Proposing the need for a new gold standard for assessment of long head of biceps pathology

Abstract

Purpose: The aim of this cadaveric study was to demonstrate that standard arthroscopic techniques fail to evaluate areas of predilection of long head of biceps (LHB) pathology and assess the safety and efficacy of direct tenoscopy as an alternative. Methods: Seven specimens were evaluated. The LHB was tagged to mark the intra-articular length and the maximum excursion of the tendon achieved using a hook/grasper. This was compared against the visualization achieved with direct tenoscopy. The t-test was used to compare data. The safety of direct tenoscopy was evaluated at open exploration and also by measurement of pre- and post-operative compartment pressures. Results: The mean intra-articular and extra-articular lengths of the tendon were 23.9mm and 82.3mm respectively. The mean length of tendon that could be visualized by pulling it into the joint with a hook was significantly less than with a grasper (Lateral decubitus: hook 29.9mm, grasper 33.9mm, mean difference 4mm, p=0.0032. Beach chair: hook 32.7mm, grasper 37.6mm, mean difference 4.9mm, p=0.0001). The mean length of the extra-articular part of the tendon visualized using a hook was 6mm in lateral decubitus and 8.9mm in beach chair position. The maximum length visualized using a standard technique was 14mm (17%). Direct tenoscopy allowed visualisation of the entire length of the LHB tendon and was safe with respect to compartment pressure and no evidence of iatrogenic injury to local structures at open exploration. Conclusion: Pulling the tendon into the joint with a hook does not allow visualization of known sites of predilection of tendinopathy. Surgeons should be aware that this technique is inadequate and results in missed diagnoses. It can no longer be regarded as a gold standard. Direct tenoscopy allows visualization of the entire length of the LHB tendon and represents a potentially useful strategy for reducing the rate of missed diagnoses.