Operative times and perioperative morbidity data is shown in Table 23.2. It can be seen that proximal tenodesis involved significantly less operative time, both for the tenodesis procedure alone and also for the entire operative procedure. Perioperative morbidity was not statistically different despite the additional surgical approach and violating the proximal humeral bone with distal tenodesis in regard to PAR narcotic consumption and total PAR times. This was true for both the combined proximal tenodesis and when comparing the isolated tenodesis to the isolated distal tenodesis.

Final outcomes are shown in Table 23.3. There were no complications in the arthroscopic group. Only two patients complained of minimal deformity. In the subpectoral group, there were no failures of fixation with screw and washer technique. No neurologic injuries occurred. There was one superficial infection, which was successfully managed with oral antibiotics. Operative times both for the actual tenodesis and the overall procedure were significantly less for arthroscopic tenodesis. Perioperative morbidity was the same for both procedures at all times evaluated. No increase in stiffness was noted at any time with proximal tenodesis.

Cost was significantly different between the two treatments. Assuming a facility charge of $650/15 min, this would be a mean cost increase of over $600 per case. Proximal tenodesis implant costs are negligible, as it would be either a suture and spinal needle or a suture of an anchor already used for the rotator cuff repair. While the subpectoral technique described here is the original technique described using a screw and ligament washer [43] with minimal implant charges, the more widely used interference screw technique would result in significant additional charges. Cost of a biocomposite (30% biphasic calcium phosphate and 70% PLDLA) screw was 299.25 marked up to 1147.37 and a biotenodesis screw (PLLA) 271.75 marked up to 947.62. While cost is always difficult to assess, this calculation would mean an increased cost of 1647.37, billed to the patient in a hospital setting and absorbed by the surgery center in an outpatient setting.

The controversy of proximal versus distal biceps tenodesis has been an issue since originally reviewed by Sanders et al. [35]. They first raised concerns about reoperation rates for proximal biceps tenodesis. Careful review of this paper however showed that revision surgery rarely resulted in a satisfactory outcome. Gregory et al. [16] represent the only publication on revision biceps tenodesis. While improvement was noted, 5/21 had unsatisfactory results, and lack of data prevented analysis of the technique of the proximal tenodesis failures. Werner et al. [45] represent the only other level four study comparing proximal and distal tenodesis, which also showed increased stiffness between the two techniques using an arthroscopic interference screw. Follow-up was as little as 4.5 months. While stiffness was increased short term, there was no long-term difference in outcomes. While their and this paper represent level three data only, the combination of a relative absence of any comparative data suggesting superior outcomes with distal biceps tenodesis and the numerous level four case series with excellent results (5,712,18) with proximal tenodesis suggests that the cost of distal tenodesis, especially with interference screw fixation, may be unnecessary. Gombera et al. [15] recently presented their results with arthroscopic versus open tenodesis. Both techniques were distal, however, and one serious neurologic injury occurred in the open subpectoral group. They concluded that open tenodesis might have an increased risk of complications. Although numerous concerns have been raised about “hidden lesions” of the biceps [14, 15, 21, 27, 45] creating symptoms post proximal tenodesis, their clinical relevance remains unclear absent studies that show increased complications with proximal tenodesis that are corrected with subsequent distal tenodesis.

Complications with open subpectoral tenodesis were rare in our series [44, 46], consistent with other series of experienced surgeons performing this technique [4, 23–25, 28, 34]. Problems do occur with open subpectoral tenodesis, however. Neurologic injury is not unheard of, as what occurred in the series of Gombera [15] and also reported in four cases by Rhee [33]. Dickens [8] showed that numerous structures were “at risk” with this approach. Iatrogenic fractures continue to be reported. While not reported in our series [46] or Ngo’s [28], they continue to occur [37], and the Rush team reports a biomechanical study showing a 30% decrease in strength with placement of an 8 mm drill hole [26]. This would be further compounded by the expected bone resorption that would occur around a PLLA implant with time. Koch et al. [20] reported a disturbing rate of failure of interference screw fixation, the reason of which was unclear. They did point out that in vitro mechanical strength superiority could be offset by biologic factors that cause the tenodesis to fail. None of these complications are reported with arthroscopic tenodesis.

It is important to understand that failed shoulder surgery exists with and without proximal tenodesis. The patient with a poor result can be a frustration to the surgeon looking for a solution. The data suggesting that these patients will benefit from revision to distal tenodesis is minimal despite the attractive basic science and clinical speculation about retention of the biceps within the groove [14, 21, 22, 27, 32, 35], and revision surgery to subpectoral tenodesis on this basis should be offered with caution at this time. While widely quoted, Sanders et al.’s study showed that few of the patients revised to distal tenodesis were actually improved [35].