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J Shoulder Elbow Surg (2015) -, 1-9

Biomechanics of a novel technique for

suprapectoral intraosseous biceps tenodesis
Nels Sampatacos, MDa, Blake P. Gillette, MDb, Stephen J. Snyder, MDb,
Heath B. Henninger, PhDc,d,*

The Doctors Clinic, Silverdale, WA, USA
Southern California Orthopaedics Institute, Van Nuys, CA, USA
Department of Orthopaedics, Orthopaedic Research Laboratory, University of Utah, Salt Lake City, UT, USA
Department of Bioengineering, University of Utah, Salt Lake City, UT, USA

Background: The Caspari-Weber (C.W.) tenodesis is a standard miniopen intraosseous technique to fix the
long head of the biceps tendon. The suprapectoral intraosseous biceps tenodesis (SPIBiT) is a novel arthro-
scopic, intraosseous, tendon-sparing alternative using a cortical button. No biomechanical data exist
comparing the time-zero performance of the SPIBiT and C.W. constructs.
Methods: Nine pairs of human cadaver shoulders were tested. The SPIBiT used a finger-trap suture pattern
holding the tendon inside a humeral tunnel above the pectoralis tendon, anchored with a cortical button on
the anterior humerus distal to the bicipital groove. The subpectoral C.W. used a Krackow suture technique.
Specimens underwent 500 cycles of uniaxial loading, followed by ultimate failure testing.
Results: The SPIBiT was placed in 5 left and 4 right humeri (5 female, 4 male; 59  6 years). The C.W.
was initially stiffer (P ¼ .003), whereas the SPIBiT exhibited higher energy dissipation (hysteresis;
P ¼ .006). Metrics decreased for both constructs over 500 cycles (P  .050). Constructs failed through su-
ture bunching and tendon tearing within the main suture bundle. The SPIBiT exhibited a novel failure in 2
specimens, with the cortical button pulling distally and suture cutting through cortical bone. Failure
occurred at 272.0  114.3 N and 282.3  59.4 N for the SPIBiT and C.W., respectively (P ¼ .766).
The C.W. was stiffer (P < .001).
Conclusion: The SPIBiT is an arthroscopic suprapectoral intraosseous alternative to the C.W. biceps
tenodesis, but in light of the novel failure mode, clinical use is not recommended. Future investigations
should quantify the impact of construct compliance on healing, and future constructs should avoid suture
point loading on thin cortical bone.
Level of evidence: Basic Science Study, Biomechanics.
Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees.
Keywords: Biceps tendon; tenodesis; C.W. technique; intraosseous; biomechanics

This investigation was supported by funding from Stryker (Kalamazoo, *Reprint requests: Heath B. Henninger, PhD, Department of Ortho-
MI, USA). Surgical hardware was also donated by Stryker. paedics, Orthopaedic Research Laboratory, Department of Bioengineering,
This study was exempt from Institutional Review Board approval per University of Utah, 590 Wakara Way, Rm A0122, Salt Lake City, UT
University of Utah IRB #11755, ‘‘Biomechanical Testing of Orthopaedic 84108, USA.
Devices Using Decedent Tissue Models.’’ E-mail address: (H.B. Henninger).

1058-2746/$ - see front matter Ó 2015 Journal of Shoulder and Elbow Surgery Board of Trustees.
2 N. Sampatacos et al.

Biceps tenodesis is used to treat pathologic conditions button for robust fixation distal to the bicipital groove.
involving the long head of the biceps tendon (LHB), Despite these potential advantages, there are no studies
including LHB tears, superior labral anterior-posterior evaluating the biomechanical properties of this construct.
lesions in older patients, and LHB instability.7 Numerous Therefore, the purpose of this study was to compare the
techniques have been described and vary on the basis mechanical behavior of the SPIBiT and the C.W. biceps
of the location of fixation of the LHB in relation to tenodesis. We hypothesized that there would be no differ-
the tendon of the pectoralis major (suprapectoral vs. ence in cyclic loading properties or failure properties be-
subpectoral)1–4,9,11,18,30 and the method of visualization tween the SPIBiT and C.W. constructs.
(open vs. arthroscopic).9,10,30,31 The ideal technique should
provide adequate visualization to perform the procedure
safely, with sufficient fixation strength to resist displace- Methods
ment during the period of tendon to bone healing.
Numerous fixation methods have been described for Specimen preparation
tenodesis of the LHB, including suture anchors, interfer-
ence screws, cortical button fixation on the anterior and Nine pairs of fresh frozen human cadaver shoulders were
posterior humerus, and bone tunnels (e.g., keyhole tech- thawed at room temperature before dissection. Each
nique).2,9,31,34 Techniques also differ in terms of intra- shoulder was dissected down to the glenohumeral joint, and
osseous vs. extraosseous fixation of the tendon. Although any specimen with significant soft tissue disease, including
controversial, evidence suggests that intraosseous tendon biceps fraying or tears, previous rupture, fractures, or evi-
length and tendon-bone diametrical mismatch both affect dence of prior surgery, was excluded. The upper border of
the healing capacity and biomechanics of the tendon- the pectoralis major tendon insertion was marked on the
bone interface.12 Because nonbiologic constructs may bone and tendon with a surgical pen as a reference point for
ultimately fail with cyclic loading in the absence of healing, implant placement. The LHB attachment to the superior
augmentation of healing with intraosseous fixation may labrum at the supraglenoid tubercle was cut, and the hu-
improve the construct’s longevity. merus was disarticulated. All soft tissue was removed from
Coined the ‘‘C.W.’’ biceps tenodesis after Drs. Richard the humerus, leaving the proximal humerus, biceps tendon,
Caspari and Stephen Weber, an arthroscopically assisted, and biceps muscle belly. The width and thickness of each
miniopen, subpectoral biceps tenodesis method is a ‘‘gold tendon were measured with a digital caliper for calculation
standard’’ for intraosseous biceps tenodesis.31 Using bone of tissue cross-sectional area.
tunnels without an implant, the C.W. procedure is a
modification of the original keyhole technique described in The SPIBiT construct
1975.9 Although it is clinically successful, displacement
of the construct on the order of 8 to 10 mm after cyclic A distal hole was placed at the mark on the humerus
loading17 may affect healing potential and long-term indicating the upper border of the pectoralis major tendon
construct longevity. Also, to obtain adequate visualization (Fig. 1, A). The 2-mm guide pin from a cannulated reamer
and to protect the adjacent neurovascular structures, an set was drilled through the anterior humeral cortex and left
open incision in the axilla is required. This may affect in place. A reamer 0.5 mm larger than the biceps tendon
cosmesis, increase the risk of infection or nerve or vascular width was then used to drill over the guide pin. Another
damage, and add to the time and cost of the procedure. By hole in the anterior cortex was placed 25 mm proximal
placing LHB fixation above the pectoralis major tendon and to the uppermost edge of the distal hole using the same
below the bicipital groove, an arthroscopic biceps tenodesis guide pin.
in the distal suprapectoral region may reduce the risk of On the tendon, a second mark was made 25 mm prox-
infection, neurovascular injury, and ‘‘groove pain.’’16,19,27 imal to the upper border of the pectoralis major tendon plus
However, this location carries its own unique challenges. the radius of the distal bone hole (Fig. 1, A). The tendon
The regional bone morphology is unique as it transitions was cut 15 mm proximal to this second mark. Beginning
from cortical to soft metaphyseal bone with a very thin 10 mm distal to the level of the tendon coinciding with the
cortex and minimal underlying cancellous bone. In this upper border of the pectoralis tendon, a finger-trap style
area, traditional screw or push-in anchors may find limited suture construct was placed (Fig. 1, B).26 Briefly, a simple
application as they rely on substantial bone quality for half-hitch was placed with a strand of No. 3-4 polyethylene
secure fixation.35 suture (Force Fiber; Tornier, Montbonnot Saint Martin,
On the basis of these observations from the clinic and France), then clamped with the tip of a hemostat to main-
literature, a new arthroscopic suprapectoral intraosseous tain tension (Fig. 2). Next, both ends of the suture were
biceps tenodesis technique (SPIBiT) was developed. This passed completely around the tendon with each suture tail
procedure incorporates intraosseous fixation with a small angled at 45 from the long axis of the tendon. This
bone tunnel matching the tendon diameter, a tendon- sequence was repeated until the fourth half-hitch was tied at
sparing finger-trap suturing technique,26,33 and a cortical the level of the proximal hole. Hemostats were sequentially
Biomechanics of intraosseous biceps tenodesis 3

A third pass around the tendon was made with the wrapping
limb, trapping the nonwrapping limb. The wrapping suture
was then passed under the second wrap of the rolling hitch
to lock it. The rolling hitch was ‘‘dressed’’ by working all
loops together adjacent to the last half-hitch that still had a
hemostat in place. The last hemostat was removed, and the
finger-trap suture construct was tightened by pulling on the
suture ends. With use of a free needle, the 2 tails of suture
were passed into the tendon so that they exited the mid-
substance of the proximal free tendon end.
To place the SPIBiT, a suture shuttling device was
passed into the proximal hole to retrieve the free suture,
shuttling the construct through the bone tunnels from distal
to proximal. The tendon was pulled into the distal tunnel
until the distal-most half-hitch was 10 mm distal to the
center of the distal hole, indicating that the resting tension
of the biceps had been restored. The free suture ends
exiting the proximal hole were then passed through a
13  4-mm button (G-Lok; Stryker, Kalamazoo, MI, USA),
and the button was reduced down to the bone and secured
with a Revo knot (Fig. 1, C).
It is of note that when the finger-trap suture is tied, the
biceps tendon shortens, accounting for the discrepancy
between the intraosseous tendon length and the distance
between bone tunnels. The final suture construct spans
50 mm, with 10 mm remaining extraosseous to protect the
tendon as it courses over the edge of the distal bone hole.
This results in 40 mm of intraosseous tendon between the
bone tunnels, separated by 25 mm plus the radius of the
measured biceps tendon.
The arthroscopic technique is carried out as described
before, but in addition to standard portals, an anterior
accessory biceps portal (ABP) is used. With the arthroscope
in the lateral subacromial portal while viewing anteriorly,
the bicipital groove is identified and defined with the use of
cautery through the anterior midglenoid portal. All drilling
is performed through the ABP, and the biceps tendon is
retrieved out of this portal. Once it is exteriorized, the
tendon is clamped close to the skin and the finger-trap
configuration is tied to match the predetermined resting
tension. Any remaining cancellous bone is cleared with the
use of a curved rasp entering through the ABP into the
distal hole. The suture shuttling device is then placed in the
anterior midglenoid portal and into the proximal hole with
Figure 1 The suprapectoral intraosseous biceps tenodesis removal of the passing suture out the larger distal hole by a
(SPIBiT). (A) Layout of the proximal and distal holes on the grasper in the ABP. Finally, the passing suture is tied to the
humerus and relevant markings on the biceps tendon. (B) Finger- biceps suture, shuttled intraosseously, and tied arthro-
trap suture arrangement; Nels Net on the biceps tendon. (C) The scopically to the cortical button with a Revo knot.
SPIBiT secured to the proximal humerus with a cortical button.
The C.W. construct
removed as each additional half-hitch was placed so that
only 2 hemostats were in place at a time. The humerus was marked at the upper border of the pec-
The final half-hitch was then converted into a ‘‘rolling toralis major tendon, marking the location of the proximal
hitch.’’ One suture end was passed twice around the tendon, drill hole.14 The biceps tendon was cut 25 mm proximal to
and the other suture limb was laid down on the tendon. the upper border of the pectoralis major tendon, then
4 N. Sampatacos et al.

Figure 2 Finger-trap suture construct. (A) A single half-hitch is tied over the tendon at the distal mark on the tendon. (B) Securing the
first half-hitch with a hemostat on the hitch to maintain tension, pass each strand around the tendon in opposite directions heading
proximally. Tie them together with a single half-hitch. (C) Continue this process heading proximally until 4 separate half-hitches have been
placed. Remove distal hemostats sequentially as proximal half-hitches are tightened. The final half-hitch should be placed over the proximal
mark on the tendon. (D) Retaining the final hemostat, pass the first leg of suture around the tendon in the same direction. (E) Wrap the first
leg around the tendon a second time. (F) Align the second suture leg with the tendon, laying it over the loops of the first suture leg. (G)
Loosely pass the first leg around the tendon again. (H) Secure the second leg to the surface of the tendon with a half-hitch made by the first
leg. (I) Tighten the half-hitch made by the first leg. (J) While cinching the proximal knot, remove the hemostat from the last half-hitch. (K)
Using a free Keith needle, pass both free suture legs through the central third of the residual 1-cm tendon stub. (L) Pull the free ends of
suture through the tendon to complete the finger-trap sequence. The free ends are then shuttled through the holes in the humerus (distal to
proximal) to complete the bone tunnel portion of the construct. (From Sampatacos N, Getelman MH, Henninger HB. Biomechanical
comparison of two techniques for arthroscopic suprapectoral biceps tenodesis: interference screw versus implant-free intraosseous tendon
fixation. J Shoulder Elbow Surg 2014;23:1731-9. Used with permission of Elsevier.)

marked 35 mm distal to its proximal end. A hole 0.5 mm distal edge of the proximal hole using the guide pin from
greater than the tendon width was drilled at the mark on the the cannulated reamer set. Using No. 3-4 suture, 5 throws
humerus. A second hole was then made 25 mm distal to the of a Krackow stitch were passed beginning at the proximal
Biomechanics of intraosseous biceps tenodesis 5

tendon end heading distally for 35 mm, crossing the tendon,

and returning proximally for 5 throws. This results in
10 mm of tendon with suture material remaining distal to
the proximal hole in an effort to protect the tendon as it
courses 180 over the edge of the proximal bone hole. A
suture shuttling device was passed into the distal hole to
retrieve the free suture ends, shuttling the construct through
the bone tunnels from proximal to distal. The tendon was
pulled into the proximal tunnel until the marks on the bi-
ceps and bone lined up, indicating that 25 mm of biceps
was pulled into the bone and that the resting tension of the
biceps was restored. The 2 suture limbs exiting the distal
tunnel were placed with 1 limb on either side of the biceps
tendon, then tied over top of the biceps using a Revo knot
(Fig. 3).

Experimental protocol
Figure 3 Schematic of SPIBiT (A) and C.W. (B) constructs in
Mechanical testing was adapted from previously published the proximal humerus.
protocols.26,34 Each humerus was inverted and mounted in
a custom holding fixture for testing. A soft tissue cryoclamp test. The effect size was calculated from the respective
secured the biceps muscle-tendon unit to the Instron actu- means and standard deviations, and calculations were
ator (Instron 1331 Load Frame, Model 8800 controller; carried out with G*Power 3.1.8 All data are presented as
Instron Corp., Norwood, MA, USA) and 1 kN load cell mean  standard deviation.
(Dynacell Model 2527-130, Instron Corp.). The humerus
and biceps tendon were aligned such that the tensile forces
were applied along the axis of the humerus, thus approxi- Results
mating the in vivo biceps muscle-tendon force vector.
The following test protocol was applied to each spec- Average specimen age was 59  6 years, with 5 female, 4
imen: preload at 0.5 MPa (constant stress ¼ force/cross- male donors. The SPIBiT was placed in 5 left and 4 right
sectional area of native tendon) for 2 minutes, followed humeri. There were no differences in specimen prepara-
by cyclic loading for 500 cycles at 1 Hz up to 8% clamp- tion metrics. Neither tendon cross-sectional
to-construct strain, followed by a pull-to-failure test at area (12.6  3.7 mm2) nor clamp-to-construct length
1 mm/s. Note that 8% clamp-to-construct strain keeps the (29.3  2.3 mm) differed by group (P ¼ .508 and
tissue below microstuctural failure limits5,23 and provides P ¼ .662, respectively).
a consistent metric by which to load the specimens. Clamp- Peak stress and modulus from the first cycle were
to-construct strain was measured as the change in length higher for the C.W. than for the SPIBiT (Table I). The
divided by the initial length, where initial length was SPIBiT exhibited higher peak hysteresis than the C.W.
measured from the cryoclamp to the nearest boundary of (hysteresis ¼ energy dissipation ¼ area between loading
the tested construct. The construct was regularly moistened and unloading stress-strain curves as a percentage of
with a saline spray while time, force, and actuator loading curve). All metrics decreased significantly from
displacement data were continuously recorded throughout cycle 1 to cycle 500 (D; P  .001; power  0.96). The
testing. stress decreased more for the C.W. than for the SPIBiT after
500 cycles, but as a relative percentage, both constructs
Data analysis decreased by approximately 65%. By magnitude, the C.W.
softened more than the SPIBiT (D modulus) but finally did
A pairwise experimental design reduced error between not differ from the peak for the SPIBiT (P ¼ .584). After
specimens due to tissue variability and bone density. A 500 cycles, the hysteresis of the 2 constructs did not differ
priori power analyses revealed that 7 pairs would provide (P ¼ .079).
80% power to detect a significant difference in construct There were no differences in yield properties between
stiffness between groups with an effect size of 0.6 and the C.W. and SPIBiT (Table II). Yield is defined as the
significance level of P  .05.26,34 All comparisons were point on the stress-strain curve where the linear region of
made with paired t tests with significance at P  .05. Post the response deviates, indicating nonrecoverable plastic
hoc power calculations were carried out for all metrics with deformation of the tissue or construct. Failure mechanisms
significant differences using a 2-tailed matched pairwise differed slightly between constructs. All C.W. specimens
6 N. Sampatacos et al.

Table I Cyclic testing data for the SPIBiT and C.W. tenodesis constructs (mean  SD)
Construct Peak stress Peak modulus Peak D Stress D Modulus D Hysteresis (%)
(MPa) (MPa) hysteresis (%) (MPa) (MPa)
SPIBiT 2.9  1.1 66.5  28.3 43.3  3.6 -1.9  0.8) -27.9  17.5) -14.5  4.3)
C.W. 4.3  1.5 116.2  44.6 38.3  4.0 -2.8  1.0) -45.1  17.5) -13.2  4.8)
P value (between constructs) .028 .003 .006 .045 .025 .527
Power (between constructs) 0.59 0.92 0.86 0.49 0.61 d
) P  .050 for D between cycles 1 and 500.

Table II Failure testing data for the SPIBiT and C.W. tenodesis constructs (mean  SD)
Construct Yield stress Yield strain First failure First failure Ultimate failure Ultimate failure Failure
(MPa) (%) stress (MPa) strain (%) stress (MPa) strain (%) modulus (MPa)
SPIBiT 5.3  2.4 17.8  8.5 12.7  6.7 46.9  21.3 21.8  8.3 99.6  35.2 47.8  15.5
C.W. 7.3  3.5 13.3  3.2 15.5  4.3 32.3  8.8 23.4  3.4 108.0  42.0 93.6  31.9
P value .201 .190 .179 .024 .619 .653 <.001
Power d d d 0.61 d d 0.99

failed through construct suture bunching, followed by SPIBiT exhibited a unique failure mechanism in 2 of 9
tearing of the tendon distal to the main suture bundle. All specimens (both female specimens) in which the suture cut
specimens exhibited a staged failure during the bunching through the cortical bone with the button intact. In light of
process, with initial gross tissue tearing followed by these failures, this arthroscopic technique is no longer
a higher stress-strain ultimate failure. The SPIBiT also advocated, and constructs with high-strength suture point
consistently exhibited a multistage failure mechanism with loading on a thin cortex should be avoided.
ultimate tissue tearing distal to the construct. The button During cyclic loading, both constructs saw peak stress
and suture remained secure in all but 2 cases (female support drop by approximately 65% over the 500 test cycles
specimens) in which the suture pulled distally and cut when deformed to 8% strain. Stress relaxation is common
through cortical bone with the button intact (Fig. 4). during cyclic testing of ligament and tendon as the tissue
Only the first failure strain and failure modulus differed accommodates repeated loading, but compliance and
between constructs; otherwise, stress-strain failure metrics settling in the suture construct may exacerbate this effect. A
did not reach statistical significance. The C.W. had the similar result was seen in prior testing of finger-trap style
highest failure modulus, consistent with the moduli from suture constructs in biceps tenodesis,26 and the relative drop
cyclic testing. When converted to load, yield occurred at was in agreement with prior laboratory investigations in
62.9  27.2 N and 84.2  32.8 N for the SPIBiT and C.W., which constant displacement protocols were used.26,34 The
respectively (P ¼ .218). First failure occurred at SPIBiT initially had higher energy restoration, but hyster-
148.9  62.6 N and 180.4  26.4 N for the SPIBiT and esis decreased significantly over the 500 cycles. There were
C.W., respectively (P ¼ .172). Ultimate failure occurred at no differences between constructs after 500 cycles, where
272.0  114.3 N and 282.3  59.4 N for the SPIBiT and energy is stored in both the tendon and suture bundles.
C.W., respectively (P ¼ .766). From a functional standpoint, this could shield the tissue
from microscale damage to the collagen fibers and fascicles
during repeated loading. However, the increased micro-
Discussion motion between the tendon and bone tunnel may have
a detrimental effect of poor osseous integration during
This study was the first to characterize the time-zero healing.
biomechanical properties of the SPIBiT construct for The primary mechanism of failure differed slightly
intraosseous LHB tenodesis. The hypothesis of comparable between constructs. The C.W. failed through construct
properties between SPIBiT and C.W. constructs was partly bunching and tissue tearing distal to the suture bundle. The
supported by the results. Judged against the C.W., the SPIBiT also underwent construct bunching, but in 2 of 9
SPIBiT was more compliant during cyclic and failure cases, the suture and button cut through cortical bone and
loading, but both techniques had similar ultimate failure provided additional overall deformation of the construct.
loads (w275 N). Both constructs ultimately failed by tissue This unique failure mechanism is due to high point loading
tearing within or distal to the suture bundles, but the of the suture on the cortical bone in specimens that
Biomechanics of intraosseous biceps tenodesis 7

displacement after cyclic loading was inferior to 3 other

constructs. Although the ultimate failure load was within
an expected window of 150 to 300 N, the displacement of
9.4  2.8 mm after cyclic loading was speculated to affect
healing potential and long-term construct integrity
in vivo. Both constructs in the present study deformed
with ultimate strain ranging from 50% to 167% of the
initial clamp-to-construct strain, which is more compliant
than interference screws but similar to anchor and finger-
trap tenodesis constructs. Whereas these results illustrate
that both the SPIBiT and C.W. have time-zero failure
strength comparable to the strongest constructs tested in
the literature, the effect of additional compliance in
tendon preservation and biologic healing in patients is yet
to be determined.
Regarding the potential for healing, micromotion within
the tunnel from suspensory fixation may lead to less robust
biologic bone-tendon healing.13 Nebelung et al20 biopsied
the femoral wall of 5 hamstring anterior cruciate ligament
reconstructions (4 suspensory, 1 biocomposite interference
screw) taken back for second-look arthroscopy. Among the
suspensory cases, all had granulation tissue and woven
bone between the hamstring tendon and lamellar bone
of the femur. With the interference screw, there was a
metaplastic fibrocartilage with collagen fibers connecting
the tendon-bone interface. Despite this, in 50% of the
Figure 4 Example of SPIBiT construct failure due to the
suture’s pulling distal and cutting the cortical bone of the proximal
suspensory hamstring cases, the anterior cruciate ligament
humerus (n ¼ 2 of 9 specimens). The arrow denotes the distance remained intact without instability. Because no comparable
the construct moved under the failure loading protocol studies have been performed for biceps tenodesis, the
(w10 mm). relative tradeoff of compliance and tendon preservation vs.
stiffness and increased tendon-bone healing will need to be
presumably had lower bone density. Both specimens were further clarified by patient clinical outcomes and failures.
female, but no bone density studies were performed to Higher compliance could limit construct failure
confirm this conjecture. With a wider tendon contacting compared with interference screw tenodesis techniques.
similar cortical bone, as in the C.W., this type of failure is Biomechanical studies have suggested that the interference
unlikely. screw may be the strongest and stiffest of the constructs
Both constructs exhibited staged failures, whereby and that differences in fixation strength between the
sequential bunching of the suture and release from the suprapectoral and subpectoral locations may not be sig-
primary cortical hole caused a ratcheting effect in the load nificant.21,22,29 Yet, there are several drawbacks to the use
and deformation. Only the first and ultimate failures were of interference screws. Early interference screw failure may
noted in Table II as they were consistently present between occur from tendon damage as the sharp screw threads
trials. Clinically, the first failure may be more important as compress the tendon against the cortical bone.15 There are
it will release the tension on the tendon, making it essen- also reports of complications caused by the osseous defect
tially nonfunctional, yet these constructs may have enough that results from the large hole (up to 10 mm) required for
tension to maintain muscle contours, avoiding a Popeye screw placement, and screw materials may be linked to cyst
deformity. However, this is a time-zero measure, and time- formation.32 Humeral fracture could also result from the
dependent morphologic changes in tendon integrity cannot stress riser caused by the cortical defect.24,28
be accounted for in the present study. Some authors have advocated avoiding any fixation or
The ultimate failure loads in the present study averaged residual biceps tendon within the bicipital groove because
275 N (162-485 N), with no differences between con- of concerns about groove pain.16,19,27 However, a recent
structs. These values are in agreement with prior studies study by Brady et al6 showed that in more than 1000 pa-
of suture anchor and finger-trap style tenodesis constructs tients with an arthroscopic proximal biceps tenodesis above
and trend on the high end of interference screw studies the groove, the rate of biceps-related revision was <0.4%.
(150-300 N).11,17,25,26,34 In a human cadaveric model, Although only a cadaveric study, observation of the posi-
Mazzocca et al17 reported the load to failure of a tion of the cortical button showed it to reside in the lower
C.W.-equivalent construct to be 242.4  51.3 N, but the end of the groove, and it was no thicker than the greater and
8 N. Sampatacos et al.

lesser tuberosities to each side, thereby reducing the chance symptoms in patients with massive irreparable rotator cuff tears. J
of potential irritation. Bone Joint Surg Am 2007;89:747-57.
This study does have limitations. First, this was a time- 2. Boileau P, Krishnan SG, Coste JS, Walch G. Arthroscopic biceps
zero study in cadaveric tissue, which limits conclusions on tenodesis: a new technique using bioabsorbable interference screw
the effects of healing and tissue viability vs. the in vivo case. fixation. Arthroscopy 2002;18:1002-12.
The cadaver tendons were outwardly healthy as noted during 2002.36488
preparation, with no signs of disease, which may not be 3. Boileau P, Neyton L. Arthroscopic tenodesis for lesions of the long
head of the biceps. Oper Orthop Traumatol 2005;17:601-23. http://dx.
representative of tissues presented for tenodesis in clinical
populations. One pair of shoulders was excluded because of 4. Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R.
an LHB tear not reported on donor summaries provided with Arthroscopic treatment of isolated type II SLAP lesions: biceps
the tissue, which was presumably asymptomatic. Because tenodesis as an alternative to reinsertion. Am J Sports Med 2009;37:
determination of biomechanical rigidity precedes arthro- 929-36.
5. Bonifasi-Lista C, Lake SP, Small MS, Weiss JA. Viscoelastic prop-
scopic feasibility, an open technique was used in these ex- erties of the human medial collateral ligament under longitudinal,
periments to maximize precision and accuracy of construct transverse and shear loading. J Orthop Res 2005;23:67-76. http://dx.
placement. Finally, the button/suture failure mechanism
seen in 2 female specimens with the SPIBiT may have been 6. Brady PC, Narbona P, Adams CR, Huberty D, Parten P, Hartzler RU,
directly attributable to bone quality, which was not quanti- et al. Arthroscopic proximal biceps tenodesis at the articular margin:
evaluation of outcomes, complications, and revision rate. Arthroscopy
fied by bone density imaging in the present study to confirm 2015;31:470-6.
this hypothesis. However, paired shoulders were randomized 7. Denard PJ, Dai X, Hanypsiak BT, Burkhart SS. Anatomy of the biceps
between constructs to minimize potential differences in tendon: implications for restoring physiological length-tension relation
inherent tissue quality and bone density. during biceps tenodesis with interference screw fixation. Arthroscopy
8. Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible
statistical power analysis program for the social, behavioral, and
Conclusion biomedical sciences. Behav Res Methods 2007;39:175-91.
9. Froimson AI, O I. Keyhole tenodesis of biceps origin at the shoulder.
The SPIBiT and C.W. constructs have similar failure Clin Orthop Relat Res 1975;112:245-9.
strengths compared with interference screws but with 10. Gartsman GM, Hammerman SM. Arthroscopic biceps tenodesis:
increased compliance, which has yet to be clinically operative technique. Arthroscopy 2000;16:550-2.
proven to be protective or detrimental to ultimate healing. 11. Golish SR, Caldwell PE 3rd, Miller MD, Singanamala N,
In light of the novel failure mode of bone cutout, we Ranawat AS, Treme G, et al. Interference screw versus suture anchor
no longer advocate the SPIBiT construct at our institution, fixation for subpectoral tenodesis of the proximal biceps tendon:
but further studies will be needed to determine the clinical a cadaveric study. Arthroscopy 2008;24:1103-8.
outcome and healing of constructs with increased 1016/j.arthro.2008.05.005
12. Greis PE, Burks RT, Bachus K, Luker MG. The influence of tendon
compliance. Ultimately, constructs with high-strength su- length and fit on the strength of a tendon-bone tunnel complex. A
ture point loading on thin cortical bone should be avoided. biomechanical and histologic study in the dog. Am J Sports Med 2001;
13. Hsu SL, Wang CJ. Graft failure versus graft fixation in ACL recon-
struction: histological and immunohistochemical studies in rabbits.
Disclaimer Arch Orthop Trauma Surg 2013;133:1197-202.
Stephen J. Snyder serves as a consultant for Synthes, 14. Jarrett CD, McClelland WB Jr, Xerogeanes JW. Minimally invasive
proximal biceps tenodesis: an anatomical study for optimal placement
DJO, and Mitek; receives royalties from Linvatec, DJO, and safe surgical technique. J Shoulder Elbow Surg 2011;20:477-80.
Pacific Research, Wright Medical, Arthrex and Lippin-
cott WW; and receives research support from Smith 15. Koch BS, Burks RT. Failure of biceps tenodesis with interference screw
& Nephew, Ossur Medical, DJO, Linvatec, Pacific fixation. Arthroscopy 2012;28:735-40.
Research, Mitek, and Biomet. All the other authors, their arthro.2012.02.019
16. Lutton DM, Gruson KI, Harrison AK, Gladstone JN, Flatow EL.
immediate families, and any research foundation with Where to tenodese the biceps: proximal or distal? Clin Orthop
which they are affiliated have not received any financial Relat Res 2011;469:1050-5.
payments or other benefits from any commercial entity 1691-z
related to the subject of this article. 17. Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA. The
biomechanical evaluation of four fixation techniques for proximal
biceps tenodesis. Arthroscopy 2005;21:1296-306.
18. Mazzocca AD, Noerdlinger MA, Romeo AA. Mini open and sub
References pectoral biceps tenodesis. Oper Tech Sports Med 2003;11:24-31.
1. Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, Trojani C. 19. Millett PJ, Sanders B, Gobezie R, Braun S, Warner JJ. Interference
Isolated arthroscopic biceps tenotomy or tenodesis improves screw vs. suture anchor fixation for open subpectoral biceps tenodesis:
Biomechanics of intraosseous biceps tenodesis 9

does it matter? BMC Musculoskelet Disord 2008;9:121. http://dx.doi. ligament. J Shoulder Elbow Surg 2012;21:66-71.
org/10.1186/1471-2474-9-121 1016/j.jse.2011.01.037
20. Nebelung W, Becker R, Urbach D, R€opke M, Roessner A. Histological 28. Sears BW, Spencer EE, Getz CL. Humeral fracture following sub-
findings of tendon-bone healing following anterior cruciate ligament pectoral biceps tenodesis in 2 active, healthy patients. J Shoulder
reconstruction with hamstring grafts. Arch Orthop Trauma Surg 2003; Elbow Surg 2011;20:e7-11.
123:158-63. 020
21. Patzer T, Rundic JM, Bobrowitsch E, Olender GD, Hurschler C, 29. Slabaugh MA, Frank RM, Van Thiel GS, Bell RM, Wang VM,
Schofer MD. Biomechanical comparison of arthroscopically perform- Trenhaile S, et al. Biceps tenodesis with interference screw fixation: a
able techniques for suprapectoral biceps tenodesis. Arthroscopy 2011; biomechanical comparison of screw length and diameter. Arthroscopy
27:1036-47. 2011;27:161-6.
22. Patzer T, Santo G, Olender GD, Wellmann M, Hurschler C, 30. Snyder SJ. Arthroscope-assisted biceps tendon surgery. In: Snyder SJ,
Schofer MD. Suprapectoral or subpectoral position for biceps tenod- editor. Shoulder arthroscopy. New York: McGraw-Hill; 1994. p. 61-76.
esis: biomechanical comparison of four different techniques in both 31. Snyder SJ. Biceps tendon. In: Snyder SJ, editor. Shoulder arthroscopy.
positions. J Shoulder Elbow Surg 2012;21:116-25. Philadelphia: Lippincott Williams & Wilkins; 2003. p. 74-96.
10.1016/j.jse.2011.01.022 32. Sprowson AP, Aldridge SE, Noakes J, Read JW, Wood DG. Bio-
23. Provenzano PP, Heisey D, Hayashi K, Lakes R, Vanderby R Jr. Sub- interference screw cyst formation in anterior cruciate ligament
failure damage in ligament: a structural and cellular evaluation. J Appl reconstruction 10-year follow up. Knee 2012;19:644-7. http://dx.doi.
Physiol 2002;92:362-71. org/10.1016/j.knee.2012.01.004
24. Reiff SN, Nho SJ, Romeo AA. Proximal humerus fracture after 33. Su WR, Chu CH, Lin CL, Lin CJ, Jou IM, Chang CW. The modified
keyhole biceps tenodesis. Am J Orthop (Belle Mead NJ) 2010;39: finger-trap suture technique: a biomechanical comparison of a novel
E61-3. suture technique for graft fixation. Arthroscopy 2012;28:702-10.
25. Richards DP, Burkhart SS. A biomechanical analysis of two biceps
tenodesis fixation techniques. Arthroscopy 2005;21:861-6. http://dx. 34. Tashjian RZ, Henninger HB. Biomechanical evaluation of subpectoral biceps tenodesis: dual suture anchor versus interference screw fixation.
26. Sampatacos N, Getelman MH, Henninger HB. Biomechanical com- J Shoulder Elbow Surg 2013;22:1408-12.
parison of two techniques for arthroscopic suprapectoral biceps jse.2012.12.039
tenodesis: interference screw versus implant-free intraosseous tendon 35. Tingart MJ, Apreleva M, Lehtinen J, Zurakowski D, Warner JJ. An-
fixation. J Shoulder Elbow Surg 2014;23:1731-9. chor design and bone mineral density affect the pull-out strength of
1016/j.jse.2014.02.027 suture anchors in rotator cuff repair: which anchors are best to use in
27. Sanders B, Lavery KP, Pennington S, Warner JJ. Clinical success of patients with low bone quality? Am J Sports Med 2004;32:1466-73.
biceps tenodesis with and without release of the transverse humeral