The biceps tendon and shoulder arthroplasty - the "inside-out" tenodesis.

We strive to maintain the long head of the biceps tendon in performing shoulder arthroplasty unless it is frayed or unstable. While contrary to the opinion of some, we do not find that the biceps becomes a 'pain generator' after arthroplasty: specifically in our experience it is very rare for our patients with a "biceps-on" arthroplasty to have postoperative issues with their biceps tendon. 

However at the time of arthroplasty, if the biceps is unstable or frayed, a tenodesis can easily be performed using what we call the 'in and out' technique.

In this technique, we transect the biceps at its insertion to the supraglenoid tubercle, make a  hole in the strong bone of the biceps groove about 5 cm below the humeral neck cut. The proximal end of the long head tendon is threaded through this hole and then brought out the neck cut. When the humeral component is driven into position, it robustly fixes the long head tendon so that no modification of the post operative rehabilitation is necessary.

Here's a photo from the OR. The patient had inflammatory arthritis with biceps tendon involvement. The lower blue arrow points to the hole in the bicipital groove with the tendon entering it. The upper blue arrow points to the tendon (with a single traction suture in it) exiting the medullary space where it will be fixed when the prosthesis is seated. The other six sutures have been placed for repair of the subscapularis.

And a diagram from Steve Lippitt

Here's another example from this week. At surgery the biceps tendon was flattened, frayed and unstable. After release from the supraglenoid tubercle, the biceps tendon was passed through a hole created in the cortical bone of the bicipital groove and then led out through the humeral neck cut. As the humeral prosthesis is inserted, the biceps tendon is tensioned by traction (see suture in the tendon at lower right). Seating the humeral implant secures the tendon. This technique adds minimal time to the case, avoids the challenge of placing a tenodesis screw, and avoids the potential tenuousness of suturing the tendon to soft tissue. 

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The total shoulder arthroplasty (see this link).

The ream and run technique is shown in this link.

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

Shoulder rehabilitation exercises (see this link).

Follow on twitter: Frederick Matsen (@shoulderarth)

The biceps and the rotator cuff

The prevalence of rotator cuff pathology in the setting of acute proximal biceps tendon rupture

These authors performed MRI's on 20 men and 7 women with acute ruptures of the proximal biceps tendon. The dominant side was involved in 20 injuries (74%), and a low-energy trauma mechanism of injury was involved in 23 (85%). Of the patients, 11 (41%) reported a history of antecedent shoulder pain.

Magnetic resonance imaging assessment revealed that 93% of patients had evidence of rotator cuff disease, including 13 full-thickness tears. Of the full-thickness tears, 3 were small, 6 medium, 2 large, and 2 massive. Pathology of the subscapularis tendon was identified in 7 patients (26%).

Comment: Patients with rupture of the long head of the biceps are likely to have rotator cuff defects; patients with  cuff defects are likely to have involvement of the long head of the biceps tendon. This association is not surprising for several reasons: 

(1) both cuff defects and biceps ruptures usually result from age-related degeneration of tendon quality

(2) the cuff and the long head of the biceps are physically proximal to each other, both contributing to the stability of the shoulder through concavity compression; thus compromise of one is likely to increase the load experienced by the other.

A normal shoulder:

A shoulder with a rotator cuff tear and a degenerating biceps tendon

A few things to keep in mind:
Shoulders with impending biceps tendon rupture may demonstrate pain on active elevation that disappears once the rupture of the biceps tendon is complete.

It is not possible to restore the normal shoulder function of the long head biceps tendon once it is ruptured. A biceps tenodesis simply stabilizes the ruptured long head to the humerus after the tendon has left the shoulder.

Many patients with ruptures of the long head of the biceps tendon become functional and minimally symptomatic without surgery.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

How we do a biceps tenodesis with shoulder arthroplasty?

We stive to maintain the long head of the biceps tendon in performing shoulder arthroplasty unless it is frayed or unstable. While contrary to the opinion of some, we do not find that the biceps becomes a 'pain generator' after arthroplasty.
However, if the biceps is unstable or frayed, a tenodesis can easily be performed using what we call the 'in and out' technique.
In this technique, we transect the biceps at its insertion to the supraglenoid tubercle,  make a 8 mm hole in the strong bone of the biceps groove 10 cm below the humeral neck cut. The proximal end of the long head tendon is threaded through this hole and then brought out the neck cut. When the humeral component is driven into position, it robustly fixes the long head tendon so that no modification of the post operative rehabilitation is necessary.

Here's a photo from yesterday's OR. The patient had inflammatory arthritis with biceps tendon involvement. The lower blue arrow points to the hole in the bicipital groove with the tendon entering it. The upper blue arrow points to the tendon (with a single traction suture in it) exiting the medullary space where it will be fixed when the prosthesis is seated. The other six sutures have been placed for repair of the subscapularis.

And a diagram from Steve Lippitt

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Consultation for those who live a distance away from Seattle.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Biceps tenodesis in the setting of rotator cuff repair - does it make a difference?

Clinical and radiologic results of arthroscopic biceps tenodesis with suture anchor in the setting of rotator cuff tear

These authors wanted to find the  clinical and radiologic results of arthroscopic biceps tenodesis in 84 patients having rotator cuff repair. The description of the management of the rotator cuff tear is sparse: "The residual biceps tendon was cut from a site just proximal to the sutures, and the remaining stump was excised at an attachment site to the superior labrum. Afterward, the rotator cuff and combined lesion were addressed." The anatomic outcome of the cuff surgery was not described even though 60 patients had post op MRI's.

Clinical measures were improved after surgery. Eleven patients had popeye deformity, indicating failure of the tenodesis, yet the presence of this deformity did not correlate with poorer clinical scores. postoperative magnetic resonance imagine analysis, 15 patients (25%) showed distal migration of tenodesed biceps tendon, although only 6 (7.1%) had clinical popeye. 

While the authors concluded that "arthroscopic biceps tenodesis with 1 suture anchor resulted in good clinical outcomes at 2 years postoperatively", the data presented do not show a relationship between the clinical outcome and the success of the tenodesis. The data presented do not suggest any advantage of tenodesis over tenotomy and do not distinguish the relative roles of the biceps surgery and the cuff surgery in determining the clinical result.

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Does Open Repair of Anterosuperior Rotator Cuff Tear Prevent Muscular Atrophy and Fatty Infiltration? CORR

Does Open Repair of Anterosuperior Rotator Cuff Tear Prevent Muscular Atrophy and Fatty Infiltration? CORR

This article reports results of 23 shoulders with combined tears of the supraspinatus and upper subscapularis repaired with open surgery. The supraspinatus was repaired to a trough, the biceps was usually tenodesed, and the subscapularis was repaired to the lesser tuberosity. At a minimum of 36 months, two of the supraspinatus repairs had failed. Successful repair did not prevent the progression of fatty infiltration. Post operative Constant scores were not related to the degree of fatty infiltration.

These are important lesions to distinguish from isolated supraspinatus tears for two reasons: (1) repair of the subscapularis seems important to prevent propagation of the tear and (2) biceps instability is always a concern because of the likely disruption of the the transverse humeral ligament. Two of our former colleagues prepared a masterful treatise on the anatomy of this area: Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. Read it!

Once again we see a that, in spite of the technique of repair, failure of cuff repairs is not uncommon. See our previous posts on this topic.

Finally, since we're talking recently about the value equation (benefit/cost), it is time that we question the value of MRI's and ultrasound examinations to assess fatty infiltration/fatty atrophy. We are having difficulty understanding how these findings inform clinical decision-making in the management of cuff pathology. Is this assessment valuable?

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If you have suggestions for topics you'd like us to address in this blog, please send an email to shoulderarthritis@uw.edu.

Use the "Search the Blog" box to the right to find other topics of interest to you. 

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery.

See the countries from which our readers come on this post.