Nerve Proximity During Bicortical Drilling for Subpectoral Biceps Tenodesis: A Cadaveric Study


      The long head of the biceps can develop tendonitis and tendinosis, which can lead to pain in the bicipital groove. The use of bicortical button fixation allows for a smaller defect in the humerus compared with tenodesis screws, reducing the risk of fracture. Our objective is to evaluate the exit location of our bicortical button and its relation to relevant posterior nervous structures.


      We performed anatomic dissection of 6 fresh-frozen cadaveric upper extremities. At the level of the inferior border of the pectoralis major tendon, the musculotendinous junction of the long head of the biceps was identified. At the base of the bicipital groove, a 3.2-mm guidewire was advanced perpendicularly through both the anterior and posterior cortex. Posteriorly, the radial and axillary nerves were carefully dissected. For each dissection, we recorded the closest distance from the posterior cortical hole created by our drill to both the axillary and radial nerves using digital calipers.


      The mean distance from the axillary nerve to the posterior drill hole was 25.1 mm (95% confidence interval, 21.6 to 28.6 mm). The mean distance from the radial nerve to the posterior drill hole was 30.3 mm (95% confidence interval, 27.2 to 33.4 mm).


      With placement of the tenodesis at the inferior aspect of the bicipital groove in conjunction with the musculotendinous junction, open subpectoral tenodesis of the long head of the biceps can be performed using bicortical button fixation without risk to the posterior nervous structures.

      Clinical Relevance

      This cadaveric study suggests that posterior proximal humerus nervous structures can be avoided with proper tenodesis placement.
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        • Walch G.
        • Edwards T.B.
        • Boulahia A.
        • Nove-Josserand L.
        • Neyton L.
        • Szabo I.
        Arthroscopic tenotomy of the long head of the biceps in the treatment of rotator cuff tears: Clinical and radiographic results of 307 cases.
        J Shoulder Elbow Surg. 2005; 14: 238-246
        • Boileau P.
        • Baque F.
        • Valerio L.
        • Ahrens P.
        • Chuinard C.
        • Trojani C.
        Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears.
        J Bone Joint Surg Am. 2007; 89: 747-757
        • Szabo I.
        • Boileau P.
        • Walch G.
        The proximal biceps as a pain generator and results of tenotomy.
        Sports Med Arthrosc. 2008; 16: 180-186
        • Bhatia D.N.
        • DasGupta B.
        Surgical correction of the “Popeye biceps” deformity: Dual-window approach for combined subpectoral and deltopectoral access and proximal biceps tenodesis.
        J Hand Surg Am. 2012; 37: 1917-1924
        • Mazzocca A.D.
        • Rios C.G.
        • Romeo A.A.
        • Arciero R.A.
        Subpectoral biceps tenodesis with interference screw fixation.
        Arthroscopy. 2005; 21: 896
        • Amaravathi R.S.
        • Pankappilly B.
        • Kany J.
        Arthroscopic keyhole proximal biceps tenodesis: A technical note.
        J Orthop Surg (Hong Kong). 2011; 19: 379-383
        • Ahmad C.S.
        • ElAttrache N.S.
        Arthroscopic biceps tenodesis.
        Orthop Clin North Am. 2003; 34: 499-506
        • Snir N.
        • Hamula M.
        • Wolfson T.
        • Laible C.
        • Sherman O.
        Long head of the biceps tenodesis with cortical button technique.
        Arthrosc Tech. 2013; 2: e95-e97
        • Sears B.W.
        • Spencer E.E.
        • Getz C.L.
        Humeral fracture following subpectoral biceps tenodesis in 2 active, healthy patients.
        J Shoulder Elbow Surg. 2011; 20: e7-e11
        • Arora A.S.
        • Singh A.
        • Koonce R.C.
        Biomechanical evaluation of a unicortical button versus interference screw for subpectoral biceps tenodesis.
        Arthroscopy. 2013; 29: 638-644
        • Burkhead Jr., W.Z.
        • Scheinberg R.R.
        • Box G.
        Surgical anatomy of the axillary nerve.
        J Shoulder Elbow Surg. 1992; 1: 31-36
        • Bertelli J.A.
        • Kechele P.R.
        • Santos M.A.
        • Duarte H.
        • Ghizoni M.F.
        Axillary nerve repair by triceps motor branch transfer through an axillary access: Anatomical basis and clinical results.
        J Neurosurg. 2007; 107: 370-377
        • Guse T.R.
        • Ostrum R.F.
        The surgical anatomy of the radial nerve around the humerus.
        Clin Orthop Relat Res. 1995; : 149-153
        • Nho S.J.
        • Reiff S.N.
        • Verma N.N.
        • Slabaugh M.A.
        • Mazzocca A.D.
        • Romeo A.A.
        Complications associated with subpectoral biceps tenodesis: Low rates of incidence following surgery.
        J Shoulder Elbow Surg. 2010; 19: 764-768
        • Ma H.
        • Van Heest A.
        • Glisson C.
        • Patel S.
        Musculocutaneous nerve entrapment: An unusual complication after biceps tenodesis.
        Am J Sports Med. 2009; 37: 2467-2469
        • Dickens J.F.
        • Kilcoyne K.G.
        • Tintle S.M.
        • Giuliani J.
        • Schaefer R.A.
        • Rue J.P.
        Subpectoral biceps tenodesis: An anatomic study and evaluation of at-risk structures.
        Am J Sports Med. 2012; 40: 2337-2341
        • Jarrett C.D.
        • McClelland Jr., W.B.
        • Xerogeanes J.W.
        Minimally invasive proximal biceps tenodesis: An anatomical study for optimal placement and safe surgical technique.
        J Shoulder Elbow Surg. 2011; 20: 477-480
        • Denard P.J.
        • Dai X.
        • Hanypsiak B.T.
        • Burkhart S.S.
        Anatomy of the biceps tendon: Implications for restoring physiological length-tension relation during biceps tenodesis with interference screw fixation.
        Arthroscopy. 2012; 28: 1352-1358
        • Lafrance R.
        • Madsen W.
        • Yaseen Z.
        • Giordano B.
        • Maloney M.
        • Voloshin I.
        Relevant anatomic landmarks and measurements for biceps tenodesis.
        Am J Sports Med. 2013; 41: 1395-1399
        • Sanders B.
        • Lavery K.P.
        • Pennington S.
        • Warner J.J.
        Clinical success of biceps tenodesis with and without release of the transverse humeral ligament.
        J Shoulder Elbow Surg. 2012; 21: 66-71
        • Lutton D.M.
        • Gruson K.I.
        • Harrison A.K.
        • Gladstone J.N.
        • Flatow E.L.
        Where to tenodese the biceps: Proximal or distal?.
        Clin Orthop Relat Res. 2011; 469: 1050-1055