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The Proximal Long Head Biceps Tendon (LHBT) Rupture: LHBT Tenodesis for Symptomatic Chronic Ruptures and Revision LHBT Tenodesis


Introduction

Ruptures of the long head of the biceps tendon (LHBT) usually occur in patients with intrinsic tendon degeneration and concomitant rotator cuff tears. Even though nonoperative management is successful in most patients, some patients may suffer from persistent symptoms such as weakness, pain, cramping, and cosmetic deformity. The same symptoms may arise after a surgical biceps tenotomy or after a failed biceps tenodesis. A variety of techniques for biceps tenodesis have been described, including both open and arthroscopic technique with multiple fixation sites and devices.

Procedure

Subpectoral Biceps Tenodesis

With the arm abducted and slightly internally rotated, the skin is incised along the axillary crease from 1 cm superior to 3 cm inferior to the inferior border of the pectoralis major tendon. Using the interval between the pectoralis major tendon superiorly and the short head of the biceps inferiorly, the LHBT is retrieved in the bicipital groove, externalized, and whipstitched. A unicortical bone tunnel is reamed in the inferior aspect of the bicipital groove and the tendon is inserted using an interference screw, additionally tying the sutures on top of the screw.

Patient History

  • Usually previous pain in the shoulder and/or upper arm

  • Sudden painful event usually with trauma (spontaneous rupture based on degenerative changes)

  • Previous surgical tenotomy or LHBT tenodesis

  • Popeye deformity

  • Pain, cramping

  • Weakness with elbow flexion and supination

  • Frequently associated with a rotator cuff tear

Patient Examination

  • Popeye deformity ( Figs. 51.1 , 51.2 )

    FIG. 51.1, Anterior view of a 47-year-old right-hand-dominant patient demonstrating Popeye deformity after previous LHBT tenodesis of his right arm.

    FIG. 51.2, Lateral view of a 47-year-old right-hand-dominant patient demonstrating Popeye deformity after previous LHBT tenodesis of his right arm.

  • Pain along the bicipital groove and extending distally

  • Cramping

  • Weakness with elbow flexion and supination

( Fig. 51.3 )

FIG. 51.3, MRI (T2, coronal view) of the right upper arm of this patient, demonstrating a failed LHBT tenodesis with an intact tenodesis screw at the humeral insertion site (indicated by red arrow) and a retracted LHBT stump (indicated by the red circle) with a gap of approximately 3 cm.

Imaging

  • Plain x-rays, usually normal, can rarely display widening or fracture of the previous tenodesis drill hole.

  • CT: only rarely indicated in case of suspected bony pathology.

  • MRI: displays the tendon stump length and quality (best visualized in T2, coronal view) and amount of distal retraction. Surrounding edema in the acute phase. LHBT absent from bicipital groove on shoulder view. May need more distal MRI to see the retracted LHBT.

Treatment Options: Nonoperative and Operative

  • Nonoperative treatment: usually effective but will have persistent deformity.

  • Operative treatment: Open subpectoral tenodesis is the method of choice. Arthroscopic and open suprapectoral tenodesis is not feasible once the LHBT is retracted.

Surgical Anatomy

  • Axillary crease

  • Inferior border of the pectoralis major tendon and anterior border of the deltoid muscle

  • Interval between the pectoralis major tendon superiorly and the short head of the biceps tendon inferiorly

  • Inferior aspect of the bicipital groove

Surgical Indications

  • Failed nonoperative management

  • Pain, cramping, weakness with elbow flexion and supination

  • Patient not willing to accept cosmetic deformity

Surgical Technique Setup

Positioning

  • Beach-chair position ( Fig. 51.4 )

    FIG. 51.4, Operating room setup for revision biceps tenodesis. The patient is placed in the beach-chair position with a pneumatic arm-holder. The arm is placed in abduction and slight internal rotation to expose the bicipital groove.

  • Pneumatic arm-holder

  • Diagnostic shoulder arthroscopy first

  • Arm in abduction and slight internal rotation

  • Easy access to the bicipital groove

Possible Pearls

  • Diagnostic shoulder arthroscopy prior to tenodesis may recognize and address potential intraarticular pathologies. There may be a remnant biceps stump in the joint.

  • Allow for intraoperative assessment of biceps length-tension relationship by elbow motion

  • Extend the incision far enough distally to retrieve the retracted LHBT. Incision courses obliquely along the anterior border of the deltoid.

  • Identify tendon and muscle tendon units. Visualize the muscle tendon junction and use a nerve stimulator if unsure of anatomy.

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