Finished Product

AR-3682

Shoulder

Product

The FiberTak button is an all-suture button that can be used in lieu of traditional metal buttons for both bicortical and unicortical tension slide tenodesis techniques. The button is a reinforced 2.6 mm diameter sheath preloaded with two 2-0 FiberLink™ sutures that are used to shuttle the whipstitch limbs through the sheath.
Features &amp; Benefits
<ul>
 <li>Button first technique to help eliminate the need to find the drill hole</li>
 <li>2-0 FiberLink sutures colored blue and white/black for easy identification</li>
 <li>No metal-FiberTak is not visible on x-ray</li>
 <li>17% stronger than metal buttons1</li>
 <li>2.6 mm drill reduces the bone socket 19% over the traditional 3.2 mm bone socket commonly used for metal buttons</li>
</ul>
1. Arthrex, Inc. Data on file (APT 04066). Naples, FL; 2019

The all-suture FiberTak® button can be used for both inlay and onlay distal and proximal biceps tenodesis. The 2.6 mm-diameter sheath is preloaded with two 2-0 FiberLink™ sutures that are used to shuttle the #2 FiberWire® suture or SutureTape whipstitch limbs through the sheath. The FiberLink sutures are loaded in opposite directions, allowing for a tension-slide reduction technique.

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Subpectoral Biceps Tenodesis Using the FiberTak® Button Implant System

Paul M. Sethi, MD (Greenwich, CT), demonstrates a bicortical subpectoral biceps tenodesis using an all-suture FiberTak® button. The button is a reinforced 2.6 mm-diameter sheath preloaded with two 2-0 FiberLink™ sutures that are used to shuttle the whipstitch limbs through the sheath. The all-suture button can be used in lieu of traditional metal buttons for unicortical and bicortical tension-slide techniques.

Subpectoral Biceps Tenodesis Using a FiberTak® Button

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Subpectoral Biceps Tenodesis ® Using the FiberTak Button Surgical Technique Subpectoral Biceps Tenodesis Using The FiberTak® Button Metal Button vs FiberTak Button1 Ultimate Load (N) The 2.6 mm drill reduces the implant socket diameter by 19% compared to the traditional 3.2 mm drill used with metal buttons. The all-suture construction of the FiberTak button is not visible on x-ray and has tested to be 17% stronger than metal buttons.1 550 500 450 400 350 300 250 200 150 0 Metal Button FiberTak Button The all-suture button is preloaded with two 2-0 FiberLink™ sutures that are used to shuttle the #2 FiberWire® suture or SutureTape whipstitch limbs through the sheath. The implant system includes the FiberTak button, 2.6 mm drill, drill guide, FiberLoop® suture, and a free needle. The button-first technique eliminates the need to find the tunnel after drilling. The FiberLink sutures are loaded in opposite directions and are used to shuttle the whipstitch limbs through the button, allowing for a tension-slide reduction technique. Surgical Technique Place the patient in the beach chair or lateral decubitus position with the arm in 90° of abduction and 60°-90° of external rotation. Make a 2 cm to 3 cm incision in the axilla at the inferior border of the pectoralis major. Bluntly dissect to identify the pectoralis major and the long head of the biceps. Whipstitch the biceps tendon using the FiberLoop suture. Load the FiberLink sutures in opposite directions to allow for a tension-slide reduction technique (a). a 02 | Subpectoral Biceps Tenodesis Using The FiberTak Button Unicortical Onlay Subpectoral Biceps Tenodesis 1 Place the drill guide at the desired location and drill the first cortex using the 2.6 mm drill. Chucking the drill pin at the black line allows the drill to extend 20 mm out of the drill guide. 3 Remove the inserter and guide. Lightly pull evenly on the FiberLink™ sutures to ensure that the button is deployed. Separate the FiberLink sutures (blue and white/black on each side) and pull on each link to ensure it slides easily. 2 Leave the guide in place and insert the button through the guide. Tap on the handle until the inserter is flush with the drill guide. Remove the orange tab. 4 Shuttle a whipstitch limb through the button using one of the FiberLink sutures. Be sure not to shuttle the thickened portion of the FiberLoop® suture through the button. Use slight tugs once the suture meets the button sheath. Discard the FiberLink shuttle suture once the whipstitch limb has been passed through the button. Pull lightly on the remaining shuttle link to verify that the button is set. Shuttle the second whipstitch limb through the sheath in the opposite direction using the remaining link. Subpectoral Biceps Tenodesis Using The FiberTak Button | 03 5 Use the tension-slide technique to reduce the tendon onto the bone. 04 | Subpectoral Biceps Tenodesis Using The FiberTak Button 6 Pass one limb back through the tendon using the free needle and tie a knot to complete the repair. Bicortical Inlay Subpectoral Biceps Tenodesis 1 Drill a unicortical socket using the appropriate size pilotheaded reamer. 3 Leave the guide in place and insert the button through the guide. Lightly tap on the handle until the button is inserted across the far cortex. Remove the orange tab. 2 Insert the drill guide into the socket and drill through the far cortex using the 2.6 mm drill. Chucking the drill pin at the black line allows the drill to extend 20 mm out of the drill guide. 4 Remove the inserter and guide. Lightly and evenly pull on the FiberLink™ sutures to ensure that the button is deployed on the far cortex. Separate the FiberLink sutures (blue and white/black on each side) and pull on each link to ensure it slides easily. Subpectoral Biceps Tenodesis Using The FiberTak Button | 05 5 Shuttle a whipstitch limb through the button using one of the FiberLink™ sutures. Be sure not to shuttle the thickened, spliced portion of the FiberLoop® suture through the button. Use slight tugs once the suture meets the button sheath. Discard the FiberLink shuttle suture once the whipstitch limb has been passed through the button. Pull lightly on the remaining shuttle link to verify that the button is set. Shuttle the second whipstitch limb through the button in the opposite direction using the remaining link. 6 Use the tension-slide technique to reduce the tendon into the bone socket. 06 | Subpectoral Biceps Tenodesis Using The FiberTak Button 7 7b Pass one limb back through the tendon using a free needle and tie a knot. If desired, insert a tenodesis screw into the socket to complete the repair (7b). Ordering Information Implants Product Description Item Number FiberTak® Button Implant System Includes FiberTak button, drill guide, 2.6 mm spade-tip drill, FiberLoop® suture, and free needle AR-3680 FiberTak Button AR-3681 2.6 mm Spade-Tip Drill AR-3682 Optional Instruments and Implants for Bicortical Tenodesis Option Product Description Item Number 7 mm Pilot-Headed Reamer AR-1452 BioComposite SwiveLock® Biceps Tenodesis Screw, 7 mm × 10 mm AR-1662BCS-710 Reference 1. Arthrex, Inc. Data on file (APT-04066). Naples, FL; 2019. Subpectoral Biceps Tenodesis Using The FiberTak Button | 07 This description of technique is provided as an educational tool and clinical aid to assist properly licensed medical professionals in the usage of specific Arthrex products. As part of this professional usage, the medical professional must use their professional judgment in making any final determinations in product usage and technique. In doing so, the medical professional should rely on their own training and experience and should conduct a thorough review of pertinent medical literature and the product’s directions for use. Postoperative management is patient-specific and dependent on the treating professional’s assessment. Individual results will vary and not all patients will experience the same postoperative activity level or outcomes. View U.S. patent information at www.arthrex.com/corporate/virtual-patent-marking © 2020 Arthrex, Inc. All rights reserved. | www.arthrex.com | LT1-000166-en-US_A

Subpectoral Biceps Tenodesis Using the FiberTak® Button

Paul M. Sethi, MD (Greenwich, CT), demonstrates an anterior inlay distal biceps repair technique with a FiberTak® button and tenodesis screw. The FiberTak button, which is not visible on x-ray, allows for a button-first approach through a 2.6 mm tunnel. The button is preloaded with two shuttle links that are used to shuttle the whipstitch limbs through the button, allowing for a tension-slide tendon reduction technique.

Distal Biceps Tenodesis Repair Using the FiberTak® Button

Biceps Tenotomy Versus Tenodesis Scientific Update The biceps tendon is a common cause of pain in the shoulder. There are several controversies regarding the biceps tendon, one of which is when to treat with tenotomy or tenodesis. Tenotomy is the quickest and lowest cost approach. Tenodesis aims to maintain function and cosmesis. This controversy can be explored via three outcomes: patient preferences, the presence of a postoperative Popeye deformity, and functional outcome. Patient Preferences and Popeye Deformity An important factor in comparing biceps tenotomy to tenodesis is patient preference. Unlike the rotator cuff, the biceps tendonhas strong societal associations. Moreover, its visibility often lends itself to serving as a reflectionof the overall quality of surgery to the patient. Surveys examining patient preferences have shown that regardless of age, patients prefer tenodesis over tenotomy. As expected,a postoperative Popeye deformity is much more common following tenotomy procedures. Galdi B, Southren DL, Brabston EW, Popkin CA, Jobin CM, Levine WN, Ahmad CS Patients have strong preferences and perceptions for biceps tenotomy versus tenodesis. Arthroscopy. 2016;32(12):2444-2450. doi:10.1016/j.arthro.2016.04.022 • In this study, 100 patients with a mean age of 49 years (range 19 to 79 years) were surveyed regarding preferences for biceps tenotomy or tenodesis. - Patients were told that tenotomy would lead to quicker recovery but a higher incidence of a popeye deformity and temporary cramping - Strength, motion, and pain relief were presented as being similar • 64% of patients stated they would prefer a tenodesis. • Women were more likely to prefer tenodesis. • Age was NOT predictive of preference. Takeaways • The majority of patients preferred tenodesis over tenotomy regardless of age. • Women are more likely to prefer tenodesis. Hong CK, Chang CH, Hsu KL, Kuan FC, Wang PH, Su WR Patients older than 55 years prefer biceps tenodesis over tenotomy to the same degree as young patients. J Orthop Sci. 2020;25(3):416‐422. doi:10.1016/j.jos.2019.05.007 • In this study, 135 patients with a mean age of 56 years were surveyed about biceps preferences using the same questionnaire at used by Galdi et al. - Taiwanese population of patients actually undergoing surgery. • Again, 64% stated they would prefer tenodesis. - No difference in preference comparing patients older or younger than 55 years of age. • The most important reason for selecting tenodesis was the avoidance of a Popeye deformity. • The most important reason for selecting tenotomy was shorter rehabilitation. • Greater number of hours of exercise per week was associated with a preference for tenodesis. Takeaways • From the studies above, one can infer that patients still have strong preferences for tenodesis over tenotomy, regardless of age. • Shorter rehab is the most important factor for patients to prefer tenotomy. It is important to consider that most biceps procedures are done in conjunction with rotator cuff repair, and rehab will be dictated by the rotator cuff and thus not shortened in that setting. Slenker NR, Lawson K, Ciccotti MG, Dodson CC, Cohen SB Biceps tenotomy versus tenodesis: clinical outcomes. Arthroscopy. 2012;28(4):576-582. doi:10.1016/j.arthro.2011.10.017 • This was a systematic review of 433 tenodeses and 699 tenotomies. • Level of evidence: IV. • Popeye deformity: - 43% of tenotomy. - 8% of tenodesis. • Takeaway: Postoperative Popeye deformity is 5 times higher (43% compared to 8%) following tenotomy compared to tenodesis. Functional Outcome Functional outcome is often reported to be no different between tenodesis and tenotomy. It is important, however, to note that this statement is typically based on the use of functional outcome scores, such as the ASES or SANE score, which are not specific to the biceps. A close inspection of the data reveals differences in symptoms and strength between tenotomy and tenodesis. Mirzayan R, McCrum C, Butler RK, Alluri RK Risk factors and complications following arthroscopic tenotomy of the long head of the biceps tendon. Orthop J Sports Med. 2020;8(2):2325967120904361. doi:10.1177/2325967120904361 • In this study, 192 patients who underwent tenotomy were retrospectively reviewed in the Kaiser Health System. - 72% had a concomitant rotator cuff repair. • Level of evidence: III • The overall complication rate was 37%. - Popeye deformity 14% - Subjective weakness 10% - Cramping 10% • Male patients had 3.9 times the odds of developing a cosmetic Popeye deformity. • 4% of patients had a revision of their tenotomy to an open tenodesis. • Takeaway: In the largest series of biceps tenotomy reported, complications following tenotomy are common, including reoperation for subjective symptoms. García-Rellán JE, Sánchez-Alepuz E, Mudarra-García J Increased fatigue of the biceps after tenotomy of the long head of biceps tendon. Knee Surg Sports Traumatol Arthrosc. 2018;26(12):3826-3831. doi:10.1007/s00167-018-5007-2 • Strength and fatigue were evaluated in 26 patients who underwent tenotomy. • Level of evidence: III. • Tests were performed preoperatively and postoperatively 1 year after surgery and compared to the opposite side. • Postoperatively, a Popeye deformity was observed in 58%. • Maximum strength improved after tenotomy but remained lower than the opposite side (252 N compared to 280 N; P < .001). • Time to fatigue decreased after surgery by nearly 50% (quicker onset of fatigue) from 142 seconds to 94 seconds (P < .01). Takeaways • Arm flexion strength after tenotomy is decreased compared to the contralateral arm. • Flexion endurance decreases after tenotomy. Wittstein JR, Queen R, Abbey A, Toth A, Moorman CT 3rd Isokinetic strength, endurance, and subjective outcomes after biceps tenotomy versus tenodesis: a postoperative study. Am J Sports Med. 2011;39(4):857-865. doi:10.1177/0363546510387512 • This is a retrospective review of 19 tenotomies and 16 tenodeses evaluated 2 years postoperative. • Level of evidence: III • ASES and SANE functional scores were recorded. Flexion and supination strength were measured with dynamometer and compared to the contralateral side. • Results: - No difference in functional scores - Tenotomy led to 20% decrease in supination strength - Tenodesis led to 22% increase in supination strength Takeaways: • There is no difference in postoperative ASES or SANE scores following tenotomy or tenodesis. • Supination strength decreases after tenotomy and may increase after tenodesis. In this study, the difference was 40% between procedures (-20 compared to + 22%). Lee HJ, Jeong JY, Kim CK, Kim YS Surgical treatment of lesions of the long head of the biceps brachii tendon with rotator cuff tear: a prospective randomized clinical trial comparing the clinical results of tenotomy and tenodesis. J Shoulder Elbow Surg. 2016;25(7):1107-1114. doi:10.1016/j.jse.2016.02.006 • This is a prospective randomized controlled trial of 128 patients undergoing tenotomy or tenodesis in conjunction with rotator cuff repair. - Tenodesis was performed with an interference screw technique • Level of evidence: I • No differences noted in functional outcome according to ASES or Constant scores. • Popeye deformity 3 times higher in tenotomy group (20% compared to 6%; P = .04). • No differences in elbow flexion strength. • Supination strength higher in the tenodesis group. Takeaways: • Level 1 evidence indicates that functional outcome of the shoulder based on ASES and constant scores are not different after tenotomy or tenodesis. • However, forearm supination strength is lower after tenotomy. www.arthrex.com © 2020 Arthrex, Inc. All rights reserved. DOC1-000345-en-US_A Aflatooni JO, Meeks BD, Froehle AW, Bonner KF Biceps tenotomy versus tenodesis: patient-reported outcomes and satisfaction. J Orthop Surg Res. 2020;15(1):56. doi:10.1186/s13018-020-1581-3 • This retrospective comparative study examines the outcomes and satisfaction with tenodesis compared to tenotomy. - 111 arthroscopic tenodeses with interference screw - 104 tenotomies • Level of evidence: III • Satisfaction was similar overall - 88% tenodeses “very satisfied” - 75% tenotomies “very satisfied” • Subjective complaints - 59% of tenotomies have at least one complaint compared to 37% of tenodeses (P < .01) - Tenotomies were twice as likely to have multiple complaints (31% compared to 16%) - Spasms/cramping 2.5 times more common with tenotomy - Shoulder pain 1.9 times more common with tenotomy Takeaways • Tenodesis trends toward higher patient satisfaction. • Tenodesis is associated with fewer postoperative problems, such as cramping and shoulder pain.

Biceps Tenotomy Versus Tenodesis Scientific Update

Biceps Tenodesis: Options for Fixation Scientific Update A variety of options exist for fixation in performing biceps tenodesis. Options range from soft- tissue tenodesis alone, in which the biceps is sewn to the remaining rotator cuff, or anchor- based fixation. The latter is superior from a biomechanical standpoint and has been clinically shown to improve outcomes. Anchor-based options include suture anchors, interference screws, and buttons. Anchor-based fixation can also be divided into onlay and inlay techniques. With an onlay technique, the tendon lies on the cortical surface of the humerus (eg, unicortical button). With an inlay technique, a portion of the tendon is delivered into the socket (eg, interference screw technique). In recent years, onlay techniques have become more popular based on ease of the procedure and biomechanical and clinical data. Soft-Tissue Tenodesis Compared To Anchor-Based Fixation Scheibel M, Schröder RJ, Chen J, Bartsch M Arthroscopic soft-tissue tenodesis vs bony fixation anchor tenodesis of the long head of the biceps tendon. Am J Sports Med. 2011;39(5):1046-1052. doi:10.1177/0363546510390777 • This was a prospective evaluation of 57 arthroscopic biceps tenodeses comparing method of fixation. - 24 soft-tissue tenodeses - 20 anchor-based tenodeses with a suture anchor • Postoperative Constant scores were the same between the two groups. • The long head of the biceps (LHB) score (a scoring system to assess the biceps based on cramping, cosmesis, and elbow flexion strength) was improved in the anchor-based group. • Healing was improved in the anchor-based group. - 25% healing with soft-tissue fixation - 65% with anchor-based fixation • Takeaway: Healing and LHB scores are improved with an anchor-based technique compared to a soft-tissue method for biceps tenodesis. Hwang JT, Yang CJ, Noh KC, Yoo YS, Hyun YS, Lee YB, Liu X Which is better for arthroscopic tenodesis of the long head of the biceps: soft-tissue or bony interference fixation? Arthroscopy. 2016;32(4):560-567. doi:10.1016/j.arthro.2015.10.024 • This was a randomized controlled trial of soft-tissue tenodesis to anchor-based biceps tenodesis with an interference screw. - 25 soft-tissue tenodesis - 28 anchor-based tenodesis with a 5.5 mm interference screw - 2-year follow-up • ASES scores were similar between groups. • Elbow flexion strength was higher in the anchor-based group (P = .006). • Healing by ultrasound was higher in the anchor-based group (P = .046). - 93% interference-screw group - 72% soft-tissue group • Takeaway: Biceps healing and postoperative elbow flexion strength are higher with an anchor-based tenodesis compared to a soft-tissue tenodesis. McCrum CL, Alluri RK, Batech M, Mirzayan R Complications of biceps tenodesis based on location, fixation, and indication: a review of 1526 shoulders. J Shoulder Elbow Surg. 2019;28(3):461-469. doi:10.1016/j.jse.2018.09.005 • This was a retrospective evaluation of 1526 patients who underwent biceps tenodesis in the Kaiser Health System. - 996 tenodeses were done “out of the groove” (subpectoral) ☐ 209 soft-tissue based ☐ 6 keyhole ☐ 781 anchor-based (anchor, tenodesis screw, or button) - 530 tenodeses were done “in the groove” (arthroscopic) ☐ 144 soft-tissue based ☐ 386 anchor based • There was no difference in postoperative pain based on location. • Soft-tissue tenodeses had higher new onset post-op pain (11.9% compared to 2.6%; P < .001) and subjective weakness (8.5% compared to 3.9%; P < .001) compared to the use of an anchor. Takeaways • Postoperative pain does not vary based on location of tenodesis. • Tenodesis performed with an anchor is more reliable than soft-tissue tenodesis alone. Anchor-Based Options Chiang FL, Hong CK, Chang CH, Lin CL, Jou IM, Su WR Biomechanical comparison of all-suture anchor fixation and interference screw technique for subpectoral biceps tenodesis. Arthroscopy. 2016;32(7):1247-1252. doi:10.1016/j. arthro.2016.01.016 • This was a biomechanical evaluation of subpectoral tenodesis with 2 inlay techniques in 16 cadaveric shoulders. - An all-suture anchor placed bicortically ☐ Near cortex reamed to 5 mm to allow tendon to dock in the canal - An 8 mm interference screw • Cyclic displacement was slightly higher in the all-suture anchor group (8.1 mm compared to 3.4 mm; P = .0002). • Load-to-failure was equal between the 2 groups (239 N compared to 254 N; P = .878). • Takeaway: Cyclic displacement is slightly higher (5 mm) with a biocortical all-suture anchor technique compared to an interference screw. However, there is no difference in load-to-failure between techniques. Cagle PJ, Jr., London DA, Gluck MJ, Morel S, Parsons BO Long head of biceps tenodesis at the superior aspect of the biceps groove: A biomechanical comparison of inlay and onlay techniques. Shoulder Elbow. 2020;12(1):12-17. doi:10.1177/1758573218815281 • Biomechanical evaluation of proximal biceps tenodesis in 6 cadavers. • Tendons were whipstitched and secured at the articular margin. - Inlay technique with a 7 mm interference screw - Onlay technique with a 4.75 SwiveLock® anchor • No difference in load-to-failure between the groups. • Takeaway: An onlay technique has equivalent biomechanical strength to an inlay technique with an interference screw for proximal biceps tenodesis. Buchholz A, Martetschläger F, Siebenlist S, et al Biomechanical comparison of intramedullary cortical button fixation and interference screw technique for subpectoral biceps tenodesis. Arthroscopy. 2013;29(5):845-853. doi:10.1016/j. arthro.2013.01.010 • Biomechanical comparison of subpectoral tenodesis in 10 matched paired cadavers. - Onlay technique with a unicortical button (BicepsButton™ technique) - Inlay technique with an interference screw • No differences in load-to-failure or cyclic displacement between groups. • Takeaway: A unicortical onlay button technique has equivalent biomechanical strength to an inlay technique with an interference screw. Park JS, Kim SH, Jung HJ, Lee YH, Oh JH A prospective randomized study comparing the interference screw and suture anchor techniques for biceps tenodesis. Am J Sports Med. 2017;45(2):440-448. doi:10.1177/0363546516667577 • This was a randomized controlled trial of interference screw fixation compared to suture anchor fixation for biceps tenodesis. - 33 interference screws (8 mm interference screw) - 34 suture anchors - Postoperative MRI or ultrasound was used to assess healing • There were 7 failures in the screw group (21%). • There were 2 failures in the anchor group (6%). • In a multivariate analysis, interference screw fixation and higher work level were associated with failure • Takeaway: While biomechanically robust, there is risk of clinical failure with an interference screw technique likely secondary to the screw cutting into the tendon during insertion and the sharp angle (90°) of fixation. Tan H, Wang D, Lebaschi AH, Hutchinson ID, Ying L, Deng XH, Rodeo SA, Warren RF Comparison of bone tunnel and cortical surface tendon-to-bone healing in a rabbit model of biceps tenodesis. J Bone Joint Surg Am. 2018;100(6):479-486. doi:10.2106/JBJS.17.00797 • This was a rabbit study of biceps tenodesis to evaluate inlay compared to onlay technique. - Rabbits were harvested at 8 weeks and healing was evaluated • Healing was similar between groups. • Healing occurred at the cortical surface in both groups with tendon-bone interdigitation. • There was minimal tendon-bone healing within the bone tunnels in the inlay group. • Takeaway: In the rabbit model, the majority of the healing of biceps tenodesis occurs to the cortex. This data supports an onlay technique assuming biomechanical equivalence. Lacheta L, Rosenberg SI, Brady AW, Dornan GJ, Millett PJ Biomechanical comparison of subpectoral biceps tenodesis onlay techniques. Orthop J Sports Med. 2019;7(10):2325967119876276. doi:10.1177/2325967119876276 • This was a biomechanical evaluation of 2 techniques for unicortical onlay biceps tenodesis in 10 cadavers. - Metal button (BicepsButton™ button) - All-suture anchor (1.8 mm FiberTak® anchor) • There was no difference in load-to-failure between groups. • The failure modes differed. - Metal button: 100% tendon tearing - All-suture anchor: 56% tendon tearing; 44% knot failure Takeaways • Biomechanical properties are similar between onlay techniques using a button or all-suture anchor. • Tissue quality, stitch configuration, and knot security are greater limiting factors in biceps tenodesis than anchor pull-out. www.arthrex.com © 2020 Arthrex, Inc. All rights reserved. DOC1-000354-en-US_A Duerr RA, Nye D, Paci JM, Akhavan S Clinical evaluation of an arthroscopic knotless suprapectoral biceps tenodesis technique: Loop ‘N’ Tack™ tenodesis. Orthop J Sports Med. 2018;6(6):2325967118779786. Published 2018 Jun 26. doi:10.1177/2325967118779786 • Retrospective evaluation of 59 patients treated with an onlay technique. - Loop ‘N’ Tack suture fixation - Knotless anchor • Zero postoperative popeye deformities. • 5% of patients had biceps cramping with overuse. • 97% of patients were satisfied. • Takeaway: An onlay technique for biceps tendoesis, in this case with a Loop ‘N’ Tack suture configuration, is associated with excellent clinical outcomes.

Biceps Tenodesis: Options for Fixation Scientific Update

Biceps Tenodesis: When and Where Scientific Update There is controversy both about when and where to perform biceps tenodesis. One must understand the incidence of pathology and literature indicating where to perform tenodesis. Then, a decision is made about location of the tenodesis. Incidence of Pathology The evidence indicates that biceps pathology is common in the setting of a rotator cuff tear. Notably, the arthroscopic appearance of the biceps often underestimates the disease as microscopic studies demonstrate that findings are common regardless of gross appearance. This information should be considered when assessing studies that compare rotator cuff repairs with and without treatment of the biceps. Desai SS, Mata HK Long head of biceps tendon pathology and results of tenotomy in full-thickness reparable rotator cuff tear. Arthroscopy. 2017;33(11):1971-1976. doi:10.1016/j.arthro.2017.06.018 • Prospective evaluation characterizing the arthroscopic appearance of the biceps in 141 shoulders undergoing arthroscopic cuff repair of a full-thickness tear. • The overall incidence of biceps pathology was 36%. • Biceps pathology increased with tear size: - 27% with small and medium cuff tears - 45% with large tears - 70% with massive tears • Biceps pathology was most common in patients with subscapularis tears - 67% with a supraspinatus and subscapularis tear - 100% with a combined supraspinatus/infraspinatus and subscapularis tear Takeaways • Biceps pathology is common with rotator cuff tears and increases in incidence with increasing tear size. • There is a strong association between biceps pathology and tears of the subscapularis such that identification of one should alert the surgeon to the other. Walch G, Nové-Josserand L, Boileau P, Levigne C Subluxations and dislocations of the tendon of the long head of the biceps. J Shoulder Elbow Surg. 1998;7(2):100-108. doi:10.1016/s1058-2746(98)90218-x • Retrospective evaluation of 71 cases of biceps subluxation treated with open or arthroscopic surgery. • In 24% of cases, the biceps subluxation or dislocation was not identified by preoperative CT arthrogram. • In 97% (69 of 71) of cases, there was an associated subscapularis tear. - The remaining 2 had a supraspinatus tear. Takeaways • Biceps subluxation can be missed in a quarter of cases on advanced imaging such as CT arthrogram. • The presence of biceps subluxation is always associated with a rotator cuff tear, particularly of the subscapularis tendon. Murthi AM, Vosburgh CL, Neviaser TJ The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg. 2000;9(5):382-385. doi:10.1067/mse.2000.108386 • Prospective evaluation of 200 consecutive patients undergoing shoulder arthroscopy. - A tissue sample was taken and underwent histological examination in all cases - In 80 cases, the biceps was felt to be torn or degenerated and was tenodesed - In 120 cases, the biceps was normal on inspection • In the tenodesis or “grossly abnormal” group, all showed microscopic changes. • In the “grossly normal” biceps group, 63% had microscopic evidence of chronic inflammation. - 89% of cases with a full-thickness rotator tear had microscopic evidence of disease - 84% of cases with a partial rotator cuff tear had evidence of disease Takeaways • Arthroscopic appearance underestimates microscopic inflammation of the biceps tendon. • In the vast majority of rotator cuff tears, the biceps is inflamed despite normal arthroscopic appearance, with a rate of up to 89% for a full-thickness tear. When to Perform Tenodesis As seen above, there is a high incidence of biceps pathology, particularly in the setting of a rotator cuff tear. Literature regarding when to treat the biceps and leave the biceps is sparse with few comparative studies. Much is inferred from the fact pathology of the biceps is common based on histological evaluation and the biceps is often grossly affected on arthroscopic visualization. It is clear that the biceps is a common source of pain (as evidenced by improvement after treatment). Tenodesis leads to improvement in outcomes when the subscapularis requires repair. Biceps tenodesis may also improve short-term outcomes of a rotator cuff repair. Edwards TB, Walch G, Sirveaux F, Molé D, Nové-Josserand L, Boulahia A, Neyton L, Szabo I, Lindgren B Repair of tears of the subscapularis. J Bone Joint Surg Am. 2005;87(4):725-730. doi:10.2106/ JBJS.D.02051 • Retrospective evaluation of 84 shoulders that underwent subscapularis repair. - In 80 cases, the biceps was treated with tenodesis or tenotomy. - In 4 cases, the biceps was recentered and left. • The patients treated with recentering had poorer outcomes. Takeaway • Outcomes of subscapularis repair are improved when the biceps is also addressed with a tenodesis or a tenotomy. Boileau P, Baqué F, Valerio L, Ahrens P, Chuinard C, Trojani C Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007;89(4):747-757. doi:10.2106/ JBJS.E.01097 • Retrospective review of 68 patients who underwent biceps tenotomy or tenodesis for a massive irreparable rotator cuff tear. - Minimum 2-year follow-up • 78% of the patients were satisfied with the treatment. • The mean Constant score improved from 46 points preoperatively to 67 points postoperatively (P < .001). Takeaway • Given the treatment of the biceps alone leads to improvement in symptoms, the biceps is a significant source of pain in massive rotator cuff tears. Godéneche A, Kempf JF, Nové-Josserand L, Michelet A, Saffarini M, Hannink G, Collin Pl Tenodesis renders better results than tenotomy in repairs of isolated supraspinatus tears with pathologic biceps. J Shoulder Elbow Surg. 2018;27(11):1939-1945. doi:10.1016/j. jse.2018.03.030 • Retrospective evaluation of 249 rotator cuff repairs 10 years following surgery. - 39% were open repairs; 61% were arthroscopic repairs. - In 120 cases, the biceps were observed to be normal. ☐ 106 cases left intact - In 129 cases, the biceps were observed to be pathologic. ☐ 120 cases treated with tenodesis or tenotomy • There were no differences in postoperative Constant scores between those with a normal biceps who did not have treatment and those with a pathologic biceps that had treatment. • Patients treated with a tenodesis had improved Constant scores compared to those who had a tenotomy (P = .025). Takeaways • Long-term outcomes are not different in patients who have a concomitant biceps procedure in association with a rotator cuff tear. Notes • The results should be interpreted with the understanding that 39% were open repairs and therefore the presence of biceps pathology may have been underestimated. • The results do not necessarily reflect short-term outcomes (see Watson et al). Watson ST, Robbins CB, Bedi A, Carpenter JE, Gagnier JJ, Miller BS Comparison of outcomes 1 year after rotator cuff repair with and without concomitant biceps surgery. Arthroscopy. 2017;33(11):1928-1936. doi:10.1016/j.arthro.2017.05.009 • Retrospective review of 80 patients 1 year following arthroscopic rotator cuff repair (ARCR). - In 35 cases, the biceps was left untreated - In 45 cases, the biceps was tenodesed or tenotomized • Patients who had biceps treatment had lower ASES scores at baseline (49 compared to 59; P = .032). • Patients who had biceps treatment had greater improvement in postoperative scores. - ASES scores (43 with compared to 24 without; P = .002) - Pain (49 compared to 36; P = .020) Takeaway • Addressing the biceps leads to improved early outcomes (1 year) in the setting of ARCR compared to leaving the biceps intact with ARCR. www.arthrex.com © 2020 Arthrex, Inc. All rights reserved. DOC1-000353-en-US_A Where to Perform Tenodesis In terms of location, some authors have reported concern about location of the tenodesis. However, most of these studies are small patient cohorts or case series only. The largest studies (see McCrum et al for example), as well as randomized controlled trials, show that tenodesis location does not impact outcomes. What appears most important is the quality of fixation. McCrum CL, Alluri RK, Batech M, Mirzayan R Complications of biceps tenodesis based on location, fixation, and indication: a review of 1526 shoulders. J Shoulder Elbow Surg. 2019;28(3):461-469. doi:10.1016/j.jse.2018.09.005 • Retrospective evaluation of 1526 patients who underwent biceps tenodesis from the Kaiser Health System. - 996 tenodeses were done out of the groove (subpectoral). - 530 tenodeses were done in the groove (arthroscopic). • No difference in postoperative pain based on location. • Revision was higher for procedures in the groove (1.5% compared to 0.6%; P = .001). • Infection was higher for open procedures (2.3% compared to 0.6%; P = .029). • Soft-tissue tenodeses had higher new onset post-op pain (11.9% compared to 2.6%; P < .001) and subjective weakness (8.5% compared to 3.9%; P < .001) compared to the use of an anchor. Takeaways • Postoperative pain does not vary based on location of tenodesis. • For complications, there is a trade-off based on location of the tenodesis (revision vs infection). • Tenodesis performed with an implant is more reliable than soft-tissue tenodesis alone. Mardani-Kivi M, Keyhani S, Ebrahim-Zadeh MH, Hashemi-Motlagh K, Saheb-Ekhtiari K Rotator cuff tear with concomitant long head of biceps tendon (LHBT) degeneration: what is the preferred choice? open subpectoral versus arthroscopic intraarticular tenodesis. J Orthop Traumatol. 2019;20(1):26. doi:10.1186/s10195-019-0531-5 • Randomized controlled trial of 60 patients undergoing arthroscopic rotator cuff repair. - 30 arthroscopic tenodeses (high in the groove with a suture anchor) - 30 open tenodeses (subpectoral with an interference screw) • There were no differences in outcomes at 6 months or 2 years postoperative. Takeaway • Level 1 evidence indicates no difference in functional outcomes based on location of tenodesis either at 6 months or 2 years postoperative.

Biceps Tenodesis: When and Where Scientific Update

FiberTak® Button

Child (D)

Procedure

Use the all-suture FiberTak button in lieu of traditional metal buttons for both bicortical and unicortical tension-slide techniques. Its 2.6 mm-diameter sheath is preloaded with 2-0 FiberLink™ sutures that are used to shuttle the whipstitch limbs through the sheath.
Features and Benefits
- Button-first technique helps eliminate need to find the drill hole
- 2-0 FiberLink sutures in blue and white/black for easy identification
- All-suture FiberTak button is not visible on x-ray
- 17% stronger than metal buttons1
- 2.6 mm drill reduces the hole 19% compared to the 3.2 mm hole commonly used for metal buttons
Reference
1. Arthrex, Inc. Data on file (APT 04066). Naples, FL; 2019.

FiberTak® Button Tenodesis Technique

As part of the distal biceps repair procedure, the tension-slide technique with the BicepsButton™ implant provides a simple, reproducible, and biomechanically stable repair. This tensioning technique reliably draws the tendon against the distal cortex of the bone socket. Adding a tenodesis screw improves the biomechanical strength and allows the tendon to be placed in a more anatomic position.
The all-suture FiberTak® button can be used in lieu of traditional metal buttons for both bicortical and unicortical tension-slide tenodesis techniques.

2.6 mm Spade Tip Drill

AR-3682

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