Subpectoral Biceps Tenodesis
Biceps tenodesis is a common procedure performed for tendinopathy of the long head of the biceps brachii (LHB). Indications include partial-thickness LHB tear, tendon subluxation with or without subscapularis tear, and failed conservative management of bicipital tenosynovitis. Biceps tenodesis may also be performed for superior labrum anterior to posterior tears.
Evaluation of biceps stability is important in the treatment of LHB pathology. We advocate a technique of subpectoral biceps tenodesis. Interference screw fixation has demonstrated biomechanical superiority in laboratory models. If there are any concomitant operations, such as rotator cuff repair, the postoperative rehabilitation protocol may need to be adjusted. Overall, subpectoral biceps tenodesis with interference screw fixation has had excellent clinical outcomes and low complication rates.
Werner and colleagues34 encountered stiffness more than any other complication and found it to be more common in their arthroscopic group (9.4%) than in their open group (6.0%). They used intra-articular corticosteroid injections and physical therapy to successfully treat all cases of postoperative stiffness. Humeral fracture is uncommon after tenodesis.37,42 In a recent biomechanical study, however, Euler and colleagues40 found a significant reduction (25%) in humeral strength after a laterally eccentric, malpositioned biceps tenodesis. This decreased osseous strength may increase susceptibility to humeral shaft fracture, especially when interference screw fixation is used. Sears and colleagues37 and Dein and colleagues42 presented case reports of humeral fracture after biceps tenodesis with an interference screw.
For patients with fixation failure or continued anterior shoulder pain, revision biceps tenodesis is safe and effective. Heckman and colleagues43 and Gregory and colleagues44 showed revision tenodesis can lead to excellent pain relief and functional outcomes, for it allows complete removal of the biceps from the groove and preserves biceps function. Gregory and colleagues44 revised subpectoral biceps tenodesis for either continued pain or fixation failure and found significant improvements in pain and function a mean of 33.4 months after surgery. Anthony and colleagues45 performed biceps tenodesis for failed surgical tenotomies and autorupture of the LHB tendon. In their study of 11 patients, this surgery resulted in symptom improvement, patient satisfaction, resolution of Popeye deformity, and predictable return to activity.
Conclusion
LHB tendon pathology is a significant source of anterior shoulder pain and functional limitation. Diagnosis and treatment of this pathology can be challenging, and it is important to identify any concomitant pathologies or other pain sources. After failed nonoperative management, surgeons have the option of mini-open subpectoral biceps tenodesis—a safe, reliable, and effective treatment with excellent outcomes. Although multiple fixation options are available, we think that, based on the current literature, fixation with a bioabsorbable interference screw remains the best option. This procedure has demonstrated efficacy for revision biceps tenodesis, failed biceps tenotomy, and autorupture of the biceps.
