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Editorial Commentary: Shoulder Subpectoral Biceps Tenodesis Significantly Increases the Humeral Fracture Risk—Is This a Reason to Look for Alternatives?

      Abstract

      Subpectoral tenodesis is performed at the surgical neck of the humerus. In a cadaveric study, the insertion of a unicortical PEEK (polyether ether ketone) screw decreased the torsional load to failure (fracture) by 30% compared with intact control specimens but was similar to unicortical reaming without screw insertion. Placing the biceps tendon into the tunnel and securing it with a unicortical screw reduced the torsional load to failure by 20%. Whether these facts are significant is currently unknown, but the creation of a stress riser is a concern and may possibly result in surgical neck fractures.
      Subpectoral biceps tenodesis is typically performed at the lower border or just proximal to the pectoralis major tendon.
      • Mazzocca A.D.
      • Rios C.G.
      • Romeo A.A.
      • Arciero R.A.
      Subpectoral biceps tenodesis with 387 interference screw fixation.
      Anatomically, this region is defined as the surgical neck of the humerus and is the second most common fracture location of the upper extremity.
      • Baron J.A.
      • Barrett J.A.
      • Karagas M.R.
      The epidemiology of peripheral fractures.
      • Chu S.P.
      • Kelsey J.L.
      • Keegan T.H.
      • et al.
      Risk fracture for proximal humerus fracture.
      Major risk factors are related to low bone mass and falls.
      • Chu S.P.
      • Kelsey J.L.
      • Keegan T.H.
      • et al.
      Risk fracture for proximal humerus fracture.
      More than 90% of these fractures result from a fall, a mechanism not that uncommon in the athletic, contact, and team sports population.
      • Chu S.P.
      • Kelsey J.L.
      • Keegan T.H.
      • et al.
      Risk fracture for proximal humerus fracture.
      • Palvanen M.
      • Kannus P.
      • Parkkari J.
      • et al.
      The injury mechanisms of osteoporotic upper extremity fractures among older adults: A controlled study of 287 consecutive patients and their 108 controls.
      Sabick et al.

      Sabick MB, Cook TD, Decker MJ, Torry MR, Hawkins RJ. Humeral torque in professional baseball pitchers: Implications for humeral shaft fractures during the pitch. Presented at the International Society of Biomechanics XVIIIth Congress, Zurich, Switzerland, July 8-13, 2001.

      have calculated a torque of 200 Nm during pitching with internal rotation of the proximal humerus reproducing the typical mechanism of a humeral fracture. In a later study they have shown that peak torque reached a value of 92 Nm at the end of the cocking phase, averaging 48% of the theoretical torsional strength of the humerus.
      • Sabick M.B.
      • Torry M.R.
      • Kim Y.K.
      • Hawkins R.J.
      Humeral torque in professional baseball pitchers.
      In normal bone the torsional stiffness is approximately 6.4 Nm/°.
      • Maldonato Z.M.
      • Seebeck J.
      • Heller M.O.
      • Hepp P.
      • Lill H.
      • Duda G.N.
      Straining of the intact and fractured proximal humerus under physiological-like loading.
      These values should be taken into consideration when evaluating surgical techniques in this anatomic region. So, surely, drilling an 8-mm unicortical tunnel as part of the surgical technique for a subpectoral tenodesis creates a stress riser and most likely increases fracture risk.
      Mellano, Frank, Shin, Jain, Zuke, Mascarenhas, Shewman, Cole, Romeo, Verma, and Forsythe,
      • Mellano C.
      • Franks R.M.
      • Shin J.
      • et al.
      Subpectoral biceps tenodesis with PEEK interference screw: A biomechanical analysis of humeral fracture risk.
      in their study titled “Subpectoral Biceps Tenodesis With PEEK Interference Screw: A Biomechanical Analysis of Humeral Fracture Risk,” have performed a biomechanical analysis investigating fracture risk when performing a subpectoral biceps tenodesis and assessed 3 scenarios: drilling of an 8-mm unicortical tunnel, insertion of an 8 × 12–mm PEEK (polyether ether ketone) screw, and insertion of a whipstitched long head of the biceps tendon and fixation with an 8 × 12–mm PEEK screw. Not surprisingly, the unicortical tunnel drilling reduced the torque to fracture from 72 N in intact control specimens to 52 Nm. There were no significant differences for stiffness. Surprisingly, the insertion of a unicortical screw to fill the hole made no difference for either torque or stiffness. However, the combination of the tendon and screw resulted in an increase in torsional torque to failure to 62 Nm, and the stiffness increased to 5 Nm/°.
      • Mellano C.
      • Franks R.M.
      • Shin J.
      • et al.
      Subpectoral biceps tenodesis with PEEK interference screw: A biomechanical analysis of humeral fracture risk.
      Although these differences were found to be significant, the clinical meaning of these findings can be debated. The authors could not provide a plausible explanation for why the addition of the screw-tendon combination improved torque and stiffness compared with the empty hole or screw-only setting. The baseline is that the torque required to fracture the proximal humerus was reduced by 20% to 30% and stiffness decreased between 4% and 9% for all 3 test setups when compared with intact specimens. So, when considering the data of Sabick et al.

      Sabick MB, Cook TD, Decker MJ, Torry MR, Hawkins RJ. Humeral torque in professional baseball pitchers: Implications for humeral shaft fractures during the pitch. Presented at the International Society of Biomechanics XVIIIth Congress, Zurich, Switzerland, July 8-13, 2001.

      • Sabick M.B.
      • Torry M.R.
      • Kim Y.K.
      • Hawkins R.J.
      Humeral torque in professional baseball pitchers.
      and applying the findings to the current study,
      • Mellano C.
      • Franks R.M.
      • Shin J.
      • et al.
      Subpectoral biceps tenodesis with PEEK interference screw: A biomechanical analysis of humeral fracture risk.
      the theoretical torsional strength was reduced from 200 N to 140 to 160 N. Is this sufficient for a pitcher to continue with his or her career? The clinical outcomes have been reported to be good in the general population, but pain or discomfort with maximum velocity was common in pitchers undergoing biceps tenodesis.
      • Mazzocca A.D.
      • Cote M.
      • Arciero C.L.
      • Romeo A.A.
      • Arciero R.A.
      Clinical outcomes after subpectoral tenodesis with an interference screw.
      • Smith D.S.
      • Dugas J.R.
      • Emblom B.A.
      • Cain E.L.
      Biceps tenodesis in pitchers.
      In addition, the most common complaint was subjective weakness, as well as a decrease in velocity.
      • Mazzocca A.D.
      • Cote M.
      • Arciero C.L.
      • Romeo A.A.
      • Arciero R.A.
      Clinical outcomes after subpectoral tenodesis with an interference screw.
      • Smith D.S.
      • Dugas J.R.
      • Emblom B.A.
      • Cain E.L.
      Biceps tenodesis in pitchers.
      So, it appears that despite favorable clinical outcomes in the general population, overhead athletes have some limitations.
      More concerning are the increasing numbers of case reports describing proximal humeral fractures after biceps tenodesis.
      • Dein E.J.
      • Huri G.
      • Gordon J.C.
      • McFarland E.G.
      A humerus fracture in a baseball pitcher after biceps tenodesis.
      • Friedel R.
      • Markgraf E.
      • Schmidt I.
      • Dönicke T.
      Proximal humerus shaft fracture as a complication after keyhole-plasty.
      • Reiff S.N.
      • Nho S.H.
      • Romeo A.A.
      Proximal humerus fracture after keyhole biceps tenodesis.
      • Sears B.W.
      • Spencer E.E.
      • Getz C.L.
      Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients.
      The question remains whether it is a good idea to produce a stress riser at the surgical neck. We cannot answer this question based on the available evidence or based on the results of this study, but common sense suggests that we potentially create problems. What are the alternatives? The work from Boileau et al.
      • Boileau P.
      • Parratte S.
      • Chuinard C.
      • Roussane Y.
      • Shia D.
      • Bicknell R.
      Arthroscopic treatment of isolated type II SLAP lesions: Biceps tenodesis as an alternative to reinsertion.
      suggests that a suprapectoral tenodesis may be a viable alternative. In a small comparative study 87% of patients returned to the previous level of sports.
      • Boileau P.
      • Parratte S.
      • Chuinard C.
      • Roussane Y.
      • Shia D.
      • Bicknell R.
      Arthroscopic treatment of isolated type II SLAP lesions: Biceps tenodesis as an alternative to reinsertion.
      Burkhart and colleagues
      • 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.
      performed biceps tenodesis at the articular margin and reported good results and very low complication rates. For now, we have several options available. None of them is superior, and we have to make decisions based on our personal beliefs and patients' requirements rather than scientific evidence.

      Supplementary Data

      References

        • Mazzocca A.D.
        • Rios C.G.
        • Romeo A.A.
        • Arciero R.A.
        Subpectoral biceps tenodesis with 387 interference screw fixation.
        Arthroscopy. 2005; 21: 896
        • Baron J.A.
        • Barrett J.A.
        • Karagas M.R.
        The epidemiology of peripheral fractures.
        Bone. 1996; 18: 209S-213S
        • Chu S.P.
        • Kelsey J.L.
        • Keegan T.H.
        • et al.
        Risk fracture for proximal humerus fracture.
        Am J Epidemiol. 2004; 160: 306-370
        • Palvanen M.
        • Kannus P.
        • Parkkari J.
        • et al.
        The injury mechanisms of osteoporotic upper extremity fractures among older adults: A controlled study of 287 consecutive patients and their 108 controls.
        Osteoporos Int. 2000; 11: 822-831
      1. Sabick MB, Cook TD, Decker MJ, Torry MR, Hawkins RJ. Humeral torque in professional baseball pitchers: Implications for humeral shaft fractures during the pitch. Presented at the International Society of Biomechanics XVIIIth Congress, Zurich, Switzerland, July 8-13, 2001.

        • Sabick M.B.
        • Torry M.R.
        • Kim Y.K.
        • Hawkins R.J.
        Humeral torque in professional baseball pitchers.
        Am J Sports Med. 2004; 32: 892-898
        • Maldonato Z.M.
        • Seebeck J.
        • Heller M.O.
        • Hepp P.
        • Lill H.
        • Duda G.N.
        Straining of the intact and fractured proximal humerus under physiological-like loading.
        J Biomech. 2003; 36: 1865-1873
        • Mellano C.
        • Franks R.M.
        • Shin J.
        • et al.
        Subpectoral biceps tenodesis with PEEK interference screw: A biomechanical analysis of humeral fracture risk.
        Arthroscopy. 2018; 34: 806-813
        • Mazzocca A.D.
        • Cote M.
        • Arciero C.L.
        • Romeo A.A.
        • Arciero R.A.
        Clinical outcomes after subpectoral tenodesis with an interference screw.
        Am J Sports Med. 2008; 36: 1922-1929
        • Smith D.S.
        • Dugas J.R.
        • Emblom B.A.
        • Cain E.L.
        Biceps tenodesis in pitchers.
        Orthop J Sports Med. 2017; 5 (2325967117S00212 suppl 6)
        • Dein E.J.
        • Huri G.
        • Gordon J.C.
        • McFarland E.G.
        A humerus fracture in a baseball pitcher after biceps tenodesis.
        Am J Sports Med. 2014; 42: 877-879
        • Friedel R.
        • Markgraf E.
        • Schmidt I.
        • Dönicke T.
        Proximal humerus shaft fracture as a complication after keyhole-plasty.
        Unfallchirurgie. 1995; 21 ([in German]): 198-201
        • Reiff S.N.
        • Nho S.H.
        • Romeo A.A.
        Proximal humerus fracture after keyhole biceps tenodesis.
        Am J Orthop (Belle Mead NJ). 2010; 39: E61-E63
        • Sears B.W.
        • Spencer E.E.
        • Getz C.L.
        Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients.
        J Shoulder Elbow Surg. 2011; 20: e7-e11
        • Boileau P.
        • Parratte S.
        • Chuinard C.
        • Roussane Y.
        • Shia D.
        • Bicknell R.
        Arthroscopic treatment of isolated type II SLAP lesions: Biceps tenodesis as an alternative to reinsertion.
        Am J Sports Med. 2009; 37: 929-936
        • 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

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