Saithna A, Jordan RW. Southport and Ormskirk Hospitals NHS Trust, UKAdnan.Saithna@nhs.net

BACKGROUND

Contemporary literature reports that physical examination tests and imaging modalities for pathology of the long head of biceps (LHB) tendon have low sensitivities and specificities. The vast majority of studies use arthroscopic evaluation of the LHB as a benchmark for comparison. To the our knowledge, no previous studies have evaluated whether arthroscopy is a valid gold standard.

OBJECTIVES

This systematic review seeks to evaluate the validity of arthroscopy as a gold standard by answering two research questions:1. Does arthroscopy adequately visualise areas of predilection of pathology of the LHB tendon?2. What is the rate of missed diagnoses of LHB pathology at arthroscopy when compared to an open approach?

RESULTS

A total of 575 patients were included from 4 clinical studies [1,2,3,4]. The rate of missed diagnoses at arthroscopy when compared to a subsequent open approach varied from 33% to 49%.Tendon excursion data (the maximum length of LHB that could be seen at arthroscopy) was obtained from 4 studies [1,4,5,6]. This data is summarised pictorially below.

CONCLUSIONS REFERENCES

METHODS

Full details of study methodology are available via PROSPERO, the international prospective register of systematic reviews.In summary, all published studies reporting the rate of missed diagnoses of LHB pathology at arthroscopy vs open surgery and/or reporting the maximum length of LHB tendon visualised at arthroscopy were included for review and data extraction. Pooled results were critically analysed.

This systematic review concludes that glenohumeral arthroscopy fails to visualise Denard Zone C which is a proven area of predilection of pathology of the LHB tendon. This failure to adequately visualise the extra-articular part of the tendon results in a high (33-49%) rate of missed diagnoses compared to an open approach

This means that published sensitivity and specificity data for physical examination and imaging tests based on arthroscopy as a benchmark are invalid because arthroscopy is an inadequate gold standard for the diagnosis of LHB pathology.

 1.Gilmer BB, DeMers AM, Guerrero D, Reid JB, Lubowitz JH, Guttman D (2015) Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis. Arthroscopy 31:29-34.2. Moon SC, Cho NS, Rhee YG (2014) Analysis of “Hidden Lesions” of the extra-articular biceps after subpectoral biceps tenodesis: The subpectoral portion as the optimal tenodesis site. Am J Sports Med 43:63-68.3. Murthi AM, Vosburgh CL, Neviaser TJ (2000) The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg 9:382-385.4. Taylor SA, Khair MM, Gulotta LV et al. (2015) Diagnostic glenohumeral arthroscopy fails to fully evaluate the biceps-labral complex. Arthroscopy 31:215-224. 5. Festa A, Allert J, Issa K, Tasto JP, Myer JJ (2014) Visualization of the extra-articular portion of the long head of the biceps tendon during intra-articular shoulder arthroscopy. Arthroscopy 30:1413-1417.6. Saithna A, Longo A, Leiter J, Old J, MacDonald PM. Shoulder Arthroscopy Does Not Adequately Visualize Pathology Of The Long Head Of Biceps Tendon. Orthopaedic Journal of Sports Medicine January 2016 vol. 4 no. 17. Denard PJ, Dai X, Hanypsiak BT, Burkhart SS (2012) Anatomy of the biceps tendon: implications for restoring physiological length-tension relation during biceps tenodesis with interference screw fixation. Arthroscopy. 28:1352-1358.

Published Sensitivity and Specificty Data for Physical Examination and Imaging Tests Evaluating The Long Head of Biceps Tendon are Invalid

The photograph on the left demonstrates an anatomical specimen (right shoulder, viewed from anterolaterally). The suture in the LHB was placed at glenohumeral arthroscopy to demonstrate the maximum length of tendon visualized in this specimen. The image on the right shows infra- and supraspinatus (dark blue), and subscapularis (light blue). The LHB tendon is divided into 3 sections as described by Denard et al (A: green 0-2.5cm, B: grey 2.5-5.6cm and C: red >5.6cm). Lines 1-4 demonstrate the mean maximum LHB tendon lengths visualized at arthroscopy in the studies reported by Gilmer (32mm), Saithna (32.7mm), Taylor (49.5mm) and Festa (50mm) respectively. None of the studies reported visualising beyond Denard zone B. However, this is a common site of pathology and Moon et al reported that tears were observed in zone C in 78% of patients at open subpectoral tenodesis – an area not visualised arthroscopically in any of the included studies