Thank you for the introduction. Our disclosures are listed online. No funding was received for any part of this study. We're all aware that biceps tenesis is an effective treatment for long head biceps tendon pathology. There are multiple fixation techniques ranging from interference screws to suture anchors and buttons. The objective of this study was to evaluate construct stability and tendon lengthening remodeling in two groups, arthroscopic super pictorial versus mini open sub pictorial techniques. Both groups utilize the same fixation system. A bit of background. A previous randomized study that we conducted demonstrated that there was no significant difference in clinical outcomes, functional outcomes, or PROMs in arthroscopic super pictorial versus mini open techniques. There was, however, a difference with respect to surgical time, with seven minutes of additional time in the arthroscopic approach, and along with two centimeters less tendon tissue being resected in the arthroscopic group. Our current study is comparative prospective cohort series. We consecutively enrolled 30 patients in each group. We were empowered to detect a 15 millimeter difference. The radiocerametic analysis was performed with tantalum beads. Remember, our objective is to evaluate construct stability and tendon lengthening remodeling. We included patients between the ages of 18 and 65 who were scheduled for biceps teniasis with symptomatic tendinopathy. They had positive tension tests. We excluded those patients for revision surgery, arthroplasty, or those who had ruptured their biceps tendons traumatically. We collected perioperative data pertaining to tendon appearance, physical examination, and all patients completed a shoulder questionnaire. We paid particular attention to cosmesis and the presence of a Popeye deformity. Our primary outcome was an AP radiograph to detect tantalum bead migration. This was obtained intraoperatively and at one week and 12 weeks postoperatively. Clinical failure was defined as the presence of a Popeye deformity. The tantalum bead was attached just beneath the whip stitch tendon with a 2-0 ethabond suture. Stability was confirmed with a hemostat to gravity. You're all familiar with the open subpectoral technique. Please note that the tendons were whip stitched with number two fiber wire and that a cannulated screw was utilized through which the number two fiber wire was tied into itself to create a closed loop. This is a quick video of the subpectoral technique. The whip stitch is close to the muscle tendinous junction. Of course, that's dictated by the extensive tendon pathology. We visualized the point of insertion. A very minimal degree of tension was applied when the screw was dunked in the socket and we tied the number two fiber loop into itself. With the superpectoral technique, please note that we extract the tendon through the anterosuperlateral portal which was an arthroscopic approach initially. The tendon is similarly whip stitched and the suture is also tied into itself to close the loop. This is also a short video illustrating this technique. So you'll note that the same insertion device is utilized. It's virtually an identical technique with a number two fiber wire whip stitched and a tenesis screw compressing the tendon. We paid careful attention to not wrapping the tendon around the screw and the tangential bead is just at the base of that whip stitch with both approaches. And that's the superior border of the pec major there. All patients were available for follow up. We did not observe any Popeye deformities and no patients complained of cosmetic deformity. Demographically, these were very similar groups with respect to age, gender, and body habitus. The percentage of concurrent procedures performed was also not statistically different. With respect to bead migration, at one week we saw between two and three millimeters of migration and this was not different between the two groups. At three months, there was an average of 24.7 and 26 millimeters of migration, which of course was not statistically different. So both groups had equivalent degrees of migration at both time points. Similar results were obtained in a distal bicep study, which also utilized tangeline beads. The mean tendon lengthening was about 23 millimeters and the greatest change was observed between zero and four weeks with 11 millimeters of displacement. The least amount of change occurred between eight and 16 weeks. So this study raises the question of what's happening with the biceps tendon during healing. We're all familiar with these phases of fibroplasia, early and late remodeling, but what this study suggests is that there's quite a bit of elongation. In conclusion, we observed significant bead migration, which we believe is a proxy for construct stability, tendon lengthening, and remodeling. There were no significant differences between the arthroscopic, suprapectoral, and mini open subpectoral techniques. In one week, the construct appears to be stable with only three millimeters of distal migration. At three months, there's significant remodeling with 25 millimeters of migration. Remember, the fixation systems were identical. The clinical relevance of this is that tendon elongation following biceps tenodesis occurs. It occurs irrespective of location, whether it's a suprapec or subpec, and it does not seem to affect clinical outcomes. So whether this remodeling occurs through the tendon itself or through muscle sarcomere elongation is yet to be defined. The results of this study have spurred us to investigate similar findings in suture anchors and button techniques and to allow for a comparison amongst them all. Thank you.

arthroscopic superpectoral technique

mini-open subpectoral technique

biceps tenodesis

tendon lengthening remodeling

clinical outcomes