Name: Biceps Tenodesis: Distal Techniques
Uploaded: 2015-08-27T00:00:00Z
Channel: Arthrex

<p>Matthew Provencher, MD, (Boston, MA) discusses current trends in Superior Labrum Anterior and Posterior (SLAP) and biceps repair, particularly the trend to address SLAP injuries with a primary biceps tenodesis. He also discusses other biceps pathology and details how to address these with a suprapectoral repair using an interference screw as well as a subpectoral repair using a screw or a cortical button.</p>

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VPT1-00542-EN | A | Biceps Tenodesis: Distal Techniques

Matthew T. Provencher

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Biceps Tenodesis: Distal Techniques

So we've already addressed a lot of this. This is I think this is a unique case that's actually a 27 year old in the top right corner, releasing the lateral aspect of the biceps groove and actually had a normal anchor position of the slap. And so these things can be hidden down the shoulder. So a good clinical exam understanding what's going on with the patient. But this really remains pretty hard. And one of the hardest things for us to really diagnose in terms of figuring out what to do with the biceps. Well, I can tell you we probably fixed too many. I certainly fixed too many. And I think some of this was indications, although some would certainly argue with me. I do think a well done slap repair is still very good. I think Knotless fixation should be a big part of this, but if you look internationally, we're against a little bit of a of a tide here that really says almost 100% tenodesis if you're in France or certain other parts of the world where only 20% in the slap repair group did well and got back to athletics in Pascal's hands and overall with 87% of the athletes returned. And you can see sort of similar findings with a very low complication revision rate. What Paul just presented has reigned supreme in our patients and in slightly older patients. No way. Steve Webber looked at our board in the board outcomes in the United States. And this is actually the trend has gone the other way now. But if you look at this, the slap cases were 9% of all shoulder cases, which was well beyond what's described in the incidence literature in terms of Slap. And what was interesting is specialists at a higher rate of repair, maybe trained in it, thought about it and three times repairs versus the current incidence. This is J.P. Warner's data in terms of what he's done for Slap repairs. And you can see slap repairs in green and tenodesis in blue. And so you can see sort of where his practice has migrated in terms of this Boston shoulder experience over the last 20 years in terms of repairs versus tenodesis. And then if you look at from the master of slap and biceps injuries who helped coin this term with Jimmy Andrews, the age for optimal outcomes after slap repair appears to be getting younger. But again, I want to emphasize that we're not all slap tears belong. Not all slap tears belong to the dinosaur. And there still are some very good indications to fix these, especially with the technology that's available here, such as the tapes and the knotless areas. And this is absolutely somewhere where I truly believe Knotless fixation is very important. In the shoulder is the superior 180 degrees, but really the whole labrum now is really a knotless type of construct for me. But especially when we first started with the knotless techniques, the 180 degrees of the glenoid was an area that I really liked using knotless fixation. So addressing these abnormal lesions is understand to understand the anatomy. It's very complex. Lateral stability is usually not the issue. It's provided by the supraspinatus and the lateral portion of the humeral ligament. But this is the board's question for you. The humeral ligament is really the most important. It gets reinforced from the superior glenohumeral ligament but also the SpeedScap fibers. And as Chris just showed on the on the demo, you can actually blend right over into the biceps groove with some of the SpeedScap. And actually that's sometimes part of your repair process. So we stay away from that medially. If you're going to release it in the groove so you don't injure the sub GAP if there's no sub GAP issues. Now one of the things I think is completely underappreciated is the stability of the biceps. And I've been humbled by this again and again with some dynamic ultrasound testing or clicking or catching complaints in the shoulder. You can see this really easily, and it doesn't take much to displace the biceps, just even the superior part of it. And if you have a subscapularis tear, you need to you need to be looking for this because it will a very high chance that it's unstable. If you have an unstable biceps, you should also be looking for a subscapularis tear. These go hand in hand and need to be addressed. Here's an example of a quote unquote lipstik biceps. There's a normal vascular pattern on the anterior aspect of the of the biceps tendon. What I'm showing here, however, is that this pattern is a little bit more than we would like. And so it's more of a pathologic pattern. You can see the cobblestoning, you can see a little bit more of the inflammation. So it's a lipstick lesion of the biceps. But there is a normal vessel pattern there. Just don't take normal vessels. You have to have a little bit of that cobblestoning that inflammation associated with it. Pascal has shown this CT arthrogram and X-ray arthrogram of this finding of an hourglass biceps. I have not seen this. I'll continue to look for it, but he described hypertrophy and buckling of the biceps. So as Jimmy Andrews has taught a lot of us, if you want to do a slap repair order an MRI, we have to be really careful with this. We have to be careful about what the MRI says and what our radiologists say. And that's why we are all as good as the radiologists in here in terms of reading our own MRIs. But these are typical findings of a slap to tear. Here's the lesion below. And you can see the the vertical extension with a little bit of horizontal extension into the into the slap anchor. And you can see that this is frayed. It's torn. There's erythema at the base. And so this is the typical appearance of a slap two. And now here's a slap three lesion where you actually get more of a separated bucket component. And don't underestimate these. Steve has written this up in terms of primary repair. And a lot of times these are in younger patients. I fixed a number of these in ages 14 to 18 year old wrestlers and football players. It's just the way it happens. But you can you have to be prepared for this. If you see something like this on the ArthroRome to be able to address this. And this is something that if you resect this, you're taking out a good portion of their labrum. So you have to have some techniques. And this is a beautiful spot for knotless kind of around the world fixation we talked about yesterday in order to repair this and then also up the biceps proper, especially in a younger patient. And then we have these dreaded slap fours. And if we look at all of these, the classification system is probably just okay. And a lot of people call a slap three, a slap four, a slap four, a slap two. However, what I can tell you is that if you look on the sagittal oblique here, Mr. Arthur Graham. If you see some of that signal in the biceps tendon, be very wary about degeneration and higher grade slap injuries. We looked at magnetic resonance arthrography because I was really not satisfied with trying to just predict this clinically history and from exam, although at the end of the day, we probably still get back to that being the most reliable mechanism. So we looked at Mr. Arthrogram and we looked at a bunch of different things. This is just one of the things we found. It was a higher signal grade, like I showed you in that image, as well as much flatter biceps in those that were symptomatic. So on a good Mr. Arthrogram or even a good Mr.. You can see this and just have an idea that there might be some things going on in the biceps. If you see that this is the study I alluded to, and I think the So's and the brass type of thing with 1000 plus patients that is looking at this and collecting data prospectively is going to be the way we're going to find out how to figure this out in the future. But we started I started this study at about 2003. We were using a different outcomes analysis program at the time, and it was actually on paper, and we went to web based. This actually helped us do this study and follow this. And we enrolled about 500 patients. But actually we got down to about 179 when we met. All the strict inclusion and exclusion criteria. And what we found was after a typical Slap two repair, which at the time we started in 2003 and four was all with SutureTak, either single or double loaded. It was a posterior based repair of the posterior aspect of the biceps route. And what we found was most of these patients did pretty well. 70% of them did well. So I'm not here to say slap repair does not work. But what we did find in those that didn't do well or the overall motion, they were they were stiff. And we changed our rehabilitation protocols based on this. And after the study was done for less sling time and more range of motion, that helped a little bit. But there was still some other things going on. And so we called this with really strict criteria. And this number is probably a little literally is probably inflated a little bit too high. But we did have about 50 that underwent tenodesis Odysseus because of continued pain, stiffness and problems. And I'll show you the results on that and what it was. What we found on the multivariate was those age 36 or higher had a had a higher risk of failure. In the multivariate analysis, smokers workers, comp type of population was worse. But what we found was the revision surgery with Athena. Odysseus, much like your findings, reigned supreme. And many of these patients who were going to get boarded out of the military, which for them was a career ending type of thing, were able to stay in the military, and certainly something that I didn't want to have to be responsible for. We were able to get them back with a sub pack. Odysseus, what if we just cut the biceps? And many people advocate that? Let's just be done with it. I can tell you I've never really been happy with this procedure. I have patients that continue to come back, and even in 60, 70 year old men and women, I have such a low threshold. If I'm going to do any biceps work to sit and not think about the anatomy. The problem is, is we've recently published is the cramping and failures that occur after after this problem, and they don't get it right away, but they'll get the Popeye, and some of them may not even recognize it. But what they do is they get cramping with activities. And this fatigue discomfort is an Kelly and Steve O'Brien described. So I want to talk about this a little bit because, you know, as part of the brass group and SOS and things going forward, I think we have to be a little bit better in terms of our communication and classification and use Superpack or sub pack. And if you talk to Tony Romeo and Gus Mazorca about this, who I think and correct me if I'm wrong, Reinhold, but really helped coin the term sub pack tenodesis. We have to be pretty careful. And what sub pack means literally is underneath the pack. So this could be anywhere underneath the pack. It could be very superior. It could be very inferior. It could be where you showed the complications of the screw hole. Paul. But we have to be careful, I think, and we need to be clear in our terminology. And so I think we're getting a little bit better at kind of above the pectoral, pectoral major, or superior to the pec. Inferior to the pec or the inferior border of the Pec. Superior border of the Pec. We can't. We have to be careful with the subpac. Term. Because subpac really means anywhere up and down a five centimeter area underneath the pec. So we really have to think about this and come up with the correct term. And I would propose something like superior to the PEC or inferior to the PEC in a sub. It's a sub pectoral. But we have to be a little bit clear about exactly where that is. So I'm releasing this arthroscopically. And you know, I used to I still do these arthroscopically and put it at the bottom of the groove. Very nice video of how to do this at the top of the groove before you have to really make sure you get this correct if you're going to do this. Arthroscopically, I do think releasing this transverse ligament and the coracohumeral ligament is important to get there. We have to trim and measure the distance. And Gus and Tony have worked this out really well. You should pull this article from arthroscopy. Remove about two to 2.5cm. Distance is very important and many of you may have seen this. But we do. I do think if we get it within 3 to 5mm, we can consistently make that happen. And so here's right at the bottom of the groove of the humeral bone socket. And fixing this with a screw or a myriad of fixation options. Now I'm going to go over some of these. And here's your completed fixation at the bottom of the groove. And a really nice option does not take too long. And so this is kind of superior to the PEC major as you see it right there right at the bottom of the groove. Well what about distal versus proximal. This study was alluded to by JP and you really have to dissect it down. But overall distal techniques fared a little bit better but not much better. And the bottom line is proximal is probably as good as distal as long as you're addressing the pathology. Not not missing any of those hidden lesions like I showed you on that video. But my preference for a long time has been this what's called at least the sub pectoral tenodesis or the inferior Border of the pec. Pectoral tenodesis. A little bit redundant, but we have to be clear that it's at the bottom of the pec, or about one centimeter superior to the inferior border of the pec. And the muscle tendon junction has been well worked out to be of the biceps to be right in that area of the bottom of the pec. So you can get this length tension relationship really well. Mazaka has written this up extensively and you can. The key here is I don't he had a very low complication rate in his in his study and review. And the key is you got to make sure you have the biceps. You can see I only use retractors laterally. Nothing medially. I don't use any Chandlers. I don't use any pointed Homans. I don't put any pressure on that conjoint. Everything is only lateral and all my maneuvers are based laterally. So you're going to be completely safe if it's lateral. You also need to make sure. And the biggest key for this is pushing the biceps up against the pec fascia. So that if you push that right up against the pec fascia, you can retrieve it out really easily. And you know that you're getting the long head of the Biceps massacre followed 50 shoulders for about two and a half years and had overall really good outcomes. Now I excluded our rotator cuff abnormalities in our in our prospective Slap study. But what you see is a lot of these patients have concomitant pathology with the slap. And so the rotator cuff, those with rotator cuff tears did much worse in terms of biceps issues. Paul showed this really well in terms of what the failure complex is. It's around 300 Newtons. Keep in mind that a well-tied arthroscopic knot is probably a couple hundred Newtons around there, 200 to 225 Newtons. We probably need 100 to 150 newtons of biceps work when we're looking at this biomechanically. And there's really tons of options here. All of them are very good. My workhorse has been a peak tenodesis screw or a biocomposite screw, and now much more with a pec button. And you can see the pec button on the bottom of the bottom x ray there, which is instead of the bicortical technique, which was originally described with a competitor button technique by Pascal Barlow in Arthroscopy Journal, where he drilled across both cortices. This is a cortical technique, just like we do with PEC major repair, and I've used this device in many different types of tendon fixations now, including mcls, lcls, patellar tendon, etc. and now biceps. So this is a really nice option. One thing you do want to keep in mind if you do use a tenodesis screw, is that as soon as you get through that cortex in that location, the cancellous bone is not very robust. And so you're relying on cortex fixation. That's why the pec button is a really good option. It's a very small hole and much smaller than a 6 or 7 or eight millimeter. So what we wanted to do was look at what happens if you just didn't get the screw quite right. And this has happened to me. It's either been recessed or you leave it out by a couple threads or you recess it by a thread. And so what we found by putting the these screws in that. Yeah, if you get it correct, if it was flush with the cortex you had a much better strength of fixation. If it was 50% of the depth, it was still good. Well exceeded what you needed for the biceps, but it was a little bit weaker. And if you actually recessed the whole screw and it sort of was floating there, some people worry about that. Still no issue. We had over 200 newtons of pullout and there was no difference of elongation. So we can do we can definitely do better if we get this perfect or think about other options. So what about younger patients with a biceps? Tenodesis. This is we wrote this up and this is in publication now, but for whatever reason, it was for either failed slap or otherwise. We had 27 patients, all less than 30. And what was amazing is these patients do quite well, so I would not worry too much in a well indicated patient i.e. not a thrower, not an overhead athlete, maybe not a volleyball player, but those are more of a working population. This type of patient is going to do really well with a tenodesis that's indicated. Dedicated. And finally, I just want to end up on the failed slap. And you can see we've learned a lot from our study studies. And but we've also had a lot of patients referred to me either with auto tenotomy and they continue with cramping or failed tenodesis or otherwise for a variety of fixation. We don't really know why. This is why it's an isolated pain generator. What are the implications of just a slap repair? And so this is now just recently out we had 58 patients who were referred in. Some of these were either mine my partners or referred in to me with a mean age of 30, 32 years. All of them had biceps signs. And this is what you're seeing. This is why I don't like knots in this area, because it's a tight area. And once that shoulder starts moving around, you can get chondral damage. You can see all the inflammation. This is typical findings after kind of a quote unquote failed slap. And that's why I like to be very minimally invasive in this area and use knotless technology. Now all of these patients underwent a revision. He was either for failed slap or auto tenotomy, etc. with the tenodesis, all were PowerPick and the motion, just like you showed in your study, was vastly improved. The outcome scores, the pain scores were vastly improved. And if you look at the same score, almost up to 90, starting from a same score of about 60, which was pretty remarkable for something starting with a failure. We do know this may be an issue. It's an area that's poor healing of slap tears with or without surgery, and why degenerative type of tears may persist in this location. It can be a viable option for a failed slap repair. This is from Brockmeyer out of University of Virginia, as a salvage option serves the majority of patients very well. And then here is for auto rupture of a failed surgical tenotomy. And this is why I don't favor this. And I really favor fixation somewhere of your choice to fix this in a relatively active population. We had a range of 33 to 56 years, and these patients all had cramping with activity, deformity or pain. And then they did very well in terms of their tenodesis.

Biceps Tenodesis: Distal Techniques

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