Tendinosis / Rupture / Subluxation / Hypertrophy

 

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

Inflammation

Thickening

Tearing

Usually seen with subscapularis tear www.boneschool.com/SLAP-tears
Can completely rupture    
Biceps Tendonopathy Arhroscopy Medially Subluxed Biceps Tendon Popeye Biceps

 

Examination

Speed's test Yergason's test O'Brien's test

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

Speeds Test Yergason's Test Obriens Test

 

Rupture - Popeye appearance

 

Popeye Sign BicepsPopeye Biceps

 

MRI

 

Normal

 

MRI Enlocated Biceps Tendon

 

Tendonitis

 

Biceps Tendonitis MRI

 

Tendonosis / thickening

 

MRI tendinopathy

 

Medial Subluxation

 

Biceps Medially Dislocated and Torn SSCMedially Dislocated Biceps Tendon with Torn SubscapularisBiceps Tendon Medially Dislocated

 

Arthroscopy 

 

Normal

 

Arthroscopy Normal Biceps Tendon Arthroscopy Normal Biceps Exit

 

Tendonopathy

 

Biceps Tendonopathy Grade 2 ArthroscopyShoulder Biceps Moderate TendonopathyBiceps Tear near complete

 

Dislocated Biceps

 

Shoulder Scope Dislocated Biceps TendonMedially Subluxed Biceps Tendon

 

Management

 

Nonoperative

 

Physiotherapy

Cortisone injections

 

Operative management

 

Tendinopathy

 

Options

 

Tearing < 50%: Debridement

Tearing > 50%: Tenotomy / tenodesis

 

Tenotomy v Tenodesis

 

MacDonald et al AJSM 2020

- RCT of tenotomy v tenodesis

- no difference in outcomes / cramping / supination strength

- increased cosmetic deformity / popeye in tenotomy (33%) versus tenodesis (10%)

 

Tenotomy

 

Arthroscopy Biceps 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

 

Portalslap

Portal just anterior to supraspinatus tendon

 

slapslapslap

Tag biceps and release

 

slapslapslap

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

 

Biceps Subpectoral TenodesisSubpectoral Biceps Tenodesis

 

Arthrexbtbt

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

 

 

 

 

 

 

 

 

 

Biceps Tenodesis Intra articular

 

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

 

Biceps Tenodesis First PassBiceps Tenodesis PDSBiceps Tenodesis First Suture

 

Biceps Tenodesis Second PassBiceps Tenodesis CompletedBiceps Tendon Insertion Cut

 

Attempt Figure 8 Suture Configuration

 

Biceps Tenodesis Step 1Biceps Tenodesis Step 2

 

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

 

Arthroscopy Tagging Biceps TendonArthroscopy Secured Biceps Tendon

 

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

 

Biceps Subpectoral TenodesisSubpectoral Biceps Tenodesis