shoulder arthroscopy does not adequately visualise pathology of the lhb tendon

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Challenging the Gold Standard:

Challenging the Gold Standard: Shoulder Arthroscopy Does Not Adequately Visualise Pathology of the LHB TendonSaithna A1,2, Longo A1, Leiter J1, Old J1, MacDonald PM1

The Pan Am Clinic, Winnipeg, CanadaSouthport and Ormskirk Hospitals Trust, Merseyside, UK

Even in 2016 Identification of symptomatic long head biceps pathology continues to be a clinical challenge

Verma NN.Editorial Commentary: Long Head Biceps Pathology: How Do We Find It? Arthroscopy: The Journal of Arthroscopic and Related Surgery 2016:32(2):245Diagnostic tests have low sensitivities and specificitiesPathology of the LHB frequently occurs in combination with other shoulder pathologies which can confuse the clinical picture

Arthroscopy may be the most sensitive and specific diagnostic modality

Carr RM, Shishani Y, Gobezie R. How accurate are we in detecting biceps tendinopathy? Clin Sports Med. 2015

Consistent with traditional orthopaedic teachingBUT, no validation of arthroscopy as a gold standard in the literature

Hypothesis: Arthroscopy is an Inadequate Gold Standard for Diagnosis of LHB PathologyThis hypothesis was evaluated through:

Cadaveric study to evaluate how much LHB is actually visualized at arthroscopySystematic Review of the Literature

Cadaveric Study

7 fresh frozen cadavers with intact LHBMean age 74 (range 44-96). All femaleFully thawed for at least 24 hoursArthroscopy performed by two fellowship trained shoulder surgeons

Tagging of LHB

Excursion with hook and re-tagging

Excursion with grasper and re-tagging

Determining overall length visualised

LHB retrieved at open approachMTJ identified and digital calipers used to determine respective lengthsMean overall length 106mm (94-125mm)Statistical analyses using paired t-test

Max excursion

*mean difference 2.8mm, p=0.0327Lat Versus Beach Chair

*Lat decubitus: Hook versus grasper, mean difference 4mm, p=0.0032

*Beach chair: Hook versus grasper, mean difference 4.9mm, p=0.0001Hook versus Grasper

Conclusions of Cadaveric Study

A grasper allows greater excursion Not used clinically due to iatrogenic injuryData reported by Gilmer et al 2015 and Taylor et al 2015, over-estimate tendon excursion

Conclusions of Cadaveric Study

A beach chair position allows a greater excursion of compared to lateral decubitusBut