From June 2014 to January 2018, a total of 42 patients with an isolated LHBT lesion were treated with our modified double-row technique for arthroscopic biceps tenodesis, and operations were performed by the same group of surgeons. This study was approved by the Ethics Committee at our hospital.
The inclusion criteria were: ineffectiveness of conservative treatment for >3 months; age ≤70 years; high demands for function and appearance; and confirmed presence of isolated LHBT damage (partial-thickness tear or fray of LHBT tendon of >25% to 50%; LHBT subluxation or dislocation; refractory inflammation of the tendon) during the surgery.
The exclusion criteria were: age >70 years; obsolete rupture and retraction of the LHBT; and combination with other shoulder disorders (such as neuropathy, rotator cuff diseases, Bankart lesion, shoulder fractures, etc.).
Under general anesthesia, the patient was placed in the side-lying position with the affected upper extremity abducted by 20º to 30º and flexed at 20º; longitudinal traction was provided with a weight of 5 to 10 lb (Star SleeveTraction System; Arthrex, Naples, FL).
Standard posterior and anterior portals were established for intra-articular examination. After a thorough examination of the glenohumeral joint, the distal part of the tendon was drawn into the joint with a retriever to evaluate any pathologies of the portion within the intertubercular sulcus.
A spinal needle was utilized to pierce the LHBT into the joint cavity, and a radiofrequency device (Smith & Nephew, Andover, MA, USA) was used to sever the tendon at its junction with the glenoid insertion and debride the stump. The spinal needle was used to keep the LHBT in position and later to help find the location of the bicipital groove in the subacromial space.
Initially, the arthroscope was inserted into the subacromial space through the posterior portal. The routine lateral and anterolateral portals were established. The subacromial bursa was debrided, and acromioplasty was performed if necessary. Then the arthroscope was inserted into the lateral portal. Through the anterolateral portal, the spinal needle which was located at the bicipital groove was found, and the biceps sheath was opened. The LHBT was totally released to the level of the musculotendinous junction with the radiofrequency device. After that, the tendon was pulled out of the bicipital groove, and the inflamed tissue and synovium around the tendon and at the groove was debrided with the radiofrequency device. On the proximal part of the bicipital groove, a fresh bleeding bone bed was created. A double-loaded suture anchor (5.5-mm AR-1927BCF-45, corkscrew; Arthrex, Naples, FL) was placed into the groove at about 1 cm distal to its starting point (i.e., close to its entrance) via the anterolateral portal (Fig. 1A), and one suture was pulled out for cerclage of the distal row. A BirdBeak device (Arthrex, Naples, FL) was applied to penetrate the LHBT. One strand of the remaining suture was pulled through the tendon to make a suture loop (Fig. 1B,C), and the other strand of the remaining suture was pulled through the loop (Fig. 1D). The two strands of the suture were pulled to the anterior portal and untied temporarily.
Next, about 1 cm distal to the proximal loop made by the suture anchor, the middle part of the suture previously pulled out was grabbed to pass under the biceps tendon to form a loop (Fig. 2A). Both strands of the suture were pulled through the loop to tie the tendon (Fig. 2B). A PushLock (Arthrex, Naples, FL) was fixed into the groove about 1 cm distal to the first anchor with both strands of the suture threaded through the PushLock and tightened. The suture tails were trimmed short(Fig. 2C).
Then, both strands of the suture of proximal anchor were pulled to the anterolateral portal and tied using standard suture techniques. The tendon stump proximal to the suture anchor was debrided with the radiofrequency device. Finally, the elbow was flexed and extended to check the stability of the construct. The biceps tenodesis was now completed in the groove by the modified double-row technique (Fig. 2D).
After operation, no shoulder sling was applied. Passive and active range-of-motion exercises were allowed immediately after the surgery, but active biceps flexion was prohibited for 2 weeks. Unrestricted active elbow activity and resistance exercises begun from the fifth week. Full recovery to sport activity was not granted until 3 months after the operation.
Follow-up and Outcome Evaluation
Preoperatively, all the patients were evaluated using the Constant-Murley shoulder (CS) score, the University of California Los Angeles (UCLA) score, and the visual analogue scale (VAS). All patients were followed up at 2 weeks, 6 weeks, 3 months, 6 months, and 12 months after surgery, and the final postoperative follow-up review, and the final follow-up results were recorded. Postoperative complications were recorded.
Statistical analysis was performed using SPSS 22.0 software. Data are expressed as average ± standard deviation (SD), and the Wilcoxon rank sum test was used to perform statistical analysis. P<0.05 was considered as statistically significant.