Osteomyelitis: A Rare Complication After Subpectoral Biceps Tenodesis

摘要

The long head of the biceps tendon can be a source of persistent pain and dysfunction. After failure of nonoperative management, two surgical techniques, tenotomy or tenodesis, can be used to treat this condition. Tenodesis is preferred when the patient is young, is highly active, or seeks an improved cosmetic appearance. ~( 4 , 6 , 9 , 17 , 19 ) Tenodesis can be performed either open or arthroscopically with the biceps tendon placed proximally on the humerus or underneath the pectoralis major tendon insertion. ~( 13 , 18 ) Multiple fixation techniques are available for the tenodesis, such as interference screw, suture anchor, tunnel, and keyhole techniques, and these methods have similar complications. These complications include biceps tendon rerupture, hematoma, infection, persistent pain, nerve injury, cosmetic deformity, and humeral fracture. ~( 4 , 6 , 9 , 12 , 13 , 20 – 22 ) Current data are scarce regarding the clinical complications of open subpectoral biceps tenodesis with interference screw fixation. In this case study, we present what we believe is the first documented case report of osteomyelitis with this technique. Case Report A 29-year-old, right-hand-dominant man, who was a former military servicemember, injured his right shoulder on active duty while lifting weights in 2007. A physician outside of our institution diagnosed the patient with a type 2 superior labrum anterior and posterior (SLAP) tear, and he attempted a trial of physical therapy. In November 2012, the patient underwent an arthroscopic SLAP repair, which was converted to an open subpectoral biceps tenodesis with interference screw fixation. Postoperatively, the patient had no immediate issues other than minor pain. Six months after the procedure, the patient presented to our department with increasing right shoulder pain. He reported no specific history of recent trauma, fever, chills, or prior infection elsewhere; however, he had increased swelling and purulent drainage from the posterior aspect of his arm near his axilla ( Figure 1 ). Initial cultures of the drainage were negative, but repeat cultures grew Proteus mirabilis . Computed tomography scans revealed a lytic defect and bony sequestrum of the humerus suggestive of osteomyelitis ( Figure 2 ). Furthermore, magnetic resonance imaging revealed a visible fluid collection at the tenodesis site as well as a partially displaced bioabsorbable screw that was protruding several millimeters out of the humeral cortex ( Figure 3 ). Figure 1. Initial clinical presentation: 2 draining wounds are shown near the anterior (right arrow) and posterior (left arrow) aspect of patient’s arm near his axilla. Figure 2. Computed tomography images of the patient’s humerus: (A) 3-dimensional reconstructed image shows a lytic defect (arrow); (B) axial image shows bony sequestrum (arrow). Figure 3. A proton density–weighted, fat-suppressed image of the tenodesis site shows a fluid collection with increased signal and a protruding screw (arrow). Subsequently, the patient underwent formal irrigation and debridement of the wound, removal of the bioabsorbable screw and suture material, and debridement of the bony cortex. The wound was packed with calcium sulfate impregnated with antibiotics. Bone cultures were positive for P mirabilis . The patient received a 6-week course of intravenous antibiotics. After his treatment course, he followed up with our department for a year. He had complete resolution of his drainage and pain, and he made a full functional recovery with no limitation to his military training or sporting activities. Discussion Biceps tenodesis has had favorable clinical outcomes in the treatment of injuries of the long head of the biceps tendon after failure of conservative measures. ~( 9 , 12 , 25 , 27 ) Mazzocca et al ~( 17 ) reported that tenodesis retained the natural length-tension relationship of the biceps muscle. Slenker et al ~( 25 ) reported a significantly lower incidence of cosmetic deformity with tenodesis compared with tenotomy (8% vs 43%, respectively). Other studies have reported a lower incidence of biceps cramping and soreness with tenodesis. ~( 27 ) Provencher et al ~( 23 ) found that subpectoral biceps tenodesis is an efficient and reproducible technique that requires minimal dissection without any violation of muscle tendon units. Because complications can occur with subpectoral tenodesis, further investigation of this approach is warranted. We could find no reported cases of osteomyelitis in patients who had undergone an open subpectoral tenodesis with interference screw fixation. In the largest clinical series, entailing 353 patients, Nho et al ~( 21 ) reported a total of 7 complications of the following types: a deep postoperative wound infection requiring irrigation and debridement with 2 weeks of intravenous antibiotics, musculocutaneous neuropathy, persistent pain, reflex sympathetic dystrophy, and fixation failure. Other reported complications have include