Operative Techniques in Orthopaedic Surgery (4 Volume Set) 1st Edition

7. Arthroscopic Treatment of Biceps Tendonopathy

J. R. Rudzki and Benjamin S. Shaffer

DEFINITION

images The long head of the biceps tendon has long been recognized as a potential source of pain and cause of shoulder impairment.1,19,20,33

images Although biceps tendon pathology can occur in isolation, it more frequently occurs concomitantly with rotator cuff disease, and its neglect may account for a subset of patients who fail to respond to rotator cuff repair.

images Pathology of the long head of the biceps tendon presents in a spectrum from subtle tendinopathy observed on diagnostic imaging studies to frank tearing or subluxation appreciated intraoperatively.

images Because the functional significance of the biceps tendon long head has been the subject of considerable debate, treatment has often been tailored more to patient symptoms, activity levels, and expectations rather than strict operative criteria.

images The ideal indications and optimal operative technique remain controversial, although recent advances in arthroscopic technology have led to an evolution of surgical strategies.

ANATOMY

images The long head of the biceps brachii originates from the supraglenoid tubercle and the superior aspect of the glenoid labrum.

images Multiple anatomic variants of the long head biceps tendon origin have been described, the most common of which involves an equal contribution from the anterior and posterior labrum.32

images The tendon travels intra-articularly (but extrasynovially) an average of 35 ± 5 mm toward the intertubercular (bicipital) groove between the greater and lesser tuberosities.28

images The mean tendon length is 9.2 cm, with greatest width at its origin (about 8.5 × 7.8 mm).23

images At the site of intra-articular exit lies the annular reflection or biceps pulley, whose fibers are derived from the superior glenohumeral, the coracohumeral ligament, and the superficial or anterior aspect of the subscapularis tendon (FIG 1). Externally this structure's counterpart is the transverse humeral ligament.

images The bicipital groove has been a topic of significant study in the literature for its relevance to arthroplasty and it has been implicated as a contributing factor to tendinopathy involving the long head of the biceps.6,26

images The dimensions of the bicipital groove vary along its mean 5-cm length. At its entrance, the width ranges from 9 to 12 mm, and the depth is about 2.2 mm. In its midportion, the groove narrows to a mean width of 6.2 mm and depth of about 2.4 mm, which may contribute to the entrapment of a hypertrophic intra-articular component; this has been referred to as the “hourglass biceps.”6,15,26

images The bicipital groove internally rotates from proximal to distal with a mean change in rotation of the lateral lip estimated at about 16 degrees.15

images The biomechanical significance of the biceps tendon long head is controversial. Some authors have advocated a role of the long head of the biceps in contributing to shoulder stability in overhead athletes.12,25Other authors, in separate studies, have used electromyographic analysis to conclude that the long head of the biceps tendon does not contribute to shoulder stability.18,36

images

FIG 1  A. Arthroscopic view of long head of biceps tendon and proximal aspect of bicipital groove. B. Anatomy pertinent to surgery involving the long head of the biceps tendon.

images The extent of functional loss of supination and elbow flexion strength after biceps tenotomy has not been clearly established and is a source of controversy in the literature but may be estimated at 10%.34

PATHOGENESIS

images Long head of biceps tendinopathy encompasses a spectrum of pathology, including intratendinous signal change, synovitis of the sheath, partial tearing, and frank tendon rupture (FIG 2).

images The etiology of long head biceps tendinopathy is thought to be multifactorial.

images Identifiable causes include degenerative changes (usually in association with rotator cuff disease),19,33,34 degenerative os teophyte spurring and stenosis within the bicipital groove,6,26 inflammatory disease, traumatic injury, lesions of the biceps pulley complex or subscapularis tendon, and subtle forms of glenohumeral instability or superior labral anterior posterior (SLAP) tears.

images Lesions of the pulley complex (which contributes to stability of the tendon within the intertubercular groove) or tears of the upper subscapularis tendon may permit intra-articular subluxation and mechanical symptoms.

images “Hidden” cuff tears within the rotator interval or compromise of the annular reflection pulley may permit extra-articular long head biceps subluxation, which can lead to pathologic changes to the long head biceps tendon.

images Tears of the superior labrum such as type II SLAP tears and more subtle patterns of instability such as the peel-back mechanism in throwing athletes can also cause bicipital tendinopathy.

images

FIG 2  Arthroscopic images of tendinopathy and tearing of the long head of the biceps tendon.

NATURAL HISTORY

images Little is known about the natural history of biceps tendinopathy, so prediction of a patient's clinical course is difficult.

images Patients with high-grade tendinopathy, either in isolation or in association with cuff tears, seem to be at risk of subsequent rupture.

images Spontaneous rupture often alleviates the chronic pain preceding the event.34

PATIENT HISTORY AND PHYSICAL FINDINGS

images As for bicipital tendinopathy, patients' historical presentations vary.

images Patients may complain of anterior shoulder pain exacerbated by resisted elbow flexion and supination.

images The history and character of shoulder pain is less helpful in making the diagnosis than the appropriate physical examination and diagnostic imaging findings in a relevant context.

images Biceps tendon disorders can present either in isolation or in association with other pathology, typically tears of the rotator cuff.

images Pain due to biceps pathology is often referred to the bicipital groove area.

images Physical examination findings are variable but typically include focal tenderness to palpation over the course of the biceps long head in the bicipital groove.

images Examinations and tests to perform include:

images Speed's test: low sensitivity and specificity (estimated 32% to 68% and 56% to 75%); may be indicative of biceps tendinopathy in appropriate clinical setting

images Yergason's test: A positive result suggests biceps tendinopathy in the appropriate clinical context.

images Active compression test: Primarily assists in differentiating between symptomatic superior labral pathology and acromioclavicular joint pathology. A positive result may suggest biceps tendinopathy in the appropriate clinical context.

images Despite these recommendations, few studies have corroborated the sensitivity, reliability, or accuracy of these findings.

IMAGING AND OTHER DIAGNOSTIC STUDIES

images Magnetic resonance imaging (MRI) and ultrasound are the primary methods by which biceps tendinopathy is diagnosed.

images For the diagnosis of subluxation or dislocation of the long head of the biceps, ultrasound has a reported sensitivity of 96% to 100% and specificity of 100%.2 For the assessment of complete rupture or the determination of a normal tendon, ultrasound has a sensitivity of 50% to 75% and specificity of 100%. Ultrasound is most useful to demonstrate pathology in the intertubercular groove and has been shown to be highly operator-dependent.

images MRI can identify intratendinous tendon abnormality, bicipital sheath hypertrophy, concomitant superior labral and rotator cuff pathology, the intra-articular course of the tendon, and the relationship of the biceps to the structures of the annular reflection pulley that stabilize it (FIG 3).

DIFFERENTIAL DIAGNOSIS

images Long head biceps brachii tendinitis or tenosynovitis

images Long head biceps brachii partial tear

images Long head biceps brachii rupture

images Long head biceps brachii instability or subluxation

images

FIG 3  Coronal MR image showing a normal-appearing biceps tendon in the bicipital groove adjacent to a normal subscapularis tendon and overlying annular reflection pulley.

images SLAP tear

images Acromioclavicular joint pathology

images Anterosuperior rotator cuff tear

images Subcoracoid impingement

images Subscapularis pathology

NONOPERATIVE MANAGEMENT

images Treatment of biceps tendinopathy depends in part on whether it presents in isolation as a primary problem or is associated with other pathology.

images Alternative nonoperative management of suspected biceps pathology includes activity modification, a course of nonsteroidal anti-inflammatory medication, and corticosteroid injections targeted directly into the biceps sheath within the intertubercular groove. Such an injection can be both therapeutic and diagnostic.4

images Some authors have advocated injection under ultrasound guidance.

images Long head biceps ruptures traditionally have been treated with nonoperative management, based on the perception that this problem rarely results in any significant impairment.

images Patients may object, however, to the presence of a “Popeye” deformity (bulge in the volar aspect of the midportion of the brachium) (FIG 4) and possible fatigue-related cramping.

SURGICAL MANAGEMENT

images Surgical decision making includes patient factors, biceps tendon structural compromise, and concomitant shoulder pathology.

images

FIG 4  “Popeye” deformity of the left arm.

images With respect to tendon involvement, nonscientific relative surgical indications include symptomatic partial-thickness tearing or fraying greater than 25% to 50% of its diameter, or tendon subluxation or dislocation from its normal position within the bicipital groove.

images Patient factors influencing treatment include the patient's age and activity level, occupation, desired recreational activities, and expectations.

images Because the biceps tendon is a known “pain generator,” its evaluation and inclusion in treatment of cuff disorders is particularly important.

images Preoperative consideration must be given to anticipate operative strategies if encountered.

images Operative alternatives in treating biceps tendon disorders include débridement, tenolysis (release of the biceps tendon long head), and tenodesis, in which the biceps is reattached to either bone or soft tissue of the proximal humerus. Each has advantages and disadvantages (Table 1).

images The selected surgical approach should take into consideration patient factors, intraoperative findings, and surgeon preference and comfort.

images Patient factors include age, work, recreational and activity demands, expectations, and perspective on influence of cosmesis.

images Intraoperative findings influence decision making in a number of ways, including bone quality, soft tissue quality, the presence of injury to the biceps sling or subscapularis, and the presence of instability.

images Surgeon factors include arthroscopic proficiency and experience and concomitant surgical procedures that may influence the treatment approach (eg, swelling in the subacromial space during concomitant arthroscopic rotator cuff repair).

images Few studies have compared surgical alternatives within the same population of patients. Most such comparative studies have design flaws due to patient and pathology heterogeneity, in addition to procedures addressing frequent concomitant pathology.

image

images

FIG 5  Arthroscopic débridement of a partial-thickness tear.

images The ideal indications for débridement versus tenolysis versus tenodesis (soft tissue or bone) remain unclear at this time.

images Arthroscopic débridement is an initial component of nearly every biceps tendon surgical procedure.

images In cases of fraying or partial tearing, débridement alone may be adequate to eliminate its contribution as a pain generator (FIG 5).

images This is particularly true in cases in which the preoperative workup did not suggest the biceps as a significant component of patient symptoms, and when concomitant pathology may otherwise explain the patient's presentation.

images The degree of tendon involvement requiring definite surgical management with either tenolysis or tenodesis has not been scientifically established in the literature and varies depending on concomitant pathology.

images Some authors have advocated consideration of addressing the biceps tendon surgically with débridement alone when less than 50% of the tendon's diameter appears involved (in addition to addressing any concomitant pathology), but assessing the percentage of tendon involvement is an inexact science.

images When the biceps is thought to be the predominant cause of symptoms or occurs in isolation, débridement alone may fail to adequately address the pathology and relieve the patient's symptoms.

images With regard to tenodesis studies, biomechanical analysis has focused on construct strength.

images Several tenodesis techniques provide sufficient construct strength, based on load-to-failure and cyclic displacement data.

images One such study found that one particular interference screw tenodesis had a statistically significant greater resistance to pullout than a double suture anchor technique.28

images Despite biomechanical testing, the actual amount of fixation strength necessary (and whether there is clear superiority of bone or soft tissue reattachment) is unknown.

Preoperative Planning

images Clinical evaluation to determine the contribution of the biceps tendon to patient symptoms is an important component of decision making and helps when encountering biceps pathology.

images Examinations for cuff pathology, particularly in the rotator interval (“hidden lesions” of the cuff) and for subscapularis integrity (belly press or lift-off test) are necessary components of the preoperative workup.

images Accurate preoperative evaluation should include appropriate radiographs to assess bicipital and acromial (outlet view) morphology.

images The bicipital groove view permits assessment of groove depth and the presence of osteophytes but may be unnecessary given the typical quality of routine axial MR images.8

images MR images can be viewed to assess for biceps continuity (sagittal and coronal views) and intratendinous signal change (axial views) as well as tendon subluxation (axial and coronal views).

images Attention must be paid when examining MR films to evaluate the appearance of the adjacent subscapularis, whose upper border is an important restraint against inferior biceps subluxation.

Positioning

images Positioning is a matter of surgeon preference.

images When biceps tendon pathology is perceived to be isolated or a significant component of the patient's presentation, we have found that beach-chair positioning affords optimal orientation.

images Biceps tenodesis or tenolysis can also be easily performed in the lateral decubitus position.

images All bony prominences are carefully padded and the neck is maintained in a neutral position, ensuring adequate circumferential exposure to the scapula (posteriorly) and medial to the coracoid (anteriorly).

images Alternatively, depending on surgeon preference, the patient may be placed in the lateral position.

Approach

images Standard arthroscopic portals for this procedure include the posterolateral portal for initial viewing, an anterior “operative” rotator interval portal, and the direct lateral subacromial portal (operative and viewing).

images Additional accessory portals within the antero-supero-lateral aspect of the rotator interval may facilitate work in the subdeltoid space during tenodesis.

images On initial arthroscopic examination, the biceps is carefully inspected along its course from the posterosuperior glenoid labral attachment to its exit within the bicipital sheath.32

images Examination should include both visualization along the course and down the sheath (enhanced by use of a 70-degree lens) and palpation.

images Because only a portion of the biceps tendon long head is visualized within the joint, the biceps tendon must be translated into the joint using a probe, switching stick, or some tissue-safe tool. This enhances the surgeon's ability to visualize tendinopathic changes that may otherwise go unrecognized.

images Meticulous examination of the proximate annular reflection pulley and subscapularis tendon insertion is obligatory.

images Biceps long head abnormalities can include.

images Hyperemia, seen in patients with adhesive capsulitis or in biceps instability

images Overt subluxation: Most commonly subluxation is inferior due to injury to its inferior restraints, composed of the upper subscapularis tendon, or bicipital sling, composed of the intra-articular extension of the coracoacromial and coracohumeral ligaments.

images Subtle subluxation: Some authors have described a subtle instability pattern in which biceps tendon excursion within the otherwise normal-appearing sheath is greater than normal and deserves “stabilization.”

images Biceps “incarceration”: Some authors advocate the arthroscopic active compression test to assess for this uncommon entity. This test is performed intraoperatively with the arm positioned in forward elevation, slight adduction, and internal rotation.

TECHNIQUES

BONY TENODESIS

Arthroscopic Interference Screws

images  Before release at the superior labral attachment, the biceps long head must be controlled.

images This is best achieved by the securing suture about 1 to 2 cm distal to the attachment.

images This can be done either via spinal needle and PDS percutaneously, or by suture passage using a variety of available suture-shuttling instruments.

images The biceps tendon attachment is then released at the anterosuperior glenoid using a bipolar cautery, arthroscopic scissors or basket, or retractable knife.

images  The suture tagging the long head of the biceps tendon is then retrieved though an anterior skin incision just outside the arthroscopic cannula and secured with a Kelly clamp.

images  The arthroscope is redirected into the subacromial space. Using the direct lateral portal, an arthroscopic bursectomy facilitates adequate visualization within the subdeltoid space and selection of the site of tenodesis.

images  Visualization of the anterosuperior proximal humerus in the subdeltoid space may be facilitated by placing the traditional lateral portal slightly more anteriorly, as advocated by Romeo et al.29

images With the camera repositioned in this lateral portal, the long head of the biceps tendon is identified in the sheath within the intertubercular groove (just lateral to the lesser tuberosity); this can be facilitated by a spinal needle.

images  Using the small incision through which the biceps has been retrieved, the bicipital sheath is now incised with an arthroscopic scissors, electrocautery device, or retractable arthroscopic knife.

images  The release is performed along the lateral aspect of the sheath to minimize any risk to the subscapularis tendon's insertion.

images  The release should also be deep enough only to visualize the groove and tendon within it, because the ascending branch of the anterior humeral circumflex artery (the primary blood supply to the humeral head) lies beneath.

images  This incision in the bicipital sheath is carried proximally to the lateral aspect of the rotator interval and the tendon is then retrieved through either the anterior or accessory anterolateral portal and secured with a clamp.

images  The proximal end of the tendon is then resected after first placing a nonabsorbable whipstitch just distal to the site of intended tenotomy.

images Because the interference screw can cause fraying of conventional first-generation sutures, the whipstitch is better composed of a newer second-generation material such as FiberWire or Herculine.

images  The suture should be placed 10 to 20 mm distal to the exposed proximal portion, depending on how much diseased tendon is present, how much was resected intraoperatively, and the intended location of the tenodesis.

images  When using an interference screw, the surgeon must ensure that the length of the suture is sufficient to pass through the cannulated interference screwdriver (TECH FIG 1).

images Attention to suture management by use of cannulas is critical at this point. They ensure optimal visualization and soft tissue and suture management and minimize iatrogenic trauma to adjacent soft tissues.

images  A guidewire for the tenodesis screw is driven into the intertubercular groove about 15 mm distal to the superior aspect of the groove (at the leading edge of the supraspinatus insertion).29 The guidewire is inserted perpendicular to the groove to a depth of 30 mm.

images  The scope is repositioned within the lateral (or most anterior lateral) portal and a cannulated 8-mm reamer is drilled to a depth of about 30 mm under direct arthroscopic visualization.

images  The guidewire is removed and a screw is selected for tenodesis. Usually an 8-mm bioabsorbable implant is chosen, but this varies depending on bone quality.

images  The proximal tendon is then retrieved with its previously placed whipstitch from the subdeltoid space out through the anterolateral portal.

images  One limb of the whipstitch is loaded to the tenodesis screwdriver, and the bioabsorbable screw is loaded.

images  The suture limb within the screwdriver is secured with a clamp at the top of the driver, thereby fixing the tendon at the tip of the insertion device for delivery to the base of the tunnel.

images  The tendon and driver are inserted the full depth of the tunnel, and the interference screw is advanced while maintaining the driver position and suture tension. It should be advanced such that it is flush with the cortical surface of the intertubercular groove.

images  The two remaining suture limbs (one exiting the cannulated screw, the other trailing between the screw and the bone tunnel) are arthroscopically tied on the top of the interference screw, providing further reinforcement.

images  The arthroscopic portals and subacromial space are irrigated thoroughly and injected with local anesthetic with epinephrine.

Arthroscopic Suture Anchors

images  Before being released at the superior labral attachment, the biceps long head must be controlled. This is best achieved by securing the suture about 1 to 2 cm distal to the attachment.

images

TECH FIG 1  Arthroscopic interference screw method of tenodesis of the long head of the biceps tendon. The arthroscope is in the lateral subacromial working portal. A. The tendon is placed into the recipient hole in the bicipital groove and securely fixed with an interference screw. B. Completed tenodesis.

images  This can be achieved either via spinal needle and PDS percutaneously or by suture passage using a variety of available suture-shuttling instruments.

images  The biceps tendon attachment is then released at the anterosuperior glenoid using a bipolar cautery, arthroscopic scissors or basket, or retractable knife.

images  The tagging 0 PDS suture controlling the proximal aspect of the tendon is pulled through the anterior portal skin incision outside of the cannula and secured with a Kelly clamp.

images  The arthroscope is redirected into the subacromial space, where a bursectomy is performed from a direct lateral portal for adequate visualization within the subdeltoid space. The site of tenodesis is then selected based on surgeon preference.

images  The intertubercular groove is identified by incising the annular reflection pulley as described above, and an arthroscopic burr is used to prepare the intertubercular groove by generating a bleeding bony bed.

images  Next, two suture anchors are inserted (one proximal and one about 1 to 1.5 cm distal) within the prepared intertubercular groove, and sutures from these anchors are shuttled through the long head of the biceps tendon using a spinal needle and 0 PDS suture or a penetrating grasper device to securely fix the biceps into the groove.

images  Although simple mattress sutures may be effective at achieving fixation, compromised tissue quality may lend to gradual suture–tissue failure, with pulling out of the tendon and failure.

images An alternative locking knot configuration can be achieved using multiple percutaneous shuttling sutures, retrieved through the anterior interval cannula (TECH FIG 2).

images Alternatively, the Mahalik biceps hitch, as described by Mahalik and Snyder, affords excellent fixation of the biceps tendon for tenodesis.

images  An alternative technique involves an intra-articular tenodesis. Advantages include the ability to perform the procedure without requiring movement of the scope from the joint to the subacromial space, or subacromial bursectomy.

images In this procedure, a stay suture is placed at the origin of the biceps sheath just at the anterior margin of the supraspinatus.

images Flexion of the shoulder and use of a 70-degree lens facilitate identification of the most superior aspect of the bicipital groove. This will be the site of tenodesis.

images The biceps tendon is released from its origin, with the stay sutures percutaneous (at the site of spinal needle penetration).

images The anterosuperior portal is used to target the proximal humeral tenodesis site, generating a healing response along the proximal centimeter of the bicipital groove. By rotating and flexing the shoulder, the biceps tendon can be translated to permit good visualization of the tenodesis site and to facilitate subsequent targeting for anchor placement.

images Several alternative fixation techniques exist, the most common of which is anchor insertion, followed by suture passage and knot tying through the proximal tendon stump.

images Alternatively, the surgeon may make multiple passes through the biceps tendon (using a locking stitch of nonabsorbable suture such as FiberWire) and then use a knotless-type anchor (such as the Arthrex “push-lock” or “swivel-lock”) to perform a secure tenodesis in a percutaneous fashion over a previously placed small-diameter cannula. This latter technique is particular good in cases with cuff tears, in which the proximal bicipital groove is so readily accessible.

images

TECH FIG 2  Arthroscopic images showing intra-articular tenodesis of the long head of the biceps tendon at the proximal aspect of the bicipital groove. A. Anchor placement. B. Suture passage. C. Knot tying. D. Completed tenodesis.

SOFT TISSUE TENODESIS

Arthroscopic Fixation

images  This technique, in which the biceps tendon is secured to the soft tissues in the rotator interval, is based on the percutaneous intra-articular transtendon (PITT) technique described by Sekiya30 and Rodosky10(TECH FIG 3).

images  A spinal needle is placed percutaneously through the lateral aspect of the rotator interval proximate to the annular reflection pulley and then through the biceps tendon, about 1 to 2 cm distal to its supraglenoid origin.

images

TECH FIG 3  Percutaneous transtendinous or soft tissue tenodesis of the long head of the biceps tendon. A. Coronal plane view of suture fixation to secure the long head of the biceps tendon to the adjacent soft tissue structures in the proximal portion of the bicipital groove. B. Sagittal view showing the fixation with the arm in forward elevation and the knots secured in the subdeltoid space.

images  A 0 PDS suture is then shuttled through the tendon; it is retrieved through the anterior interval portal using a grasper.

images  This suture is then replaced by shuttling a nonabsorbable suture (such as no. 2 FiberWire or other comparable suture).

images  This process is repeated 5 to 6 mm distally along the biceps tendon's course just proximal to the superior aspect of the intertubercular groove. Ideally, this second suture is of a different color so that the first set of suture limbs can be distinguished from the second.

images  Next, the limb of the no. 2 nonabsorbable suture exiting the cannula is shuttled with the second PDS back through the biceps and annular reflection pulley. A mattress suture is placed in these structures. It exits the skin through two separate punctures made by the spinal needle passages.

images  A tenotomy is performed via the anterior interval portal using an Arthrocare wand, needle-tip Bovie, arthroscopic scissors, or up-biting narrow meniscal basket.

images  The intervening residual stump is excised and the arthroscope repositioned within the subacromial space, which is carefully débrided to enhance visualization and retrieval of the two suture sets.

images Retrieval of the percutaneous suture pairs is facilitated with an arthroscopic “crochet hook.”

images An alternative technique for retrieving hard-to-find sutures involves making a small incision directly over the percutaneous suture exit sites and loading the suture limb within a single-loop knot pusher, which is then pushed through the skin and into the cleared anterior subacromial space. The sutures are then easily identified and grasped, unloading from the knot pusher, which is withdrawn without difficulty.

images  Upon retrieval, which can be done one at a time, mattress sutures are tied under direct arthroscopic visualization in the anterior subacromial space.

images  After thorough irrigation, the joint, subacromial space, and arthroscopic portals are infiltrated with 0.25% Marcaine with epinephrine.

ARTHROSCOPIC BICEPS TENOTOMY

images  In the appropriately selected patient, the procedure is carried out by simply releasing the biceps tendon at its attachment site from a rotator interval portal while viewing from posteriorly.

images  The intervening segment of diseased biceps tendon(in cases of tendinopathy) can be resected.

images  Distal migration of the tendon can be discouraged by either leaving a residual wider portion of the diseased tendon just proximal to the proximal bicipital groove or by including a small piece of the anterior superior labrum at the time of tenotomy.

images  Either of these strategies may preclude the tendency for distal translation and formation of a “Popeye” muscle.

images

POSTOPERATIVE CARE

images The postoperative protocols for long head biceps tendon surgery vary according to the specific technique (débridement, tenotomy, or tenodesis).

images Often the protocol will depend on the concomitant procedures, such as rotator cuff repair, performed.

images In general, after tenotomy, sling immobilization is used for 4 to 6 weeks, with passive elbow flexion and extension as dictated by the surgeon's preference and comfort level.

images Forceful, active elbow flexion is prohibited for 6 weeks, by which time it is expected that the biceps tendon will have scarred into the groove or “autotenodesed” sufficiently to begin active motion.23

images This period of protection also serves to minimize the potential for a Popeye deformity and fatigue-related cramping.

images To further minimize the risk of distal retraction, some surgeons have described the use of a compressive wrap around the arm.

images If too tight, however, the effect may be that of a tourniquet, leading to pain, swelling, and ecchymoses.

images After biceps tenodesis, patients are immobilized in a sling for 4 to 6 weeks, with the amount of active-assisted elbow flexion and extension dictated by surgeon preference and comfort.

images Active elbow flexion is prohibited for about 6 to 8 weeks to allow tenodesis healing.

images Some surgeons favor limiting the last 15 to 20 degrees of terminal extension for 4 to 6 weeks after surgery to minimize stress at the tenodesis site.

images Active elbow flexion exercises are then slowly incorporated into the rehabilitation program after 6 to 8 weeks, with strengthening delayed until the third postoperative month.

OUTCOMES

images Outcome interpretation is challenging because of the limited number of studies and the lack of homogeneous patient populations. Surgical procedures to the biceps are typically only one component of surgically treated shoulder pathology in most studies.

images Arthroscopic tenodesis

images Checchia et al7 reported 93% good and excellent results in 14 of 15 patients, as determined by UCLA scores, who underwent arthroscopic rotator cuff repair and transtendinous soft tissue tenodesis at a mean follow-up of 32 months.

images Boileau et al5 reported their results of arthroscopic biceps tenodesis with interference screw fixation at mean follow-up of 17 months with a Constant score improvement from 43 preoperatively to 79 at latest follow-up (P <0.005).

images The historical literature regarding biceps tenodesis defines a range of unacceptable or poor results ranging from 6% to 40%.16

images The results of open biceps tenodesis have been variable and are summarized in Table 2. Briefly, the results of arthroscopic tenodesis to date indicate that the procedure is an effective treatment for refractory biceps tendinopathy in appropriately indicated patients and may be more favorable for patients under 60 years of age.

images Arthroscopic tenotomy

images Outcomes of arthroscopic tenotomy suggest that in the appropriately selected patient, this procedure can reliably provide pain relief, with minimal functional limitations or functional improvement.

images Gill et al11 in 2001 reported their results of tenotomy in 30 patients at a mean follow-up of 19 months. These patients scored an average of 82 by the American Shoulder and Elbow Surgeons (ASES) grading scale (but no preoperative comparison data were available) and a significant reduction in pain and improvement in function. They reported 87% satisfactory results and a complication rate of 13%, including one patient with a painless cosmetic deformity, two patients with loss of overhead function and subacromial impingement, and one patient with persistent pain.

images

images Kelly et al16 reported the results of 54 arthroscopic tenotomies at a mean of 2.7 years of follow-up, with 68% good to excellent results. However, 70% had a Popeye sign, and 38% of patients reported fatigue-related discomfort. They found minimal loss of elbow strength as assessed by biceps curls, and 0% loss for individuals over 60. Fatigue-related discomfort was not present in the patients over 60.

images Walch et al33 in 1998 reported the results of 307 arthroscopic tenotomies of the long head of the biceps in conjunction with cuff tear treatment. They found a statistically significant improvement in the mean Constant score from 48 to 68 points and reported 87% satisfactory results.

images In summary, the results of arthroscopic tenotomy to date indicate that the procedure is an effective treatment for refractory biceps tendinopathy in appropriately selected patients and may be more favorable for patients over 50 to 60 years of age.

COMPLICATIONS

images The primary complications of tenodesis include persistent pain, failure of the tenodesis, and refractory tenosynovitis.

images Failure of the tenodesis to heal may result in rupture of the tendon with distal retraction. In such cases, as often occurs in patients with spontaneous biceps tendon rupture, symptoms usually resolve with time.

images One study has suggested that the quality of remaining tendon available for tenodesis can significantly affect the success of the procedure.5

images Recent evidence suggests that oral nonsteroidal antiinflammatory medication may inhibit healing, so this may be a suboptimal postoperative analgesic option.

images The primary complications of tenotomy are:

images Cosmetic deformity in the form of a Popeye sign

images Fatigue-related cramping

images Potential slight decrease in elbow supination and flexion strength

REFERENCES

1.     Alpantaki K, McLaughlin D, Karagogeos D, et al. Sympathetic and sensory neural elements in the tendon of the long head of the biceps. J Bone Joint Surg Am 2005;87:1580–1583.

2.     Armstrong A, Teefey SA, Wu T, et al. The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. J Shoulder Elbow Surg 2006;15:7–11.

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