➢ Although nonoperative options exist for the treatment of mild symptoms or lesser abnormalities such as tendinopathy of the long head of the biceps, surgical intervention has been shown to be appropriate therapy for symptomatic partial tears of the long head of the biceps, subluxation of the long head of the biceps, biceps pulley lesions, and some superior labrum anterior-posterior (SLAP) lesions.
➢ Biceps tenodesis can be performed with use of open or arthroscopic methods and has emerged as a preferred technique for the treatment of abnormalities of the long head of the biceps in younger persons, athletes, laborers, and those wishing to avoid likely cosmetic deformity.
➢ Numerous studies comparing outcomes between biceps tenotomy and tenodesis have demonstrated that although biceps tenotomy is a much simpler procedure and requires less rehabilitation, it may result in a cosmetic deformity, possible cramping and fatigue pain of the biceps, and a decrease in elbow flexion and supination power.
➢ Open subpectoral tenodesis and arthroscopic biceps tenodesis both provide favorable outcomes, and neither technique has been shown to be superior to the other.
Lesions of the intra-articular long head of the biceps tendon have long been considered important pain generators in the shoulder1-3. Despite considerable research into the anatomy of the long head of the biceps and the various abnormalities that affect it, controversy remains regarding the function of the long head of the biceps and, most importantly, appropriate treatment of its disorders4.
Although nonoperative options exist for the treatment of mild symptoms or tendinopathy of the long head of the biceps, operative intervention may be indicated for symptomatic partial tears of the long head of the biceps, subluxation of the long head of the biceps, biceps pulley lesions, and some superior labrum anterior-posterior (SLAP) lesions2,5-19. Biceps tenotomy and biceps tenodesis are two procedures that have emerged as quick, simple, and cost-effective methods for the treatment of isolated abnormalities of the long head of the biceps, isolated superior glenoid labral abnormalities in patients who are more than forty years of age, and combined lesions of the biceps-labrum complex1,4-6,10,12,17,20-23.
Biceps tenotomy can be performed relatively simply and reproducibly and provides predictable pain relief without requiring substantial postoperative rehabilitation4,12,17,22,24. In general, biceps tenotomy is indicated for patients who are more than fifty-five to sixty years of age who are not involved in heavy labor17,21,23,25. The decreased postoperative rehabilitation allows for a quicker return to activities and reduces the risk of postoperative stiffness. Although tenotomy is simpler to perform, it may result in a cosmetic deformity, possible cramping and fatigue pain of the biceps, and a decrease in elbow flexion and supination power8,26-29. These unfortunate consequences of biceps tenotomy have led to the increasing popularity of biceps tenodesis.
Tenodesis has emerged as a preferred technique for the treatment of abnormalities of the long head of the biceps in younger persons, athletes, laborers, and those wishing to avoid likely cosmetic deformity4. Although there is no consensus in the literature regarding tenotomy as compared with tenodesis, tenodesis allows better ability to return to physical activity, improved cosmesis, and closer approximation of normal anatomy despite longer rehabilitation times and increased technical difficulty8,10,12,14,20,23,27,30-36.
This review will discuss the indications for biceps tenodesis, will detail the various described techniques and fixation methods, and will present an overview of the available data from the literature regarding clinical outcomes after tenodesis.
Physical Examination and Diagnosis
A comprehensive history, a physical examination, and a period of nonoperative therapy are important in the initial management of a patient with suspected abnormality of the long head biceps or the superior aspect of the labrum that may require biceps tenodesis. Physical examination should include evaluation of both shoulders as well as the adjacent joints and the cervical spine. Provocative tests for proximal biceps abnormalities, including the Speed test37, and tests for superior labral abnormality, such as the O’Brien test38, should be performed. Several studies have demonstrated benefit in the physical examination of the patient with primary SLAP pathology39,40.
Differential injections can provide a useful adjunct in the diagnostic workup. A diagnostic and potentially therapeutic subacromial injection can be given at the first office visit and can be easily followed by an intra-articular injection on a subsequent visit. Tenderness over the acromioclavicular joint could warrant an additional acromioclavicular injection. These injections can help to differentiate the source of symptoms.
Radiographic evaluation should mirror that of a patient in whom a primary SLAP tear is suspected, including standard radiographs of the shoulder (anteroposterior, axillary lateral, and outlet views). Magnetic resonance imaging (MRI), typically with contrast arthrography, is the imaging modality of choice to evaluate the soft-tissue structures of the shoulder to confirm an unclear diagnosis or to evaluate for concomitant abnormalities, including those involving the rotator cuff, the anterior or posterior aspect of the glenoid labrum, or the articular cartilage.
A combination of patient-related factors, physical examination findings, the response to injections, and MRI findings should assist the surgeon in deciding whether a tenodesis (or tenotomy) will appropriately relieve the symptoms.
Anatomy and Indications for Biceps Tenodesis
Abnormalities of the Long Head of the Biceps Tendon
Because of the location of the long head of the biceps tendon, its attachments to surrounding structures, and its mobile nature, there are many reasons for symptomatic abnormalities to develop. The more commonly encountered diagnoses include tendinosis, partial tendon tears, SLAP tears, tendon subluxation from the intertubercular groove, and biceps pulley lesions1. Proximal biceps tendinosis is a disease entity often seen as a secondary process associated with the other types of biceps abnormality or degenerative rotator cuff tears and subacromial impingement41. Primary tendinosis, or tendinosis without any other associated shoulder abnormality, is rare42. MRI may demonstrate intra-substance edema and intra-articular flattening of the tendon (Fig. 1)43. Arthroscopically, the tendon will appear hyperemic and synovitic but may not have any obvious longitudinal splits43. However, with continued inflammation and insults from the original abnormality, the tendon eventually may develop partial tears44.
The contribution of the long head of the biceps tendon to SLAP tears continues to be increasingly recognized. The pathophysiology is mostly thought of as a traction injury to the labrum because traction on the biceps can detach the superior aspect of the labrum from the glenoid when the arm is brought into abduction and external rotation45. Arthroscopically, this is visualized by a positive peel-back sign46. Additionally, SLAP lesions may propagate into the substance of the biceps tendon; such lesions are classified as Type IV according to the system of Snyder et al.47.
Patient Age and Activity Considerations
Once conservative measures have failed and operative treatment has been indicated, the surgeon and patient must decide on the most appropriate intervention, commonly either tenotomy or tenodesis. Considerations in this decision should include patient age, athletic participation, employment, and concern over cosmesis; however, the existing evidence provides tenuous support with regard to the use of these variables during the decision-making process17.
An advanced patient age of more than fifty-five to sixty years is a commonly used indication for tenotomy, with tenodesis being recommended in patients younger than fifty years of age (Level-V evidence)17. This recommendation is mostly because of the lower demand that older patients place on the biceps and their infrequent participation in manual labor. Additionally, some physicians who advocate tenotomy for older patients believe that there is a lower risk for a cosmetic deformity due to age-related muscle atrophy25.
Desired postoperative functional expectations should also be a consideration as there is conflicting evidence regarding strength deficits after tenotomy17. One case series of 132 patients48 showed that sixty patients (45%) had a small but significant decrease in elbow strength after tenotomy (p = 0.001), and another series showed a 20% decrease in elbow flexion and supination strength after tenotomy23. In contrast, postoperative evaluation of isokinetic strength did not reveal a difference in elbow flexion or supination strength between patients who underwent tenotomy and those who underwent tenodesis49. However, published data are equivocal regarding the outcomes of tenodesis and tenotomy.
A cosmetic biceps deformity can result in patient consternation. A recent systematic review of 433 tenodesis procedures and 699 tenotomy procedures demonstrated a deformity in 300 patients (43%) who underwent tenotomy and thirty-four patients (8%) who underwent tenodesis; thus, discussing the risk even with patients undergoing tenodesis is important17. The risk appears to be higher in men but does not depend on patient age, arm dominance, or body mass index48.
Biceps Tenodesis Techniques
The biceps tendon and its superior labral attachment should be thoroughly evaluated during diagnostic arthroscopy prior to proceeding with biceps tenodesis. In addition to patient-related factors such as age and activity level, the tendon should be evaluated for partial tearing or degeneration as well as subluxation. The superior labral attachment should be evaluated for fraying or traction-related superior labral tears.
Open Subpectoral Tenodesis
After an arthroscopic inspection of the biceps tendon during the diagnostic shoulder arthroscopy, the tendon is typically tagged with a suture to avoid over-retraction and is then tenotomized.
The open tenodesis technique described by Mazzocca et al.50 is commonly used. With this technique, a 3-cm vertical incision is made near the axillary fold, just medial to the insertion of the pectoralis major tendon, with 2 cm of the incision distal to the inferior border of the tendon and 1 cm superior to this border (Fig. 2, A). The skin and the subcutaneous tissue are incised sharply. Deep to the subcutaneous fat, fascia is identified and is incised longitudinally, with care being taken to only incise the fascia distal to the pectoralis tendon. At this point, digital palpation through this fascial defect should allow localization of the biceps tendon and confirmation of the correct dissection plane. A pointed Hohmann retractor is placed around the lateral border of the humerus for lateral and proximal retraction of the pectoralis major. A right-angled clamp is then inserted deep to the biceps tendon, and the tendon is delivered out of the wound (Fig. 2, B). To protect the medial neurovascular structures, a Chandler retractor is placed around the medial humeral border and deep to the coracobrachialis (Fig. 2, C). Controlled, careful retraction prevents traction injuries to surrounding nerves.
The tendon is transected 20 to 25 mm proximal to the musculotendinous junction, and this length provides sufficient tendon to be placed in the bone tunnel while maintaining the proper length-tension relationship. A high-strength suture is placed in the remaining tendon with use of a whip-stitch technique. The osseous bed is prepared and is centered 1 cm proximal to the inferior border of the pectoralis major.
A variety of fixation implants and techniques are available. Interference screws, suture anchors, and soft-tissue tenodesis are three commonly used techniques. The use of bone tunnels combined with interference screw fixation is the most commonly used technique because of evidence demonstrating superior pull-out strength of the screw and tendon31,51-53. However, in the recent biomechanical study by Papp et al., the mean load to failure was 263.2 N in the group treated with two suture anchors along with closure of the transverse humeral ligament over the repair, compared with 159.4 N in the group treated with interference screw fixation54. Tunnel location in the center of the intertubercular groove should be 1 cm proximal to the inferior border of the pectoralis major tendon and, with use of a cannulated reamer, should be drilled to the appropriate depth and diameter, depending on the implant and the size of the tendon. When relying on suture anchor fixation, frequently two anchors are chosen with the inferior of the two placed in the same location as the tunnel used for the interference screw. The remaining anchor is inserted 1 cm superior to the first in the intertubercular groove.
The bone tunnel with suture fixation technique commonly follows the description provided by Snyder55. One bone tunnel is drilled at the same location as for the interference screw fixation, and then two smaller tunnels are drilled distally. The tendon is pulled through the proximal tunnel, and then the two limbs of the whip stitch are brought out through the distal tunnels and are tied over the osseous bridge. A modified version of the bone tunnel technique, described by Said et al., uses two bone tunnels and, after the tendon is fed through the tunnel, it is sutured back on top of itself56. Cortical buttons57, osseous keyholes9, and long head-to-short head biceps side-to-side tenodesis20 are less commonly used techniques.
Arthroscopic Biceps Tenodesis
Biceps tenodesis also can be performed completely arthroscopically, negating the need for a separate axillary incision as required by the open subpectoral technique. This technique is attractive as biceps abnormality can be addressed concomitantly with additional shoulder abnormalities, including rotator cuff tears, labral tears, or impingement. Several techniques for arthroscopic biceps tenodesis have been described. These techniques can be categorized according to the location of tenodesis and the method of fixation.
Three locations for arthroscopic biceps tenodesis have been described: high suprapectoral sites (at the entrance to the bicipital groove), low suprapectoral sites (just above the pectoralis major tendon), and soft-tissue sites2,5,11,27,34,58-72. The earliest descriptions of arthroscopic biceps tenodesis appeared in the early 2000s and recommended a high suprapectoral location, just below the articular cartilage within the biceps groove, leaving a substantial amount of residual biceps tendon proximal to the pectoralis major tendon27,58,61,63,64. More recently, largely because of concern that retained tendon can lead to persistent bicipital groove pain, some authors have advocated for a low suprapectoral position, just proximal to the pectoralis major tendon (Level-V evidence)34,73.
Diagnostic arthroscopy is performed first. The tendon is arthroscopically released from its superior labral attachment. Several authors have described placing a percutaneous spinal needle through the tendon prior to release in order to maintain the length and tension relationship of the tendon34,73,74. Other authors have described the placement of traction sutures to allow externalization of the tendon through the skin portals27,28,61,63,65. Once the tendon is released, additional anterior or anterolateral portals are created to access the tendon and its fixation site as needed. The tendon is fixed with use of a variety of methods, including interference screws or suture anchor fixation.
Numerous authors have advocated the use of suture anchor fixation for arthroscopic biceps tenodesis. Gartsman and Hammerman provided one of the earliest descriptions of an all-arthroscopic biceps tenodesis and recommended utilizing two suture anchors to secure the biceps tendon58. Nord et al. also recommended the use of a suture anchor, with placement just proximal to the entrance of the bicipital groove64. Several other authors have also recommended suture anchor fixation66,75.
Interference screw fixation is the other commonly reported method of fixation for arthroscopic biceps tenodesis. This method was initially described by Boileau et al., who used a bioabsorbable interference screw27. Romeo et al.34, Lo and Burkhart61, and Kim and Yoo63 also have advocated for the use of interference screw fixation.
The authors of the current article employ an arthroscopic suprapectoral biceps tenodesis involving the use of an interference screw. Once the decision to proceed with biceps tenodesis is made, the biceps tendon is stabilized within the glenohumeral joint with use of a spinal needle to preserve tensioning (Fig. 3, A and B). The tendon is tenotomized from the superior aspect of the labrum, and the biceps stump is debrided with an arthroscopic shaver. The arthroscopic instruments are then moved to the subacromial space. As the surgeon moves anteriorly along the bicipital groove, the biceps tendon is identified just proximal to the pectoralis major insertion. A suprapectoral location for tenodesis is identified just proximal to the pectoralis and is cleared with use of electrocautery (Fig. 3, C and D). A guide pin is then inserted through a separate anterolateral portal (Fig. 4, A). The tenodesis site is then reamed, typically 0.5 mm larger than the size of the intended interference screw (which is most commonly a 7 or 8-mm screw) (Fig. 4, B). The tendon is then inserted into the reamed site, and the interference screw is placed (Fig. 4, C and D). Typically, a suture is subsequently sewn over the top to reinforce the fixation (Fig. 4, E and F).
Outcomes After Biceps Tenodesis
Comparative Outcomes Between Biceps Tenodesis and Tenotomy
A well-studied issue regarding biceps tenodesis is the comparative outcomes between biceps tenodesis and biceps tenotomy. Biceps tenotomy is a much simpler procedure and requires less rehabilitation, but it may result in a cosmetic deformity, possible cramping and fatigue pain of the biceps, and a decrease in elbow flexion and supination power8,26-29.
Osbahr et al., in a retrospective study of 160 patients, compared the appearance of the biceps muscle after tenotomy with the appearance of the muscle after tenodesis14. In that study, biceps tenodesis was performed in patients who were under fifty years of age and in conjunction with all operations that already required an open rotator cuff repair, whereas biceps tenotomy was performed only in patients who were generally older than fifty years of age who did not perform manual labor. Osbahr and colleagues found that in the majority of patients in whom a biceps tenotomy had been performed, the cosmetic appearance of the biceps muscle, the grade of muscle spasms of the biceps, and the level of anterior shoulder pain were not different from those in patients in whom a tenodesis had been performed14.
Koh et al. provided Level-II evidence comparing biceps tenodesis and tenotomy for the treatment of biceps tendon lesions in the setting of rotator cuff tears23. Those authors prospectively enrolled ninety patients, with equal numbers undergoing tenotomy or tenodesis in a sequential fashion. The rate of cosmetic deformity was significantly greater in the tenotomy group than in the tenodesis group (27% compared with 9%; p = 0.0360), but there was no difference between the groups in terms of postoperative cramping, elbow flexion strength, or the final American Shoulder and Elbow Surgeons (ASES)76-78 and Constant scores79,80.
Several systematic reviews have assimilated the numerous additional studies on this topic. Frost et al.21 identified six studies comparing tenotomy and tenodesis14,29,30,81-83. The evaluated studies were generally Level-IV evidence and did not demonstrate any significant differences between tenotomy and tenodesis other than a cosmetic deformity being present in 3% to 70% of patients who underwent tenotomy21.
Slenker et al. recently performed a systematic review of articles reporting outcomes of both biceps tenotomy and tenodesis17. Sixteen studies met the inclusion criteria, including four studies that compared the procedures directly14,23,30,81. Analysis of the 433 tenodesis procedures revealed a good or excellent outcome in 74% of patients, with an 8% rate of cosmetic deformity. Analysis of the 699 tenotomy procedures revealed good or excellent outcome in 77% of patients, with a 43% occurrence of cosmetic deformity. Postoperative groove or biceps pain was found in forty-three (19%) of 226 cases of tenotomy and eighteen (24%) of seventy-four cases of tenodesis. Slenker et al. arrived at conclusions similar to those of Frost et al.: tenotomy and tenodesis have comparably favorable results in the literature, with the only major difference being a higher rate of cosmetic deformity following biceps tenotomy.
Clinical Outcomes After Open Subpectoral Biceps Tenodesis
There is sufficient evidence in the literature to support the use of open biceps tenodesis as a procedure for pain in the long head of the biceps. However, the weaknesses of the current literature are that most studies do not isolate particular biceps abnormality, the tenodesis is often performed in conjunction with other shoulder procedures, there is a slight variability in terms of technique and fixation implants, there are no long-term prospective trials assessing the durability of this operation, and there is no postoperative assessment of healing.
Mazzocca et al., in a study of forty-one patients, demonstrated improved clinical outcomes at a mean of twenty-nine months after open subpectoral biceps tenodesis with interference screw fixation, although worse outcomes were noted in patients with concomitant rotator cuff abnormality12.
Millett et al. reported additional encouraging results in a study comparing the outcomes of open subpectoral tenodesis with interference screw fixation (n = 34) with those of open subpectoral tenodesis with suture anchor fixation (n = 54)75. After an average duration of follow-up of thirteen months, both groups had significant improvement in the average visual analog scale (VAS) score for pain (from 9 to 2 points), the average ASES score (from 28 to 76 points), and the average abbreviated modified Constant score (from 29 to 59 points) (p < 0.0001 for all). Clinical outcome scores did not differ between the interference screw and suture anchor groups, but there was a slightly higher rate of intertubercular groove pain in the suture anchor subset (7%) compared with the interference screw subset (3%).
As anterosuperior rotator cuff tears are often seen in conjunction with biceps abnormality84,85, Nho et al. specifically evaluated the outcomes for thirteen patients who had undergone arthroscopic cuff repair and open subpectoral biceps tenodesis with use of interference screw fixation13. The ASES and Simple Shoulder Test scores demonstrated significant improvement (p < 0.001 for both) after an average duration of follow-up of thirty-five months.
As with all operative procedures, open biceps tenodesis is not without its complications. Commonly discussed complications are persistent pain, fixation failure, infection, hematoma or seroma formation, humeral fracture, and injuries to surrounding neurovascular structures53,86,87. A chart review of 353 patients who underwent subpectoral biceps tenodesis using interference screw fixation revealed a complication rate of 2.0% (seven patients)86. The complications included two patients with persistent intertubercular groove pain, two patients with a cosmetic deformity from fixation failure, one patient with a deep infection, one patient with musculocutaneous neuropathy, and one patient with complex regional pain syndrome.
Rhee et al. discussed four cases of iatrogenic neurological injuries involving the medial and posterior cords of the brachial plexus (two cases), the median nerve (one case), and the musculocutaneous nerve (one case) that had occurred during open subpectoral tenodesis with interference screw fixation87. All four patients exhibited immediate neurological deficits postoperatively, and all showed continued neurologic deficits at the time of the latest follow-up. Two patients underwent nerve transfers after it was recognized, during exploration, that the median and musculocutaneous nerves had inadvertently been tenodesed. The recommendation of careful soft-tissue retraction and visualizing the biceps tendon should not be discounted.
Clinical Outcomes After Arthroscopic Biceps Tenodesis
The clinical outcomes of arthroscopic tenodesis are not as well reported as those of open subpectoral tenodesis. However, reasonable clinical outcomes have been reported in terms of function and pain relief. Boileau et al., in a study of forty-three patients who underwent arthroscopic biceps tenodesis with a bioabsorbable interference screw, reported that the average Constant score improved from 43 points preoperatively to 79 points postoperatively27. The authors did not note any elbow flexion or extension deficits when the involved side was compared with the contralateral side. The strength of the biceps on the involved side averaged 90% of that on the contralateral side, and the shape and contour of the biceps were conserved in all but two patients.
Nord et al. reported the preliminary results for eleven patients who were followed for an average of twenty-four months after arthroscopic biceps tenodesis with suture anchor fixation64. Ninety-one percent of the patients had a good or excellent result according to the University of California at Los Angeles (UCLA) scale80,88,89, and 100% of patients were satisfied with the cosmetic result. No additional outcome measures were reported.
Boileau et al. advocated the use of arthroscopic biceps tenodesis with an interference screw as an alternative technique for the treatment of type-II SLAP lesions6. In that study, ten patients underwent SLAP repair with suture anchors and fifteen underwent arthroscopic biceps tenodesis with an interference screw. In the tenodesis group, the average Constant score improved from 59 to 89 points and 93% (fourteen) of the fifteen patients were satisfied or very satisfied. Thirteen (87%) of the fifteen patients in the biceps tenodesis group were able to return to the previous level of sports participation, compared with only two (20%) of the ten patients in the SLAP repair group. Four patients who had a failed SLAP repair underwent subsequent biceps tenodesis, resulting in a successful outcome and a full return to the previous level of sports activity.
Lutton et al., in a retrospective study of seventeen patients who underwent arthroscopic suprapectoral biceps tenodesis with an interference screw, compared the clinical outcomes for five patients in whom the tenodesis was performed proximally (in the upper half of the groove) with those for twelve patients in whom it was performed distally (in the lower half of the groove or in the humeral shaft)90. Two patients had persistent groove pain at the twelve-month follow-up; both patients had undergone tenodesis in the upper half of the groove. The overall ASES score improved from 49 points preoperatively to 78 points postoperatively, and the average Constant score improved from 58 points preoperatively to 81 points postoperatively. No patient developed noticeable deformity of the biceps muscle. No substantial complications, such as humeral fracture, infection, or nerve injury, were noted.
Soft-tissue tenodesis techniques also have been described but have been associated with a higher rate of failure as compared with suture anchor and interference screw techniques. In a recent study, Scheibel et al. compared thirty patients who had undergone arthroscopic soft-tissue biceps tenodesis and twenty-seven patients who had undergone osseous fixation tenodesis72. The authors found a better long head of the biceps score, examiner-dependent evaluation of the cosmetic result, and structural integrity of the tenodesis construct in the osseous fixation cohort as compared with the soft-tissue tenodesis cohort. Sekiya et al. presented a description of a percutaneous soft-tissue technique and reported predictable pain relief, absence of cosmetic deformity, and good patient satisfaction in their four-year experience using the technique60.
Lesions of the biceps-labrum complex of the shoulder are commonly encountered and can lead to substantial pain and dysfunction. When nonoperative options have failed, biceps tenodesis offers a reconstructive option to relieve pain and to restore function while minimizing the risk of cosmetic deformity or fatigue cramping. Numerous options for biceps tenodesis exist, including arthroscopic and open techniques; soft-tissue, suprapectoral, and subpectoral locations; and suture anchor and interference screw fixation. Clinical outcome studies have shown improvement in terms of pain and function after numerous tenodesis methods, although no individual method of tenodesis has been demonstrated to yield superior results to date.
Source of Funding: No source of external funding was used for this study.
Investigation performed at the University of Virginia, Charlottesville, Virginia
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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