Presentation
Two months ago the open tenodesis of the long head biceps tendon (LHBT) was performed. A fever, pain and swelling in the postoperative scar appeared about a month after the operation with the following purulent discharge. A referring physician suggested a suture fistula.
Patient Data
In the anterior portion of the deltoid muscle there is a complex curvilinear fistula, surrounding the pectoralis major tendon, connected with the LHBT, attached to the screw-anchor (signal void) in the humerus. Around the screw, one can see a bone marrow edema, which has a high signal on STIR sequence. Note minimal bone resorption along the upper and the lower border of the screw with the bone cortex. On the anterior surface of the humerus, a small periosteal thickening is better evident on T1.
There are several modifications of the open LHBT tenodesis. The primary difference between them is in surgical implants, sites and technique, which are used for LHBT fixation to a humerus. This can be an interference screw or a suture anchor. With the interference screw threads of the screw itself attach the tendon to the walls of a bone tunnel. With the suture anchor, the tendon is attached to the bone anchor (which is also a screw without a head) by a double-looped suture (figure).
In the anterior portion of the deltoid muscle there is a complex curvilinear fistula (asterix on axial PD/fs), surrounding the pectoralis major tendon, connected with the LHBT, attached to the screw-anchor (signal void) in the humerus. Around the screw (thin arrow), one can see a bone marrow edema, which has a high signal on STIR sequence. Note minimal bone resorption along the upper and the lower border of the screw with the bone cortex (thick arrow). On the anterior surface of the humerus, a small periosteal thickening is evident (blue line) on T1.
Needle aspiration and culture discovered Staphylococcus Aureus.
Impression: These are signs of a contact osteomyelitis. The CT recommended but wasn't performed.
Secondary admittance one year later. Weakness on flexion in the arm appeared a month ago. A small palpable mass on the front surface of the shoulder.
The fistula around the pectoralis major tendon persists. It drains to a subcutaneous fluid collection on the anterior surface of the arm, which proved to be pus. The screw anchor migrated from the bone tunnel along with the thickened and torn LHBT.
The fistula (asterix) around the pectoralis major tendon (large open arrow) persists. It drains to a subcutaneous fluid collection on the anterior surface of the arm (asterix), which proved to be pus. The screw anchor migrated from the bone tunnel along with the thickened and torn LHBT. There's no bone marrow edema and a periosteal thickening which could assign a sterile bone.
Needle aspiration and culture didn't find any bacterial growth.
Case Discussion
Surgical treatment of the long head biceps tendon (LHBT) tears consists of arthroscopic suprapectoral and open subpectoral biceps tenodesis. Although arthroscopic evaluation of LHBT has always been the gold standard, the limited excursion of the tendon into the articular cavity makes it challenging to recognize reliably the full extent of the pathology 1. In up to 47% of the patients, there was extraarticular propagation of the lesion, which had been underestimated during arthroscopy 2,3. Meanthewhyle open surgery had a significantly higher rate of infectious complications compared to arthroscopic procedures 4.