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

1. The Pan Am Clinic, Winnipeg, Canada2. Southport 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):245

• Diagnostic tests have low sensitivities and specificities• Pathology 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 teaching• BUT, 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 arthroscopy

• Systematic Review of the Literature

Cadaveric Study

• 7 fresh frozen cadavers with intact LHB• Mean age 74 (range 44-96). All female• Fully thawed for at least 24 hours• Arthroscopy 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 approach• MTJ identified and digital calipers

used to determine respective lengths• Mean overall length 106mm (94-

125mm)• Statistical analyses using paired t-

test

Max excursion

*mean difference 2.8mm, p=0.0327

Lat Versus Beach Chair

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

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

Hook versus Grasper

Conclusions of Cadaveric Study• A grasper allows greater excursion

• Not used clinically due to iatrogenic injury• Data 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 decubitus• But <3mm and unlikely to be of clinical importance

• Main conclusion is that only a small proportion of the extra-articular portion of the tendon is seen and a large proportion is not visualized

Moon et al, AJSM 2015: 84% had lesions beyond 5.6cm at OSPBT

Gilmer, Arthroscopy 2015 32mmSaithna, OJSM 2016 33.7mmTaylor, Arthroscopy 2015 49.5mmFesta, Arthroscopy 2015 50mm

Systematic Review

Rate of missed diagnoses in Systematic Review

• Rate of missed diagnoses 30-50%• 50%, Murthi (n=200), 2000 JSES.• 30%, Gilmer (n=62), 2014 Arthroscopy.• 47%, Taylor (n=277), 2015 Arthroscopy.

Conclusions and Key Messages• Pulling the LHB into joint is an inadequate way of

evaluating for pathology - a “normal” arthroscopy does not exclude it

• Published sensitivity and specificity data based on arthroscopy as a gold standard are invalid because it is an inadequate benchmark

• New arthroscopic techniques are required to reduce the rate of missed diagnoses

Questions?.....