Disorders of the Biceps Labral Complex: Arthroscopic Sub-Deltoid Tenodesis

Introduction

Tenodesis of the long head of biceps is most commonly used for the surgical management of biceps tendinopathy, but may also be used for lower-demand patients with type 2 or 4 superior labrum anterior-posterior (SLAP) tears, either as an open procedure or arthroscopically. The loss of the intraarticular biceps doesn’t affect the stability of the shoulder in cadaveric models, but seems to remove this portion of the biceps as a pain generator. The procedure is being performed with increasing frequency, and about half are performed arthroscopically. However, the proportion of these surgeries performed arthroscopically is increasing at a faster rate, particularly in the USA. This may be due to the improvement in specific devices that allow a more easily reproducible result. The advantage of an arthroscopic biceps tenodesis is related to the smaller incisions and the ability to address other concomitant pathology.

Procedure

Arthroscopic biceps tenodesis may be performed using standard anterior and posterior portals with the addition of two specific anterior portals, a viewing portal approximately 5 cm from the anterolateral corner of the acromion, and a biceps portal created from out to in using a needle to guide placement. We perform it using a specific interference screw, although several different implants and techniques exist. The decision regarding implant choice is surgeon dependent.

Patient History

• Anterior shoulder pain

• Associated shoulder weakness

• May be associated history of injury or may be insidious onset

Patient Examination

• Tenderness over bicipital groove

• Speed test: The patient’s elbow is extended, forearm supinated, and the humerus elevated to 60 degrees. The examiner resists humeral forward flexion. Pain in the bicipital groove is considered a positive response ( Fig. 48.1 ).

  

• Yerguson Test: The patient’s elbow is flexed and their forearm pronated. The examiner holds their arm at the wrist. The patient actively supinates against resistance. Pain localized to the bicipital groove is considered a positive test result.

• AERS Test: Abduction external rotation supination test. The patient’s arm is positioned in 90 degrees of abduction and external rotation. The patient is asked to supinate against resistance. A positive response is pain over the LHBT ( Fig. 48.2 ).

  

Imaging

Ultrasound scan (USS) may reveal evidence of bicipital tendinosis or increased fluid surrounding the tendon; a guided injection may provide temporary relief providing further localizing evidence of pathology.

Magnetic resonance imaging (MRI) scan may provide evidence of biceps pathology or other related pathology.

Treatment Options: Nonoperative and Operative

• Nonsurgical management–guided injection

• Biceps tenotomy

• Biceps tenodesis (at various sites as per related chapters)

Surgical Anatomy

• Biceps anchor—Check for SLAP lesion

• Biceps tendon—Should be pulled into the joint with a probe to assess pathology in the groove

• Biceps pulley

( Fig. 48.3 )

Surgical Indications

• Bicipital pain

• Positive clinical examination

• Imaging abnormalities as above

• Temporary response to guided injection

Surgical Technique Setup