Anatomic and Radiographic Comparison of Arthroscopic and Open Biceps Tenodesis Sites 1 Johannsen AM; 1 Macalena JA; 2 Carson EW; 1,3 Tompkins M Conclusions References Introduction Clinical Significance Acknowledgements Materials & Methods • Arthroscopic and open subpectoral surgical techniques are both commonly utilized approaches for proximal biceps tenodesis of the long head of biceps brachii. A central limitation to the widespread use of an arthroscopic approach for biceps tenodesis is that the tendon may be tenodesed too proximally in the bicipital groove, leading to persistent pain and tendinopathy 1,2,3 . The purpose of this study was to determine the tenodesis location in arthroscopic and open techniques for proximal biceps tenodesis in relation to clinically pertinent anatomic and radiographic landmarks. Hypothesis • Arthroscopic biceps tenodesis would not be significantly different in location from open subpectoral biceps tenodesis. • Both techniques will place the tenodesis tunnel distal to the bicipital groove Specimens • 10 matched-pair cadaveric arm specimens used • One side underwent arthroscopic, the other open approach Surgical Procedure • Two surgeons performed procedures • Biceps tendon tagged in transverse humeral ligament • Arthroscopic tenotomy performed Open • Longitudinal incision along superior axilla • Blunt dissection along inferior border of pectoralis • Biceps tendon identified, placed as far superior along tract as possible Arthroscopic • Three portals: posterior, lateral, anterior, antero-inferior • Antero-inferior: Distal to bicipital groove, over biceps tendon • Tendon incised in bicipital groove and brought through antero-inferior portal • Site as far distal as possible identified and reamed • Tendon secured in tunnel with screw Measurements • Gross measurements conducted to bony and soft tissue landmarks (table 1, figure 1) by two measurers • AP and lateral X-rays performed, measurements conducted using PACS software by two measurers Statistics • Paired T-tests were used to analyze the data. P-values <0.05 were considered significant Gross Measurements The difference between the tenodesis site for arthroscopic and open subpectoral procedures was significant in all measurements. Averaging all four measurements together, the subpectoral site was 2.2 cm distal to the arthroscopic approach. The arthroscopic location was always distal to the bicipital groove (Figure 1, Table 1). Radiographic Measurements AP and lateral radiography displayed that the open subpectoral tunnel was placed 2.1 cm distal to the arthroscopic technique. The average width of the humerus at the tenodesis site was on average 8.5 mm larger for the arthroscopic location. The percent of tunnel diameter as compared to humeral width at the tunnel site was significantly smaller (25%) in the arthroscopic approach as compared to the open approach. Figure 1. Figure 1. This figure displays the pertinent anatomy of an arthroscopic biceps tenodesis. Note that this represents a more proximal placement than the average tunnel in this study since it is proximal to the superior border of the latissimus dorsi tendon, but the placement remains inferior to bicipital groove. (Sup.= superior, Inf.= inferior, Lat.= latissimus, Pec.= pectoralis, BG= Bicipital groove) 1. Lutton DM, Gruson KL, Harrison AK, Gladstone JN, Flatow EL. Where to Tenodese the Biceps: Proximal or Distal. Clin Orthop Relat Res. 2011;469:1050-1055 2. Provencher MT, LeClere LE, Romeo AA. Subpectoral Biceps Tenodesis. Sports Med Arthrosc Rev . 2008;16(3):170-176. 3. Sanders B, Laverly KP, Pennington S, Warner JJ. Clinical success of biceps tenodesis with and without release of the transverse humeral ligament. J Shoulder Elbow Surg. 2012;21:66-71. . Results 1. Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN 2. Department of Orthopaedic Surgery, University of Virginia, CharloAesville, VA 3. TRIA Orthopaedic Center, Minneapolis, MN • Open biceps tenodesis placed the tenodesis tunnel approximately 2cm distal to the arthroscopic technique • Both techniques were distal to the bicipital groove • Both techniques should avoid persistent post-operative bicipital groove pain • Open tenodesis may have a higher risk of risk humeral site fracture Figure 2. Radiographic images of arthroscopic and open tenodesis tunnels in a matched pair specimen. Image A displays the AP and B the lateral view of the arthroscopic tenodesis tunnel. Image C displays the AP and D the lateral view of the open tenodesis tunnel. Tenodesis tunnels are labeled with a black arrow in each radiograph. D Table 1. This table displays average measurements with standard deviations from clinically-pertinent landmarks to the superior lip of the humeral tenodesis tunnel for arthroscopic and open tenodesis techniques. Values are expressed in both measurements (A) and as percentages relative to the humeral diameter at the lower border of the latissimus dorsi tendon (B) (BG= bicipital groove, Lesser Tuber.=Lesser Tuberosity, L. dorsi= Latissimus dorsi). • This may allay concern about the bicipital groove as a pain source using this arthroscopic technique • Radiographic guidelines for assessment of tunnel placement may be used reliably to assess accurate tunnel placement • Humeral fracture risk may be a greater concern for the open approach compared to the arthroscopic approach We would like to thank the Department of Orthopaedic Surgery at the University of Minnesota for financial support, TRIA Orthopaedic Center for their use of facilities and financial support, and Arthrex for the donation of the tendon anchors used in this study. .
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Anatomic and Radiographic Comparison of Arthroscopic and Open Biceps Tenodesis Sites 1Johannsen AM; 1Macalena JA; 2Carson EW; 1,3Tompkins M
Conclusions
References
Introduction
Clinical Significance
Acknowledgements
Materials & Methods
• Arthroscopic and open subpectoral surgical techniques are both commonly utilized approaches for proximal biceps tenodesis of the long head of biceps brachii. A central limitation to the widespread use of an arthroscopic approach for biceps tenodesis is that the tendon may be tenodesed too proximally in the bicipital groove, leading to persistent pain and tendinopathy1,2,3. The purpose of this study was to determine the tenodesis location in arthroscopic and open techniques for proximal biceps tenodesis in relation to clinically pertinent anatomic and radiographic landmarks.
Hypothesis • Arthroscopic biceps tenodesis would not be significantly
different in location from open subpectoral biceps tenodesis. • Both techniques will place the tenodesis tunnel distal to the
bicipital groove
Specimens • 10 matched-pair cadaveric arm specimens used • One side underwent arthroscopic, the other open approach
Surgical Procedure • Two surgeons performed procedures • Biceps tendon tagged in transverse humeral ligament • Arthroscopic tenotomy performed Open • Longitudinal incision along superior axilla • Blunt dissection along inferior border of pectoralis • Biceps tendon identified, placed as far superior along tract as
possible Arthroscopic • Three portals: posterior, lateral, anterior, antero-inferior
• Antero-inferior: Distal to bicipital groove, over biceps tendon
• Tendon incised in bicipital groove and brought through antero-inferior portal
• Site as far distal as possible identified and reamed • Tendon secured in tunnel with screw
Measurements • Gross measurements conducted to bony and soft tissue
landmarks (table 1, figure 1) by two measurers • AP and lateral X-rays performed, measurements conducted
using PACS software by two measurers Statistics • Paired T-tests were used to analyze the data. P-values <0.05
were considered significant
Gross Measurements The difference between the tenodesis site for arthroscopic and
open subpectoral procedures was significant in all measurements. Averaging all four measurements together, the subpectoral site was 2.2 cm distal to the arthroscopic approach. The arthroscopic location was always distal to the bicipital groove (Figure 1, Table 1).
Radiographic Measurements AP and lateral radiography displayed that the open subpectoral
tunnel was placed 2.1 cm distal to the arthroscopic technique. The average width of the humerus at the tenodesis site was on average 8.5 mm larger for the arthroscopic location. The percent of tunnel diameter as compared to humeral width at the tunnel site was significantly smaller (25%) in the arthroscopic approach as compared to the open approach.
Figure 1. Figure 1. This figure displays the pertinent anatomy of an arthroscopic biceps tenodesis. Note that this represents a more proximal placement than the average tunnel in this study since it is proximal to the superior border of the latissimus dorsi tendon, but the placement remains inferior to bicipital groove. (Sup.= superior, Inf.= inferior, Lat.= latissimus, Pec.= pectoralis, BG= Bicipital groove)
1. Lutton DM, Gruson KL, Harrison AK, Gladstone JN, Flatow EL. Where to Tenodese the Biceps: Proximal or Distal. Clin Orthop Relat Res. 2011;469:1050-1055
2. Provencher MT, LeClere LE, Romeo AA. Subpectoral Biceps Tenodesis. Sports Med Arthrosc Rev. 2008;16(3):170-176.
3. Sanders B, Laverly KP, Pennington S, Warner JJ. Clinical
success of biceps tenodesis with and without release of the transverse humeral ligament. J Shoulder Elbow Surg. 2012;21:66-71.
.
Results
1. Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN 2. Department of Orthopaedic Surgery, University of Virginia, CharloAesville, VA
3. TRIA Orthopaedic Center, Minneapolis, MN
• Open biceps tenodesis placed the tenodesis tunnel approximately 2cm distal to the arthroscopic technique
• Both techniques were distal to the bicipital groove
• Both techniques should avoid persistent post-operative bicipital groove pain
• Open tenodesis may have a higher risk of risk humeral site fracture
Figure 2. Radiographic images of arthroscopic and open tenodesis tunnels in a matched pair specimen. Image A displays the AP and B the lateral view of the arthroscopic tenodesis tunnel. Image C displays the AP and D the lateral view of the open tenodesis tunnel. Tenodesis tunnels are labeled with a black arrow in each radiograph.
D
Table 1. This table displays average measurements with standard deviations from clinically-pertinent landmarks to the superior lip of the humeral tenodesis tunnel for arthroscopic and open tenodesis techniques. Values are expressed in both measurements (A) and as percentages relative to the humeral diameter at the lower border of the latissimus dorsi tendon (B) (BG= bicipital groove, Lesser Tuber.=Lesser Tuberosity, L. dorsi= Latissimus dorsi).
• This may allay concern about the bicipital groove as a pain source using this arthroscopic technique
• Radiographic guidelines for assessment of tunnel placement may be used reliably to assess accurate tunnel placement
• Humeral fracture risk may be a greater concern for the open approach compared to the arthroscopic approach
We would like to thank the Department of Orthopaedic Surgery at the University of Minnesota for financial support, TRIA Orthopaedic Center for their use of facilities and financial support, and Arthrex for the donation of the tendon anchors used in this study.
.
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