16 Arthroscopic Biceps Transfer

10.1055/b-0039-167665

16 Arthroscopic Biceps Transfer

Helen S. Zitkovsky, Samuel A. Taylor, and Stephen J. O’Brien

Abstract

Biceps labral complex (BLC) disease is common and can exist as isolated pathologies or concomitantly with other shoulder pathologies. Physical examination is critical to selecting the most appropriate intervention. Biceps tendon transfer to the conjoint tendon is a safe and reproducible technique that is performed arthroscopically and addresses both intra- and extra-articular BLC disease without the need for bony anchors.

Arthroscopic subdeltoid biceps transfer is a soft-tissue biceps tenodesis procedure popularized by the senior author (S. J. O.) to address some of the inadequacies of both biceps tenotomy and various bony bicep tenodesis for refractory biceps tendinitis, both in isolation and in association with biceps-labral complex disorders.

Kelly et al ¹ showed that although biceps tenotomy was very successful in patients older than 60 years, the cramping and cosmetic deformity noted in younger, more active patients was problematic.

Many papers have chronicled problems with biceps tenodesis, with anywhere from 10 to 20% of patients having daily pain, both with activity and rest. ² ^, ³ In addition, we have seen some severe cases of reflex sympathetic dystrophy that have also occurred secondary to the chronic pain from proximal biceps tenodesis (Stephen J. O’Brien, personal communication).

Open subpectoral biceps tenodesis has had issues with neurovascular injuries, infection, and bony fractures. ⁴ ^– ⁷ In addition, any tenodesis to a bone construct will heal with significant scar at the bony tenodesis site. ⁸

With the biceps transfer technique, the long head of the biceps tendon (LHBT) is released in the glenohumeral joint, and then transferred arthroscopically in the subdeltoid space to the conjoint tendon (NOT the coracoid process). The senior author has completed approximately 1,000 biceps transfers to date. The short- and medium-term outcomes have been published. ⁹ ^, ¹⁰

There has been only one intraoperative complication, an important case to learn from, involving damage to both a branch of the axillary artery (the anterior humeral circumflex) and the median nerve, in a patient having had three prior shoulder surgeries (one complicated by a pulmonary embolus) with encasing scar surrounding anomalous anatomy of the brachial plexus and conjoint tendon not previously described (now seen twice since). This will be discussed, with the lessons learned. Although figures are provided here along with a highlight video, the entire procedure, unedited and edited, can be viewed on VuMedi.

16.1 Surgical Technique

16.1.1 Setup and Anesthesia Technique

The patient is placed in the beach-chair position ( Fig. 16.1a), and after appropriate sedation, an interscalene block is administered to the patient with local anesthetic and steroids to help give a long-lasting block. A laryngeal mask airway is also placed by the anesthesiologist to protect the patient’s airway and to allow for deepening of the anesthesia plane when going outside the block in the subdeltoid space. If this deepening does not occur, the pressure of the fluid in the subdeltoid space can stimulate the patient. This may result in increased blood pressure and subsequent bleeding, or movement of the patient as this may lighten the anesthetic plane. The blood pressure is monitored to keep the systolic blood pressure less than 110 mm Hg to control bleeding in the subdeltoid space. Although a fluid pump can be employed, the senior author prefers gravity flow ( Fig. 16.1b).

**Fig. 16.1 (a)** Patient in the beach-chair position with a laryngeal mask airway. **(b)** Gravity flow setup.

This procedure can also be done in the lateral decubitus position for physicians who prefer this for their arthroscopic shoulder procedures.

16.1.2 Examination under Anesthesia, Arthroscopic Evaluation, and Exposure in the Subdeltoid Space

Before being placed in an arm holder, the involved shoulder is evaluated for range of motion, stability, and ease of glide.
The arthroscope is introduced posteriorly to evaluate the anterior glenohumeral joint ( Fig. 16.2a, b).
Then a second rotator interval portal is placed anterosuperiorly, and the arthroscope is placed through this portal to evaluate the posterior half of the glenohumeral joint ( Fig. 16.2c). Any abnormal anatomical features are highlighted through digital pictures.
Of note, with regard to the biceps labrum complex, we have recently described “biceps chondromalacia,” which occurs from chronic abrasion of the LHBT on the humeral head ⁷ ( Fig. 16.2c):
- Referencing just the biceps labrum complex for now, the course and integrity of the biceps tendon is evaluated. Care is taken to make sure that the biceps is not subluxed or dislocated in the groove.
The subscapularis is evaluated to make sure that it is intact. Additionally, partial tears may be seen of the LHBT. Any biceps chondromalacia is evaluated by both degree and position. Medial biceps chondromalacia would imply that the patient may be an incarcerator, where the patient’s pathology may include the LHBT “incarcerating” between the humeral head and glenoid ( Fig. 16.3 ). The senior author (S. J. O.) has described an “arthroscopic active compression test” in which bicipital incarceration can be demonstrated (Video 16.1). This should be performed on all patients undergoing arthroscopy with any consideration of a biceps labrum complex pain.
Additional arthroscopic investigation should include the “biceps pull test,” as described by Taylor et al ¹¹ to look for damage or other abnormalities of the LHBT in the proximal one-half of the bicipital tunnel by using a nerve hook to pull the LHBT into the joint ( Fig. 16.4 ).
The labrum is then evaluated for tearing. A preoperative MRI also may be helpful to identify, and then arthroscopically treat, a labral cyst if present in association with a labral tear. Every effort is made to preserve the labrum even though the biceps will be released and transferred to the conjoint tendon in the subdeltoid space.
Care is taken to release any vincula associated with the LHBT ( Fig. 16.5 ).
The arthroscope is then removed from the glenohumeral joint and the patient is repositioned with regard to the arm and arm holder for subdeltoid arthroscopy. The arm is placed in a 90/90 positioning ( Fig. 16.6 ). This allows for the humeral head to fall back in the glenohumeral joint so as not to partially obstruct the subdeltoid space.
The subacromial space is then entered and enough subacromial bursa is removed anteriorly to identify the coracohumeral ligament ( Fig. 16.7a, b).
The coracohumeral ligament is then tracked to the coracoid process ( Fig. 16.7c). This is a very important step, that is, to identify the bony coracoid, to ensure that you are in the right plane, and will be able to properly identify the conjoined tendon and not confuse it with an anomalous axillary artery or brachial plexus, which we have seen 3 times in the 1,000 cases. This will be discussed later.
After establishing a superolateral viewing portal and pectoralis working portal in the subdeltoid space, a very important clockwise approach is employed to gain exposure to the subdeltoid space ( Fig. 16.8, Video 16.2).
From the coracoid process, the soft tissue above the conjoined tendon is released down to the pectoralis major. Then the bursa is released laterally over to the lateral aspect of the proximal humerus above the pectoralis major insertion. This allows for a very nice space to work in. We call it “a room with a view” ( Fig. 16.9 ). It is probably the biggest take-home message here, as it allows for very clear and safe viewing and working outside the glenohumeral joint.