CHAPTER 27 – Proximal Biceps Tenodesis

Biceps tendinopathy rarely occurs in isolation. Rather, it is usually associated with a spectrum of concomitant shoulder disorders, including subacromial impingement, rotator cuff tears, biceps instability, and SLAP tears. A diligent work-up is essential for correct identification and treatment of these associated pathologic entities.

The role of the long head of the biceps tendon has been heavily debated in the literature. Electromyography literature and biomechanical cadaver studies provide evidence of a role as a secondary humeral head depressor ^{[7] [18]}; this function appears more pronounced in the unstable shoulder.^[1] Others, however, argue that the long head of the biceps tendon is a vestigial structure.

Although there is no clear consensus on the surgical treatment of symptomatic, refractory, isolated biceps tendinopathy, it is generally agreed that débridement is indicated for partial tears affecting 30% to 50% of the tendon substance. ^{[1] [3] [19]} Advocates of tenotomy base their approach on the benign natural history and good functional outcomes of traumatic biceps ruptures. However, complications such as cosmetic (“Popeye”) deformity due to distal retraction of the muscle belly, supination weakness, and muscle spasm have led to the development of numerous tenodesis techniques.^[5] Recent series have reported a 70% incidence of Popeye deformity and 38% incidence of elbow flexion fatigue with tenotomy alone.^[13]

Arthroscopic biceps tenodesis techniques are plentiful in the literature (
Table 27-1

). Described techniques include proximal fixation with interference screws, suture anchors, and suturing to the conjoined tendon, rotator cuff, and even transverse humeral ligament. Interference screw tenodesis demonstrated failure loads before tendon migration that were three times higher than after tenotomy alone in a cadaver model.^[21] Failure of proximal stabilization has been attributed to the retention of diseased, inflamed, pain-generating tendon and synovium within the fixed confines of the intertubercular groove.^[15] Securing the biceps tendon distal to the intertubercular groove with a subpectoral tenodesis approach removes the diseased tendon entirely and restores the proper biceps length-tension relationship to ensure optimal bicipital function. Biceps tenodesis is therefore recommended over biceps tenotomy for three reasons:

	1.	maintenance of the length-tension relationship of the biceps muscle by establishment of a new origin of biceps attachment at the appropriate length to prevent muscle atrophy;
	2.	maintenance of elbow flexion and supination strength for maximum elbow function; and
	3.	better cosmetic appearance.

Multiple biomechanical cadaver and animal studies have shown increased load to failure with biotenodesis techniques over suture anchor, keyhole, and tunnel techniques.^[14] Our preferred surgical technique for the treatment of isolated biceps tendinopathy is an open subpectoral tenodesis with a biotenodesis screw, ^{[10] [11] [17]} which is discussed in this chapter.

Author		Study	Results
Richards and Burkhart[16] (2005)	Biomechanical cadaver study	7-mm biotenodesis screw vs. 2	7-mm biointerference screw: 233.5 ± 55.5 N
	Load to failure	Mitek GII anchors	2 Mitek G2 anchors: 135.5 ± 37.8 N
Wolf et al[21] (2005)	Biomechanical cadaver study	Tenodesis vs. tenotomy	Tenotomy: 110.7 N
	Load to failure		Tenodesis: 310.8 N
Ozalay et al[14] (2005)	Biomechanical cadaver study	Tunnel vs. interference screw vs. suture anchor vs. keyhole	Tunnel: 229 ± 44.1 N
			Interference screw: 243.3 ± 72.4 N
	Load to failure		Suture anchor: 129.0 ± 16.6 N
			Keyhole: 101.4 ± 27.9 N
Jayamoorthy et al[5] (2004)	Biomechanical sheep study	Keyhole vs. biointerference screw vs. metal interference screw	Keyhole: 303 N
	Load to failure		8-mm biointerference screw: 234 N
			Metal interference screw: 201 N
Mazzocca et al[9] (2005)	Biomechanical cadaver study	Subpectoral bone tunnel (SBT) vs. arthroscopic suture anchor (SA) vs. subpectoral interference screw (SIS) vs. arthroscopic interference screw (AIS)	Cyclic gap formation:
	Load to failure and cyclic gap formation		SBT: 9.39 ± 2.82 mm
			AIS: 5.26 ± 2.60 mm
			SIS: 1.53 ± 0.60 mm
			SA: 3.87 ± 2.11 mm
			No differences in load to failure
Osbahr et al[13] (2002)	Retrospective review	Tenodesis vs. tenotomy	No difference in cosmesis, pain, or spasm
Gill et al[4] (2001)	Case series	30 biceps tenotomy, 19 months of followup	90% return to sports
			96.7% return to work
			13.3% complication rate (Popeye sign)
Boileau et al[2] (2002)	Case series	Biceps tenodesis with interference screw fixation (8 or 9 mm)	90% strength of normal side
			No elbow motion loss
			2 initial failures (7-mm screw)
Nord et al[12] (2005)	Case series	Tenodesis with anchor through subclavian port	11 patients, 2-year followup: 90% good–excellent results
Kelly et al[6] (2005)	Case series	Tenotomy	68% good, very good, or excellent result
			70% Popeye sign
			38% fatigue with resisted elbow flexion

Preoperative Considerations

History

A typical history includes the following:

	•	Anterior shoulder pain radiating to biceps muscle
	•	Pain that awakens the patient from sleep
	•	Pain with forward shoulder elevation and forearm supination. Anteromedial pain is indicative of acromioclavicular joint disease.
	•	Association with other shoulder disease, typically rotator cuff tear

Physical Examination

	•	Pain in intertubercular groove that moves laterally with external rotation
	•	No pain with cross-arm adduction or acromioclavicular joint palpation
	•	Positive result of O’Brien, Speed, and Yergason tests
	•	Positive result of subpectoral biceps tenderness test[5]: pain with palpation of the biceps tendon under the inferior border of the pectoralis major tendon. With the arm in neutral rotation, resisted internal rotation tensions the pectoralis major tendon. The biceps tendon can be palpated just distal to the inferior border of the pectoralis major, pressing laterally. Specificity of the subpectoral biceps tenderness test can be improved if a glenohumeral lidocaine injection provides symptomatic relief.

Imaging

	•	Anteroposterior, scapular oblique, and axillary views
	•	Magnetic resonance arthrography, if indicated
	•	Ultrasonography, if available

Indications and Contraindications

The decision to treat biceps disease surgically is predicated on a clinical presentation of bicipital groove pain, provocative test results, response to injection, and failed nonoperative management. Findings on arthroscopic examination may include biceps tendinosis occurring with or without concurrent rotator cuff disease, biceps tendinosis in association with superior labral anterior-posterior (SLAP) lesions, and tendinosis secondary to instability of the biceps tendon. Instability of the biceps tendon can occur with disruption of the lateral aspect of the superior glenohumeral ligament and coracohumeral ligament, as observed in association with anterior supraspinatus tendon tears, or with disruption of the medial aspect of the coracohumeral ligament, often seen with a subscapularis tear. Instability of the biceps tendon is generally treated with a biceps tenodesis because reconstruction of the coracohumeral ligament attachment on the humerus has generally not been satisfactory.

Absolute contraindications to biceps tenodesis include any medical condition that precludes the safe administration of anesthesia or renders the patient unstable for operative intervention.

Surgical Technique

Anesthesia and Positioning

The senior author prefers beach chair positioning with interscalene block plus general anesthesia; the regional block alone is insufficient to anesthetize the axillary incision adequately. A complete examination under anesthesia is performed on both upper extremities to examine for concurrent pathologic processes of the shoulder or elbow.

Surgical Landmarks, Incisions, and Portals

Landmarks

	•	Coracoid
	•	Acromion
	•	Clavicle
	•	Pectoralis major tendon

Portals and Approaches

	•	Posterior portal
	•	Anterior portal
	•	Axillary fold incision at inferior border of pectoralis major tendon

Structures at Risk

•

Axillary fold incision at inferior border of pectoralis major tendon: cephalic vein, musculocutaneous nerve (overzealous retraction), pectoralis major insertion (retraction)

Examination Under Anesthesia and Diagnostic Arthroscopy

Examination under anesthesia is performed to ensure full range of motion and glenohumeral stability.

Diagnostic arthroscopy evaluates the intraarticular biceps tendon, rotator cuff, glenoid labrum, glenohumeral ligaments, and chondral surface.

Specific Steps (
Box 27-1

)

1. Arthroscopic Preparation

Glenohumeral arthroscopy is begun with a standard posterior viewing portal (
Fig. 27-1

). A dry inspection of the intraarticular biceps tendon is performed initially because the pump pressure will result in vascular compression, causing the tenosynovitis to be “washed out.” Injection or tendon fraying is indicative of bicipital disease. It is unknown how much biceps fraying can be accepted without the need for intervention, but some authors have proposed up to 30% to 50%. Additional inspection of the more distal tendon portions is accomplished by pulling the biceps tendon into the glenohumeral joint with a probe.

Box 27-1 

Surgical Steps

1.    Arthroscopic preparation    2.    Biceps tenotomy    3.    Exposure    4.    Tendon preparation    5.    Tunnel preparation    6.    Tenodesis    7.    Closure

2. Biceps Tenotomy

A basket forceps is inserted through the anterior cannulated portal to transect the biceps tendon at the superior labral junction (
Fig. 27-2

). Care is taken to avoid inadvertent damage to the superior glenoid labrum.

3. Exposure

With the arm slightly abducted and externally rotated, the inferior border of the pectoralis major tendon is palpated. A 3- to 4-cm incision is performed in line with the axillary fold, with one quarter of the incision above and three quarters of the incision below the inferior border of the pectoralis major tendon. A No. 15 blade scalpel is used to incise the subcuticular tissues. After hemostasis has been achieved with the electrocautery, Gelpi or Weitlaner self-retaining retractors are inserted to improve exposure. The overlying fatty tissue is cleared until the fascia overlying the pectoralis major, coracobrachialis, and biceps is identified (
Fig. 27-3

). Once the inferior border of the pectoralis major has been identified, the fascia overlying the coracobrachialis and biceps is incised in line with the incision. If these anatomic landmarks are not easily identified, the dissection is probably too lateral, especially if the cephalic vein is seen in the deltopectoral groove, in which case the dissection is also too proximal.

Blunt dissection with Mayo scissors and finger dissection sweep posterior to the pectoralis major tendon. The biceps tendon can be palpated in the intertubercular groove behind the pectoralis major tendon. A pointed curved Hohman retractor is placed on the lateral humeral cortex to retract the pectoralis tendon insertion superior and lateral. A blunt Chandler retractor is positioned on the medial cortex to retract the coracobrachialis and short head of the biceps. Vigorous medial retraction should be avoided to prevent injury to the musculocutaneous nerve. The long head of the biceps musculotendinous junction should be visualized. A right-angled clamp is then used to bluntly open the biceps sheath and deliver the tendon into the wound (
Fig. 27-4

).

4. Tendon Preparation

A No. 2 FiberWire (Arthrex, Inc., Naples, Fla) is used to sew a modified Krakow stitch starting 2.5 cm proximal to the musculotendinous junction (
Fig. 27-5

). The remaining tendon is removed sharply with a No. 15 blade scalpel. The two ends of FiberWire exiting the biceps tendon are tied together with a square knot.

5. Tunnel Preparation

The periosteum 1 cm proximal to the pectoralis major tendon is reflected sharply off the humerus, forming a rectangle measuring approximately 2 × 1 cm (
Fig. 27-6

). A 2.4-mm threaded guide pin is drilled up to but not penetrating the far cortex. The starting point is just proximal to the inferior edge of the pectoralis major tendon and situated in the intertubercular groove, centered in the medial to lateral direction on the humerus (
Fig. 27-7A

). Subsequently, an 8-mm reamer is used to overream the guide pin without violating the posterior cortex. The reamer is then carefully backed out by hand to avoid tunnel widening on exiting (
Fig. 27-7B

). A headlight may be used to assist with illumination. An Arthrex 8- × 12-mm biotenodesis screw is loaded on the tip of the cannulated tenodesis screwdriver. A nitinol loop retrieves a strand of FiberWire through the cannulated screwdriver. The retrieved FiberWire tensions the biceps tendon to the screwdriver tip, and a needle driver secures the FiberWire tightly against the handle of the screwdriver.

6. Tenodesis

The biceps tendon is pushed into the humeral tunnel and secured in place by the advancing biotenodesis screw until the screw head is countersunk. The tunnel may be tapped before screw insertion if dense cortical bone is encountered. After screw insertion, the biceps tendon should be draped over and covering the tenodesis screw. A right-angled clamp can be used to elevate the biceps tendon to ensure complete seating of the screw.

7. Closure

After copious irrigation, 3-0 Monocryl buried sutures close the deep subcutaneous tissue. Steri-Strips are applied to the skin. The wound is injected with 5 mL of 0.25% bupivacaine (Marcaine).

Postoperative Considerations

Follow-up

Sutures are removed on the seventh postoperative day. The three-view radiographic examination is repeated to assess tunnel placement.

Rehabilitation

Postoperative management is dictated by concomitant procedures.

Isolated Biceps Tenodesis

	•	Progression from passive to active-assisted to full range of motion
	•	Strengthen at 12 weeks
	•	Full activity at 4 to 6 months
	•	If the intraoperative construct is resilient: return to work in 2 weeks
	•	Early full range of motion
	•	Functional rehabilitation

Rotator Cuff Repair

	•	Passive range of motion first 6 weeks, then progression from active-assisted to active range of motion
	•	Immediate elbow range of motion and grip strengthening

Acromioplasty

	•	Passive range of motion with rapid progression to active-assisted and active range of motion
	•	Immediate elbow range of motion and grip strengthening
	•	Follow isolated biceps tenodesis protocol

Complications

	•	Infection
	•	Spitting of subcutaneous sutures due to the very thin skin
	•	Construct failure
	•	Persistent pain
	•	Musculocutaneous or axillary nerve injury
	•	Humerus fracture
	•	Potential reaction to biodegradable screw
	•	Hematoma or seroma
	•	Functional tenotomy

PEARLS AND PITFALLS

•    Make the incision more inferior, if desired, for dissection closer to the axilla. The fat stripe marks the inferior pectoralis border. The biceps tendon is under the pectoralis tendon.    •    Place a curved Hohman retractor inferior to the pectoralis tendon and around the lateral cortex to retract the pectoralis superolaterally.    •    Inadvertent placement of the Hohman retractor in the intertubercular groove may sweep the biceps medially and out of view. Remove and reposition the retractor if the biceps tendon is not visible.    •    Place retractors before locating the tendon.    •    Be careful not to plunge medially with the Chandler retractor—the brachial artery is at risk.    •    Feel the intertubercular groove and the medial and lateral cortex to ensure centered guide pin placement.    •    Ream 8-mm hole through near cortex only.    •    For thick cortical bone, a tap is available for near cortex.    •    Begin the modified Krakow stitch and transect the biceps tendon 2.5 cm from the musculotendinous junction. (Measurement from unpublished anatomic studies; the natural biceps contour dips down under the pectoralis. The biceps muscle peak is three or four fingerbreadths from the inferior edge of the pectoralis.)    •    It is better to err too short rather than too long. It is difficult to overtighten the construct.    •    Tie the ends of the modified Krakow stitch together before loading the tenodesis driver.    •    The 8- × 12-mm biotenodesis screw is built for cortical fixation. The small taper makes it difficult to start.    •    Ream to far cortex but do not ream on the way out, which widens the tunnel. Unchuck reamer at far cortex and reverse reamer out by hand.    •    During screw insertion, the biceps tendon rotates around the screw. This is to be expected. The tendon drapes the screw when it is seated.    •    The pectoralis major covers the biceps when the Hohman retractor is removed.    •    Coagulate superficial bleeding vessels.

Results

Our experience includes 20 patients with more than 2 years of followup. The preoperative to postoperative scores averaged the following increases: Rowe score, 57 to 91; American Shoulder and Elbow Surgeons score, 42 to 86; Simple Shoulder Test score, 5 of 12 to 10 of 12; Constant-Murley score, 45 of 75 to 67 of 75.