Journal of the American Animal Hospital Association 41:121-127 (2005)
© 2005 American Animal Hospital Association
Arthroscopic Biceps Tenodesis: Technique and Results in Six Dogs
James L. Cook, DVM, PhD, Diplomate ACVS,
Keith Kenter, MS, MD, Diplomate NBME and
Derek B. Fox, DVM, PhD, Diplomate ACVS
From the Comparative Orthopaedic Laboratory (Cook, Fox), University of Missouri, Columbia, Missouri 65211 and the Department of Orthopaedic Surgery, Sports Medicine and Shoulder Reconstruction (Kenter), University of Cincinnati, Cincinnati, Ohio 45267.
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Abstract
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Biceps tenodesis was performed using an arthroscopic-assisted technique on six dogs diagnosed with chronic bicipital tendon pathology. The technique was performed using two different fixation methods (i.e., cannulated interference screw, cannulated screw and tissue washer). All six dogs had successful outcomes in terms of return to full function at a mean follow-up time of 11.7 months after surgery. Arthroscopic biceps tenodesis is a feasible option for surgical management of biceps tendon pathology, and it may have advantages over open tenodesis and open or arthroscopic tenotomy. Further study is needed before definitive recommendations regarding indications, complications, and prognosis associated with arthroscopic biceps tenodesis can be made.
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Introduction
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Pathology affecting the biceps tendon of dogs has been reported as a frequent cause of forelimb lameness and typically requires treatment.1–4 Recognized conditions affecting the biceps tendon of dogs include tenosynovitis, partial or complete rupture, avulsion, tendinitis, tendinosis, displacement, and bipartite tendon.1–4 The pathology, epidemiology, and diagnostics associated with these conditions have been described in the veterinary literature.1–7 Nonsurgical management of biceps tendon pathology may be effective in some cases.1–4 However, surgical management often becomes necessary in a significant number of these animals.1–4,8 The reported surgical treatment options for biceps tendon disease include tenodesis, tenotomy, primary repair, debridement, transposition, and lavage.1–4,8 Based on the published veterinary literature, biceps tenodesis via an open approach and open or arthroscopic biceps tendon release (tenotomy) are the most common surgical procedures used to treat biceps tendon problems in dogs.1–3,8 Open tenodesis has been associated with good and excellent outcomes in dogs.1–3 To the authors’ knowledge, only one study has reported the results of tenotomy for treatment of biceps tendon problems in dogs. That study reported the results of arthroscopic biceps tenotomy in five dogs treated for bicipital tenosynovitis, with good to excellent results in all five dogs based on subjective measures over a 6-month follow-up period.8
Both tenotomy and tenodesis are used in people for treatment of biceps tendon pathology.9–15 Indications and recommendations for tenotomy versus tenodesis vary among types of pathology, patient age, activity level and expectations, and surgeons’ preferences.9–15 Good and excellent results have been reported for both tenodesis and tenotomy in people, and many surgeons recommend achieving competence in both techniques to provide comprehensive treatment options and patient care.11–15
A minimally invasive, arthroscopic-assisted technique for biceps tenodesis in dogs was developed based on the procedure performed in humans, and it was used for the treatment of selected cases of biceps pathology in dogs.9,10 The purposes of this report are to describe the technique used for arthroscopic tenodesis in dogs and to present subjective results in a small number of clinical cases treated with this procedure.
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Materials and Methods
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The medical records of all dogs that underwent arthroscopic-assisted biceps tenodesis were retrospectively reviewed. Inclusion criteria for this study were performance of an arthroscopic biceps tenodesis between December 2001 and November 2003, availability of medical records data for review, and ability to obtain follow-up data from the owners. Data retrieved from the medical records included age, gender, breed, and weight of the dog; relevant history; physical examination findings; radiographic and ultrasonographic findings; arthroscopic findings and surgical manipulations performed; follow-up examinations; and complications associated with surgery. Owners were interviewed at recheck appointments or via telephone in all cases to determine perceived outcome after surgery. Outcome was considered excellent if the dog returned to full function in all activities without antiinflammatory medications and had no evidence of pain, lameness, or exercise intolerance. Outcome was considered good if the dog improved after surgery and returned to full function with no pain or lameness when treated with antiinflammatory medications and/or had mild exercise intolerance. All other outcomes were considered to be poor.
Surgical Technique
The dogs were anesthetized and routinely prepared for aseptic surgery of the forelimb. Each dog was placed in lateral recumbency with the affected limb up. One-centimeter skin incisions were made, and arthroscopic portals were created using a blunt obturator and cannula.a The technique was performed using a caudolateral camera portal and two instrument portals (i.e., craniolateral and cranial) [Figure 1
]. The arthroscopeb was inserted, and the joint was thoroughly evaluated for pathology of all relevant structures. The biceps tendon was then identified. Two different devices were used for fixation of the biceps tendon, and the surgical technique varied slightly depending on fixation type. For the cannulated interference screw fixation technique, a 16-gauge spinal needlec or other suture-passing device was inserted through the craniolateral portal and through the biceps tendon at its proximal aspect [Figure 2]. Suture (#2 braided polyblend sutured or 0 polypropylene suturee with the needle removed) was passed through the tendon. The suture-passing device was removed, and both ends of the suture were grasped through the cranial portal and pulled through the skin using arthroscopic grasping forceps. The suture ends were clamped with a mosquito forceps.
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Figure 1— Illustration showing the anatomical locations of the three portals used for arthroscopic-assisted biceps tenodesis performed in the dogs of this study.
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Figure 2— Arthroscopic view of a biceps tendon of a dog from a caudolateral camera portal. Suture (0 polypropylene) has been passed through the tendon to allow for manipulation of the tendon during tenodesis.
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The biceps tendon was then released at its attachment of origin on the supraglenoid tubercle using a basket forceps, scalpel blade, or motorized shaver [Figures 3A, 3B]. An intramedullary pinf was then inserted through the cranial portal to locate the point of drilling for tendon fixation insertion. The point of fixation placement was the most distal point in the biceps groove that was visible arthroscopically with the shoulder held at a weight-bearing angle (approximately 130° to 150°). The appropriate drill sleeve for the intended fixation device was then inserted over the pin [Figure 4]. The pin was removed, and the appropriate drill bit was inserted through the drill sleeve and used to drill a hole through the cis cortex (i.e., the near cortex) of the proximal humerus. The drill bit and sleeve were removed, and the fixation device was inserted and tightened to fix the tendon to the proximal humerus [Figure 5]. It was imperative that the elbow be held in extension and an adequate length of tendon ensured prior to insertion of either fixation device.
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Figures 3A, 3B— Arthroscopic views of a biceps tendon of a dog from a caudolateral camera portal. The tendon is being transected at its origin using a basket forceps (A), causing complete detachment and distal retraction (B). The polypropylene suture is seen attached to the retracted tendon in 3B.
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Figure 4— Arthroscopic view of an Arthrex biceps tenodesis drill sleeve (DS) being inserted over an intramedullary pin (IM) in the biceps groove (BG) of the humerus.
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Figure 5— Arthroscopic view of an Arthrex biceps tenodesis cannulated interference screw (S) being placed in the biceps groove of the humerus for tenodesis of the biceps tendon of origin.
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Of the two different fixation devices, the Arthrex Biceps Tenodesis Systemg employed a cannulated interference screw for fixation [Figure 6]. A 5.5-mm, nonabsorbable interference screw was used for all cases (n=4) operated with this device. When using this system, the suture in the tendon was pulled through the cannulated screw using the driver. The screw was inserted into the hole, pulling the tendon with it, and the screw was tightened until it was flush with the bone [Figure 7].
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Figure 7— Illustration showing method of fixation of the biceps tendon of origin (T) when using the Arthrex biceps tenodesis cannulated interference screw (CS) with suture (S) for arthroscopic biceps tenodesis into bone (B) in the biceps groove.
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Alternatively, a 3.0-mm cannulated screwh and tissue washeri were used in two cases [Figure 8]. When using the cannulated screw and washer, the cannulation wire was placed through the cranial portal of the tendon at the most distal point in the biceps groove that was visible arthroscopically (while the tendon was still attached at the supraglenoid tubercle). The shoulder was held at a weight-bearing angle, and the elbow was held in extension during wire placement. The drill bit was then inserted over the wire, and the hole was drilled through both cis- and trans-cortices (i.e., the near and far cortices). The cannulated screw with washer was then driven through the tendon into the hole and tightened until the washer firmly engaged the tendon and contacted the underlying bone. The biceps tendon was then transected at its attachment of origin on the supraglenoid tubercle using a basket forceps.
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Figure 8— Illustration showing method of fixation of the biceps tendon (T) when using the screw (S) and tissue washer (W) method for arthroscopic biceps tenodesis into bone (B) in the biceps groove.
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The skin incisions were closed routinely, and postoperative radiographs were obtained in all dogs [Figures 9A, 9B]. Clients were instructed to allow only short leash walks and to restrict the dog to a cage, crate, or kennel when unobserved for 6 weeks after surgery. If the dog could bear weight on the operated limb with no evidence of pain or displacement of the biceps muscle, and no evidence of implant failure was present at the 6-week recheck, a progressive return to full activity was encouraged over the subsequent 6 weeks. Range-of-motion exercises and nonconcussive activities such as swimming and leash walking were encouraged during the second 6-week period. Full, unrestricted activity was allowed after 12 weeks of rehabilitation.
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Figures 9A, 9B— Mediolateral radiographic views of two different dogs (case nos. 1, 3) immediately after arthroscopic biceps tenodesis using the Arthrex biceps tenodesis cannulated interference screw method (A) and the screw and tissue anchor method (B).
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Results
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Six cases met the criteria for inclusion in this study. Ages of the dogs ranged from 3 to 7 years, with a mean of 4.8 years and a median of 4.5 years. Gender and breed data are provided in the Table. All cases had unilateral lameness (right [n=3], left [n=3]) and abnormalities of the biceps tendon based on physical examination, radiographic examination of both shoulders and both elbows, ultrasonographic examination of both biceps tendons, and arthroscopic findings in the affected shoulder. Three dogs had chronic bicipital tenosynovitis; two dogs had partial rupture of the biceps tendon; and one dog had a partial avulsion of the tendon. Four dogs were working dogs, and two dogs were very active pets. All cases were managed nonsurgically (e.g., antiinflammatory medications and activity restriction) for various amounts of time and had not responded (n=4) or had become refractory (n=2) to nonsurgical therapy.
Biceps tenodesis was performed using the described arthroscopic-assisted technique in all cases. Follow-up times ranged from 5 months to 18 months (mean 11.7 months, median 12.5 months). Complications consisted of a seroma in one dog that resolved with exercise restriction and application of warm, moist compresses. No biceps muscle displacement or laxity was noted following surgery. Return of supraspinatus, infraspinatus, and brachial muscle mass symmetry and resolution of lameness were evident in all cases. All dogs were judged to have good (n=3) or excellent (n=3) outcomes according to the owners. Owners reported that full return to function was typically evident by 12 to 18 weeks after surgery [see Table
].
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Discussion
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Arthroscopic biceps tenodesis was technically feasible to perform in medium- and large-breed dogs and resulted in successful functional outcomes in all dogs in this study. The technique was technically demanding, but repetition and experience allowed for more efficient and precise implementation of the procedure. In addition, the technical demands, surgical time, and associated costs far exceeded those expected for tenotomy. However, the indications as well as the long-term outcomes of arthroscopic biceps tenotomy versus tenodesis have not been determined in dogs. Therefore, it is important to explore the feasibility and results of both techniques until definitive conclusions regarding their efficacy can be drawn from scientific data.
In people, tenotomy is becoming more popular than tenodesis for treatment of the majority of biceps long-head tendon-of-origin problems.11,12,14,15 Tenotomy has been reported to provide similar outcomes in terms of cosmetic appearance, anterior shoulder pain, and degree of muscle spasms in humans with chronic bicipital pain.11 However, to the authors’ knowledge, no studies have compared functional outcomes of arthroscopic biceps tenotomy versus tenodesis in terms of limb strength and activity levels in the human or veterinary literature. In addition, tenodesis is typically recommended over tenotomy in athletic people, especially those who participate in overhead athletic activities.13–15 The authors of the present report were motivated by this recommendation to develop an arthroscopic biceps tenodesis technique for dogs in order to determine if this technique was preferentially indicated in dogs with biceps tendon pathology. It was felt that athletic dogs might benefit from tenodesis when compared to tenotomy. In addition, since dogs have the added function of weight bearing in the fore-limb, it was thought that tenodesis might be advantageous for dogs. This consideration was supported by the excellent long-term results of open biceps tenodesis reported by Stobie, et al.3 Although outcomes were good in the study reported here, long-term studies are needed to determine the effects of arthroscopic tenotomy versus tenodesis on muscle, elbow, and limb function before definitive recommendations regarding indications, complications, and prognosis can be made.
Two different fixation techniques were used in the dogs of the present study. Each technique has advantages and disadvantages. The primary advantages of the cannulated interference screw system include its purpose-designed instrumentation, security of fixation, and proven efficacy in people.10 The disadvantages of the system include the associated costs, ease of access to the equipment, and limited applications for veterinary surgery. The advantages of the screw and washer technique include its lower cost, greater applicability, and accessibility. The fact that the tendon is not pulled into the bone using this latter technique is a perceived disadvantage in terms of long-term strength of fixation. However, both techniques are feasible, and the choice of technique may initially be based on surgeon preference.
Biceps tendon problems are typically chronic problems requiring compliance in treatment, careful monitoring, and patience. As is true for management of any orthopedic problem, weight management and physical rehabilitation are critical for a successful outcome when treating biceps tendon problems using any modality.
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Conclusion
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Arthroscopic biceps tenodesis was a feasible option for surgical management of biceps tendon pathology and may have advantages over open tenodesis and open or arthroscopic tenotomy, such as decreased morbidity and improved function. Prospective, randomized, and controlled studies comparing treatment options for biceps tendon disorders are needed before definitive recommendations regarding arthroscopic biceps tenodesis can be made.
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Footnotes
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a 2.9-mm, short cannula with obturator; Smith & Nephew, Inc., Andover, MA 01810 
b 2.7-mm, 30° foreoblique arthroscope; Smith & Nephew, Inc., Andover, MA 01810
c 16-gauge spinal needle; Sherwood, St. Louis, MO 63103
d FiberWire suture; Arthrex, Naples, FL 34104
e 0 Prolene; Ethicon, Somerville, NJ 08876
f Steinmann intramedullary pin; IMEX Veterinary, Longview, TX 75603
g Bio-Tenodesis System; Arthrex, Naples, FL 34104
h 3.0-mm cannulated screw; Synthes, Monument, CO 80132
i Spiked washer; Synthes, Monument, CO 80132
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References
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Abstract
Introduction
