Biceps Tenodesis: Anatomic Tensioning

Patient-specific mini-open subpectoral long head of the biceps tenodesis with anatomic tensioning: A surgical technique

Long head of the biceps tendon pathology is a well-described proximal shoulder pain generator. While optimal treatment strategy remains controversial, popular operative management includes biceps tenodesis. However, appropriate restoration of the anatomic length-tension relationship of the biceps with tenodesis remains a challenge. We aim to describe a patient-specific technique utilizing a mini-open subpectoral approach to mark the long head of the biceps myotendinous junction location within the intertubercular groove prior to arthroscopic origin tenotomy. This technique offers the ability to restore anatomic tensioning of the long head of the biceps without relying on variable anatomic relationships, additional portals, tools, or technical challenges.

Does the timing of tenotomy during biceps tenodesis affect the incidence of Popeye deformity and clinical outcome? An analysis of short-term follow-up of 2 techniques

BACKGROUND

There are multiple techniques that attempt to maintain anatomic length-tension relationship during biceps tenodesis. However, no direct comparison has been performed with respect to the timing of biceps tenotomy during biceps tenodesis. This study aims to assess the incidence of Popeye deformity and clinical outcomes of 2 all-arthroscopic techniques for biceps tenodesis based on timing of the biceps tenotomy.

METHODS

A consecutive series of patients undergoing arthroscopic biceps tenodesis with concomitant rotator cuff tears were enrolled from 2019 to 2021. Biceps tenodesis performed after tenotomy formed the first cohort (group 1). The other cohort had biceps tenodesis performed prior to biceps tenotomy (group 2). Postoperative anterior arm pain, biceps muscle spasms, and patient perceptions of the appearance of the bicep muscle were assessed. In addition, patient-reported outcomes (PROs) were collected at 3 months and minimum 6 months postoperatively.

RESULTS

A total of 71 patients were eligible for participation and 62 patients (53% female, age 58.7 ± 9.0 years) were enrolled (n = 33 in group 1, and n = 29 in group 2). There were no differences between groups with respect to gender, age, and laterality of biceps tenodesis, as well as type and size of rotator cuff repair. At 3-month follow-up, Veterans RAND 12-Item Health Survey (VR-12) physical health summary scores were significantly improved in group 2 (44.8 ± 9.7) compared with group 1 (34.1 ± 3.4) (P = .03). In addition, patients in group 2 experienced significantly less pain in their anterior arm than patients in group 1 (19% vs. 33%, P = .02). There were no differences in biceps muscle spasm (3.4% vs. 5.2%, P = .21) and no other differences in PROs between groups. Final follow-up averaged 11.6 ± 3.3 months in group 1 and 11.8 ± 5.5 months in group 2. There were no significant differences in patient-perceived biceps Popeye deformity between group 1 (12.1%) and group 2 (0%) (P = .652). Furthermore, there were no differences in American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form, EuroQol-5 Dimension, Patient-Reported Outcomes Measurement Information System Global Health (PROMIS 10) physical health, PROMIS 10 depression, VR-12 physical health summary, and Single Assessment Numeric Evaluation scores between the 2 technique groups.

CONCLUSION

Patients with tenotomy performed after tenodesis had better VR-12 physical health summary scores and less arm pain than patients with tenotomy performed before tenodesis at 3-month follow-up. However, there were no differences in any outcome at final follow-up of nearly 1-year. In addition, there were no differences in perceived Popeye deformity between groups at any time period.

All-Arthroscopic Anatomic Length-Tension Biceps Tenodesis With Unicortical Button

The long head of the biceps tendon is a frequent cause of persistent anterior shoulder pain. Biceps tenodesis is a popular choice for surgical management of this pathology, with myriad approach and fixation variations described. We describe an all-arthroscopic suprapectoral biceps tenodesis in the anatomic length-tension relation using a unicortical button. This technique offers an alternative method that provides proper tendon fixation at anatomic length with minimized additional surgical morbidity and postoperative complications.

Arthroscopic Biceps to Subscapularis Tenodesis: A Surgical Technique

A wide variety of techniques are available for tenodesis of the long head of the biceps tendon, and current literature does not favor any one in particular. We present a simple method for arthroscopic soft tissue biceps tenodesis that uses the subscapularis tendon as the anchor. This 5-step technique is time-efficient, technically simple, cost effective, and does not require powered instruments or specialized implants.

Characterization of the Proximal Long Head of Biceps Tendon Anatomy Using Magnetic Resonance Imaging: Implications for Biceps Tenodesis

BACKGROUND

Biceps tenodesis is a common treatment for proximal long head of biceps (LHB) tendon pathology. To maintain biceps strength and contour and minimize cramping, restoration of muscle-length tension and appropriate positioning of the tenodesis is key. Little is known about the biceps musculotendinous junction (MTJ) anatomy, especially in relation to the overlying pectoralis major tendon (PMT), which is a commonly used landmark for tenodesis positioning.

PURPOSE

To characterize the in vivo topographic anatomy of the LHB tendon, in particular the MTJ relative to the PMT, using a novel axial proton-density magnetic resonance imaging (MRI) sequence.

STUDY DESIGN

Descriptive laboratory study.

METHODS

In total, 45 patients having a shoulder MRI for symptoms unrelated to their biceps tendon or rotator cuff were prospectively recruited. There were 33 men and 12 women, with a mean age of 37 ± 13 years (range, 18-59 years). All patients underwent routine shoulder MRI scans with an additional axial proton density sequence examining the LHB tendon and its MTJ. Three independent observers reviewed each MRI scan, and measurements were obtained for (1) MTJ length, (2) the distance between the proximal MTJ and the superior border of the PMT (MTJ-S), (3) the distance between the distal MTJ to the inferior border of the PMT, and (4) the width of the PMT.

RESULTS

The average position of the MTJ-S was 5.9 ± 10.8 mm distal to the superior border of the PMT. The mean MTJ length was 32.5 ± 8.3 mm and the width of the PMT was 28.0 ± 7.3 mm. We found no significant correlation between patient age, height, sex, or body mass index and any of the biceps measurements. We observed wide variability of the MTJ-S position and identified 3 distinct types of biceps MTJ: type 1, MTJ-S above the PMT; type 2, MTJ-S between 0 and 10 mm below the superior border of the PMT; and type 3, MTJ-S >10 mm distal to the superior PMT.

CONCLUSION

In this study, the in vivo anatomy of the LHB tendon is characterized relative to the PMT using a novel MRI sequence. The results demonstrate wide variability in the position of the MTJ relative to the PMT, which can be classified into 3 distinct subtypes or zones relative to the superior border of the PMT. Understanding this potentially allows for accurate and anatomic placement of the biceps tendon for tenodesis.

CLINICAL RELEVANCE

To our knowledge, this is the first study to radiologically analyze the in vivo topographic anatomy of the LHB tendon and its MTJ. The results of this study provide more detailed understanding of the variability of the biceps MTJ, thus allowing for more accurate placement of the biceps tendon during tenodesis.

Physiologic Long Head Biceps Tendon Excursion Throughout Shoulder Range of Motion: A Cadaveric Study

Background:

Restoration of the long head of the biceps tendon (LHBT) length-tension relationship is critical in preserving muscle strength and efficiency when performing biceps tenodesis. While static anatomic landmarks such as the inferior border of the pectoralis major may be used intraoperatively to achieve this, shoulder position may affect the excursion of the biceps tendon and represents another variable to consider.

Purpose/Hypothesis:

The purpose of this study was to quantitatively evaluate the normal excursion of LHBT that occurs through a glenohumeral range of motion. We also sought to determine whether elbow position affects LHBT excursion. We hypothesized that LHBT excursion will be affected by glenohumeral flexion and extension, and elbow extension will result in increased excursion at each glenohumeral position compared with a neutral position.

Study Design:

Controlled laboratory study.

Methods:

A total of 10 fresh-frozen specimens underwent a standard approach for subpectoral biceps tenodesis. The LHBT was identified and tagged with a radiopaque marker within zone 3 of the bicipital tunnel. A total of 3 K-wires were then drilled into the osseous floor: one at the level of the marker in the LHBT, one at 1 cm proximal, and a third 1 cm distal. All 3 K-wires were then cut flush with the anterior humeral cortex. The specimens were next placed into 8 different positions, and the excursion of the LHBT was measured by referencing the K-wires using static fluoroscopic imaging. The results were analyzed using 1-way analysis of variance testing followed by Tukey honestly significant difference testing for pairwise comparison between each individual position and the reference position.

Results:

The average total LHBT excursion was 24.4 ± 5.2 mm between the neutral shoulder position and the other shoulder positions tested. The position of the LHBT was significantly different in the reference position compared with each of the other 7 shoulder positions (P < .001). Additionally, the 2 positions of shoulder extension had different LHBT excursions when compared with each position of shoulder flexion (P < .0001). For each shoulder position tested, the position of the LHBT was not significantly different in elbow flexion compared with extension.

Conclusion:

There is approximately 24 mm of LHBT excursion throughout the glenohumeral range of motion, with significantly different amounts of excursion in glenohumeral flexion and extension. Elbow position does not significantly affect LHBT excursion. Positioning the shoulder in extension during biceps tenodesis may overtension the biceps, while positioning the shoulder in flexion may undertension the biceps relative to the neutral position. Further research is needed to identify the optimal shoulder position for biceps tenodesis.

Clinical Relevance:

Shoulder positioning is an important consideration in establishing a normal length-tension relationship during biceps tenodesis. When compared with flexed shoulder positions, LHBT excursion significantly differs in positions of extension and in a neutral position.

Arthroscopic Onlay Articular Margin Biceps Tenodesis for Long Head of the Biceps Tendon Pathology

The long head of the biceps (LHB) tendon is a common source of shoulder pain. LHB tendon pathology typically occurs with concomitant rotator cuff or labrum injuries but can occasionally occur in isolation as biceps tendinopathy or rupture. Tenodesis has been increasingly used to treat LHB tendon pathology, and numerous techniques have been developed that vary in approach, fixation construct, and fixation location. In this Technical Note, we describe an arthroscopic onlay articular margin biceps tenodesis with suture anchors. This technique has several advantages, namely intra-articular visualization of the tenodesis, strong fixation to high density bone of the articular margin, and most importantly, preservation of the anatomic length-tension relationship.

Surgical management of type II superior labrum anterior posterior (SLAP) lesions: a review of outcomes and prognostic indicators

A Type II SLAP (superior labrum anterior posterior) lesion is a tear of the superior glenoid labrum with involvement of the long head of the biceps tendon insertion. In patients that do not improve with conservative treatment, there is a great deal of variability in the surgical management of these injuries that includes arthroscopic SLAP repair, arthroscopic SLAP repair with biceps tenodesis, biceps tenodesis alone and biceps tenotomy. Each surgical technique has specific effects on a patient's postoperative course and functional recovery. Rehabilitation strategies may be best formulated on an individual basis with an open line of communication between the operating surgeon and the physical therapist. Despite an increased incidence in treatment, there is currently no consensus on the optimal surgical procedure or treatment algorithm for Type II SLAP injuries. However, in middle-aged or older patients (>35) with Type II SLAP tears, either arthroscopic suprapectoral or mini-open subpectoral biceps tenodesis is recommended due to the higher failure rates observed with arthroscopic SLAP repair in this patient group. Although more patients present with a 'Popeye' sign after biceps tenotomy, long-term functional outcome is similar between biceps tenodesis compared to tenotomy. However, more patients will experience biceps fatigue or cramping after the tenotomy procedure. Biceps tenodesis is preferred in younger, more active patients, while tenotomy is preferred in the middle-aged or older and lower demand patients. The aim of this paper is to provide a brief description of the different surgical techniques employed to address Type II SLAP lesions (arthroscopic repair, biceps tenodesis, and biceps tenotomy) and provide a review of available literature regarding outcomes and prognostic factors associated with each technique.