My name is Dr. Nick Hilverma from Rush University Medical Center in Chicago, and I'd like to speak to you today sharing some thoughts on biceps tenotomy and tenodesis, high, low, inside or on the bone. My disclosures are available through the academy's online disclosure program. Whenever we discuss biceps pathology and treatment, I think it's important to review the biceps anatomy. The long head biceps originates from the supraglenoid tubercle and the superior glenoid labrum and is often associated with labral conditions. Distally it attaches to the biceps tuberosity and has significant anatomic variability during its intraarticular and attachment onto the labrum. Anatomic considerations should be kept in mind in that the biceps has both an intraarticular and an extraarticular component. The intraarticular component is about three and a half centimeters in length. The extraarticular component is about five to six centimeters in length and cannot be seen arthroscopically but may be a cause of anterior shoulder pain and therefore should be evaluated in the preoperative setting and also should be considered when determining a location for tenodesis. In regards to surgical anatomy, we can divide the biceps into three zones. Zone one includes the traditional bony bicipital groove. Zone two is between the distal aspect of the groove and the superior aspect of the pectoralis major and finally zone three which is in the subpectoral region and these are applicable with regard to the location of a tenodesis. When determining should the biceps be removed from the shoulder joint, I think it's important to keep in mind the function of the biceps which remains highly controversial. The comparative anatomy and EMG data suggests a minimal role for biceps and shoulder activities. However, the biomechanical data suggests a secondary but possibly important role particularly at end range of motion or in those patients with high shoulder demands such as overhead athletes or patients experiencing shoulder instability. The indications for tenodesis are multiple and they include primarily inflammatory conditions such as primary tenosynovitis or tenosynovitis associated with rotator cuff pathology, instability that is often occurring with subscapularis tears, traumatic rupture where cosmesis may influence the decision for tenodesis, and finally, more recently, biceps tenodesis has been used in the management of slap lesions, type 2, type 4, or revision situations. There's been extensive discussion in regards to whether one should perform a tenodesis versus a simple tenotomy. I think the data is fairly clear that with regard to patient-reported outcomes and clinical outcomes, for the vast majority of patients, there's no difference in clinical-reported outcomes with tenotomy compared to tenodesis. There is a significant prevalence of Popeye deformity, up to 30 to 40 percent in patients undergoing tenotomy, and it's important that patients understand the risk of a cosmetic deformity in order to make an informed decision regarding tenotomy versus tenodesis. In addition, I think it's important in patients with legal claims such as workers' compensation or personal injury claims where a deformity may be misconstrued as a disability that tenodesis may be considered. In addition, there are some patients who experience cramping or fatigue discomfort associated with tenotomy, and therefore patients with high shoulder demands may be better served with a tenodesis. On the contrary side, tenodesis does require a longer rehabilitation time and may have a higher complication risk. When considering the location of tenodesis, this was a paper that was written by J.P. Warner where he determined that patients that had a proximal tenodesis had a much higher rate of persistent anterior shoulder pain and a higher rate of revision surgery and suggested that we should consider distal locations for tenodesis or at least decompression of the groove segment of the long head biceps. And this really highlighted the debate between the location for an appropriate tenodesis procedure. Orthoscopic techniques have become favored over time, particularly as we've developed different types of mechanical constructs in order to perform a biceps tenodesis in an orthoscopic fashion. And we can consider things like a bone tunnel, cortical button, keyhole techniques, suture anchors, or interference screws. And we've gotten to the point now where the biomechanical performance is essentially similar between any of these techniques, whether it's inlay or onlay using an interference screw versus an anchor. Although there has been a trend towards lower rates of post-op Popeye deformity in an onlay configuration, higher revision rates in an inlay approach. One of the arguments that gets made for inlay versus onlay is potential healing within a tunnel versus just laying the tendon on a bone. This was the subject of a rabbit study performed by Scott Rodeo where they were able to show no difference in terms of the performance of a repair comparing an inlay technique to an onlay technique. Finally, the outcomes of inlay versus onlay published in AJSM, over 1,500 patients with a mean follow-up of 11 months, equivalent patient outcomes with no difference in cramping, deformity, subjective weakness reported. So it really seems as though this is essentially a dealer's choice. There has been a recent shift towards an arthroscopic approach. In 2007, this was less than 1% of cases. In 2017, it's now about 60% of cases. And there seems to be an equivalent rate of outcomes, including Popeye deformity and patient-reported outcomes between an open and an arthroscopic technique. Lower cost has been associated with open tenodesis, and the open technique is technically less demanding. When we look at outcomes of open versus arthroscopic technique, this was a study that was performed out of our institution at Rush where we compared an open subpectral technique to an arthroscopic superpectoral technique, 77 patients followed up to one year after surgery and no difference in patient-reported outcome, functional outcomes, complication rates, or Popeye deformity. So again, it's really what the surgeon is most comfortable with in terms of location as well as onlay versus inlay, proximal versus distal. I'll share with you my preferred techniques for both arthroscopic and open biceps tenodesis. I prefer an onlay technique for arthroscopic superpectenodesis. Here you can see a right shoulder. We begin by first releasing the tendon. We identify the tendon within the groove using an anterior portal. We can then use a standard all-suture anchor that's placed at the base of the groove. We pass sutures in a cinch configuration, and alternatively, we now have knotless-type suture anchors that are available in order to perform this while avoiding knot tying as you see here. I generally prefer using two anchors as my experience has been that there's a lower rate of failure with two anchors. We've recently submitted for publication our comparison between one anchor and two anchors and found the difference of about 10% Popeye deformity versus 1% Popeye deformity. For the open subpectral approach, this is done through a small incision, which is made at the base of the axillary fold. We open the incision. We identify the plane between the inferior border of the pectoralis major and the short head of the biceps as you see here. We can then elevate the inferior border of the pectoralis major and medially retract the short head of the biceps, and this allows exposure and isolation of the long head, which can then be removed from the wound. At this point, one can either perform an interference screw fixation versus a suture-based fixation. In this case, we're demonstrating an interference screw fixation. The tendon is docked into the tunnel, generally about 10 to 15 millimeters above the musculotendinous junction. It's pinned to the back wall of the humerus. I generally reinsert the proximal portion of the tendon into the tunnel so that only one limb of the tendon is undergoing interference screw fixation, and then we choose either a 7x12 or 8x12 millimeter interference screw in order to complete the tenodesis as you see here. Here are some references discussing some of the literature that was cited during this talk. Thank you very much for your attention.

biceps tenotomy

biceps tenodesis

Popeye deformity

arthroscopic techniques

inflammatory conditions