Biceps Tenodesis: Arthroscopic Intramedullary Docking (Screw Versus Button)

INTRODUCTION

Accurate diagnosis and treatment of anterior shoulder pain is critical in managing the painful shoulder. Patient history, physical examination, selective injection, and diagnostic imaging all aid in diagnosing pain originating from the long head biceps tendon (LHBT) complex. Although isolated LHBT pathology is common in overhead throwing and contact athletes, concomitant biceps pathology is often associated with rotator cuff tears. Persistent proximal biceps pain despite conservative treatment may be an indication for surgery.

Numerous surgical techniques have been described for the LHBT including tenotomy, arthroscopic intra-articular tenodesis, arthroscopic extra-articular tenodesis, and open subpectoral tenodesis. All these techniques are effective. This chapter reviews arthroscopic suprapectoral tenodesis with screw and unicortical button fixation. The critical feature of LHBT tenodesis is the avoidance of cosmetic deformity.

INDICATIONS

The decision to perform biceps tenodesis is usually made preoperatively. The unexpected finding of a structurally abnormal biceps tendon, SLAP tear extending into the biceps tendon, hourglass biceps, or a subluxed biceps are intraoperative factors that influence the decision to perform tenodesis. Hourglass biceps, also seen with rotator cuff tears, involves the intra-articular portion of the tendon becoming hypertrophic and incarcerated in the joint, which does not allow easy gliding in the bicipital groove and can cause entrapment of the tendon during forward elevation.¹

Biceps tenodesis is indicated for a variety of pathology relating to the LHBT complex (Figure 26-1). Superior labrum tears (SLAP) may be treated with direct repair in young overhead athletes. However, SLAP tears after age 30, in revision settings, and in the occasional competitive overhead athlete may be treated with tenodesis. Treatment of SLAP tears in overhead athletes is perpetually evolving, which is beyond the scope of this chapter. Intra-articular fraying and tearing of the biceps involving more than 25% of the tendon and concomitant subscapularis tears are additional indications for tenodesis. Finally, persistent pain over the bicipital groove despite normal tendon morphology is an indication, as it can be difficult to fully evaluate the entire biceps tendon arthroscopically.²^,³

FIGURE 26-1 Examples of LHBT pathology seen during arthroscopy.

PREOPERATIVE PREPARATION

Distinguishing LHBT tendinopathy from acromioclavicular joint pain, capsulitis, and subscapularis tears is critical in the evaluation of anterior shoulder pain. LHBT pain can be present at rest and often radiate down the anterior arm.⁴ Bicipital groove tenderness to palpation is reproducible and a very common finding in patients with LHBT pathology. A complete physical examination of the LHBT should include special testing with Speed, Yergason, and O’Brien maneuvers.⁵ Through inspection of the humerus, LHBT rupture may sometimes produce the classic “Popeye” sign, characterized by retraction of the tendon with bulging of the muscle belly distally.⁶

Imaging is sometimes useful in the evaluation of the LHBT. A complete X-ray series is often considered normal but may help identify other pathology.⁷ MRI/MRA allows for better characterization of the soft-tissues and LHBT.⁸ Ultrasound, although user-dependent, can be better utilized for identifying LHBT instability as compared to LHBT tears.⁹ Diagnostic injections are used selectively into the bicipital sheath to treat LHBT pathology, while arthroscopy is the most definitive diagnostic tool available.¹⁰

TECHNIQUE

There are several arthroscopic biceps tenodesis techniques described in the literature utilizing all-suture suture anchors, interference screws, and cortical buttons.¹¹^, ¹²^, ¹³ ^and ¹⁴ Soft-tissue LHBT tenodesis has also been performed. For example, LHBT tenodesis can be performed in the rotator interval, but this has been associated with scarring and tendon instability.¹⁵ Others have described an arthroscopic technique with LHBT attachment to the conjoint tendon, which allows for shared LHBT load with the short head and promotes soft-tissue healing with good results.¹²^,¹⁶ Some recommend LHBT tenodesis to either the supraspinatus or subscapularis,¹⁷ whereas others describe an all-arthroscopic subpectoral tenodesis to the pectoralis major tendon.¹⁸ In the absence of rotator cuff tears, however, there is no difference in outcomes for arthroscopic suprapectoral versus subpectoral locations of
LHBT tenodesis.¹⁹ Others argue arthroscopic LHBT tenodesis should be located in the bicipital groove, as other nonanatomical positions have been shown to cause persistent pain and overall shoulder dysfunction.²⁰

Author’s Preferred Techniques

The patient is placed in the beach chair position. A standard diagnostic shoulder arthroscopy is performed with evaluation of the labrum, rotator cuff, and glenohumeral space. The LHBT and the LHBT anchor as it attaches to the superior labrum can be visualized and probed. A shaver is used for debridement of any labral or chondral injuries. We describe two intramedullary docking techniques for arthroscopic LHBT tenodesis using either a tenodesis screw or a unicortical button.

Tenodesis Screw (