Proximal Biceps (LH) Roundtable

Proximal Biceps (LH) Roundtable Moderator Laurence D. Higgins, M.D. Brigham and Women s Hospital Harvard Medical School Boston, MA Panelists Jeffrey S. Abrams, M.D. University Medical Center at Princeton Princeton, New Jersey Richard L. Angelo, M.D. University of Washington Seattle, Washington Sumant G. butch Krishnan, M.D. Shoulder & Elbow Service, The Carrell Clinic Dallas, Texas Laurent P. Lafosse, M.D. Clinique Generale Annecy, France Edward G. McFarland, M.D. Johns Hopkins University Baltimore, Maryland visit DePuyMitekBiceps.com for techniques referenced inside

INTRODUCTION Edward G. McFarland, M.D.; Prakasit Sanguanjit, M.D.; Atushi Tusaki, M.D.; Nathan K. Endres, M.D The biceps tendon has become a hot topic in the orthopaedic community. Pathologic conditions of the biceps tendon that may cause symptoms include tenosynovitis and partial tears. New conditions have also been introduced in the literature, including the hourglass biceps described by Pascal Boileau. In this condition, intratendinous swelling causes loss of full elevation of the arm due to a mechanical block 5. Nikhil Verma and Stephen O Brien, M.D. have described a similar condition which can be visualized during arthroscopy with the arm in a position similar to an active compression test 31. With the arm in this position, the biceps tendon becomes redundant and can be seen folding into the joint. There remains a considerable amount of controversy regarding the diagnostic criteria for these newly described entities. In general, the protean nature of the examination for supposed biceps tendon conditions continues to make the decision to treat inexact. Another controversy when it comes to the biceps tendon is whether tenotomy or tenodesis is the preferred treatment for symptomatic biceps tendon disorders. While several surgeons suggest that biceps tenotomy is adequate treatment 2,16,26, others suggest that a tenodesis gives more predictable pain relief and strength 1,18,21. Since tenodesis seems to result in a lower incidence of muscle cramping than tenotomy, many surgeons now advocate tenodesis in the majority of cases, particularly in active individuals 1,20,32,33. Opinions also differ regarding the best way to perform a biceps tenodesis. This year at the American Academy of Orthopaedic Surgeons meeting in Chicago, several papers and videos were dedicated to new techniques for biceps tenodesis 13. Some authors suggest that tenodesis is best performed open 3,4,9-12,17,22,23,27 while others advocate all-arthroscopic techniques 1,6-8,19,25,29,30,32. Some surgeons suggest the biceps tendon can be sutured intra-articularly to the rotator cuff interval tissue, or extra-articularly to the bicipital groove 23, the proximal humerus 11,21 or even to the coracoid process 28. There is also lack of consensus about the best form of fixation of the biceps tendon, with some recommending keyhole techniques 4,14,24, interference screw fixation in a tunnel 1,6,29, suture anchor fixation 8,15,19,25 or just suture fixation to surrounding structures 30. The goal of this roundtable is to present the current state-of-the-art in the evaluation, treatment and results of patients with biceps problems.

Proximal Biceps (LH) Roundtable moderator Laurence D. Higgins, M.D. Chief of Sports Medicine & Shoulder Service Department of Orthopedic Surgery Brigham and Women s Hospital Harvard Medical School Boston, Massachusetts Q1. The biceps is not a new phenomenon; why does there seem to be a lot of buzz around the biceps as of late? panelists Jeffrey S. Abrams, M.D. Orthopaedic Surgeon Executive Committee of ASES Education & Learning Ctr. Committee of AANA Continuing Medical Education Committee of AAOS University Medical Center at Princeton Princeton, New Jersey The biceps is considered a pain generator. It may be problematic for a patient, in spite of successful treatment of impingement or their rotator cuff pathology. Richard L. Angelo, M.D. Clinical Assistant Professor Department of Orthopaedics University of Washington Former Chairman, Education Committee of AANA Team Physician: University of Washington, Seattle, Washington Anterior shoulder pain is relatively common and there is a realization that we can t just term all anterior shoulder pain, impingement, and expect it to go away with a cortisone injection or an acromioplasty. We are learning more about the intricacies of biceps pathology, i.e. not just tendonitis, tearing and dislocation, but sling lesions and more subtle forms of subluxation. Sumant G. butch Krishnan, M.D. Shoulder and Elbow Service, The Carrell Clinic Clinical Assistant Professor, University of Texas Southwestern Medical Center Dallas, Texas That is hard to say. DePalma described biceps pathology in 1951. The last 20 years have seen increased interest due to the work of Neviaser, Walch, and Burkhead. However, only recently has the advent of arthroscopic biceps treatments been readily available. Laurent P. Lafosse, M.D. Director of Shoulder Fellowship Program President of Alps Surgery Institute Shoulder Training Center Clinique Generale Annecy, France More knowledge of the shoulder anatomy and pathology allows surgeons the ability now to focus on more specific topics and specific classification of the elements involved in the shoulder pathology. Edward G. McFarland, M.D. Professor of Orthopaedic Surgery Division of Sports Medicine and Shoulder Surgery Johns Hopkins University, School of Medicine Team Physician: Baltimore Orioles, Johns Hopkins University Baltimore, Maryland We don t know the exact function of the biceps tendon. I think that the increased interest is because arthroscopically we can see what might be pathology, and so there is the impulse to do something about it. Q2. How prevalent is biceps pathology? Is biceps pathology/pain being misdiagnosed or under diagnosed? Abrams: Biceps pathology is being underdiagnosed currently. The frequency of the problem, however, still remains a question. Angelo: True prevalence is difficult to determine because we don t have highly reliable diagnostic tools available to detect early pathology. I am convinced that extra-articular biceps tendonitis is under-diagnosed and under-treated. Krishnan: Biceps pathology is both misdiagnosed and under-diagnosed. At least 20-30% of patients with anterior shoulder pain (glenohumeral or subacromial) will have a component of biceps pathology as a pain generator. mcfarland: I believe it is being over-diagnosed. Isolated biceps tendon pathology without coexisting rotator cuff disease is very uncommon and almost rare. Partial tears are very uncommon. Anterior shoulder pain is relatively common and there is a realization that we can t just term all anterior shoulder pain, impingement, and expect it to go away with a cortisone injection or an acromioplasty.- Angelo, M.D. 2

Biceps Roundtable Q3. Discuss your treatment pathway preoperatively and intra-operatively? At what point do you actively manage bicep pathology? Jeffrey S. Abrams, M.D. Princeton, New Jersey Pre-operatively, patients should be well informed of their diagnosis and the potential for intraoperative findings including a biceps tendon tear. The intraoperative decisions include a full diagnostic exam, evaluating the tendon both with the articular view and causing the biceps to be drawn within the joint to illustrate the part of the biceps that is often beneath the transverse ligaments. Biceps pathology is both misdiagnosed and under-diagnosed. At least 20-30% of patients with anterior shoulder pain (glenohumeral or subacromial) will have a component of biceps pathology as a pain generator. - Krishnan, M.D. by internally and externally rotating the shoulder at 90 of flexion, again with the biceps under load. This may detect subtle forms of subluxation. These tests appear to be more sensitive, but we don t have validity data as yet. Most patients will have had a MRI pre-operatively, so we will have a reasonably accurate idea of its overall integrity. During the operative procedure, if an estimated 75% of the tendon is intact and stable, an arthroscopic debridement alone is performed. Otherwise, if the tendon is drawn into the joint with a blunt instrument, shows significant inflammation or fraying in what would be the inter-tubercular groove segment, then an extra-articular biceps sheath release is performed. I m not aware of a reliable technique to restore stability to a subluxated tendon, so if the biceps sling shows significant disruption or the tendon is clearly subluxated, we would proceed to a tenodesis. Lafosse: If the cuff is intact or partially torn, clinical suspicion of biceps is done by Lift Off and ARIS test (Supination as the shoulder is positioned in abduction and internal rotation) but only arthroscopy will confirm the exact degree of lesion. Q4. What percentages of your rotator cuff cases have bicep pathology? Of those, what percentage needs active management (tenotomy/tenodesis) beyond debridement alone? an absorbable interference screw technique is employed in addition to a routine arthroscopic cuff repair. Sumant G. Krishnan, M.D. Dallas, Texas 20-30% of my rotator cuff cases; active treatment in 15-20% of cases. I m not aware of a reliable technique to restore stability to a subluxated tendon, so if the biceps sling shows significant disruption or the tendon is clearly subluxated, we would proceed to a tenodesis. - Angelo, M.D. Laurent P. Lafosse, M.D. Annecy, France 43% of my rotator cuff cases have bicep pathology, and I treat 100% of the cases. Richard L. Angelo, M.D. Seattle, Washington Other than local tenderness, examination findings for biceps pathology may be sparse. We perform test wherein the biceps is placed under a load by having the patient attempt to flex the elbow against resistance while taking the arm from 0 to 140 of flexion in an attempt to produce movement of the biceps in the groove while under load. A second exam is performed Abrams: As for patients with rotator cuff cases, approximately 10-15% of the rotator cuff surgical cases have coexistent biceps tendon pathology that require additional surgery. Angelo: 40% of my rotator cuff cases; active treatment in 70% of the affected cases. If a low demand patient has a supraspinatus or subscapularis tear, sutures from the anchor closest to the bicipital groove serve to fix the biceps using a locking, whip stitch. Otherwise, if the rotator cuff is intact a soft tissue tenodesis is performed. If the patient is younger than 60 or higher demand, Q5. Several reports have debated the degree to which the biceps plays in shoulder function. What are your thoughts on joint stability when the biceps is not present due to rupture, tenotomy or tenodesis to bone? How about supination and flexion strength when the proximal biceps is not tenodesed? Abrams: Humeral head depression occurs with a healthy biceps tendon with the arm in maximum external rotation. When a patient has a rotator cuff dysfunction, there is not satisfactory humeral head de- 3

Biceps Roundtable pression from a biceps tendon. Rupturing of the biceps creates cramping that often disappears in about six months time. Angelo: With the exception of the overhead or throwing athlete, the loss of proximal biceps function (tearing or detachment) does not appear to contribute significantly to shoulder stabilization. We have not specifically measured elbow flexion or forearm supination strength, but the loss is probably less that 10%. Cramping of the biceps muscle is occasionally an issue in a young laborer, particularly if they are performing repetitive supination activity, i.e. and electrician or installer who is frequently using a screwdriver or wrench. Krishnan: No effect on joint stability. Loss of supination strength is likely 15-20% without tenodesis of some sort. Bigger worry is debilitating cramping and fatigue when using biceps. Q6. Discuss your patient selection for tenodesis versus tenotomy. Upon followup for tenodesis and tenotomy, how have your patients done? Angelo: As a soft tissue tenodesis has become easy to do, we have done fewer tenotomies to prevent distal migration of the long head preventing a Popeye deformity, this technique does not appear to result in pain or complications that we are aware of. For tenotomy, usually patients over 60- ish who are primarily concerned with pain relief and are unconcerned about the possibility of a Popeye deformity. Following a tenotomy in low demand patients, the pain relief has been consistently good and our incidence of biceps muscle deformity is approximately 20%. For tenodesis only 1 failure out of the last 40 who underwent a bony tenodesis. Rarely, a patient will experience persistent pain following a bony tenodesis, and it is not necessarily clear why. Krishnan: Tenodesis in patients under age 65 who have: biceps instability, biceps pre-rupture; and biceps disinsertion/slap lesions in patients over 50. Tenotomy in patients over 65 or low demand, sedentary and/or obese patients who do not worry about cosmesis. Factors for tenodesis: cosmesis, avoidance of fatigue/cramping, and small concern regarding strength. Factors for tenotomy: ease, and reliable pain relief; the only downside is potential for fatigue/ cramping and cosmesis. The results of our non-randomized study had only 2 failures in the initial 43 patients. The success rate for pain relief is approximately 92%. Lafosse: I do not perform any tenotomies, as it is the less anatomical procedure; and has no advantage for the patient compared to the tenodesis. Humeral head depression occurs with a healthy biceps tendon with the arm in maximum external rotation. - Abrams, M.D. Edward G. McFarland, M.D. Baltimore, Maryland Since, I rarely do a tenotomy anymore, it is safe to say that there has to be a very good reason not to do a tenodesis. However, I have done the rare tenotomy in a patient who was very sick and wanted the operation to be as short as possible. My personal impression is that patients with a tenodesis have less cramping than those who have had a tenotomy, but I would agree with studies that suggest their function is about the same. Q7. What is your current technique for a proximal bicep tenodesis? Why? Abrams: Tenodesis avoids cramping in the biceps muscle and cosmetically is favorable to patients to avoid the Popeye deformity. I perform mostly arthroscopic repairs. When the problem is adjacent to the transverse ligament or interval, I perform an arthroscopic tenodesis either to soft tissue or to bone using suture anchors. Weightlifters, patients with a tendon problem extending distally, and patients who place a priority on cosmesis may consider a subpectoral open approach with suture anchors. Angelo: If the patient is relatively low demand with respect to the use of their arm and older, perhaps over 50, we will often perform a soft-tissue tenodesis arthroscopically. If the patient is relatively high-demand, a young laborer or middleaged athlete, a bony tenodesis is preferred using a bioabsorbable interference screw. We believe that fixation into a bony tunnel gives the best opportunity to regain as much strength as possible and prevent cramping with repetitive forceful supination by fixing the tendon securely with its muscle at the resting length. Krishnan: I primarily use an arthroscopic interference screw technique 34,35 with the DePuy Mitek MILAGRO Bioreplaceable Interference Screw in the bicipital groove as originally described by Pascal Boileau with a deviation, in which the pin doesn t exit posteriorly Lafosse: DePuy Mitek SPIRALOK absorbable anchor at the entrance of the intertubercular groove utilizing one of the two ORTHOCORD sutures in a lasso loop technique to securely fixate the biceps tendon. Two different techniques are used in terms of approach and portals depending on whether the cuff is widely torn or not. Clinically, the anchor technique works and tying the tendon by the lasso loop technique is very reliable. I ve done a prospective study with anchor and suture for 60 patients. Only 3 patients had a failure with a Popeye, which results in 95% excellent results. Also, it is not a painful technique as none of the patients who had an isolated biceps tenodesis complained about pain. 4

Biceps Roundtable Edward G. McFarland, M.D. Baltimore, Maryland I still perform my rotator cuff surgery with a mini-open approach, so it is easy to perform a tenodesis of the biceps with the DePuy Mitek LUPINE Loop anchor through a small incision in the deltoid. The technique is easy and buries the tendon in the groove. The technique does not need advanced arthroscopic skills nor does it require any special equipment. Of the 75 or more that I have done this way, only two have become detached, and they were both on patients who fell hard enough to disrupt any type of tenodesis. The physical examination is inexact, and diagnostic injections into the biceps area have not been adequately studied as a diagnostic tool. MRI does not really give you great assessment of the biceps tendon. Consequently, it is best to deal with the pathology when it is encountered at the time of arthroscopy and we have to make a judgment on whether it is or potentially is contributing to the patient s symptoms. Q8. What is important when fixating the bicep tendon? (i.e. proper tension, fixation strength, ease of technique, minimal disruption, etc.) - McFarland, M.D. For tenodesis, only 1 failure out of the last 40 who underwent a bony tenodesis. Rarely, a patient will experience persistent pain following a bony tenodesis, and it is not necessarily clear why. Jeffrey S. Abrams, M.D. Princeton, New Jersey When securing the biceps tendon, the goal is to create a minor surgical approach. The goal is to avoid complications to other parts of the surgery, which include the rotator cuff repair. Tensioning the biceps tendon is a priority in certain cosmetically oriented individuals (i.e., weightlifters). Strength of fixation can be achieved with any of a number of fixation methods. The avoidance of adhesions and pain at the tenodesis site is the goal. - Angelo, M.D. Richard L. Angelo, M.D. Seattle, Washington Depends on the patient - if significant demand is expected, fixation security and reproducing the normal tension and resting length of the biceps muscle are important. If the goal is primarily to avoid a deformity from occurring or eliminating pain from the diseased intra-articular or intertubercular groove segment, then ease of tenodesis technique is important. Time to perform the bony tenodesis is also a consideration if a large rotator cuff repair is involved. Q9. How would you treat a fit 50-year-old female patient who suffers from severe anterior shoulder pain isolated near the bicipital groove? This patient is a medium activity worker. Because of shoulder pain, she gave up playing tennis on the weekends, but would like to resume playing tennis. She has failed conservative care and has decided on surgery, but is concerned about incision scars and her overall appearance. MRI has revealed partial thickness cuff tear. Abrams: Pre-operative discussion of the potential options for the patient would include arthroscopic evaluation, subacromial decompression and treatment to the rotator cuff and biceps tendon. Tendon repair will be either to a suture anchor if the rotator cuff is repaired, or a tenodesis to the adjacent tendon if the cuff integrity was felt to be satisfactory. My bicep tenodeses have a success rate for pain relief and full satisfaction of approximately 92%. - Krishnan, M.D. I do not perform any tenotomies, as it is the less anatomical procedure; and has no advantage for the patient compared to the tenodesis. - Lafosse, M.D. Angelo: Diagnostic arthroscopy: If the tendon is intact and stable, then evaluate for tendonitis at the level of the groove by delivering 3 or 4 centimeters of the tendon into the joint using a blunt instrument. If inflamed, then pass a spinal needle through the tendon as a marker. Go to the subacromial space, perform a limited anterior bursectomy, and following the spinal needle as a guide, release the biceps sheath from the 5

Biceps Roundtable transverse humeral ligament distally for 3 centimeters. Debride the cuff as necessary. Sumant G. Krishnan, M.D. Dallas, Texas Has she been injected in the bicipital groove and subacromial space with cortisone? This would be first line along with PT. If this fails, and biceps pathology is clearly present, she would receive a scope SAD/DCR/ biceps tenodesis. This is assuming that the cuff is not structurally significant and patient has no cuff weakness. 43% of my rotator cuff cases have bicep pathology, and I treat 100% of the cases. - Lafosse, M.D. Laurent P. Lafosse, M.D. Annecy, France I believe it is a partial supraspinatus tear close to the bicipital groove and would propose an arthroscopic exploration. First, I would ask for an EMG to check the suprascapular nerve as she is a tennis player and has some risk of nerve entrapment at the coracoid notch. If EMG were positive, I would do an arthroscopic nerve release. I would probably perform an association of biceps tenodesis, rotator cuff repair and adapted acromioplasty. Mcfarland: Arthroscopy - specifically looking for SLAP lesions, and would make sure that the portion of the biceps tendon in the groove was examined arthroscopically. If she had no biceps tendon pathology, I would debride her rotator cuff and perform a subacromial debridement. If she had a biceps partial tear, I would perform a tenodesis. Q10. How would you treat a 30-year-old male athlete who participates in fast pitch baseball and has had one shoulder procedure - to repair a SLAP lesion, along with an acromioplasty and distal clavicle resection? One year later, he continues to suffer from severe anterior shoulder pain near the bicipital groove. MRI has ruled out a rotator cuff tear, but reveals significant bicep fraying. Abrams: I would choose a biceps tenodesis after a failed SLAP repair. The biceps tendon would be sewn to the adjacent rotator interval prior to dividing the long head of the biceps. The knots will be closed on the bursal side of the interval to avoid any articular irritation. Angelo: It depends what significant fraying means. If there were less than 75% intact tendon fibers, a bony biceps tenodesis would provide the best likelihood of pain relief and function. Krishnan: Arthroscopic biceps tenodesis. Lafosse: I would perform an arthroscopic biceps tenodesis as well. Mcfarland: Arthroscopy. If he had internal impingement with peeling off of his labrum, then some form of anterior capsular tightening would be necessary. If he had failed a SLAP repair, the options are to repeat the repair, but in those cases I prefer to do a biceps tenodesis. Q11. How would you treat a 75-year-old overweight male patient with low activity level? The patient has had repeated injections, and failed conservative care. MRI shows the presence of a medium size slightly retracted crescent shape tear of the rotator cuff with a 60% torn bicep tendon. Abrams: I would perform a 2-suture anchor repair of the rotator cuff tear and the biceps tenodesis would occur to the same two anchors along its lateral border of the footprint. As tears enlarge, the biceps can be used to augment the cuff repair. Angelo: Arthroscopic rotator cuff repair and a biceps tenotomy. Krishnan: Scope, subacromial decompression, distal clavicle resection, and arthroscopic rotator cuff repair with biceps tenotomy. Clinically, the anchor technique works and tying the tendon by the lasso loop technique is very reliable. I ve done a prospective study with anchor and suture for 60 patients. Only 3 patients had a failure with a Popeye, which results in 95% excellent results. Also, it is not a painful technique as none of the patients who had an isolated biceps tenodesis complained about pain. - Lafosse, M.D. Lafosse: Arthroscopic biceps tenodesis, acromioplasty with or without cuff repair according to the possibility to reduce and fix the cuff in order to prevent extension of the cuff tear, but would not push to far the fixation of the cuff if the tendon and/or the bone appears too weak. Mcfarland: If the patient had a tear of his biceps tendon and rotator cuff at the time of arthroscopy, I would repair his rotator cuff and perform a tenodesis of his biceps tendon through a mini-open approach. 6

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Arthroscopy, 2002; 18; 1002-1012. DePuy Mitek, Inc., 2006. All rights reserved. Printed in the USA. P/N 900930 For more information, call your DePuy Mitek representative at 1-800-382-4682 or visit us at www.depuymitek.com. DePuy Mitek, Inc., 325 Paramount Drive, Raynham, MA 02767. www.shoulderpainsolutions.com www.depuymitekbiceps.com