Biceps tenodesis: Arthroscopic techniques

Pathology of the long head of the biceps tendon (LHBT) has long been recognized as a significant cause of shoulder pain that can affect the entire scope and quality of a patient’s activity level. The diagnosis of this particular disease process can be challenging because there are many other anatomic structures that can produce anterior shoulder pain, and there is often overlap between these various pathologies. While debate exists about whether pathology of the LHBT is a primary disease process or is secondary to concurrent disease processes such as impingement or subscapularis dysfunction, ^, the end result is a painful shoulder that can be a persistent cause of disability for patients who are often physiologically young and active. There are several nonoperative treatment options for LHBT pathology, including physical therapy, steroid injection, biologic injections, and others. However, patients who have continued symptoms despite extensive nonoperative treatments are often indicated for surgical intervention. Surgical treatment options for LHBT pathology include tenotomy, tenodesis, and tendon relocation with reconstruction of the biceps pulley.

Although the pathologic LHBT was commonly debrided or treated with tenotomy in the past, tenodesis has become a more common treatment option for LHBT pathology. ^, However, there is an increased risk of wound breakdown with open biceps tenodesis techniques, and studies have failed to demonstrate a clear, significant functional improvement with tenodesis over tenotomy. ^{, ,} Despite a clear functional benefit of tenodesis over tenotomy, tenodesis does offer improved cosmetic appearance, maintenance of elbow flexion and supination strength, maintenance of the biceps muscle length-tension relationship, and decreased cramping when compared to tenotomy. As such, tenodesis is more commonly used than tenotomy. However, the type of tenodesis has been a persistent subject of debate.

The course of the LHBT is unique, and the path taken by the tendon can contribute to pathologic conditions that result in a painful shoulder. The tendon is intra-articular, but transitions to an extrasynovial portion that averages 9 cm in length and 5 to 6 cm in diameter. The tendon originates from the supraglenoid tubercle and the superior labrum, which is known as the biceps anchor. From this starting position, the tendon exits the glenohumeral joint by passing through the rotator interval, under the coracohumeral ligament, and descending into the intertubercular groove. The “bicipital groove” is reported to be variable in its dimensions, with an average depth of 4.3 mm. This variation is reported to be a factor in biceps instability and other pathologic conditions, including tendinopathy of the LHBT. ^, The LHBT is contained between the greater and lesser tuberosities by a sling of tissue composed of fibers from the anterior rotator cuff (supraspinatus and subscapularis), the coracohumeral ligament, and the superior glenohumeral ligament (SGHL). The SGHL, which arises from the supraglenoid and the base of the coracoid, travels within the rotator interval, forming a semicircular sling anteriorly for the lateral part of the intra-articular LHBT before attaching at the lesser tuberosity of the proximal humerus. When adhesions are present, pain localized to the bicipital groove can be a cause of failure for those patients undergoing an arthroscopic proximal biceps tenodesis or tenotomy.

Both arthroscopic and open techniques can be used for tenodesis. Fixation methods include interference screws, suture anchors, metal or bioabsorbable buttons, suture fixation to the conjoint tendon, or suture fixation to the rotator interval. This chapter will focus on arthroscopic biceps tenodesis techniques.