Chapter 46

Current Techniques for Biceps Tenodesis

Guillermo Arce

Introduction

The long head of the biceps tendon (LHBT) is a frequent source of shoulder pain due to tendon instability or degenerative changes. Tendon instability can be located on the superior labrum anterior-posterior (SLAP) insertion site or at the bicipital groove. Details of SLAP repair are depicted in a different chapter of this book. In patients older than 40 years of age, current research demonstrates that biceps tenodesis outperforms SLAP repair.

In the presence of tendon instability at the bicipital groove, the outcome following biceps pulley reconstruction is often unpredictable, therefore adjunctive tenodesis remains essential. LHBT degenerative changes are common findings and often require a surgical approach.

Even though biceps tenotomy constitutes a valuable option for the elderly patient, young and/or athletic patients with biceps pathology typically require tendon fixation at the proximal humerus or at the adjacent soft tissue structures. Surgeons, even experts, often face a dilemma when choosing the most suitable place for biceps tendon fixation and how to do it right. The goal of this chapter is to describe the advantages and drawbacks of the current most popular techniques for biceps tenodesis.

Procedure

The LHBT fixation site can be either: 1) proximal, close to the glenohumeral joint, or 2) suprapectoral, at the level of the bicipital groove but above the falciform ligament and pectoralis major, or 3) or subpectoral, distal to the pectoralis major. The most common ways to fix the LHBT are: 1) to stitch the tendon to the cortical bone with suture anchors, 2) to attach the tendon with sutures to the soft tissue structures nearby, or 3) to steer the tendon inside the bone socket and lock it with interference screws. These three techniques will be further detailed in this section.

Patient History and Examination

Patients usually complain about pain above the shoulder level during sports or working activities. The pain is located mainly anterior, but lateral or posterior irradiation is not uncommon. Physical signs and examination maneuvers are described in Box 46.1.

Imaging

Contrasted magnetic resonance imaging (MRI) is critical to evaluate SLAP lesions, whereas dynamic ultrasound is best suited for the assessment of LHBT instability at the groove. After a relatively short learning curve, and with the help of the new light and mobile echography devices, the surgeon can easily scan the LHBT and evaluate its mobility in and outside its groove. Tissue quality and increased fluid around the tendon can also be detected by the ultrasound examination.

Noncontrasted MRI is key to defining surrounding structures such as subscapularis or supraspinatus tendons. Coronal and axial slices also delineate static tendon position and the amount of liquid at the bicipital sheath (Fig. 46.1).

Patient Position and Anesthesia

Even though these procedures can be performed with the patient in lateral decubitus, the beach chair position is preferred by us for any anterior shoulder “out of the box” procedure. For greater access to the anterior shoulder extraarticular structures such as bicipital groove, coracoid, cojoined tendon, and pectoralis major, the scope should be placed at the lateral portal with the patient sitting upright. This is an ergonomic and comfortable position for holding the scope at the lateral portal. Another relative benefit of the beach chair position is the ability to operate under interscalene block alone without the need of general anesthesia. For security reasons, and in order to prevent brain desaturation events during the procedure, we strongly recommend measuring regional brain oxygen saturation with disposable scalp transducers (INVOSTM Technology, Medtronic, Minneapolis, MN).

BOX 46.1 Physical Exam Findings in LHBT Instability or Tendinosis

• One finger pain at the bicipital groove about 7 cm below the acromion level with the arm in 10 degrees of internal rotation.
• Yergason Test: Pain with resisted forearm supination.
• Speed Test: Pain with resisted forward flexion in 90 degrees, the elbow fully extended and the forearm supinated.
• Active Compression Test. O’Brien Sign: The arm is 90 degrees of forward flexion, adduction 15 degrees, full internal rotation (thumb down) with a downward force from the examiner.
• Abbot and Sanders. Pain and snap at the bicipital groove during passive arm motion back and forth from abduction-external rotation to adduction-internal rotation.
• Bear Hug and Upper Cut Test. Active and resisted motion with the elbow flexed in the contralateral shoulder or anterior direction.

All the herein described techniques are performed with the scope located at the lateral portal. We typically use one or two anterior portals to debride, manipulate, and finally fix the biceps tendon. The entire scapula and arm are prepared and draped to allow unrestricted access to the anterior and posterior shoulder structures. After drawing the bony landmarks on the skin, four arthroscopic portals are established as follows: 1) a conventional posterior portal 2 centimeters distal and medial to the posterolateral acromion edge is used for primary glenohumeral joint and subacromial inspection; 2) with the scope at a posterior portal, a lateral portal is established with an outside-in technique between the middle and anterior third of the humeral head, 3 centimeters lateral to the acromion lateral edge. Surgeons must be aware that the humeral head at the sagittal plane is one-third anterior to the lateral acromion edge. Therefore the lateral portal must be placed the between the medial and the anterior third of the humeral head, not centered at the lateral acromion border; 3) two anterior portals are located with an outside-in technique at the proximal and distal portions of the bicipital groove.

The arm position is at 30 degree flexion, with approximately 10 degree internal rotation and 30 degree abduction. This position allows distension of the subacromial bursa and ensures a clear view of the bicipital groove, whereas when the elbow is flexed at 90 degrees, the biceps tendon is relaxed.

Surgical Anatomy: Arthroscopic Findings

As preoperative detection of biceps tendon instability is often challenging, it is vital to recognize the normal anatomy and to be able to assess the surrounding structures of the biceps tendon intraoperatively. The LHBT conditions and stability are evaluated with the Ramp test.

The medial and lateral bands of the coracohumeral ligament are the main biceps tendon stabilizers at the upper part of the pulley. The expansions of the subscapularis and the supraspinatus tendons constitute the roof of the upper part of the bicipital groove and are quite important in keeping the biceps steady at the bone trough.

The anatomic structures that contribute to biceps stability at its groove are described in Box 46.2. All of them need to be assessed in detail during the diagnostic arthroscopy (Fig. 46.2).

BOX 46.2 Biceps Pulley Components and Lhbt Stabilizers

• Coracohumeral ligament. Medial and lateral bands
• Superior glenohumeral ligament
• Subscapularis
• Supraspinatus
• Bone trough
• Transverse ligament
• Falciform ligament over the pectoralis major

Treatment Options

Even though the literature is controversial about the best technique and place to perform a biceps tenodesis, there are four main surgical procedures to consider: 1) to fix the LHBT with anchors or interference screws near the joint; 2) to suture the LHBT to nearby soft tissue structures such as the cojoined tendon and the short head of the biceps; 3) to place the fixation point lower at the groove of the suprapectoral area with interference screws; 4) to fix the biceps at the subpectoral area with an open approach. This later modality will be described in another section of this book.

Most Common Surgical Techniques

Proximal Biceps Tenodesis With Suture Anchors

In patients with low demands, proximal biceps tenodesis (close to the shoulder joint) is frequently performed as an adjunct procedure during rotator cuff repair. The LHBT is easily identified through the cuff tear and can be fixed to bone with one or two suture anchors in a single- or double-row fixation technique. Details of the technique are as follows:

Step 1: The sliding surface of the bicipital groove is first debrided to create a healing scenario for the tendon fixation. A curette or a shaver are used to remove the pulley cortical sliding tissue.

BOX 46.3 Pearls of the Proximal LHBT Tenodesis with Suture Anchors

• Fast. No special dissection is required.

• There is no need to be prepared with additional biceps-specific implants. Regular suture anchors for cuff repair can be used.

• Tendon length and tension are easily obtained.

• Sutures from the biceps tenodesis can also be used to repair the anterior cable of the cuff.
Step 2: A double-loaded suture anchor is located close to the tendon. For this procedure, we usually perform the Lasso Loop Technique described by Lafosse, et al. A curved tip suture passer (Rhino Suture Passer, Arthrex Inc, Naples, Florida) penetrates the LHBT close to the anchor and grabs one suture limb from the anchor. The suture passer is partially retrieved from the tendon and a loop is obtained. The suture passer is introduced through this loop to grab the distal limb of the same suture and pass it through the loop. The Lasso Loop is then ready. After doing so, the suture passer penetrates the tendon again and retrieves the other suture limb from the anchor in a similar manner. This second suture will be the post (Figs 46.3 and 46.4).
Step 3: These two passages through the tendon need a nonsliding knot. The suture limb that passed simple through the tendon represents the post and the lasso becomes the loop. While pulling from the post, the surgeon perceives how the tendon is constrained against the bone.