n tips & techniques Section Editor: Steven F. Harwin, MD
Open Subpectoral Biceps Tenodesis: Reliable Treatment for All Biceps Tendon Pathology Patrick Kane, MD; Philip Hsaio, BS; Bradford Tucker, MD; Kevin B. Freedman, MD, MSCE
Abstract: Long head of the biceps (LHB) tendon pathology is a common cause of pain in the shoulder. Pathology encountered includes biceps tendon tears and tendonitis, biceps anchor or superior labral tears, and biceps subluxation or instability. Current surgical treatment options for LHB disorders include tenotomy and tenodesis. Tenodesis prevents cosmetic deformity and biceps cramping with activity. Open subpectoral tenodesis anatomically restores the length-tension relationship of the biceps muscle and removes all diseased biceps from the bicipital groove. The authors present their technique of open subpectoral tenodesis, which demonstrates a high success rate with consistent pain relief and dependable fixation. [Orthopedics. 2015; 38(1):37-41.]
A
lthough the function of the long head of the biceps (LHB) tendon is controversial, the LHB tendon has long been recognized as a potential cause of pain in the shoulder. Patients with LHB tendon disorders typically
present with anterior shoulder pain in the bicipital groove. Biceps tendon disorders are frequently associated with other shoulder pathology, such as glenohumeral arthritis and rotator cuff tears.1,2 Several physical examination maneu-
The authors are from the Division of Sports Medicine, Rothman Institute of Orthopaedics at Thomas Jefferson University, Philadelphia, Pennsylvania. Dr Kane, Mr Hsaio, and Dr Freedman have no relevant financial relationships to disclose. Dr Tucker is a paid consultant for and is on the speakers bureau of DePuy Synthes; and holds stock in Johnson & Johnson. Correspondence should be addressed to: Kevin B. Freedman, MD, MSCE, Rothman Institute at Bryn Mawr, Medical Arts Pavilion, 825 Old Lancaster Rd, Ste 200, Bryn Mawr, PA 19010 ([email protected]). Received: September 27, 2013; Accepted: November 8, 2013; Posted: January 19, 2015. doi: 10.3928/01477447-20150105-04
vers, such as Speed’s, Yergason’s, and O’Brien’s tests, have been developed to isolate LHB tendon pathology. However, several level I and level II studies have questioned their accuracy.3,4 Advanced imaging or visualization during shoulder arthroscopy confirms the diagnosis of LHB disease. Failure to treat biceps pathology while addressing associated shoulder disorders can lead to persistent shoulder pain following surgery. The current surgical treatment options for LHB pathology include tenotomy (release) vs tenodesis (reattachment). Some systematic reviews have shown no difference between these 2 techniques, while other studies have shown increased biceps pain and cramping, cosmetic deformity, and patient dissatisfaction with tenotomy.5-7 As a result, younger, high-demand patients are usually treated with tenodesis. There are several potential reattachment sites for the biceps tendon, including the lesser tuberosity, coracoid, bicipital groove, short head of the bi-
ceps, pectoralis major tendon, and subpectoral bone tunnels.8-11 The optimal location for LHB tenodesis remains controversial. Currently, no level I or II studies exist comparing tenodesis above, within, or below the bicipital groove. However, there are several advantages to subpectoral biceps tenodesis. First, subpectoral tenodesis can reliably restore the anatomic length-tension relationship of the biceps muscle by placing the musculotendinous junction of the biceps at the inferior border of the pectoralis major tendon. Other techniques can have difficulty determining the appropriate tension to the remaining biceps tendon. In addition, the subpectoral location removes the entire diseased segment of biceps, whereas techniques at or above the bicipital groove can leave a segment of biceps within the groove that leads to continued shoulder pain. Tenodesis can be achieved through a variety of fixation methods, including interference screw, suture fixation, anchors, bone
JANUARY 2015 | Volume 38 • Number 1 37
n tips & techniques
Figure 1: Skin and subcutaneous incision centered over the pectoralis major tendon within the axillary fold. Figure 2: Superficial dissection and retraction to the level of the pectoralis major tendon (PM) and short head of the biceps (SB).
subpectoral tenodesis with bone tunnels and suture fixation. This method provides reliable pain relief with anatomic fixation, has minimal implant-associated costs, and can treat all biceps pathology.
Materials and Methods
Figure 5: Center hole of approximately 7 to 8 mm after the guide pin and acorn reamer have been removed.
tunnels, and soft-tissue tenodesis. Several biomechanical studies have shown that most techniques provide adequate fixation.12-15 Biceps tenodesis is also becoming a preferred option for primary treatment of Type II SLAP (superior labrum anterior and posterior) tears.16-18 The authors’ preferred method of fixation for biceps tendon pathology is an open
38
Patients with LHB tendon disorders undergoing shoulder arthroscopy and open subpectoral biceps tenodesis performed by the senior author (K.B.F.) between 2005 and 2012 were eligible for inclusion in this study. Patients who were seen at a minimum of 1-year follow-up were included. Patients lost to follow-up before 1 year were excluded. All patients were diagnosed with LHB tendon disease, based on preoperative evaluation and findings during shoulder arthroscopy. The primary indication for shoulder arthroscopy as well as concomitant procedures such as rotator cuff repair was noted
Figure 3: Long head of the biceps (LHB) tendon brought out of the bicipital groove with a Krackow stitch placed at the musculotendinous junction. Excess tendon that is to be excised remains attached above the Krackow suture.
for each patient. All patients had a minimum of 1-year follow-up, and dissatisfaction or complications were noted.
Surgical Technique Following diagnostic shoulder arthroscopy, the LHB tendon is released from the superior labrum and labral debridement is performed as needed. Remaining shoulder surgery, such as rotator cuff repair, is performed, and tenodesis is performed at the conclusion of the operation. An approximately 2- to 3-cm skin incision centered over the pectoralis major tendon is made within the axillary fold (Figure 1). The border of the pectoralis major superiorly and the short head of the biceps inferomedially is identified and the overlying fascia is divided (Figure 2). Following blunt dissection, the pectoralis major and short head of the biceps tendons are retracted and the LHB tendon can be identified
Figure 4: Excess long head of the biceps (LHB) tendon excised. A Krackow suture remains at the musculotendinous junction.
within the underlying bicipital groove. A Hohmann retractor can be placed directly through the pectoralis major tendon to retract the tendon lateral to the bicipital groove. The LHB tendon is then delivered from the groove and a locking Krackow stitch is placed at the musculotendinous junction with a #2 Orthocord suture (DePuy Mitek, Raynham, Massachusetts) (Figure 3). Excess biceps tendon is excised after this stitch is completed, leaving 1 to 2 cm of tendon remaining from the musculotendinous junction (Figure 4). The bicipital groove is exposed with electrocautery and a 2.4-mm guide pin is placed just superior to the inferior margin of the pectoralis tendon. A 7.5-mm acorn reamer is placed over top of the guide pin and used to make a unicortical central drill hole (Figure 5). The 2.4mm drill pin is again used to make 2 accessory holes distal to the previously placed central hole. When completed,
ORTHOPEDICS | Healio.com/Orthopedics
n tips & techniques
Figure 6: Illustration showing the final drill hole configuration. An equilateral triangle is made with approximately 1 cm between each hole.
an equilateral triangle is made among the 3 drill holes with approximately 1 cm separating each hole (Figure 6). A short straight blade from the Spectrum Suture Passer (CONMED, Largo, Florida) is then used to place a passing O-PDS suture (Ethicon, Somerville, New Jersey) from the accessory drill hole to the central hole. A crochet hook from the rotator cuff repair tray is used to retrieve the PDS suture from the central drill hole. After the first PDS suture is retrieved, the process is repeated with the other accessory hole (Figure 7). A simple loop is then made in each PDS suture to shuttle the #2 Orthocord suture through the central hole and out the accessory holes on each side of the bicipital groove (Figure 8). The sutures are tensioned and the biceps tendon is docked in the central hole within the intramedullary canal in the bicipital groove (Figure 9). The 2 suture limbs are then tied on the lateral side of the tendon to prevent tendon strangulation (Figure 10). The musculotendinous junction of
Figure 7: Central hole and accessory holes with shuttling PDS suture (Ethicon, Somerville, New Jersey).
Figure 8: Illustrations showing the shuttling technique of the PDS suture loop (Ethicon, Somerville, New Jersey) (A). A Krackow suture from the biceps tendon is fed into the PDS shuttle loop (B). The PDS shuttle loops are drawn out of each accessory drill hole to deliver the 2 Krackow suture limbs through the accessory holes (C).
Figure 9: Biceps tendon pulled into the center hole with previously shuttled Krackow sutures.
the LHB can be seen directly beneath the inferior border of the pectoralis tendon, providing anatomic fixation (Figure 11). The fascia is left open, the wound is irrigated, the subcutaneous tissue is closed with a 2-0 Vicryl suture (Ethicon), and the skin is closed with a running Monocryl suture (Ethicon). Postoperatively, the patient is placed in a standard sling. Patients have no restriction in elbow motion following surgery. Elbow flexion is limited
Figure 10: Illustration showing the biceps tendon pulled into the central drill hole and the suture limbs appropriately tensioned and secured. A lateral view of the biceps tendon within the central drill hole (inset).
to 5 lb for the first 6 weeks, and then advanced as tolerated.
Results One hundred two patients with an average age of 53.8 years underwent open subpectoral biceps tenodesis performed by the senior au-
Figure 11: Final tenodesis of the long head of the biceps (LHB) tendon with the musculotendinous junction at the inferior margin of the pectoralis major tendon (PM), restoring the anatomic length-tension relationship.
thor (K.B.F.) between 2005 and 2012. The indications for shoulder arthroscopy are listed in Table 1. Concomitant procedures at the time of tenodesis are listed in Table 2. Ninety-eight percent of patients (100 of 102) reported
JANUARY 2015 | Volume 38 • Number 1 39
n tips & techniques
Table 1
Indications for Surgical Treatment Indication
No. of Patients
SLAP extending to biceps
51 (50%)
SLAP tear only
21 (20.6%)
Isolated biceps pathology
42 (41.2%)
Biceps subluxation
6 (5.9%)
Supraspinatus or subscapularis tear
43 (41.6%)
Abbreviation: SLAP, superior labrum anterior and posterior tear.
from recurrent rotator cuff tear, 3 patients reported pain from recurrent impingement requiring subacromial injection, and 1 patient developed postoperative stiffness from a concomitant labral repair that required arthroscopic capsular release. No humerus fractures occurred.
Discussion Table 2
Concomitant Procedures at the Time of Biceps Tenodesis Procedure
No. of Patients
Rotator cuff repair
80 (78.4%)
Subacromial decompression
97 (95.1%)
Debridement
97 (95.1%)
SLAP repairs
21 (20.6%)
Abbreviation: SLAP, superior labrum anterior and posterior tear.
Table 3
Cost Comparison of Subpectoral Bone Tunnel and Suture Fixation Technique Versus Interference Screw Technique Technique
Cost
Bone tunnel and suture O-PDS suturea
$2.02
High-strength sutureb
$41.40
Total
$43.42
Interference screw c
Kit
$175.00 c
Interference screw
$285.00
Total
$460.00
a
Ethicon, Somerville, New Jersey. DePuy Mitek, Raynham, Massachusetts. c Arthrex, Naples, Florida. b
satisfaction with surgery. One patient reported persistent bicipital groove pain, and 1 patient developed an infection of the biceps tenodesis site that required irrigation
40
and debridement. One patient experienced loss of fixation with resultant biceps deformity, but reported no pain and was satisfied with his results. Five patients reported pain
The open subpectoral biceps tenodesis technique described here provides the treating orthopedic surgeon with a valuable method for managing all biceps tendon pathology. A low complication rate and high rates of patient satisfaction and pain relief were found with this technique. As previously mentioned, no level I or II studies exist comparing tenodesis above, within, or below the bicipital groove. However, subpectoral tenodesis completely removes the tendon from the bicipital groove, where pathology frequently extends, and eliminates pain from residual stenosis or from tenosynovitis from remaining, inflamed synovium.19 Several studies report reliable symptom relief, maintenance of the anatomic length-tension relationship, and a low incidence of failure with subpectoral tenodesis.20,21 One study showed a higher revision rate for tenodesis within the biceps groove compared with distal fixation (12% vs 2.7%).22 Additionally, previously reported rates of success and return to play for arthroscopic repair of Type II SLAP lesions have varied greatly (22% to 75%).16-18 One study showed
higher rates of satisfaction and return to work or play for tenodesis compared with repair.23 The results from the current study support the use of subpectoral tenodesis for the management of these lesions as well. Finally, when compared with other fixation methods, suture tenodesis using the technique described here is associated with minimal additional implant costs and uses readily available instrumentation. Bone tunnel and suture fixation vs the interference screw technique differ in cost by more than $400 (Table 3).
Conclusion Open subpectoral biceps tenodesis represents a reliable surgical technique for treating all LHB tendon disorders, including biceps tendonitis and tears, subluxation, and Type II SLAP tears. This particular technique provides predictable pain relief and high success rates, has minimal implantassociated costs, and has demonstrated a low rate of complications.
References 1. Beall DP, Williamson EE, Ly JQ, et al. Association of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior portions of the rotator cuff. AJR Am J Roentgenol. 2003; 180(3):633-639. 2. Murthi AM, Vosburgh CL, Neviaser TJ. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg. 2000; 9(5):382-385. 3. Holtby R, Razmjou H. Accuracy of the Speed’s and Yergason’s tests in detecting biceps pathology and SLAP lesions:
ORTHOPEDICS | Healio.com/Orthopedics
n tips & techniques
comparison with arthroscopic findings. Arthroscopy. 2004; 20(3):231-236. 4. Kibler BW, Sciascia AD, Hester P, Dome D, Jacobs C. Clinical utility of traditional and new tests in the diagnosis of biceps tendon injuries and superior labrum anterior and posterior lesions in the shoulder. Am J Sports Med. 2009; 37(9):1840-1847. 5. Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR. Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg. 2011; 20(2):326332. 6. Frost A, Zafar MS, Maffulli N. Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii. Am J Sports Med. 2009; 37(4):828-833. 7. Koh KH, Ahn JH, Kim SM, Yoo JC. Treatment of biceps tendon lesions in the setting of rotator cuff tears: prospective cohort study of tenotomy versus tenodesis. Am J Sports Med. 2010; 38(8):1584-1590.
8. Gumina S, Carbone S, Perugia D, Perugia L, Postacchini F. Rupture of the long head biceps tendon treated with tenodesis to the coracoid process: results at more than 30 years. Int Orthop. 2011; 35(5):713-716. 9. Hitchcock HH, Bechtol CO. Painful shoulder: observations on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am. 1948; 30(2):263-273. 10. Becker DA, Cofield RH. Te nodesis of the long head of the biceps brachii for chronic bicipital tendinitis: long-term results. J Bone Joint Surg Am. 1989; 71(3):376-381. 11. Mariani EM, Cofield RH, Askew LJ, Li GP, Chao EY. Rupture of the tendon of the long head of the biceps brachii: surgical versus nonsurgical treatment. Clin Orthop Relat Res. 1988; 228:233-239. 12. Klepps S, Hazrati Y, Flatow E. Arthroscopic biceps tenodesis. Arthroscopy. 2002; 18:10401045. 13. Mazzocca AD, Bicos J, San tangelo S, Romeo AA, Arciero RA. The biomechanical evaluation of four fixation tech-
niques for proximal biceps tenodesis. Arthroscopy. 2005; 21(11):1296-1306. 14. Kilicoglu O, Koyuncu O, Demirhan M, et al. Timedependent changes in failure loads of 3 biceps tenodesis techniques: in vivo study in a sheep model. Am J Sports Med. 2005; 33(10):1536-1544. 15. Ozalay M, Akpinar S, Karaeminogullari O, et al. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy. 2005; 21(8):992-998. 16. Ide J, Maeda S, Takagi K. Sports activity after arthroscopic superior labral repair using suture anchors in overheadthrowing athletes. Am J Sports Med. 2005; 33(4):507-514. 17. Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: an analysis of one hundred and thirty-nine cases. J Bone Joint Surg Am. 2003; 85(1):66-71. 18. Nam EK, Snyder SJ. The diagnosis and treatment of superior labrum, anterior and posterior (SLAP) lesions. Am J Sports Med. 2003; 31(5):798-810. 19. Lutton DM, Gruson KI, Har-
rison AK, Gladstone JN, Flatow EL. Where to tenodese the biceps: proximal or distal? Clin Orthop Relat Res. 2011; 469(4):1050-1055. 20. Mazzocca AD, Cote MP, Arciero CL, Romeo AA, Arciero RA. Clinical outcomes after subpectoral biceps tenodesis with an interference screw. Am J Sports Med. 2008; 36(10):1922-1929. 21. Millett PJ, Sanders B, Gobezie R, Braun S, Warner JJ. Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: does it matter? BMC Musculoskelet Disord. 2008; 9:121. 22. Sanders BS, Warner JJP, Pennington S, et al. Biceps tendon tenodesis: success with proximal versus distal fixation. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; February 2007; San Diego, California. 23. Boileau P, Parratte S, Chui nard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic treatment of isolated type II SLAP lesions: biceps tenodesis as an alternative to reinsertion. Am J Sports Med. 2009; 37(5):929936.
JANUARY 2015 | Volume 38 • Number 1 41
Open Subpectoral Biceps Tenodesis: Reliable Treatment for All Biceps Tendon Pathology Patrick Kane, MD; Philip Hsaio, BS; Bradford Tucker, MD; Kevin B. Freedman, MD, MSCE
Abstract: Long head of the biceps (LHB) tendon pathology is a common cause of pain in the shoulder. Pathology encountered includes biceps tendon tears and tendonitis, biceps anchor or superior labral tears, and biceps subluxation or instability. Current surgical treatment options for LHB disorders include tenotomy and tenodesis. Tenodesis prevents cosmetic deformity and biceps cramping with activity. Open subpectoral tenodesis anatomically restores the length-tension relationship of the biceps muscle and removes all diseased biceps from the bicipital groove. The authors present their technique of open subpectoral tenodesis, which demonstrates a high success rate with consistent pain relief and dependable fixation. [Orthopedics. 2015; 38(1):37-41.]
A
lthough the function of the long head of the biceps (LHB) tendon is controversial, the LHB tendon has long been recognized as a potential cause of pain in the shoulder. Patients with LHB tendon disorders typically
present with anterior shoulder pain in the bicipital groove. Biceps tendon disorders are frequently associated with other shoulder pathology, such as glenohumeral arthritis and rotator cuff tears.1,2 Several physical examination maneu-
The authors are from the Division of Sports Medicine, Rothman Institute of Orthopaedics at Thomas Jefferson University, Philadelphia, Pennsylvania. Dr Kane, Mr Hsaio, and Dr Freedman have no relevant financial relationships to disclose. Dr Tucker is a paid consultant for and is on the speakers bureau of DePuy Synthes; and holds stock in Johnson & Johnson. Correspondence should be addressed to: Kevin B. Freedman, MD, MSCE, Rothman Institute at Bryn Mawr, Medical Arts Pavilion, 825 Old Lancaster Rd, Ste 200, Bryn Mawr, PA 19010 ([email protected]). Received: September 27, 2013; Accepted: November 8, 2013; Posted: January 19, 2015. doi: 10.3928/01477447-20150105-04
vers, such as Speed’s, Yergason’s, and O’Brien’s tests, have been developed to isolate LHB tendon pathology. However, several level I and level II studies have questioned their accuracy.3,4 Advanced imaging or visualization during shoulder arthroscopy confirms the diagnosis of LHB disease. Failure to treat biceps pathology while addressing associated shoulder disorders can lead to persistent shoulder pain following surgery. The current surgical treatment options for LHB pathology include tenotomy (release) vs tenodesis (reattachment). Some systematic reviews have shown no difference between these 2 techniques, while other studies have shown increased biceps pain and cramping, cosmetic deformity, and patient dissatisfaction with tenotomy.5-7 As a result, younger, high-demand patients are usually treated with tenodesis. There are several potential reattachment sites for the biceps tendon, including the lesser tuberosity, coracoid, bicipital groove, short head of the bi-
ceps, pectoralis major tendon, and subpectoral bone tunnels.8-11 The optimal location for LHB tenodesis remains controversial. Currently, no level I or II studies exist comparing tenodesis above, within, or below the bicipital groove. However, there are several advantages to subpectoral biceps tenodesis. First, subpectoral tenodesis can reliably restore the anatomic length-tension relationship of the biceps muscle by placing the musculotendinous junction of the biceps at the inferior border of the pectoralis major tendon. Other techniques can have difficulty determining the appropriate tension to the remaining biceps tendon. In addition, the subpectoral location removes the entire diseased segment of biceps, whereas techniques at or above the bicipital groove can leave a segment of biceps within the groove that leads to continued shoulder pain. Tenodesis can be achieved through a variety of fixation methods, including interference screw, suture fixation, anchors, bone
JANUARY 2015 | Volume 38 • Number 1 37
n tips & techniques
Figure 1: Skin and subcutaneous incision centered over the pectoralis major tendon within the axillary fold. Figure 2: Superficial dissection and retraction to the level of the pectoralis major tendon (PM) and short head of the biceps (SB).
subpectoral tenodesis with bone tunnels and suture fixation. This method provides reliable pain relief with anatomic fixation, has minimal implant-associated costs, and can treat all biceps pathology.
Materials and Methods
Figure 5: Center hole of approximately 7 to 8 mm after the guide pin and acorn reamer have been removed.
tunnels, and soft-tissue tenodesis. Several biomechanical studies have shown that most techniques provide adequate fixation.12-15 Biceps tenodesis is also becoming a preferred option for primary treatment of Type II SLAP (superior labrum anterior and posterior) tears.16-18 The authors’ preferred method of fixation for biceps tendon pathology is an open
38
Patients with LHB tendon disorders undergoing shoulder arthroscopy and open subpectoral biceps tenodesis performed by the senior author (K.B.F.) between 2005 and 2012 were eligible for inclusion in this study. Patients who were seen at a minimum of 1-year follow-up were included. Patients lost to follow-up before 1 year were excluded. All patients were diagnosed with LHB tendon disease, based on preoperative evaluation and findings during shoulder arthroscopy. The primary indication for shoulder arthroscopy as well as concomitant procedures such as rotator cuff repair was noted
Figure 3: Long head of the biceps (LHB) tendon brought out of the bicipital groove with a Krackow stitch placed at the musculotendinous junction. Excess tendon that is to be excised remains attached above the Krackow suture.
for each patient. All patients had a minimum of 1-year follow-up, and dissatisfaction or complications were noted.
Surgical Technique Following diagnostic shoulder arthroscopy, the LHB tendon is released from the superior labrum and labral debridement is performed as needed. Remaining shoulder surgery, such as rotator cuff repair, is performed, and tenodesis is performed at the conclusion of the operation. An approximately 2- to 3-cm skin incision centered over the pectoralis major tendon is made within the axillary fold (Figure 1). The border of the pectoralis major superiorly and the short head of the biceps inferomedially is identified and the overlying fascia is divided (Figure 2). Following blunt dissection, the pectoralis major and short head of the biceps tendons are retracted and the LHB tendon can be identified
Figure 4: Excess long head of the biceps (LHB) tendon excised. A Krackow suture remains at the musculotendinous junction.
within the underlying bicipital groove. A Hohmann retractor can be placed directly through the pectoralis major tendon to retract the tendon lateral to the bicipital groove. The LHB tendon is then delivered from the groove and a locking Krackow stitch is placed at the musculotendinous junction with a #2 Orthocord suture (DePuy Mitek, Raynham, Massachusetts) (Figure 3). Excess biceps tendon is excised after this stitch is completed, leaving 1 to 2 cm of tendon remaining from the musculotendinous junction (Figure 4). The bicipital groove is exposed with electrocautery and a 2.4-mm guide pin is placed just superior to the inferior margin of the pectoralis tendon. A 7.5-mm acorn reamer is placed over top of the guide pin and used to make a unicortical central drill hole (Figure 5). The 2.4mm drill pin is again used to make 2 accessory holes distal to the previously placed central hole. When completed,
ORTHOPEDICS | Healio.com/Orthopedics
n tips & techniques
Figure 6: Illustration showing the final drill hole configuration. An equilateral triangle is made with approximately 1 cm between each hole.
an equilateral triangle is made among the 3 drill holes with approximately 1 cm separating each hole (Figure 6). A short straight blade from the Spectrum Suture Passer (CONMED, Largo, Florida) is then used to place a passing O-PDS suture (Ethicon, Somerville, New Jersey) from the accessory drill hole to the central hole. A crochet hook from the rotator cuff repair tray is used to retrieve the PDS suture from the central drill hole. After the first PDS suture is retrieved, the process is repeated with the other accessory hole (Figure 7). A simple loop is then made in each PDS suture to shuttle the #2 Orthocord suture through the central hole and out the accessory holes on each side of the bicipital groove (Figure 8). The sutures are tensioned and the biceps tendon is docked in the central hole within the intramedullary canal in the bicipital groove (Figure 9). The 2 suture limbs are then tied on the lateral side of the tendon to prevent tendon strangulation (Figure 10). The musculotendinous junction of
Figure 7: Central hole and accessory holes with shuttling PDS suture (Ethicon, Somerville, New Jersey).
Figure 8: Illustrations showing the shuttling technique of the PDS suture loop (Ethicon, Somerville, New Jersey) (A). A Krackow suture from the biceps tendon is fed into the PDS shuttle loop (B). The PDS shuttle loops are drawn out of each accessory drill hole to deliver the 2 Krackow suture limbs through the accessory holes (C).
Figure 9: Biceps tendon pulled into the center hole with previously shuttled Krackow sutures.
the LHB can be seen directly beneath the inferior border of the pectoralis tendon, providing anatomic fixation (Figure 11). The fascia is left open, the wound is irrigated, the subcutaneous tissue is closed with a 2-0 Vicryl suture (Ethicon), and the skin is closed with a running Monocryl suture (Ethicon). Postoperatively, the patient is placed in a standard sling. Patients have no restriction in elbow motion following surgery. Elbow flexion is limited
Figure 10: Illustration showing the biceps tendon pulled into the central drill hole and the suture limbs appropriately tensioned and secured. A lateral view of the biceps tendon within the central drill hole (inset).
to 5 lb for the first 6 weeks, and then advanced as tolerated.
Results One hundred two patients with an average age of 53.8 years underwent open subpectoral biceps tenodesis performed by the senior au-
Figure 11: Final tenodesis of the long head of the biceps (LHB) tendon with the musculotendinous junction at the inferior margin of the pectoralis major tendon (PM), restoring the anatomic length-tension relationship.
thor (K.B.F.) between 2005 and 2012. The indications for shoulder arthroscopy are listed in Table 1. Concomitant procedures at the time of tenodesis are listed in Table 2. Ninety-eight percent of patients (100 of 102) reported
JANUARY 2015 | Volume 38 • Number 1 39
n tips & techniques
Table 1
Indications for Surgical Treatment Indication
No. of Patients
SLAP extending to biceps
51 (50%)
SLAP tear only
21 (20.6%)
Isolated biceps pathology
42 (41.2%)
Biceps subluxation
6 (5.9%)
Supraspinatus or subscapularis tear
43 (41.6%)
Abbreviation: SLAP, superior labrum anterior and posterior tear.
from recurrent rotator cuff tear, 3 patients reported pain from recurrent impingement requiring subacromial injection, and 1 patient developed postoperative stiffness from a concomitant labral repair that required arthroscopic capsular release. No humerus fractures occurred.
Discussion Table 2
Concomitant Procedures at the Time of Biceps Tenodesis Procedure
No. of Patients
Rotator cuff repair
80 (78.4%)
Subacromial decompression
97 (95.1%)
Debridement
97 (95.1%)
SLAP repairs
21 (20.6%)
Abbreviation: SLAP, superior labrum anterior and posterior tear.
Table 3
Cost Comparison of Subpectoral Bone Tunnel and Suture Fixation Technique Versus Interference Screw Technique Technique
Cost
Bone tunnel and suture O-PDS suturea
$2.02
High-strength sutureb
$41.40
Total
$43.42
Interference screw c
Kit
$175.00 c
Interference screw
$285.00
Total
$460.00
a
Ethicon, Somerville, New Jersey. DePuy Mitek, Raynham, Massachusetts. c Arthrex, Naples, Florida. b
satisfaction with surgery. One patient reported persistent bicipital groove pain, and 1 patient developed an infection of the biceps tenodesis site that required irrigation
40
and debridement. One patient experienced loss of fixation with resultant biceps deformity, but reported no pain and was satisfied with his results. Five patients reported pain
The open subpectoral biceps tenodesis technique described here provides the treating orthopedic surgeon with a valuable method for managing all biceps tendon pathology. A low complication rate and high rates of patient satisfaction and pain relief were found with this technique. As previously mentioned, no level I or II studies exist comparing tenodesis above, within, or below the bicipital groove. However, subpectoral tenodesis completely removes the tendon from the bicipital groove, where pathology frequently extends, and eliminates pain from residual stenosis or from tenosynovitis from remaining, inflamed synovium.19 Several studies report reliable symptom relief, maintenance of the anatomic length-tension relationship, and a low incidence of failure with subpectoral tenodesis.20,21 One study showed a higher revision rate for tenodesis within the biceps groove compared with distal fixation (12% vs 2.7%).22 Additionally, previously reported rates of success and return to play for arthroscopic repair of Type II SLAP lesions have varied greatly (22% to 75%).16-18 One study showed
higher rates of satisfaction and return to work or play for tenodesis compared with repair.23 The results from the current study support the use of subpectoral tenodesis for the management of these lesions as well. Finally, when compared with other fixation methods, suture tenodesis using the technique described here is associated with minimal additional implant costs and uses readily available instrumentation. Bone tunnel and suture fixation vs the interference screw technique differ in cost by more than $400 (Table 3).
Conclusion Open subpectoral biceps tenodesis represents a reliable surgical technique for treating all LHB tendon disorders, including biceps tendonitis and tears, subluxation, and Type II SLAP tears. This particular technique provides predictable pain relief and high success rates, has minimal implantassociated costs, and has demonstrated a low rate of complications.
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