Biceps Tenotomy Versus Tenodesis in Active Patients Younger Than 55 Years: Is There a Difference in Strength and Outcomes?

BACKGROUND: Proximal biceps pathology is a significant factor in shoulder pain. Surgical treatment options include biceps tenotomy and subpectoral biceps tenodesis. Tenotomy is a simple procedure, but it may produce visible deformity, subjective cramping, or loss of supination strength. Tenodesis is a comparatively technical procedure involving a longer recovery, but it has been hypothesized to achieve better outcomes in younger active patients (<55 years). HYPOTHESIS: This study investigated the outcomes of younger patients who underwent either a biceps tenotomy or tenodesis as part of treatment for shoulder pain. The hypothesis was that, apart from cosmetic deformity, there will be no difference in outcome between the 2 treatment options. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Isometric strength and endurance testing of operative and nonoperative shoulders for forearm supination (FS) and elbow flexion (EF) were tested utilizing an isometric dynamometer. Objective physical assessment was also performed. Subjective outcomes using the modified American Shoulder and Elbow Surgeons score (ASES); Disability of the Arm, Shoulder, and Hand (DASH); visual analog scale (VAS); and perceived biceps symptoms were collected. RESULTS: A total of 42 patients (22 tenotomy, 20 tenodesis) with an average follow-up of 3.3 years were studied. The average age at follow-up was 49.9 years. Thirty-five percent (7/20) of tenotomy patients exhibited a "Popeye" deformity, compared with 18.2% (4/22) of tenodesis patients. Strength prior to fatiguing exercise was similar between tenodesis and tenotomy for FS (6.9 vs 7.3 lbs; P < .05), EF in neutral (35.4 vs 35.4 lbs), and EF in supination (33.8 vs 34.2 lbs). Strength was not significantly different between groups for isometric strength and endurance measures. Subjective functional outcome measured by the DASH, ASES, and VAS scores were similar between groups. Frequency of complaints of cramping was higher in the tenotomy group (4/20 vs 1/22), and complaints of pain were higher in the tenodesis group (11/22 vs 5/20). CONCLUSION: Despite increased demands and activity placed on biceps function in a younger population, this study showed no differences in functional and subjective outcome measurements. The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon can continue to be based on surgeon and patient preference.

Arthroscopic Treatment of Suprascapular Neuropathy from a Suprascapular Notch Cyst Using a Lateral Subacromial Approach.

INTRODUCTION: We describe a safe surgical technique for arthroscopic decompression of a suprascapular notch cyst in the setting of compressive suprascapular neuropathy. STEP 1 POSITION THE PATIENT: Position the patient in the standard beach-chair position. STEP 2 MARK ANATOMIC LANDMARKS: Palpate and mark the subcutaneous landmarks of the shoulder in preparation for later arthroscopy. STEP 3 DIAGNOSTIC ARTHROSCOPY: Create standard anterior and posterior portals for glenohumeral visualization. STEP 4 PERFORM SUPRASCAPULAR CYST DECOMPRESSION THROUGH A LATERAL SUBACROMIAL APPROACH: Establish accessory superior and lateral portals and transition to a lateral viewing portal to perform suprascapular notch decompression. STEP 5 RELEASE THE TRANSVERSE SCAPULAR LIGAMENT: Establish a G Portal and release the transverse scapular ligament using arthroscopic scissors. STEP 6 CLOSURE: Perform arthroscopic lavage of the subacromial space and glenohumeral joint and close arthroscopic portals. RESULTS: As suprascapular nerve entrapment is a relatively rare entity, with only a limited number of studies from which to draw conclusions regarding the outcomes of arthroscopic suprascapular nerve release, Shah et al. recently reported on their results in twenty-four patients using this surgical technique.IndicationsContraindicationsPitfalls & Challenges.

Coracoclavicular ligament reconstruction: coracoid tunnel diameter correlates with failure risk.

The current study compared tunnel diameter as an independent risk factor for fixation failure from the coracoid after transcoracoid coracoclavicular reconstruction. The effect of variation in coracoid size and scapular bone density on fixation failure was also studied. Sixty-two cadaveric scapulae were randomized into 1 of 4 groups: a control group with no coracoid hole, a group with a 4-mm transcoracoid tunnel, a group with a 6-mm transcoracoid tunnel, and a group with a socket technique using a 6-mm hole superiorly with a 4-mm hole inferiorly. Bone density measures for all specimens were performed. Coracoid dimensions were quantified. Using a cortical button device, all specimens were loaded to failure with an Instron servohydraulic testing machine (Instron Corp, Canton, Massachusetts). All drilled specimens failed by button pullout, and all control specimens failed by coracoid fracture. Average pullout strength for each tunnel subgroup was as follows: 4 mm, 296.9 N; 6 mm, 146.2 N; 6-4 socket, 261.8 N; control, 762.9 N. No difference was found with respect to tunnel subgroups in base height (P=.25) or bone density (P=.44). Load to failure for the control group was significantly higher than for the other 3 techniques. The 4-mm tunnel load to failure was significantly higher than that for the 6-mm tunnel (P=.006). No difference was found between the 4-mm tunnel and the 6-4 socket technique (P=.853). Although it was not statistically significant, a very strong trend was seen toward increased strength of the 6-4 socket over the 6-mm tunnel (P=.051). The study results show that when employing a transcoracoid reconstruction technique, a 4-mm tunnel technique is significantly stronger than a 6-mm tunnel technique. None of the coracoids drilled with the various tunnels approached the strength of the native coracoid controls using a looped wire technique.

A biomechanical comparison of anterior cruciate ligament suspensory fixation devices in a porcine cadaver model.

BACKGROUND: Suspensory fixation use during anterior cruciate ligament reconstruction has increased due to ease of use and high pullout strength. We hypothesize that there are no significant differences in biomechanical performance among four types of suspensory fixation devices: Stryker VersiTomic G-Lok, Smith & Nephew Endobutton, Biomet ToggleLoc, and Arthrex RetroButton. METHODS: Forty fresh frozen porcine femurs and flexor digitorum profundus tendons were obtained. Each tendon graft was sized to 8.5mm or 9.0mm. Ten of each device were used to fix the grafts in the femur at the 2 o'clock (left) or 10 o'clock (right) position. The graft-femur complex was secured to a servohydraulic test machine in line with the femoral tunnel. The graft was cyclically loaded from 50 to 250 N for 1000 cycles at 1 Hz then loaded to failure at 20mm/min. Actuator load and displacement were recorded. Data were analyzed with multiple one-way ANOVA and Tukey HSD post-hoc tests. Bonferroni correction was applied resulting in P ≤ 0.005 considered statistically significant for ANOVA, P ≤ 0.05 for Tukey. FINDINGS: There were no significant differences in cyclic displacement among any of the groups (P=0.43). The only significant difference in failure properties is the Endobutton exhibited at least 50% greater displacement at failure than the other three devices. INTERPRETATION: Suspensory femoral soft tissue fixation devices are biomechanically similar with respect to failure load but differ in failure displacement. However, there was no significant difference in displacement after cyclic loading. All four fixation devices should withstand the forces associated with daily activities without failure.

Radiographic evaluation of midterm failure rates following metal-on-metal hip resurfacing.

This prospective study examined patient characteristics and radiographic findings for 89 subjects undergoing total hip resurfacing. Thirteen (14.6%) of 89 hips have required revision. Female sex, smaller implant size, and diagnosis of osteonecrosis were associated with lower device survival. No significant differences in acetabular cup angle and stem angle were observed between revised and nonrevised hips. Revision rates for the first 25 hips were 24% and 8% for the last 64 hips. Females accounted for 56% of subjects 1 to 25 and 23% of subjects 26 to 89. Despite representing only 33% of included subjects, females accounted for 62% of revision procedures. The lower device survival proportion in subjects 1 to 25 could not be attributed to acetabular or femoral component malpositioning and can likely be explained by a significantly higher proportion of females enrolled early in the study.

Trace metal analysis following locked volar plating for unstable fractures of the distal radius.

An increase in the utilization of metallic devices for orthopaedic interventions from joint replacement to fracture fixation has raised concern over local metal ion release and possible systemic sequelae due to dissemination of these ions. Our purpose was to determine whether serum titanium concentrations were elevated in patients who had previously received a locked volar distal radius plate. Our hypothesis was that the simple presence of titanium alone in a relatively fixed implant was not enough to raise serum titanium levels. Twenty-two potential subjects who had received a volar locked distal radius plate were identified through review of a single surgeon's operative logs. Eleven met inclusion criteria. Serum titanium levels were measured in these subjects and compared to both current and historical control groups. We found no difference between controls and our study group with the exception of one control subject who is employed as a welder. This is in contrast to previous studies from our institution which found increases in titanium levels in hip and spine implants. We conclude that a locking titanium volar distal radius plate does not raise serum titanium levels in this population.