Subpectoral biceps tenodesis
Yogesh Joshi, Chetan Bhalla, Mehek Asad and Asad Syed discuss differing techniques for the repair, tenotomy and tenodesis of the long head of the biceps
Biceps pathology in shoulder problems has been studied extensively in literature; controversies still exists for the optimum treatment for the condition. Pathology related to the long head of biceps (LHB) has been described, including LHB tendinitis, LHB tears, superior labral anterior posterior (SLAP) lesions and instability of LHB in the groove. Numerous treatment modalities have been described to treat these conditions which can be broadly classified into repair, tenotomy and tenodesis of the LHB tendon. With advances in arthroscopic techniques and instrumentation, many of the procedures are performed with arthroscopic assistance. Here we describe techniques which have been described to perform biceps tenodesis with a subpectoral approach.
Indications
According to the literature available, indications vary according to the opinion of the authors, and include partial thickness LHB tear >25% diameter, medial subluxation of LHB tendon, tendon subluxation with subscapularis tear, SLAP lesion grade IV and higher, SLAP repair failure and chronic anterior shoulder pain with LHB tendinitis [1–5]. Some studies have indicated that massive, irreparable rotator cuff tears in low demand patients may be treated with LHB tenodesis for pain relief [5,6]. Revision of failed proximal tenodesis or failed tenotomy are a few of the specific indications for subpectoral LHB tenodesis (SPBT), which are not addressed by proximal tenodesis [5].
Rationale
As the site of tenodesis is distal to the bicipital groove, the pathology related to the intertubercular groove itself is eliminated. The advantage of SPBT over tenotomy is the preservation of the muscle length–tension relationship and maintenance of elbow flexion and supination strength [7]. Moreover, it maintains the cosmesis of biceps bulk in the arm. SPBT creates less disruption to the deltoid muscle and sub-pectoral structures compared with arthroscopic tenodesis techniques [5]. It does not require advance arthroscopic skills as it is technically less demanding [5]. Proximal tenodesis may lead to residual redundant tendon, persistent groove pathology or sub-coracoid biceps impingement, which may lead to persistent LHB symptoms [5,8].
Operative technique
The patient is placed in the beach chair position and examination under anaesthesia is performed. A diagnostic arthroscopy is subsequently performed through a posterior portal and the biceps tendon is evaluated for any inflammation, tear, SLAP lesion or instability. Evaluation might be assisted with ‘dry arthroscopy’ to determine the true extent of inflammation of the intra-articular biceps tendon. An anterior portal is then made and a probe is inserted to retract the biceps tendon into the joint and evaluate the intertubercular portion of LHB. Concurrently, attention is given to the biceps anchor and to the superior labrum to evaluate any SLAP injury. Biceps pulley is also evaluated in the rotator interval and any subluxation of the LBT noted. Fraying of the biceps tendon is associated with pathology in approximately 30–50% of instances [9]. The biceps tenotomy is then performed through the anterior portal using arthroscopy scissors or radiofrequency ablator. The free end of the tendon can be left alone or tagged using a polydioxanone (PDS) using a long spinal needle.
The arm is then abducted and externally rotated to palpate the inferior border of the pectoralis major tendon. An incision is made along the axillary crease for better cosmetic outcomes. Dissection is then taken straight down to the bone, avoiding medial vascular and neurological structures. The LHB tendon is then identified after sharp dissection over the fascia overlying the pectoralis major tendon. The plane of dissection is kept below the inferior border of pectoralis major fibres which run horizontally. The LHB tendon is identified by deep palpation of the anterior humerus as a longitudinal tendinous structure. Medial dissection is avoided and the conjoint tendon is gently retracted medially to avoid damage to the musculocutaneous nerve.
The proximal LHB tendon is then retrieved into the wound using a tendon hook. The inferior border of the pectoralis major is then retracted proximally using a blunt right angle retractor. The position of tenodesis is marked at a point 1cm proximal to the inferior border of the pectoralis major tendon. Finally, the tenotomy of the LHB tendon is performed, leaving 2cm of tendon proximal to the musculotendinous junction.
Fixation techniques
Fixing the tendon in the bone tunnel [10]
After preparing the end of the tendon with a Krackow stitch, a bone tunnel is made at the pre-marked site. Two drill holes are made just inferior to it and the suture ends attached to the end of the prepared tendon are passed through the tunnel into the drill holes. The tendon is then pulled into the tunnel by pulling the suture ends, and tied after adequate tensioning (Figure 1).
Figure 1. Diagram of biceps tenodesis using bone tunnels
Fixing the tendon with an int