Shoulder Surgery

Biceps Tenodesis

Biceps Tenodesis

Biceps tenodesis is a minimally invasive keyhole procedure to re-anchor the biceps tendon at the top of the arm bone (subpectoral tenodesis). Patients wear a sling for six weeks and start therapy two weeks after surgery. Strengthening and training for your sport commences at 3 months; full unrestricted contact sport is possible at 3-4 months after surgery.

The Biceps Tendon runs in a narrow groove in the front of your shoulder joint. Either due to acute trauma, repetitive overuse, or chronic degeneration over time, the biceps tendon may become inflamed (tendonitis) and cause pain during certain movements of the shoulder. If the biceps tendon is causing problems in your shoulder it can be either be:

  • Moved out of the shoulder joint (Tenotomy) or
  • Re-anchored to a new place in the arm-pit (Tenodesis)

Dr Pant performs a Biceps Tenodesis using the sub-pectoral (under the armpit) position to anchor the tendon. He deploys the button intra-cortical (inside the canal of the arm bone) – this minimises “groove” pain that other techniques may not address.

 

Medical diagram showing the anatomy of the shoulder involved in a Biceps Tenodesis

The key point is to remember which conditions in your shoulder are “time urgent” and which are not. Dr Pant will clearly outline this for you during your consultation.

Time urgent conditions:

Biceps tendon dislocation (out of the groove). When the biceps tendon is “subluxed” or “dislocated” out of the groove it can cut into the subscapularis tendon and cause further damage, you should consider surgery sooner rather than later.

Other considerations

Shoulder Function

  • If you are unable to undertake basic tasks or to look after yourself, unable to drive, unable to get dressed, or have difficulty with hygiene and toileting.

Shoulder Pain

  • Pain with activity and even at rest
  • Night pain, especially if it wakes you from sleep
  • Unable to sleep on your affected shoulder
  • Increasing requirements of pain relief tablets
  • Multiple failed cortisone injections
  • Not responding to physiotherapy

Work

  • If it is limiting your ability to work
  • Especially if you are in a manual job requiring repeated overhead activity

Sport

  • If you are unable (even after a period of rest and activity modification)  to participate in your chosen leisure activity or sport and you wish to continue to do so

Prevent further shoulder damage

  • There are certain conditions where it may be better to repair your shoulder before further damage occurs
  • Dr Pant will carefully analyse your MRI scan and determine if this is the case for you (especially in younger patients)
  • The procedure is under a General Anaesthetic where you will be positioned on your side and the affected arm secured in a special arm holder.
  • Small key-hole incisions (about 1cm) are made and the camera and surgical instruments are placed inside the shoulder. Usually, 3-4 small  incisions are enough (depending on what else needs to be repaired)
  • A thorough 15-point examination of the shoulder joint and torn Labrum is made via the arthroscopic camera and pictures are taken to document findings.
  • The biceps tendon is released from inside the shoulder joint. A 2cm incision is then made near the armpit and the biceps tendon is carefully identified, prepared and re-anchored to the bone using a metallic button.
  • Any other unexpected injuries/tears are noted and repaired via key-hole at the same time if needed.
  • The key-hole incisions and biceps incision are closed with sutures, dressings applied and a custom sling used to position the arm correctly.
  • Dr Pant will then organise close follow up at regular intervals and liaise with your Team Doctor/Physiotherapist to maximise your recovery

Medical diagram showing where the Biceps tendon is release and re-anchored during a Biceps Tenodesis

There are three essential components to a good outcome from surgery:

  • Your surgeon
  • You as a patient
  • Your physiotherapist

Post-operative physiotherapy

Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.

The JPL pathway allows for self-directed, early passive shoulder range of movement:

  • Passive = assisted with your other arm
  • Active = you move the affected arm independently

Therapy overview 

After the surgery you will be in a sling and protect your shoulder to allow the shoulder to heal. At two weeks after the surgery Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.

The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the shoulder begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder strengthening is commenced at 12 weeks post Biceps Tenodesis surgery.

Sling

  • A sling is required for the first 2-6 weeks after your surgery
  • In some instances you may only need a sling for 1-2 weeks – Dr Pant will discuss these cases with you.

The type of sling is selected specific to you and your shoulder surgery

  • Subacromial Decompression +/- Biceps tenotomy/tenodesis – Normal sling

Driving after shoulder surgery

  • After shoulder surgery, you will be in a sling and you may be unable to drive
  • This does vary depending on the complexity of your surgery and the patient. Some patients may be able to drive at 2 weeks, and some may not be able to drive for the full 6-12 weeks. This will be discussed at your follow up appointments.

Showering and getting dressed

  • You may take the sling off to shower
  • Lean forward and allow your arm to “dangle” to wash under your arms
  • The dressings applied are waterproof and you may shower with them on
  • Usually before you are discharged from Hospital, your dressings are changed after your morning shower.
  • These “new” dressings are then kept intact until your review at 10-14 days
  • If the dressings start to peel at the edges – you may reinforce them
  • If the dressings discolour with discharge (yellow or green) you may have a wound infection; do not be alarmed just yet – please notify SSU (02 9215 6100 or admin@drpant.com.au) and we will give you a plan.
  • When getting dressed, you may use your good arm to move your affected (operated arm) to place your arms through the sleeves carefully

Sleeping after Shoulder Surgery

  • Most patients find it difficult to lie flat after shoulder surgery (especially after rotator cuff repair)
  • Consider using a few pillows to prop yourself up and sleep at a slight incline; this may be necessary for 4-6 weeks after surgery. You should keep your sling on while asleep.

Elbow and hand movement

  • Keep your elbow and hands joints moving and supple for the duration of time you are in the sling
  • The best time to move your elbow (into full extension and flexion) is when you are in the shower, just out of the shower and about to get dressed.

Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications.

The risk of complications after biceps tenodesis surgery is less than 1% in the Sydney Shoulder Unit experience. General risks include:

  • Infection
  • Bleeding
  • Wound healing problems
  • Damage to blood vessels or nerves
  • Sensory changes around the surgical scar

Specific risks relating to biceps tenodesis surgery:

  • Frozen shoulder (5% risk). Improves over 3-6 months and will generally not affect your outcome or need further surgery.
  • Reoperation and failure of surgery. When performing a shoulder reconstruction, your surgeon is using your own tissue to repair what is damaged. The weakest point in the repair is your own tissue. The longer the history of damage and frequency of dislocations/instability prior to surgery, the more likely the tissue quality is poor.

There are three areas where your biceps tenodesis surgery may fail:

  • Bone-Anchor interface. The anchors today are very high in quality and usually do not fail; sometimes if your bone is soft (older patients), the anchor may pull out of the bone.
  • Anchor-Suture interface. This area is typically very strong and not a source of common failure
  • Suture-Tissue interface. This is the weakest point and the most common reason for the failure of surgery (usually due to poor tissue quality)

There are special techniques in tissue management and suture choice to reduce failure rates.

Failure of Biceps Tenodesis (Re-anchoring of the tendon) is reported at between 2-6% (but in the SSU experience it is < 1%)

Patients who smoke, use tobacco products, have diabetes, or are elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound and bone healing.

Most healthy patients, however, cope well with keyhole shoulder surgery and are unlikely to have complications.

With careful patient selection and good surgical technique, the outcome after biceps tenodesis surgery is excellent, with >95% satisfaction in most published studies. An experienced shoulder surgeon will be able to diagnose your biceps tendonitis and also treat any other causes of shoulder pain, such as shoulder impingement or a subscapularis tendon tear. As with any other operation on the shoulder, it is important to be thorough in the assessment and precise during surgery to deliver the best outcomes.

Patient results

Rotator Cuff Tear

This 53 year old lady presented with right-sided shoulder pain after injuring her shoulder at work. She underwent a period of rest, cortisone injection and 3 months of physiotherapy without improvement.

After a careful history and examination, an MRI scan was undertaken. The MRI showed a Rotator Cuff Tear with Biceps Tendonitis.

The images taken at surgery (key-hole) demonstrate significant biceps tendonitis with inflammation and thickening of the tendon. The biceps tendon was taken out of the shoulder joint and re-anchored under the arm-pit (biceps tenodesis). The bursitis and bone spur was cleaned out and the rotator cuff tear was repaired with 4 anchors with good compression of the tendon foot-print.

She was discharged home the following day after surgery and placed in a sling for six weeks. She underwent JPL rehab which commenced at two weeks post-surgery. Strengthening commenced at months under the guidance of her physiotherapist.

She no longer has her previous shoulder pain and has good power of her rotator cuff.

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