25 Subpectoral Biceps Tenodesis

Jacob M. Kirsch and Michael T. Freehill

Summary

Subpectoral biceps tenodesis is a safe, reliable, and efficient procedure for managing various pathologies of the long head of the biceps (LHB) tendon. The LHB tendon is a common source of shoulder pain and generally occurs concomitantly with rotator cuff disease and labral injuries. A number of strategies exist to address the LHB including tenotomy and multiple tenodesis techniques. Subpectoral biceps tenodesis offers a distinct advantage by removing all diseased tissue from the bicipital groove. This potentially reduces the incidence of persistent pain, which otherwise may be left unaddressed with more proximally based techniques. Additionally, subpectoral biceps tenodesis may better restore the anatomic resting length and tension of the LHB, thereby providing a more cosmetic result with a decreased likelihood of biceps cramping. The all-suture double-loaded anchor utilizes a smaller osseous pilot hole and the benefit of unicortical intramedullary fixation. A small self-retrieving suture device (Accupass Direct, Smith & Nephew, London, UK) allows for smaller diameter soft tissue penetration while performing a double-lasso-loop configuration, resulting in a circumferential capture of the tendon. This subpectoral biceps tenodesis technique offers reliable pain relief, high patient satisfaction rates, and low rates of complications.

Keywords: biceps tendonitis/tenosynovitis, biceps tenodesis, SLAP, all-suture anchor

25.1 Patient Positioning and Planning the Surgical Approach

? Beach chair position with extremity in pneumatic arm holder (Spider2, Smith & Nephew).

? Abduct arm to identify and mark the inferior border of the pectoralis major tendon.

? Adduct arm to identify a crease to be utilized for skin incision.

? Roughly a 3 cm incision in marked axillary skin crease.

25.2 Surgical Technique

25.2.1 Surgical Exposure

? Abduct and slightly externally rotate the arm to expose axillary crease.

? 3 cm skin incision with No. 15 blade knife.

? Curved Metzenbaum scissors to bluntly dissect, exposing the interval between the pectoralis major tendon inferior border and the conjoined tendon critical plane to avoid neurovascular injury.

? A sharp Hohmann retractor placed deep to the pectoralis major tendon and over the lateral humeral cortex exposing the long head of the biceps (LHB) tendon.

? A blunt Hohmann retractor can be placed anterior (lateral) to the conjoined tendon to retract, helping visualization and to isolate the LHB; no retractive force is placed here. Hold the retractor straight to the bone.

? Once the LHB is confirmed, the blunt Hohmann is repositioned to reflect the LHB medially and expose the bicipital groove.

? A small Cobb elevator is used to roughen the periosteum of the bicipital groove at the planned tenodesis site.

25.2.2 Placing the Suture Anchor

The drill guide is placed at the planned tenodesis site and a unicortical pilot hole is made using a 2.8 mm drill. It is critical to stay perpendicular to the bicipital groove to avoid an eccentric hole and increased humeral stress riser.

The 2.8-mm,double-loaded all-suture anchor is then placed into the pilot hole and deployed.

The blunt Hohmann retractor is used to assist with visualization of the LHB.

A right-angle clamp is used to secure the LHB proximal to the planned tenodesis site.

Using a small diameter suture shuttle device, one of the suture limbs is passed through the LHB at the same level as the anchor. This suture will function as a post and provides an anatomic in situ position for the tenodesis for theoretical appropriate tensioning and symmetry.

25.2.3 Arthroscopic Portal Placement

Standard arthroscopic posterior and anterior portals are made following passing the initial suture though the LHB tendon.

25.2.4 Initiate Shoulder Arthroscopy

? Diagnostic arthroscopy.

? Tenotomy of the LHB is performed with an arthroscopic cutter or radiofrequency device.

? A stump of tissue is left to ensure the superior labrum is not breached. After the tenotomy, the remaining stump is gently debrided with a motorized shaver to recontour the superior labrum.

25.2.5 Completing the Tenodesis

? Returning to the surgical incision in the axilla, the sharp Hohmann retractor is replaced and the LHB is pulled from the shoulder into the wound.

? Using the opposite limb of the suture that was initially passed through the LHB as the post, a circumferential double-lassoloop is performed using the following steps:

? Pierce the LHB, retrieve the suture limb (nonpost), and pull part way through the tendon such that a loop is formed.

? Place the suture passer through this suture loop and then around one side of the LHB to retrieve the same suture tail and pull through. This completes half of the circumferential tenodesis for that suture limb.

? Complete the 360� circumferential tenodesis by repeating the above two steps; however, this time, pass around the other side of the LHB to retrieve the suture tail.

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Video 25.1 Surgical demonstration of a subpectoral biceps tenodesis with an all-suture double-loaded anchor.

? Once the circumferential tenodesis is complete for the first suture, the second suture in the double-loaded all-suture anchor is passed.

? As before, one limb is initially passed through the tendon in its entirety. This functions as another post.

? Using the opposing limb of this second suture, the circumferential tenodesis is completed using the steps described above.

? Once both sutures have been passed, the two suture limbs, which are posts of both sutures, are pulled delivering the tendon into the wound and down to the suture anchor against the periosteum.

? Each suture set is then tied and cut.

? The biceps tendon is then cut a minimum of 1 cm above the tenodesis site to avoid loss of suture fixation.

25.2.6 Wound Closure

? The wound is copiously irrigated.

? A layered closure is performed with 2?0 Vicryland a subcuticular running 3?0 Monocryl.

? Skin glue is optional, but is our preferred approach.

? A sterile nonadherent dressing strip is placed over the wound and then covered with a sterile dressing (? Video 25.1).

25.3 Tips and Tricks

? Establishing the plane between the pectoralis and the conjoined tendon is critical to avoid neurovascular injury.

? Retractor placement under the pectoralis and over the lateral humerus is essential for adequate exposure.

? In situ tenodesis helps approximate anatomic biceps length and tension.

? The all-suture double-loaded anchor utilizes a smaller osseous pilot hole and the benefit of unicortical intramedullary fixation.

? Double-lasso-loop configuration results in circumferential capture of the tendon for better definitive fixation.

25.4 Pitfalls and Complications

? Dissection beneath the conjoined tendon on initial dissection may lead to iatrogenic neurovascular injury.

? Avoid aggressive retraction of the conjoined tendon to minimize likelihood of iatrogenic neurovascular injury.

? The pilot drill hole should be perpendicular to the bicipital groove to avoid an eccentric stress riser, which could lead to fracture.

25.5 Rehabilitation

? Phase I: Passive range of motion (PROM) (starts 1 week post-op).

? Non-weight-bearing (NWB), sling at all times.

? PROM at the elbow (flexion/extension and forearm supination/pronation) to minimize activity of biceps.

? Phase II: Active range of motion (AROM) (starts 4 weeks post-op).

? NWB, wean from sling.

? Progress shoulder PROM to active assisted range of motion (AAROM) and AROM all planes to tolerance.

? Phase III: Strengthening (starts 6?8 weeks post-op).

? No heavy lifting at this time.

? Initiate biceps curls and supination/pronation with light resistance, progress as tolerated.

? Phase IV: Advanced strengthening (starts 10 weeks post-op).

? Return to full strenuous work/recreational activities.

? Avoid military press and wide grip bench press.

25.6 Rationale for Approach

? The LHB tendon is a common source of shoulder pain.1,2,3,4,5,6,7

? Subpectoral biceps tenodesis.8

? Reduces pain.

? High patient satisfaction.

? Removes all diseased tissue from the bicipital groove.

? Low complication rate.

? Aesthetically pleasing.

? All-suture anchor uses a small unicortical pilot hole theoretically decreasing the likelihood of iatrogenic fracture.

? In situ tenodesis may better restore the anatomic resting length and tension of the LHB, resulting in more predictable symmetric contour of the biceps and lower incidence of biceps cramping.

References

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[2] Werner BC, Pehlivan HC, Hart JM, et al. Increased incidence of postoperative stiffness after arthroscopic compared with open biceps tenodesis. Arthroscopy. 2014; 30(9):1075?1084

[3] Moon SC, Cho NS, Rhee YG. Analysis of ?hidden lesions? of the extra-articular biceps after subpectoral biceps tenodesis: the subpectoral portion as the optimal tenodesis site. Am J Sports Med. 2015; 43(1):63?68

[4] Werner BC, Lyons ML, Evans CL, et al. Arthroscopic suprapectoral and open subpectoral biceps tenodesis: a comparison of restoration of length-tension and mechanical strength between techniques. Arthroscopy. 2015; 31(4):620?627

[5] Szab� I, Boileau P, Walch G. The proximal biceps as a pain generator and results of tenotomy. Sports Med Arthrosc Rev. 2008; 16(3):180?186

[6] Carr RM, Shishani Y, Gobezie R. How accurate are we in detecting biceps tendinopathy? Clin Sports Med. 2016; 35(1):47?55

[7] Elser F, Braun S, Dewing CB, Giphart JE, Millett PJ. Anatomy, function, injuries, and treatment of the long head of the biceps brachii tendon. Arthroscopy. 2011; 27(4):581?592

[8] Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Mazzocca AD, Romeo AA. Complications associated with subpectoral biceps tenodesis: low rates of incidence following surgery. J Shoulder Elbow Surg. 2010; 19(5):764?768