What is biceps tenodesis?

Biceps Tenodesis: Surgical Procedure for Biceps Tendon Pathology

Biceps tenodesis is a surgical procedure that addresses pathologies of the long head of the biceps tendon by detaching it from its original insertion and reattaching it to a new location, typically to address pain caused by inflammation or instability of the tendon. 1

Definition and Purpose

• Biceps tenodesis involves detaching the long head of the biceps tendon from its original attachment and reattaching it to a different location, usually to the humerus or soft tissue 1, 2
• The procedure is performed to treat various biceps tendon pathologies including biceps tendinitis, SLAP tears, rotator interval pulley lesions, and failed SLAP repairs 3
• It aims to eliminate pain while maintaining the length-tension relationship of the biceps muscle to preserve function 2

Types of Biceps Tenodesis Techniques

Based on Location:

• Suprapectoral tenodesis: Performed at or above the pectoralis major tendon 2

  • Potential disadvantage: The biceps may be fixed proximally to zones of degeneration and inflammation, potentially causing residual pain 2

• Subpectoral tenodesis: Performed below the pectoralis major tendon 2, 4

  • Advantage: Locates the fixation distal to any biceps tendon degeneration or inflammation zone 2
  • Particularly beneficial for professional athletes due to solid fixation 2
  • Low complication rate of approximately 2.0% 4

Based on Technique:

• Loop 'N' Tack biceps tenodesis: Shows high shoulder function scores and low pain scores one year postoperatively 1
• Arthroscopic proximal subpectoral tenodesis: Can be performed fully arthroscopically with all-suture anchor and soft-tissue tenodesis to the pectoralis major tendon 2
• Open subpectoral biceps tenodesis (OBT): Commonly performed with bioabsorbable interference screw fixation 4

Clinical Outcomes

• Both Loop 'N' Tack and subpectoral biceps tenodesis techniques show significant improvements in patient-reported outcomes 1
• Patients typically report high shoulder function scores and low pain scores one year postoperatively 1
• The procedure has a minimal risk of complications when measured one year postoperatively 1

Potential Complications

• Overall complication rate for open subpectoral biceps tenodesis is approximately 2.0% 4
• Possible complications include:
  • Persistent bicipital pain (0.57%) 4
  • Failure of fixation resulting in Popeye deformity (0.57%) 4
  • Deep postoperative wound infections (0.28%) 4
  • Musculocutaneous neuropathy (0.28%) 4
  • Reflex sympathetic dystrophy (0.28%) 4
  • Interference screw fixation failures (rare but reported) 5

Diagnostic Approach for Biceps Tendon Pathology

• MRI is the most accurate imaging modality for diagnosing biceps tendon tears, with an accuracy of 86.4% compared to ultrasound (45.5%) 6
• Plain radiographs should be the first imaging study to rule out associated fractures or bony abnormalities 6, 7
• The FABS (flexion-abduction-supination) view is recommended for optimal visualization of the biceps tendon on MRI 6, 7

Clinical Considerations

• The American Academy of Orthopaedic Surgeons is unable to recommend for or against biceps tenotomy or tenodesis when performing shoulder arthroplasty in patients with glenohumeral osteoarthritis due to insufficient evidence 8
• Surgical practice regarding biceps tendon management during arthroplasty is largely based on anecdotal experience rather than evidence 8
• Revision biceps tenodesis may be necessary in cases of symptomatic failure, particularly in young active patients 3

Pitfalls to Avoid

• Failing to distinguish between partial and complete tears, which requires accurate imaging (preferably MRI) 6, 7
• Relying solely on ultrasound for diagnosis, which has limitations in accuracy compared to MRI 6, 7
• Inadequate fixation can lead to failure and Popeye deformity, requiring revision surgery 3