Arthroscopic Inlay Biceps Tenodesis Using a Tendon-Docking Anchor

Management of long head of the biceps tendon (LHBT) pathology is accomplished through a biceps tenotomy or tenodesis. While both modalities provide beneficial outcomes, a biceps tenodesis may confer improved cosmesis, functional outcomes, and decreased muscle cramping postoperatively. Many procedural considerations are undertaken prior to a tenodesis, such as the surgical approach and fixation device. While similar clinical outcomes are achieved between an open subpectoral and arthroscopic suprapectoral biceps tenodesis (ASPBT) with interference screw (IS) fixation, the latter technique offers a minimally invasive modality. The primary indications for an ASPBT include superior labrum anterior posterior (SLAP) tears, LHBT tears, biceps instability, bicipital tunnel disease, biceps pulley lesions, and biceps tenosynovitis. Contraindications to the arthroscopic approach include a distal lesion of the biceps tendon below the pectoralis major tendon (PMT). The IS may be used to create a biomechanically stiffer construct. With the arthroscope in the lateral portal, the distal aspect of the bicipital groove proximal to the superior border of the PMT is identified and opened. The LHBT is subsequently mobilized and released. An anterosuperolateral portal is localized with a spinal needle positioned perpendicular to the bicipital tunnel, 1.5 cm proximal to the superior border of the PMT. The biceps is then removed ex vivo and whip-stitches are sewn beginning 1 cm proximal to the myotendinous junction of the LHBT. After firmly associating the LHBT with the tip of the IS, a guidewire is placed 1.5 cm superior to the superior border of the PMT, perpendicular to the humerus, and a reamer is used to prepare a 6-, 7-, or 8-mm diameter socket. The tendon is inserted through the accessory portal into the tunnel, followed by screw fixation. Suture tails are tied with 5 alternating half hitches, each secured via an arthroscopic knot pusher. ASPBT with IS fixation provides significant pain relief, improves range of motion (ROM), and enhances quality of life. ASPBT with IS fixation provides significant improvements in patient-reported and functional outcomes and thus can be an acceptable treatment for LHBT pathology. The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Objectives:Our group has previously reported the 1-year outcomes arthroscopic suprapectoral biceps tenodesis (ASPBT) versus open subpectoral biceps for the management of long head of the biceps tendon (LHBT) pathology. While patients had similar 1-year biceps strength and pain, any ongoing changes in functional outcomes is yet unknown. We aimed to directly compare clinical outcomes of ASPBT versus OSPBT with interference screw fixation, distal to the bony bicipital groove, at 2 years follow-up.Methods:Eighty-seven patients undergoing biceps tenodesis for LHBT disease were randomized into the ASPBT group or OSPBT group. Both techniques utilized polyether ether ketone (PEEK) inference screws for tenodesis fixation. Patients completed American Shoulder and Elbow Surgeon (ASES), Constant subjective, and Single Assessment Numeric Evaluation (SANE) questionnaires preoperatively, and again at 6 months, 12 months and final follow-up at minimum 24 months.Results:Seven-five patients (37/46 randomized to ASPBT [80%], 38/41 randomized to OSPBT [93%]) with a mean age of 50.3 ± 10.4 years and a mean body mass index of 28.9 ± 6.3 were included in clinical outcome analyses. Mean final follow-up was 35.1 months (ASPBT: 35.4 months, OSPBT: 34.9 months, range 24-63 months). Comparison of demographic characteristics and intraoperative findings showed no significant difference in age, gender, concomitant procedures, and rotator cuff disease. No statistically significant differences in ASES (P =.26), Constant subjective scores (P = .60), and SANE scores (P = .74) were found at final follow-up. Clinical outcomes scores showed no significant improvement from 12.6 months to final follow-up at 35.1 months (ASPBT: ASES, P=0.42; Constant, P=0.23; SANE, P=0.43 v. OSPBT: ASES, P=0.76; Constant, P=0.57; SANE, P=0.64). The mean SANE score in the ASPBT group had a statistically nonsignificant, 6.1-point increase from 1 to 3 years post-operatively (p = .23), which was greater than the minimal clinically importance difference (MCID). No patients required revision of biceps tenodesis in either group.Conclusions:No significant differences in patient-reported outcomes and complication rates were found at any time point between subjects undergoing ASPBT or OSPBT, utilizing the same interference screw technique, for the management of LHBT pathology.Table 1Patient Demographic and Other CharacteristicsTable 2Intraoperative FindingsTable 3Patient Reported Outcome measuresTable 4Patient Reported Outcome Measures Difference from 12 Months to Final Follow-Up

Objective:The aim of this study was to compare the results of patients who underwent biceps tenotomy or tenodesis alongside rotator cuff rupture repair (RCRR), as well as to assess its relationship with alterations in subacromial volume. The hypothesis was that patients undergoing biceps tenodesis would experience greater improvements in outcome scores 2 years after the surgery and larger subacromial volumes as the long head of the biceps tendon maintains its tension.Methods:This is a retrospective study including patients who underwent an RCRR concomitant with a biceps procedure (88 tenotomy and 63 tenodesis) with a minimum of 2 years of follow-up between January 2015 and December 2022.Results:Preoperative subacromial volumes of the tenotomy and tenodesis groups were 3.89 cm3 and 3.87 cm3, respectively, which were similar (P = .287). Postoperative subacromial volume was 4.29 cm3 in the tenotomy group and 4.51 cm3 in the tenodesis group (P = .000). Preoperative, postoperative first year and postoperative final follow-up Constant scores were 43.3, 83.1 and 84.8, respectively, in the tenotomy group and 43.7, 86.9 and 89.0, respectively, in the tenodesis group. A statistically significant difference was found between the 2 groups in terms of postoperative Constant scores (P = .000 for both parameters). Volume changes and Constant score changes were significantly correlated (P = .012 and r = 0.513). Although preoperative Visual Analog Scale scores were comparable between the tenodesis and tenotomy groups (P = .076), the tenodesis group demonstrated significantly lower pain scores at both the 1-year follow-up and final evaluation (P = .002 and P = .007, respectively).Conclusion:In this study, biceps tenodesis was superior to tenotomy in terms of outcome scores. The results also revealed that subacromial volume increases significantly following biceps tenodesis compared to biceps tenotomy and has a moderate relationship with postoperative Constant scores, unlike Visual Analog Scale score.Level of Evidence:Level III, Therapeutic study.

Background:Subpectoral biceps tenodesis can be performed with cortical fixation using different repair techniques. The goal of this technique is to obtain a strong and stable reduction of biceps tendon in an anatomic position.Purpose/Hypothesis:The purpose of this study was to compare (1) displacement during cyclic loading, (2) ultimate load, (3) construct stiffness, and (4) failure mode of the biceps tenodesis fixation methods using onlay techniques with an all-suture anchor versus an intramedullary unicortical button. It was hypothesized that fixation with all-suture anchors using a Krackow stitch would exhibit biomechanical characteristics similar to those exhibited by fixation with unicortical buttons.Study Design:Controlled laboratory study.Methods:Ten pairs of fresh-frozen cadaveric shoulders (N = 20) were dissected to the humerus, leaving the biceps tendon-muscle unit intact for testing. A standardized subpectoral biceps cortical (onlay) tenodesis was performed using either an all-suture anchor or a unicortical button. The biceps tendon was initially cycled from 5 to 70 N at a frequency of 1.5 Hz. The force on the tendon was then returned to 5 N, and the tendon was pulled until ultimate failure of the construct. Displacement during cyclic loading, ultimate failure load, stiffness, and failure modes were assessed.Results:Cyclic loading resulted in a mean displacement of 12.5 ± 2.5 mm for all-suture anchor fixation and 29.2 ± 9.4 mm for unicortical button fixation (P = .005). One all-suture anchor fixation and 2 unicortical button fixations failed during cyclic loading. The mean ultimate failure load was 170.4 ± 68.8 N for the all-suture anchor group and 125.4 ± 44.6 N for the unicortical button group (P = .074), with stiffness 59.3 ± 11.6 N/mm and 48.6 ± 6.8 N/mm (P = .091), respectively. For the unicortical button, failure occurred by suture tearing through tendon in 100% of the specimens. For the all-suture anchor, failure occurred by suture tearing through tendon in 56% and knot failure in 44% of the specimens.Conclusion:The all-suture anchor fixation using a Krackow stitch for subpectoral biceps tenodesis provided ultimate load and stiffness similar to unicortical button fixation using a nonlocking whipstitch. The all-suture anchor fixation technique was shown to be superior in terms of displacement during cyclic loading when compared with the unicortical button fixation technique. However, the results of this study help to show that the fixation method used on the humeral side is less implicative of the overall construct strength than stitch location and technique, as the biceps tendon tissue and stitch configuration seem to be the limiting factor in subpectoral onlay tenodesis techniques.Clinical Relevance:All-suture anchors have a smaller diameter than traditional suture anchors, can be inserted through curved guides, and preserve humeral bone stock without compromising postoperative imaging. This study supports use of the all-suture anchor fixation technique for subpectoral biceps tenodesis, with high biomechanical fixation strength and low displacement, as an alternative to the subpectoral onlay biceps tenodesis technique.

Background: Anterior shoulder pain is frequently attributed to pathology of the long head of the biceps tendon (LHBT), leading to the common surgical practice of tenotomy or tenodesis during rotator cuff repair. However, the routine sacrifice of a macroscopically normal LHBT remains controversial due to potential postoperative complications and a lack of consensus regarding the precise nosological origin of pain when intrinsic tendon damage is absent. Objective: This article describes the "biceps box" concept, a functional geometric model designed to map the anatomical environment of the LHBT and differentiate between intrinsic tendon lesions and extrinsic damage to adjacent stabilizing structures. Key Points: The LHBT is modeled within a rectangular cuboid representing the rotator interval. The posterior wall comprises the five-layered supraspinatus tendon, while the superior wall consists of the coracohumeral complex and superior glenohumeral ligament (SGHL). The subscapularis and SGHL form the anterior wall, and the lateral wall is defined by the biceps pulley and semicircular humeral ligament. This tissue continuum maintains LHBT stability through interconnected structures, including the fasciculus obliquus and rotator cable. Clinical studies indicate that interobserver reliability in diagnosing LHBT instability is often low, potentially leading to unnecessary surgical intervention. Furthermore, the model accounts for sensory innervation of the rotator interval by the lateral pectoral nerve, suggesting that anterosuperior humeral head decentering may result in nerve entrapment and referred pain. Conclusion: The biceps box model provides a framework for identifying anterior shoulder pain arising from extrinsic structural or neurological involvement. This approach encourages conservative management, such as dynamic humeral centering and targeted nerve blocks, when the LHBT appears healthy.

Objectives: Arthroscopic biceps tenodesis (BT) is a common surgical procedure for treatment of anterior shoulder pain due to long head of the biceps pathology. BT can be accomplished via several different techniques. There continues to be a paucity of literature comparing the different techniques and fixation devices. The purpose of this study was to compare 4 different techniques for accomplishing a BT utilizing radiostereometric analysis. Methods: This study was a prospectively enrolled non-randomized trial of patients undergoing BT. All patients were treated at a single institution by 1 of 4 surgeons. Four different techniques were analyzed, 1) open BT with screw fixation, 2) open BT with single anchor fixation, 3) arthroscopic BT with screw fixation, and 4) arthroscopic BT with two suture anchor fixation. After the BT was completed a tantalum bead was sewn to the long head of the biceps tendon. This bead acted as a marker of the position of the biceps tendon. X-rays were taken during surgery while the patient remained sedated to establish time zero bead position. Follow up x-rays were completed at the patients 1st post-operative visit and 12 week post-operative visit. Position of the bead was measured at each time point in mm from the proximal most point of the humerus to its position distally. Results: A total of 60 patients were included in the analysis, with 15 patients in each of the 4 groups. Final bead position differed significantly for the open and arthroscopic techniques (107.35±20.39mm, 65.64±23.69mm, p<0.001), but did not differ significantly between the two open techniques and the two arthroscopic technique (p>0.05). The open technique resulted in 7.69±5.98mm of distal migration while the arthroscopic technique resulted in a similar amount of distal migration, 8.93±2.71mm. Conclusion: Short-term radiographic outcomes following open and arthroscopic biceps tenodesis revealed that each technique results in stable fixation of the tendon with minimal migration. Although a statistically significant migration occurred, this is likely clinically insignificant. This initial migration observed could be due to increased tensioning of the tendon when the patient is awake versus sedated.

The All-Inside Arthroscopic Loop Tenodesis Procedure to Treat Long Head of Biceps Tendon Pathologies

Chinese Knot Stitch Technique: A Simple Technique for Arthroscopic Biceps Tenodesis

The impact of rotator cuff deficiency on structure, mechanical properties, and gene expression profiles of the long head of the biceps tendon (LHBT): Implications for management of the LHBT during primary shoulder arthroplasty.

Background: Biceps tenodesis around the pectoralis major insertion may alter resting tension on the biceps, leading to unfavorable clinical outcomes. Hypothesis: The anatomic relationship between the musculotendinous junction (MTJ) of the biceps and the pectoralis major tendon will provide guidelines for anatomic location to perform biceps tenodesis with the goal of re-establishing biceps tension. Study Design: Descriptive laboratory study. Methods: Cadaveric dissections were performed that reflected the pectoralis major tendon and exposed the long head of the biceps tendon (LHBT). Calipers were used to measure the longitudinal width of the pectoralis major tendon at the humerus, 2 cm away from the humerus, and at its proximal expansion on the humerus. The distance from the proximal extent of the pectoralis major tendon footprint to the beginning of the MTJ of the biceps and the length of the MTJ of the biceps were recorded. The location of the distal end of the MTJ of the biceps relevant to the inferior border of the pectoralis major tendon was calculated. Results: The average longitudinal width of the pectoralis major tendon at its humeral insertion was 76.8 mm, the width 2 cm away from the humerus averaged 37.3 mm, and the proximal expansion averaged 13.3 mm. The MTJ of the biceps began an average of 32.4 mm distal from the proximal aspect of the pectoralis major footprint and extended for an average of 78.1 mm. The MTJ of the LHBT was calculated to extend 3.3 cm distal to the inferior border of the pectoralis major footprint. Conclusion: The MTJ of the biceps begins further proximal than may be appreciated intraoperatively. Knowledge of the anatomic relationships between the LHBT, its MTJ, and the pectoralis major tendon provides helpful guidelines for the biceps tenodesis site. The final resting spot of the most distal aspect of the MTJ of the LHBT after tenodesis should be approximately 3 cm distal to the inferior edge of the pectoralis major tendon footprint on the humerus.

Objectives:Pathology of the long head of the biceps tendon is a recognized source of shoulder pain in adults that can be treated with tenotomy or tenodesis when non-operative measures are not effective. It is not clear whether arthroscopic or open biceps tenodesis has a clinical advantage. To date, we are not aware of any studies that directly compare clinical outcomes between an arthroscopic and an open technique for tenodesis of the long head of the biceps brachii. The purpose of this study was to determine whether a difference in outcomes and complications exists between matched cohorts after biceps tenodesis utilizing an open subpectoral versus an all-arthroscopic suprapectoral technique.Methods:A prospective database was reviewed for patients undergoing an all-arthroscopic suprapectoral or open subpectoral biceps tenodesis. Adult patients with a minimum 18-month follow-up were included. Patients undergoing a concomitant rotator cuff or labral repair were excluded. The groups were matched to age within 3 years, sex, and time to follow-up within 3 months. Pain improvement, development of a popeye deformity, muscle cramping, post-operative ASES scores, satisfaction scores, and complications were evaluated.Results:Forty-six patients (23 all-arthroscopic, 23 open) patients with an average age of 57.2 years (range, 45-70) were evaluated at a mean 28.7 months (range, 18-42) follow-up. No patients in either group developed a popeye deformity or complained of arm cramping. There was no significant difference in mean ASES scores between the open and all-arthroscopic groups (92.7 vs. 88.9, P = 0.42, Table 1). Similarly, there was no significant difference between patient satisfaction scores (8.9 vs. 9.1, P = 0.73). Eighteen patients (78.3%) in the arthroscopic cohort and sixteen patients (69.6%) in the open cohort fully returned to athletic activity (P = 0.50). There were no complications in the all-arthroscopic group. There were two complications in the open group (superficial incisional erythema, and brachial plexopathy) that resolved by final follow-up.Conclusion:Biceps tenodesis is a reliable treatment option for pathology of the long head of the biceps that may avoid arm cramping and a cosmetic “popeye” deformity that can occur following tenotomy. Open subpectoral and all-arthroscopic suprapectoral are two commonly used techniques to reattach the biceps tendon distal to the bicipital groove. In this study, patients undergoing an all-arthroscopic tenodesis experienced similar pain relief, shoulder function, and return to athletic activity as patients undergoing an open tenodesis. An open subpectoral technique may increase the risk of complications secondary to a larger incision and increased surgical dissection. Larger studies with longer follow-up would help delineate the long-term effects and potential differences between an all-arthroscopic suprapectoral and open subpectoral biceps tenodesis.

The management of the long head of the biceps tendon (LHBT) during shoulder arthroscopy has been a subject of controversy for many years, with evolving discussions and trends. Despite long-standing debate, the nature of the surgical indication regarding how to treat concomitent LHBT injuries has undergone changes in recent years. It now extends beyond the timing of tenotomy to encompass considerations of alternative methods for preserving the LHBT, along with an ongoing exploration of how it can be effectively utilized in reconstructive shoulder surgery. Recent techniques describe approaches to using LHBT in a wide range of procedures, from shoulder instability to rotator cuff tears. Additionally, LHBT-based reconstructive techniques have surfaced for addressing what were formerly denoted as irreparable rotator cuff tears. While current literature provides detailed anatomical descriptions of the LHBT and many reports of novel, advanced techniques, there is still much debate regarding the decision-making process in each case. Because of the growing number of emerging techniques and the escalating debate in the subsequent paper, a decision has been made to present the current literature review concerning the potential utilization of LHBT in shoulder arthroscopy. In a dedicated video, we demonstrate the main arthroscopic techniques employed by the authors in their daily practice.

Subpectoral Biceps Tenodesis With PEEK Interference Screw: A Biomechanical Analysis of Humeral Fracture Risk

Podium Presentation Title: Arthroscopic Suprapectoral vs. Open Subpectoral Bicep Tenodesis at Three-Year, Mid-Term Follow-Up

The shoulder.