Abstract
Background:
The long head of the biceps tendon (LHBT) has long been considered an intra-articular pain generator in the shoulder. While nonoperative treatment modalities can be acceptable for less severe presentations of LHBT pathology, surgical treatment options such as tenotomy and tenodesis remain controversial for recalcitrant cases. Open subpectoral biceps tenodesis allows for removal of all pathologic tissue from the bicipital groove, and all-suture anchor fixation utilizes a small caliber unicortical drill hole, which can potentially reduce the risk of a stress riser and iatrogenic fracture.
Indications:
In this study, we present a male patient with a history of left anterolateral shoulder pain worse overhead activities who has failed extensive physical therapy and other conservative measures. After extensive discussion regarding the treatment options, surgery in the form of shoulder arthroscopy, extensive debridement, rotator cuff repair, and open subpectoral biceps tenodesis was recommended and the patient had opted to proceed. For the purposes of this video, we focus on the open subpectoral biceps tenodesis portion of the procedure.
Results:
Open subpectoral biceps tenodesis can reduce pain with low complication and high satisfaction rates.
Discussion:
In this surgical technique study, we underline the importance position of the skin incision in axillary crease as well as skin tensioning when making the incision and retracting the conjoint tendon. We also highlight a locking lasso loop and double luggage tag fixation technique using a double-loaded all-suture anchor for the biceps tenodesis. We also provide technique commentary for appropriate restin tension of the LHBT. Finally, we review outcomes, postoperative management, rehabilitation protocol, and technique pearls and pitfalls.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video transcription
In this video, we describe surgical technique for an open subpectoral biceps tenodesis using an all-suture anchor with locking lasso double luggage tag suture configuration. While there are countless suture configuration and fixation options for biceps tenodesis, we present a novel suture configuration technique which minimizes passes through the tendon and improves fixation. In addition, we provide surgical technique pearls and pitfalls for this approach. We also review our postoperative management, rehabilitation protocol as well as return-to-play (RTP) and functional outcomes.
Background
The long head of the biceps tendon (LHBT) has long been considered an intra-articular pain generator in the shoulder. While nonoperative treatment modalities can be acceptable for less severe presentations of LHBT pathology, the surgical technique for tenodesis, including both open and arthroscopic techniques, remains a subject of debate, particularly for recalcitrant cases. Forsythe et al 3 and Belk et al 1 have previously demonstrated reduction of pain with low complication and high satisfaction rates after tenodesis. In particular, open subpectoral biceps tenodesis allows for removal of all pathologic tissue from the bicipital groove. In addition, the fixation method using an all-suture anchor utilizes a small caliber unicortical drill hole, which can potentially reduce the risk of a stress riser and iatrogenic fracture.4,7
Indications
In this video, we present a 54-year-old active male patient with a 3-month history of right shoulder pain after lifting a heavy object. He states the pain is located over the lateral and anterolateral aspect of the shoulder, and the pain is worse with overhead activities and sleeping at night. He has poor preoperative functional outcomes as presented here, and has failed conservative management in the form of activity modification, anti-inflammatories, and extensive physical therapy. Clinical examination had demonstrated a normal appearance of the right shoulder and biceps muscle with point tenderness overlying the bicipital groove as well as diminished and asymmetric shoulder range of motion. He was also noted to have rotator cuff weakness and positive external impingement signs with provocative testing. Imaging results were notable for biceps tendinopathy along with full thickness tearing of the posterosuperior rotator cuff tendons.
Given the patient's age, desire to return to physical activity, and failure of conservative therapy, there was extensive discussion regarding the various treatment options, and the patient decided to proceed with surgical intervention consisting of arthroscopic debridement, rotator cuff repair, and open subpectoral biceps tenodesis. This technique for biceps tenodesis is preferred as it allows removal of tenosynovitis from the bicipital groove and LHBT as well as possibility of adjusting the tension of LHBT prior to final fixation. For the purposes of this video, we will be focusing on the surgical technique of the open subpectoral biceps tenodesis.
Technique Description
In the beach chair position, the inferior border of the pectoralis major tendon is marked with the shoulder in abduction and slight external rotation. With the arm at the side, a crease is then identified in the axilla, which is marked for roughly a 3-cm incision. The arm is then returned to the abducted and slightly externally rotated position. A 15-blade knife is used to go through the skin and take in no deeper than the dermal layer. Metzenbaum scissors are utilized in the longitudinal fashion in line with the direction of the nerves to find the interval between the pectoralis major tendon and the conjoint tendon. The fascia in this interval is then breached and blunt dissection is carried down to the bicipital groove. The LHBT is palpated with the pulp of the fingertip. A sharp Hohmann retractor is then placed over the lateral cortex allowing retraction of the pectoralis major tendon. At this point, a blunt Hohmann retractor is placed medial and inferior to the LHBT on the medial lip of the bicipital groove to gently retract the conjoint tendon and the neurovascular structures. It is important to note that the blunt Hohmann medially is not retracting aggressively, but just resting on the medial lip. The LHBT is clearly seen and the sheath is incised using Metzenbaum scissors longitudinally along the tendon. The blunt Hohmann retractor then reflects LHBT out of the groove, and a periosteal elevator is used to remove the soft tissue in this area to prepare for anchor placement. At this point, the drill guide for the anchor is placed and centered in the groove taking absolute care to be perpendicular to the bone. A unicortical hole is drilled and a 2.8-mm double-loaded all-suture anchor is inserted through the guide. The guide is then gently pulled back to ensure the anchor is not deployed against the far cortex. A blunt Hohmann retractor is again introduced and placed against the bone rather than retracting the conjoint tendon. A right angle clamp is then used to retrieve the LHBT from medial to lateral direction and proximal to the tenodesis site. At this point, 1 limb from the first pair of sutures is passed in situ to set the resting length and tension of the tendon. This limb will become a postsuture later when fixed definitively at this site.
A diagnostic arthroscopy then follows. A standard posterior viewing portal is established. An inside-out anterior working portal is then placed. The LHBT is then brought into the joint with a probe for further evaluation. A complex longitudinal tear of the LHBT is noted, and an arthroscopic biter is used to perform the biceps tenotomy leaving 8 mm to 1 cm, which can be further recontoured later. Once this is completed, we return to the remaining portion of the tenodesis.
The arm is then positioned in abduction and slight external rotation. The sharp Hohmann retractor is repositioned over the lateral cortex and retracts the undersurface of the pectoralis major tendon once more. The blunt Hohmann retractor is placed against the bone medially to reflect the conjoint tendon. A right angle clamp is used to retrieve the LHBT. The inflamed synovium is identified and debrided to avoid leaving behind a potential pain generator. The remainder of the tenodesis will then be performed. The right angle clamp is moved to the end of the LHBT for control and tension. The sister limb to the first postsuture previously passed is then passed through the tendon perpendicular to the postsuture limb with a self-retrieving suture passer and then the tail of the same suture is retrieved back through itself creating a locking lasso loop. At this point, the same suture (sister limb to the post) is passed circumferentially around the tendon in a luggage tag configuration both above and below the postsuture in opposite directions creating double luggage tags. Thus, the first suture from the anchor has 1 limb that acts as a post and the other with a locking lasso loop and double luggage tag construct, 1 on each side of the post. Attention is now redirected to the second pair of sutures from the anchor. Once again, 1 limb is passed through the tendon and will become the postsuture. This limb is passed proximal to the previous postsuture limb. The sister limb of the second suture is passed in a similar manner creating a locking lasso loop and double luggage tags on each side of the post.
Both posts are then identified and pulled to reduce the LHBT to its anatomic position in the groove. Using arthroscopic knot-tying principles, tension is placed on 1 of the posts and the sister limb is tied around it. The excess suture is cut away with an 11-blade knife. The remaining second suture is secured in an identical fashion, and the excess suture cut away once more. The excess tendon is now trimmed as well, leaving at least 5 to 8 mm from the tenodesis site. The surgical site is then copiously irrigated with normal saline. The skin edges are reapproximated using 2-0 Vicryl sutures and the skin closed using a 3-0 Monocryl in a running subcuticular fashion. Skin glue and a nonadherent dressing are applied. The patient is then placed in an abduction sling.
Results
Our postoperative rehabilitation involves a 4-phase protocol approximately 12 to 16 weeks in duration. This of course takes into account any additional procedures that have been performed, such as a rotator cuff repair. The program includes focus on initial weightbearing restrictions with passive range of motion, then transitioned to active-assisted range of motion and active range of motion, followed by biceps strengthening with light resistance, and finally with advanced strengthening including returning to work and recreational activities.
Discussion
Return-to-play (RTP) outcomes following subpectoral biceps tenodesis is encouraging in the young and active population. Provencher et al 6 demonstrated an 82% return to full activity level at a mean of 4.1 months in 101 active-duty military personnel following subpectoral biceps tenodesis with significant improvement in Western Ontario Rotator Cuff and Single Assessment Numeric Evaluation scores. Similarly, Lorentz et al 5 observed significant improvement in clinical outcomes of the American Shoulder and Elbow Surgeons score, visual analog scale score for pain, subjective shoulder value, and patient satisfaction in an overhead athlete cohort with an 81.8% RTP rate. Finally, Chalmers et al 2 reported on RTP rates after biceps tenodesis in professional baseball players, noting an overall 35% RTP rate across all players, with a higher rate of 80% among position players compared with 17% among pitchers, over a minimum of 24-month follow-up period between 2010 and 2013.
When marking the incision for an open biceps tenodesis, it is crucial to align the incision with an axillary crease. In addition, it is important to minimize skin tension during the incision and while retracting the conjoint tendon to protect the neurovascular structures. Furthermore, attention is particularly focused on developing the plane between the inferior border of the pectoralis major tendon and the conjoint tendon, a critical step in the procedure. It is also important to note that the pilot holes for the anchors must be drilled perpendicular to the bicipital groove. Moreover, passing the initial postsuture limb prior to the tenotomy allows for a reproducible method of setting the resting tension of the LHBT during the tenodesis. Finally, caution should be exercised to prevent the anchor from engaging against the far cortex, as this may result in misfiring of the mechanism.
Footnotes
Submitted December 29, 2023; accepted April 9, 2024.
One or more of the authors has declared the following potential conflict of interest or source of funding: M.T.F. is a paid consultant for Smith & Nephew and Tornier and receives intellectual property royalties from Smith & Nephew. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
