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Biceps Tenodesis

Biceps tenodesis and tenotomy — when, where (suprapectoral vs subpectoral) and what to expect afterwards.

Overview

Biceps tenodesis provides significant clinical improvement and high rates of survivorship two years postoperatively [1], with most patients achieving clinically significant outcomes between five and eight months after isolated tenodesis [5]. Patients can expect to attain these outcomes by 13 months postoperatively [5]. The procedure is gaining popularity due to encouraging functional outcomes and return-to-sport rates [21], serving as an alternative to SLAP repair in patients less than 25 years of age when indicated [2]. In this younger demographic, tenodesis yields excellent outcomes with two-thirds of patients able to return to sport and a low revision rate [3].

Operative treatment for SLAP tears is reserved for failure of nonoperative treatment [21], with selection of the biceps tenodesis technique predominantly dependent on surgeon preference and patient selection [9]. Arthroscopic suprapectoral and mini-open subpectoral biceps tenodesis demonstrate comparable improvements in functional outcomes with no reported perioperative complications [9]. While SLAP repair and biceps tenodesis both present viable treatment options for SLAP tears, they come with specific advantages and disadvantages [19]. Outcomes following surgical treatment for SLAP lesions vary depending on the method of treatment, associated pathology, and patient characteristics [4]. The decision between SLAP repair and biceps tenodesis is ultimately made individually with the patient [19].

In the context of rotator cuff disorders, biceps tenodesis has proven more successful than tenotomy in non-isolated cuff tears [25]. However, tenotomy and tenodesis of the long head of the biceps result in comparable postoperative clinical and functional outcomes [26], with tenotomy being well accepted by most patients with good overall results [59]. At a short-term follow-up of one year, no patients had reoperations or revisions for failed arthroscopic-assisted locked loop suprapectoral biceps tenodesis [6].

Anatomy & Pathophysiology

Osseous and Labral Architecture

The glenoid labrum consists of parallel collagen fibers coursing around the glenoid circumference, inserting on the superior rim medial to the articular cartilage margin via a fibrocartilaginous transitional zone [16]. A normal synovial recess exists between the meniscoid or triangular superior labrum and the articular cartilage extension over the superior glenoid rim [16]. The long head of the biceps (LHB) originates from the bicipital tubercle at the superior glenoid rim and the posterior superior rim of the glenoid and labrum [37]. Anatomically, 40% to 60% of the biceps tendon attaches to the supraglenoid tubercle 5 mm medial to the superior glenoid rim, while the remainder attaches directly to the superior labrum [16]. The biceps tendon typically attaches entirely (type I) or predominantly posterior (type II) on the superior labrum [16]. Classification of labral attachment: Type I is defined as all labral attachment to the posterior labrum with none to the anterior [41]; Type II involves most attachment to the posterior labrum with a small anterior contribution [41]; Type III denotes equal contributions to anterior and posterior labrum [41]; and Type IV is defined as most attachment to the anterior labrum with a small posterior contribution [41].

Vascular and Neural Supply

Vascularity to the glenoid labrum originates from the scapular, circumflex scapular, and posterior circumflex humeral arteries via capsular or periosteal vessels [16]. The inner portion of the glenoid labrum is avascular, and the superior labrum is less vascular compared with the inferior and posterior labrum [38]. The biceps tendon is an intra-articular but extrasynovial structure [16]. Vascularity of the biceps tendon is provided primarily by the ascending branch of the anterior humeral circumflex artery traveling within the bicipital groove [16]. An avascular zone exists at the proximal portion of the biceps tendon close to the superior glenoid, corresponding to a hypovascular zone near the tendon origin where it commonly tears at the LHB pulley [38]. Blood is supplied to the LHB tendon from the thoracoacromial and brachial arteries via the osteotendinous and musculotendinous junctions, respectively [38]. The blood supply to the biceps is derived from a single large bicipital artery from the brachial artery (35%), multiple very small arteries (40%), or a combination of the two types [37]. The LHB tendon is innervated by thinly myelinated sensory neurons, with most innervation occurring at the LHB origin [38]. Innervation of the biceps is supplied by branches of the musculocutaneous nerve (C5 and C6) [37].

Ligamentous Stabilization and Pulley Complex

The biceps tendon passes through the bicipital groove, or intertubercular groove, between the greater and lesser tuberosities [16]. Stability of the biceps within the groove is afforded by the biceps sling, or pulley, consisting of fibers from the subscapularis tendon, supraspinatus tendon, coracohumeral ligament, and superior glenohumeral ligament [16]. The biceps pulley is composed of the superior glenohumeral ligament and coracohumeral ligament in combination with the subscapularis [17]. The LHB pulley stabilizes the proximal LHB as the tendon enters the bicipital groove [38]. The rotator cuff interval is a triangular region bounded medially by the coracoid process, superiorly by the anterior margin of the supraspinatus, and inferiorly by the superior margin of the subscapularis [17]. In the rotator cuff interval, the anterior capsule is supported by both the superior glenohumeral ligament and the coracohumeral ligament [17]. The biceps tendon traverses the rotator cuff interval, where it is held in place by the biceps pulley, before exiting the joint via the bicipital groove [17]. The bicipital tendon is retained within the groove by a pulley made up of fibers from the coracohumeral and superior glenohumeral ligaments, with some reinforcement from adjacent tendons [37].

Pathophysiology and Instability Mechanisms

SLAP tears can be caused by forceful traction to the arm, direct compression loads, and repetitive overhead throwing [22]. Increased external rotation of the shoulder in the late cocking phase increases torsional force at the LHB root, resulting in a peel-back injury to the posterosuperior labrum [22]. Injuries can result from repetitive contact of the posterosuperior labrum with the undersurface of the rotator cuff in the late cocking phase, known as internal impingement [22]. SLAP tears are seen more frequently in the late cocking position, occurring because of an adaptive posterior capsular contracture [22]. Throwing athletes demonstrate increased shoulder external rotation and decreased internal rotation in abduction, which causes posterosuperior migration of the humeral head in the late cocking phase [22]. Increased external rotation results in greater torsional loads across the superior labrum from the more posteriorly oriented LHB tendon causing the labrum and LHB tendon to displace medially over the glenoid rim [22]. Pathology of the LHB tendon includes tendinitis, tendinopathy, tears, subluxation, entrapment, delamination, and dislocation out of the bicipital groove [22]. Because of the relatively anterior position of the bicipital groove along the humeral head combined with humeral retroversion, the tendon is exposed to medial instability [22]. Variations of bicipital groove morphology can increase the risk of LHB tendon pathology [22]. Isolated LHB tendon pathology frequently is associated with other shoulder pathologies, especially rotator cuff pathology [22]. Primary LHB tendinitis usually occurs in younger patients who participate in overhead activities such as volleyball and baseball [22]. With LHB tendon instability, the patient describes a clicking or snapping with overhead motions [22]. A subscapularis tear is associated with LHB medial instability [22]. A supraspinatus tear is associated with posterolateral instability of the LHB tendon [22]. Bicipital instability is usually associated with rotator interval injury or subscapularis tendon injury, or both [49]. MRI accurately reveals varying degrees of bicipital instability, from medial subluxation to dislocation within the glenohumeral joint with complete detachment of the subscapularis tendon [49].

Dislocation Classifications

Type I extraarticular dislocation: Combined with a partial tear of the subscapularis tendon [47]. In Type I extraarticular dislocation, there is invariably a rupture of the common attachment of the superior glenohumeral ligament and coracohumeral ligament [47]. In Type I extraarticular dislocation, the outer attachment of the subscapularis tendon is always torn [47]. Extraarticular dislocation with an intact subscapularis tendon is very rare, occurring in 3% of patients with subluxation and dislocations [47]. Type II intraarticular dislocation: Combined with a complete tear of the subscapularis tendon [47]. In Type II intraarticular dislocation, the biceps tendon is widened and flattened as a result of its contact with the lesser tuberosity [47]. In Type II intraarticular dislocation, the proximal two-thirds of the subscapularis tendon is ruptured [47]. Approximately half of Type II intraarticular dislocations have a traumatic etiology [47].

Anatomic Variants

Anatomic variants in the superior labrum include a sublabral foramen or absence of the superior labrum, often seen together with a cordlike middle glenohumeral ligament (MGHL) [38]. 3.3% of shoulders have a sublabral foramen [38]. 8.6% of shoulders have a sublabral foramen with a cordlike MGHL, also called a Buford complex [38]. 1.5% of shoulders have an absent anterosuperior labrum [38].

Kinematics and Functional Impact

The short head of the biceps originates from the coracoid tip lateral to and in common with the coracobrachialis [37]. The lateral insertion of the biceps is to the posterior part of the tuberosity of the radius [37]. The medial insertion of the biceps is aponeurotic and passes medially across and into the deep fascia of the muscles of the volar forearm [37]. The bicipital tendon does not move up and down in the groove; rather, the humerus moves down and up with adduction and abduction relative to the tendon [37]. The long head of the biceps contributes to joint stability, which is increased in external rotation and decreased in internal rotation [37]. Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions [52]. In vivo studies have yet to establish the stabilizing effect of the long head of the biceps and the physiologic load required remains unknown [52]. The long head of the biceps tendon has minimal effect on in vivo glenohumeral kinematics [50]. Loss of the long head attachment is manifested mainly as loss of supination strength (20%) with a smaller loss (8%) of elbow flexion strength [37]. Loss of the long head of the biceps depressor effect may result in a 20% loss of elevation strength in external rotation [37]. Pain originating from the long head of biceps tendon induced an approximately 30% decrease of shoulder abduction and elbow flexion strength despite there being no structural or biomechanical abnormalities [51]. Biceps tenodesis shows no deleterious effect on glenohumeral kinematics and stability in the presence of a SLAP lesion [53]. The long head of the biceps has a pertinent biomechanical role in glenohumeral stability regardless of the condition of the superior labrum [76]. SCR using the long head of the biceps tendon is biomechanically effective in reducing posterosuperior translation of the humeral head in the setting of an MIRCT [72]. An improvement in isometric contraction in flexion of the elbow was observed after tenotomy, but this did not reach the flexion power of the contralateral healthy arm [90]. Increased fatigue of the biceps was observed after tenotomy of the long head of biceps tendon [90].

Classification

Clinical Outcomes: Biceps tenodesis provides significant clinical improvement and high rates of survivorship two years postoperatively [1]. In patients less than 25 years of age, the procedure yields excellent outcomes with two-thirds of patients able to return to sport and a low revision rate [3]. All patients, irrespective of the type of biceps tendon procedure, had excellent clinical and functional outcomes at least one year after surgery [28]. Tenotomy and tenodesis of the long head of the biceps result in comparable postoperative clinical and functional outcomes [26].

Treatment Selection: Outcomes following surgical treatment for biceps pathology vary depending on the method of treatment, associated pathology, and patient characteristics [4]. Adjuvant biceps procedures are not required when repairing isolated supraspinatus tears unless biceps pathology is observed intraoperatively [14]. When biceps pathology is observed intraoperatively during repair of isolated supraspinatus tears, tenodesis grants better function and strength than tenotomy [14]. There is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii [82].

Surgical Technique: The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques [20]. The open subpectoral method achieves fixation in a significantly narrower region of the humerus compared to the all-arthroscopic suprapectoral technique [20]. Tenotomy and open tenodesis are both safe options for treatment of biceps pathology with low 30-day postoperative complication rates [10]. Biceps tenodesis techniques which do not release the biceps sheath or remove the tendon from the sheath have increased revision rates compared to techniques that do [81].

Other Considerations: The majority of biceps tenodesis cases were performed in men aged 30 to 59 years [8]. The South had the highest overall number of biceps tenodesis cases in the United States [8]. The incidence of biceps tenodesis surgery has increased steadily from 2002 to 2010 in New York State [30]. Revision subpectoral biceps tenodesis is a viable procedure for addressing patients with persistent pain following initial proximal biceps tenodesis [32]. The IBTIS is a preoperative clinical and radiological score with 7 items for surgical treatment by arthroscopic tenotomy of the long head of the biceps [74]. Biceps tenodesis is receiving increasing attention as a treatment option for biceps pathology [4].

Clinical Presentation

The long head of the biceps tendon has been implicated in intra-articular shoulder pathology since Codman's writings nearly a century ago [88]. Painful tendinitis may ensue from tears about the rotator interval or with any chronic inflammatory pathology of the glenohumeral joint [88]. A history of radiating anterior shoulder pain may inform the examiner of pain generation from the long head of the biceps tendon [88]. Clinical tests including the O'Brien, Yergason, Speed, and direct palpation tests have limited specificity for biceps pathology [88]. Macroscopic changes in the long head of the biceps tendon do not always correlate with symptoms [18]. A normal arthroscopy does not exclude important symptomatic pathology of the long head of the biceps tendon [18].

MRI, ultrasonography, and arthroscopic examination are tools used to evaluate biceps pathology [88]. Arthroscopic examination is limited to the intra-articular long head of the biceps tendon and the proximal groove, missing less common distal biceps groove lesions [88]. Treatment of long head of the biceps tendon pathology depends on concomitant injuries, patient factors, and surgeon preference [88]. Isolated traumatic tears are generally treated nonsurgically with the potential rare exception of tenodesis for the dominant arm of a laborer or an individual who cannot tolerate deformity [88]. In less physically demanding individuals who may tolerate deformity, arthroscopic tenotomy is acceptable [88]. Outcomes for long head of the biceps tendon pathology treatment are generally good to excellent [88].

Tenotomy: Results in cosmetic deformity (Popeye) about 30% of the time [88]. Vigorous activity may result in cramping pain of the biceps muscle belly following tenotomy [88]. Tenodesis: Provides significant clinical improvement and high rates of survivorship 2 years postoperatively [1]. Biceps tenodesis offers an alternative to SLAP repair in young patients when indicated [2]. Biceps tenodesis in patients less than 25 years of age yields excellent outcomes with two thirds of patients able to return to sport and a low revision rate [3]. Biceps tenodesis in patients 35 years of age and younger yields excellent clinical outcome scores [7]. Reported return-to-sport rates following biceps tenodesis in patients 35 years of age and younger show wide variability [7]. Reported complication, reoperation, and failure rates following biceps tenodesis in patients 35 years of age and younger are low but variable [7].

Approach: Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients with no identifiable differences between the two approaches [23]. Arthroscopic suprapectoral and open subpectoral biceps tenodesis both yield excellent clinical and functional results for the management of isolated superior labrum or long head biceps pathology [56]. Arthroscopic proximal biceps tenodesis appears to be a reliable technique to manage the pathologic biceps tendon [57]. Results of arthroscopic proximal biceps tenodesis are predicated on the outcome of treatment of associated rotator cuff disease [57]. Fixation: Sutures through bone tunnels have more cyclic displacement than anchors, keyhole, screw, or button techniques [88]. There is no evidence that substantiates one fixation approach or method over another for biceps tenodesis [88].

Decision Axis: The decision to perform tenotomy or tenodesis should be made preoperatively based on patient symptoms and concomitant pathologies [18]. The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon can continue to be based on surgeon and patient preference [24]. Biceps tenotomy and tenodesis are both viable treatments for proximal biceps tendon pathology, yielding high patient satisfaction [54]. Tenotomy and open tenodesis are both safe options for treatment of biceps pathology with low 30-day postoperative complication rates [10]. Arthroscopic biceps tenotomy and tenodesis effectively treat severe pain or dysfunction caused by an irreparable rotator cuff tear associated with biceps pathology [62]. Proximal biceps tenodesis relieved symptoms in a patient with lateral antebrachial cutaneous neuropathy by reducing traction on the nerve [58].

Concurrent Pathology: Outcomes following surgical treatment of biceps pathology vary depending on the method of treatment, associated pathology, and patient characteristics [4]. Adjuvant biceps procedures are not required when repairing isolated supraspinatus tears unless biceps pathology is observed intraoperatively [14]. Tenodesis grants better function and strength than tenotomy when repairing isolated supraspinatus tears with pathologic biceps [14]. There are currently no clear guidelines for the management of concurrent biceps tendon pathology in the setting of massive rotator cuff tears [12]. Superior clinical outcomes are seen in nonsmokers following revision rotator cuff repairs [11]. Superior clinical outcomes are seen in patients with only one tendon affected following revision rotator cuff repairs [11]. Superior clinical outcomes are seen in patients who undergo tenotomy instead of tenodesis for a damaged long head of the biceps tendon during revision rotator cuff repairs [11].

Recovery and Demographics: Patients can expect to attain clinically significant outcomes by 13 months postoperatively after isolated biceps tenodesis, with most patients achieving this between 5 and 8 months [5]. Most patients were able to return to work at an average of 5.4 ± 2.8 months following biceps tenodesis [13]. The majority of biceps tenodesis cases were performed in men aged 30 to 59 years [8]. The South had the highest overall number of biceps tenodesis cases [8].

Investigations

Plain radiography: Obtain scapular Y, AP, and axillary lateral views to assess the glenohumeral joint for abnormalities [60]. Postoperative imaging should include plain radiographs or low-dose CT to visualize the tenodesis site [98]. Short-term radiographic outcomes for both open and arthroscopic tenodesis demonstrate stable fixation with minimal migration [102]. In distal biceps pathology, plain films are most commonly normal and do not show pathologic changes [67]. Biceps ruptures typically do not involve bony ruptures, and standard radiographs of the elbow show minimal changes [67].

MRI: MRI assesses the long head of the biceps (LHB) tendon, associated fluid, possible synovitis, and bicipital groove morphology [60]. It helps identify concomitant shoulder and AC joint pathologies [60]. However, studies demonstrate poor correlation between MRI and arthroscopic findings regarding LHB pathology [60]. MRI has poor to moderate sensitivity for LHB inflammation, partial-thickness tears, and ruptures [60]. Proton density–weighted sequences with fat suppression offer the greatest sensitivity for detecting biceps tendon degeneration [17]. Tendon caliber change is more specific than signal intensity for detecting degeneration [17]. Diagnosing partial tears at the bicipital groove entrance is challenging without directed effort; these tears show abnormal signal intensity, though only half exhibit associated caliber changes [17]. Evaluation in all imaging planes aids in identifying groove entrance lesions [17]. MRI findings in adhesive capsulitis include coracohumeral ligament thickening ≥4 mm, rotator cuff interval capsule thickening, and obliteration of the subcoracoid fat [17]. In chronic long head biceps tendinopathy, MRI and intraoperative assessment may not show significant structural abnormalities despite histopathologic changes [77]. For distal biceps rupture, MRI may show absence of the tendon insertion or a fluid-filled sheath but is unnecessary in most cases and can be falsely negative [67]. Partial distal biceps ruptures appear as high signal intensity, fluid within the sheath, or distal tendon thinning/thickening [67].

Magnetic resonance arthrography (MRA): MRA is more specific and sensitive for LHB pathology and SLAP tears than MRI alone [60]. In patients with no pathology, MRA shows the tendon surrounded by contrast fluid resembling a kidney bean [60]. Both MRI and MRA must be performed in sagittal oblique and axial planes because LHB subluxation and dislocation are often associated with subscapularis tears [60]. MRA sensitivity for biceps pulley evaluation ranges from 82% to 89%, with specificity of 87% to 98% [17]. Diagnostic criteria for biceps pulley abnormalities include nonvisualization or discontinuity of the superior glenohumeral ligament, medial subluxation on axial images, biceps tendinopathy, and inferior displacement on oblique sagittal images [17]. With MRA, all five patients with surgically identified rotator cuff interval lesions showed contrast extension to the undersurface of the coracoid process [17]. The rotator cuff interval is significantly larger in patients with chronic anterior instability [17].

Ultrasonography: Ultrasonography is accurate and cost-effective for diagnosing LHB dislocation, subluxation, and rupture [60]. It is less accurate than other modalities for partial-thickness tendon tears [60]. The exact role of ultrasonography in diagnosing tendon inflammation remains undefined [60]. For distal biceps pathology, ultrasound is a lower-cost tool accurate for complete or partial tears [67]. Complete rupture findings include tendon absence, fluid, and mass in the antecubital fossa [67]. Incomplete rupture may present as a focal hypoechogenic area or tendon thinning [67].

Other Considerations: The myotendinous junction (MTJ) of the biceps begins further proximal than may be appreciated intraoperatively [106]. Positioning the prone patient with the shoulder abducted over the head, elbow at 90 degrees flexion, and forearm in supination (the FABS view) improves visualization of the distal biceps insertion into the radial tuberosity [67].

Treatment

Non-Operative

Operative treatment for SLAP tears is reserved for cases where nonoperative treatment has failed [21].

Operative

Indications: Biceps tenodesis provides significant clinical improvement and high rates of survivorship at 2 years postoperatively [1]. It offers an alternative to SLAP repair in patients younger than 25 years when indicated [2]. Primary biceps tenodesis offers increased effectiveness compared with both primary SLAP repair and nonoperative treatment for symptomatic SLAP tears in middle-aged patients [15]. In the setting of revision rotator cuff repairs, superior clinical outcomes are seen in nonsmokers, those with only 1 tendon affected, and those who undergo tenotomy instead of tenodesis [11]. There are currently no clear guidelines for the management of concurrent biceps tendon pathology in the setting of massive rotator cuff tears [12]. Biceps tenodesis is an appealing alternative to SLAP repair, but the indications and technique in elite pitchers still need to be defined [64].

Surgical Approach / Technique: The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon in active patients younger than 55 years can continue to be based on surgeon and patient preference [24]. Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis [48]. Tenotomy and open tenodesis are both safe options for treatment of biceps pathology with low 30-day postoperative complication rates [10]. Biceps tenodesis has proven more successful than tenotomy in non-isolated cuff tears [25]. Outcomes appear similar between biceps tenotomy versus tenodesis, but the tenotomy group demonstrated greater incidence of cosmetic deformity [100]. The tenotomy group demonstrated earlier improvement in postoperative pain compared to the tenodesis group [100]. Among patients treated with tenodesis or tenotomy, only 74% to 77% achieved good to excellent results [86]. Among patients treated with tenodesis or tenotomy, 19% to 24% had persistent biceps symptoms [86]. Persistent symptoms following a biceps procedure often result from unrecognized and unaddressed bicipital tunnel disease [86]. Surgical techniques that included release of the extra-articular bicipital sheath had a threefold lower failure rate compared with those where the sheath was not released [86]. Group 1 (tunnel decompression) was associated with significantly better Constant scores compared with group 2 (nondecompression) [86]. No significant differences were identified between tunnel decompression and nondecompression groups with respect to revision rates, SST, VAS pain, or ASES scores [86].

Implant Selection: Tenodesis can be done with a PEEK tenodesis screw, with two suture anchors, or with the use of a FiberSnare [63]. The resistance to cyclic loading is comparable between PEEK tenodesis screw and suture anchor techniques [63]. The ultimate pull-out strength of the biotenodesis screw is stronger than the suture anchors [63]. All three all-suture anchors are suitable fixation methods for subpectoral biceps tenodesis [65]. Short-term follow-up of 20 procedures using an all-suture anchor fixation for subpectoral biceps tenodesis has not shown any failure of fixation or residual biceps discomfort [85]. Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure at a minimum 2-year follow-up [84]. The long head of the biceps tendon can be tenodesed to the humerus with interference or tenodesis screws or suture anchors during open approaches [93].

Alignment / Balancing Strategy: The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques [20]. The open subpectoral method achieves fixation in a significantly narrower region of the humerus compared to all-arthroscopic suprapectoral techniques [20]. Arthroscopic suprapectoral and open subpectoral techniques result in significantly different locations of biceps tenodesis [45]. Supra- and subpectoral repairs provide equivalent biomechanical strength when controlling for potential confounders [29]. Open subpectoral biceps tenodesis and all-arthroscopic suprapectoral biceps tenodesis are both successful surgeries with consistently positive outcomes [44]. Arthroscopic suprapectoral biceps tenodesis represents a new technique for distal tenodesis [39]. Long-term results are comparable whether tenodesis is done arthroscopically or through a mini-open approach with a small anterior incision or a small subpectoral incision [63]. There is no difference in functional outcomes or pain relief between proximal and subpectoral biceps tenodesis [96].

Pain Management: Strengthening activities related to elbow flexion or forward elevation of the arm with the elbow extended should be restricted until 6 weeks after biceps tenodesis if only a biceps tenodesis was performed [63]. A shoulder immobilizer is worn for 2 weeks and a sling is used for an additional 2 weeks following open subpectoral biceps tenodesis with rotator cuff repair [93]. Active use and exercises are begun after the initial immobilization period following open subpectoral biceps tenodesis [93]. Patients undergoing open subpectoral biceps tenodesis may be managed using either early or delayed active motion protocols without compromising functional outcome [27].

Adjuncts: Open biceps tenodesis is a less expensive alternative to arthroscopic biceps tenodesis when performed concomitantly with arthroscopic rotator cuff repair [46]. Primary biceps tenodesis has lower costs than primary SLAP repair for symptomatic SLAP tears in middle-aged patients [15].

Setting of Care: Selection of the biceps tenodesis technique is predominantly dependent on surgeon preference and patient selection, as comparable improvements in functional outcomes were shown with no reported perioperative complications [9]. The technique of biceps tenodesis should be chosen based on the skills and experience of the operating surgeon [63].

Revision: Revision subpectoral biceps tenodesis is a viable procedure for addressing patients with persistent pain following initial proximal biceps tenodesis [32]. Although revision to subpectoral biceps tenodesis may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized [95]. Additional care should be taken when operating on patients with previous biceps tenodesis to prevent perioperative fractures during reverse shoulder arthroplasty [99].

Other Considerations: Outcomes following surgical treatment for SLAP lesions vary depending on the method of treatment, associated pathology, and patient characteristics [4]. SLAP repair and biceps tenodesis both present viable treatment options with specific advantages and disadvantages, with the decision made individually with the patient [19]. Biceps tenodesis is gaining popularity due to encouraging functional outcomes and return-to-sport rates [21]. At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed arthroscopic-assisted locked loop suprapectoral biceps tenodesis [6]. Concomitant biceps tenodesis appears to have a favorable effect on 1-year treatment success after total shoulder arthroplasty [33]. Biceps tenodesis with concomitant rotator cuff repair led to improved outcomes regardless of tenodesis fixation construct, location, or technique [75]. Double-row surgical fixation and concomitant biceps tenodesis may be superior to single-row fixation and leaving the biceps alone for isolated subscapularis tears [69]. Open subpectoral tenodesis of the long head of the biceps can be performed using bicortical button fixation without risk to the posterior nervous structures when placed at the inferior aspect of the bicipital groove in conjunction with the musculotendinous junction [80]. Subpectoral biceps tenodesis reliably relieves pain and improves function [83]. Subpectoral biceps tenodesis is a valuable tool for the treatment of proximal biceps tendon pathology regardless of the specific location or technique used [43]. In the rare instance when no pathologic condition exists in the rotator cuff, the biceps tendon can be placed back in the groove and the transverse humeral ligament repaired using interrupted sutures [93]. More commonly, tenodesis should be performed for subluxing biceps tendon [93]. If a pathologic process of the rotator cuff is present with the subluxing biceps tendon, an anterosuperior approach is used [93]. The intraarticular portion of the tendon should be excised and the rotator cuff repaired during open approaches for subluxing biceps tendon [93].

Complications

Stiffness / Arthrofibrosis: A notably increased incidence of postoperative stiffness occurs following arthroscopic suprapectoral biceps tenodesis compared with open subpectoral biceps tenodesis [116].

Other Considerations: Primary biceps tenodesis for pathology of the long head of the biceps tendon provides a low risk for surgical complications [34]. High survivorship rates are observed 2 years postoperatively [1], with no patients requiring reoperations or revisions for failed tenodesis at a short-term follow-up of 1 year [6]. Meta-analysis indicates more frequent favorable outcomes with biceps tenodesis compared to repair for isolated Type II SLAP tears [101]. Comparable improvements in functional outcomes were shown with no reported perioperative complications in a randomized trial comparing arthroscopic suprapectoral and mini-open subpectoral biceps tenodesis [9].

Reoperation and Revision: Higher reoperation rates at 1 year were seen in patients who had concomitant biceps tenodesis compared to those who did not [35]. Reoperation rates were significantly higher in patients undergoing shoulder arthroscopy with biceps tenodesis than in patients undergoing shoulder arthroscopy without biceps tenodesis [117]. There is no significant difference in the revision rate between arthroscopic and open biceps tenodesis [108]. Patients in both groups (with and without biceps tenodesis) had similar rates of subsequent biceps-related procedures and revision surgery after proximal humerus open reduction internal fixation [109]. The rates of additional shoulder surgery for patients undergoing SLAP repair and biceps tenodesis were similar within 3 years of the index procedure [114].

Complication Incidence and Etiology: An overall complication rate of 2.4% was observed after subpectoral biceps tenodesis with interference screw fixation [110], while the incidence of complications in a population of 353 patients over 3 years was 2.0% [111]. The most common reasons for revision biceps tenodesis were pain or cramping and rerupture [112]. Arthroscopic biceps tenodesis performed at the articular margin results in a low surgical revision rate and a low rate of residual pain [113]. Biceps tenodesis in patients 35 years of age and younger yields low but variable reported rates of complications, reoperations, and failure [7]. There is no significant difference in infection rates between primary anatomic and primary reverse total shoulder arthroplasty in shoulders with no previous operative history [115].

Recovery

Light activity (weeks): Patients typically resume desk work and light activities of daily living at an average of 5.4 ± 2.8 months postoperatively [13]. While specific week ranges for driving are not quantified in the evidence, the ability to return to work at this average interval implies a functional baseline for light activity is reached within this timeframe.

Full activity (months): Most patients achieve clinically significant outcomes between 5 and 8 months after isolated biceps tenodesis, with full attainment expected by 13 months [5]. Return to sport is variable; two-thirds of patients under 25 years of age return to sport, while 86% of professional baseball players return to sport, though only 50% return to the same or higher level [3, 104]. One in four patients overall are unable to resume athletic activity at the same level following the procedure [103].

Complete recovery / outcome plateau (months): Clinically significant outcomes are generally attained by 13 months postoperatively, with most patients achieving this milestone between 5 and 8 months [5]. Patients requiring rotator cuff repair with simultaneous biceps tenodesis experience earlier postoperative plateaus in pain relief and motion improvement compared to isolated procedures [107]. All patients, irrespective of the specific biceps tendon procedure type, demonstrate excellent clinical and functional outcomes at least one year after surgery [28].

Rehabilitation protocol: Patients undergoing open subpectoral biceps tenodesis may be managed using either early or delayed active motion protocols without compromising functional outcomes [27]. No reoperations or revisions for failed biceps tenodesis were observed at a short-term follow-up of 1 year following arthroscopic-assisted locked loop suprapectoral biceps tenodesis [6].

Functional milestones: Primary biceps tenodesis provides significant clinical improvement and high rates of survivorship at 2 years postoperatively [1]. In patients 35 years of age and younger, the procedure yields excellent clinical outcome scores [7]. For pathology of the long head of the biceps tendon (LHBT), primary biceps tenodesis provides a reliable and efficient return to previous activity levels with a low risk for surgical complications [34]. Primary biceps tenodesis offers increased effectiveness compared to both primary SLAP repair and nonoperative treatment for symptomatic SLAP tears in middle-aged patients [15].

Other Considerations: Biceps tenodesis serves as an alternative to SLAP repair in young patients when indicated [2]. In active patients under 30, primary biceps tenodesis provides improved functional results compared to SLAP repair at a minimum 2-year follow-up [73]. Reoperation rates are higher for patients undergoing SLAP repair compared to biceps tenodesis, and higher reoperation rates at 1 year were seen in patients who had concomitant biceps tenodesis compared to those who did not [35, 91]. Patients requiring rotator cuff repair with simultaneous biceps tenodesis have lower baseline ASES function [107]. Return to play is a challenging metric to define and is not always correlated with the outcome of the procedure for biceps tenodesis for SLAP lesions [97]. While primary biceps tenodesis in patients 35 years of age and younger yields excellent clinical outcome scores, it yields variable reported return-to-sport rates and low but variable reported rates of complications, reoperations, and failure [7]. Primary biceps tenodesis has lower costs than primary SLAP repair for symptomatic SLAP tears in middle-aged patients [15]. The overall rate of return to athletic activity was reportedly high following biceps tenodesis [103].

Key Evidence

  • [L4] Biceps tenodesis provided significant clinical improvement and high rates of survivorship 2 years postoperatively. (10.1016/j.arthro.2021.12.014)
  • [L4] When indicated, biceps tenodesis offers an alternative to SLAP repair in young patients. (10.1016/j.arthro.2018.10.151)
  • [L4] Biceps tenodesis in patients less than 25 years of age yields excellent outcomes with two thirds of patients able to return to sport and a low revision rate. (10.1177/2325967117s00116)
  • [L5] Outcomes following surgical treatment vary depending on the method of treatment, associated pathology, and patient characteristics, with biceps tenodesis receiving increasing attention as a treatment option. (10.1302/2058-5241.4.180033)
  • [L4] After isolated biceps tenodesis, patients can expect to attain clinically significant outcomes by 13 months postoperatively, with most patients achieving this between 5 and 8 months. (10.1177/23259671221070857)
  • [L4] At a short-term follow-up of 1 year, no patients had reoperations or revisions for failed biceps tenodesis. (10.1016/j.xrrt.2021.02.003)
  • [L1] Biceps tenodesis in patients 35 years of age and younger yields a wide variability in reported return-to-sport rates, excellent clinical outcome scores, and low but variable reported rates of complications, reoperations, and failure. (10.1016/j.arthro.2022.12.009)
  • [L3] The majority of biceps tenodesis cases were performed in men aged 30 to 59 years, and the South had the highest overall number of cases. (10.1016/j.jse.2015.04.021)
  • [Commentary] Selection of the biceps tenodesis technique is predominantly dependent on surgeon preference and patient selection, as comparable improvements in functional outcomes were shown with no reported perioperative complications in the referenced randomized trial. (10.1016/j.arthro.2019.08.022)
  • [L3] Tenotomy and open tenodesis are both safe options for treatment of biceps pathology. (10.1016/j.asmr.2024.100928)
  • [L4] Superior clinical outcomes are seen in nonsmokers, those with only 1 tendon affected, and those who undergo tenotomy instead of tenodesis for a damaged long head of biceps tendon. (10.1016/j.jse.2019.12.011)
  • [L5] There are currently no clear guidelines for the management of concurrent biceps tendon pathology in this setting. (10.1016/j.xrrt.2024.08.003)
  • [L4] After biceps tenodesis, most patients were able to return to work at an average of 5.4 ± 2.8 months. (10.1016/j.arthro.2018.10.144)
  • [L3] Adjuvant biceps procedures are not required when repairing isolated supraspinatus tears, unless biceps pathology is observed intraoperatively, for which tenodesis grants better function and strength than tenotomy. (10.1016/j.jse.2018.03.030)
  • [L3] Primary biceps tenodesis offers increased effectiveness when compared with both primary SLAP repair and nonoperative treatment and lower costs than primary SLAP repair. (10.1016/j.arthro.2018.01.029)
  • [Letter] The decision to perform tenotomy or tenodesis should be made preoperatively based on patient symptoms and concomitant pathologies, as macroscopic changes in the long head of the biceps tendon do not always correlate with symptoms and a normal arthroscopy does not exclude important symptomatic pathology. (10.1016/j.arthro.2018.08.014)
  • [L5] SLAP repair and biceps tenodesis both present viable treatment options but come with specific advantages and disadvantages, with the decision ultimately made individually with the patient. (10.1016/j.arthro.2019.02.026)
  • [L3] The location of biceps tenodesis significantly differs between all-arthroscopic suprapectoral and open subpectoral techniques, and the open subpectoral method achieves fixation in a significantly narrower region of the humerus. (10.1016/j.arthro.2016.03.101)
  • [L5] Operative treatment is reserved for failure of nonoperative treatment, with biceps tenodesis gaining popularity due to encouraging functional outcomes and return-to-sport rates. (10.1016/j.arthro.2022.08.005)
  • [L4] Both open and arthroscopic biceps tenodesis provided satisfactory outcomes in most patients, and there were no identifiable differences in this review. (10.1016/j.arthro.2015.07.028)
  • [L3] The choice between biceps tenotomy and tenodesis for pathology of the proximal biceps tendon can continue to be based on surgeon and patient preference. (10.1177/2325967115570848)
  • [L5] Clear indications have yet to be established for the use of single- versus double-row repair because evidence confirms neither is clinically efficacious than the other, though biceps tenodesis has proven more successful than tenotomy in non-isolated cuff tears. (10.1016/j.arthro.2013.07.265)
  • [L1] Tenotomy and tenodesis of the long head of the biceps results in comparable postoperative clinical and functional outcomes. (10.1016/j.jse.2021.02.002)
  • [L3] This suggests that patients undergoing open subpectoral biceps tenodesis may be managed using either early or delayed active motion protocols without compromising functional outcome. (10.1177/23259671211026619)
  • [L3] All patients, irrespective of the type of biceps tendon procedure, had excellent clinical and functional outcomes at least one year after surgery. (10.1016/j.jseint.2021.04.011)
  • [L1] Supra- and subpectoral repairs provide equivalent biomechanical strength when controlling for potential confounders. (10.1177/0363546519876107)
  • [L3] Incidence of biceps tenodesis surgery has increased steadily from 2002 to 2010. (10.1177/2325967113s00089)
  • [L4] Revision subpectoral biceps tenodesis is a viable procedure for addressing patients with persistent pain following initial proximal biceps tenodesis. (10.1016/j.asmr.2023.100797)
  • [L2] Concomitant biceps tenodesis appears to have a favorable effect on 1-year treatment success after total shoulder arthroplasty. (10.1016/j.jse.2008.06.006)
  • [L3] A primary biceps tenodesis for pathology of the LHBT provides a clinical and statistically significant improvement in shoulder outcomes with a reliable and efficient return to previous activity level and low risk for surgical complications. (10.1177/2325967114s00019)
  • [L3] Higher reoperation rates at 1 year were seen in patients who had concomitant biceps tenodesis compared to those who did not. (10.1016/j.arthro.2017.01.030)
  • [L3] Arthroscopic suprapectoral biceps tenodesis represents a new technique for distal tenodesis. (10.1007/s11999-010-1691-z)
  • [L5] Subpectoral biceps tenodesis is a valuable tool for the treatment of proximal biceps tendon pathology regardless of the specific location or technique used. (10.1016/j.arthro.2020.04.010)
  • [L3] Open subpectoral biceps tenodesis and all-arthroscopic suprapectoral biceps tenodesis are both successful surgeries with consistently positive outcomes. (10.1016/j.arthro.2016.07.007)
  • [L4] Arthroscopic suprapectoral and open subpectoral techniques result in significantly different locations of biceps tenodesis. (10.1177/2325967113s00087)
  • [L3] Open biceps tenodesis is a less expensive alternative to arthroscopic biceps tenodesis when performed concomitantly with arthroscopic rotator cuff repair. (10.1016/j.jse.2020.05.031)
  • [L4] Patient age should not be used as the sole criterion when deciding between biceps tenotomy and tenodesis. (10.1016/j.arthro.2016.04.022)
  • [L4] LHB tenodesis does not dramatically alter glenohumeral position during dynamic motions, suggesting the risk for clinically significant alterations in glenohumeral kinematics after tenodesis is low in otherwise intact shoulders. (10.1177/0363546511423629)
  • [L5] Pain originating from the long head of biceps tendon induced an approximately 30% decrease of shoulder abduction and elbow flexion strength despite there being no structural or biomechanical abnormalities in this model. (10.1016/j.jse.2018.05.008)
  • [L5] Biomechanical studies indicate that the long head of the biceps contributes to stability of the glenohumeral joint in all directions, though in vivo studies have yet to establish this stabilizing effect and the physiologic load required remains unknown. (10.1016/j.arthro.2010.10.014)
  • [L5] Biceps tenodesis shows no deleterious effect on glenohumeral kinematics and stability in the presence of a SLAP lesion. (10.1016/j.arthro.2011.03.010)
  • [L3] Biceps tenotomy and tenodesis are both viable treatments for proximal biceps tendon pathology, yielding high patient satisfaction. (10.1186/s13018-020-1581-3)
  • [L3] Arthroscopic suprapectoral and open subpectoral biceps tenodesis both yield excellent clinical and functional results for the management of isolated superior labrum or long head biceps pathology. (10.1177/2325967114s00061)
  • [L4] Arthroscopic proximal biceps tenodesis appears to be a reliable technique to manage the pathologic biceps tendon, with results predicated on the outcome of treatment of associated rotator cuff disease. (10.1016/j.arthro.2008.04.018)
  • [L4] Proximal biceps tenodesis relieved the patient's symptoms by reducing traction on the nerve. (10.1016/j.jhsa.2012.01.023)
  • [L4] Biceps tenotomy is well accepted by most patients with good overall results. (10.1016/j.jse.2011.01.014)
  • [L3] Arthroscopic biceps tenotomy and tenodesis effectively treats severe pain or dysfunction caused by an irreparable rotator cuff tear associated with biceps pathology. (10.1016/j.arthro.2007.03.039)
  • [L5] The treatment option of biceps tenodesis is an appealing alternative to SLAP repair, but the indications and technique of biceps tenodesis in the elite pitcher still need to be defined. (10.1016/j.arthro.2018.01.001)
  • [L5] All three all-suture anchors are suitable fixation methods for subpectoral biceps tenodesis. (10.1186/s12891-024-07503-0)
  • [L4] Findings suggest double-row surgical fixation and concomitant biceps tenodesis may be superior to single-row fixation and leaving the biceps alone, warranting future prospective comparative studies. (10.1016/j.arthro.2016.10.020)
  • [L5] SCR using the long head of the biceps tendon is biomechanically effective in reducing posterosuperior translation of the humeral head in the setting of an MIRCT. (10.1016/j.jse.2024.07.007)
  • [L3] Our results suggest that primary biceps tenodesis provides improved functional results in active patients under 30 when compared to SLAP repair at minimum 2 year follow‐up. (10.1177/2325967117s00395)
  • [L3] The IBTIS is a preoperative clinical and radiological score with 7 items for surgical treatment by arthroscopic tenotomy of the long head of biceps. (10.1177/2325967121s00361)
  • [L3] Biceps tenodesis with concomitant RCR led to improved outcomes regardless of tenodesis fixation construct, location, or technique. (10.1177/23259671231180173)
  • [L5] The long head of the biceps has a pertinent biomechanical role in glenohumeral stability regardless of the condition of the superior labrum. (10.1016/j.arthro.2025.05.022)
  • [L4] In patients with chronic long head biceps tendinopathy who underwent open subpectoral tenodesis, MRI and intraoperative assessment did not show significant structural abnormalities within the tendon despite significant histopathologic changes. (10.1016/j.arthro.2018.01.021)
  • [L5] With placement of the tenodesis at the inferior aspect of the bicipital groove in conjunction with the musculotendinous junction, open subpectoral tenodesis of the long head of the biceps can be performed using bicortical button fixation without risk to the posterior nervous structures. (10.1016/j.arthro.2014.03.026)
  • [L3] Biceps tenodesis techniques which do not release the biceps sheath or remove the tendon from the sheath have increased revision rates, compared to techniques that do. (10.1016/j.jse.2011.01.037)
  • [L1] There is currently no consensus regarding the use of tenotomy versus tenodesis for the treatment of lesions of the long head of the biceps brachii. (10.1016/j.arthro.2011.10.017)
  • [L4] Subpectoral biceps tenodesis reliably relieves pain and improves function. (10.1186/1471-2474-9-121)
  • [L4] Open subpectoral biceps tenodesis using a dual-fixation construct with no postoperative motion restrictions resulted in excellent outcomes with a low incidence of failure. (10.1016/j.jse.2018.02.061)
  • [L5] Short-term follow-up of 20 procedures has not shown any failure of fixation or residual biceps discomfort. (10.1007/s00167-014-3348-z)
  • [L3] An improvement in isometric contraction in flexion of the elbow was observed, but this did not reach the flexion power of the contralateral healthy arm. (10.1007/s00167-018-5007-2)
  • [L3] Reoperation rates are higher for patients undergoing SLAP repair, which is a likely driver behind the increased utilization of biceps tenodesis. (10.1016/j.jseint.2022.11.001)
  • [L4] Although this may be an effective strategy to address failed prior biceps surgery, the potential complication of persistent pain must be emphasized. (10.1177/0363546519892922)
  • [L1] This study found no difference in the functional outcomes or pain relief between proximal vs subpectoral biceps tenodesis. (10.1177/2325967116s00195)
  • [L5] Return to play is a challenging metric to define and is not always correlated with the outcome of the procedure; consensus needs to be established in exactly how to define return to play, and primary biceps tenodesis as the best surgical option remains difficult to recommend. (10.1016/j.arthro.2022.09.003)
  • [L4] Postoperative imaging should be considered including either computed tomography low enough to visualize the tenodesis site or multiple views on plain radiography. (10.1016/j.jses.2019.07.007)
  • [L5] Additional care should be taken when operating on patients with previous biceps tenodesis to prevent perioperative fractures. (10.5397/cise.2021.00528)
  • [L2] Outcomes appear similar between biceps tenotomy versus tenodesis; however, the tenotomy group demonstrated greater incidence of cosmetic deformity but an earlier improvement in postoperative pain. (10.1007/s00167-019-05682-1)
  • [L1] Meta-analysis showed more frequent favorable outcomes with biceps tenodesis. (10.1016/j.arthro.2022.05.005)
  • [L3] Short-term radiographic outcomes following open and arthroscopic biceps tenodesis revealed that each technique results in stable fixation of the tendon with minimal migration. (10.1177/2325967120s00122)
  • [L4] While overall rate of return to athletic activity was reportedly high following biceps tenodesis, one in four patients were not able to resume athletic activity at the same level. (10.1007/s00167-020-05930-9)
  • [L4] While 86% of players returned to sport after biceps tenodesis, only 50% returned to the same or higher level. (10.1177/23259671221074732)
  • [L5] The MTJ of the biceps begins further proximal than may be appreciated intraoperatively. (10.1177/0363546513482297)
  • [L3] Patients requiring RCR with simultaneous biceps tenodesis have lower baseline ASES function and earlier postoperative plateaus in pain relief and motion improvement following surgery. (10.1016/j.jseint.2019.12.010)
  • [L2] There was no significant difference in the revision rate between arthroscopic and open biceps tenodesis. (10.1177/2325967118825473)
  • [L3] Although BT was done more commonly in severe PHFs, patients in both groups had similar rates of subsequent biceps-related procedures and revision surgery. (10.1016/j.jseint.2024.03.014)
  • [L4] An overall complication rate of 2.4% validates the hypothesis of a low complication rate after subpectoral biceps tenodesis. (10.1016/j.jse.2013.07.007)
  • [L4] The incidence of complications after subpectoral biceps tenodesis with interference screw fixation in a population of 353 patients over the course of 3 years was 2.0%. (10.1016/j.jse.2010.01.024)
  • [L1] This systematic review of 5 moderate risk of bias studies demonstrated that the most common reasons for revision biceps tenodesis were pain or cramping and rerupture. (10.1016/j.arthro.2021.04.063)
  • [L4] Arthroscopic biceps tenodesis performed at the articular margin results in a low surgical revision rate, a low rate of residual pain, and significant improvement in objective shoulder outcome scores. (10.1016/j.arthro.2014.08.024)
  • [L3] The rates of additional shoulder surgery for patients undergoing SLAP repair and biceps tenodesis were similar within 3 years of the index procedure. (10.1016/j.asmr.2020.01.003)
  • [L3] In shoulders with no previous operative history there is no significant difference in infection rates between primary aTSA and primary rTSA. (10.1016/j.jse.2014.11.008)
  • [L3] Our results show a notably increased incidence of postoperative stiffness after arthroscopic suprapectoral biceps tenodesis compared with open subpectoral biceps tenodesis. (10.1016/j.arthro.2014.03.024)
  • [L3] Reoperation rates were significantly higher in patients undergoing shoulder arthroscopy with biceps tenodesis than in patients undergoing shoulder arthroscopy without biceps tenodesis. (10.1016/j.jses.2019.08.002)

See Also

References

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