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Regarding “A 70° Arthroscope Significantly Improves Visualization of the Bicipital Groove in the Lateral Decubitus Position”

      We read with great interest the article by Sheean et al.
      • Sheean A.J.
      • Hartzler R.U.
      • Denard P.
      • Ladermann A.
      • Hanypsiak B.T.
      • Burkhart S.S.
      A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position.
      that focused on addressing the recently highlighted failure of standard glenohumeral arthroscopy to adequately visualize areas of predilection of pathology of the long head of biceps (LHB) tendon. We agree that this is an important clinical issue because systematic review has shown that failure to adequately evaluate the tendon can lead to rates of missed diagnoses as high as 30% to 50%.

      Jordan RW, Saithna A. Physical examination tests and imaging studies based on arthroscopic assessment of the long head of biceps tendon are invalid [published online November 26, 2015]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3862-7.

      Recently, the use of a grasper,
      • Gilmer B.B.
      • DeMers A.M.
      • Guerrero D.
      • Reid J.B.
      • Lubowitz J.H.
      • Guttman D.
      Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis.
      • Taylor S.A.
      • Khair M.M.
      • Gulotta L.V.
      • et al.
      Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex.
      direct tenoscopy of the bicipital groove,
      • Saithna A.
      • Longo A.
      • Leiter J.
      • Old J.
      • MacDonald P.M.
      Proposing the need for a new gold standard for assessment of long head of biceps pathology.
      and use of a 70° scope
      • Sheean A.J.
      • Hartzler R.U.
      • Denard P.
      • Ladermann A.
      • Hanypsiak B.T.
      • Burkhart S.S.
      A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position.
      have been evaluated as potentially useful strategies to address the inadequacies of standard techniques. We would like to highlight some of the issues with these strategies. First, to our knowledge, none of the authors of previous studies that report tendon excursion using a grasper
      • Gilmer B.B.
      • DeMers A.M.
      • Guerrero D.
      • Reid J.B.
      • Lubowitz J.H.
      • Guttman D.
      Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis.
      • Taylor S.A.
      • Khair M.M.
      • Gulotta L.V.
      • et al.
      Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex.
      routinely use this technique in clinical practice. Although the use of a grasper does confer greater visualization than pulling the LHB into the joint with a probe, it results in unacceptable iatrogenic injury to the tendon.
      • Saithna A.
      • Longo A.
      • Leiter J.
      • Old J.
      • MacDonald P.M.
      Shoulder arthroscopy does not adequately visualize pathology of the long head of biceps tendon.
      The data from these studies should therefore be interpreted with caution as they overestimate the visualization that is typically achieved in vivo. Sheean et al.
      • Sheean A.J.
      • Hartzler R.U.
      • Denard P.
      • Ladermann A.
      • Hanypsiak B.T.
      • Burkhart S.S.
      A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position.
      suggest that the use of a 70° arthroscope should be routine. Although we agree that it confers advantages in visualization of other pathology (e.g., subscapularis tears) we feel that its utility for the assessment of LHB pathology may have been overstated. Although a statistically significant advantage in terms of increased visualization was reported, this does not necessarily equate to an important clinical advantage. Currently the minimal clinically important difference with respect to the length of the LHB visualized in order to reduce the rate of missed diagnoses is not known, so the value of the increased visualization of 26.3 ± 6.2 mm (70° arthroscope) versus 14 ± 4.7 mm (30° arthroscope) reported by Sheean is not clear. However, what is clear is that several authors have highlighted that pathology frequently occurs in the most distal part of the tendon
      • Taylor S.A.
      • Khair M.M.
      • Gulotta L.V.
      • et al.
      Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex.
      • Moon S.C.
      • Cho N.S.
      • Rhee Y.G.
      Analysis of “hidden lesions” of the extra-articular biceps after subpectoral biceps tenodesis: The subpectoral portion as the optimal tenodesis site.
      and this area is not visualized using the described technique.
      Moon et al.
      • Moon S.C.
      • Cho N.S.
      • Rhee Y.G.
      Analysis of “hidden lesions” of the extra-articular biceps after subpectoral biceps tenodesis: The subpectoral portion as the optimal tenodesis site.
      reported outcomes from 36 patients who underwent rotator cuff repair followed by open subpectoral tenodesis. The LHB was categorized into the three zones described by Denard et al.,
      • Denard P.J.
      • Dai X.
      • Hanypsiak B.T.
      • Burkhart S.S.
      Anatomy of the biceps tendon: Implications for restoring physiological length-tension relation during biceps tenodesis with interference screw fixation.
      zone A, the proximal 2.5 cm of the tendon, zone B, between 2.5 and 5.6 cm and zone C, distal to 5.6 cm. The incidence of tears was 100% in zone B and 77.8% in zone C. Degenerative changes were observed for all cases in zones A and B and in more than 80% of cases in zone C. Moon et al.
      • Moon S.C.
      • Cho N.S.
      • Rhee Y.G.
      Analysis of “hidden lesions” of the extra-articular biceps after subpectoral biceps tenodesis: The subpectoral portion as the optimal tenodesis site.
      described those lesions occurring in zones B and C as “hidden” because they are not visualized at arthroscopy. Although Sheean et al.
      • Sheean A.J.
      • Hartzler R.U.
      • Denard P.
      • Ladermann A.
      • Hanypsiak B.T.
      • Burkhart S.S.
      A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position.
      demonstrated that a 70° scope does allow greater visualization, the numerical values presented allow us to reasonably conclude that these most distal areas still cannot be visualized using this strategy. On that basis, although a 70° scope may (and this is not proven by clinical results) increase diagnostic yield, a “normal” arthroscopy is still unable to exclude pathology, and the surgeon must give more value to information gained from the patient's history and clinical examination rather than the absence of intraoperative findings when deciding if there is an indication for either tenotomy or tenodesis.
      • Taylor S.
      Editorial commentary: Using a 70° arthroscope to evaluate the biceps tendon and rule out bicipital tunnel disease is better than using a 30° arthroscope… but still inadequate.
      We have recently described a technique for more complete evaluation of the LHB using biceps tenoscopy.
      • Saithna A.
      • Longo A.
      • Leiter J.
      • Old J.
      • MacDonald P.M.
      Proposing the need for a new gold standard for assessment of long head of biceps pathology.

      Saithna A, Longo A, Leiter J, Old J, MacDonald PM. Biceps tenoscopy: Arthroscopic evaluation of the extra-articular portion of the long head of biceps tendon Arthrosc Tech. Forthcoming. doi:10.1016/j.eats.2016.08.018.

      This requires no additional equipment and is easy to perform. It has the advantage of being able to visualize the full extent of the bicipital groove and the LHB up to the musculotendinous junction. It also allows retrograde instrumentation, which gives the potential to treat pathology within the groove, for example, debridement of tendinopathic lesions and excision of adhesions/osteophytes.
      We would also like to make a final comment on the limitations of the study reported by Sheean et al. They state that because they performed their study in the lateral position, it is unclear as to the extent to which these results are generalizable to shoulder arthroscopy performed in the beach chair position.
      • Sheean A.J.
      • Hartzler R.U.
      • Denard P.
      • Ladermann A.
      • Hanypsiak B.T.
      • Burkhart S.S.
      A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position.
      We feel it is useful to share our data on this. When using a 30° scope, we found that an optimally positioned arm in the beach chair position demonstrates a trend toward improvement in LHB tendon excursion compared with a lateral decubitus position but this was not significant (beach-chair positions, mean excursion 32.7 ± 4.23 mm; 95% CI, 28.6-36.8 mm, lateral decubitus, 29.9 ± 3.89 mm; 95% CI, 25.7-34 mm). On that basis, it was concluded that choosing the beach-chair position over lateral decubitus or removing the arm from traction in lateral decubitus to optimally position it are unlikely to confer an important clinical advantage with respect to the length of tendon that could be visualized using standard arthroscopic techniques.
      • Saithna A.
      • Longo A.
      • Leiter J.
      • Old J.
      • MacDonald P.M.
      Shoulder arthroscopy does not adequately visualize pathology of the long head of biceps tendon.
      In closing, we feel that although the use of a 70° scope may confer some advantages, its major limitation is likely to be a high false negative rate because of inability to visualize most of zones B and C. For that reason, we feel that biceps tenoscopy represents a potentially more useful strategy but we accept that clinical results are needed, and multicenter prospective evaluation of this technique is planned in order to determine its role in the diagnosis and management of LHB pathology.

      References

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        • Hartzler R.U.
        • Denard P.
        • Ladermann A.
        • Hanypsiak B.T.
        • Burkhart S.S.
        A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position.
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        • Lubowitz J.H.
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        • Khair M.M.
        • Gulotta L.V.
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      2. Saithna A, Longo A, Leiter J, Old J, MacDonald PM. Biceps tenoscopy: Arthroscopic evaluation of the extra-articular portion of the long head of biceps tendon Arthrosc Tech. Forthcoming. doi:10.1016/j.eats.2016.08.018.

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