11.2 Pre-Operative Complications (Indications)

A thorough diagnosis is imperative for successful surgical treatment and so patient satisfaction. An accurate diagnosis may be made through a comprehensive history, physical examination and appropriate imaging studies. Patients with biceps pathology commonly complain of an anterior shoulder pain that may radiate distally and display tenderness to palpation over the bicipital groove itself. Biceps instability often causes additional mechanical symptoms, typically during rotation with the arm in abduction. Specific clinical tests such as Yergason’s, Speed’s, ARES and O’Brien’s test should be performed and the non-affected shoulder should be examined for symmetry, as many of these examinations often produce a certain degree of discomfort, even in the non-pathological shoulder.

Concomitant shoulder pathologies are more the rule than the exception when it comes to LHB tendon pathologies. A comprehensive shoulder examination, including the cervical spine, must, therefore, be performed.

In our practice, plain radiographs and magnetic resonance imaging (MRI) are routinely performed prior to surgery. In younger patients with shoulder instability or if an isolated LHB pathology, including SLAP or Pulley lesion, is suspected MR arthrogram is the imaging of choice due to its higher diagnostic accuracy compared to non-contrast MRI [4–6]. Ultrasonography can be very helpful in the diagnosis of LHB tendon pathology as it allows dynamic testing, but with the limitation of being highly operator dependent [7].

During diagnostic arthroscopy the intraarticular portion of the biceps tendon must be assessed thoroughly, from its insertion site at the supraglenoid tubercle, to the biceps reflection pulley and intertubercular groove. By pulling the LHB tendon into the joint with a probe, more distal portions of the tendon may be examined, however the surgeon must be aware that even by this manoeuvre not all lesions of the LHB tendon within the groove will be visualized [8–10]. Patient history, clinical examination as well as imaging should be taken into account in deciding whether or not to perform a LHB tenotomy or tenodesis. If a patient is complaining of typical biceps-related symptoms and has positive provocation tests but no obvious structural lesions during an arthroscopic procedure, LHB tenotomy or tenodesis should be considered nonetheless [11].

Conversely, we do not recommend routine LHB management in patients with a rotator cuff lesion in the absence of biceps signs. If there are no focal biceps symptoms, nor positive signs on physical examination or diagnostic arthroscopy, the LHB tendon can be safely left alone during cuff repair [12–14].

When the surgeon has decided on performing LHB tendon surgery, tenotomy and tenodesis are the two primary options. As mentioned earlier, LHB tenotomy does carry the risk of “Popeye deformity” and potentially of post-operative muscle belly cramping. While the latter is usually self-limiting, cosmetic deformity of the upper-arm may be of concern for certain patients, especially for young and slim patients [15].

When it comes to post-operative functional outcomes, however, tenotomy and tenodesis show comparably favourable results in large systematic reviews [16–20]. Likewise, elbow flexion and forearm supination strength have also been found to be comparable between these techniques [15, 17, 18, 20–22].

Given the potential side-effects of tenotomy, we believe that counselling patients appropriately prior to surgery, and considering their specific demands and expectations is absolutely vital in order to enable shared-decision making and avoid patient dissatisfaction.

We generally recommend LHB tenodesis in younger and more physically active patients as well as those concerned about cosmesis.

In all others we perform a so-called “Y-tenotomy” technique, as popularised by Laurent Lafosse. For this technique the LHB insertion site is detached from the 11 to 1 o’clock glenoid position. The cut labrum and LHB tendon form the shape of a “Y”, which gives this technique its name (Fig. 11.2). The bulky labral end-piece of the “Y-shape” lodges underneath the transverse ligament in the bicipital groove, thereby performing an auto-tenodesis. In our own experience this technique is easy, fast, effective and results in deformity that is very subtle, if present at all. Clinical outcome studies are, however, pending.

Probably the most debated question in LHB management is the “Where?” to fix the tendon during tenodesis. Options include high, close to the articular margin of the humeral head, suprapectoral and subpectoral. While high and suprapectoral LHB tenodeses are nowadays usually performed arthroscopically, subpectoral tenodesis is an open procedure. Potential benefits and complications of the location of fixation, as well as of the different options for fixation, will be discussed in the following sections.

11.3 Per-Operative Complications

By its nature biceps tenotomy is an easier, quicker and safer procedure than any tenodesis technique, without any clear direct potential complications. Even for a novice shoulder arthroscopist intra-operative complications such as neurovascular, cartilage and soft-tissue injuries are fairly uncommon. While the same is true for the above mentioned “Y-tenotomy” technique, care must be taken not injure the suprascapular nerve, which lies at the spinoglenoid notch approximately 19 mm medial to the glenoid, during posterior labral dissection [23].

When considering LHB tenodesis techniques, the most straightforward technique to perform arthroscopically is probably the high LHB tenodesis, at the articular margin. High LHB tenodeses do not require any further arthroscopic dissection and are usually performed with the scope in the standard posterior visualisation portal (Fig. 11.3a–d). Major complications to neurovascular structures are not described. Fixation may be achieved using suture anchor, tenodesis screw or an endobutton system, and remaining sutures may be used for antero-superior rotator cuff repair if applicable [24].

Suprapectoral tenodesis, on the other hand, needs additional dissection and a release of the transverse ligament at the intertubercular groove. Visualization is typically obtained via a lateral extra-articular portal. Clearly, a higher degree of arthroscopic skill is needed to perform this technique. Despite a cadaveric study demonstrating the close proximity of the low anterolateral portal, needed for suprapectoral LHB tenodesis, to a small distal branch of the axillary nerve, to our knowledge no neurovascular complications have been reported in the current literature [25–27].

By contrast, a major criticism of the open subpectoral LHB tenodesis is the proximity of the brachial plexus to the tenodesis site, which may place neurovascular structures at risk. This has been investigated previously in cadaveric studies [28, 29]. In the current literature several clinical reports of iatrogenic brachial plexus injuries during open subpectoral biceps tenodesis have been published [25, 30–34].

If one decides to perform a subpectoral LHB tenodesis in conjunction with an arthroscopic procedure, consider performing it early in the surgery as swelling of the arm may distort the anatomy and relations, and may increase the risk of neurovascular injuries.

Fixation can be achieved with a tenodesis screw, suture anchors or an endobutton system. When using tenodesis screws, make sure that the prepared tunnel for the interference screw is drilled large enough to fit tendon and screw. Consider drilling the bone socket 0.5 mm larger than the screw and smooth the bony edges with a shaver to avoid damage to the tendon by the pressure of the threads or sharp edges during screw insertion. The importance of this point is underlined by the findings of a case series of three failures of LHB interference screw tenodesis, that showed all failures to have occurred at the tendon-screw interface, implying some damage to the tendon during insertion [35]. Furthermore, rotation of the graft around the screw during insertion may also weaken the construct and alter graft tension [36]. The importance of preserving the correct length-tension-relation in LHB tenodesis has been stressed previously [37, 38].

We tend to perform a LHB tenodesis with rather less tension as we believe that this reduces LHB irritation and so post-operative pain, and in our experience does not cause appreciable deformity. Overtensioning, however, should be avoided at all costs. In a current cadaveric study, Werner et al. [38] found that in interference screw tenodeses there is a tendency to over-tension the tendon, with a significantly greater over-tensioning in arthroscopic suprapectoral, as compared with open subpectoral LHB tenodeses (2.15 vs. 0.78 cm).

Use of suture anchors may reduce the risk of the above-mentioned issues with tendon tension, however, when using a suture anchor for fixation, tapping of the cortical bone is recommended to avoid anchor breakage during insertion, as the bone at the intertubercular groove is usually very solid.

For all techniques, clear arthroscopic cannulas may be used to avoid injury to the surrounding soft tissue during drilling.

11.4 Immediate Postoperative Complications

Immediate post-operative complications of LHB management include infection and early failure of fixation.

Wound infections following biceps management are rare. Open subpectoral tenodesis is thought to carry the highest risk of deep wound infection as this technique requires a separate incision close to the armpit. This hypothesis is supported by an analysis of a large private-payer database of 33,481 patients undergoing a rotator cuff repair with biceps tenodesis/tenotomy. The infection rate was highest in the open biceps tenodesis group and the lowest in the tenotomy group [12].

Nho et al. [33], however, reported a generally low rate of complications following open subpectoral LHB tenodesis of 2.0% in 353 patients; only one patient (0.28%) presented with a deep wound infection.

Gottschalk et al. [39] described two cases with superficial infection among 29 patients and Abtahi et al. [30] similarly found four superficial infections in 103 patients (4%) treated with open subpectoral LHB tenodesis.

Gombera et al. [25] compared open subpectoral and all-arthroscopic suprapectoral tenodesis and reported complications in two of 23 patients (8.7%) in the open tenodesis group including one superficial wound erythema that resolved with oral antibiotics, and one patient with transient brachial plexopathy. The group of all-arthroscopic suprapectoral LHB tenodesis (23 patients) had no complications.

Brady et al. [40] published the outcomes of 1083 patients that underwent a high biceps tenodesis at the articular margin with an interference screw and found a revision rate of 4.1% overall and a biceps related revision rate of 0.4%. No infections were reported by the authors.

Early failure of LHB fixation is rare and may be explained by an inappropriate surgical technique, trauma or non-compliance. Usually, LHB tenodesis techniques allow an early post-operative functional treatment and the post-operative treatment is rather dictated by concomitant procedures, i.e. rotator cuff repair. Strengthening of the biceps is usually forbidden for 3 months post-operatively.

11.5 Mid-Term Complications

Residual groove pain is a typical mid-term complication following biceps tenodesis and is thought to be particularly associated with high LHB tenodesis at the articular margin [41, 42].

Advocates of an open subpectoral technique argue that only by subpectoral fixation of the LHB tendon, can the degenerative and inflamed superior portion be completely removed from the pathological intertubercular groove, and so eliminate persistent post-operative pain [3]. This approach is supported by Moon et al. [9], who found, in a retrospective evaluation, that most LHB tendon lesions extend beyond the bicipital groove, to the distal extra-articular portion of the LHB.

Advocates of high fixation claim, however, that even in patients with substantial inflammation and degeneration in the intertubercular groove, a high tenodesis eliminates the motion within the groove and thereby effectively treats any biceps related pain [40].

Others stress the importance of releasing the biceps sheath during tenodesis. Sanders et al. [42] demonstrated that techniques which release the biceps sheath had a significantly lower revision rate when compared to techniques that did not (6.8% vs. 20.6%). Considering the prior cited publication of Brady et al. [40] on “high in the groove” LHB tenodesis, who had a biceps related revision rate of only 0.4% in 1083 patients without releasing the biceps sheath, the revision numbers of Sanders et al. appear surprisingly high however.

In comparative studies between arthroscopic suprapectoral and open subpectoral LHB tenodesis, Gombera et al. [25] as well as Werner et al. [27] found no significant differences regarding pain relief or clinical outcomes between both groups.

Regarding the kind of fixation, Millett et al. [43] described a significantly higher likelihood of persistent bicipital groove pain when suture anchors were used for open subpecoral tenodesis compared to tenodesis screws.

As discussed earlier, “popeye deformity” is probably the most significant downside of LHB tenotomy, occuring in 17–70% of cases following LHB tenotomy [15, 16, 19–21, 44]. For many patients the superior cosmesis compared to tenotomy is the primary reason to undergo a LHB tenodesis. Therefore, a deformity that occurs after a LHB tenodesis must be regarded as a failure of treatment.

Multiple biomechanical studies have shown that tenodesis with an interference screw provides a superior primary stability when compared to single suture anchor, endobutton or bone tunnel fixation [45–49], however, Mazzocca et al. [46] demonstrated that two suture anchors are biomechanically equivalent to interference screw fixation.

Most clinical reports of LHB tenodesis show a low incidence of failure and popeye deformity, equally so for all current techniques. Nho et al. [33] noted a failure rate of 0.57% in 353 patients that underwent open subpectoral tenodesis with interference screw. Werner et al. [27] and Gombera et al. [25] in their comparative studies of arthroscopic suprapectoral and open subpectoral biceps tenodesis with screws, reported no failures in either group.

Castricini et al. [15], however, reported a popeye deformity in 20.8% of cases of LHB tenodesis (suprapectoral with interference screw fixation) compared to 58.1% of LHB tenotomy at 24 months follow-up.

Friedman et al. [21] found a popeye deformity in 18.2% of patients that had an open subpectoral LHB tenodesis with suture anchor fixation, compared to 35% of tenotomy patients. All patients in this study were active patients, younger than 55 years old, which may explain the high rates of failures in this particular population.

Despite the previously mentioned biomechanical evidence in favour of interference screw fixation, comparative clinical studies of interference screws vs. suture anchor fixation are scarce. Park and colleagues [50] compared both fixation modalities in a prospective randomized controlled study using MRI imaging. Interestingly, anatomic failure on MRI examination was significantly higher in the interference screw group (21.2%) compared to the suture anchor group (5.8%), however, both groups showed similar outcomes with regard to popeye deformity. This divergent definition of clinical failure, makes a comparison to the above mentioned studies difficult. Anatomic failure in this study was also significantly affected by more physically demanding levels of work.

Further reported mid-term complications in the current literature are reflex-sympathetic-dystrophy and post-operative shoulder stiffness [33, 51–53]. While reflex-sympathetic-dystrophy is a rare finding irrespective of open or arthroscopic techniques, Werner et al. [54] found post-operative shoulder stiffness to be the only significant complication in 249 patients that underwent LHB tenodesis. Interestingly, stiffness was notably increased after arthroscopic suprapectoral biceps tenodesis as compared to open subpectoral biceps tenodesis (17.9% vs. 5.6%). The authors explained this finding as being a result of the necessary arthroscopic dissection around the tenodesis site during arthroscopic suprapectoral tenodesis, with potentially increased fluid extravasation and bleeding in the region of the bicipital sheath, or a potential overtensioning of the biceps tendon. Further risk factors for stiffness found in this study were female sex and smoking.

Stiffness following biceps tenodesis is, however, almost always self-limiting and large study cohorts show extremely low revision rates for shoulder stiffness for all tenodesis techniques [12, 40].

A further complication, unique to subpectoral tenodesis, is humeral fracture at the cortical drill hole. Sears and colleagues [55] published a case report of two patients that suffered a proximal humerus fracture 4 and 6 months, respectively, after subpectoral biceps tenodesis. While one patient had a fall down a small hill, the second patient reported no specific trauma. Both patients underwent open reduction and plate fixation.

Euler et al. [56] stressed the importance of central screw placement during subpectoral tenodesis to avoid this specific complication. The authors found in a biomechanical study, that an eccentrically drilled 8 mm bone socket will significantly reduce bone stability by 25% compared to 10% if the biceps tenodesis is placed concentrically. When using a subpectoral biceps tenodesis technique, surgeons should be aware of this technical error.

11.6 Long Term Complications

We are not aware of any specific long-term complications of LHB management. While failure of fixation with popeye deformity as well as humeral fracture may also occur in the long-term, usually following trauma, these are complications more usually occurring during the mid-term period.

In the literature no specific long-term complications for LHB management have been reported.