Biceps tenodesis: Open techniques

OVERVIEW

Chapter synopsis

Biceps tenodesis is an effective treatment for pathologies of the long head of the biceps tendon. This chapter presents a technique for a mini-open subpectoral biceps tenodesis using a technique with an all-suture anchor preloaded with needles. This technique allows efficient and proper tendon fixation while minimizing potential complications.

Important points

Be sure that concomitant problems such as rotator cuff pathology are diagnosed and addressed.
Thoroughly evaluate the biceps tendon arthroscopically by pulling the extra-articular portion into the joint. Arthroscopic findings should correlate with the clinical examination.
Meticulous preparation of the humeral surface is the key to augment healing and preventing the tendon from migrating once attached.

Clinical and surgical pearls

A 3-cm longitudinal incision should be made just beneath the inferior border of the pectoralis major and just medial to the anterior-medial border of the deltoid, lateral to the axillary crease.
Placing the lateral retractor through the pectoralis tendon one third above the inferior border allows for excellent exposure of the tenodesis site.
A Chandler retractor should be placed on the medial aspect of the humerus to protect the neurovascular structures, this should stay directly on bone and remain vertical without medial angulation.
A 1.9-mm drill hole reduces the risk of postoperative fractures.

Clinical and surgical pitfalls

Too medial of an incision presents potential harm and risk to the neurovascular structures.
Leaving tendon in the intertubercular groove may be a source of persistent discomfort or “groove pain.” This can be a pitfall of arthroscopic techniques.
Avoid retractor misplacement or overzealous medial retraction; this can damage the musculocutaneous nerve.
Too large of a drill hole used in interference screw techniques increases the risk of postoperative fracture.

Introduction

Long head of the biceps (LHB) pain is a well-recognized cause of anterior shoulder pain that can significantly affect a patient’s quality of life and activity level. This pathology can indicate a variety of different surgical treatments ranging from debridement to tenotomy and tenodesis, depending on specific patient characteristics. These surgical procedures are a viable next step for patients on whom nonoperative management has failed and who have a symptomatic biceps pathology, or for patients who have specific rotator cuff pathologies and degenerative joint disease. ^, One of the mainstays of conservative treatment used in indicating patients with isolated biceps symptomatology includes a significant reduction in pain immediately following an ultrasound-guided injection of local anesthetic.

While debridement and tenotomy may be acceptable treatments for select patients, increasing evidence has shown that tenodesis provides improved cosmesis, endurance, return to sport, and strength outcomes in comparison to tenotomy, with comparable revision rates. Biceps tenodesis can be performed using a variety of techniques and sites of fixation to include arthroscopic, mini-open, suprapectoral, and subpectoral. We prefer a mini-open subpectoral tenodesis which provides reliable fixation and clinical outcomes in addition to low complication rates, residual pain, and stiffness. This chapter presents a mini-open subpectoral biceps tenodesis, a technique with a double-loaded all suture anchor (Biceps FiberTak; Arthrex, Naples, FL) loaded with broad 1.3-mm suture tape and swedged-on needles that prevent slippage while allowing the anchor to enter a small diameter (1.9-mm) drill hole, minimizing the risk of postoperative complications including a fracture.

Preoperative considerations

History

Pain is localized to the anterior aspect of the shoulder (in or near the location of the bicipital groove). This pain may or may not radiate to the biceps muscle belly distally.
Associated shoulder pathology may include rotator cuff disease, glenohumeral arthritis, subscapularis pathology, previous fracture, and superior labral pathology (superior labral anterior-posterior [SLAP] tears)
Pain occurs with functions that require use of the biceps: forward shoulder elevation, active forearm supination, active elbow flexion.

Physical examination

A recent systematic review reported that of all LHB tests, the uppercut test and the biceps groove tenderness to palpation test together have the highest sensitivity and specificity of known physical examination maneuvers to aid in diagnosis.
- Uppercut test: the patient performs an “uppercut” motion with the elbow flexed and attempt forward elevation of the shoulder while the examiner resists the upward movement. The test is considered positive when pain is felt in the anterior shoulder or there is a painful pop or click.
- Biceps groove tenderness: Tenderness over the bicipital groove, which lies 7 cm distal to the acromion, and is seen to migrate laterally with external rotation and medially with internal rotation of the shoulder.

Imaging

Standard shoulder plain radiographs may include true anteroposterior (AP), scapular oblique, and axillary views.
Magnetic resonance imaging (MRI) or magnetic resonance arthrography is performed as indicated for an associated pathology such as rotator cuff disease or superior labral pathology.
Musculoskeletal ultrasound can include dynamic testing when the differential diagnosis includes a subluxing biceps tendon.

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