Subpectoral, Suprapectoral, and Top-of-Groove Biceps Tenodesis Procedures Lead to Similar Good Clinical Outcomes: Comparison of Biceps Tenodesis Procedures

Editorial Commentary: Failure Following Biceps Long Head Tenodesis Includes Popeye Sign, Cramping, and Tendon Migration

The long head of the biceps tendon (LHBT) is often referred to as a "pain generator" around the shoulder, and tenodesis of the LHBT is a commonly used surgical method for treating pathologies of the tendon. Current literature indicates that tenodesis of the LHBT can lead to reduced pain, improved shoulder function, and a low failure rate. However, the definition of failure following LHBT tenodesis varies. Clinically, postoperative cramping is generally considered a sign of treatment failure, while the appearance of a Popeye sign is usually regarded as a mechanical failure. In addition, recent research shows increased migration of the tenodesed biceps tendon is associated with inferior clinical outcome. While some degree of tendon migration can occur as a physiological response to the shortening of the muscle-tendon unit, excessive migration may be caused by loosening at the tendon-implant interface or suture cut-through. This can lead to painful cramping or weakness in the shoulder. The findings explain why some patients experience cramping or pain in the bicipital groove after LHBT tenodesis, even in the absence of a Popeye sign. When evaluating biomechanical studies, it is essential to consider not only the ultimate load failure but also the elongation that occurs with cyclic loading. Biomechanical study shows cyclic displacement was greater in both all-suture anchor and all-suture button groups versus interference screw fixation. If this results in clinical tendon migration, these fixation methods might result in inferior outcome, illustrating the importance of cyclic loading.

Knotted single lasso loop has a lower stiffness and comparable ultimate failure strength compared with knotless whipstitch fixation in onlay tenodesis

BACKGROUND

Suture and knotless anchor onlay tenodesis are two common treatments for biceps lesions; however, there is a paucity of biomechanical studies evaluating the efficacy and structural integrity of these techniques.

METHODS

Tendons were harvested from four lower extremity fresh cadaver specimens, including the extensor digitorum longus, peroneus longus, peroneus brevis, and anterior tibialis tendons. Each tendon diameter was recorded using a digital Vernier caliper. Sixteen 3D printed proximal humeri models were allocated to either the single lasso loop with suture anchor (SLL) group or the whipstitch with knotless suture anchor (WSA) group. Each tenodesis model was initially tested on an electrodynamic material testing instrument under a cyclic load ranging from 5 to 70 N at a speed of 1.25 mm/s. The force on the tendon was then returned to 5 N, which was pulled until the ultimate failure of the construct. Displacement during cyclic loading, ultimate failure load, stiffness, and failure modes were assessed.

RESULTS

Fourteen tenodesis models were validated, and two models were discarded due to technical errors. No significant differences between the two groups were observed regarding tendon diameter, ultimate failure load, and displacement at ultimate failure load. However, the construct stiffness for the SLL group was lower than that of the WSA group (58.02 ± 5.62 N/mm vs. 72.24 ± 15.63 N/mm, P = 0.043).

CONCLUSION

The SLL group had a lower construct stiffness than the WSA group, whereas construct displacement and ultimate failure load were similar in both groups. Therefore, SLL biceps tenodesis may offer a convenient alternative, with lower tendon migration fixation, while performing an arthroscopic biceps tenodesis.

LEVEL OF EVIDENCE

Basic Science Study.

Arthroscopic Suprapectoral Biceps Tenodesis: A Knotless, Onlay, All-Suture Anchor Technique

Anterior shoulder pain is a common complaint often caused by pathology of the long head of the biceps such as biceps tendinitis, partial biceps tears, biceps instability, and SLAP lesions. Surgical treatment of biceps pathology includes tenotomy versus tenodesis, with tenodesis being favored in young, active patients owing to less cramping pain and superior outcomes in terms of shoulder function and cosmesis. Various surgical techniques for tenodesis of the long head of the biceps exist, with varying indications. Subpectoral biceps tenodesis is primarily indicated for zone 2 to 3 tendon pathology and revision biceps tenodesis. Secondary indications include overhead athletes, chronic biceps tendinopathy, and rotator cuff repair. Proximal arthroscopic biceps tenodesis performed "high in the groove" has been shown to preserve biceps length and reduce Popeye deformity compared with tenotomy. Knotless techniques are becoming popular; they provide low-profile fixation that limits knot abrasion and is not reliant on knot security for fixation. We present a variation of suprapectoral biceps tenodesis using knotless fixation in an onlay technique.

Arthroscopic Inlay Biceps Tenodesis Using a Tendon-Docking Anchor

Pathology of the long head of the biceps tendon can be treated surgically with a multitude of tenodesis techniques; however, there is a lack of consensus on which technique provides the most optimal outcomes. Commonly used methods include inlay tenodesis with a bone tunnel and interference screw construct and onlay tenodesis with anchors or unicortical buttons. Although current methods typically provide satisfactory outcomes, many surgeons believe complications and failure rates remain suboptimal across techniques. In this article, we present an arthroscopic suprapectoral biceps tenodesis technique using an anchor device that was developed to address the shortcomings of current techniques, optimize outcomes, and minimize risk.

How to Expose the Long Head of the Biceps Tendon in Shoulder Arthroscopy Efficiently: The Tubercle-Traction and Touch-Tendon Method

Arthroscopic tenodesis of the long head of the biceps tendon (LHBT) is a common procedure in a series of bicipital tendinopathies, including tendinitis, SLAP lesions, and tendon instability. Locating and exposing the LHBT during arthroscopy present a technical challenge in tenodesis. Blind exploration of the subacromial space may result in inadvertent tendon transection and iatrogenic damage to surrounding structures, leading to increased patient trauma, bleeding, and operation time. Using the tubercle-traction and touch-tendon method facilitates a roadmap-style, accurate, prompt exposure of the LHBT, minimizing blind exploration-related damage to the subacromial bursal area and adjacent structures, which is conducive to early and rapid postoperative shoulder recovery for patients.

Editorial Commentary: Outcomes of Shoulder Biceps Tenotomy Versus Tenodesis Are Difficult to Determine From Nonrandomized Studies Due to Selection Bias: Tenodesis Is More Commonly Performed on Younger Males

The long head of the biceps tendon is a common source of anterior shoulder pain, frequently addressed during rotator cuff repairs. Surgical management typically involves either tenotomy or tenodesis, each offering distinct advantages and disadvantages. Tenotomy, a straightforward procedure with a short rehabilitation period, is well suited for low-demand patients but carries a higher risk of Popeye deformity and cramping pain. In contrast, tenodesis, which reattaches the long head of the biceps tendon, minimizes these risks and is preferred for younger, active patients. Randomized controlled trials have shown equivalent functional outcomes for both techniques, with tenotomy associated with a higher risk of cosmetic deformity. The choice of a specific technique often reflects patient age, activity demands, and cosmetic concerns. Surgeons are more likely to select tenodesis for younger, male patients. Thus, nonrandomized studies introduce confounding variables and selection bias that can obscure clear recommendations based on the literature.

Arthroscopic Intra-articular Biceps Tenodesis With All-Suture Anchor

Background

Biceps tenodesis can be used to treat both superior labral anterior and posterior (SLAP) tears and degenerative biceps pathologies in the setting of rotator cuff pathology or as stand-alone techniques. Research has shown that arthroscopic biceps tenodesis has comparable outcomes to open tenodesis with the benefit of being less invasive.

Indications

Surgical indications for intra-articular tenodesis of the long head of the biceps (LHB) include SLAP tear, failed SLAP repair, partial-thickness LHB tear, biceps instability, tenosynovitis, and clinical examination consistent with LHB pain.

Technique Description

We present our technique for arthroscopic intra-articular biceps tenodesis with a top-of-the-groove all-suture anchor using percutaneous suture passage with a spinal needle and polydioxanone suture. Sutures are shuttled through the LHB in situ before releasing the tendon from the labrum.

Results

The authors have seen excellent clinical results using this method without any cases of tenodesis failure. Prior studies have shown subpectoral, suprapectoral, and top-of-the-groove biceps tenodesis to have similar good clinical outcomes at multiple time points.

Discussion/Conclusion

This technique is advantageous as it is time efficient and cost-effective, and tension on the biceps can be easily maintained as suture is passed through the tendon in situ before the tendon is released from the superior labrum.

Patient Consent Disclosure Statement

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Arthroscopic Suprapectoral Biceps Tenodesis Using an Onlay Technique

Tenodesis of the long head of biceps is a common shoulder surgical procedure. Tenodesis can be performed either arthroscopically or open and within the glenohumeral joint, within the bicipital groove, or below the pectoralis major tendon insertion. Arthroscopic tenodesis of the biceps tendon reduces the risk of infection. Our technique may also address persistent pain due to over tensioning of the tenodesis or from lesions hidden within the groove, such as bicipital synovitis or partial tendon tears, that are not visualized in a standard open technique. We describe an all-arthroscopic onlay technique for biceps tendon fixation at an extra-articular position within the bicipital groove, above the pectoralis major insertion. The technique uses standard arthroscopic equipment and a single knotless suture anchor.

Arthroscopic Subpectoral Tenodesis of the Long Head of the Biceps Brachii

The long head of the biceps brachii is a common pain generator in the shoulder that is often managed surgically with tenotomy or tenodesis. The clinical outcomes after tenotomy and tenodesis are comparable. However, tenodesis is preferred in the active population owing to complications associated with tenotomy, including cosmetic deformity, early fatigue, and cramping. Controversy surrounds both the approach and location of tenodesis. Both open and arthroscopic techniques have been described. An arthroscopic approach is used for tenodesis within the intertubercular groove between the humeral head articular margin and superior border of the pectoralis major but has the drawback of pathologic tendon retained in the groove. An open approach is generally reserved for subpectoral tenodesis, which has the advantage of no retained pathologic tendon but has the drawbacks of an open approach. We describe an all-arthroscopic technique for subpectoral tenodesis of the long head of the biceps brachii at the lower border of the pectoralis major.

Anatomical Description and Technical Considerations of the Portal of Willingboro for All-Arthroscopic Biceps Tenodesis

The portal of Willingboro is a unique portal designed as a means of all arthroscopic biceps tenodesis for biceps tendinopathy. The portal allows for tenodesis to be efficiently and effectively performed in the subgroove space with low technical demand. This Technical Note provides detailed descriptions of the anatomical structures and standard shoulder arthroscopy portals relevant to the location of the portal of Willingboro. The structures discussed include the standard anterior, posterior, and lateral shoulder arthroscopy portals along with the axillary and musculocutaneous nerves, subscapularis and pectoralis major tendons, axillary artery, and major bony anatomic landmarks of the shoulder region. These descriptions may be used as a guideline or reference for safe creation of the portal of Willingboro.

Arthroscopic Suprapectoral Retensioning Biceps Tenodesis

Tendinopathy of the long head of biceps is a relatively common pathology that we usually see in most of our shoulder arthroscopy procedures. Surgical treatment for long head of biceps tendinopathies ranges from simple biceps tenotomy to biceps tenodesis depending on many factors, two of which are the age and the patient's level of activity. Various techniques in the literature for biceps tenodesis have been described, such as whether to do it open or arthroscopically, suprapectoral or subpectoral, as well as the type of fixation to be used. However, the optimal option is still debatable. In this Technical Note, we describe an arthroscopic technique for distal suprapectoral biceps tenodesis using a knotless corkscrew anchor that has many advantages, such as being an all-arthroscopic with the ability to retension the tendon after implantation. We support our technique with photos and videos with detailed explanations of the technique.

Cost-Effective, Implant-Free, All-Suture Modified Subpectoral Biceps Tenodesis Technique

Tendinopathy and partial tears of the long head of the biceps tendon are a common cause of anterior shoulder pain and are often associated with many other shoulder pathologies. Multiple open and arthroscopic tenodesis techniques exist in the literature, with varying locations along the proximal humerus and a multitude of different implants. This article describes a cost-effective, implant-free, subpectoral biceps tenodesis technique that can be used as open or in conjunction with arthroscopy. Our technique differs from other tunnel techniques in its modified docking configuration into the intraosseous canal, decreasing stresses at the bone-tendon interface. With the cost amounting to 5% to 10% of techniques using implants, this is a cost-saving and reliable option for tenodesis.