Biceps Tenodesis

Introduction

The most common type of biceps tendon tear is a detachment (partial or complete) of one of the biceps tendons within the shoulder joint. At the shoulder, there are two attachments of the biceps tendon- one within the joint (long head of biceps) and the other in front of the shoulder joint (the short head of the biceps). Usually, injuries to the biceps tendon at the shoulder involve the long head of the biceps. The long head of the biceps passes through the shoulder joint and attaches to the labrum. When this attachment is torn, it is a so-called SLAP tear of the shoulder. SLAP (Superior Labrum Anterior to Posterior) tears are usually caused by injuries associated with repetitive over arm motions such as throwing a ball, falling on an outstretched arm or lifting a heavy object. Biceps tendon tears in the shoulder are commonly associated with rotator cuff tears, and are a common source of shoulder pain.

Biceps tenodesis describes the surgical procedure usually performed for the treatment of the damaged long head of biceps within the shoulder joint. This procedure can be performed as an isolated procedure or in conjunction with rotator cuff repairs.

During a biceps tenodesis surgery, the tendon is detached (if not already completely torn already) from its normal attachment within the shoulder joint and reattached to the humerus (arm bone) further down.

Surgery aims to relieve the pain and restore stability to the shoulder joint for activities of daily living and sport.

Indications for Surgery

  • Persistent pain.
  • Instability of shoulder interfering with activities of daily living, work or sport.

Other treatments are available. They range from no treatment and living with condition, to trial of injection, physiotherapy or exercises. However, these conservative treatments do not stabilise the shoulder and may not relieve the pain.

Pre-operative Instructions

The patient’s history, symptoms and clinical examination usually suggests a biceps tear and it may be in combination with a rotator cuff tear. Dr Lane will advise a MRI scan which will support the diagnosis. If conservative treatment has failed and pain and instability continue, then surgery is recommended. Dr Lane will give a give a full explanation of the procedure, expected recovery and surgical risks. Educational leaflets supplied by the Australian Orthopaedic Association are also available for further patient information.

If you have a pre-existing medical condition, you may be reviewed by a further specialist such as cardiologist or other specialised physician and anaesthetist prior to surgery.

Anti-inflammatory drugs such as Feldene, Naprosyn, Nurofen, Brufen, Voltaren, Mobic and Celebrex should be stopped 5 days before surgery. Aspirin or other blood thinning drug use prior to surgery should be discussed with Dr Lane, as this would depend on the patient’s underlying medical condition. The shoulder to be operated on should be free of cuts, scratches or sores as this can increase the risk of infection. If there is evidence of damage to the skin, your surgery will be postponed until healed.

The majority of biceps tenodesis procedures are done as a day procedure but occasionally requires an overnight stay. Our reception staff will give clear instructions about your admission time and location.

You should not eat or drink 6 hours prior to surgery.

Bring to hospital:

  • List of medications.
  • Relevant scans and X-rays.
  • Medicare, DVA or Private Health Care cards.

Once your details have been taken in the admissions area:

  • The duty nurse will take your clinical details and baseline observations.
  • A theatre gown given to wear. The shoulder to be operated on will be inspected by the nursing staff, washed with an anti-septic solution and then covered with a sterile drape.
  • TED stockings will be applied to the legs to reduce the risk of thrombosis after surgery.

You will be taken to the theatre complex by the nursing staff and then into the anaesthetic bay next to the operating room. There you will meet Dr Lane and the anaesthetist. Bicep tenodesis is performed under a general anaesthetic when the patient is asleep. The anaesthetic may also involve a regional nerve block which aids post-operative pain relief.

Procedure

Once asleep in theatre the patient will be placed on the side and the shoulder to be operated on uppermost, and the arm lifted with a heist and weighted upwards.

The shoulder, upper chest and arm are then prepped with anti-septic solution and patient covered with sterile drapes with a window for the operative site.

The initial part of the procedure is performed arthroscopically. The arthroscope is placed in the posterior portal in the shoulder joint, and a needle is passed through biceps tendon through the anterior portal.  A suture is then passed through the needle, caught with a grabber and then extracted- this prevents losing the tendon when it is cut. After the tendon is secured with a suture, an arthroscopic scissors cuts the tendon from its origin. A small incision (2 -3 cm) is then made over the front of the shoulder to reveal the biceps tendon. The cut tendon sheath is then extracted from the wound. The tendon is then trimmed and a non-absorbable suture is placed in the top of the tendon. A guide wire and reamer are used to make a deep bone tunnel in the humerus and the tendon is then fixed back into the bone with a special anchor screw.

The arthroscopic small portal incisions are then closed with Steri-stripes and larger incision at the front of the shoulder, sutured. Sterile primapores and dressings applied. The arm will be placed in a sling. Surgery usually takes 60 mins.

At the end of the procedure, the patient will be taken to recovery. When adequately awake, observations stable and comfortable, the patient will be discharged home. A script will be given for pain relief and you will also be given some strong painkillers such as endone or panadene forte for the first 36 hours following your operation. It is important that someone takes you home.

Post-operative Instructions

After surgery, the arm is put in a sling. This helps protect the repair. You will be able to use your fingers, wrist and elbow after surgery and can write within a few days. Please keep the dressing dry until seen by Dr Lane 10 to 14 days after surgery. The outer bulky dressing can be removed with 3 days, leaving the primapore intact.

At the first post-operative review, the sutures will be removed. At this time, you will be given further instructions to follow which can be used in conjunction with physiotherapy programme. It is recommended that the arm remain in a sling for 6 weeks after surgery and avoid lifting, pulling or carrying more than 2 kg.  You must be careful not to lift more than 2 kg at waist level with your operated arm for the first 4 months after surgery. Work at waist level is started at 4 months but it generally takes 4 to 6 months before beginning occasional work at shoulder level.

The patient can return to clerical work after 1-2 weeks after surgery but heavy lifting and overhead use, not for 6 months.

Return to sport is a staged process depending on the level of activity. The patient can start to enjoy walking at 2 weeks, stationary cycle at 2 months and jogging and regular cycling at 3 months. Swimming, running and underhand tennis and gentle golf strokes at 4-6 months. Overhead activities and contact sport avoided for 6 months following surgery. The success of the surgery is usually about 90%. Sometimes the bicep muscle is rounder than the other side but this is because it is difficult to get the correct length. However, the muscle strength returns and the pain much better after repair.

Risks

General complications associated with anaesthetic (rare)

  • Death.
  • Myocardial infarction (heart attack).
  • Stroke.
  • Pneumonia.
  • Deep Venous Thrombosis.

Local Complications (uncommon)

  • Bleeding.
  • Nerve injury – this usually resolves between 2 days to 6 weeks. Occurs in 1% of patients. Permanent nerve injury resulting in weakness or numbness is rare.
  • Infection – usually superficial and resolves with oral antibiotics. Occurs in 1 % of patients. Deep infection involving the repair may require intravenous antibiotics, repeat surgeries and lengthy stays in hospitals but this is rare.
  • Failure of biceps tendon repair to heal or it may re- injure after a major fall, wrench or pull.
  • Stiffness. Rehabilitation lessens the risk of stiffness.

Patients who are smokers, diabetic and have multiple pre-existing medical conditions have a higher risk of adverse complications.