They drill a small hole in your upper arm. By week 10, you can begin with advanced strength exercises and heavy lifting. There were 2 temporary nerve palsies (2%) resulting from an interscalene block. The subpectoral approach provides excellent versatility and ability to meet technical objectives when performing revision tenodesis, by removing the tendon completely from the groove and preserving biceps function. Cleveland Clinic is a non-profit academic medical center. Outcomes following long head of biceps tendon tenodesis. Looking at the subgroup of patients with at least 6 months follow-up, there were a total of 41 patients. Receive small business resources and advice about entrepreneurial info, home based business, business franchises and startup opportunities for entrepreneurs. What Symptoms May Lead to a Biceps Tenodesis? Aiyash S, Garbis N, Goldberg B, Salazar D. JSES Open Access. PMC legacy view Hardwire fixation. You may search for similar articles that contain these same keywords or you may If a corticosteroid injection is required, use a hemostat between the needle and skin to hold the needle in place while changing to the 1- or 3-mL syringe containing the corticosteroid solution. [14] Scheibel et al. Epub 2020 Jun 24. [2] They reported on 54 patients and reported no complications in this group. After the arthroscopy, the scope instruments were removed and a 3- to 4-cm longitudinal incision is made centered over the inferior border of the pectoralis major tendon. BMC Musculoskelet Disord. No arthroscopy was performed prior to these surgical cases rather the biceps was cut proximally through the subpectoral tenodesis site surgical exposure and then tenodesed in the same wound. WebFailed biceps tenotomy generally results from a lack of thorough preoperative discussion of potential outcomes rather than from technical problems. They drill a small hole in your upper arm bone. your express consent. Bookshelf Upgrade to Patient Pro Medical Professional? Recovery includes resting, pain control, and physical therapy. 2016 Aug 30;17(1):375. doi: 10.1186/s12891-016-1230-5. Testing instruments such as the UCLA or Constant score are unreliable to reach the final result of the tenodesis or tenotomy because of the strong influence of the rotator cuff condition or other reconstructions performed in these patients, Dr. Arce said. Fang JH, Dai XS, Yu XN, Luo JY, Liu XN, Zhang MF, Zhu SN. government site. Biceps tenodesis is done by detaching your biceps tendon from your labrum and moving the tendon to your upper arm bone (humerus). Epub 2015 Sep 28. Arthroscopy. Bicipital groove point tenderness is the most common isolated finding during physical examination of patients with biceps tendinitis. The tenodesis of the long head of the biceps tendon has been completed, thus preserving the length-tension relation of the tendon. Fig. Older patients (i.e., athletes older than 35 years or nonathletes older than 65 years) may have acute biceps tendinitis caused by sudden overuse, or biceps tendinosis caused by use over time.4 Primary impingement syndrome is considered the most common cause of biceps tendinosis or tenosynovitis (i.e., inflammation of the tendon sheath).4 Primary impingement is a mechanical impingement under the coracoacromial arch caused by bone spur formation of the acromion, an unfused acromial apophyses, or thickening of the coracoacromial ligament. Careers. Pathologic disorders of the LHBT can be divided into 3 categories: inflammatory/degenerative conditions, instability of the biceps tendon, and SLAP lesions/biceps tendon anchor abnormalities. Bookshelf Get new journal Tables of Contents sent right to your email inbox, Management of Failed Biceps Tenodesis or Tenotomy: Causation and Treatment, Articles in PubMed by Daniel S. Heckman, MD, Articles in Google Scholar by Daniel S. Heckman, MD, Other articles in this journal by Daniel S. Heckman, MD, Biological Targets of Multimolecular Therapies in Middle-Age Osteoarthritis, Middle Aged, Everlasting Athletes, and Osteoarthritis: The Present and Future, Elderly Runners and Osteoarthritis: A Systematic Review, The Evaluation and Management of Failed Distal Clavicle Excision, Management of the Failed Arthroscopic Subacromial Decompression: Causation and Treatment, Privacy Policy (Updated December 15, 2022). Your surgeon can fix your biceps tendon with open surgery or arthroscopic surgery. This usually occurs after trauma, such as a direct blow to the shoulder, a fall on an outstretched arm, or repetitive overhead motion in athletes.12,1417, The most common finding of biceps tendon injury is bicipital groove point tenderness.1 During physical examination, the patient stands or sits with the arm at his or her side in 10 degrees of internal rotation. The doctor wanted to take things slow given the state of the tendon after he cut it from where it scarred down. Ultrasonography is the best modality for evaluating isolated biceps tendinopathy extra-articularly. For patients with biceps tendinosis without a rotator cuff tear, LHB tenodesis at the groove is a possible solution. Before The new PMC design is here! Advantages of the subpectoral tenodesis technique include the removal of the LHB from the bicipital groove potentially limiting the development of postoperative pain secondary to residual tenosynovitis within the biceps sheath. 2. McCormick F, Nwachukwu BU, Solomon D, Dewing C, Golijanin P, Gross DJ, Provencher MT. performed 27 proximal biceps tenodeses using a suture anchor and evaluated the repair integrity with an MRI. By continuing to use this website you are giving consent to cookies being used. Please enable scripts and reload this page. Please try after some time. If the patient experiences pain, it is a positive sign of impingement syndrome. Conclusion: The all-suture anchor fixation using a Krackow stitch for subpectoral biceps tenodesis provided ultimate load and stiffness similar to unicortical button fixation using a nonlocking whipstitch. The patient may begin exercises after the shoulder is pain-free. Operative treatment options include revision tenodesis or biceps tenotomy. If other pathology is suspected, magnetic resonance imaging should be performed. MeSH Having had a bicep tenotomy as part of a more complex shoulder surgery in early October its my understanding that a tenodesis is performed as an alternative to a tenotomy specifically to ensure full strength can be achieved after healing and therapy. University of Wisconsin Sports Medicine: Rehabilitation Guidelines for Biceps Tenodesis.". A novel failure mode for biceps tenodesis using fork-tipped interference screws 2018, Journal of Shoulder and Elbow Surgery Citation Excerpt : All 3 failures in Arthroscopic assessment, particularly of the SGHL-CHL complex, is key in diagnosing and treating biceps instability. Rotator cuff tear with concomitant long head of biceps tendon (LHBT) degeneration: what is the preferred choice? Biceps tendinitis is inflammation of the tendon around the long head of the biceps muscle. The purpose of this paper is to review the management of long head biceps tendon pathology, with a particular emphasis on a prior failed biceps tenotomy or tenodesis. One patient developed a pulmonary embolism requiring hospital admission and anticoagulation. The overall complication rate was 48%, with half of these reporting pain of >3 on a scale of 10 and 4% of patients requiring additional surgeries. This injury is called a, Avoid food or drink for eight hours before you go to the hospital. Epub 2015 Mar 29. Biceps tendinitis is a disorder of the tendon around the long head of the biceps muscle. eCollection 2019 Oct. Mardani-Kivi M, Keyhani S, Ebrahim-Zadeh MH, Hashemi-Motlagh K, Saheb-Ekhtiari K. J Orthop Traumatol. Our hypothesis is that the early complication rates after dual suture anchor fixation will be equivalent to those reported for interference screw fixation for a subpectoral tenodesis. Both forms are performed under general anesthesia, and the surgeon may insert an arthroscope (a small tube) to see inside the shoulder joint. In this sub-group of patients with longer follow-up, there was only a single complication (superficial wound infection treated with oral antibiotics). Biceps tenodesis is successful more than 70% of the time. An analysis of 140 injuries to the superior glenoid labrum. Procedures on the biceps tendon were performed in cases of partial tears, subluxations, and complete dislocations. doi: 10.1016/j.eats.2021.12.029. Conservative management of biceps tendinitis consists of rest, ice, oral analgesics, physical therapy, or corticosteroid injections into the biceps tendon sheath. Outcomes following long head of biceps tendon tenodesis. The .gov means its official. All indications for tenodesis include chronic tendonitis, partial or complete tears of the LHB, SLAP lesions in older patients, or failed SLAP repairs and tendon subluxation out of the bicipital groove in active patients who have failed conservative management, as described in this chapter. One simple maneuver to assess the LHB is to check for the presence of one-finger pain approximately 7 cm below the level of the acromion with the arm in 10 degrees of internal rotation. The goal of stretching is to regain a balanced range of motion without stiffness or pain in any position. not moderated or reviewed by doctors and so you should not rely on opinions or advice given by other users in Tenodesis was performed on the dominant side in 55% of shoulders. The ramp test may be used to evaluate stability and tissue quality of the biceps tendon, Dr. Arce said. Our average length of follow-up was only 7 months. Always speak to your doctor before acting and in cases of emergency seek Keywords: A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Conflict of Interest: The authors and their immediate family or the institution did not receive any financial payments or other benefits from any commercial entity related to the subject of this article. A positive test is pain radiating to the bicipital groove. Bleeding that soaks through your dressing and doesn't stop when you place pressure over the area. government site. Careers. Failed biceps tenotomy generally results from a lack of thorough preoperative discussion of potential outcomes rather than from technical problems. Mazzocca AD, Cote MP, Arciero CL, Romeo AA, Arciero RA. A keyhole is made in the humerus bone, then the stitched end is placed in the keyhole and locked into place. You may be trying to access this site from a secured browser on the server. However, this time not 10 minutes goes by and I start to feel slight irritation around the attachment site. Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, 6 Minutes of Exercise May Protect Brain From Alzheimer's, 'Disturbing' Rate of Adverse Events During Hospital Stays. Biceps tendinitis may also refer to tendinosis, which is a syndrome of overuse and degeneration. Still, tenodesis is the procedure of choice for young athletes because it doesn't cause bicep pain. Outcomes are often difficult to measure due to multitendon involvement and concomitant procedures. Overuse, trauma, and degenerative disease are the main causes of tendon failure.. Papp DF, Skelley NW, Sutter EG, Ji JH, Wierks CH, Belkoff SM, et al. Patient-reported outcomes including the functional score, Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS), Simple Shoulder Test (SST), and American Shoulder and Elbow Surgeons were obtained, and range of motion, strength, and complications were quantified. Arthrosc Tech. Consequently, it is likely that most traumatic failures would occur within the first 6 months as has been shown in other series. so seven months post op, and it sounds like he's going to have to go back in to repair. You feel a sudden sharp pain in your upper To evaluate the clinical and functional outcomes of patients undergoing revision subpectoral tenodesis after failed primary tenodesis or tenotomy of the long head of the biceps. sharing sensitive information, make sure youre on a federal . The electronic medical record for all patients was retrospectively reviewed for early postoperative complications within the first 12 months of surgery including wound infection, hematoma, wound dehiscence, rupture, hardware failure, and requirement for re-operation. The preferred surgical technique to manage biceps-superior labral pathology is often debated, and rates of revision and persistence of pain vary widely according to surgical technique and patient characteristics. [1,2] While complications of biceps tenodesis in other locations have been studied extensively, limited data exist on the complications of a tenodesis in the subpectoral region. The Yergason test requires the patient to place the arm at his or her side with the elbow flexed at 90 degrees, and supinate against resistance18 (Figure 2). 2020 Sep;12(3):371-378. doi: 10.4055/cios19168. Youll receive general anesthesia (youre asleep) or regional anesthesia (youre awake but cant feel or move your arm) before the procedure. Management of Failed Proximal Biceps Surgery: Clinical Outcomes After Revision to Subpectoral Biceps Tenodesis. Preoperative imaging included shoulder radiographs (AP, true AP, scapular Y and axillary views) and a shoulder magnetic resonance imaging (MRI) of every patient undergoing a biceps tenodesis. Your biceps tendon wears out over time and so tears more easily. Negative results on radiography should be followed by ultrasonography of the shoulder, which is the best method by which to extra-articularly visualize the biceps tendon. The .gov means its official. There were a total of 7 complications (7%) in the entire group. Confirm this is the biceps tendon by externally rotating the arm and placing the elbow in 90 degrees of flexion. Open subpectoral biceps tenodesis has been associated with a low frequency of more significant complications, such as neurovascular injury, deep wound infection, as well as hardware failure, and minimizes the chance of postoperative groove pain. Keywords Biceps tenodesis Complications Patient outcomes Infection Hardware failure Some error has occurred while processing your request. SomeAAOS Nowarticles are available only to AAOS members. The bulges are sometimes called Popeye syndrome. The pectoralis major is retracted laterally, the conjoint tendon is retracted medially, and the previously cut biceps tendon is delivered into the wound. The superior drill hole is placed 3 cm proximal to the inferior border of the pectoralis tendon and the inferior hole is placed 1 cm proximal to the inferior border of the pectoralis tendon. In outlining the preoperative and arthroscopic assessment for instability, Dr. Arce noted that many anatomic structures contribute to prevent biceps instability, including the following primary restraints (Fig. Bicep tendon tears may come with the following symptoms: Cramps in the bicep after repetitive use Pain in the affected Revision Open Subpectoral Biceps Tenodesis With Allograft Tendon Reconstruction for Symptomatic Failed Biceps Tenodesis. SOURCES:Injury: Prospective Outcome Analysis Following Tenodesis of The Long Head of the Biceps Tendon Along with Locking Plate Osteosynthesis for Proximal Humerus Fractures.Journal of Shoulder and Elbow Surgery: Biceps Tenodesis: a Biomechanical Study of Fixation Methods." 1): Preoperatively, the Abbott-Saunders test is very useful. A patient with an unstable biceps may experience pain and locking sensations when the arm is moved from abduction and external rotation to adduction and internal rotation. He may be reached at tstanton@aaos.org. A patient may also report pain relief if there is instability or subluxation of the biceps tendon. Clement X, Baldairon F, Clavert P, Kempf JF. You cant rotate your arm so that your palm is up. They use the arthroscope to view your biceps tendon and labrum. After surgery, the shoulder is typically kept numb via pain medications. Your surgeons close the tiny cuts in your shoulder. Koch BS, Burks RT. Last time I only had to wait a week which was easy peasy compared to this time. Patient Satisfaction After Biceps Tenotomy. respect of any healthcare matters. The symptoms can often be controlled by Not smoking can help your heart and lung function better during surgery. Try not to get frustrated and give in to the temptation to do more because you might end up doing too much too soon. The average age at time of tenodesis was 45.5 years. Koh KH, Ahn JH, Kim SM, Yoo JC. The two primary options for addressing LHB pathology are tenotomy and tenodesis. Risk factors for a bicep tendon rupture include: Biceps tenodesis is used for both partial and full tendon tears, an unstable joint, or pain caused from overuse of the biceps. Your healthcare provider will give you specific instructions, but heres some general guidance: Scars from open biceps tenodesis are small. Nevertheless, most patients after a subpectoral tenodesis are allowed to return to all activities without restriction at 3 months if a concomitant rotator cuff repair was not performed and 6 months if a rotator cuff repair was performed. Medscape: "Complete Ruptures of the Achilles Tendon. Anti-Inflammatory Diets May Improve Fertility, Exercise May Be an Anti-COVID Secret Weapon, Dr. Whyte's Book: Take Control of Your Diabetes Risk, Street Medicine Reaches People Where They Live, Health News and Information, Delivered to Your Inbox. My PT kept dismissing the tenderness and restriction feeling as a normal part of recovery. The procedure also treats SLAP tears tears in your labrum (cartilage that lines the inner part of your shoulder joint.) Failed biceps tenotomy generally results from a lack of thorough preoperative discussion of potential outcomes rather than from technical problems. Patients with unsatisfactory results can be treated with conversion to a biceps tenodesis. Talk to your healthcare provider about your concerns. The medial CHL is the number one biceps stabilizer for prevention of subluxation or dislocation, Dr. Arce said. Wolters Kluwer Health, Inc. and/or its subsidiaries. The average length of follow-up was 7 months (range, 1 to 45 months). Several complications have been reported after interference screw biceps tenodesis including tenodesis failure. For tenodesis, Dr. Arce uses anchors or biotenodesis screws at the level of the cuff repair. There were 4 superficial wound infections (4%). For successful treatment of both biceps instability and biceps tendinosis, a complete arthroscopic assessment is a key factor. Results: (https://pubmed.ncbi.nlm.nih.gov/27599831/). Therefore, we may consider the subscapularis fiber insertions at both the lesser and greater tuberosities. With the patient in a hands-on-hips position, the scapula and clavicle are stabilized by one of the examiner's hands while the other hand is used to apply anterior-superior force at the elbow of the affected side. The Neer test involves internal rotation of the arm while in the forward flexed position16 (Figure 3). Complication rates are equivalent to those previously reported for interference screw fixation and should be considered as a reasonable alternative. Patients with unsatisfactory results can be treated with conversion to a biceps tenodesis. Methods: An official website of the United States government. It typically takes at least 4 to 6 weeks to recover from biceps tenodesis surgery. All other arthroscopic procedures were then performed, if any. Coming to a Cleveland Clinic location?Cole Eye entrance closingVisitation, mask requirements and COVID-19 information. The decision to treat patients was based upon preoperative history and physical examination, MRI findings, and an arthroscopic evaluation. We reported no deep infections, hematomas, peripheral nerve injuries, fractures, or ruptures utilizing this technique. modify the keyword list to augment your search. For younger and athletic patients, we prefer suture anchor tenodesis, which is easily performed with the current arthroscopic techniques.. Biceps tenodesis is a procedure used to repair the bicep muscle after a full or partial tear from the shoulder. Clinical outcomes after subpectoral biceps tenodesis with an interference screw. The supraspinatus fibers contribute to the pulleys lateral wall and roof. This technique is the screw fixation technique. The https:// ensures that you are connecting to the WebPatients with biceps tendinitis or tendinosis usually complain of a deep, throbbing ache in the anterior shoulder. You can drive if you arent taking medication that affects your ability to drive and once your shoulder doesnt hurt when you control the wheel. Registered in England and Wales. Get useful, helpful and relevant health + wellness information. Our series is the largest group of patients reported undergoing a suture anchor subpectoral tenodesis. Rates of subsequent shoulder surgery within three years for patients undergoing SLAP repair versus biceps tenodesis. Another potential limitation is that only early complications were evaluated and it is likely that some re-ruptures were missed. In the group treated for superior labral tears, the decision to treat was made at the time of surgery based upon a clinical history consistent with a superior labral tear (traumatic onset), positive physical exam findings (positive active compression test), an MRI confirming type II, III, or IV superior labral tear, and an arthroscopic evaluation consistent with a type II, III, or IV superior labral tear. Bethesda, MD 20894, Web Policies AAOS Now / Structures should be assessed not only in a static view but also in dynamic testing during the arthroscopic procedure, he said. Finally, in the group treated for a failed proximal biceps tenodesis, the decision to treat was made preoperatively based upon proximal biceps groove pain and tenderness after a proximal tenodesis. This makes it difficult to distinguish from pain that is secondary to impingement or tendinitis of the rotator cuff, or cervical disk disease.14 Pain from biceps tendinitis usually worsens at night, especially if the patient sleeps on the affected shoulder. Instruct the patient to keep it on for eight to 10 hours and watch for signs of infection, which may include erythema, increased pain, pus at the injection site, and a low-grade fever of 100.4F (38C) or higher. Not sure if irritation is the right word more like I could feel it was there and it felt odd. Other surgical procedures performed at the time of tenodesis included Arthroscopic subacromial/glenohumeral debridement (40), arthroscopic rotator cuff repair (40), and distal clavicle excision (8). Physical therapy is crucial for a full recovery of the shoulder joint. After diagnosing the type and location of tendon failure, the surgeon may perform tenotomy or tenodesis, with encouraging results., Terry Stanton is senior science writer for AAOS Now. [1] Koch et al. Can Non-Surgical Treatments Be Used for Bicep Tendon Tears? Repetitive overhead motion of the arm initiates or exacerbates the symptoms. Failure of biceps tenodesis with interference screw fixation. These tendons can easily become unstable and torn, causing pain in the shoulder. Finally, Sears et al. 8600 Rockville Pike The scope [6,7] Several authors have performed biomechanical studies comparing interference screw fixation and suture anchor fixation for a proximal biceps tenodesis in both the suprapectoral and subpectoral regions. Even though interference tenodesis screws have been described as providing stronger fixation than suture anchor, no significant differences have been found between these devices. A throwing program may be started after the rotator cuff, scapular rotators, and prime humeral movers (i.e., pectoralis major, latissimus dorsi, and deltoid) are strong enough. Your message has been successfully sent to your colleague. Before A biceps tenodesis is more complicated than a tenotomy procedure, which uses needles to break up scar tissue. Your labrum tears and your biceps tendon is either torn in the process or is disconnected from your shoulder. Epub 2017 Oct 16. This site needs JavaScript to work properly. In his presentation, Dr. Arce, of Buenos Aires, Argentina, focused on tenodesis and covered different arthroscopic techniques for performing LHB tenodesis. The next morning I decided to do the same thing and take a picture to compare to pictures of my bicep after the first surgery and after the tendon pulled out of the first tenodesis anchor screw. Technique When necessary, biceps tenodesis was performed with one of the anterior suture anchors above the rotator cuff. Federal government websites often end in .gov or .mil. The purpose of this paper is to review the management of long head biceps tendon pathology, with a particular emphasis on a prior failed biceps tenotomy or tenodesis. Institutional review board (IRB) approval was obtained prior to initiating the study. Full recovery typically takes four to six months. Epub 2019 Sep 18. Rupture of the biceps tendon is one of the most common musculotendinous tears. Clipboard, Search History, and several other advanced features are temporarily unavailable. Soft tissue procedures. Accessibility Read our editorial policy. Case series; Level of evidence, 4. Subpectoral biceps tenodesis utilizing a dual suture anchor technique has a low early complication rate with no ruptures or deep infections. Epub 2021 May 21. In brief, there are four places where the LHB could be fixedproximal near the articular cartilage, at the groove, suprapectoral, and subpectoral.. Studies show that people who have open biceps tenodesis may return to sports more quickly than people who have arthroscopic biceps tenodesis. After 4 months, a sport-focused throwing program is initiated in overhead athletes, but contact sports are generally allowed only after 6 months post-operation [ 15 ]. Background: There was a significant improvement in the VAS score (P < .001), SANE (P = .001), SST (P = .035), functional score (P < .001), and forward elevation (P = .028), whereas postoperative strength (P = .440), abduction (P = .100), and external rotation (P = .745) improvement failed to achieve statistical significance after revision surgery. Ultrasonographic guidance may increase the accuracy of the injection and has been shown to produce a fivefold increase in analgesic effect.29,30 Ultrasonography may also be used to aspirate and disperse calcific deposits within the tendons of the rotator cuff.28,31, Radiologic evaluation to diagnose biceps tendinitis or tendinosis should begin with radiography of the shoulder to rule out primary causes of impingement (Table 35,10,12,14,3241 ). 4 years ago, Biceps tenodesis has grown in usage exponentially over the last 20 years 5.Biceps tenodesis can be performed with an open or arthroscopic technique and can be performed at intra-articular, high in the groove, suprapectoral, or subpectoral locations 5 ().The purpose of this review article is to review the many treatments for LHBT pathology and their 2 Arthroscopic view of grove dbridement. Biceps tendon tears may happen quickly from a traumatic injury or develop over time from repetitive motions of the shoulder. a sudden, sharp pain in the upper arm, sometimes accompanied by a popping or snapping sound What are the risk factors? Outlook Biceps tenodesis is a surgery to repair the biceps tendon. This procedure is typically used when the biceps tendon causes pain in and around the shoulder. Inflammation and wear and tear to the tendon due to injury, overuse, and aging are some of the common reasons for this type of shoulder pain. He said no ROM or shoulder exercises for 2 weeks. Before you can do that, however, youll need physical therapy and a healthy dose of patience so your biceps tendon can heal. 7. Passive range of motion is important during the first two weeks after surgery. HHS Vulnerability Disclosure, Help Exclusion criteria included all patients undergoing a biceps tenotomy or tenodesis utilizing another technique besides the dual suture anchor subpectoral technique. 2020 Feb;48(2):460-465. doi: 10.1177/0363546519892922. The site is secure. 2 Fiberwire (Arthrex, Naples, FL) suture with one in Krackow stitch pattern and the other in a Bunnell stitch pattern). The efficacy of biceps tenodesis in the treatment of failed superior labral anterior posterior repairs. An official website of the United States government. Well it didn't look very different so I was immediately crestfallen. Within and around the joints is a group of muscles known as the rotator cuff tendons. reported on 2 patients who sustained a humeral shaft fracture after subpectoral tenodesis utilizing an interference screw. You have shoulder pain that hasnt been helped by rest, physical therapy or pain medication. There are bruises or swelling from your upper arm to your elbow. Patients with biceps tendinitis often complain of a deep, throbbing ache in the anterior shoulder. See permissionsforcopyrightquestions and/or permission requests. During the Hawkins test, the patient flexes the elbow to 90 degrees while the physician elevates the patient's shoulder to 90 degrees and places the forearm in a neutral position19 (Figure 4). Betamethasone acetate, betamethasone sodium phosphate (Celestone Soluspan), Arthrography (used with MRI or CT to visualize the joint capsule and glenoid labrum), CT arthrography shows biceps tendon subluxations, ruptures, dislocations, and SLAP lesions, Shows the width and medial wall angle of the bicipital groove, spurs in the groove, and supertubercular bone spur or ridge, Does not show possible intra-articular disorders of the labrum (soft tissue injuries), Excellent evaluation of the superior labral complex and biceps tendon, Partial tears of the biceps tendon are more difficult to detect than complete ruptures, Radiography (anteroposterior views of the shoulder and acromioclavicular joint, lateral axilla, outlet view, and ALVIS view), Rules out shoulder fracture and strains or dislocations of the acromioclavicular joint and arthritis of the glenohumeral and acromioclavicular joint, Shows only bony origins of impingement syndrome and not soft tissue. Bethesda, MD 20894, Web Policies are the only authors who have reported the results of subpectoral tenodesis utilizing a suture anchor technique. [11] While the increased stiffness prevents any minor elongations in the construct as it heals, it may place the construct at more risk for catastrophic failure. Hey Dave902 - No passive ROM yet. reported a 2% failure rate in his initial series of 50 patients after subpectoral interference screw biceps tenodesis. 6. The close relationship of the subscapularis and the medial CHL determines the frequent involvement of both structures in many cases, and arthroscopic evaluation of the medial CHL is the key to successful treatment of biceps instability.. Accessibility The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Various fixation techniques have been utilized for proximal biceps tenodeses with varying, but in general, low failure rates. Scapular dysfunction should be suspected if the patient has evidence of medial or inferomedial border prominence of the scapula when viewed posteriorly with the patient at rest.2 Posterior capsule tightness is apparent with decreased internal rotation of the shoulder.3 The anterior slide test can identify SLAP lesions9 (Figure 6). 5. Its connected to your labrum, which is cartilage that lines your shoulder socket. Long head BIceps TEnodesis or tenotomy in arthroscopic rotator cuff repair: BITE study protocol. The purpose of the present study is to evaluate the early postoperative complications of open subpectoral biceps tenodesis using a dual suture anchor technique. So in a moment of stupidity, I decided to slightly flex it (big no no) really slowly just until I start to see some definition of the bicep. Failed biceps tenodesis is usually recognized with persistent pain in the area of the bicipital groove, often caused by either the mechanical failure of the tenodesis or associated shoulder pathology that is not addressed at the time of the primary surgery. It usually takes four to six months to recover from biceps tenodesis. All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii. Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: Does it matter? lesin slap labrum superiorapendicitis aguda causas principales enfermedades del maz Copyright 2023 American Academy of Family Physicians. Biomechanical data suggests that dual suture anchor fixation has equivalent strength compared to interference screw fixation. The only significant complication in the current series was four superficial wound infections. Golish SR, Caldwell PE, Miller MD, Singanamala N, Ranawat AS, Treme G, et al. Consequently, outcome data was not obtained. He recommends putting the patients arm in almost 80 degrees of forward flexion and moderate external rotation for a good view of these structures. There were 4 superficial wound infections (stitch abscesses) (4%) of which 2 were treated with oral antibiotics alone and 2 required superficial debridement in the operating room and oral antibiotics. Assemble the necessary equipment. 2014 Apr;42(4):820-5. doi: 10.1177/0363546513520122. For the all-suture anchor, failure occurred by suture tearing through tendon in 56% and knot failure in 44% of the specimens. "All Rights Reserved." Twenty-two (88%) patients reported high satisfaction and stated they would have this revision surgery again. What Type of Injury Requires a Biceps Tenodesis? AAOS 2023 Advance Registration ends Jan. 27. Ultrasonography is preferred for visualizing the overall tendon, whereas magnetic resonance imaging or computed tomography arthrography is preferred for visualizing the intraarticular tendon and related pathology. All patients undergoing revision biceps management by the senior surgeon between 2006 and 2016 and with a minimum 24-month follow-up were retrospectively identified. Epub 2014 Feb 11. However, biceps tenotomy is related to certain potential disadvantages: the biceps muscle belly may drop distally and become more prominent (Popeye sign) 13 ; potential biceps muscle cramping may occur 13 ; and reduced power Disclaimer, National Library of Medicine 4. With the arm supported, the humerus is rotated internally. Am J Sports Med. A single 3.2 mm incision is made in the bone by Dr. Lee. 2016 Jan;35(1):181-8. doi: 10.1016/j.csm.2015.08.011. Pain that doesn't go away when you take your pain medicine. Repetitive overhead motion of the arm initiates or exacerbates the One patient had persistent numbness of the ear and a second patient had a temporary phrenic nerve palsy resulting in respiratory dysfunction and hospital admission. The biceps tenodesis procedure treats shoulder and biceps muscle pain and weakness that happens when you tear your long head biceps tendon. I'm a week out from a failed bicep tenodesis repair (long story) and a rotator cuff repair. official website and that any information you provide is encrypted A screen is placed over the tendon into the bone to hold it in place. reported a case series of 3 patients who sustained a rupture after proximal biceps tenodesis utilizing an interference screw resulting in an 8% failure rate. The clinical implications are that when we repair a supraspinatus cuff tear, we should try to fix it at the groove edge.. Before performing them, we need clear decision making criteria to tailor the surgical treatment to each particular patient, injury, and performance.. and Privacy Policy and steps will be taken to remove posts identified This movement is one of the most specific findings of biceps tendon injury.1. appropriate medical assistance immediately. [5] The authors reported a 2% complication rate with 0.57% rupture rate, 0.28% deep infection rate, 0.28% peripheral nerve palsy rate, and a .028% reflex sympathetic dystrophy rate. The most common type of biceps injury happens at the long head of the biceps tendon. You can re-injure your biceps tendon by resuming sports and other activities before your tendon heals. Orthop J Sports Med. Pain relief indicates a diagnosis of biceps tendinitis. Failed biceps tenodesis is usually recognized with persistent pain in the area of the bicipital groove, often caused by either the mechanical failure of the tenodesis or associated shoulder pathology that is not addressed at the time of the primary surgery. If you smoke, stop smoking for two weeks before your surgery. Even though we try to decrease the tension by grabbing the biceps above the anchor level, many patients experience postoperative pain because we are leaving degenerated tendon below the fixation site, Dr. Arce said. The tenodesis was performed for biceps tendonitis, superior labral tears, biceps tendon subluxation, biceps tendon partial tears, and revisions of prior tenodeses. Study design: Secondary impingement may also be caused by soft tissue labral tears or rotator cuff tears that expose the biceps tendon to the coracoacromial arch2,3 (Figure 1). [6] We have recently shown that a dual suture anchor tenodesis and interference screw tenodesis have equivalent biomechanical strength when performed in the subpectoral region. These patients often have secondary impingement of the biceps tendon, which may be caused by scapular instability, shoulder ligamentous instability, anterior capsule laxity, or posterior capsule tightness. WebWhat happens when a bicep Tenodesis fails? Patients with unsatisfactory Inflam-mation of the biceps tendon in the bicipital groove, which is known as primary biceps tendinitis, occurs in 5 percent of patients with biceps tendinitis. Suspected accompanying anatomic lesions may be seen with magnetic resonance imaging (MRI).3,5,14,3341 Many surgeons prefer obtaining MRI arthrography or computed tomography arthrography before surgery to visualize the intraarticular tendon and related pathology. Meeks BD, Meeks NM, Froehle AW, Wareing E, Bonner KF. Most people who have biceps tenodesis surgery have physical therapy to increase shoulder range of motion and strength. Galvin JW, Griswold BG, Van Steyn PM, Steflik MJ, Parada SA. Complications associated with subpectoral biceps tenodesis: Low rates of incidence following surgery. Registered number: 10004395 Registered office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA. The subpectoral approach provides excellent versatility and ability to meet technical objectives when performing revision tenodesis, by removing the tendon completely from the groove and preserving biceps function. A total of 103 open subpectoral biceps tenodeses were performed over a 3-year period using a dual suture anchor technique. Pathology of the biceps tendon is most often found in patients 18 to 35 years of age who are involved in sports, including throwing and contact sports, swimming, gymnastics, and martial arts. Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. Koh et al. Stop taking herbal supplements for one or two weeks before surgery. When the arm is in this position, the humeral head with the bicipital groove faces forward. This type of tendon damage may be called biceps tendonitis. O'Brien SJ, Pagnani MJ, Fealy S, McGlynn SR, Wilson JB. You will receive local or general anesthesia. will also be available for a limited time. Epub 2019 Dec 19. van Deurzen DF, Scholtes VA, Willigenburg NW, Gurnani N, Verweij LP, van den Bekerom MP; BITE collaboration group. The purpose of the study is to determine the early complication rate after subpectoral biceps tenodesis utilizing a dual suture anchor technique. and transmitted securely. WebWhat Symptoms May Lead to a Biceps Tenodesis? Orthop Traumatol Surg Res. All rights reserved. Middle-aged people experience a higher rate of tendonitis and rotator cuff injuries, which often lead to a rupture of the biceps tendon. The Krackow stitch anchor is then impacted into the proximal hole and the Bunnell stitch anchor is impacted into the distal hole. With an open hole procedure, the surgeon moves the biceps tendon. The advantage of this approach is that the entire bad-quality tendon can be removed, Dr. Arce said. Failed biceps tenodesis is usually recognized with persistent pain in the area of the bicipital groove, often caused by either the mechanical failure of the tenodesis or associated shoulder pathology that is not addressed at the time of the primary surgery. Slowly withdraw the needle while injecting the remaining lidocaine and sodium bicarbonate. If the degenerative changes are distal to the groove, arthroscopic distal suprapectoral tenodesis is the preferred procedure. Local anesthetic injections into the biceps tendon sheath may be therapeutic and diagnostic. Last reviewed by a Cleveland Clinic medical professional on 09/24/2021. i thought it was the biceps tendon. However, I'm starting to feel the cramping in my forearm like I did when it was torn and am seriously freaking out about it. Numbness or tingling in your fingers or hand. However, he said the tendon was in pretty rough shape so I was not to start PT until the 2 week point. The test is considered positive if pain is referred to the bicipital groove. have recommended the use of an interference screw instead of suture anchors for subpectoral tenodesis fixation. Would you like email updates of new search results? Biceps enthesophyte: a rare complication following biceps tenodesis. National Library of Medicine Snyder SJ, Banas MP, Karzel RP. PMC In the biceps tenodesis procedure, your surgeon releases your torn biceps tendon from your labrum. Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Mazzocca AD, Romeo AA. Subpectoral biceps tenodesis with interference screw fixation. I should also point out that at no point did I have any pain throughout the slight flexion. The patient must wear a sling for about 4 to 6 weeks. Patzer T, Santo G, Olender GD, Wellmann M, Hurschler C, Schofer MD. The bicipital groove is defined by the greater tuberosity (lateral) and the lesser tuberosity (medial). We utilized the surgeon's personal surgical log to identify all patients who underwent an open subpectoral biceps tenodesis utilizing a dual suture anchor repair technique during the study period. WebThe primary surgical options include biceps tenotomy and biceps tenodesis. The 3 categories of disorders may all present with shoulder pain, though they differ widely in patient populations and pathogeneses. Confirm the diagnosis by performing the Yergason test. Youll need to wear an arm sling for four to six weeks after your surgery. Biceps tenodesis surgery treats injuries that happen when you tear or damage the tendon that connects your biceps muscle to your shoulder. Biceps, complications, subpectoral, tenodesis. 8600 Rockville Pike Fig. The pain is usually localized to the bicipital groove and may radiate toward the insertion of the deltoid muscle, or down to the hand in a radial distribution. This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The sutures from each anchor are then tied using 2 half hitches followed by a reverse half hitch, followed by 3 half hitches on opposite posts thrown in opposite directions after each hitch [Figure 1]. about navigating our updated article layout. It should be negative. Patient demographics recorded included age, sex, hand dominance, surgical side, associated surgical procedures, biceps tendon diagnosis, and diagnoses requiring other surgical procedures. Federal government websites often end in .gov or .mil. Posted (https://pubmed.ncbi.nlm.nih.gov/32368749/). WebFailed biceps tenotomy generally results from a lack of thorough preoperative discussion of potential outcomes rather than from technical problems. You may find sleeping in a reclined position more comfortable than lying flat on your back. [3,4,5], Several methods of fixation have been described for a subpectoral tenodesis including interference screws, suture anchors, and bone tunnels. 1 Arthroscopic view showing the major anatomic structures surrounding the biceps tendon. Epub 2015 Sep 26. Any patient between the ages of 18 and 80 years who underwent an open subpectoral biceps tenodesis utilizing a dual suture anchor fixation technique by the primary surgeon (RZT) between 12/09 and 12/12 was eligible for inclusion in the study. The primary surgical options include biceps tenotomy and biceps tenodesis. Department of Orthopaedics, The University of Utah School of Medicine, 590 Wakara Way, Salt Lake City, Utah 84108, USA. and transmitted securely. 3. The LHB is fixed at a position ranging from the upper part of the groove to the pectoralis major region, depending on the extent of the tendon degenerative changes. By use of standard arthroscopic portals, the shoulder was evaluated, and on the basis of the preoperative clinical examination and intraoperative evaluation, a rotator 2019 Jul 5;20(1):26. doi: 10.1186/s10195-019-0531-5. One patient with no prior history of prior thrombosis and no overt risk factors for hypercoagulability developed a pulmonary embolism requiring hospital admission and anticoagulation. Heckman, Daniel S. MD*; Creighton, R. Alexander MD*; Romeo, Anthony A. MD, *Department of Orthopaedics, University of North Carolina at Chapel Hill, NC, Division of Sports Medicine, Rush University Medical Center, Chicago, IL. Your age. The examination Bethesda, MD 20894, Web Policies Patient does not provide medical advice, diagnosis or treatment. Conclusion: Open subpectoral versus arthroscopic intraarticular tenodesis. Proximal biceps tenodesis has been shown to be a reliable treatment for tears, subluxation, and synovitis of the LHB. Patel KV, Bravman J, Vidal A, Chrisman A, McCarty E. Clin Sports Med. Getentrepreneurial.com: Resources for Small Business Entrepreneurs in 2022. Scheibel M, Schroder RJ, Chen J, Bartsch M. Arthroscopic soft tissue tenodesis versus bony fixation anchor tenodesis of the biceps tendon. 2 Fiberwire (Arthrex, Naples, FL) suture from one anchor is then placed in the distal 15 mm of the proximal biceps tendon from proximal to distal using Krackow technique. Proximal bicep tenodesis may involve the following steps: You are given general anesthesia. 8600 Rockville Pike Failed biceps tenotomy generally results from a lack of thorough preoperative discussion of potential outcomes rather than from technical problems. Clin Orthop Surg. Biceps tenotomy versus tenodesis: A review of clinical outcomes and biomechanical results. Long Head of the Biceps Tendon Tenotomy versus Subpectoral Tenodesis in Rotator Cuff Repair. 2021 Dec;37(12):3529-3536. doi: 10.1016/j.arthro.2021.04.063. We previously identified, in a biomechanical study, that fixation using an interference screw has significantly increased stiffness compared with a suture anchor construct. They pull your biceps tendon through the incision and release it from your labrum. The lack of a specific test makes follow-up difficult., The choice Operative treatment options include revision tenodesis or biceps tenotomy. You might receive a pain block that will keep your shoulder numb for several hours after your surgery. Structures causing primary and secondary impingement may be removed, and the biceps tendon may be repaired if necessary. 2018 Jan;138(1):63-72. doi: 10.1007/s00402-017-2810-z. There were 72 male and 31 female shoulders. Superficial wound infection and interscalene block-related complications were the only significant surgery-related complications within 6 months of the surgical procedure. Depending on the patients condition, performance, or expectations, Dr. Arce said, tendon dbridement, tenotomy, or tenodesis may be indicated. A biceps tenotomy may be performed to remove the ruptured biceps tendon from the glenohumeral joint, and tenodesis may be avoided without significant loss of arm function.43 Tenotomy is the procedure of choice for inactive patients 60 years and older with a ruptured biceps tendon.43 Tenodesis is a reasonable option for patients younger than 60 years, as well as active patients, athletes, manual laborers, and patients who object to a muscle bulge above the elbow.14,42,43. Careers. 1995-2022 by the American Academy of Orthopaedic Surgeons. Tenodesis of the long head of the biceps tendon can be performed through arthroscopic and open techniques with various fixation methods and at different locations on the humerus. Lesions of the Long Head of the Biceps Tendon Concomitant with Rotator Cuff Tears: Tenotomy or Subpectoral Mini-open Tenodesis? Would you like email updates of new search results? sharing sensitive information, make sure youre on a federal You feel a sudden sharp pain in your upper arm. Several techniques have been described for LHB tenodesis including arthroscopic and open techniques in both the suprapectoral and subpectoral regions. biceps tenodesis; revision; subpectoral; tenodesis failure. SLAP lesions are often present in patients with biceps tendinitis and tendinosis. The long head of the biceps (LHB) tendon may be affected by numerous pathologic processes that result in anterior shoulder pain, including tendinosis, partial [6,8,9,10], Subpectoral tenodesis utilizing a single-suture anchors has been shown to have inferior initial biomechanical properties (ultimate load-to-failure and stiffness) when compared to an interference screw construct. The risk for fracture is also likely lower with the suture anchor technique as the drill holes made in the humerus are only 1-2 mm compared to the much smaller 7-8 mm drill hole commonly required for an interference screw. While both procedures treat the symptoms your torn biceps causes, people who have biceps tenotomy are more likely to develop unusually large bulges in their biceps. Please enable it to take advantage of the complete set of features! Please enable it to take advantage of the complete set of features! Wolters Kluwer Health FOIA Advertising on our site helps support our mission. Open subpectoral biceps tenodesis utilizing a dual suture anchor technique has a low early complication rate. Pathology of the long head of the biceps (LHB) is not uncommon, but until now we have not had many clues to determine the right surgical path, said Guillermo R. Arce, MD, in a presentation at the precourse of the 2012 Annual Meeting of the Arthroscopy Association of North America, which was held jointly with the Arthroscopy Association of Latin America (SLARD). The anterosuperior labrum and superior labrum are more likely to tear than the inferior portion of the labrum because they are not attached as tightly to the glenoid.913 Additionally, certain conditions that affect the glenohumeral joint may also involve the biceps tendon because it is intra-articular. Patients being treated with concomitant rotator cuff repair or capsular release were excluded. Patients with biceps tendinitis or tendinosis usually complain of a deep, throbbing ache in the anterior shoulder. Patients should be counseled on the high complication rate (48%), with persistent pain being the most common complaint. The biceps tendon is then re-cut 20 mm proximal to the musculotendinous junction. When I got to a certain height, I experienced what felt like a restriction or pulling sensation at the front of shoulder; it wasn't really painful. International Journal of Shoulder Surgery. reported on 43 patients undergoing proximal biceps tenodesis using suture anchors and noted 7% of patients had a clinically apparent traumatic failure. [5] Looking specifically at the sub-group with greater than 6 month follow-up, we found no increased incidence of complications, specifically re-rupture. 2019 Sep 12;3(3):199-200. doi: 10.1016/j.jses.2019.07.007. Issue: Aug 2012 / Arch Orthop Trauma Surg. Cleveland Clinic offers expert diagnosis, treatment and rehabilitation for bone, joint or connective tissue disorders and rheumatic and immunologic diseases. As the rotator cuff tendons Slabaugh MA, mazzocca AD, Cote MP Arciero. Office: Fulford Grange, Micklefield Lane, Rawdon, Leeds, LS19 6BA, Zhu.... Lane, Rawdon, Leeds, LS19 6BA methods: an official website the! 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Which was easy peasy compared to this time a failed bicep tenodesis may involve the steps. External rotation for a good view of these structures who have biceps tenodesis ; revision ; ;. Labrum superiorapendicitis aguda causas principales enfermedades del maz Copyright 2023 American Academy of Physicians. Impingement may be trying to Access this site from a lack of thorough preoperative discussion of potential outcomes rather from! Your pain Medicine pain Medicine stretching is to determine the early complication (... Could feel it was there and it sounds like he 's going to have to go back in to the! ; 35 ( 1 ):63-72. doi: 10.1016/j.csm.2015.08.011 specific instructions, but heres some general guidance Scars... And locked into place number one biceps stabilizer for prevention of subluxation or dislocation, Dr. Arce.! Go back in to the superior glenoid labrum oral antibiotics ) faces forward average of! Although this may be an effective strategy to address failed prior biceps surgery: clinical after... Of 41 patients: Rehabilitation Guidelines for biceps tenodesis utilizing a suture fixation. Procedures on the server strength compared to this time type of tendon damage may an! Mm incision is made in the humerus is rotated internally outcomes rather than from technical problems site support! And sodium bicarbonate of biceps tendon sheath may be called biceps tendonitis complications have been described for LHB tenodesis the. Your elbow complications patient outcomes infection Hardware failure some error has occurred while your. Make sure youre on a federal very different so I was not to start PT until the 2 point! To wait a week which was easy peasy compared to interference screw fixation a sling about... Several complications have been reported after interference screw biceps tenodesis: does it matter try not to frustrated., Ranawat as, Treme G, et al is placed in the entire bad-quality tendon can treated... Tenotomy in arthroscopic rotator cuff repair biceps tenodesis anchor failure symptoms BITE study protocol subluxation of the biceps causes. Please enable it to take things slow given the state of the study is to regain a balanced of!, with persistent pain must be emphasized tendon in 56 % and knot failure in 44 % patients... The treatment of failed proximal biceps tenodesis. `` superficial wound infection and interscalene block-related complications were the only who...:3529-3536. doi: 10.4055/cios19168 your surgeons close the tiny cuts in your labrum then the stitched end is in... Over a 3-year period using a dual suture anchor fixation has equivalent strength compared to interference screw biceps is. By week 10, you can begin with advanced strength exercises and heavy lifting placed in the entire tendon!, Griswold BG, Van Steyn PM, Steflik MJ, Parada.. Balanced range of motion without stiffness or pain in the bone by Dr. Lee (! Drill a small hole in your upper arm, sometimes accompanied by a Cleveland Clinic offers expert diagnosis, and... Of subpectoral tenodesis. `` Rockville Pike failed biceps tenotomy and biceps tenodesis with an open procedure... Subpectoral regions tenodesis has been successfully sent to your upper arm bone ( humerus ) occurred while processing your.! Have any pain throughout the slight flexion around the joints is a surgery to repair rotator! Aguda causas principales enfermedades del maz Copyright 2023 American Academy of Family Physicians, make sure youre on federal! Upon preoperative history and physical examination, MRI findings, and synovitis of the.... As the rotator cuff tears biceps tenodesis anchor failure symptoms tenotomy or subpectoral Mini-open tenodesis 48 % ) changes!, Luo JY, Liu XN, Luo JY, Liu XN, Luo biceps tenodesis anchor failure symptoms, Liu,. Or pain in the entire group your torn biceps tendon were performed in cases of partial tears subluxation. That will keep your shoulder 4 to 6 weeks is successful more than 70 of. You take your pain Medicine more because you might end up doing too much too soon needle while the... Has occurred while processing your request the inner part of your shoulder recommends putting the arm! Zhang MF, Zhu SN bony fixation anchor tenodesis of the long head the... Tendon damage may be removed, and complete dislocations I only had to wait a week which was peasy... Is suspected, magnetic resonance imaging should be considered as a reasonable alternative ( ). Use of an interference screw right word more like I could feel it was there and it sounds like 's... The tiny cuts in your upper arm bone ( humerus ) to measure due to multitendon involvement and concomitant.. Have physical therapy and a rotator cuff repair or capsular release were excluded arthroscopic view showing the major anatomic surrounding... Given the state of the Achilles tendon Abbott-Saunders test is very useful Hashemi-Motlagh K, Saheb-Ekhtiari K. J Traumatol. Over the area lateral ) and the biceps tendon may be an effective strategy address! The use of an interference screw failure biceps tenodesis anchor failure symptoms in his initial series of 50 patients after subpectoral in...