14 Open Suprapectoral Biceps Tenodesis
Abstract
The long head of the biceps tendon (LHBT) is a widely accepted pain generator in the shoulder, both in isolation and concomitantly with other pathologies. Recent paradigm shifts suggest a more intimate and interdependent relationship between the LHBT and the labrum, together making the biceps-labrum complex (BLC). The BLC can be broken down into three clinically relevant zones: inside (the biceps anchor and the superior labrum), junction (intra-articular segment of LHBT and the stabilizing biceps pulley at the articular margin), and bicipital tunnel. There are a number of techniques to address pathology of the BLC, both arthroscopic and open. This chapter presents a technique for open suprapectoral biceps tenodesis that effectively addresses pathologic lesions occurring inside and junction zones and within zones 1 and 2 of the bicipital tunnel. We will briefly discuss the preoperative evaluation of patients with shoulder pain and suspected BLC pathology, followed by the surgical decision-making and technique along with pearls and pitfalls of the procedure. Finally, we will outline a postoperative rehabilitation protocol to optimize outcomes and minimize postoperative complications.
14.1 Introduction
The long head of the biceps tendon (LHBT) is a widely accepted pain generator in the shoulder, both in isolation and concomitantly with other pathology. Historically, the LHBT and the labrum were thought of as two separate entities. However, recent paradigm shifts suggest a more intimate and interdependent relationship between the two structures, more frequently referred to as the biceps-labrum complex (BLC) today. The extra-articular segment of the LHBT is enclosed in a fibro-osseous structure known as the bicipital tunnel, 1 which can serve as a location of possible hidden lesions related to biceps tendonitis and resultant shoulder pain. 2
The BLC can be broken down into three clinically relevant zones: inside, junction, and bicipital tunnel. “Inside” includes the biceps anchor and the superior labrum. “Junction” includes the majority of the intra-articular segment of LHBT and the stabilizing biceps pulley at the articular margin. The “bicipital tunnel” may be broken down further into three specific zones. Zone 1 represents what is traditionally considered the bicipital groove, extending from the articular margin to the distal margin of the subscapularis tendon. Zone 2, deemed “no man’s land” because of its relative invisibility to standard diagnostic arthroscopy above, extends from the distal margin of the subscapularis tendon to the proximal margin of the pectoralis major tendon. Zone 3 consists of the subpectoralis region.
A large portion of the extra-articular LHBT that resides in the bicipital tunnel is not visualized during diagnostic arthroscopy. In their cadaveric study, Taylor et al found that 55% of the LHBT relative to the proximal margin of the pectoralis major insertion was not visualized by standard diagnostic glenohumeral arthroscopy. 2 Further, in the clinical portion of the same study, diagnostic arthroscopy failed to identify extra-articular bicipital tunnel lesions in 47% of chronically symptomatic patients. 2
There are a number of techniques to address pathology of the BLC, both arthroscopic and open. Here, we present a technique for open suprapectoral biceps tenodesis that effectively addresses pathologic lesions occurring inside and junction zones and within zones 1 and 2 of the bicipital tunnel. We will briefly discuss the preoperative evaluation of patients with shoulder pain and suspected BLC pathology, followed by the surgical decision-making and technique along with pearls and pitfalls of the procedure. Finally, we will discuss a postoperative rehabilitation protocol to optimize outcomes and minimize postoperative complications.
14.2 Preoperative Evaluation
A thorough history and physical examination are imperative to arrive at an accurate diagnosis when BLC pathology is suspected, especially given the high prevalence of hidden extra-articular bicipital tunnel disease. Patients with BLC pathology will complain of shoulder pain, which is often dull and aching in nature. While predominately activity related, some may describe night pain especially in the setting of concomitant rotator cuff tear. During repetitive overhead motion such as throwing, patients with BLC pathology may complain of snapping or subluxation of the biceps tendon in and out of the groove, which they can misinterpret as shoulder instability. A careful, directed history and physical examination are important to parse this out; additionally, they will often have point tenderness along the bicipital tunnel.
Taylor et al described the “3-pack” examination: a trio of physical examination maneuvers that can be used to screen for BLC pathology. 3 The 3-pack has a high sensitivity and negative predictive value (NPV) and is therefore a good screening tool for BLC pathology. The first of the three tests is the bicipital tunnel palpation test, where the examiner manually palpates the LHBT along its extra-articular course while the arm is passively internally and externally rotated to localize pain to the LHBT tunnel. Next is the active compression test (O’Brien sign) in which the examiner places a downward-directed force onto the patient’s arm that is held forward flexed at 90 degrees, adducted 10 to 15 degrees, and internally rotated such that the thumb points downward. The examination is then repeated with the palm facing upward. The test is positive when the patient has a reproduction of their clinical pain described as inside the shoulder with the thumb down and the pain is reduced with the palm up. The final test of the 3-pack is the throwing test where the examiner provides isometric resistance to the patient’s arm as it is in the late-cocking position of the throwing motion: shoulder abducted to 90 degrees, elbow flexed at 90 degrees with maximal external rotation. The authors found the O’Brien sign and bicipital tunnel palpation to have sensitivities of 95.7 and 97.8% with NPVs of 92.6 and 96.4%, respectively, for bicipital tunnel disease. 3 Put another way, if these two tests were positive, one must have a high index of suspicion for bicipital tunnel disease. If either one or both of these tests are negative, a surgeon can reliably rule out hidden lesions of the bicipital tunnel.
MRI and ultrasound techniques may be used to aid in the diagnosis of BLC pathology, but should not be relied upon as the sole diagnostic modality. 4
Many different surgical techniques have been described to address refractory BLC symptoms ranging from simple tenotomy to arthroscopic tenodesis, or open tenodesis. Location, fixation, and technique are highly varied in clinical practice. We tend to group tenodesis techniques into those that decompress the bicipital tunnel (subdeltoid transfer to conjoint tendon, open subpectoral biceps tenodesis, and open suprapectoral biceps tenodesis) and those that do not decompress the tunnel (tenotomy, proximal soft tissue, and proximal tendon to bone techniques). Suprapectoral biceps tenodesis is a simple, time-efficient bicipital tunnel decompressing technique that effectively addresses both intra-articular and extra-articular BLC diseases.
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