professor of Orthopaedic Surgery, Center for Shoulder, Elbow, and Sports Medicine, Columbia University Medical Center, 622 West 168th St, PH11 Center, Room 1113, New York, NY 10032, U.S.A. E-mail: csa4@cumc. columbia.edu Ó 2016 Published by Elsevier on behalf of the Arthroscopy Association of North America 0749-8063/15903/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.03.101
to evolve, and the management of symptomatic LHB disorders is the subject of considerable research and controversy.3-5 Biceps tenodesis has emerged as the preferred surgical technique for younger individuals, athletes, manual laborers, and those wishing to avoid cosmetic deformities.3 Tenodesis attempts to maintain the appropriate length-tension relationship of the biceps brachii, therefore lessening muscle spasms and “Popeye” deformity with evidence of improved return to physical activity, despite longer rehabilitation times.6-8 A variety of tenodesis techniques have been described and can vary according to method of exposure,1,3,5,9,10 choice of fixation,11-13 and intended tenodesis site.14,15 The 2 primary procedures are the arthroscopic “suprapectoral” method, which places the tenodesis above the pectoralis minor (PM) tendon, either within or distal to the bicipital groove,9,10,16 and the open “subpectoral” tenodesis.8,11,17-19 With the suprapectoral technique, there are concerns that LHB tenodesis within the groove may be a potential source of persistent anterior shoulder pain due to continued diseased tendon within the groove.8,17,18 Therefore, the subpectoral tenodesis technique has the advantage of tenodesis below the PM tendon, completely removing pathologic LHB tendon from the bicipital groove. Although rare, complications
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including nerve injury, deep infection, and fracture have been reported with the open subpectoral tenodesis.20-22 The optimal technique still remains uncertain, and studies directly comparing all-arthroscopic suprapectoral and open subpectoral methods have been demonstrated both to be safe and to yield excellent outcomes.23,24 Despite the high frequency of biceps tenodesis procedures, there are few investigations reporting tunnel position radiographically.25-27 The all-arthroscopic tenodesis attempts to position the tunnel distal to the bicipital groove, but anatomic landmarks can be challenging to determine arthroscopically, and it is possible that discrepancies may exist between intended and actual sites of tenodesis. Likewise, body habitus and the proximity of neurovascular structures can make the subpectoral exposure challenging and affect the capacity to place the tenodesis tunnel at the correct level and in the center of the humerus. The purpose of our study was to provide a detailed account of the location of LHB tenodesis tunnels using an all-arthroscopic suprapectoral technique in a prospective group of patients. These patients were then compared with a retrospective group of open subpectoral tenodesis in patients of similar characteristics. We hypothesize that there is no difference between the rates of tunnel placement distal to the bicipital groove between the open and arthroscopic techniques.
Methods The research protocol was approved by the Institutional Review Board of Columbia University Medical Center. The study contained 2 groups of subjects: a prospective, all-arthroscopic suprapectoral tenodesis group and a retrospective open subpectoral group. The prospective, all-arthroscopic patients were recruited over a 6-month period from January to June of 2014. Inclusion criteria were as follows: (1) all-arthroscopic suprapectoral biceps tenodesis and (2) radiograph of operative shoulder obtained at first postoperative visit. Exclusion criteria included concomitant open shoulder procedures. For the open subpectoral tenodesis group, a retrospective review of all patients who underwent open biceps tenodesis at our institution over a 3-year period from January 2011 to December 2014 was completed. A consecutive series of patients were identified, and inclusion criteria were as follows: (1) open subpectoral biceps tenodesis, (2) postoperative radiographs available for review, and (3) medical records available for review. Exclusion criteria were (1) concomitant open shoulder procedures other than tenodesis, (2) concomitant shoulder arthroplasty, and (3) subsequent procedures performed on operative shoulder. The electronic medical records of all patients satisfying the inclusion and exclusion criteria were reviewed.
Demographic data including age, gender, body mass index (BMI), smoking status, dominant shoulder, and workers’ compensation status were recorded. Operative notes were examined for details of tenodesis technique and concomitant shoulder procedures including rotator cuff repair, acromioplasty, and distal clavicle resection. All procedures were performed by 3 fellowship-trained shoulder surgeons in high-volume clinical practices. Two surgeons commonly used an all-arthroscopic biceps tenodesis technique attempting to tenodese the tendon distal to the bicipital groove at the upper border of the PM tendon; the other surgeon commonly used an open subpectoral biceps tenodesis technique. Surgical Technique The choice of tenodesis technique was by surgeon preference. The all-arthroscopic and open tenodesis procedures were performed in the modified beachchair position under regional (interscalene) anesthesia and sedation. The surgical arm was positioned and adjusted during the procedures using a limb positioner. Standard arthroscopic portals including a posterior viewing and anterior working portal through the rotator interval were used. The LHB was released from its superior labral attachment using arthroscopic scissors, and the remaining stump and superior labrum were debrided. A tagging suture was not placed in the LHB. The arthroscope was inserted into the subacromial space, and a lateral portal was created using an outsidein technique. Bursectomy of the subdeltoid space was completed to facilitate visualization. Concomitant procedures including rotator cuff repair, acromioplasty, and distal clavicle resection were performed as indicated. All-Arthroscopic Suprapectoral Biceps Tenodesis. The all-arthroscopic suprapectoral biceps tenodesis technique was performed according to the method of Lutton et al.16 (Fig 1). The 30 arthroscope was redirected into the anterolateral portal, and the arm positioned to 60 of forward elevation, 30 of external rotation, and 30 of abduction to aid in identification of the LHB within the bicipital groove. Electrocautery was used to release the biceps sheath posterior at the distal groove region, and the LHB tendon was identified. The transverse humeral ligament was left intact covering the groove. Transverse fibers of the falciform ligament from the pectoralis major tendon may cover the inferior portion of the groove in approximately onethird of cases and were removed. The upper boarder of the PM tendon was isolated and identified with electrocautery. An accessory anteroinferior “biceps portal” was established after localization with an 18gauge spinal needle for the appropriate orthogonal angle to the anticipated bony tenodesis site, located below the groove and just proximal to the PM tendon.
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Fig 1. Arthroscopic intraoperative right shoulder images demonstrating biceps tendon within the bicipital groove (A), diseased biceps tendon brought outside of skin through the “biceps portal” (B), identification of pectoralis major tendon at inferior bicipital groove (C), and fixation of the biceps tendon into humerus with interference screw (D). (LHB, long head of the biceps.)
The intended site for tenodesis was marked on the humerus to maintain the appropriate length-tension relationship.28 The LHB was retrieved through the biceps portal with a Kelly clamp and secured with a no. 2 high-tensile suture passed in a whipstitch configuration ending approximately 25 to 30 mm from the tenotomised end. The proximal tendon was excised, and the LHB was sized to determine humeral socket diameter. With the LHB tendon pulled out through the biceps portal and controlled with sutures, the tenodesis site was confirmed arthroscopically to be just below the groove in a bony site that was no longer grossly concave nor bound by the transverse humeral ligament. A terminally threaded guide pin was inserted through the biceps portal unicortically into the desired tenodesis location, and the near cortex overreamed by 0 to 0.5 mm to the anticipated screw diameter using a cannulated reamer. After trial measurement of the LHB tendon size, the appropriate sized cannulated biotenodesis screw (6.25 mm to 8 mm 15 mm) was
loaded and secured to the distal end of the LHB with an additional no. 2 suture running through the cannulated tenodesis screw (Arthrex Inc., Naples FL). The tendon was inserted into the depth of the humeral socket, and the tenodesis screw advanced 1 mm proud of the cortical surface at the tenodesis site. The no. 2 suture passed through the screw was tied to the no. 2 whipstitched suture to create a suture anchor type construct to reinforce the interference screw tenodesis. Open Subpectoral Biceps Tenodesis. The open subpectoral biceps tenodesis was performed according to the method of Mazzocca et al.17 A 3 to 4 cm longitudinal incision was made lateral to the axillary crease. The PM fascia was incised in line with its fibers, and the interval developed by blunt dissection to expose the bicipital groove. A blunt Hohmann retractor was placed deep to the inferior border of the PM tendon on the lateral aspect of the humerus, and the tenotomised LHB was identified. The LHB was
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delivered out of the incision with the assistance of a right-angled clamp and a no. 2 high-tensile suture placed in a whipstitch configuration starting just proximal to the myotendinous junction. The proximal diseased portion of the tendon and surrounding tenosynovium was excised, and the tendon was sized. The bicipital groove was palpated, the periosteum reflected using an elevator, and the desired tenodesis location marked on the humerus. The tunnel was positioned in the center of the humerus just proximal to the resting position of the PM tendon, with the arm in a neutral position, to maintain the lengthtension relationship of the biceps tendon.28 A unicortical terminally threaded guide pin was placed at the tenodesis site and the anterior humeral cortex overreamed by 0.5 mm. The LHB was loaded into the cannulated biotenodesis screw (5.5 to 8 mm 15 mm) and delivered into the humeral tunnel and secured in a similar fashion as described in the all-arthroscopic technique. Radiographic Measurements Patients underwent postoperative anteroposterior (AP), internal rotation, external rotation, outlet, and axillary radiographic views of the shoulder. Each radiograph was performed with a 25-mm marker ball used for standardization and magnification correction during measurements. Digital images were analyzed using Centricity Enterprise Web V3.0 (GE Healthcare OEC, Waukesha, WI). The following anatomical landmarks were identified on the AP images: the superior articular margin of the humeral head, the superolateral aspect of the greater tuberosity, and the inferior articular margin of the humeral head. The most distal extent of the bicipital groove was demarcated by the inferior border of the lesser tuberosity on a neutral AP radiograph. All measurements were performed in parallel with the long axis of the humerus from each anatomic landmark to the most proximal edge of the tenodesis tunnel (Fig 2). The humeral shaft width, defined as the distance from outer medial to lateral cortices, at the level of the tenodesis tunnel was measured perpendicular to the long axis of the humerus. All measurements were performed by an orthopaedic surgeon fellowship trained in shoulder arthroscopy and a clinical orthopaedic fellow, who were blinded to type of tenodesis technique. Statistical Analysis Data were analyzed using SAS 9.4 (SAS Institute, Cary, NC)29; P < .05 was considered statistically significant. Univariate analyses were performed using the c2 test for categorical variables (patient sex, smoking status, workers’ compensation status, dominant arm, concomitant procedures) and the 2-tailed Student’s t-test for continuous variables (age, BMI). Means and
Fig 2. Postoperative anteroposterior left shoulder radiographs of the shoulder with measured distances from anatomical landmarks to proximal lip of tenodesis tunnel: superior articular margin (1), superolateral greater tuberosity (2), inferior border of bicipital groove (3), inferior articular margin (4), and humeral width (5).
standard deviations (SD) were calculated, and independent t tests were used to compare measured landmark distances. All measurements were averaged between 2 independent and blinded measurers for a single reported average distance and SD.
Results A total of 30 all-arthroscopic suprapectoral biceps tenodesis procedures were performed at our institution during the study period of January to June of 2014. Twenty patients were eligible for inclusion, and 10 patients’ digital postoperative radiographs were not available for review. Twenty of 89 patients who underwent open subpectoral biceps tenodesis were included after retrospective review of the patient database, postoperative radiographs, and operative reports on consecutive patients from January 2011 to December 2014. Of the patients excluded, 52 had a concomitant total shoulder arthroplasty, 14 did not have digital postoperative radiographs available for review, and 3 had other open bony procedures. The demographic characteristics and operative details of each patient group are listed in Table 1. There were no significant differences between the all-arthroscopic and open subpectoral groups with respect to mean age, BMI, sex, workers’ compensation status, smoking, or involvement of the dominant arm. For concomitant procedures, a significantly greater number of acromioplasties was performed in the open subpectoral group (P ¼ .022). The radiographic findings are listed in Table 2. The tenodesis location for the open subpectoral group was approximately 28 mm distal compared with the
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BICEPS TENODESIS RADIOGRAPHIC CHARACTERISTICS Table 1. Patient Demographics Variable Age,* yr Body mass index* Male sex Workers’ compensation Smoker Dominant arm Concomitant procedures Rotator cuff repair Acromioplasty Distal clavicle excision
All-Arthroscopic Open Subpectoral P Tenodesis Tenodesis Value 47.9 14.2 55.9 12.4 .067 29.5 8.7 28.4 4.1 .470 10 (50) 10 (50) .752 1 (5) 1 (5) 1.00 1 (5) 4 (20) .151 13 (65) 13 (65) 1.00 8 (40) 9 (45) 4 (20)
14 (70) 16 (80) 3 (15)
.057 .022 .677
NOTE. Data are expressed as n (%) unless otherwise indicated. *The value is given as the mean and standard deviation.
suprapectoral group for each measured landmark (P < .001; Fig 3). The average width of the humerus was 30.4 5.87 mm and 22.9 5.1 mm for the all-arthroscopic and open subpectoral groups, respectively, with a mean difference of 7.5 mm (P < .001). All 20 patients in the open subpectoral group had the tenodesis tunnel placed distal to the bicipital groove at a mean distance of 40.3 13.3 mm. Seventeen of 20 patients (85%) had the tenodesis tunnel placed distal to the groove in the all-arthroscopic group at a mean distance of 13.6 9.49 mm. The tenodesis tunnels identified within the groove were placed in contact with the most distal 5 mm of the groove. When examining the tenodesis position relative to the medial-lateral width of the humerus, 2 cases (10%) of lateral eccentric tunnel placement were identified in the open subpectoral group and no cases (0%) were identified in the all-arthroscopic group. There were 2 instances (10%) of bicortical tunnel reaming in the all-arthroscopic group, while no cases (0%) were identified in the patients who underwent open subpectoral tenodesis. There were no intraoperative fractures associated with tenodesis or tunnel reaming in either group.
Discussion The open subpectoral method consistently positioned the tenodesis tunnel 28 mm distal to that of the all-arthroscopic suprapectoral group. In addition, the subpectoral tenodesis site had a humeral diameter that was 25% narrower at the level of the tenodesis tunnel.
All patients in the open subpectoral group had the tenodesis tunnel placed distal to the bicipital groove by a mean distance of 40 mm, but interestingly only 85% of the all-arthroscopic group’s tunnels were positioned entirely distal to the groove. The preferred location of the LHB tenodesis is a topic of considerable controversy without consensus in the orthopaedic community. Clinically significant disease and tenosynovitis of the LHB tendon may extend beyond the intraarticular portion and have an inflammatory component extending through the entire bicipital groove.30 To eliminate the possibility of this pathology causing persistent anterior shoulder pain, other investigators have advocated positioning the tenodesis site distal to the groove.8,17,19 Modifications to extra-articular all-arthroscopic tenodesis techniques such as release of the biceps sheath and identification of the PM tendon were introduced in an effort to help achieve tunnel placement as distal as possible.16 Evidence suggests decreased incidences of persistent pain and revision rates for distal tenodesis locations compared with proximal sites using an all-arthroscopic approach.16,31 With distal placement of the LHB tenodesis, revision rates for all-arthroscopic methods approach that of open subpectoral tenodesis without the complication profile.23,24 Lutton et al.16 retrospectively assessed 17 patients who underwent all-arthroscopic suprapectoral tenodesis for tunnel position relative to the bicipital groove. Five tenodeses were placed within the upper half of the groove, 2 within the distal portion of the groove, and 10 entirely distal with no portion of the tendon in contact with the groove. Two of the patients with tenodesis placed within the upper half of the groove had tenderness at the site on physical exam and persistent postoperative pain at 1 year from time of surgery. The authors did not quantify tunnel or groove position and did not provide details for the radiographic interpretation of the procedure. Johannsen et al.25 anatomically and radiographically evaluated the tenodesis location after all-arthroscopic suprapectoral and open subpectoral tenodesis in 20 matched cadaver shoulders. Upon dissection, all tenodeses were distal to the bicipital groove; the all-arthroscopic location on average was 9.8 8.6 mm distal, and the open location, 32.8 7.8 mm distal.
Table 2. Radiographic Findings Landmark to Tenodesis Site Superior articular margin of humeral head Greater tuberosity Inferior articular margin of humeral head Inferior bicipital groove border Humeral width
All-Arthroscopic Tenodesis 46.5 11.2 30.5 9.8 8.9 10.9 13.6 9.5 30.4 5.9
Open Subpectoral Tenodesis 74.4 13.1 59.5 13.1 36.6 12.6 40.3 13.3 22.9 5.1
NOTE. Values (mm) are shown as mean standard deviation measurements from clinically pertinent landmarks.
Difference 27.9 28.9 27.6 26.7 7.5
P Value <.001 <.001 <.001 .302 <.001
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Fig 3. Postoperative anteroposerior left shoulder radiograph: allarthroscopic suprapectoral biceps tenodesis (A) and open subpectoral biceps tenodesis (B). The arrow points to the tenodesis tunnel.
In our study, 3 of 20 (15%) suprapectoral tenodesis locations were placed within the distal 5 mm of the bicipital groove on postoperative radiographs, despite arthroscopic confirmation of finding the PM tendon, clearing the infragroove region to a flat bony tenodesis site, and staying distal to the transverse humeral ligament overlying the groove. In our surgical technique, we routinely release the biceps sheath until the proximal extent of the PM tendon can be visualized as a landmark in an attempt to place the tenodesis site as distal as possible. The discrepancy between our intended and actual tenodesis positions, as measured radiographically, may reflect variations in groove morphology and the upper boarder of the PM tendon location. It is possible that some biceps grooves extend distally beneath the PM tendon or that some PM tendons extend proximally to cover a portion of the lower biceps groove. Additional anatomic variations include the presence of the falciform ligament in approximately onethird of cases. The ligament is identified by the intersection of the transverse fibers of the pectoralis major tendon over the biceps sheath and may be mistaken for fibers of the PM tendon.32 Other factors such as fluid extravasation and soft-tissue swelling from concomitant procedures may contribute to the difficulty in identifying the arthroscopic anatomy, but this was not our experience with the all-arthroscopic technique. Rather, we found that excessive tissue swelling made tenodesis length-tension assessment difficult as the proximal biceps tendon could not easily be pulled out of the biceps portal for whipstitch suturing and resection of the proximal 25 mm of diseased tendon. Subdeltoid and subacromial visualization can also be impaired by inflamed bursa and profuse bleeding, which is directly related to the systolic blood pressure of the patient.33 Using calibrated postoperative radiographs, the location of the tenodesis site was approximately 28 mm
distal in the open subpectoral group compared with in the all-arthroscopic suprapectoral group for each anatomic landmark. Johannsen et al.25 reported open tenodesis tunnels were on average 22 mm distal to the arthroscopically created tunnels in matched cadaver shoulders in reference to the greater tuberosity and the inferior margin of the humeral head. They also measured the mean difference in humeral width at the level of tenodesis to be 8.5 mm. This is slightly larger than the 7.5 mm mean difference found in our investigation but still represents a 25% difference in humeral diameter at the subpectoral tenodesis site versus the suprapectoral site. The authors used live fluoroscopy to perform measurements and did not specify how humerus position was standardized or if image magnification was corrected. Similarly, Werner et al.27 reported a single measurement from the top of the humeral head to the tenodesis site in a retrospective review comparing postoperative stiffness in patients undergoing arthroscopic and open biceps tenodesis. The open group’s tenodesis tunnel was consistently 23 mm distal to that of the arthroscopic group, and the authors suggested that the incidence of postoperative stiffness increased with a more superior tenodesis placement. Cadaver data have previously described the proximal origin of the PM tendon to be approximately 56 mm from the top of the humeral articular surface.34 In our study, the mean distance from the superior articular margin of the humerus to the tenodesis site in the open group was 74.4 mm, or 18.4 mm on average inferior to the leading edge of the PM tendon. The all-arthroscopic technique positioned the tenodesis a mean distance of 46.5 mm from the top of the humerus, or an average of 9.5 mm proximal to the PM tendon. The discrepancy in distance is at least partly attributed to the diameter of the tenodesis screw, which is referenced at the superior
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Although exceedingly rare, humeral fracture after open subpectoral LHB tenodesis has been reported.36,37 Most fractures are attributed to malpositioned screws or drills holes, and biomechanical testing in cadaver specimens has shown that lateral eccentric tunnel placement can reduce humeral strength by up to 25%.38 We did report 2 cases (10%) of lateral eccentric tunnel placement, defined as lateral placement by a distance equal to 30% of the medial-lateral width of the humerus on a standard anteroposterior radiograph (Fig 5). The surgeon must ensure that both the medial and lateral cortices of the humerus are visualized before committing to tenodesis position, especially in cases involving large soft-tissue envelopes where maintaining exposure can be challenging.
Fig 4. Postoperative anteroposterior radiograph of the right shoulder demonstrating the “double ring” sign (arrow) consistent with bicortical reaming of the humerus.
boarder of the PM tendon. These findings are consistent with those of Werner et al.,26 who retrospectively reported the absolute distance from the top of the humeral head in open subpectoral tenodeses of 75.2 mm compared with 48.9 mm with an allarthroscopic technique. The authors did not comment on tenodesis location in relation to the bicipital groove or humerus width at the level of the tenodesis. Several additional radiographic irregularities that have not been previously reported were also identified during review of the radiographs. Both tenodesis techniques require unicortical drilling and reaming of the anterior cortex of the humerus, but the soft, largely cancellous bone in the suprapectoral region may be at risk of bicortical penetration. A depth gauge can be used to detect breaches in the posterior cortex of the humerus prior to reaming, and a guide with depth limiter may also be protective. A “double ring” tenodesis tunnel was present in 2 of the 20 (10%) allarthroscopic suprapectoral tenodeses suspicious of bicortical reaming (Fig 4). There was no evidence of posterior cortex penetration with open subpectoral tenodesis. Penetration of the posterior cortex of the humerus in the suprapectoral region is concerning as the axillary nerve has been shown to be within 10.5 mm of the guide pin and in direct contact with the nerve in 20% of cases in cadaver studies.35
Limitations This investigation does not report clinical outcomes, and specific clinical implications of tenodesis location are not implied. The measurement technique was performed using caliper software, but precise landmark determination has a degree of subjectivity and has not been validated. The relatively small sample sizes of the comparative groups are noteworthy and potentially a source of beta error. In addition, the open subpectoral tenodesis group was identified retrospectively and may contain biases inherent to retrospective study design. The study also used 3 surgeons to perform the procedures, and the choice of technique was by surgeon preference and not randomized, which could
Fig 5. Postoperative anteroposterior radiograph of the left shoulder demonstrating lateral eccentric tenodesis tunnel placement in the subpectoral region.
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potentially introduce performance bias, and some variation in technique could exist over the study period. Lastly, fixation was achieved for both the allarthroscopic and open tenodesis techniques using an interference screw. A variety of other tenodesis techniques have been described and are used including suture anchor, button fixation, and soft-tissue methods. Each technique has its own unique benefits and potential complications, thus limiting the generalizability of the results to surgeons who use alternate fixation techniques other than interference screws.
Conclusions The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques, and the open subpectoral method achieves fixation in a significantly narrower region of the humerus.
References 1. Ahrens PM, Boileau P. The long head of biceps and associated tendinopathy. J Bone Joint Surg Br 2007;89: 1001-1009. 2. Elser F, Braun S, Dewing CB, et al. Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon. Arthroscopy 2011;27:581-592. 3. Nho SJ, Strauss EJ, Lenart BA, et al. Long head of the biceps tendinopathy: diagnosis and management. J Am Acad Orthop Surg 2010;18:645-656. 4. Werner BC, Brockmeier SF, Gwathmey FW. Trends in long head biceps tenodesis. Am J Sports Med 2015;43: 570-578. 5. Werner BC, Burrus MT, Miller MD, Brockmeier SF. Tenodesis of the long head of the biceps: a review of indications, techniques, and outcomes. JBJS Rev 2014;2: e3. 6. Boileau P, Baque F, Valerio L, et al. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am 2007;89:747-757. 7. Hsu AR, Ghodadra NS, Provencher MT, et al. Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg 2011;20: 326-332. 8. Mazzocca AD, Cote MP, Arciero CL, et al. Clinical outcomes after subpectoral biceps tenodesis with an interference screw. Am J Sports Med 2008;36:1922-1929. 9. Ahmad CS, ElAttrache NS. Arthroscopic biceps tenodesis. Orthop Clin North Am 2003;34:499-506. 10. Boileau P, Neyton L. Arthroscopic tenodesis for lesions of the long head of the biceps. Oper Orthop Traumatol 2005;17:601-623. 11. Golish SR, Caldwell PE 3rd, Miller MD, et al. Interference screw versus suture anchor fixation for subpectoral tenodesis of the proximal biceps tendon: a cadaveric study. Arthroscopy 2008;24:1103-1108. 12. Mazzocca AD, Bicos J, Santangelo S, et al. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy 2005;21:1296-1306.
13. Ozalay M, Akpinar S, Karaeminogullari O, et al. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy 2005;21:992-998. 14. Franceschi F, Longo UG, Ruzzini L, et al. Soft tissue tenodesis of the long head of the biceps tendon associated to the Roman bridge repair. BMC Musculoskelet Disord 2008;9:78. 15. Scheibel M, Schroder RJ, Chen J, et al. Arthroscopic soft tissue tenodesis versus bony fixation anchor tenodesis of the long head of the biceps tendon. Am J Sports Med 2011;39:1046-1052. 16. Lutton DM, Gruson KI, Harrison AK, Gladstone JN, Flatow EL. Where to tenodese the biceps: proximal or distal? Clin Orthop Relat Res 2011;469:1050-1055. 17. Mazzocca AD, Rios CG, Romeo AA, Arciero RA. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy 2005;21:896. 18. Millett PJ, Sanders B, Gobezie R, et al. Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: does it matter? BMC Musculoskelet Disord 2008;9: 121. 19. Provencher MT, LeClere LE, Romeo AA. Subpectoral biceps tenodesis. Sports Med Arthrosc 2008;16:170-176. 20. Ma H, Van Heest A, Glisson C, Patel S. Musculocutaneous nerve entrapment: an unusual complication after biceps tenodesis. Am J Sports Med 2009;37:2467-2469. 21. Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Mazzocca AD, Romeo AA. Complications associated with subpectoral biceps tenodesis: low rates of incidence following surgery. J Shoulder Elbow Surg 2010;19:764-768. 22. Rhee PC, Spinner RJ, Bishop AT, Shin AY. Iatrogenic brachial plexus injuries associated with open subpectoral biceps tenodesis: a report of 4 cases. Am J Sports Med 2013;41:2048-2053. 23. Gombera MM, Kahlenberg CA, Nair R, Saltzman MD, Terry MA. All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii. Am J Sports Med 2015;43:1077-1083. 24. Werner BC, Evans CL, Holzgrefe RE, et al. Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of minimum 2-year clinical outcomes. Am J Sports Med 2014;42:2583-2590. 25. Johannsen AM, Macalena JA, Carson EW, Tompkins M. Anatomic and radiographic comparison of arthroscopic suprapectoral and open subpectoral biceps tenodesis sites. Am J Sports Med 2013;41:2919-2924. 26. Werner BC, Miller MD, Lyons ML, et al. Biceps tenodesis: how low do you go? A comparison of location between arthroscopic suprapectoral and open subpectoral techniques. Ortho J Sports Med 2013;1. 27. Werner BC, Pehlivan HC, Hart JM, et al. Increased incidence of postoperative stiffness after arthroscopic compared with open biceps tenodesis. Arthroscopy 2014;30:1075-1084. 28. Denard PJ, Dai X, Hanypsiak BT, Burkhart SS. Anatomy of the biceps tendon: implications for restoring physiological length-tension relation during biceps tenodesis with interference screw fixation. Arthroscopy 2012;28: 1352-1358. 29. SAS [computer program]. Version 9.4. Cary, NC: SAS Institute, 2013.
BICEPS TENODESIS RADIOGRAPHIC CHARACTERISTICS 30. DePalma AF, Callery GE. Bicipital tenosynovitis. Clin Orthop Relat Res 1954;3:69-85. 31. Sanders B, Lavery K, Pennington S, Warner JJP. Biceps tendon tenodesis: success with proximal versus distal fixation (SS-16). Arthroscopy 2008;24. e9-e9. 32. David TS, Schildhorn JC. Arthroscopic suprapectoral tenodesis of the long head biceps: reproducing an anatomic length-tension relationship. Arthrosc Tech 2012;1:e127-e132. 33. Morrison DS, Schaefer RK, Friedman RL. The relationship between subacromial space pressure, blood pressure, and visual clarity during arthroscopic subacromial decompression. Arthroscopy 1995;11:557-560. 34. Murachovsky J, Ikemoto RY, Nascimento LG, Fujiki EN, Milani C, Warner JJ. Pectoralis major tendon reference (PMT): a new method for accurate restoration of humeral
35.
36.
37.
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length with hemiarthroplasty for fracture. J Shoulder Elbow Surg 2006;15:675-678. Sethi PM, Vadasdi K, Greene RT, Vitale MA, Duong M, Miller SR. Safety of open suprapectoral and subpectoral biceps tenodesis: an anatomic assessment of risk for neurologic injury. J Shoulder Elbow Surg 2015;24:138-142. Reiff SN, Nho SJ, Romeo AA. Proximal humerus fracture after keyhole biceps tenodesis. Am J Orthop 2010;39: E61-E63. Sears BW, Spencer EE, Getz CL. Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients. J Shoulder Elbow Surg 2011;20:e7-e11. Euler SA, Smith SD, Williams BT, Dornan GJ, Millett PJ, Wijdicks CA. Biomechanical analysis of subpectoral biceps tenodesis: effect of screw malpositioning on proximal humeral strength. Am J Sports Med 2015;43:69-74.
Purpose: To provide a detailed account of the location of the long head of the biceps (LHB) tenodesis tunnels using an all-arthroscopic suprapectoral technique in a prospective group of patients. These patients were then compared with a retrospective group of open subpectoral tenodesis patients of similar characteristics. Methods: Postoperative radiographs from a prospective group of all-arthroscopic suprapectoral LHB tenodeses were compared with a retrospective group of open subpectoral tenodeses. Digital anteroposterior images were used to measure distances from clinically pertinent radiographic landmarks to tenodesis tunnel sites. Results: Forty patients (20 all-arthroscopic, 20 open) met the inclusion criteria. The inferior border of the bicipital groove was located a mean distance of 33.7 6.9 mm from the top of the humeral head. The mean distance measured in the open group was approximately 28 mm (P < .001) distal compared with the arthroscopic group. The humeral diameter was 7.5 5.4 mm narrower at the subpectoral tenodesis site (P < .001). All 20 patients in the open subpectoral group had tenodesis tunnels placed distal to the bicipital groove compared with 17 of 20 patients (85%) in the all-arthroscopic group. There were 2 cases of lateral wall cortical reaming during subpectoral tenodesis but no periprosthetic humeral fractures. There were 2 cases of bicortical reaming during the all-arthroscopic tenodesis with no known complications. Conclusions: The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques, and the open subpectoral method achieves fixation in a significantly narrower region of the humerus. Level of Evidence: Level III, retrospective comparative study.
P
athological lesions of the long head of the biceps (LHB) tendon are a common source of persistent anterior shoulder pain.1,2 Treatment strategies continue
From the Center for Shoulder, Elbow and Sports Medicine, Columbia University, New York, New York, U.S.A. The authors report the following potential conflicts of interest or sources of funding: C.M.J. receives support from the Journal of Bone and Joint Surgery, American; Highlights; Shoulder and Elbow; Journal of Shoulder and Elbow Surgery; Accumed; and Toriner. C.S.A receives support from Arthrex, Major League Baseball, and Stryker. W.N.L. receives support from American Board of Orthopaedic Surgery, American Orthopaedic Association, Journal of the American Academy of Orthopaedic Surgeons, and Zimmer. This study was reviewed and approved by the Columbia University Medical Center Institutional Review Board, protocol no. IRB-AAAP3050. Received October 6, 2015; accepted March 24, 2016. Address correspondence to Christopher S. Ahmad, M.D., Chief, Sports Medicine Service, Co-Director, Center for Shoulder, Elbow, and Sports Medicine, Director, Pediatric and Adolescent Sports Medicine, Biomechanics Research, Professor of Orthopaedic Surgery, Center for Shoulder, Elbow, and Sports Medicine, Columbia University Medical Center, 622 West 168th St, PH11 Center, Room 1113, New York, NY 10032, U.S.A. E-mail: csa4@cumc. columbia.edu Ó 2016 Published by Elsevier on behalf of the Arthroscopy Association of North America 0749-8063/15903/$36.00 http://dx.doi.org/10.1016/j.arthro.2016.03.101
to evolve, and the management of symptomatic LHB disorders is the subject of considerable research and controversy.3-5 Biceps tenodesis has emerged as the preferred surgical technique for younger individuals, athletes, manual laborers, and those wishing to avoid cosmetic deformities.3 Tenodesis attempts to maintain the appropriate length-tension relationship of the biceps brachii, therefore lessening muscle spasms and “Popeye” deformity with evidence of improved return to physical activity, despite longer rehabilitation times.6-8 A variety of tenodesis techniques have been described and can vary according to method of exposure,1,3,5,9,10 choice of fixation,11-13 and intended tenodesis site.14,15 The 2 primary procedures are the arthroscopic “suprapectoral” method, which places the tenodesis above the pectoralis minor (PM) tendon, either within or distal to the bicipital groove,9,10,16 and the open “subpectoral” tenodesis.8,11,17-19 With the suprapectoral technique, there are concerns that LHB tenodesis within the groove may be a potential source of persistent anterior shoulder pain due to continued diseased tendon within the groove.8,17,18 Therefore, the subpectoral tenodesis technique has the advantage of tenodesis below the PM tendon, completely removing pathologic LHB tendon from the bicipital groove. Although rare, complications
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including nerve injury, deep infection, and fracture have been reported with the open subpectoral tenodesis.20-22 The optimal technique still remains uncertain, and studies directly comparing all-arthroscopic suprapectoral and open subpectoral methods have been demonstrated both to be safe and to yield excellent outcomes.23,24 Despite the high frequency of biceps tenodesis procedures, there are few investigations reporting tunnel position radiographically.25-27 The all-arthroscopic tenodesis attempts to position the tunnel distal to the bicipital groove, but anatomic landmarks can be challenging to determine arthroscopically, and it is possible that discrepancies may exist between intended and actual sites of tenodesis. Likewise, body habitus and the proximity of neurovascular structures can make the subpectoral exposure challenging and affect the capacity to place the tenodesis tunnel at the correct level and in the center of the humerus. The purpose of our study was to provide a detailed account of the location of LHB tenodesis tunnels using an all-arthroscopic suprapectoral technique in a prospective group of patients. These patients were then compared with a retrospective group of open subpectoral tenodesis in patients of similar characteristics. We hypothesize that there is no difference between the rates of tunnel placement distal to the bicipital groove between the open and arthroscopic techniques.
Methods The research protocol was approved by the Institutional Review Board of Columbia University Medical Center. The study contained 2 groups of subjects: a prospective, all-arthroscopic suprapectoral tenodesis group and a retrospective open subpectoral group. The prospective, all-arthroscopic patients were recruited over a 6-month period from January to June of 2014. Inclusion criteria were as follows: (1) all-arthroscopic suprapectoral biceps tenodesis and (2) radiograph of operative shoulder obtained at first postoperative visit. Exclusion criteria included concomitant open shoulder procedures. For the open subpectoral tenodesis group, a retrospective review of all patients who underwent open biceps tenodesis at our institution over a 3-year period from January 2011 to December 2014 was completed. A consecutive series of patients were identified, and inclusion criteria were as follows: (1) open subpectoral biceps tenodesis, (2) postoperative radiographs available for review, and (3) medical records available for review. Exclusion criteria were (1) concomitant open shoulder procedures other than tenodesis, (2) concomitant shoulder arthroplasty, and (3) subsequent procedures performed on operative shoulder. The electronic medical records of all patients satisfying the inclusion and exclusion criteria were reviewed.
Demographic data including age, gender, body mass index (BMI), smoking status, dominant shoulder, and workers’ compensation status were recorded. Operative notes were examined for details of tenodesis technique and concomitant shoulder procedures including rotator cuff repair, acromioplasty, and distal clavicle resection. All procedures were performed by 3 fellowship-trained shoulder surgeons in high-volume clinical practices. Two surgeons commonly used an all-arthroscopic biceps tenodesis technique attempting to tenodese the tendon distal to the bicipital groove at the upper border of the PM tendon; the other surgeon commonly used an open subpectoral biceps tenodesis technique. Surgical Technique The choice of tenodesis technique was by surgeon preference. The all-arthroscopic and open tenodesis procedures were performed in the modified beachchair position under regional (interscalene) anesthesia and sedation. The surgical arm was positioned and adjusted during the procedures using a limb positioner. Standard arthroscopic portals including a posterior viewing and anterior working portal through the rotator interval were used. The LHB was released from its superior labral attachment using arthroscopic scissors, and the remaining stump and superior labrum were debrided. A tagging suture was not placed in the LHB. The arthroscope was inserted into the subacromial space, and a lateral portal was created using an outsidein technique. Bursectomy of the subdeltoid space was completed to facilitate visualization. Concomitant procedures including rotator cuff repair, acromioplasty, and distal clavicle resection were performed as indicated. All-Arthroscopic Suprapectoral Biceps Tenodesis. The all-arthroscopic suprapectoral biceps tenodesis technique was performed according to the method of Lutton et al.16 (Fig 1). The 30 arthroscope was redirected into the anterolateral portal, and the arm positioned to 60 of forward elevation, 30 of external rotation, and 30 of abduction to aid in identification of the LHB within the bicipital groove. Electrocautery was used to release the biceps sheath posterior at the distal groove region, and the LHB tendon was identified. The transverse humeral ligament was left intact covering the groove. Transverse fibers of the falciform ligament from the pectoralis major tendon may cover the inferior portion of the groove in approximately onethird of cases and were removed. The upper boarder of the PM tendon was isolated and identified with electrocautery. An accessory anteroinferior “biceps portal” was established after localization with an 18gauge spinal needle for the appropriate orthogonal angle to the anticipated bony tenodesis site, located below the groove and just proximal to the PM tendon.
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Fig 1. Arthroscopic intraoperative right shoulder images demonstrating biceps tendon within the bicipital groove (A), diseased biceps tendon brought outside of skin through the “biceps portal” (B), identification of pectoralis major tendon at inferior bicipital groove (C), and fixation of the biceps tendon into humerus with interference screw (D). (LHB, long head of the biceps.)
The intended site for tenodesis was marked on the humerus to maintain the appropriate length-tension relationship.28 The LHB was retrieved through the biceps portal with a Kelly clamp and secured with a no. 2 high-tensile suture passed in a whipstitch configuration ending approximately 25 to 30 mm from the tenotomised end. The proximal tendon was excised, and the LHB was sized to determine humeral socket diameter. With the LHB tendon pulled out through the biceps portal and controlled with sutures, the tenodesis site was confirmed arthroscopically to be just below the groove in a bony site that was no longer grossly concave nor bound by the transverse humeral ligament. A terminally threaded guide pin was inserted through the biceps portal unicortically into the desired tenodesis location, and the near cortex overreamed by 0 to 0.5 mm to the anticipated screw diameter using a cannulated reamer. After trial measurement of the LHB tendon size, the appropriate sized cannulated biotenodesis screw (6.25 mm to 8 mm 15 mm) was
loaded and secured to the distal end of the LHB with an additional no. 2 suture running through the cannulated tenodesis screw (Arthrex Inc., Naples FL). The tendon was inserted into the depth of the humeral socket, and the tenodesis screw advanced 1 mm proud of the cortical surface at the tenodesis site. The no. 2 suture passed through the screw was tied to the no. 2 whipstitched suture to create a suture anchor type construct to reinforce the interference screw tenodesis. Open Subpectoral Biceps Tenodesis. The open subpectoral biceps tenodesis was performed according to the method of Mazzocca et al.17 A 3 to 4 cm longitudinal incision was made lateral to the axillary crease. The PM fascia was incised in line with its fibers, and the interval developed by blunt dissection to expose the bicipital groove. A blunt Hohmann retractor was placed deep to the inferior border of the PM tendon on the lateral aspect of the humerus, and the tenotomised LHB was identified. The LHB was
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delivered out of the incision with the assistance of a right-angled clamp and a no. 2 high-tensile suture placed in a whipstitch configuration starting just proximal to the myotendinous junction. The proximal diseased portion of the tendon and surrounding tenosynovium was excised, and the tendon was sized. The bicipital groove was palpated, the periosteum reflected using an elevator, and the desired tenodesis location marked on the humerus. The tunnel was positioned in the center of the humerus just proximal to the resting position of the PM tendon, with the arm in a neutral position, to maintain the lengthtension relationship of the biceps tendon.28 A unicortical terminally threaded guide pin was placed at the tenodesis site and the anterior humeral cortex overreamed by 0.5 mm. The LHB was loaded into the cannulated biotenodesis screw (5.5 to 8 mm 15 mm) and delivered into the humeral tunnel and secured in a similar fashion as described in the all-arthroscopic technique. Radiographic Measurements Patients underwent postoperative anteroposterior (AP), internal rotation, external rotation, outlet, and axillary radiographic views of the shoulder. Each radiograph was performed with a 25-mm marker ball used for standardization and magnification correction during measurements. Digital images were analyzed using Centricity Enterprise Web V3.0 (GE Healthcare OEC, Waukesha, WI). The following anatomical landmarks were identified on the AP images: the superior articular margin of the humeral head, the superolateral aspect of the greater tuberosity, and the inferior articular margin of the humeral head. The most distal extent of the bicipital groove was demarcated by the inferior border of the lesser tuberosity on a neutral AP radiograph. All measurements were performed in parallel with the long axis of the humerus from each anatomic landmark to the most proximal edge of the tenodesis tunnel (Fig 2). The humeral shaft width, defined as the distance from outer medial to lateral cortices, at the level of the tenodesis tunnel was measured perpendicular to the long axis of the humerus. All measurements were performed by an orthopaedic surgeon fellowship trained in shoulder arthroscopy and a clinical orthopaedic fellow, who were blinded to type of tenodesis technique. Statistical Analysis Data were analyzed using SAS 9.4 (SAS Institute, Cary, NC)29; P < .05 was considered statistically significant. Univariate analyses were performed using the c2 test for categorical variables (patient sex, smoking status, workers’ compensation status, dominant arm, concomitant procedures) and the 2-tailed Student’s t-test for continuous variables (age, BMI). Means and
Fig 2. Postoperative anteroposterior left shoulder radiographs of the shoulder with measured distances from anatomical landmarks to proximal lip of tenodesis tunnel: superior articular margin (1), superolateral greater tuberosity (2), inferior border of bicipital groove (3), inferior articular margin (4), and humeral width (5).
standard deviations (SD) were calculated, and independent t tests were used to compare measured landmark distances. All measurements were averaged between 2 independent and blinded measurers for a single reported average distance and SD.
Results A total of 30 all-arthroscopic suprapectoral biceps tenodesis procedures were performed at our institution during the study period of January to June of 2014. Twenty patients were eligible for inclusion, and 10 patients’ digital postoperative radiographs were not available for review. Twenty of 89 patients who underwent open subpectoral biceps tenodesis were included after retrospective review of the patient database, postoperative radiographs, and operative reports on consecutive patients from January 2011 to December 2014. Of the patients excluded, 52 had a concomitant total shoulder arthroplasty, 14 did not have digital postoperative radiographs available for review, and 3 had other open bony procedures. The demographic characteristics and operative details of each patient group are listed in Table 1. There were no significant differences between the all-arthroscopic and open subpectoral groups with respect to mean age, BMI, sex, workers’ compensation status, smoking, or involvement of the dominant arm. For concomitant procedures, a significantly greater number of acromioplasties was performed in the open subpectoral group (P ¼ .022). The radiographic findings are listed in Table 2. The tenodesis location for the open subpectoral group was approximately 28 mm distal compared with the
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BICEPS TENODESIS RADIOGRAPHIC CHARACTERISTICS Table 1. Patient Demographics Variable Age,* yr Body mass index* Male sex Workers’ compensation Smoker Dominant arm Concomitant procedures Rotator cuff repair Acromioplasty Distal clavicle excision
All-Arthroscopic Open Subpectoral P Tenodesis Tenodesis Value 47.9 14.2 55.9 12.4 .067 29.5 8.7 28.4 4.1 .470 10 (50) 10 (50) .752 1 (5) 1 (5) 1.00 1 (5) 4 (20) .151 13 (65) 13 (65) 1.00 8 (40) 9 (45) 4 (20)
14 (70) 16 (80) 3 (15)
.057 .022 .677
NOTE. Data are expressed as n (%) unless otherwise indicated. *The value is given as the mean and standard deviation.
suprapectoral group for each measured landmark (P < .001; Fig 3). The average width of the humerus was 30.4 5.87 mm and 22.9 5.1 mm for the all-arthroscopic and open subpectoral groups, respectively, with a mean difference of 7.5 mm (P < .001). All 20 patients in the open subpectoral group had the tenodesis tunnel placed distal to the bicipital groove at a mean distance of 40.3 13.3 mm. Seventeen of 20 patients (85%) had the tenodesis tunnel placed distal to the groove in the all-arthroscopic group at a mean distance of 13.6 9.49 mm. The tenodesis tunnels identified within the groove were placed in contact with the most distal 5 mm of the groove. When examining the tenodesis position relative to the medial-lateral width of the humerus, 2 cases (10%) of lateral eccentric tunnel placement were identified in the open subpectoral group and no cases (0%) were identified in the all-arthroscopic group. There were 2 instances (10%) of bicortical tunnel reaming in the all-arthroscopic group, while no cases (0%) were identified in the patients who underwent open subpectoral tenodesis. There were no intraoperative fractures associated with tenodesis or tunnel reaming in either group.
Discussion The open subpectoral method consistently positioned the tenodesis tunnel 28 mm distal to that of the all-arthroscopic suprapectoral group. In addition, the subpectoral tenodesis site had a humeral diameter that was 25% narrower at the level of the tenodesis tunnel.
All patients in the open subpectoral group had the tenodesis tunnel placed distal to the bicipital groove by a mean distance of 40 mm, but interestingly only 85% of the all-arthroscopic group’s tunnels were positioned entirely distal to the groove. The preferred location of the LHB tenodesis is a topic of considerable controversy without consensus in the orthopaedic community. Clinically significant disease and tenosynovitis of the LHB tendon may extend beyond the intraarticular portion and have an inflammatory component extending through the entire bicipital groove.30 To eliminate the possibility of this pathology causing persistent anterior shoulder pain, other investigators have advocated positioning the tenodesis site distal to the groove.8,17,19 Modifications to extra-articular all-arthroscopic tenodesis techniques such as release of the biceps sheath and identification of the PM tendon were introduced in an effort to help achieve tunnel placement as distal as possible.16 Evidence suggests decreased incidences of persistent pain and revision rates for distal tenodesis locations compared with proximal sites using an all-arthroscopic approach.16,31 With distal placement of the LHB tenodesis, revision rates for all-arthroscopic methods approach that of open subpectoral tenodesis without the complication profile.23,24 Lutton et al.16 retrospectively assessed 17 patients who underwent all-arthroscopic suprapectoral tenodesis for tunnel position relative to the bicipital groove. Five tenodeses were placed within the upper half of the groove, 2 within the distal portion of the groove, and 10 entirely distal with no portion of the tendon in contact with the groove. Two of the patients with tenodesis placed within the upper half of the groove had tenderness at the site on physical exam and persistent postoperative pain at 1 year from time of surgery. The authors did not quantify tunnel or groove position and did not provide details for the radiographic interpretation of the procedure. Johannsen et al.25 anatomically and radiographically evaluated the tenodesis location after all-arthroscopic suprapectoral and open subpectoral tenodesis in 20 matched cadaver shoulders. Upon dissection, all tenodeses were distal to the bicipital groove; the all-arthroscopic location on average was 9.8 8.6 mm distal, and the open location, 32.8 7.8 mm distal.
Table 2. Radiographic Findings Landmark to Tenodesis Site Superior articular margin of humeral head Greater tuberosity Inferior articular margin of humeral head Inferior bicipital groove border Humeral width
All-Arthroscopic Tenodesis 46.5 11.2 30.5 9.8 8.9 10.9 13.6 9.5 30.4 5.9
Open Subpectoral Tenodesis 74.4 13.1 59.5 13.1 36.6 12.6 40.3 13.3 22.9 5.1
NOTE. Values (mm) are shown as mean standard deviation measurements from clinically pertinent landmarks.
Difference 27.9 28.9 27.6 26.7 7.5
P Value <.001 <.001 <.001 .302 <.001
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Fig 3. Postoperative anteroposerior left shoulder radiograph: allarthroscopic suprapectoral biceps tenodesis (A) and open subpectoral biceps tenodesis (B). The arrow points to the tenodesis tunnel.
In our study, 3 of 20 (15%) suprapectoral tenodesis locations were placed within the distal 5 mm of the bicipital groove on postoperative radiographs, despite arthroscopic confirmation of finding the PM tendon, clearing the infragroove region to a flat bony tenodesis site, and staying distal to the transverse humeral ligament overlying the groove. In our surgical technique, we routinely release the biceps sheath until the proximal extent of the PM tendon can be visualized as a landmark in an attempt to place the tenodesis site as distal as possible. The discrepancy between our intended and actual tenodesis positions, as measured radiographically, may reflect variations in groove morphology and the upper boarder of the PM tendon location. It is possible that some biceps grooves extend distally beneath the PM tendon or that some PM tendons extend proximally to cover a portion of the lower biceps groove. Additional anatomic variations include the presence of the falciform ligament in approximately onethird of cases. The ligament is identified by the intersection of the transverse fibers of the pectoralis major tendon over the biceps sheath and may be mistaken for fibers of the PM tendon.32 Other factors such as fluid extravasation and soft-tissue swelling from concomitant procedures may contribute to the difficulty in identifying the arthroscopic anatomy, but this was not our experience with the all-arthroscopic technique. Rather, we found that excessive tissue swelling made tenodesis length-tension assessment difficult as the proximal biceps tendon could not easily be pulled out of the biceps portal for whipstitch suturing and resection of the proximal 25 mm of diseased tendon. Subdeltoid and subacromial visualization can also be impaired by inflamed bursa and profuse bleeding, which is directly related to the systolic blood pressure of the patient.33 Using calibrated postoperative radiographs, the location of the tenodesis site was approximately 28 mm
distal in the open subpectoral group compared with in the all-arthroscopic suprapectoral group for each anatomic landmark. Johannsen et al.25 reported open tenodesis tunnels were on average 22 mm distal to the arthroscopically created tunnels in matched cadaver shoulders in reference to the greater tuberosity and the inferior margin of the humeral head. They also measured the mean difference in humeral width at the level of tenodesis to be 8.5 mm. This is slightly larger than the 7.5 mm mean difference found in our investigation but still represents a 25% difference in humeral diameter at the subpectoral tenodesis site versus the suprapectoral site. The authors used live fluoroscopy to perform measurements and did not specify how humerus position was standardized or if image magnification was corrected. Similarly, Werner et al.27 reported a single measurement from the top of the humeral head to the tenodesis site in a retrospective review comparing postoperative stiffness in patients undergoing arthroscopic and open biceps tenodesis. The open group’s tenodesis tunnel was consistently 23 mm distal to that of the arthroscopic group, and the authors suggested that the incidence of postoperative stiffness increased with a more superior tenodesis placement. Cadaver data have previously described the proximal origin of the PM tendon to be approximately 56 mm from the top of the humeral articular surface.34 In our study, the mean distance from the superior articular margin of the humerus to the tenodesis site in the open group was 74.4 mm, or 18.4 mm on average inferior to the leading edge of the PM tendon. The all-arthroscopic technique positioned the tenodesis a mean distance of 46.5 mm from the top of the humerus, or an average of 9.5 mm proximal to the PM tendon. The discrepancy in distance is at least partly attributed to the diameter of the tenodesis screw, which is referenced at the superior
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Although exceedingly rare, humeral fracture after open subpectoral LHB tenodesis has been reported.36,37 Most fractures are attributed to malpositioned screws or drills holes, and biomechanical testing in cadaver specimens has shown that lateral eccentric tunnel placement can reduce humeral strength by up to 25%.38 We did report 2 cases (10%) of lateral eccentric tunnel placement, defined as lateral placement by a distance equal to 30% of the medial-lateral width of the humerus on a standard anteroposterior radiograph (Fig 5). The surgeon must ensure that both the medial and lateral cortices of the humerus are visualized before committing to tenodesis position, especially in cases involving large soft-tissue envelopes where maintaining exposure can be challenging.
Fig 4. Postoperative anteroposterior radiograph of the right shoulder demonstrating the “double ring” sign (arrow) consistent with bicortical reaming of the humerus.
boarder of the PM tendon. These findings are consistent with those of Werner et al.,26 who retrospectively reported the absolute distance from the top of the humeral head in open subpectoral tenodeses of 75.2 mm compared with 48.9 mm with an allarthroscopic technique. The authors did not comment on tenodesis location in relation to the bicipital groove or humerus width at the level of the tenodesis. Several additional radiographic irregularities that have not been previously reported were also identified during review of the radiographs. Both tenodesis techniques require unicortical drilling and reaming of the anterior cortex of the humerus, but the soft, largely cancellous bone in the suprapectoral region may be at risk of bicortical penetration. A depth gauge can be used to detect breaches in the posterior cortex of the humerus prior to reaming, and a guide with depth limiter may also be protective. A “double ring” tenodesis tunnel was present in 2 of the 20 (10%) allarthroscopic suprapectoral tenodeses suspicious of bicortical reaming (Fig 4). There was no evidence of posterior cortex penetration with open subpectoral tenodesis. Penetration of the posterior cortex of the humerus in the suprapectoral region is concerning as the axillary nerve has been shown to be within 10.5 mm of the guide pin and in direct contact with the nerve in 20% of cases in cadaver studies.35
Limitations This investigation does not report clinical outcomes, and specific clinical implications of tenodesis location are not implied. The measurement technique was performed using caliper software, but precise landmark determination has a degree of subjectivity and has not been validated. The relatively small sample sizes of the comparative groups are noteworthy and potentially a source of beta error. In addition, the open subpectoral tenodesis group was identified retrospectively and may contain biases inherent to retrospective study design. The study also used 3 surgeons to perform the procedures, and the choice of technique was by surgeon preference and not randomized, which could
Fig 5. Postoperative anteroposterior radiograph of the left shoulder demonstrating lateral eccentric tenodesis tunnel placement in the subpectoral region.
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potentially introduce performance bias, and some variation in technique could exist over the study period. Lastly, fixation was achieved for both the allarthroscopic and open tenodesis techniques using an interference screw. A variety of other tenodesis techniques have been described and are used including suture anchor, button fixation, and soft-tissue methods. Each technique has its own unique benefits and potential complications, thus limiting the generalizability of the results to surgeons who use alternate fixation techniques other than interference screws.
Conclusions The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques, and the open subpectoral method achieves fixation in a significantly narrower region of the humerus.
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