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Authors' Reply

      Our thanks to Drs. Saithna, Old, and MacDonald for their letter,

      Saithna A, Old J, MacDonald PM. Regarding “A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position”. Arthroscopy 2016;32:2432-2433.

      which gives us the opportunity to clarify the main point of our article,
      • Sheean A.J.
      • Hartzler R.U.
      • Denard P.J.
      • Lädermann A.
      • Hanypsiak B.T.
      • Burkhart S.S.
      A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position.
      which isThe improved visualization of the bicipital groove, medial sling, and subscapularis that is afforded by the 70° arthroscope confers a great advantage in diagnosing and surgically addressing subscapularis tears and associated long head of the biceps lesions and instability.
      A recent study has shown that 90% of patients with subscapularis tears have associated instability of the long head of the biceps or partial tears of the biceps tendon within the bicipital groove.

      Godeneche A, Nove-Jousserand L, Audebert A, Toussaint B, Denard P, Laedermann A. Relationship between subscapularis tears and injuries to the biceps pulley. Knee Surg Sports Traumatol Arthrosc. In press.

      This association of significant pathologic processes at the top of the bicipital groove highlights the utility of the 70° arthroscope in making that diagnosis and affording the visualization that is necessary to surgically fix the problem.
      Drs. Saithna, Old, and MacDonald suggest that biceps tenoscopy would be a better tool for visualizing the entire biceps tendon.
      • Saithna A.
      • Longo A.
      • Leiter J.
      • Old J.
      • MacDonald P.
      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 P. 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.

      However, neither of their articles that they referenced is currently accessible online, so we were not able to learn anything about their technique or results. This is obviously an unproven procedure at this point in time, so we cannot recommend discarding a proven technique (use of the 70° arthroscope) for an unproven technique (biceps tenoscopy). However, the concept is intriguing, and we look forward to further reports by the authors on their results.
      Finally, the relative importance of the location of biceps pathology remains controversial. We have long held the opinion that tenodesis in the proximal portion of the bicipital groove is effective at relieving pain generated at any point in the tendon of the long head of the biceps. Our logic is that tenodesis at the top of the groove will eliminate relative motion between the tendon and the groove, as the tendon itself does not contain any contractile elements. Without relative motion between the tendon and the bicipital groove, pain generation by that mechanism would be eliminated.
      • Burkhart S.
      • Lo I.
      • Brady P.
      • Denard P.
      The cowboy's companion: A trail guide for the arthroscopic shoulder surgeon.
      Our recent publication on arthroscopic biceps tenodesis at the top of the bicipital groove supports the concept that tenodesis in that area usually eliminates biceps pain. In that series of 1,083 arthroscopic biceps tenodesis performed at the top of the bicipital groove (the largest series ever), revision surgery for biceps-related issues was performed in only 4 patients (0.4%).
      • Brady P.C.
      • Narbona P.
      • Adams C.R.
      • et al.
      Arthroscopic proximal biceps tenodesis at the articular margin: Evaluation of outcomes, complications, and revision rate.
      If tenodesis at the top of the groove relieves pain from biceps lesions distal to the tenodesis by eliminating relative motion, then the direct visualization of distal tendon lesions (e.g., by biceps tenoscopy), though interesting, would not offer any therapeutic advantages.
      Unfortunately, our article must not have adequately emphasized the importance of the 70° arthroscope in diagnosing subscapularis tears, including occult subscapularis tears that occur distal to the medial sling
      • Koo S.S.
      • Burkhart S.S.
      Subscapularis tendon tears: Identifying mid to distal footprint disruptions.
      • Denard P.J.
      • Burkhart S.S.
      Arthroscopic recognition and repair of the torn subscapularis tendon.
      • Hartzler R.U.
      • Burkhart S.S.
      Medial biceps sling takedown may be necessary to expose an occult subscapularis tendon tear.
      ; otherwise the letter by Saithna et al. would not have focused so intensely on the biceps tendon. We firmly believe that undiagnosed subscapularis tears are the primary generators of residual pain around the bicipital groove after failed biceps tenodesis, and that routine use of the 70° arthroscope would dramatically reduce the incidence of residual pain from undiagnosed subscapularis tears.

      References

      1. Saithna A, Old J, MacDonald PM. Regarding “A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position”. Arthroscopy 2016;32:2432-2433.

        • Sheean A.J.
        • Hartzler R.U.
        • Denard P.J.
        • Lädermann A.
        • Hanypsiak B.T.
        • Burkhart S.S.
        A 70° arthroscope significantly improves visualization of the bicipital groove in the lateral decubitus position.
        Arthroscopy. 2016; 32: 1745-1749
      2. Godeneche A, Nove-Jousserand L, Audebert A, Toussaint B, Denard P, Laedermann A. Relationship between subscapularis tears and injuries to the biceps pulley. Knee Surg Sports Traumatol Arthrosc. In press.

        • Saithna A.
        • Longo A.
        • Leiter J.
        • Old J.
        • MacDonald P.
        Proposing the need for a new gold standard for assessment of long head of biceps pathology.
        Shoulder Elbow. 2015; 7: 309
      3. Saithna A, Longo A, Leiter J, Old J, MacDonald P. 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.

        • Burkhart S.
        • Lo I.
        • Brady P.
        • Denard P.
        The cowboy's companion: A trail guide for the arthroscopic shoulder surgeon.
        Lippincott Williams and Wilkins, Philadelphia2012
        • Brady P.C.
        • Narbona P.
        • Adams C.R.
        • et al.
        Arthroscopic proximal biceps tenodesis at the articular margin: Evaluation of outcomes, complications, and revision rate.
        Arthroscopy. 2015; 31: 470-476
        • Koo S.S.
        • Burkhart S.S.
        Subscapularis tendon tears: Identifying mid to distal footprint disruptions.
        Arthroscopy. 2010; 26: 1130-1134
        • Denard P.J.
        • Burkhart S.S.
        Arthroscopic recognition and repair of the torn subscapularis tendon.
        Arthrosc Tech. 2013; 2: e373-e379
        • Hartzler R.U.
        • Burkhart S.S.
        Medial biceps sling takedown may be necessary to expose an occult subscapularis tendon tear.
        Arthrosc Tech. 2014; 3: e719-e722

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