Surgical Technique: Arthroscopic and subpectoral long head of biceps tenodesis
Tenodesis of the proximal biceps leads to pain relief, preservation of function without deformity.
Disorders of the long head of the biceps tendon are a common source of shoulder pain and may occur in association with other diagnoses such as rotator cuff tears, superior labrum anterior posterior tears, impingement syndrome and capsular injuries.
However, long head of the biceps (LHB) tendonitis may also present as an isolated source of shoulder pain and be highly resistant to nonoperative treatments, including physical therapy, local corticosteroid injections, and modalities. The treatment options for disorders of the LHB continue to evolve and must include a comprehensive evaluation of the shoulder to rule out frequently encountered concomitant diagnoses.
LHB pathology includes tears, subluxation, tendonitis and high-grade SLAP and biceps attachment injuries. Subjectively, pain is typical in the anterior aspect of the shoulder and usually radiates down the arm into the anterior biceps muscle.
The shoulder pain in biceps tendonitis is exacerbated with overhead activities and is localized more distally than typical impingement type pain. LHB tendonitis is commonly regarded as a degenerative diagnosis due to mechanical shear forces, traction and compression, which is exacerbated with arm position and traction as the tendon crosses the glenohumeral joint and enters the bicipital groove on the humerus. Patients with rotator cuff dysfunction are also thought to have a predilection for concomitant LHB problems, and biceps pathology may often need to be surgically addressed in the setting of a rotator cuff tear.
Images: Illustrations by Kristin Wiendandt/Courtesy of Romeo AA
Provacative testing of a symptomatic LHB includes direct palpation over the bicipital groove, especially near the inferior aspect. The most common pain site is approximately 7 cm below the acromion with the arm internally rotated by 10º to isolate the area of the intertubercular groove. The biceps may also be palpated just inferior to the insertion of the pectoralis major (Subpectoral biceps tendon test); pain over the LHB is a positive finding.
Provocative biceps and SLAP tear tests may help differentiate the causes of shoulder pain but remain somewhat nonspecific for LHB pathology. Additional LHB and rotator cuff tests may be performed to help confirm a SLAP tear and to rule out rotator cuff pathology.
We can detect LHB instability by an audible click and potential biceps subluxation out of the groove. Testing of the subscapularis should also be included (ie, Belly press and Lift-off tests) with suspected LHB instability, since biceps instability or dislocation (medially) is associated with tears of the subscapularis insertion. Selective anesthetic and/or corticosteroid injections may be performed in either the bicipital groove or at the inferior border of the subscapularis to help differentiate and treat sources of biceps pain.
In these cases, plain radiographs are usually normal. Magnetic resonance imaging may demonstrate a SLAP tear or an intra-articular biceps tendon tear, and it allows us to visualize problems within the bicipital groove. Some surgeons have also used ultrasound to determine biceps subluxation and instability; however, it is unreliable for partial thickness tears and LHB problems within the joint.
For pain or other problems attributed to the LHB, there continues to be debate regarding optimal treatment. Concomitant shoulder pathologies should be addressed, and then attention is drawn to the LHB. The two main surgical options are LHB tenotomy or tenodesis.
In the younger, relatively active patient who would potentially be concerned about a biceps Popeye deformity post-tenotomy, the LHB tenodesis remains a predictable option with minimal complications. Although both procedures have been shown to provide adequate pain relief, the biceps tenodesis essentially eliminates the potential for strength decrease (especially supination), fatigue pain in the anterior aspect of the arm, and avoids the potential for cosmetic deformity.
If LHB tenodesis is elected, one must then decide on either proximal or distal fixation. Proximal fixation has been described within the glenohumeral joint (to the intact rotator cuff), to the conjoint tendon, and just proximal or within the bicipital groove. Distal fixation is generally in the area near the musculotendinous junction of the LHB, near the inferior border of the pectoralis major tendon. The superiority of a proximal versus distal tenodesis has yet to be established. However, there is some evidence to support the notion that by removing the LHB from the bicipital groove in a distal tenodesis, it essentially eliminates the potential for remaining pain generators due to LHB tendonitis within the groove.
We describe two techniques we use to perform either a proximal tenodesis using arthroscopic techniques or a distal tenodesis using a mini-open technique.
Arthroscopic biceps tenodesis
This procedure may be performed in either the beach chair or lateral position, and we address all associated pathology. Once the decision is made to perform a biceps tenodesis, we pass a No. 1 monofilament suture through the base of the LHB during the initial glenohumeral arthroscopy using either a penetrator device or an 18-gauge spinal needle (Figure 1). The suture serves to locate the LHB in the subacromial space and to provide proximal control during the dissection.
Once the suture is placed, the LHB is cut with either an arthroscopic basket cutter or an electrocautery device near the glenoid attachment. The biceps anchor area is trimmed, leaving a confluent superior labrum (Figure 2). The cannula is removed and the suture marked with a hemostat outside of the skin.
The arthroscope is then placed in the subacromial space from the posterior portal and subacromial decompression performed if necessary. A modified lateral portal is made anterior to the usual 50-yard line lateral portal (Figure 3), approximately 2 cm inferior to the lateral edge of the acromion. This portal can be utilized as the standard portal utilized during routine subacromial decompression, thus saving portal wounds during the case.
The 30º arthroscope is now sufficiently anterior for a view down the anterior aspect of the humerus. We use a shaver and electrocautery to gently debride tissue anterior to the bicipital groove, which is identified with retraction on the LHB via the monofilament suture.
Understanding the anatomy of the bicipital groove is an important aspect of the case. The LHB is intra-articular and extrasynovial and is surrounded by the biceps sling as it exits the joint (Figure 4). After exiting the joint, the LHB enters the bicipital groove, which is about 30 mm long and 6 mm wide and is covered by the transverse humeral ligament.
The falciform ligament is attached to the pectoralis major tendon and covers the inferior part of the bicipital groove about one-third of the time. A basket cutter is used to open the bicipital groove, starting superiorly and extending distal such that the LHB is completely released from the groove inferiorly. (Figure 5) Forearm flexion of 90º improves LHB excursion, which aids in identification at the groove. The pathology within the groove may be severe with inflammation, calcification, and degenerative changes (Figure 6).
Finding the LHB
The key points to help find the LHB within the groove:
- Perform subacromial debridement with an arthroscope in an anterolateral portal (anterior to the 50-yard line) to identify the monofilament suture;
- The anterior humeral head is visualized with the 30-degree arthroscope pointed inferiorly to the bicipital groove;
- Flex forearm 90° to increase LHB excursion;
- Perform active retraction of the LHB to help identify the proximal aspect of the groove; and
- Retract LHB sutures from an anterior portal centered over the bicipital groove.
If possible, care should be taken to preserve the rotator interval structures, including the coracohumeral ligament and the LHB retrieved at the superior aspect of the bicipital groove without excessive dissection of the interval structures. The transverse humeral ligament and falciform ligament (if present) are cut with either a basket cutter or electrocautery device. The medial aspect of the bicipital groove should be preserved in order not to violate the most lateral border and insertion of the subscapularis tendon.
Retrieving the LHB
The LHB is retrieved with the monofilament suture and pulled out of the skin. Approximately 20 mm of the most proximal portion of the LHB is removed and a No. 2 high-strength suture (Fiberwire; Arthrex) is whip-stitched into the remaining tendon for approximately 15 mm (Figure 7). The whip-stitched LHB will now accommodate a specially designed interference screw (Biotenodesis Screw, Arthrex), which allows for secure fixation of a tendon into a blind bony socket.
We use the arthroscope to visualize the bicipital groove. At the middle portion of the bicipital groove, approximately 15 mm below the anterior insertion of the supraspinatus, a guidewire is inserted through an 8.25-mm clear cannula that is placed directly in line with the tunnel (perpendicular to the humerus groove). The tendon diameter is measured with the enclosed tendon sizer on the Biotenodesis screwdriver.
A cannulated reamer is inserted over the guidewire and a unicortical bone socket is created for a depth of approximately 25 mm to accommodate a 23-mm Biotenodesis Screw. Usually an 8-mm screw (23 mm length) is used for an 8-mm bone tunnel. The screw is loaded on the end of the driver and the tendon affixed to the end of the driver, with the enclosed high strength suture placed in a loop to capture the LHB. Thus, there are four limbs of suture: two from the LHB whip-stitch and two to hold the tendon on the driver.
We insert the metal end of the screwdriver into the bony tunnel and advance the screw. The screw is inserted until flush, thus burying about 23 mm of tendon. The overall length of the proximal LHB have been well-studied in order to obtain the correct length-tension relationship and prevent a Popeye deformity.
Once the screw is seated, the two limbs that go from the tendon and through the screw are tied to each other for additional fixation. Thus, primary fixation of the LHB in the socket is accomplished with the interference fit of the screw (usually line-to-line fixation) and secondarily via the whipstitch sutures to the screw sutures (Figure 8).
The sutures are then trimmed and the arm rotated to ensure no screw or knot is prominent. The pullout strength of interference screw fixation has been investigated and shown to provide a very strong, if not the strongest biomechanical construct.
Mini-open subpectoral biceps tenodesis
The potential advantages of a mini-open subpectoral LHB tenodesis include:
- a small incision near the axillary fold that is cosmetically appealing;
- relevant anatomy is clearly identified;
- it is very efficient and reproducible with an easy learning curve; and
- it removes the majority of the tendon and associated synovium, which may be a cause of persistent pain.
The first portion of the procedure is similar to the arthroscopic tenodesis, except that it is not necessary to put a marking suture in the LHB. The LHB is tenotomized at the superior labrum, and the remaining labrum is trimmed until it is confluent with the remaining labral tissue.
At this point, the arthroscopic part of the case is completed and we make an incision near the axillary fold. The LHB is consistently found just posterior to the pectoralis major insertion. Thus, the incision is about 3 cm in length, with 2 cm below the most inferior border of the pectoralis major, and 1 cm above (Figure 9). This incision may be moved slightly more medially for patients with additional cosmesis concerns; however, the dissection should proceed directly to the humerus to avoid the medial neurovascular structures.
A self-retaining retractor is used to visualize the overlying fascia and fatty tissue, which is dissected and incised longitudinally. The inferior border of the pectoralis major is now easily palpated and the fascia overlying the biceps is incised proximally to distally to expose the LHB. A pointed Hohmann retractor is placed under the pectoralis major and a blunt Chandler goes on the medial aspect of the humerus to assist in LHB visualization. It is important to avoid rigorous medial retraction so as not to injure the musculocutaneous nerve.
A right-angle clamp or finger traction is used to pull the LHB out from underneath the pectoralis major and deliver it out of the wound. The LHB bone groove in the humerus is palpated and at a point just proximal (5 mm) to the inferior edge of the pectoralis major, the periosteum is reflected with a key elevator.
The key point in LHB preparation is to maintain the length-tension relationship. The musculotendinous junction of the LHB is consistently at the inferior border of the pectoralis major tendon and should be maintained when performing the tenodesis. Thus, the entire LHB tendon is removed except for 15 mm just proximal to the LHB musculocutaneous junction. In a similar fashion to the arthroscopic tenodesis technique, the LHB is whip-stitched, sized and then inserted into the unicortical humeral drill hole over a guide pin, which has been placed just proximal to the most inferior border of the pectoralis major tendon (Figure 10). The musculotendinous junction of the LHB should be at the level of the inferior border of the pectoralis major (Figure 11).
Postoperative rehabilitation is similar for both procedures and is typically dictated by additional surgical procedures such as rotator cuff repair. For isolated LHB procedures, the patient wears a sling for 4 weeks, during which passive motion of the glenohumeral joint, elbow and wrist progresses early to active assisted and active range of motion of all joints by 4 weeks.
The patient should be clearly informed that the main restriction is avoiding biceps contraction, biceps strengthening and resisted supination during the first 5 to 6 weeks. However, progressive range of motion and strengthening of the shoulder girdle muscles can progress to activities as early as 4 to 6 weeks postoperatively.
For more information:
- LCDR Matthew T. Provencher, MD, MC, USN, can be reached at the Naval Medical Center San Diego, Dept. of Orthopedic Surgery, 34800 Bob Wilson Drive, San Diego, CA 92134-1112; 619-532-8427; e-mail: firstname.lastname@example.org. He has no direct fiancial interest in any products or companies discussed in this article.
- Anthony A. Romeo, MD, can be reached in the Department of Orthopedic Surgery, Rush University Medical Center, 1725 W Harrison St, Suite 1063, Chicago, IL 60612-3828; 312-432-2377; e-mail: email@example.com. He is a consultant for and receives research support from Arthrex.
- Augustus D. Mazzocca, MD, MS, can be reached at University of Connecticut, 263 Farmington Ave., MARB 4th Floor, Dept. of Orthopedic Surgery. Farmington, CT 06034-4037; 860-679-6633; e-mail: firstname.lastname@example.org. He receives research support from Arthrex.
- Boileau P, Baque F, Valerio L, et al. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. J Bone Joint Surg Am. 2007;89(4):747-757.
- Gill TJ, McIrvin E, Mair SD, Hawkins RJ. Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder Elbow Surg. 2001;10(3):247-249.
- Kelly AM, Drakos MC, Fealy S, et al. Arthroscopic release of the long head of the biceps tendon: functional outcome and clinical results. Am J Sports Med. 2005;33(2):208-213.
- Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy. 2005;21(11):1296-1306.
- Mazzocca AD, Rios CG, Romeo AA, Arciero RA. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy. 2005;21(7):896.
- Romeo AA, Mazzocca AD, Tauro JC. Arthroscopic biceps tenodesis. Arthroscopy. 2004;20(2):206-213.
- Walch G, Edwards TB, Boulahia A, et al. Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: clinical and radiographic results of 307 cases. J Shoulder Elbow Surg. 2005;14(3):238-246.