Pathology of the long head of the biceps (LHB) is not uncommon, “but until now we have not had many clues to determine the right surgical path,” said Guillermo R. Arce, MD, in a presentation at the precourse of the 2012 Annual Meeting of the Arthroscopy Association of North America, which was held jointly with the Arthroscopy Association of Latin America (SLARD).
“Nevertheless,” he continued, “we have successful surgical techniques. Before performing them, we need clear decision making criteria to tailor the surgical treatment to each particular patient, injury, and performance.”
The two primary options for addressing LHB pathology are tenotomy and tenodesis. Tenotomy, Dr. Arce noted, is “easy and faster” but with some disadvantages such as poor aesthetics and a decrease in elbow flexion and supination strength. Tenodesis has been recommended for the younger, active patient.
In his presentation, Dr. Arce, of Buenos Aires, Argentina, focused on tenodesis and covered different arthroscopic techniques for performing LHB tenodesis. “In brief, there are four places where the LHB could be fixed—proximal near the articular cartilage, at the groove, suprapectoral, and subpectoral.”
Tendon instability and painful tendinosis are the two main pathologic conditions that play a role at the biceps tendon, and many patients will have both conditions. In outlining the preoperative and arthroscopic assessment for instability, Dr. Arce noted that “many anatomic structures contribute to prevent biceps instability,” including the following primary restraints (Fig. 1):
- coracohumeral ligament (CHL)
- superior glenohumeral ligament (SGHL)
- subscapularis and supraspinatus tendons
- bone trough
- transverse ligament (TL)
Preoperatively, the Abbott-Saunders test is “very useful.” A patient with an unstable biceps may experience pain and locking sensations when the arm is moved from abduction and external rotation to adduction and internal rotation. “By rotating the arm from external to internal rotation,” Dr. Arce said, “we try to get a bow-string effect of the tendon out of its pulley.”
Dr. Arce said that imaging studies demonstrating biceps tendon instability are rare “because of the dynamic nature of the problem.” High-resolution MRI slices may detect tears of the medial coracohumeral ligament (MCHL) or partial tears of the subscapularis tendon.
“It is hard to believe that primary impingement is an important player in biceps tendinosis, which is another pain generator. If an impingement syndrome contributes to biceps tendinopathy, the friction is secondary to rotator cuff failure,” he said. “Overuse, trauma, and degenerative disease are the main causes of tendon failure.”
One simple maneuver to assess the LHB is to check for the presence of “one-finger pain” approximately 7 cm below the level of the acromion with the arm in 10 degrees of internal rotation.
For successful treatment of both biceps instability and biceps tendinosis, a complete arthroscopic assessment is a key factor. During the arthroscopic examination, the SGHL-CHL complex is the primary structure in evaluating biceps instability.
“The medial CHL is the number one biceps stabilizer for prevention of subluxation or dislocation,” Dr. Arce said. “The close relationship of the subscapularis and the medial CHL determines the frequent involvement of both structures in many cases, and arthroscopic evaluation of the medial CHL is the key to successful treatment of biceps instability.”
He recommends putting the patient’s arm in almost 80 degrees of forward flexion and moderate external rotation for a good view of these structures.
He explained that the pulley roof is reinforced by subscapularis and supraspinatus tendon expansions. “Therefore, we may consider the subscapularis fiber insertions at both the lesser and greater tuberosities. The supraspinatus fibers contribute to the pulley’s lateral wall and roof. The clinical implications are that when we repair a supraspinatus cuff tear, we should try to fix it at the groove edge.”
Structures should be assessed not only in a static view but also in dynamic testing during the arthroscopic procedure, he said.
The transverse ligament and a well-vascularized tendon sheath are the main restraints of the lower pulley, he explained. “It is very important to get used to seeing the biceps anatomy in any instance of shoulder arthroscopy,” he said. “In this way, small changes in the normal anatomy can be identified and the biceps instability diagnosis can be easily addressed.”
The ramp test may be used to evaluate stability and tissue quality of the biceps tendon, Dr. Arce said. He uses a nerve hook, pulling from the tendon downward, to assess tendon quality and stability.
The findings of the diagnostic procedure determine whether the patient is a candidate for a tenotomy or a tenodesis.
For tenodesis, Dr. Arce uses anchors or biotenodesis screws at the level of the cuff repair. “Even though we try to decrease the tension by grabbing the biceps above the anchor level, many patients experience postoperative pain because we are leaving degenerated tendon below the fixation site,” Dr. Arce said. LHB tenodesis at the groove is a possible solution to this problem and is the most common technique for patients who have biceps tendinosis without a rotator cuff tear (Fig. 2).
If the degenerative changes are distal to the groove, arthroscopic distal suprapectoral tenodesis is the preferred procedure. The advantage of this approach is that the “entire bad-quality tendon can be removed,” Dr. Arce said. In the procedure, the scope is located at the lateral portal, and two anterior portals are needed to fully fix the biceps just above the pectoralis major tendon.
Outcomes may be difficult to measure because of multitendon involvement and concomitant procedures. Testing instruments such as the UCLA or Constant score “are unreliable to reach the final result of the tenodesis or tenotomy because of the strong influence of the rotator cuff condition or other reconstructions performed in these patients,” Dr. Arce said. “The lack of a specific test makes follow-up difficult.”
Overall, a number of factors determine the course of treatment for a patient with biceps symptoms. “Depending on the patient’s condition, performance, or expectations,” Dr. Arce said, “tendon débridement, tenotomy, or tenodesis may be indicated. Our approach is to perform tenotomy or soft-tissue tenodesis in low-demand patients older than 60 years. For younger and athletic patients, we prefer suture anchor tenodesis, which is easily performed with the current arthroscopic techniques.”
The LHB is fixed at a position ranging from the upper part of the groove to the pectoralis major region, depending on the extent of the tendon degenerative changes. Even though interference tenodesis screws have been described as providing stronger fixation than suture anchor, no significant differences have been found between these devices.
“The diagnosis of biceps instability or tendinosis must be based on a complete preoperative examination, imaging studies, and the findings of arthroscopic examination of the structures involved,” he said. “After diagnosing the type and location of tendon failure, the surgeon may perform tenotomy or tenodesis, with encouraging results.”
Disclosure for Dr. Arce: Mitek; Storz.
Terry Stanton is senior science writer for AAOS Now. He may be reached at firstname.lastname@example.org
- The two primary options for addressing pathologies of the long head of the biceps tendon are tenotomy and tenodesis.
- Arthroscopic assessment, particularly of the SGHL-CHL complex, is key in diagnosing and treating biceps instability.
- For patients with biceps tendinosis without a rotator cuff tear, LHB tenodesis at the groove is a possible solution. If degenerative changes are distal to the groove, arthroscopic distal suprapectoral tenodesis is the preferred procedure.
- Outcomes are often difficult to measure due to multitendon involvement and concomitant procedures.