Great, thank you. So thank you so much for the opportunity to present, and as we all know, the longhead biceps tendon is a common cause of anterior shoulder pain. Biceps tenodesis is an established technique, and there are a variety of approaches, arthroscopic and open, and numerous fixation devices. Biomechanical properties have been validated in cadaveric models, but in vivo data is lacking. We previously published on arthroscopic versus mini-open subpectoral biceps tenodesis with interference screws, and found that the location of tenodesis made no difference at final 2.9 year follow-up. Another study from our group investigating biomechanical properties demonstrated that all suture anchors had greater resistance to torsional displacement and energy prior to failure versus interference screws. The purpose of our initial study was to do an RSA analysis of biceps tenodesis, and secondarily to look at PROMs. It was a non-randomized prospective cohort study. This is our flow diagram. We had 30 patients in each group, and of the 128 eligible, 120 enrolled. We attached a tantalum bead, which is radio-opaque, with a 2.0 ethabond suture. And this is our technique. You can see that arthroscopically we can pull the tendon from the shoulder, attach the button, and in standard fashion, we drill a socket just above the superior border of the major tendon, and fixation was established in this instance with an interference screw. Arthroscopically, when suture anchors were used, we placed two in this location. We are all familiar with the subpectoral approach. Similarly, the tendon is whip-stitched. We tie a tantalum bead, and it is similarly stabilized with either an interference screw or in the all-suture anchor group, we used one single-suture, all-suture anchor. We'll skip ahead. So radiographic outcomes were obtained immediately post-op at one week and in three months. We looked at bead migration. We normalized the displacement with markers, and we measured from the top of the humeral head. The groups were very well matched. There were slight differences in mean age, hand dominance, workers' compensation status, and concurrent glenohumeral joint debridement. With respect to bead migration, there were significant differences. With one single all-suture anchor, there was almost 15 millimeters of displacement versus 4 to 5 millimeters with the interference screws, and 8 millimeters with two single all-suture anchors. This is a pairwise comparison at three months. You can see, as expected, that there is migration. The blue line is the tenodesis with a single all-suture, suture anchor, and the bottom two lines are the interference screw. The one in the middle there is the arthroscopic approach with two all-suture, suture anchors. So there's about a three-fold difference from one fixation device to the next. There were no differences in PROMs across any of these groups. So in spite of the differences observed with tendon migration, it was not felt to be clinically significant, at least per patient-reported outcomes. There were complications. There were two and three reoperations, but no differences across groups. There were four Popeye deformities. It's notable that none of those occurred with the interference screw. The patients who had a Popeye deformity had about 7 centimeters on average displacement. So that was statistically significant. At mid-term follow-up with our sub-analysis, we wanted to look at bead migration and PROMs, and secondarily, we wanted to look for predictors of achieving clinically significant outcome thresholds. So when we pooled all of four groups together, this is what the plot looks like. So effectively, we're looking at bead migration at three months, and we're trying to determine if that correlates with PROMs at three years. We had 84% follow-up. Average follow-up was 2.9 years, and again, if you had a Popeye, you had about seven or eight centimeters of displacement. The average migration, or median migration, was about 6.5 millimeters. So these constructs, by and large, are stable. This is a plot of the constant, sane, and PROMs upper extremity scores, and you can see that as migration increases, there is a decrease in the metric. So all scores decrease with increased migration. So this was statistically significant. Furthermore, across all groups, about 60% of patients achieved a CSO on each instrument. There were significant predictors. We found that patients with higher BMI, so presumably more deconditioned and heavier patients, were more likely to achieve MCID and SCB. Patients with less biceps tendon migration were also more likely to reach CSOs, specifically MCID and PAS. We were able to quantify this with a linear regression, and I'll provide an example next because it's hard to interpret otherwise. So an average man, 5'10", 200 pounds, versus the same height and 165 pounds, has about a 67% more likely chance to achieve a CSO. So the heavier, more deconditioned patient is more likely to be satisfied with this result. For every one millimeter of decreased migration, there's a 2.3% increase in likelihood of MCID. So if you have 2.5 centimeters or an inch less migration, you're 58% more likely to achieve your CSOs. There were limitations to the study, which we tried our best to mitigate with normalization. We only have radiographs at three months. Our initial study conclusions were that interferon screws are stiffer. They result in fewer Popeyes. You should think twice about using a single ulcer-seizure anchor as there was the most migration with that. But there was no difference across all groups with clinical outcomes. Popeye deformities migrated 7 centimeters. And finally, this example illustrates once again that heavier patients are more likely to achieve CSOs, and the same applies for those with less tendon migration. So finally, if you're going to do a subpectoral approach, consider the interference screw, which can also be done arthroscopically. Use two ulcer-seizure anchors or one that's double loaded. And finally, if you have a fit, high-demand patient with a low BMI, consider using an interference screw because if they do migrate more, they're more likely to not achieve a CSO.

biceps tenodesis

anterior shoulder pain

fixation devices

arthroscopic

open methods