The long head of the biceps tendon can be a common cause of shoulder pain. Isolated lesions can develop from overuse activity, trauma, and the inherent bony anatomy of the intertubercular sulcus, leading to instability.1,2 Secondary tendinitis can develop in association with impingement syndrome or rotator cuff disease.2–4
Surgical options for the treatment of biceps pathology include debridement, tenotomy, and tenodesis. Tenotomy offers a quick, well-tolerated procedure with minimal rehabilitation that results in faster postoperative recovery compared with other techniques.5–7 Despite the longer rehabilitation, tenodesis maintains the cosmetic appearance and length-tension relationship of the biceps, with a more predictable clinical outcome than tenotomy. Patient factors such as age, physical demand, activity level, body habitus, and arm size as well as cosmesis concerns play a role in surgical decision making.9
For biceps tenodesis, the open subpectoral and all-arthroscopic suprapectoral surgical approaches are commonly used. Subpectoral tenodesis is a reliable treatment option that has shown similar pain and functional outcome scores compared with suprapectoral tenodesis.10–12 Arthroscopic suprapectoral techniques are being developed to avoid the disadvantages of the open subpectoral approach.8,9 A variety of fixation techniques have been described for both open and arthroscopic approaches. Earlier studies compared traditional fixation strategies, such as the keyhole or tunnel technique, with the more recent interference screw and suture anchor fixation techniques.13–17 In addition to these bony fixation techniques, soft tissue fixation through a percutaneous intraarticular transtendon technique has been described and may be a cost-effective alternative.18,19 However, few biomechanical studies have compared suprapectoral biceps tenodesis techniques.20–22
This study compared the ultimate strength of 3 of the following suprapectoral biceps tenodesis fixation methods during load to failure testing: 2 suture anchors with lasso loops (2.9-mm JuggerKnot; Biomet, Warsaw, Indiana), an interference screw (8-mm SwiveLock; Arthrex, Naples, Florida), and 2 compressive rivets (3.5-mm SnapShot; Biomet). The study hypothesis was that the compressive rivet technique would show structural and mechanical properties similar to those of the 2 other biceps tenodesis techniques.
Materials and Methods
For this study, 15 fresh-frozen human cadaveric shoulders were used. Each shoulder was completely thawed at room temperature before dissection and tenodesis. The humerus was dissected free of all soft tissue attachments to allow for accurate measurement of the distance from the exit of the intertubercular groove to the tenodesis site. The same distance was also measured and marked on the biceps tendon before biceps tenotomy. The biceps tendon was excised from its origin at the superior labrum. The humerus was amputated 5 cm from the distal aspect of the intertubercular groove. The width of the biceps tendon at the level of the planned tenodesis site was measured and recorded. Specimens were randomly assigned to 1 of the 3 fixation methods.
Suture Anchor Technique
A 2.9-mm drill was used to make 2 unicortical pilot holes perpendicular to the humerus approximately 10 mm and 20 mm from the exit of the intertubercular groove. The first 2.9-mm JuggerKnot was then inserted through the guide and into the pilot hole drilled at the 10-mm tenodesis site. The anchor was fully seated into the bone by tapping the inserter handle with a mallet. The anchor was deployed and tensioned under the anterior cortex with a firm pull at an angle of 45° from the angle of implant insertion. After the anchor was deployed, the sutures were checked to ensure that they moved freely to secure the tendon to the bone with a lasso loop configuration, as described by Lafosse et al.23 One free limb of suture was partially passed deep to the tendon, and a loop was created. The same free limb of suture on the opposite side was then passed superficial to the tendon and through the loop to create a lasso mechanism by which the tendon was secured to the bone surface by using the nonlooped suture as the post. Two half hitch knots were thrown in the same direction, followed by 3 alternating half hitch knots. The post was then switched, and 2 additional alternating half hitch knots were thrown. This process was repeated with the second 2.9-mm JuggerKnot at the 20-mm tenodesis site. The tendon was then amputated 2 cm above the proximal tenodesis site (Figure 1).
Photographs showing surgical placement of the JuggerKnot (Biomet, Warsaw, Indiana) with lasso loop. After a hole is predrilled 10 mm from the exit site of the intertubercular groove, the JuggerKnot is malleted into place perpendicular to the bone (A). After partial passage of 1 free limb of suture deep to the tendon and to the opposite side, forceps are used to grasp the same suture limb and pass it superficial to the tendon to create the lasso mechanism (B). The anchors are secured to the bone surface with alternating half hitch knot tying (C).
Interference Screw Technique
An 8.5-mm reamer was used to drill a unicortical pilot hole perpendicular to the longitudinal axis of the humerus 20 mm from the exit of the intertubercular groove. The 8-mm forked tip SwiveLock was used to insert and position the tendon at the base of the pilot hole while it was screwed into place. The proximal and distal limbs of the tendon were held in tension to prevent coiling during insertion. The interference screw was left 1 mm proud on each shoulder specimen to ensure adequate cortical bite. The tendon was then amputated at the proximal screw, cortex, and tendon junction (Figure 2).
Photographs showing surgical placement of the SwiveLock (Arthrex, Naples, Florida). A unicortical pilot hole is predrilled 20 mm from the exit of the intertubercular groove (A). A forked tip is used to grasp and position the tendon at the base of the predrilled pilot hole (B). The SwiveLock is screwed into place with the proximal limb of the tendon amputated at the bone-screw junction (C).
Compressive Rivet Technique
A customized cannula with a serrated tip was used to hold the tendon steady against the humeral shaft. A 3.5-mm drill was then placed through this cannula and the center of the biceps tendon to make a unicortical pilot hole through both the tendon and the anterior cortex 10 mm from the exit of the intertubercular groove. The drill was removed with the cannula maintained in the same position while pressure was applied to the biceps tendon to ensure that the rivet would go through the previously made hole in the tendon and anterior cortex. The SnapShot deployment gun was placed into the cannula, and the implant head was firmly seated perpendicular to the tendon-bone complex before the trigger was pulled and the rivet was deployed. These steps were repeated to deploy a second SnapShot 20 mm from the exit of the intertubercular groove (Figure 3).
Photographs showing surgical placement of a SnapShot (Biomet, Warsaw, Indiana). With the cannula positioned in place, the tendon and anterior cortex are predrilled (A). Without moving the position of the cannula, the drill is removed and the deployment gun is inserted into the cannula (B). A SnapShot is deployed 10 mm and 20 mm from the exit of the intertubercular groove (C).
Each humerus was mounted in an electromechanical testing system and captured with a noncontacting video extensometer (Illinois Tool Works Inc, Danvers, Massachusetts). A 136-kg force load cell was used. This custom setup included 3 bicortical cross pins that secured the humeral head in an inverted position in the center of the apparatus and in the capture zone of the extensometer (Figure 4). A custom clamp with a sinusoidal profile was used to connect the biceps to the testing system. The tendon was preloaded with 10 N and then cyclically loaded with a loading rate of 5 N/s at 0 to 40 N for 50 cycles. After the cyclic loading was performed, a failure test was conducted on the same specimen at a displacement rate of 1 mm/s until peak load was observed and subsequent loading was decreased, indicating failure. Each failure was recorded with a camera, and the mode of failure was documented.
Photographs showing postsurgical placement of the custom inverted setup with the humerus specimen secured with 3 cross pins and the tendon clamped in place (A) and the testing apparatus with the camera positioned before failure testing (B).
Standard univariate analyses were conducted to determine measures of central tendency and variability. Visual inspection of the data confirmed nonnormal distribution of mean load to failure. A generalized linear model with gamma distribution and log link function with Tukey's adjusted least square means was used to determine whether there was a significant difference in mean load to failure among the 3 constructs. A second generalized linear model included patient sex as a covariate. An a priori significance level of .05 was used for all statistical tests.
The study included 12 male and 3 female shoulder specimens. The 3 techniques and their distribution by sex are shown in Table 1. Mean age was 65.2 years for the suture anchor with lasso loop group (JuggerKnot), 61.3 years for the interference screw group (SwiveLock), and 62.5 years for the compressive rivet group (SnapShot) (Table 2). Mean width of the long head of the biceps tendon at the level of the intertubercular groove was 8.6 mm (JuggerKnot), 8.4 mm (SwiveLock), and 8.7 mm (SnapShot) (Table 2). When the 3 techniques were compared, no statistically significant difference was found for age or biceps width (P>.05, Table 3). The tenodesis techniques showed 4 mechanisms of failure (Table 4). During 9 of the 10 trials, the JuggerKnot failed when the tendon slipped through the lasso loop, but the anchors remained well fixed within the pilot holes (Figure 5A). The tendon elongated with increasing load and ultimately amputated in 1 trial.
Sex Distribution for the 3 Techniques
Descriptive Statistics for the 3 Techniques
Age Distribution and Biceps Width for the 3 Techniques
Type of Failure Mechanism for Each Technique
Photographs showing postsurgical placement. JuggerKnot (Biomet, Warsaw, Indiana) failure by tendon slippage (A), SwiveLock (Arthrex, Naples, Florida) failure by tendon attenuation and amputation (B), and SnapShot (Biomet, Warsaw, Indiana) failure by tendon splitting (C).
The SwiveLock failed by tendon elongation and amputation in 5 trials and by tendon slippage in 4 trials (Figure 5B). The interference screw failed and pulled out of the bone in 1 trial. The predrilled central hole in the tendon of the Snap-Shot construct propagated a midsubstance longitudinal split through the remainder of the tendon until it pulled completely through in 7 of the 10 trials (Figure 5C). The tendon amputated in 3 of the 10 Snap-Shot tests.
The JuggerKnot with lasso loop had the highest load to failure (mean, 157.6 N; SD, 30.7 N; Table 2). Mean ultimate load for the SwiveLock was 146.4 N (SD, 52.1 N; Table 2), and the SnapShot technique had the lowest mean load to failure of 97.1 N (SD, 64.6 N; Table 2). Based on these mean values, the difference in load to failure between the JuggerKnot with lasso loop and the SnapShot was statistically significant (P=.04). No significant differences were found between the JuggerKnot with lasso loop and the SwiveLock (P=.93) or between the SwiveLock and the SnapShot (P=.10).
After adjustment for sex, no significant differences were found among the 3 techniques. Sex-adjusted least square means for load to failure decreased to 133.86 N for the JuggerKnot with lasso loop, 136.66 N for the SwiveLock, and 89.60 for the SnapShot. Therefore, after adjustment for sex, a significant difference in load to failure was no longer noted between the JuggerKnot with lasso loop and the SnapShot (P=.34). The differences in mean load to failure between the JuggerKnot with lasso loop and the SwiveLock (P=.93) or between the SwiveLock and the SnapShot (P=.15) remained statistically insignificant.
Several suprapectoral tenodesis strategies have been described for arthroscopic treatment of biceps pathology.20–22,24 This study biomechanically compared the failure strengths of a suture anchor with lasso loop, an interference screw, and a compressive rivet. The suture anchor with lasso loop showed the most consistent mode of failure, with tendon slippage, followed by the compressive rivet, with tendon splitting. The interference screw failed in a variety of ways, including tendon elongation and amputation as well as both tendon and screw pullout.
The compressive rivet had the highest recorded failure strength, 240 N, but it also was the most variable construct and had the lowest mean load to failure strength. The suture anchor with lasso loop had the highest overall mean load to failure and initially showed superior strength only compared with the rivet. However, after adjustment for sex, no significant difference was noted for ultimate load to failure among the 3 tenodesis techniques.
The ultimate load to failure for the interference screw group, 146.4 N (SD, 52.1 N) (Table 2), was lower than the findings reported for other human cadaveric studies.15,17,21,22,25,26 Multiple studies used Arthrex interference screws and reported mean failure loads of 237.6 N, 212.1 N, and 233.5 N, respectively.15,17,25 With an interference screw (Biceptor Tenodesis System; Smith & Nephew, Andover, Massachusetts), Patzer et al22 found a mean ultimate failure load of 218.3 N; however, these authors used a tendon-screw construct reinforced with suture fixation. Mean age of the cadavers in those studies was similar to the mean age in the current study. Unfortunately, for the current study, bone mineral density of the humerus specimens was not obtained, a potential confounder that could have influenced anchor fixation for all 3 techniques. However, implant failure was not a common mode of failure for any of the 3 techniques, suggesting that bone mineral density was not the reason for failure.
Failure load for the suture anchor with lasso loop construct, 157.6 N (SD, 30.7 N) (Table 2), was between the mean values of 2 earlier studies. Kaback et al26 used a lasso loop combined with a knotless anchor (Piton; Tornier, Montbonnot Saint Martin, France) and reported mean ultimate load failure of 46.6 N. Patzer et al21 used an anchor with a modified lasso loop (Healix; DePuy Synthes Sports Medicine [Mitek], Raynham, Massachusetts) and reported mean ultimate failure load of 187.1 N. Although these studies used lasso loop techniques, the anchor implants used were different than the JuggerKnot all-suture fixation, which limits comparison. No other biomechanical studies have used the JuggerKnot with lasso loop construct.
A variety of measures were taken to control for potential confounders and simulate the in vivo forces imparted on the biceps in this biomechanical study. Paired human cadaveric shoulders were used to compare randomized constructs, which controlled for discrepancies in the quality of bone or soft tissue. Two surgeons (G.V., D.H.) prepared all of the specimens. Each harvested biceps tendon and humerus specimen was wrapped in a saline-soaked towel to prevent significant dehydration, and testing was performed within an hour of tenodesis. Cyclic loading was performed before failure testing. The proximal amputation of the humerus and the inverted position of the custom setup (Figure 4) allowed the loading forces to be parallel to the longitudinal humeral axis and simulated the in vivo force vector on the long head of the biceps muscle.
Another potential confounder was the use of 2 implants for the SnapShot and JuggerKnot with lasso loop techniques vs 1 implant for the SwiveLock. The Snap-Shot and JuggerKnot are often used clinically in duplicate to create a broader footprint for tendon-bone healing. Therefore, these implants were used in duplicate to mirror the clinical application. Conversely, because the SwiveLock is not designed to be used in duplicate, only 1 implant was used.
This cadaveric study had inherent limitations. The humerus was dissected free of all soft tissues, which distorted the normal anatomic relationship and natural load bearing of the biceps tendon. Another limitation was the quality of bone and soft tissue. The integrity and hydration status of the biceps tissue may be different in vivo. Freezing alters fibril packing and orientation,28 which may affect tendon failure modes inconsistently, given the directional nature of connective tissue. Humeral bone density was not assessed and may be a potential confounder. Additionally, the time zero load testing does not account for the effects of temporal and biologic healing on the fixation construct.
The compressive rivet is a polyetheretherketone implant system that achieves fixation via a spiked head that compresses the tendon to the bone surface with flanges that expand under the cortex when the implant is deployed. The rivet implant system was designed to avoid the time and technical difficulties associated with suture passing, knot tying, and screw fixation. Only a specialized cannula, drill, and deployment gun are required to complete the tenodesis. This is the first study to evaluate the biomechanical properties of this newly developed device. Although mean load to failure was the lowest with the compressive rivet, when adjusted for sex, no statistical differences were found between the compressive rivet and the other 2 implants.
Jazrawi et al27 described the loading forces imparted on the long head of the biceps during low-load-bearing activities. With the elbow flexed at 90° and with a 1-kg weight held in the hand, the proximal biceps bears a load of 112 N.27 It is reasonable to reference this load when choosing a tenodesis technique and implant and designing a postoperative rehabilitation protocol. The standardized protocol used for this study limits weight bearing for the first 6 weeks, although the patient is allowed to perform light activities of daily living, such as eating and keyboarding. A progressive strengthening program that includes both elbow flexion and forearm supination begins at 6 weeks. Patients are usually released for full activity 3 months postoperatively.
After adjustment for sex, no statistically significant difference was found for mean load to failure among the 3 biceps tenodesis techniques. The minimum load to failure at time zero that is required to achieve effective biceps tenodesis is unknown. A prospective randomized trial comparing these suprapectoral biceps tenodesis techniques is needed to determine whether they achieve consistently successful clinical outcomes.
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- Ozalay M, Akpinar S, Karaeminogullari O, et al. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy. 2005; 21(8):992–998. doi:10.1016/j.arthro.2005.05.002 [CrossRef]
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- Sekiya LC, Elkousy HA, Rodosky MW. Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy. 2003; 19(10):1137–1141. doi:10.1016/j.arthro.2003.10.022 [CrossRef]
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Sex Distribution for the 3 Techniques
|Suture anchor with lasso loop||1 (10%)||9 (90%)||10|
|Interference screw||3 (30%)||7 (70%)||10|
|Compressive rivet||2 (20%)||8 (80%)||10|
Descriptive Statistics for the 3 Techniques
|Technique/Variable||Mean||SD||Minimum||Maximum||Median||Lower Quartile||Upper Quartile|
|Suture anchor with lasso loop|
| Maximum load, N||158||31||110||200||155||140||190|
| Age, y||65||5||57||73||65||63||67|
| Weight, kg||88||20||59||118||82||75||109|
| Height, cm||178||8||165||188||183||170||185|
| Biceps size, cm||22||5||15||33||20||20||23|
| Maximum load, N||146||52||33||220||152||128||185|
| Age, y||61||15||21||73||65||60||69|
| Weight, kg||79||21||59||118||72||64||91|
| Height, cm||173||9||165||185||169||168||185|
| Biceps size, cm||21||5||15||33||20||18||23|
| Maximum load, N||97||65||35||240||97||40||123|
| Age, y||63||16||21||73||68||60||71|
| Weight, kg||87||20||61||111||86||66||109|
| Height, cm||179||9||165||188||183||168||185|
| Biceps size, cm||22||3||18||28||23||20||23|
Age Distribution and Biceps Width for the 3 Techniques
| Suture anchor with lasso loop||65.2||4.8|
| Interference screw||61.3||14.8|
| Compressive rivet||62.5||15.5|
| Anchor screwa||.8474|
| Anchor riveta||.9251|
| Screw riveta||.9838|
|Biceps width, mm|
| Suture anchor with lasso loop||8.6||2.0|
| Interference screw||8.4||2.0|
| Compressive rivet||8.7||1.3|
| Anchor screwb||.9759|
| Anchor rivetb||.9886|
| Screw rivetb||.9317|
Type of Failure Mechanism for Each Technique
|Tendon Slippage||Tendon Splitting||Tendon Amputation||Implant-Bone Interface Failure|
|Suture anchor with lasso loop||9||0||1||0|