An abundance of methods address tenodesis of the long head of the biceps tendon (LHBT).1,2 The surgical goal is to address this pain generator in such a way that allows for strong biomechanical fixation, early active range of motion, sufficient pain relief, and satisfactory cosmesis. Unicortical button fixation has recently been shown to be biomechanically equivalent to tenodesis screw fixation.1,3 Most current techniques, however, lack a reproducible manner to ensure that the patient’s biceps is repaired in its anatomic position under preoperative tension. We postulate that an individualized approach to restoring anatomy may optimize postoperative function, decrease the incidence of cramping, and minimize the chance of cosmetic asymmetry. We present a novel tenodesis technique using a unicortical button to allow the surgeon to anatomically place and dynamically tension the biceps tendon prior to securing fixation.
The technique can be performed with the patient in either the beach chair or lateral decubitus position with general anesthetic. The arm is prepped and draped in the standard surgical fashion. The planned incision, 2.5 cm in length, is marked with 1/3 of the incision superior to and 2/3 inferior to the pectoralis major tendon which is palpated in its subcutaneous location; a skin fold adjacent to the axilla is typically utilized for cosmetic reasons.
Diagnostic arthroscopy is performed with pathology identified and treated as appropriate. Once the decision is made to proceed with tenodesis, a percutaneous spinal needle is used to pin the LHBT in its anatomic position as close to the superior edge of the bicipital groove as possible, in order to prevent intraarticular toggling with subsequent motion during the procedure. The LHBT is then released from its insertion on the glenoid (Fig. 1). The arm is then placed into slight external rotation and abduction. The skin is incised adjacent to the axillary fold with full thickness flaps developed to the deltopectoral fascia. The fascia is split longitudinally in line with the skin incision, deep to the inferior border of the pectoralis tendon, which is followed with blunt finger dissection to its insertion on the humerus. The short head of the biceps brachii can be visualized medially and the LHBT can be palpated within its groove immediately medial to the insertion of the pectoralis tendon on the humerus. A pointed Hohmann retractor is placed over the lateral humeral cortex, underneath the pectoralis insertion with care to avoid entrapping the biceps tendon. An Army-Navy retractor can be placed medially, allowing for gentle retraction of the short head of the biceps and coracobrachialis, but we avoid using a second Hohmann retractor in order to decrease risk of neurological injury.4 The biceps tendon is visualized lying within the bicipital groove.
A surgical marking pen is used to mark the LHBT where it lies, within the bicipital groove, beneath the pectoralis major tendon, proximal to the musculoskeletal junction at the level of the Hohmann retractor. The retractor serves as the landmark for individualizing the patient’s native tendon position/tension. (Fig. 2). The thin synovial layer overlying the tendon should be bluntly dissected free as the tendon tissue itself readily retains surgical ink whereas the synovial tissue does not. Alternatively, a temporary marking suture can be placed within the tendon instead of surgical ink.
Once the tendon has been marked, the previously inserted spinal needle is removed from the shoulder, and the tendon is delivered from the wound using a right angle hemostat. A periosteal sleeve is elevated at the identified position within the bicipital groove, and the cortex is roughened with a rasp to a bleeding surface. A drill measuring slightly larger than the diameter of the cortical button (eg, 4.2 mm drill for a 4 mm diameter button) is placed at the planned level of tenodesis, and a unicortical hole is drilled in the center of the groove. The length of the button used should be longer than the diameter of the drill in order to ensure adequate fixation. A guide wire can be used to aid with positioning the drill but is not routinely used in our practice.
Once the unicortical hole is drilled, a right angle hemostat is used to clear a pathway for the button to flip once introduced into the intramedullary space. A single high-strength, flat braided 2 mm nonabsorbable suture (commercially available suture or labral “tape”) is loaded onto a cortical button as shown in Figure 3. The button is then introduced into the socket and deployed within the medullary canal. Once secure cortical fixation is achieved, the LHBT is passed in a retrograde fashion (ie, distal to proximal) through the suture loop, and the suture tails are then slowly tensioned (thereby cinching the loop over the LHBT) until it secures the tendon to the humerus.
Before securing the tendon, the surgeon adjusts the tension on the tendon to ensure that the tendon is placed in its precise anatomic position relative to the pectoralis tendon using the surgical ink marker as a visual guide. The loop is tightened, and the suture tails are tied together thus tenodesing the LHBT to the bicipital groove. The proximal end of the tendon is then doubled over itself (ie, folded distally over the cinching suture and knot). A free needle is then used to pass the 2 mm flat, braided suture through the LHBT in a figure-of-eight fashion capturing the tendon both distal and proximal to the cinching loop for additional fixation. The suture tails are tied once more, thereby completing the biceps tenodesis (Fig. 4). Excess proximal tendon is removed sharply. The resultant mass of doubled tendon and suture knot remain in the bicipital groove and beneath the pectoralis major tendon, and is not palpable through the skin postoperatively.
Finally, the wound is copiously irrigated and closed in standard fashion. A surgical skin adhesive is used to seal the wound from adjacent axillary bacteria in the early postoperative period. The steps of button introduction, biceps tendon tensioning and final tendon fixation are depicted in Figure 5.
The muscle length-tension relationship has been demonstrated in biomechanical studies to be important to the ability of a muscle to function at its optimal potential.1 One of the hazards of tenotomy or nonanatomic tenodesis of the biceps is shortening of the muscle, potentially resulting in decreased strength across the elbow joint.1,3 Nonanatomic tenodesis can occur as a result of technical error in the proximal-distal placement of the tendon on the humerus or as a result of over-tensioning or under-tensioning a whip-stitched LHBT tendon as it is docked into a bone socket or secured with a suture anchor. As whip-stitching the tendon results in a fixed location on the tendon for tenodesis prior to fixation, the surgeon does not have the capacity to fine tune tenodesis height and tension relative to the patient’s individual anatomy. Denard et al previously evaluated techniques to restore the length-tension relationship of the LHBT.5 They recommended an arthroscopic technique performed adjacent to the articular margin into a bone socket of 25 mm.1,5,6 Our described technique provides an open subpectoral alternative for surgeons wishing to remove the LHBT from the entire bicipital groove. We have found this technique easy to perform even in conjunction with superior rotator cuff repair, labral repair, and arthroscopic distal clavicle excision. In the case of subscapularis repairs, however, we prefer to incorporate the tenodesis into the subscapularis repair.
The technique presented in this article addresses the length-tension relationship in a consistent and easily reproducible fashion. It allows the surgeon to mark the tendon as it rests in its anatomic position within the bicipital groove and subsequently, tenodese it at that exact position and tension. The authors are not aware of other techniques designed specifically to allow the surgeon to dynamically adjust tension prior to fixation. Like other unicortical button tenodesis techniques, this method eliminates the risk of tendon amputation by the threads of a tenodesis screw and allows for a smaller unicortical hole than many interference screw techniques.
We have performed this procedure for several years, and anecdotally have observed satisfactory cosmesis in regards to both the biceps muscle and surgical scar and have noted no strength deficiencies. However, we have not yet completed a retrospective review of these patients, and hope to publish a comparative series on our results in the future. We have performed 1 reoperation; a 51-year-old male who fell 6 weeks postoperatively resulting in a rapid elbow extension force as he landed. He had a significant popeye deformity and elected to undergo revision. At the time of surgery, the tenodesis was healed, and he was noted to have ruptured at the musculotendinous junction approximately 5 cm distal to the tenodesis.
A limitation of this technique may be the strength of the tenodesis as there are presently no biomechanical studies evaluating this method.1,3 In addition, this technique relies upon healing of the tendon to the anterior humerus and does not offer the potential advantage of healing into a socket. Although there may be a theoretical biological benefit with healing into a bone socket in the cancellous bone of the proximal humerus (ie, arthroscopic, proximal groove interference screw techniques), we do not believe that the hollow canal and cortical bone found within the subpectoral portion of the distal bicipital groove affords an advantageous healing environment when compared with the highly vascular periosteum, soft tissues and decorticated bone of the anterior humerus utilized with this technique.
Unicortical button fixation of the LHBT has been shown to be biomechanically equivalent to tenodesis screw fixation.2 We present a technique, which allows for optimization of the length-tension relationship of the biceps tendon through restoration of native anatomy by allowing the surgeon to adjust tension on the tendon based on intraoperative observations. Future studies of the biomechanical strength of this technique as well as clinical outcomes are warranted.
1. Abraham VT, Tan BH, Kumar VP. Systematic review of biceps tenodesis: arthroscopic versus open. Arthroscopy. 2016;32:365–371.
2. Arora AS, Singh A, Koonce KC. Biomechanical evaluation of a unicortical button versus interference screw for subpectoral biceps tenodesis. Arthroscopy. 2013;29:638–644.
3. Nho SJ, Reiff SN, Verma NN, et al. Complications associated with subpectoral biceps tenodesis: low rates of incidence following surgery. J Shoulder Elbow Surg. 2010;19:764–768.
4. Chiang FL, Hong CK, Chang CH, et al. Biomechanical comparison of all-suture anchor fixation and interference screw technique for subpectoral biceps tenodesis. Arthroscopy. 2016;32:1247–1252.
5. Denard PJ, Dai X, Hanypsiak BT, et al. Anatomy of the biceps tendon: implications for restoring physiological length-tension relation during biceps tenodesis with interference screw fixation. Arthroscopy. 2012;28:1352–1358.
6. Dickens JF, Kilcoyne KG, Tintle SM, et al. Subpectoral biceps tenodesis: an anatomic study and evaluation of at-risk structures. Am J Sports Med. 2012;40:23337–23341.