What Method of Fixation Is Superior for Biceps Tenodesis?

To the Editor: The recently published article about open biceps tenodesis by Diaz et al1 is highly timely and attempts to address the question of which fixation method is superior for biceps tenodesis. Management of the long head of the biceps (LHB) tendon is currently one of the most controversial topics among shoulder surgeons.2 Diaz et al1 evaluated 6 techniques for biceps tenodesis by comparing ultimate failure load (UFL) and failure mechanism. They found that UFL did not differ significantly among those techniques. The results of this study showed that the mean UFLs of the double-loaded 1.9-mm all-suture anchor, soft tissue, and interference screw groups were lower than the physiologic load on the LHB tendon. Is it the perceived contraindications? There is no doubt that sufficient primary stability, or load-bearing ability, is essential to allow direct postoperative early rehabilitation in the form of active flexion of the elbow. However, the LHB tendon accounts for 0% to 25% of the muscle’s strength in the actual situation.3 In vitro stresses on the biceps tenodesis screw, cortical button, and suture anchor in sheep, porcine, and human cadaveric specimens exposed them to submaximal loads.4,5 Further, it is likely that the patient in a sling postoperatively has less weight loading than that undergoing materials testing. It is challenging for clinicians to interpret the results of biomechanical and clinical studies for biceps tenodesis. The timezero biomechanical studies are not the same as clinical outcomes, which are paramount for patients. The pathology of the LHB is often associated with other shoulder pathologies, such as rotator cuff tear and subacromial impingement.4,5 Management of the LHB is only part of the shoulder surgery. Clinical studies, and our own clinical experience, have frequently shown no significant clinical advantage of any fixation method. It is wellknown that in orthopedic procedures such as ligament repair/ reconstruction, tendon-to-bone and tendon-to-soft tissue internal fixation constructs provide only temporary primary fixation for healing during the first 4 or 6 weeks postoperatively. Ultimate strength depends on tendon healing to or into bone. Because the effect of biological factors such as tendon ingrowth cannot be predicted based on these biomechanical experiments, it is more clinically meaningful to investigate in vivo which fixation method offers faster and stronger healing. In the absence of convincing data demonstrating improved healing, function, or pain relief for one fixation method over another, we continue to choose a comfortable and convenient method—subpectoral tenodesis with a suture anchor—for the majority of our patients. Mingjin Zhong, MD Weimin Zhu, MD Wei Lu, MD The First Affiliated Hospital of Shenzhen University Shenzhen, Guangdong Province, China The authors have no relevant financial relationships to disclose.