Biceps Tenodesis Made Easy How to Get it Right …...recurrent tears after surgery, SLAP lesions, biceps lesions - most of us believe this gives us more information, but the truth

Biceps Tenodesis Made Easy - How to Get it Right Every Time CAPT Matthew T. Provencher, MD, MC USNR The Steadman Clinic

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Biceps Tenodesis Made Easy

How to Get it Right Every Time

Matthew T. Provencher, MD CAPT MC USNR Shoulder, Knee and Sports Surgeon, The Steadman Clinic

Principal Investigator, Steadman Philippon Research Institute 181 W Meadow Dr. Suite #400

Vail, Colorado 81657

Diagnosis of Proximal Bicep Tendon Pathology:

Commonly associated with other shoulder problems (SLAP, Supraspinatus and Subscapularis tears) Tenosynovitis of the LHB tendon may occur with concomitant bursitis, rotator cuff tendonitis, SLAP, rotator cuff tear, and AC joint disorders, frozen shoulder (Neer), impingement or sometimes a combination of these conditions However, may present as an isolated source of shoulder pain. Diagnosis: combine history of anterior shoulder pain with pain to palpation over the intertubercular

groove, and positive provocative biceps tendon tension tests. Although recognized for >50 years, LBH tendonitis is increasingly recognized as a sole source of

shoulder pain, or in combination with one (or more) of the aforementioned disorders Pathophysiology Commonly regarded as a degenerative process of the tendon, although not well substantiated Blood supply – critical decrease of blood flow as tendon enters the bicipital groove NOTE: The anterior-superior labrum and glenoid has an area devoid of vascular supply that is in the area of the anterior attachment of the biceps root which is likely to adversely affect the normal healing response, either following injury or surgery. (Abrassart et al, JSES 2006;15:232-238) Mechanical forces -As the tendon is fixed to the superior labrum, it is subjected to shear forces, friction,

traction, and pressure. Mechanical causes of biceps degeneration probably predominate (Refior JSES 1995)

Deposits of acid mucopolysaccharide and disorganized collagen (disrupted) at groove exit Continued mechanical stress at narrow sites (distal biceps groove, under acromion, CA ligament, CHL

area), and impingement under the CA arch with flexion may cause degeneration. A thin rotator cuff may increase mechanical stress on the tendon, thus the hypothesis that those with cuff

dysfunction (tendonitis, partial tears, or full tears) have an increased risk for LHB tenosynovitis (Refior JSES 1995)

Incidence is related to the extent of rotator cuff degeneration and 50% of biceps tendons do not have evidence of macroscopic evidence of disease at the time of arthroscopy (Murthi, JSES 2000)

There is also degeneration of the tendon at origin on the glenoid (SLAP area) – disorganized collagen

Matthew T. Provencher, MD Biceps Tenodesis Made Easy - How to Get it Right Every Time

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and increased mucoid may be precursors to problems in this area and ultrastructure changes may be visible.

Innervation- LHB tendon contains sensory and sympathetic fibers, especially proximally (Alpantaki JBJS 2005), possibly involved in the pathogenesis of shoulder pain. LHB tendons removed during arthroscopic tenodesis demonstrate less axons and less vasularity compared to controls obtained from cadavers. There was a moderate correlation (R=0.5) between LHB vascularity scores and pain scores (Singaraju, JSES 2008).

Intraarticular pathology into groove – The “hourglass” biceps has been described – hypertrophy observed and buckling found with elevation of the arm during arthroscopy – incarceration of the tendon. Excision of intraarticular portion (remove all diseased tendon) recommended via tenodesis.(Boileau JSES 2004). I have not recognized this unique pathology of tendon incarceration in my practice, but maybe it has seen me…I will keep looking…

From Boileau et al. JSES 2004, 13:249-57 Physical Exam

Tenderness: over the intertubercular sulcus (most common finding) Rotate arm to 10 degrees on IR, palpate 7 cm below acromion, tenderness should move laterally with external rotation to differentiate from subcoracoid impingement.

Tenderness below the pectoralis major tendon at the level of the axilla Impingement Tests Neer, Hawkins- Often painful (sensitive, but not specific) Flexion / Internal Rotation (Gerber) Biceps Instability Test Full abduction + External Rotation Painful Click, palpable Yergasons’s Test (JBJS-A 1931) Elbow flexed at 90 resist supination while palpating proximal biceps Compression Rotation Test: looking for SLAP lesions in younger patients


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Supine, Abduct to 90 degrees, compression (Analogous to McMurray’s compression test) Evaluation of Subscapularis Tendon

Gerber Lift Off Belly – press test (Resch) Speeds Test-Pain with resisted forward flexion, palm up (supinated forearm) O’Briens Test-Pain with resisted arm flexion and adduction in pronation rather than supination

Special Tests Selective injections

Begin with subacromial injection - Associated impingement syndrome or rotator cuff tears may dramatically improve

with subacromial injection. If biceps pain persists, consider injection into biceps tendon sheath If considering SLAP, intraarticular injection as a test or temporary relief.

Imaging studies

Plain radiographs Standard series “Groove view” by Cone (historical value)

Demonstrates depth and width of groove Patient supine, arm in external rotation

X-ray beam directed cephalad + 15 degrees medial to long axis of the humerus Arthrogram

Outline of tendon and sheath suggest no inflammation Absent in > 30% Loss of contour may suggest inflammation / synovitis

MRI Visualize bicep, bicep groove, bony osteophytes, fluid; most studies are not precise, accurate and

of high enough quality to get consistent information in the community setting; Centers with dedicated Shoulder Radiologists seem to report better information (often Level 5 evidence, occasionally level 4)

Evaluation of SLAP lesion remains a challenge for many (< 70% accurate) MRI with arthrogram

Improved accuracy for partial-thickness rotator cuff tears, small full-thickness rotator cuff tears, recurrent tears after surgery, SLAP lesions, biceps lesions - most of us believe this gives us more information, but the truth is, we currently have no idea if the additional information is changing the way we manage biceps pain beyond what we learn clinically and arthroscopically. Indirect contrast (IV versus intraarticular injection) and High Resolution MRI (T3 magnets) are gaining popularity.

Ultrasound Excellent for LHB subluxation and dislocation, unreliable for intra-articular partial thickness

tears (Armstrong JSES 2006); definitely an underutilized imaging method in the USA. Treatment

Tendonopathy Initial treatment is based on the principles of treating tendinopathy. Rest, ice, NSAID’s, activity modification


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Physiotherapy, +/- modalities such as ionophoresis (not much scientific support) Cortisone injection(s) if initial treatment unsuccessful

Begin with subacromial; if biceps remains systematic, then inject biceps sheath May consider intraarticular injection May precipitate bicep tendon rupture (does not directly cause rupture)

Bicep Tendon rupture - ACUTE Operative vs. Nonoperative

No change in elbow flexion strength 10-20% loss of supination strength Change in shoulder function for overhead throwers is likely/possible Recent abstract/presentation (Hawkins) did not demonstrate strength deficit after

recovery from initial event Biceps Tendon rupture – CHRONIC May present to your clinic with fatigue pain complaints – do well for the first 30-

60 minutes of work and then becomes increasingly painful with markedly decreasing lifting capabilities

I consider operative tenodesis of the chronic proximal LHB rupture in laborers, heavy lifters, and those that complain of shoulder fatigue pain not related to another diagnosis.

Bicep Tendon instability – operative intervention (treat the associated pathology – think SSc tear or other rotator cuff tear)

SLAP lesion – operative intervention

Overhead athlete (posterior release? Anterior Capsulorrhaphy?) Athletes in association with an instability lesion (Bankart)

Work comp injury, especially secondary to “traction” Bicep tenodesis, +/- labral repair (In my practice, results in terms of return to work after SLAP repair alone for a work related

injury are Fair/Poor – much different than a sports-related injury) Surgical Treatment

Tenotomy Versus Tenodesis Results: Frost, Zafar, Maffulli. AJSM 2008 Systematic Review of Literature Low quality of evidence: 1 RCT, 7 prospective cohort studies, 11 retrospective cohort studies(Coleman Methodology Score 58 ± 14) Lack of evidence to advocate one technique over the other


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Boileau, Baque, Valerio, Ahrens, Chuinard, Trojani. JBJS 89A (4) : 747-57. Retrospective Cohort Study 72 shoulders with irreparable RCT treated with tenodesis (N=39) or tenotomy (N=33) 78% Satisfied, Constant Murley 66.5 Healthy-appearing Teres Minor increased ER and greater Constant score (P<0.05)

Franceschi, Longo, Ruzzini, Rizzello, Maffulli, Denaro. AJSM 2008; 36:247-253. 63 shoulders RCT with Type 2 SLAP over 50 years, followed 2.9 years Group 1(RCR + SLAP): 27.9 vs. Group 2(RCR + LHB tenotomy): 32.1 (P<0.05) RCR Franceschi, Longo, Ruzzini, Papalia, Rizzello, Denaro. Int Orthop 2007; 31(4): 537-45. 22 shoulders with arthroscopic tenodesis incorporated into RCR, followed 47,2 months Group 1 (tenodesis without tenotomy): UCLA 33 Group 2 (tenodesis with tenotomy): UCLA 32.9 No differences between groups Arthroscopic Treatment of Type II SLAP Lesions: Biceps Tenodesis as an Alternative to Reinsertion Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic Treatment of Type II SLAP Lesions: Biceps Tenodesis as an Alternative to Reinsertion. Am J Sports Med PreView, Published February 19, 2009. Level 3 Cohort Study


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Inclusion criteria: Isolated type II SLAP tear with activity related pain that failed conservative treatment Exclusion criteria: GH instability, RCT, posterosuperior glenoid impingement, biceps tendinopathy, prior shoulder surgery SLAP repair group (N = 10, mean age 37 yrs): Constant 65 to 83 pts, 60% disappointed due to persistent pain, 20% return to previous level of sport, 4 pts failed and revised to biceps tenodesis Biceps tenodesis group (N = 15, mean age 52 yrs): Constant 59 to 89 pts, 93% satisfied / very satisfied, 87% return to previous level of sport Conclusions: Biceps tenodesis is an effective alternative to SLAP repair, BUT sig difference in age b/w two groups Recommendation: SLAP repair under 30 yrs, biceps tenodesis over 30 yrs

Tenotomy Indications: Bicep pathology

Multiple Severe co-morbidities (can not tolerate tenodesis) Contraindication for tenodesis

Results: Gill, McIrvin, Mair, Hawkins: J Should Elbow Surg. 2001; 10(3):247-9 Mean ASES score: 81.8 Significant reduction in pain and improvement in function Complication rate 13.3% Osbahr, Diamond, Speer: Arthroscopy 2002;18(5):483-7 No statistically significant difference between tenotomy and tenodesis 30% incidence of cosmetic change with tenotomy

Kelly, Drakos, Fealy, Taylor, O’Brien: AJSM 2005:208-213 54 patients with arthroscopic release of LHB (some concomitant procedures) 70% had Popeye sign (at rest or during flexion) – 87% men and 36% women 68% rated E/VG/G. **38% complained of fatigue discomfort after resisted elbow flexion

Many others that suggest tenotomy is effective for relief of pain related to biceps

Open Tenodesis Performed for > 50 years Variety of techniques and procedures Becker & Cofield: JBJS 1989: 376-381. 54 shoulders, followed 13 years. Found persistent pain in 1/3 of the patients Berlemann and Bayler: JSES 1995:429-35. 15 shoulders keyhole tenodesis, followed 7 years. Up to 60% success. Local anesthetic injection prior to the operation valuable in determining

Success Mazzocca, Cote, Arciero, Romeo, Arciero, AJSM 2008; 36 (10): 1922-9.

50 shoulders subpectoral biceps tenodesis, followed 29 months. ASES 81 (89 without RCT vs. 78 with RCT),


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SST 9 (10.6 without RCT vs. 8.8 with RCT), Rowe 86, Constant Murley 87, SANE 84. 1 Failure due to pullout of tendon

Arthroscopic Tenodesis Indications: Bicep pathology Avoid / treat cramping and discomfort with strenuous use of bicep Maintain muscle length

Blix curve: the greatest muscle contraction occurs when the muscle is at its normal resting length

Cosmesis Techniques: Suture to intact rotator cuff (eg. PITT technique - Rodowsky) Incorporate into rotator cuff repair Transfer to coracoid process (Obrien) Suture anchors in bicipital groove (Gartsman, Snyder, others) Interference screw (Boileau/Walch, Burkhart, Romeo/Mazzocca)


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Arthroscopic Tenodesis with Interference Screw Fixation Cut Tendon Intraarticularly

Move arthroscope to subacromial space, lateral portal. Find falciform ligament of pectoralis tendon and underneath is the biceps tendon.

Localize accessory anterior portal with a spinal needle and remove tendon trough skin

Remove 20mm of proximal tendon. This eliminates diseased tendon from the tenodesis as well recreates an anatomic fit. Whip stitch or Krakow tendon stitch 15mm in tendon

Localize Intertubercular groove and insert 2mm guide wire. Ream over guide wire with 7 or 8mm cannulated reamer to a depth of 30mm.


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Take tendon out of accessory anterior portal and insert one suture through screw and tenodesis driver

Draw tendon tight against driver and insert into bone tunnel

Use arthroscopic knot pusher to tie suture over the top of the tenodesis screw. This technique establishes interference screw and suture anchor fixation.


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Mini-Open Bail Out Extend accessory anterior portal at the level of the Intertubercular groove. Be aware of location of axillary nerve. Insert 2mm guide wire, and ream to 30mm

Withdraw tendon from biceps groove and place #2 Fiberwire (Arthrex Inc) in a Krakow type whipstitch. Insert screw and tie knot over the top.


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Open Subpectoral Tenodesis - preferred choice REF: Mazzocca, Rios, Romeo, Arciero. Subpectoral biceps tenodesis with interference screw fixation. Arthroscopy. 2005 Jul;21(7): 896. REF: Provencher MT, LeClere LE, Romeo AA. Subpectoral Biceps Tenodesis. Sports Med Arthrosc Rev, Vol 16, No 3, Sept 2008 Advantages: Tendon marked arthroscopically and tenotomized at origin Subpectoral approach is utilized (2 cm incision) near axillary fold longitudinally Tenodesed with bioabsorbable interference screw fixation deep to pectoralis tendon Relevant anatomy is clearly identified Very efficient and reproducible with “easy learning curve” Removes tendon from confines of intertubucular groove and synovium associated (which may be

cause of persistent pain) Procedure: Evaluate biceps “dry” upon initial scope to evaluate inflamed tendon Draw biceps tendon into joint (looks at portion in the groove) Fraying almost always indicative of pathologic tenosynovitis Tenotomize at base

Tenotomize at base. Debride SLAP area if necessary. Open incision - 1 cm superior to inferior

border of pectoralis major tendon, continue 2-3 cm below inferior border OR, place in axillary crease for best cosmesis.


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Identify inferior border of pectoralis major, dissect below this level, and the sheath needs to be gently incised directly over the tendon. Palpation will identify the longitudinal structure of the biceps. Blunt Chandler is placed medially (watch musculocutaneous n.) Use right angle to identify tendon and retract out of the wound. Whip-stitch into most proximal 15 mm of the tendon, adjacent to the musculotendinous border (critical for tensioning and cosmesis)

Biotenodesis (Arthrex, Naples, FL) screw system is utilized to fix in place using 8 mm x 12 mm interference screw.

Complications Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Cole BJ, Nicholson GP, Mazzocca AD, Romeo

AA. Complications Associated with Subpectoral Biceps Tenodesis. Submitted, J Shoulder Elbow Surg, 2009.


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Over 3 yrs, 8 of 373 Biceps Tenodesis had complications with incidence of 0.71% per year. 2 pts (0.18%) with persistent bicipital pain 2 pts (0.18%) with failure of fixation with Popeye deformity 1 pt (0.09%) with deep wound infection 1 pt (0.09%) with temporary musculocutaneous neuropathy 1 pt (0.09%) with RSD 1 pt (0.09%) with proximal humerus fracture Postoperative protocol Sling x 4 weeks during sleep, during work for 2-3 weeks Discontinue sling completely at 4 weeks (if isolated procedure) Overall protocol and sling frequently dictated by concomitant procedures Progress full PROM (x 6 weeks) to active ROM Start elbow range of motion and grip strength (immediately) Avoid supination strengthening and active elbow flexion for 4 weeks May resume light work at 3-4 weeks depending on job, sooner if less demand. REF: Mazzocca, Rios, Romeo, Arciero. Subpectoral biceps tenodesis with

interference screw fixation. Arthroscopy. 2005 Jul;21(7): 896. **Biomechanics of Proximal Biceps Tenodesis** (Bone versus Soft Tissue Fixation)

Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy 2005 Nov; 21(11):1296-306.

Kilicoglu O, Koyuncu O, Demirhan M, Esenyel CZ, Atalar AC, Ozsoy S, Bozdag E, Sunbuloglu E, Bilgic B. Time-dependent changes in failure loads of 3 biceps tenodesis techniques: in vivo study in a sheep model. Am J Sports Med. 2005 Oct:33(10):1536-44.

Ozalay M, Akpinar S, Karaeminogullari O, Balcik C. Tasei A, Tandogan RN, Gecit R. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy 2005 Aug;21(8):992-8.

Golish SR, Caldwell PE, Miller MD, Singanamala N, Ranawat AS, Treme G, Pearson SE, Costic R, Sekiya JK. Interference screw versus suture anchor fixation for subpectoral tenodesis of the proximal biceps tendon: A cadaveric study. Arthroscopy 2008, Oct; 24 (10): 1103-1108.

Kusma M, Dienst M, Eckert J, Steimer O, Kohn D. Tenodesis of the long head of biceps brachii: Cyclic testing of five methods of fixation in a porcine model. J Shoulder Elbow Surg 2008; 17: 967-973.


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Summary: What are the loads on the biceps tendon? Difficult to fully characterize – in vivo determination of LHB force To maintain weight of forearm at 90 degrees to hold a 1 kg object is 112 N (Nordin 2001) Thus, it is generally inferred from biomechanical failure studies. Almost all have shown failure at the bicipital-labral complex with progressive loads in several models Force required to cause failure of superior labral complex is 289 +/- 39 N (Arm in ABER, Kuhn 2003)

External/internal rotation with rapid change in position of the humeral head affect magnitude of tension in biceps (Yeh AJSM 2005), deceleration caused the highest stress/load. Ultimate strength in a simulated biomechanical model was 508 N (+/- 134N) in deceleration, 262 (+/- 88N) in late cocking (Shepard AJSM 2004). All failed by generation of a SLAP II injury.

Kuhn demonstrated failures of 289 N in late cocking, vs. 346 N in deceleration.(Kuhn Arthroscopy ‘03)

(From Yeh, AJSM 2005)

Kuhn JE, Lindholm SR, Huston LJ, Soslowsky LJ, Blasier RB. Failure of the biceps superior labral complex: a cadaveric biomechanical investigation comparing the late cocking and early deceleration positions of throwing. Arthroscopy 2003;19:373-379.

Nordin M, Frankel VH. Biomechanics of the elbow, in Nordin M, Frankel VH (eds). Basic Biomechanics of the Musculoskeletal System. Third Edition. Philadelphia, Lippincott Williams & Wilkins, 2001

Interference screw technique:

Highest ultimate load to failure (NO Question; you want strong fixation, this is it) Least amount of displacement with cyclical loading Most rapid healing (increase fixation strength at 3 weeks in sheep model) High clinical success in multiple studies (85 – 90%)

Richards Arthroscopy 2005:861-66. Biceps tenodesis with interference screw is stronger than double suture anchor

Mazzocca Arthroscopy 2005:1296-1306 Interference screw demonstrated least amount of displacement (versus open bone


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tunnel, suture anchor) Kilicoglu AJSM 2005: 1536-44 Sheep shoulder study – Fixation improved over time (healing?), tenodesis screw

exhibited higher failure at week 3 versus day 0 (419 N versus 164 N). Tenodesis screw fixation improves over time

Suture anchors: Less fixation strength at time zero and 3 weeks (however, it often is “enough” based on published clinical studies) Less resistance to displacement with cyclical loading

Recommended Reading Andrews JR, Carson WG Jr, McLeod, Wd. Glenoid labrum tears related to the long head of the biceps. Am J Sports Med 1985:13:337-341. Becker DA, Cofield, RH. Tenodesis of the long head of the biceps brachii for chronic biciptal tendonitis. J Bone Joint Surg (Am) 1989:71:376-381 Boileau P, Kirshnan SG, Coste JS, Walch G. Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation.

Arthroscopy, 2002 Nov-Dec;18(9):1002-12. Boileau P, Parratte S, Chuinard C, Roussanne Y, Shia D, Bicknell R. Arthroscopic Treatment of Type II SLAP Lesions: Biceps Tenodesis as an

Alternative to Reinsertion. Am J Sports Med PreView, Published February 19, 2009. Clark J, Sidles JA, Matsen, FA. The relationship of the glenohumeral joint capsule to the rotator cuff. Clin Orthop 1990; 254: 29-34. Clark J, Harryman DT II. Tendons ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surgery (AM) 1992; 74:

713-725. Elkousy HA, Fluhme DJ, O’Connor DP, Rodosky MW. Arthroscopic biceps tenodesis using the percutaneous, intra-articulary trans-tendon

technique: preliminary results. Orthopedics, 2005 Nov;28(11)1316-9. Gartsman GM, Hammerman SM. Arthroscopic biceps tenodesis: operative technique. Arthroscopy 2000 July-Aug;16(5)550-2. Gerber C, Sabesta A. Impingement of the deep surface of the subscapularis tendon and the reflection pulley on the anterosuperior glenoid rim: A

preliminary report. J Shoulder Elbow Surg 200; 9: 483-90 Gerber C, Terrieer F, Ganz R. The role of the soracoid process in the chronic impingement syndrome. J Bone Joint Surg 1985; 67B: 703-8. Gill TJ, McIrvin E, Mair SD, Hawkins RJ. Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder

Elbow Surg, 2001 May-Jun;10(3):247-9. Golish SR, Caldwell PE, Miller MD, Singanamala N, Ranawat AS, Treme G, Pearson SE, Costic R, Sekiya JK. Interference screw versus suture

anchor fixation for subpectoral tenodesis of the proximal biceps tendon: A cadaveric study. Arthroscopy 2008, Oct; 24 (10): 1103-1108. Kilicoglu O, Koyuncu O, Demirhan M, Esenyel CZ, Atalar AC, Ozsoy S, Bozdag E, Sunbuloglu E, Bilgic B. Time-dependent changes in failure

loads of 3 biceps tenodesis techniques: in vivo study in a sheep model. Am J Sports Med. 2005 Oct:33(10):1536-44.Kusma M, Dienst M, Eckert J, Steimer O, Kohn D. Tenodesis of the long head of biceps brachii: Cyclic testing of five methods of fixation in a porcine model. J Shoulder Elbow Surg 2008; 17: 967-973.

Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy 2005 Nov; 21(11):1296-306.

Mariani EM, Cofield RH, Askew LJ, Li G, Chao Eys. Rupture of the tendon of the long head of the biceps brachii. Surgical versus nonsurgical treatment. Clin Orthop 1988; 228: 233-239.

Murthi AM, Vosburgh CL, Neviaser TJ. The incidence of pathologic changes of the long head of the biceps tendon. J Shoulder Elbow Surg. 2000 Sep-Oct;9(5):382-5.

Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Cole BJ, Nicholson GP, Mazzocca AD, Romeo AA. Complications Associated with Subpectoral Biceps Tenodesis. Submitted, J Shoulder Elbow Surg, 2009.

Nove-Josserand L, Levigne C, Walsh G. Isolated tears of the upper part of the subscapularis tendon. In: Gazielly DF, Gleyze P, Thomas T, editors. The Cuff. Amsterdam: Elsevier; 1997: 334-6.

Osbahr DC, Diamond AB, Speer KP. The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis. Arthroscopy 2002 May-Jun;18(5):483-7.

Ozalay M, Akpinar S, Karaeminogullari O, Balcik C. Tasei A, Tandogan RN, Gecit R. Mechanical strength of four different biceps tenodesis techniques. Arthroscopy 2005 Aug;21(8):992-8.

Pagnani MJ, Deng XH, Warren RF, Torzilli PA, O’Brien SJ. Role of the long head of the biceps brachii in glenohumeral instability: a biomechanical study in cadavera. J Shoulder Elbow Surg 1996; 5:255-262.

Pfirrmann CWA, Zanetti M, Wieshaupt D, Gerber C, Hodler J. MR arthrography of subscapularis tendon tears: detection and grading at MRI arthrography. Radiology 1999; 213: 708-14.

Richards DP, Burkhart SS. A biomechanical analysis of two biceps tenodesis fixation techniques. Arthroscopy, 2005 Jul;21(7):861-6. Romeo AA, Mazzocca AD, Tauro JC. Arthroscopic biceps tenodesis. Arthroscopy, 2004 Feb;20(2):206-13.


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Sakurai G, Ozak J, Tomita Y, Kondo T, Tamai S. Incomplete tears of the subscapularis tendon associated with tears of the supraspinatus tendon: cadaveric and clinical studies. J Shoulder E.bow Surgery 1998; 7:510-5.

Tibone JE, Elrod B, Jobe FW, et al. Surgical treatment of tears of the rotator cuff in athletes. J Bone Joint Surgery (AM) 1986; 68; 887-891. Walch G, Nove-Josserand L, Boileau P, Levigne C. Subluxation and dislocation of the tendon of the long head of the biceps. J Shoulder Elbow Surg

1998; 7:100-8. Walch G, Nove-Josserand L, Levigne C., Tears of the supraspinatus tendon associated with “hidden” lesions of the rotator interval. J Shoulder Elbow

1994; 353-60. Verma NN, Drakos M, O’Brien SJ. Arthroscopic transfer of the long head biceps to the conjoint tendon. Arthroscopy, 2005 Jun;21(6):764. Yamaguchi K, Riew KD, Galatz LM, Syme JA, Neviaser RJ. Biceps activity during shoulder motion; an electromyograpic analysis. Clin Orthop

1997; 336; 122-129. Zanetti M, Weishaupt D, Gerber C, Hodler J. Tendinopathy and rupture of the tendon of the long head of the biceps brachii

Distal Biceps Fixation:


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Additional Ref: Mazzocca AD, Alberta FG, El AttracheNS, Romeo AA. Single incision technique using an interference screw for the repair of distal biceps tendon ruptures. Oper Tech Sports Med. 2003;11:36-41. TechniquesinShoulder&ElbowSurgery9(4):182–187,2008_2008LippincottWilliams&Wilkins,PhiladelphiaAnatomicalRepairoftheDistalBicepsTendonUsingtheTension‐SlideTechniquePaulSethi,MD,JamesCunningham,MD,andSethMiller,MDOrthopaedicandNeurosurgerySpecialistsTheONSFoundationforClinicalResearchandEducationGreenwich,CTKarenSutton,MDYaleUniversitySchoolofMedicineNewHaven,CTAugustusMazzocca,MDUniversityofConnecticutHealthCenterFarmington,CT


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Biceps Tenodesis Made Easy How to Get it Right …...recurrent tears after surgery, SLAP lesions, biceps lesions - most of us believe this gives us more information, but the truth