It's a heady task, for five minutes I'll try to do what I can, but it's an honor to join this great group. It's always an honor to share the stage with such pioneers in the field. My disclosures can be found online, none of which are really relevant to the content of this talk. I will say that I have adopted the stance of my mentors, Nick Verma and Tony Romeo, and advocate for biceps killing. It is certainly something where we see this macroscopic and microscopic changes, and so this can be a very important pain generator when evaluating our patients, and this can come from a lot of different origins, as is shown in this video with subluxation. But additionally, it's about the way that the tendon interacts with the structures around the biceps tendon, including that vincula, the hemorrhagic changes in that tissue, and that really can result in pain. And unfortunately, our examination and imaging modalities are really insufficient for assessing the structure and origins of this pain, and so an arthroscopic evaluation continues to be the gold standard in all three of these zones. When you talk about treatment, we've certainly heard some things to suggest that bicep stenotomy is still a feasible treatment strategy, but unfortunately, it's really hard to anticipate those individuals that are dissatisfied, and so in my Texan population, I found myself batting a very low percentage. You can see it's a high rate of pupae deformity, as well as fatigue discomfort, and so really, we look at the ways that we can treat this reliably. It's with a biceps tenodesis, and our goals are really twofold. It's one, to preserve or maintain the length-tension relationship, as well as to maximize the strength of fixation. In terms of tenodesis fixation construct or type of treatment, there are a couple of different strategies for maintaining that length-tension relationship, and those are very well-defined, as shown in this elegant study by Denard and colleagues that looked at, with the articular margin and inlay technique, you could reliably preserve the length-tension relationship by creating a 25-millimeter socket. Similarly, if you're doing a subpectral technique, advancing that tendon two centimeters below the inferior margin of the pectoralis major, again, will preserve that. When it comes to the superpectral technique, the jury is out. There's very unreliable techniques for trying to maintain that anatomic fixation. Well, let's talk about just fundamental ways of fixation, whether inlay or onlay. Certainly, there's dogma, and then there's data, and this inlay technique does permit the desired interference screw fixation that I think we all look for, but it can result in concerns for over-tensioning and also stress riser creation, versus an onlay technique can allow you, with insight to positioning, with potentially that anchor intact to preserve that length-tension relationship, but again, as was mentioned with the two-anchor construct, strength of fixation may be somewhat compromised. Or is it? Really, when you look at these biomechanical considerations, these studies, all of which show really no difference between various different types of techniques, screw and osseobutton, suture-anchor, no difference. In fact, some of the interference screw fixation actually was compromised in the Millet study, and when you look at the clinical corollary, again, no difference in PROs, but radiographic failure may be higher risk with interference screw fixation in high-demand subsets. Additionally, the ASMI group has certainly suggested that with increasing size of socket creation, it may result in risk of these torsional fractures. And while they're not common, they certainly are seen. This may be obviated with smaller all-suture or small-diameter anchors, and you can see in this biomechanical study, it has a greater energy-to-failure and greater torsional displacement. So in terms of position, just to address that briefly, we've certainly seen the value of intra-articular technique, where a variety of different means have been described, and this is frequently done in concert with rotator cuff repair. In terms of the biceps tenodesis technique, I do use a variation of what Nick Verma has taught me, and I do a thorough decompression of that biceps groove because I do think it's an important contributor to pain, but the points are well taken. You can see in this technique, it's a variation. It's using a single-anchor technique, and rather than piercing through with that second limb, you use a tension slide technique and standard arthroscopic fixation. So in terms of the subpectral technique, which is really my go-to for those more high-demand subsets, this is done in traditional fashion, and I use a smaller-bore interference groove fixation. It can reliably restore your length-tension relationships, or it does require an incision in that axillary fold. So as that tissue gets more attenuated, you certainly want to shift that a little bit more lateral, but it can result in a cosmetic and very functional result. You can see groove preparation to remove all the soft tissue, placement of the utocortical guide pin, and then interference groove fixation. This is very low rates of secondary complication, but they do occur, and so it's important to know your local anatomy and be careful with your retractor placement. The question also relies on whether it matters whether we go high or low, and this elegant study done by Brian Forsyth suggests whether you place a peak screw in the superpectral position or subpectral position, there's really only maybe a marginal difference in surgical timing and no difference in patient-reported outcome measures with only one patient ongoing conversion to open. In terms of the systematic reviews and meta-analyses, again, they show no difference in either complication rates or patient-reported outcome measures, and so it probably is what's best in your hands. So in terms of conclusions, our physical exam and advanced imaging are the best we have outside of arthroscopic evaluation. There is no consensus on technique, and I think we've obviated many of the issues with the superpectral technique, but you must exercise caution to avoid errors in over or under tensioning. There's a heightened fracture risks, particularly in a throwing athlete population with more distally based or larger diameter sockets, and a primary biceps tenodesis can offer very reproducible clinical outcomes at a low complication rates irrespective of the type of fixation or technique. So thank you very much, and look forward to the rest of the conference. Thank you.

biceps-related pain

biceps tenodesis

fixation

biomechanical studies

clinical outcomes