Biceps Tenotomy and Tenodesis



Biceps Tenotomy and Tenodesis


Brandon J. Erickson, MD

Peter N. Chalmers, MD

Anthony A. Romeo, MD


Dr. Erickson or an immediate family member has received research or institutional support from DePuy, A Johnson & Johnson Company and Smith & Nephew and serves as a board member, owner, officer, or committee member of the American Orthopaedic Society for Sports Medicine. Dr. Chalmers or an immediate family member serves as a paid consultant to or is an employee of Arthrex, Inc. and Mitek. Dr. Romeo or an immediate family member has received royalties from Arthrex, Inc.; is a member of a speakers’ bureau or has made paid presentations on behalf of Arthrex, Inc.; serves as a paid consultant to or is an employee of Arthrex, Inc.; has received research or institutional support from Aesculap/B.Braun, Arthrex, Inc., Histogenics, Medipost, NuTech, OrthoSpace, Smith & Nephew, and Zimmer; has received nonincome support (such as equipment or services), commercially derived honoraria, or other non-research-related funding (such as paid travel) from the Arthroscopy Association of North America, Arthrex, Inc., and MLB; and serves as a board member, owner, officer, or committee member of the American Shoulder and Elbow Surgeons, Atreon Orthopaedics, and Orthopedics Today.

This chapter is adapted from Chalmers P, Sherman SL, Ghodadra N, Mather RC, Romeo AA: Biceps tenotomy and tenodesis in Flatow E, Colvin AC, eds: Atlas of Essential Orthopaedic Procedures. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2013, pp 24-27.



PATIENT SELECTION

The long head of the biceps tendon (LHBT) runs a unique anatomic course through the anterior shoulder, ascending proximally through the intertubercular groove before turning 30° medially and posteriorly, where a “pulley” composed of the coracohumeral ligament, the superior glenohumeral ligament, the supraspinatus tendon, and the subscapularis tendon supports the LHBT. The LHBT then travels intra-articularly but extrasynovially through the glenohumeral joint and inserts onto the supraglenoid tubercle and/or superior labrum.2 LHBT pathology can occur at several locations through its anatomic course: in the intertubercular groove, within the glenohumeral joint, and at its attachment site. These regions of pathology have recently been divided into three zones (inside, junction, and bicipital tunnel).1 The inside zone includes the superior labrum and the biceps anchor where labral tears and dynamic LHBT incarceration can exist. The junction includes the intra-articular portion of the LHBT and its stabilizing pulley where LHBT partial tears, LHBT subluxation, and biceps chondromalacia are often seen. The bicipital tunnel includes the extra-articular portion of the LHBT, beginning at the articular margin and continuing through the subpectoral region and the fibro-osseous confinement of the LHBT (now known as the bicipital tunnel). This area is often affected by extra-articular bicipital tunnel scar/stenosis, loose bodies, LHBT instability, and LHBT partial tears.

Depending on the location, the etiology of this tendinopathy may be osteophytes within the intertubercular groove, microtrauma from repetitive overhead activities, acromial morphology, internal impingement, ischemia, tendon instability, or trauma.3 Tendinitis and tendinosis commonly occur in association with subacromial impingement, rotator cuff pathology, tears of the anterior capsuloligamentous complex, labral tears, glenohumeral instability, and acromioclavicular arthrosis.2 Acutely, the tendon may be swollen and hemorrhagic, but with chronic friction and traction the tendon can become thinned, frayed, and atrophied, which can lead to tendon rupture, commonly with subsequent pain relief. The functional consequences of this rupture are unclear. The importance of the LHBT in shoulder function has been debated in the literature, with some authors arguing that contraction of the LHBT plays no role in shoulder motion or stability and others arguing that the LHBT acts as an important humeral head depressor.3

The LHBT is among the primary pain-generating structures of the anterior shoulder. Because LHBT tendinosis rarely occurs in isolation, however, determining whether a patient’s pain is due in part to LHBT pathology can be challenging. The history should elicit a full description of the location of the pain, the shoulder positions and movements that exacerbate this pain (eg, typically overhand or underhand throwing, lifting, or extending the arm behind the patient when placing on a seat belt), and the patient’s occupation and sporting activities. Patients may or may not give a history of a specific traumatic event.4 Classically, LHBT pain begins in the anterior shoulder and radiates distally into the biceps muscle belly. Snapping, grinding, or popping symptoms may be described. Physical examination should include a standard shoulder evaluation, including inspection, palpation, and range of motion; a complete neurovascular examination; and a battery of provocative maneuvers to test for subacromial impingement, rotator cuff tears, instability, and acromioclavicular
pathology. Unfortunately, physical examination maneuvers (O’Brien’s test, Speed test, Yergason test) are often unreliable in diagnosing biceps pathology as there is crossover with other pathologies. The “three pack” of biceps tunnel tenderness, positive O’Brien’s test, and positive throwing test has been reported to have excellent increase interrater reliability, sensitivity, and negative predictive value in the diagnosis of biceps tendon pathology.5 Of these, tenderness to palpation in the bicipital groove under the pectoralis is the most sensitive.




Preoperative Imaging

Imaging is used along with the patient’s history and physical examination to support the diagnosis of LHBT pathology. Radiographs obtained to evaluate for LHBT pathology should include AP, lateral, and axillary views of the shoulder, as well as a scapular outlet view to examine acromial pathology. The intertubercular groove can be visualized in profile by placing the cassette at the apex of the externally rotated shoulder with the radiograph beam collinear with the humeral shaft.

Traditionally, arthrography also was used to diagnose LHBT pathology. Ultrasonography also has been used and is sensitive and specific, but the technician-dependent nature of the results and limited delineation of associated intra-articular pathology limit widespread application.3 MRI has largely supplanted these methods. Findings associated with LHBT pathology include ovalization of the tendon (which is normally kidney bean-shaped), increased intrasubstance signal intensity on T2-weighted images, and tendon dislocation from the intertubercular groove.3 Magnetic resonance arthrography further increases the sensitivity and specificity of this modality for evaluation of LHBT pathology, although there are several lesions both in the biceps-labral complex as well as the bicipital tunnel that MRI can miss.3,7 In addition, it offers excellent delineation of associated shoulder injuries.

The benchmark diagnostic test is shoulder arthroscopy. Any patient undergoing shoulder arthroscopy should undergo a full evaluation of the biceps tendon. LHBT pathology is commonly discovered incidentally during glenohumeral arthroscopies performed for other indications, and the surgeon should be prepared to intervene if indicated.


Feb 2, 2020 | Posted by in ORTHOPEDIC | Comments Off on Biceps Tenotomy and Tenodesis

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