Orthop Clin N Am 34 (2003) 499 – 506
Arthroscopic biceps tenodesis Christopher S. Ahmad, MDa,*, Neal S. ElAttrache, MDb,c a
Center for Shoulder, Elbow, and Sports Medicine, Department of Orthopaedic Surgery, Columbia University, 622 West 168th Street, PH 11th Floor, New York, NY, USA b Department of Orthopaedic Surgery, University of Southern California School of Medicine, Los Angeles, CA 90033, USA c Kerlan-Jobe Orthopaedic Clinic, Los Angeles, CA, USA
Although the function of the long head of the biceps tendon in the shoulder remains controversial, there is less doubt that the biceps tendon can be a significant source of pain [1 – 9]. Many investigators therefore advocate either biceps tenotomy or tenodesis for treatment of painful biceps disorders, with significant controversy associated with each option [10 – 14]. Biceps tenodesis has suggested advantages over tenotomy that include maintenance of the length – tension relationship, prevention of muscle atrophy, maintenance of elbow flexion and supination strength, avoidance of cramping pain, and avoidance of cosmetic deformity [15]. Biceps tenodesis generally is recommended for younger patients and has been well described using open techniques [10,11,16]. More recently, all arthroscopic techniques described have been advocated especially when concomitant rotator cuff pathology or acromioclavicular (AC) joint pathology are being addressed arthroscopically. Gartsman and Hammerman [17] described an arthroscopic biceps tenodesis technique using suture anchors. Boileau et al [18] presented a technique using interference screw fixation with the guide pin drilled through the humerus to tension the biceps within a bony tunnel. Klepps et al described a technique using interference screw fixation with tensioning of the biceps delivered into a bony tunnel using suture anchors [19]. This article describes the pathology, indications, and a technique for all arthroscopic biceps tenodesis that optimizes
* Corresponding author. E-mail address:
[email protected] (C.S. Ahmad).
fixation while easing technical demands and minimizing neurovascular injury risk.
Pathology Biceps disorders have been classified as biceps instability or biceps tendonitis, in which biceps tendinitis is divided further into primary or secondary [16]. Secondary tendonitis is more common and is associated with other shoulder disorders such as rotator cuff disease. Because of the intimate association of the biceps tendon with the rotator cuff, the principal cause of biceps degeneration is attributed to mechanical impingement of the tendon against the coracoacromial arch similar to rotator cuff impingement [20 – 23]. The tendon is atrophic from the degenerative process or hypertrophic in response to the chronic inflammation from the impingement [24]. Synovitis of the biceps tendon most often occurs in the segment within the bicipital groove [25]. Primary bicipital tendonitis is less usual and requires exclusion of rotator cuff pathology for the diagnosis. The pathologic changes in the long head of the biceps have been described by Murthi et al, who prospectively studied in 200 consecutive shoulders that underwent arthroscopic subacromial decompression for impingement syndrome [26]. Histopathology revealed chronic inflammation in 63% and fibrotic degeneration in 13% of the specimens. Subluxation of the long head of the biceps is associated most commonly with loss of soft tissue restraints from rotator cuff tears [7,27 – 30]. In the presence of a subscapularis tear, the tendon can sublux
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medial and deep to the subscapularis. A frank dislocation of the long head of the biceps is associated nearly always with a subscapularis tear [16].
anterior portion of the shoulder, accompanied by a lump on the anterolateral aspect of the arm. Imaging studies
Diagnosis History Patients complain of pain localized to the anterolateral aspects of the shoulder, which radiates down the anterior arm into the biceps muscle with extension and internal rotation maneuvers of the arm [3,7,28 – 30]. Rest pain and night pain are seen later in the disease progression. The pain may be compounded by impingement syndrome or rotator cuff tendonitis when occurring concomitantly. Patients with instability of the biceps have painful snapping or clicking in the shoulder, typically in overhead positions with internal to external rotation motion. Because subluxation occurs in the presence of partial or full thickness rotator cuff defects, rotator cuff symptoms usually are also present. Frank dislocations of the long head of the biceps usually follow a traumatic event and are associated most often with complete tear of the subscapularis. The dislocation of the tendon from the groove often creates a snapping sensation. Physical examination The most common examination finding is point tenderness of the biceps tendon within the bicipital groove, which is best localized with the arm in 10° of internal rotation. The groove is palpated as a depression between the greater and lesser tuberosities. Tenderness in this area can be differentiated from rotator cuff tendinitis by external rotation of the arm. Pain related to the biceps migrates laterally with external rotation of the arm, whereas pain related to rotator cuff tendonitis radiates to the deltoid insertion and does not move with arm rotation. Other specific physical examination tests used to identify pathology of the long head of the biceps tendon include Speed’s test [3,31], Yergason’s test [32], active compression test [33], and the biceps instability test [34]. Biceps instability is tested with full abduction and external rotation attempting to elicit a painful click that may be palpable. Because instability of the biceps often is associated with a partial or complete subscapularis rupture, the liftoff test is an essential part of the biceps evaluation. Complete rupture of the long head of the biceps is identified by a cosmetic deformity from the biceps dropping toward the elbow. Shallowness occurs in the
Radiographic examination should include A-P views in neutral, internal, and external rotation, an axillary view, and scapular Y view to asses for associated abnormalities. A bicipital groove view that is not obtained routinely is performed with the patient supine, arm in external rotation and the beam directed cephalad and 15° medial to the long axis of the humerus. Ultrasound may dynamically correlate clinical examination with sites of tenderness. MRI has the advantages of visualizing the biceps in its groove and surrounding osteophytes together with associated rotator cuff pathology.
Indications Yamaguchi et al has outlined a criterion for biceps tendon management. Reversible changes are considered when degeneration includes less than 25% partial tearing and the tendon has normal position within the bicipital groove. Reversible changes are treated with observation. Irreversible changes include partial thickness tearing or fraying greater than 25%, subluxation of the tendon from the bicipital groove, or reduction in tendon size greater than 25%. Additional relative indications for biceps tenotomy or tenodesis are failed subacromial decompression with persistent symptoms attributed to the biceps. Tenodesis is performed for younger patients (less than 55 years of age) and
Fig. 1. Patient placed in the beach chair position and placement of standard posterior, modified lateral, anterolateral, and anterior portals are outlined.
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Fig. 2. Arthroscopic view of long head of biceps tendon within the glenohumeral joint. (A) More normal appearance before drawing the tendon into the joint. (B) Significant degeneration of the tendon appreciated following drawing the tendon into the joint.
especially if they are thin. For the older, less active patient, tenotomy is performed. Patients must be counseled and accept the possible deformity that can occur if the long head of the biceps retracts into the arm [18].
Technique When addressing associated pathology, the subacromial decompression and distal clavicle resection is performed before the biceps tenodesis. If a rotator cuff repair is required, however, the biceps tenodesis may be performed before the rotator cuff repair if maximum protection of the rotator cuff repair is desired.
The patient is positioned in the lateral decubitus or beach chair position and the portals are outlined as shown in Fig. 1. A standard posterior portal is created 1 – 2 cm inferior and 1 – 2 cm medial to the posterolateral edge of the acromion. Standard diagnostic arthroscopy is performed and the intra-articular portion of the biceps tendon is visualized. The anterior portal is then created just lateral to the coracoid process entering the joint superior to the lateral half of the subscapularis tendon. The biceps tendon is pulled into the joint using a probe to visualize the portion of the biceps that lies within the groove to fully evaluate the tendon. As shown in Fig. 2, significant pathology can be missed if the tendon is not drawn into the joint. If significant tearing (25%), subluxation, or severe tendonitis dem-
Fig. 3. Controlling the long head of the biceps. (A) A spinal needle passed percutaneously is used to penetrate the biceps tendon. (B) A monofilament suture is passed through the needle and retrieved out the anterior portal.
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onstrated by hemorrhagic inflammation is seen, then the decision to perform a tenodesis is confirmed. Control of the biceps is obtained by percutaneously placing an 18-gauge spinal needle through the proximal biceps, passing No. 0 monofilament sutures as shown in Fig. 3. Two sutures are placed and retrieved out the anterior portal. The tenotomy is then performed at the superior labrum using a basket as shown in Fig. 4 and the residual stump is debrided to a stable smooth margin. Visualization is then changed to the subacromial space. A lateral working portal is established just posterior and 2 – 3 cm lateral to the anterior edge of the acromion (see Fig. 1). Placing this portal more anterior than a typical lateral portal placed at the middle acromion allows better visualization of the bicipital groove. A bursectomy is performed, clearing the anterior and lateral gutters of the subacromial space and exposing the greater tuberosity. If necessary, an acromioplasty is performed at this point. The arthroscope is then placed into the lateral portal. The sutures controlling the tendon are tensioned to pull the tendon out of the defect created in the rotator cuff interval from placement of the anterior cannula. The biceps sheath and falciform ligament of the pectoralis major tendon are identified and transected using an arthroscopic blade or hook electrocautery. Care is taken to avoid damaging the biceps tendon or the traction sutures. The anterior portal cannula is removed and the biceps tendon is delivered out of the skin. The shoulder and elbow are flexed and the arm is positioned in appropriate internal/external rotation to place the biceps directly under the anterior portal to maximize the tendon delivered out of the skin. A portion (10 – 15 mm) may be excised to adjust tendon
Fig. 4. Tenotomy of long head of biceps is performed using basket instruments.
Fig. 5. Biceps tendon delivered out anterior portal and whipstitch placed.
length for proper tension for the tenodesis in the bicipital groove. The length of biceps that is intraarticular has been estimated at 35 mm with the arm adducted to the side [35]. Approximately 20 mm of tendon is placed in a bone tunnel; therefore, removing an additional 10 – 15 mm restores the appropriate length. The traction sutures are then augmented with a whipstitch of #2 nonabsorbable suture for 20 mm as shown in Fig. 5. The biceps tendon is then contoured to a uniform shape and the diameter determined with sizing guides as shown in Fig. 6. An accessory anterolateral portal is created 2 – 3 cm anterior to the anterolateral edge of the acromion (see Fig. 1). Exact position can be verified with a spinal
Fig. 6. Biceps tendon diameter sized.
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Fig. 9. Bone tunnel created in bicipital groove. Fig. 7. Bicipital groove debrided.
needle to gain the proper angle on the bicipital groove. The bicipital groove is debrided of soft tissue using a shaver or ablation device as shown in Fig. 7. With the arm slightly externally rotated for the proper angle, a 2.4-mm guide pin is placed in the center of the bicipital groove perpendicular to the surface of the bone as shown in Fig. 8. The bone tunnel is then created using a cannulated reamer the same diameter as the tendon to a depth of 25 – 30 mm as shown in Fig. 9. The anterior portal cannula is exchanged for an 8.25-mm clear cannula that accommodates the interference screw and driver. An interference screw is chosen 1 mm smaller than the hole drilled and placed on the Arthrex Bio-Tenodesis driver (Arthrex, Inc.; Naples, FL). The biceps tendon is controlled by passing the whipstitch suture through the cannulation of the driver as shown in Fig. 10. With the tendon drawn tightly against the driver, the driver and tendon is inserted into the bone tunnel as shown in Fig. 11.
Fig. 8. Guide pin placed in bicipital groove.
The screw is then advanced over the tip of the driver with constant tension on the graft into the bone tunnel. Fig. 12 demonstrates the graft fixed with the interference screw. The suture controlling the graft is then tied over the screw with standard knot-tying techniques. This creates secondary fixation from the sutures as shown in Fig. 13.
Postoperative protocol For patients undergoing rotator cuff repair and biceps tenodesis, postoperative rehabilitation is focused on protecting the rotator cuff repair. Full passive shoulder and elbow motion is performed during the first 6 weeks with avoidance of shoulder extension and internal rotation. Active shoulder motion begins at 6 weeks and is continued for 3 months when resistive exercises begin. For patients undergoing isolated
Fig. 10. Interference screw on Bio-Tenodesis screwdriver with sutures being passed through the cannulation of the driver with a wire passer.
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Fig. 11. The tip of the driver advances the graft into the tunnel and keeps constant tension on the graft while the screw is advanced.
tenodesis, full passive- and active-assisted shoulder motion exercises are begun immediately. Active biceps flexion, however, is avoided for 6 weeks. At 6 weeks, full unlimited active elbow motion and resistive exercises are begun. Several methods of open biceps tenodesis have been reported previously with excellent outcome [2,4,10 – 13,16]. The open techniques require a separate deltopectoral incision that potentially increases postoperative pain and is cosmetically less appealing. The goals of arthroscopic techniques are to achieve equal fixation strength with less morbidity. All-arthroscopic rotator cuff repairs are being performed more frequently, which also favors a concomitant all-arthroscopic biceps tenodesis. Three different arthroscopic biceps tenodesis techniques have been reported previously [17 – 19]. Gartsman and Hammerman described a technique that uses bone anchors for fixation [17]. Boileau et al described a technique that requires passage of guide-pin from anterior to posterior through the humerus, which facilitates tensioning the graft into a tunnel with fixation achieved using an interference screw. This technique carries potential risk to the neurovascular structures [18]. Klepps described a technique that uses
Fig. 12. Interference screw placement.
a bone anchor to deliver and temporarily hold the biceps into the bone tunnel while the interference screw is placed [19]. The current technique presented reduces the technical challenge while providing optimum biologic environment for healing. Biomechanic testing in cadavers of interference screw fixation using the tenodesis driver has demonstrated fixation strength from 220 – 280 N with displacements of 4 – 6 mm under cyclic loading, which compares with the open bone tunnel technique of approximately 240 N with 8 mm displacement [15]. Romeo compared open subpectoral and arthroscopic tenodesis techniques with 17 patients in each group with 7 months follow-up. There was no difference found in American Shoulder and Elbow Surgeons (ASES), simple shoulder test (SST), or visual analog scale (VAS) testing. There was a 6% reoperation rate from persistent shoulder pain in both groups. Longer follow-up is required to compare fully the different techniques [15].
Fig. 13. Fixation is achieved by the interference screw and the sutures.
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Summary The proximal biceps tendon is a significant source of shoulder pain that may be treated with biceps tenotomy or tenodesis. Biceps tenodesis has suggested advantages over tenotomy that include maintenance of the length – tension relationship, prevention of muscle atrophy, maintenance of elbow flexion and supination strength, avoidance of cramping pain, and avoidance of cosmetic deformity. The recent advancement of all arthroscopic tenodesis techniques has provided sufficient fixation strength while easing technical demands and minimizing neurovascular injury risk. With our newer techniques and better understanding of proximal biceps tendon pathology, the indications for tenodesis are evolving, and longer-term follow-up is required to fully evaluate the outcome of these procedures.
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