Original Article| Volume 36, ISSUE 12, P2975-2981, December 2020

Conversion of Failed Proximal Long Head of the Biceps Tenodesis to Distal Subpectoral Tenodesis: Outcomes in an Active Population


      To assess failure rates and patient reported outcomes following revision of failed proximal long head of the biceps (LHB) tenodesis.


      Patients from an active-military population who underwent revision proximal (suprapectoral) to distal (subpectoral) LHB tenodesis were prospectively enrolled. Patients were included if they were between the ages of 16 and 60 years presenting after a previous biceps tenodesis with mechanical failure and clinical failure, defined as Single Assessment Numeric Evaluation (SANE) or American Shoulder and Elbow Surgeons (ASES) <70. Exclusion criteria were concomitant rotator cuff repair or debridement, full-thickness rotator cuff tear, extensive labral tears, or any evidence of glenohumeral arthritis. Pre- and postoperative SANE and ASES were documented and analyzed.


      From 2004 to 2010, a total of 12 patients (all male) with a mean age of 39.9 years (range, 30-54 years) were assessed at a mean follow-up time of 29 months (range, 24-38 months). Nine patients presented with a failed tenodesis construct located at the top of the bicipital groove and 9 patients had LHB tendons originally affixed with an interference screw. Diagnostic arthroscopy revealed that the majority of patients (10/12) had excessive scarring at the site of previous fixation. Mean preoperative assessments of SANE (70.4) and ASES (59.9) improved postoperatively to SANE (90.3; P < .01) and ASES (89.8; P < .01). No patients were lost due to follow-up, and there were no reported complications or failures. All patients returned to full active duty and were able to perform all required physical tests before returning to their vocation.


      Patients presenting with symptoms following a proximal LHB tenodesis can be successfully converted to a distal (subpectoral) LHB tenodesis with favorable outcomes. Although in a small sample, there was excessive scarring and synovitis in a majority, which improved significantly when treated with a revision subpectoral tenodesis with minimal complication risk and no reported failures.

      Level of Evidence

      IV (Therapeutic case series)
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        • Walch G.
        • Nove-Josserand L.
        • Boileau P.
        • Levigne C.
        Subluxations and dislocations of the tendon of the long head of the biceps.
        J Shoulder Elbow Surg. 1998; 7: 100-108
        • Nho S.J.
        • Reiff S.N.
        • Verma N.N.
        • Slabaugh M.A.
        • Mazzocca A.D.
        • et al.
        Complications associated with subpectoral biceps tenodesis: Low rates of incidence following surgery.
        J Shoulder Elbow Surg. 2010; 19: 764-768
        • Millett P.J.
        • Sanders B.
        • Gobezie R.
        • Braun S.
        • Warner J.J.
        Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: Does it matter?.
        BMC Musculoskelet Disord. 2008; 9: 121
        • Brady P.C.
        • Narbona P.
        • Adams C.R.
        • Huberty D.
        • Parten P.
        • et al.
        Arthroscopic proximal biceps tenodesis at the articular margin: Evaluation of outcomes, complications, and revision rate.
        Arthroscopy. 2015; 31: 470-476
        • Forsythe B.
        • Agarwalla A.
        • Puzzitiello R.N.
        • Mascarenhas R.
        • Werner B.C.
        Rates and risk factors for revision open and arthroscopic proximal biceps tenodesis.
        Orthop J Sports Med. 2019; 7 (2325967118825473)
        • Griffin J.W.
        • Cvetanovich G.L.
        • Kim J.
        • Leroux T.S.
        • Riboh J.
        • et al.
        Biceps tenodesis is a viable option for management of proximal biceps injuries in patients less than 25 years of age.
        Arthroscopy. 2019; 35: 1036-1041
        • Euler S.A.
        • Horan M.P.
        • Ellman M.B.
        • Greenspoon J.A.
        • Millett P.J.
        Chronic rupture of the long head of the biceps tendon: Comparison of 2-year results following primary versus revision open subpectoral biceps tenodesis.
        Arch Orthop Trauma Surg. 2016; 136: 657-663
        • Gregory J.M.
        • Harwood D.P.
        • Gochanour E.
        • Sherman S.L.
        • Romeo A.A.
        Clinical outcomes of revision biceps tenodesis.
        Int J Shoulder Surg. 2012; 6: 45-50
        • Anthony S.G.
        • McCormick F.
        • Gross D.J.
        • Golijanin P.
        • Provencher M.T.
        Biceps tenodesis for long head of the biceps after auto-rupture or failed surgical tenotomy: Results in an active population.
        J Shoulder Elbow Surg. 2015; 24: e36-e40
        • Kennedy N.I.
        • Godin J.A.
        • Ferrari M.B.
        • Sanchez G.
        • Cinque M.E.
        • et al.
        Subpectoral biceps tenodesis: interference screw and cortical button fixation.
        Arthrosc Tech. 2017; 6: e1415-e1420
        • Provencher M.T.
        • McCormick F.
        • Peebles L.A.
        • Beaulieu-Jones B.R.
        • Dekker T.J.
        • et al.
        Outcomes of primary biceps subpectoral tenodesis in an active population: A prospective evaluation of 101 patients.
        Arthroscopy. 2019; 35: 3205-3210
        • Harris J.D.
        • Brand J.C.
        • Cote M.P.
        • Faucett S.C.
        • Dhawan A.
        Research pearls: The significance of statistics and perils of pooling. Part 1: Clinical versus statistical significance.
        Arthroscopy. 2017; 33: 1102-1112
        • Nolte P.C.
        • Pister N.
        • Holz F.
        • Egenolf M.
        • Chatterjee T.
        [Subpectoral tenodesis of the long head of the biceps tendon with an interference screw and a cortical button: Clinical and cosmetic results after 1 year].
        Orthopade. 2017; 46: 864-871
        • Overmann A.L.
        • Colantonio D.F.
        • Wheatley B.M.
        • Volk W.R.
        • Kilcoyne K.G.
        • et al.
        Incidence and characteristics of humeral shaft fractures after subpectoral biceps tenodesis.
        Orthop J Sports Med. 2019; 7 (2325967119833420)
        • 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
        • Sethi P.M.
        • Vadasdi K.
        • Greene R.T.
        • Vitale M.A.
        • Duong M.
        • et al.
        Safety of open suprapectoral and subpectoral biceps tenodesis: An anatomic assessment of risk for neurologic injury.
        J Shoulder Elbow Surg. 2015; 24: 138-142
        • 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
        • Murthi A.M.
        • Vosburgh C.L.
        • Neviaser T.J.
        The incidence of pathologic changes of the long head of the biceps tendon.
        J Shoulder Elbow Surg. 2000; 9: 382-385
        • Wittstein J.R.
        • Queen R.
        • Abbey A.
        • Toth A.
        • Moorman 3rd, C.T.
        Isokinetic strength, endurance, and subjective outcomes after biceps tenotomy versus tenodesis: A postoperative study.
        Am J Sports Med. 2011; 39: 857-865
        • Virk M.S.
        • Nicholson G.P.
        Complications of proximal biceps tenotomy and tenodesis.
        Clin Sports Med. 2016; 35: 181-188
        • Kelly A.M.
        • Drakos M.C.
        • Fealy S.
        • Taylor S.A.
        • O'Brien S.J.
        Arthroscopic release of the long head of the biceps tendon: Functional outcome and clinical results.
        Am J Sports Med. 2005; 33: 208-213
        • Cook J.B.
        • Sedory D.M.
        • Freidl M.C.
        • Adams D.R.
        Low incidence of failure after proximal biceps tenodesis with unicortical suture button.
        J Orthop. 2017; 14: 384-389
        • Taylor S.A.
        • Fabricant P.D.
        • Baret N.J.
        • Newman A.M.
        • Sliva N.
        • et al.
        Midterm clinical outcomes for arthroscopic subdeltoid transfer of the long head of the biceps tendon to the conjoint tendon.
        Arthroscopy. 2014; 30: 1574-1581
        • Frost A.
        • Zafar M.S.
        • Maffulli N.
        Tenotomy versus tenodesis in the management of pathologic lesions of the tendon of the long head of the biceps brachii.
        Am J Sports Med. 2009; 37: 828-833
        • Gurnani N.
        • van Deurzen D.F.
        • Janmaat V.T.
        • van den Bekerom M.P.
        Tenotomy or tenodesis for pathology of the long head of the biceps brachii: A systematic review and meta-analysis.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3765-3771
        • Ge H.
        • Zhang Q.
        • Sun Y.
        • Li J.
        • Sun L.
        • et al.
        Tenotomy or tenodesis for the long head of biceps lesions in shoulders: A systematic review and meta-analysis.
        PLoS One. 2015; 10e0121286
        • Hsu A.R.
        • Ghodadra N.S.
        • Provencher M.T.
        • Lewis P.B.
        • Bach B.R.
        Biceps tenotomy versus tenodesis: A review of clinical outcomes and biomechanical results.
        J Shoulder Elbow Surg. 2011; 20: 326-332
        • Tahal D.S.
        • Katthagen J.C.
        • Vap A.R.
        • Horan M.P.
        • Millett P.J.
        Subpectoral biceps tenodesis for tenosynovitis of the long head of the biceps in active patients younger than 45 years old.
        Arthroscopy. 2017; 33: 1124-1130
        • Dines D.
        • Warren R.F.
        • Inglis A.E.
        Surgical treatment of lesions of the long head of the biceps.
        Clin Orthop Relat Res. 1982; : 165-171
        • Friedman D.J.
        • Dunn J.C.
        • Higgins L.D.
        • Warner J.J.
        Proximal biceps tendon: Injuries and management.
        Sports Med Arthrosc Rev. 2008; 16: 162-169
        • Lafosse L.
        • Reiland Y.
        • Baier G.P.
        • Toussaint B.
        • Jost B.
        Anterior and posterior instability of the long head of the biceps tendon in rotator cuff tears: A new classification based on arthroscopic observations.
        Arthroscopy. 2007; 23: 73-80
        • Varacallo M.
        • Mair S.D.
        Biceps tendon dislocation and instability. StatPearls..
        StatPearls Publishing, Treasure Island (FL)2020
        • Dines D.M.
        • Warren R.F.
        • Inglis A.E.
        • Pavlov H.
        The coracoid impingement syndrome.
        J Bone Joint Surg Br. 1990; 72: 314-316
        • Gerber C.
        • Terrier F.
        • Ganz R.
        The role of the coracoid process in the chronic impingement syndrome.
        J Bone Joint Surg Br. 1985; 67: 703-708

      Linked Article

      • Editorial Commentary: Biceps Tenodesis Location May Not Matter: Go High…Go Low…Go Wherever You Want to Go!
        ArthroscopyVol. 36Issue 12
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          Tenodesis of the long head of the biceps tendon has long been a source of dialogue, discussion, debate, and dogma. In general, the shoulder literature has been exhaustive regarding various biceps tenodesis techniques and outcomes, and studies have shown positive clinical outcomes of tenodesis, regardless of location, along the proximal humerus. Fewer studies have evaluated the outcomes of revision tenodesis; however, those that have looked at this have generally found that a revision to a subpectoral tenodesis site is usually quite successful.
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