Thank you to the program committee and in the Cassandra and Rick Wright guys done a terrific job. Here's my disclosure. So very nice talk by Brian Forsythe. So biceps pain. You know what causes biceps pain? Well you guys are in the Rocky Mountains right now. This is what causes biceps pain here. And so this is what we see in our patients. And there are a lot of pathologies that cause this, right? There's inflammation, there's instability, there's rupture. So a lot of different things that may cause this biceps pain. So the problem is pain, right? The biceps is a pain generator. Whether it's a tear, it's a slap tear, biceps instability, maybe even revision surgery. So we need to get rid of that pain. So how do we do it? We can cut it and do a bicep stenotomy or we can do a tenodesis. And so what are the benefits of a tenodesis? Well potentially there's better preservation of elbow flexion and supination strength. That's that's a potential theoretical advantage. Decreased post-operative pain, avoidance of a cosmetic deformity. So then we're talking about the arthroscopic superpectral or the open subpectral. So this is an example of the arthroscopic. This is done with suture anchors. Very limited incisions, very easy to do. And this is the open subpectral. Again this is done with suture anchors. Very easy, very quick to do. So this is what we're talking about. The arthroscopic versus the subpectral. So what does the literature say? So this is a nice systematic review. Looked at the biomechanical studies. They found that there was no significant difference in ultimate load-to-failure stiffness and cyclical displacement. So again you heard from Brian. He just mentioned it. Very nice study that they did in Rush. Randomized controlled trial. No significant differences were found in patient report outcomes. No significant difference in complication rates. No patients required a revision. Surgical time, and this goes off their previous paper, was significantly greater for the superpectral. This is a systematic review that we did recently. And we compared directly compared patient reported and functional outcomes of two techniques. So we looked at, there was one level one study, seven level three studies. Looked at patient report outcomes. Looked at some clinical criteria and clinical failure rates. There were 326 arthroscopic and 381 subpectral. There are no differences in treatment failure rates or patient reported outcomes scored between the groups in any of the studies. One study found subpectral patients to have increased forward flexion, range of motion. And two studies found the superpectral patients have significantly more post-operative stiffness. So in conclusions in this systematic review, patients undergoing subpectral or superpectral bicep tenodesis can be expected to experience similar outcomes, improvements in the clinical outcomes. Superpectral patients may experience increased stiffness and decreased range of motion in the early post-operative period. So what about concomitant rotator cuff tears? Bicep tenodesis, as we know, we're often doing something else. It's not often isolated. Does this affect clinical outcomes? So this was 71 patients. They found that the subpectral had shorter surgery time and less intraoperative blood loss with the subpectral. The subpectral had better ASES and VAS scores at two weeks to three months. Here's another study, randomized controlled trial, 60 patients. Both groups had similar patient report outcomes. What about complications? What about complications? So humeral head fracture risk. Retrospective review of 157,000 patients. Open subpectral bicep tenodesis is associated with increased risk of post-operative humeral fracture. Most of these were in the age group between 65 and 74. This is a nice systematic review looking at complications with concomitant rotator cuff repair. This included a good number of different patients. Subpectral patients were more likely to have nerve injuries and neuropraxia. Superpectral patients were more likely to have persistent bicipital pain and Popeye deformity. And then lastly, this is a level 4 case series that looked at two sets of the patients. They evaluated surgical, medical, anesthetic complication rates. And although the subpectral bicep tenodesis had higher rates of wound healing issues, hematoma formation, nerve injury, DBT, and general anesthetic complications, the rates were not clinically significant and comparably low, less than 2%. So in conclusion to this, the literature points to comparable outcomes between techniques in both isolated and rotator cuff concomitant bicep tenodesis. The main observed differences are that the superpectral bicep tenodesis have increased surgical time and stiffness in early post-operative period. Subpectral biceps tenodesis have a slightly higher rates of nerve injury, wound complications, hemorrhoid fractures, although the rates remain clinically low. So what are the factors to consider as you're looking at this and you're doing this? You want to look at age, you want to look at the body habitus, OR time, number of concomitant surgical procedures, individual infection risk, and patient compliance with post-operative restrictions. So what do I really do? My bias is toward the subpectral tenodesis. I like to maintain that length-tension relationship. I keep it in situ. I put the anchor in, tie it, and then cut the biceps. I get rid of any biceps issues in the groove, so you don't have to worry about if there's anything above that. It's consistent, reliable results, quick easy procedure. When done with the suture anchor, remove the biceps that are tenodesis, and often it takes less than five minutes. The anatomy is easily defined and identified and is a very small cosmetic incision. Thank you.

biceps pain

pathologies

tenodesis

outcomes

subpectoral tenodesis