Function
LHB primary function is humeral head depressor
Also accelerate / decelerate arm in overhead sports
Anatomy
Origin - supraglenoid tubercle and superior glenoid labrum
Intra-articular - enters bicipital groove, beneath transverse humeral ligament
Problems
Tendinosis / Tendinopathy | Subluxation / Dislocation | SLAP tears |
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Inflammation Thickening Tearing |
Usually seen with subscapularis tear | www.boneschool.com/SLAP-tears |
Can completely rupture | ||
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Examination
Speed's test | Yergason's test | O'Brien's test |
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Resisted forward flexion at 90° Forearm supinated Pan in bicipital groove |
Externally rotate arm with elbow 90° Resisted supination - assess pain or popping at bicipital groove |
Shoulder flexed 90o in plane of scapula Adducted 30-45o Max internal rotation / thumb down Resist downward force causes pain No pain with external rotation / thumb up |
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Rupture - Popeye appearance
MRI
Normal
Tendonitis
Tendonosis / thickening
Medial Subluxation
Arthroscopy
Normal
Tendonopathy
Dislocated Biceps
Management
Nonoperative
Physiotherapy
Cortisone injections
Operative management
Tendinopathy
Options
Tearing < 50%: Debridement
Tearing > 50%: Tenotomy / tenodesis
Tenotomy v Tenodesis
- RCT of tenotomy v tenodesis
- no difference in outcomes / cramping / supination strength
- increased cosmetic deformity / popeye in tenotomy (33%) versus tenodesis (10%)
Tenotomy
Tenodesis
Options
Arthroscopic versus open
Suprapectoral versus infrapectoral
Arthroscopic suprapectoral biceps tenodesis
Technique
Vumedi arthroscopic suprapectoral biceps tenodesis video
Beach chair
- portal just anterior to leading edge of supraspinatus
- tag biceps tendon with high strength suture and release
- repair superior labrum with one or two anchors
- anchor biceps tendon into bicipital groove
Portal just anterior to supraspinatus tendon
Tag biceps and release
Anchor biceps tendon into bicipital groove
Open subpectoral biceps tenodesis
Technique
Vumedi open subpectoral tenodesis video
Arthrex subpectoral biceps tenodesis video using biceps button
Arthrex subpectoral biceps tenodesis surgical technique PDF
Beachchair
- arthroscopic biceps tendon release
- open approach to biceps
- incision centered on humerus below pectoralis tendon
- retract deltoid laterally / elevate pectoralis tendon / conjoint tendon medially
- find biceps tendon / shorten to 2cm of tendon / suture
- anchor biceps tendon
Bicortical open subpectoral biceps tenodesis using Arthrex Biceps Button
LHB Subluxation
Issues
Usually associated with subscapularis tear
Options
Subscapularis repair + Tenodesis / Tenotomy
Subscapularis repair with LHB stabilization
LHB stabilization
Issue
Can get stenosed painful tendon
Results
Maler et al JBJS Am 2007
- 21 patients with traumatic tear of SSC treated within 6 weeks
- open SSC repair and LHB stabilisation
- 7 had symptoms of mild tenodinopathy
- 2 recurrent instability and 1 rupture on US
Concept
- suture biceps to superior capsule using figure 8 no 2 non absorbable
Technique
- anterior portal + portal of Wilmington
- debride capsule and biceps with shaver so will heal
- use curved suture passer with no 1 PDS
- suture shuttle no 2 fibre wire
- divide 90% biceps insertion so will rupture in time
- allows healing of biceps to capsule
Attempt Figure 8 Suture Configuration
B. Arthroscopic Suprapectoral Technique
1. Secure Biceps Tendon - allows tensioning and prevents losing tendon
A. Birds Beak Passer with 2 ethibond loop
- pass loop through intact tendon at entry through RC interval
- retrieve loop out through portal and lock
- this gives strong hold on tendon
B. Pass 18 G spinal needle through biceps tendon
- thread 1 PDS or nylon
- retrieve both suture ends via portal in rotator interval
- secure with half hitches
- pass 1 loop of PDS about entire tendon and tie again
2. Resect tendon with electrocautery at insertion
3. Make portal over biceps interval into subacromial space
- release biceps tendon with electrocautery or arthroscopic scissors
4. Secure tendon
- make drill hole
- insert tendon
- secure with biotenodesis screw
- multiple techniques with specifically designed equipment
C. Open Technique for Intact Biceps
1. Divide biceps arthroscopically
- may wish to place stay suture first to avoid retraction
- biceps normally has vinculae preventing complete retraction into arm
2. Suprapectoral
- deltoid split
- between anterior and middle parts
- find biceps in groove
- pull out of wound and whip stitch with heavy suture
- drill appropriate size tunnel for fixation screw
- multiple biceps tenodesis devices
- push the tendon into the hole, then fixate with screw
3. Subpectoral
- medial incision in arm
- below inferior edge of pectoralis major
- find biceps tendon
- whip stitch
- pass through drill holes / secure with screw / secure with anchor