Biceps Tenodesis: Open Subpectoral Technique

Allen A. Yazdi

Alexander C. Weissman

Jared M. Rubin

Sarah A. Muth

Ron Gilat

Christopher M. Brusalis

Brian J. Cole

INDICATIONS

The long head of the biceps tendon (LHBT) is among the most common anatomic sites of shoulder pain and dysfunction.¹ Pathology of the biceps tendon typically originates from inflammation of the surrounding tendon sheath, instability, and/or tearing of the tendon. LHBT disorders are commonly associated with other shoulder pathologies, such as rotator cuff tears, in up to 90% of cases.² The most common pathologies requiring biceps tenodesis (BT) are LHB tearing, LHB instability, and tenosynovitis.³^,⁴ The LHBT is confluent with the superior labrum of the glenoid, and therefore pathologies of the biceps-labral complex, including superior labrum anterior and posterior (SLAP) injuries, may also be treated with BT.⁵ Traditionally, BT has been performed for SLAP tears in older patients and nonoverhead throwers. Recent studies have suggested BT in younger throwers can lead to successful return to sport rates with excellent functional outcomes.⁶^, ⁷ ^and ⁸ Although SLAP repairs can provide clinical improvement for patients with certain superior labral tear patterns, they sometimes fail and require BT during revision surgery. Thus, studies have shown that primary BT may be the favored procedure in some patients with concomitant SLAP tears, as patients experience lower reoperation rates, superior functional outcomes, and excellent rates of overall satisfaction.⁹^, ¹⁰ ^and ¹¹

BT is routinely reserved for patients whose symptoms do not abate with nonoperative treatment, which consists of deliberate activity modification, oral nonsteroidal anti-inflammatory drugs (NSAIDs), physical therapy, and ultrasound-guided corticosteroid injection (CSI) into the biceps tendon sheath.¹² If pain continues to persist, patients can be treated with surgery. In our clinical experience, patients whose symptoms improve with a CSI whose symptoms subsequently return have a particularly optimistic prognosis with BT.

Biceps tenotomy and BT show comparable clinical outcomes for pain relief and restoration of functional movements. However, patients undergoing biceps tenotomy have a higher risk of cosmetic Popeye deformity, and may report subsequent cramping and weakness.¹³^, ¹⁴^, ¹⁵^, ¹⁶ ^and ¹⁷ Tenotomy is a viable option, particularly in older patients and those with a larger body habitus where a cosmetic deformity due to a tenotomized biceps is less apparent. BT prevents this cosmetic deformity and reduces cramping pain with repetitive supination.¹⁸^,¹⁹

BT can be performed via various techniques. Although arthroscopic techniques are used commonly, many consider an open subpectoral technique to definitively move the tendon distal to the bicipital groove, and avoid the potential for persistent pain due to the location of the BT. Persistent pain with proximal fixation may be associated with anterior branches of the axillary nerve that innervate the lateral border of the LHBT proximally near the traverse humeral ligament.²⁰ Additionally, lower rates of revision have been seen with distal fixation versus proximal open or arthroscopic approaches.²¹^,²² An open subpectoral approach, as preferred by the senior author decreases the risk of persistent pain, recurrence, and revision that may be seen with proximal fixation.²³ This technique is simple, reproducible, cost-effective, and can eradicate the pathology of the biceps tendon along its entire course while providing a consistent length-tension relation.²⁴

PREOPERATIVE PREPARATION

Clinical assessment of patients with suspected LHBT pathology involves obtaining a detailed history and performing a thorough physical examination, along with relevant diagnostics to assess the patient’s shoulder condition accurately. Distinct pathologies involving the LHBT include tendonitis, partial or complete tearing, subluxation, dislocation, subscapularis tendon tears, and other associated pathologies such as rotator cuff tears and osteoarthritis of the glenohumeral joint. Moreover, there are several other pain generators around the shoulder (mainly the rotator cuff tendons) that can mask or mimic pain originating from the biceps.

History

The first step in the preoperative preparation is taking a comprehensive history of the patient’s shoulder complaints. This involves gathering information about the onset, duration, and progression of the symptoms, as well as inquiring about any specific incidents or activities that might have triggered the shoulder pain or dysfunction. Additionally, it is essential to explore the patient’s medical history, previous injuries, and any treatments they have already undergone. It is critical to record and evaluate any prior treatment such as physiotherapy, injections, and/or surgical interventions, and assess the patient’s response to each. Related to prior injections, it is critical to understand whether the corticosteroid was injected into the biceps tendon sheath, glenohumeral joint, and/or to the subacromial bursa.

The primary goal of this history-taking process is to determine the root cause of shoulder complaints and identify potential underlying issues, as well as other common concurrent pain generators. Understanding the patient’s functional limitations, level of activity, and specific desired activities that exacerbate the symptoms is crucial for tailoring the treatment plan effectively.

Physical Examination

The physical examination plays a vital role in evaluating the patient’s shoulder condition comprehensively. A proper examination involves exposing the shoulders and arms to inspect both sides (eg, for a Popeye deformity) and compare their findings. During this examination, various aspects of shoulder function are evaluated, including active and passive range of motion (ROM), strength, stability, provocative tests, and a neurovascular exam. Specific classic provocative for the biceps tendon include the Speed test and Yergason test. Our preferred tests for identifying pathology localized to the biceps-superior labral complex include the internal rotation compression test and the uppercut test. Tenderness to palpation over the bicipital groove is of great importance and should typically be performed last.²⁵ One should also attempt to assess biceps instability that can involve a more medial pain, a clunk felt when trying to translate the tendon, and a typical involvement of the subscapularis muscle. It is important to remember that, in general, the physical examination tests for biceps pathology are sensitive but have a relatively low specificity and therefore a complete exam to detect and rule out various other shoulder pathologies is always indicated. Finally, assessment for pathology commonly associated with biceps tendon pain such as subscapularis tendon tears should also be performed.

Diagnostics

Diagnostic testing is a critical component of preoperative preparation for open subpectoral BT. Ultrasonography is very useful in the clinic setting and may provide a quick and easy dynamic exam of the long head of the biceps tendon as well as adjacent structures. Moreover, the use of an ultrasound-guided lidocaine and corticosteroid injection into the biceps tendon sheath can assist in the diagnosis and potentially provide symptom resolution. Immediate significant improvement following such injection may help discern the amount of shoulder pain attributed to biceps pathology
in a patient in whom several other shoulder pathologies are present. Such a positive response to the biceps tendon sheath injection may indicate that the patient is likely to experience improvement following a BT procedure. Magnetic resonance imaging (MRI) should be obtained prior to surgical intervention to allow for adequate preparation and further treatment and follow-up. However, not infrequently, there are limited findings on the MRI associated with true biceps tendon pathology.²⁶ Finally, arthroscopic evaluation is considered the gold standard for identifying structural pathologies involving the LHBT, including partial and complete tears, synovitis, peeling, and instability with passive abduction-external rotation maneuvers. However, it is important to note that diagnostic arthroscopy has been shown to visualize approximately 55% of the LHBT relative to the superior border of the pectoralis major tendon.²⁷ Therefore, in patients in whom clinical history and physical examination suggest biceps tendinitis as a significant or primary contributor to the patient’s symptoms, BT may be performed even in the absence of overt signs of pathology on diagnostic arthroscopy or imaging for that matter.

TECHNIQUE

Preoperative confirmation of the patient’s history and physical is performed again prior to administration of regional anesthesia. Whether performed as an isolated procedure or in conjunction with other procedures, such as rotator cuff repair, our preferred method is to perform a mini-open subpectoral BT with the patient in a beach chair position and the operative arm in a sterile, pneumatic limb-positioning device (Trimano, Arthrex Inc.). The technique herein described may also be performed in the lateral decubitus position, according to the surgeon’s preference. The patient is administered an interscalene nerve block and placed under conscious sedation, with the endotracheal tube positioned toward the nonoperative shoulder to preserve a wide sterile field. Bilateral lower extremity sequential compression devices are applied that function throughout the procedure for mechanical deep vein thrombosis prophylaxis.

Standard diagnostic arthroscopy is performed via a posterior viewing portal and an anterior working portal. The intra-articular space is evaluated thoroughly to assess the integrity of glenoid and humeral head chondral surfaces, the rotator cuff tendons, the labrum circumferentially, and the biceps-labral complex. The biceps tendon is inspected and pulled into the joint with a probe. Although advanced imaging can provide little objective delineation of biceps pathology,²⁶ the arthroscopic evaluation of the biceps is of critical importance. The arthroscopic evaluation includes assessing the appearance of the biceps tendon complex, as viewed from the posterior portal and manipulated through the anterior portal (Figure 25-1). This allows for inspection and palpation for detachment at the superior labrum, splitting or tearing of the tendon itself, hypertrophy of the tendon associated with long-standing rotator cuff pathology, subscapularis tendon, and capsular stabilizer
tears at the location of where the biceps enters the glenohumeral joint. Finally, peritendinous vascular changes, or the “lip-stick” sign, may be visualized, which may be a normal finding in the absence of clinical evidence of biceps pathology (Figure 25-2).

FIGURE 25-1 Arthroscopic manipulation of the biceps tendon using a probe to assess for pathology.

FIGURE 25-2 Arthroscopic image of peritendinous vascular changes (ie, “lip-stick” sign).

Simultaneously, the arthroscope is advanced further into the joint and telescoped to look down the bicipital groove. With this maneuver, a larger proportion of the biceps tendon can be inspected. Additional findings include excessive tendon mobility and/or biceps “incarceration” within the glenohumeral joint during an abduction-external rotation maneuver. One or more of these findings, in conjunction with a patient whose clinical history and physical examination suggest biceps tendinitis, prompt proceeding with biceps tenotomy. Arthroscopic scissors are passed through the anterior portal to incise the biceps at its junction with the superior labrum (Figure 25-3). Care is taken to avoid leaving too large of a residual tendon stump, while simultaneously avoiding cutting the superior labrum itself. The intra-articular joint is visualized to ensure complete transection of the biceps tendon.

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