Galatz v. Crosby: Biceps Long Tendon: Pain Generator Requiring Tenodesis in TSA
OTW Staff • Thu, February 16th, 2017
This week’s Orthopaedic Crossfire® debate was part of the 17th Annual Current Concepts in Joint Replacement® (CCJR), Spring meeting, which took place in Las Vegas this past May. This week’s topic is “Biceps Long Tendon: Pain Generator Requiring Tenodesis in TSA.” For the proposition is Leesa M. Galatz, M.D., Icahn School of Medicine at Mount Sinai, New York, New York. Opposing is Lynn A. Crosby, M.D., Medical College of Georgia, Augusta, Georgia. Moderating is Thomas S. Thornhill, M.D., Harvard Medical School, Boston, Massachusetts.
Dr. Galatz: The biceps tendon is a pain generator in osteoarthritis, and not only that but the approach and the exposure releases all of the supporting structures of the biceps. It’s nearly impossible to create an anatomic location in an anatomic bed and have it glide after an appropriately performed total shoulder arthroplasty. We think that it is important to either do a tenotomy or a tenodesis. In addition, there is some body of literature which highlights the pathology in the tendinopathic changes that occur with osteoarthritis.
Access to the shoulder requires some type of subscapularis takedown. You can either do a lesser tuberosity osteotomy, which is my preferred approach, or you just can do a peel-off or a tenotomy. But in some way, shape or form most shoulder replacements today require a subscapularis takedown. The biceps is supported by the subscapularis, the cortical humeral ligament and the transverse humeral ligament. And those structures are released as part of the approach to the shoulder joint.
With this approach you find your anatomic landmarks and one of those is the biceps, and that defines your approach to the humeral head. You can see the biceps as it traverses posteriorly—we usually unroof that and you can see the biceps. And I can tell you that 9 times out of 10 and potentially even greater, there’s tearing, fibrillation and changes in that biceps tendon.
A total shoulder also requires release of the rotator interval, and this is to allow the subscapularis and/or lesser tuberosity osteotomy to move medial so that we can release the inferior capsule and gain good exposure. There again are a couple of different ways to approach this. You can do a subscapularis tenotomy. This is familiar, less instrumentation. You can argue about tendon healing. Some people prefer to do an osteotomy. There are some studies comparing the two and there isn’t much difference. At this point it really is surgeon preference.
We could consider Z-plasty lengthening, medial reattachment, but regardless, my important point is something has to be done to the subscapularis and the rotator interval and that disrupts your support structure for the biceps.
Again, we release the inferior capsule and part of releasing the biceps facilitates our exposure so that we can bring the nerve into view and externally rotate. Those are important points.
Moving on to some of the tendinopathy changes, a study compared MRI and ultrasound evaluation before total shoulder for 45 patients. What they found is there were 14 ruptures of the biceps, one dislocation, and 25 of them had tendonitis. So again, when you have these pathologic changes occurring in the joint, it affects the biceps tendon as well. Another study looked at sympathetic innervation in alpha 1 adrenergic receptors associated with pain. The authors found that there’s disruption of the extracellular matrix; there’s an increase in matrix metalo proteinases and matrix turnover. This is not a normal tendon and these processes are associated with tendonitis and this is a possible pain generator.
Again, your approach requires disruption of some supporting structures. Exposure is necessary and releasing of the biceps helps this. Science tells us this is not a normal tendon and there’s no evidence that doing a total shoulder arthroplasty reverses the course of the tendinopathic changes that occur.
So, tenodese the tendon and be done with it.
Dr. Crosby: I agree with everything Dr. Galatz just said about tenodesing the biceps in the total shoulder arthroplasty. I tenodese it in every case. I ask myself, ‘Why do I do that?’ Well, what do we know for sure? We know that Walch and colleagues reported on 268 total shoulder arthroplasties for osteoarthritis in the Journal Shoulder and Elbow Surgery in 2002. Patients that had biceps tenodesis had better pain relief. The Dines boys reported on 8 shoulders that Leesa just mentioned that had anterior shoulder pain after total shoulder. All patients improved after having a biceps tenodesis.
What’s the function of the long-headed tendon to the biceps muscle? Kumar and associates in CORR back in 1989 showed us that sectioning the tendon under tension produced significant superior migration of the head of the humerus in a cadaver study. By removing this interior articular segment, the tendon in surgical procedures may produce instability and dysfunction. So, we’re going to hear that again…instability and dysfunction.
Pagnani and associates in the Journal of Shoulder and Elbow Surgery in 1996 also did a cadaver study, testing glenohumeral translation. A constant force applied to this long tendon in the shoulder were tested in an elevation and rotation, they found that this force on the long head reduced anterior translation 10.4mm and inferior and superior a little less.
So, a study in the Orthopedics Journal of Sports Medicine, in 2014, showed that EMG activity is produced by flexion and abduction suggesting a dynamic role. And the biceps tendon may result in dynamic changes that could affect, again, stability.
Anatomic total shoulder complications are about 10%. There are 24 different complications that have been described and these have been divided into intraoperative and postoperative. Instability accounts for 1.5-3% of the 10% incidence of complications. Most of these are failure of the subscapularis repair, as Leesa showed us very eloquently.
So, we look back at the literature again. Again, out of Rush, Stanford and Houston reviewed 15 studies with a greater than two-year follow-up on 1,338 patients, anterior head migration was present in almost 12%, revision rate was around 3% +/- 13%. So, the subscapularis, as Leesa mentioned, can be taken down either by tenotomy, subscapularis peel or osteotomy. Certainly with osteotomy, you’re going to have to do a biceps tenodesis.
Again, out of Rush, they looked at the biomechanical similarities among subscapularis repair techniques. They mechanically tested the 3 accepted subscapularis repairs and found there is no difference biomechanically between them. It was not stated in this report whether they took out the long head of the biceps, but there was no biceps long head tendon in any of their figures.
Could the long head of the biceps make a difference in stability and the strength of the repair of the subscapularis? How about the interval closure ? Why do we do it? We do it in posterior instability, at least it’s been thought that it helped with posterior instability by reducing the anterior volume of the shoulder joint. However, this may put more pressure on the anterior subscapularis repair area when you close this interval.
So how about the study out of the Mayo Clinic—Scott Steinmann looked at the healing rate after subscapularis tenotomy by using ultrasound. Fifteen patients were evaluated at 6 months after total shoulder arthroplasty. All had biceps tenodesis performed. Seven out of 15 had complete subscapularis tears. No change on radiograph. All were worse when he looked at them clinically.
What do we know for sure? We know there are no prospective, randomized clinical trials regarding the long head of the biceps after total shoulder arthroplasty to answer this debate question. Does removing the long head tendon cause instability? I don’t know…and we don’t know. There are a lot of subscapularis sparing total shoulder arthroplasties being done now so maybe they can answer this question. But currently it’s an unanswerable question.
Moderator Thornhill: Leesa, let me start. If you use tendinopathy in an osteoarthritic situation, whether it’s a hip or whether it’s a knee, or whatever it is, there are tendinopathic changes. You don’t expect it to be normal, do you?
Dr. Galatz: No, we don’t expect it to be normal. But I think it is accepted generally that the long head of the biceps is not necessary…its presence doesn’t improve afterwards, and we know that if it becomes scarred down in the interval or in the groove, it can restrict range of motion. So, in this case, you’re not removing something necessarily just because it is tendinopathic, but also because you don’t need it for stability after a total shoulder and the scarring process could inhibit range of motion. You’re not hurting anything by doing it and you’re taking away the possibility of it being a restriction of motion and a pain generator.
Moderator Thornhill: Okay, so Lynn, is the reason you take the biceps tendon to improve your exposure to allow you to do your subscapularis tenotomy, to close the interval, or is there some other reason because of the tendon alone?
Dr. Crosby: I’ve never done a total shoulder that I didn’t take the biceps. I don’t know what would happen if I didn’t, and if I did a tenotomy I think I’d have a better chance in a normal tendon…long head tendon…I think you could probably leave it. Doing a subscapularis peel or osteotomy, you almost have to take it. It’s in your way.
Moderator Thornhill: Leesa, same question. Do you take the biceps tendon to facilitate exposure? Your subscapularis tenotomy?
Dr. Galatz: Yes, I think it does help. I think it helps with your glenoid exposure. It releases a tether from hindering posterior exposure during glenoid; and anterior exposure and there is stretch on the tendon when you dislocate that anteriorly.
Moderator Thornhill: Help me out a little bit, this may be my problem. Most of the shoulders I’ve done over the years have been on rheumatoids. They’re sort of a different animal. I must admit that it may be a HIPAA violation, but I have a total shoulder and I had a tenotomy, but I wasn’t doing the surgery. In a rheumatoid, I think it’s easier to divide the subscapularis tendon than to take off the tubercle because of the fact it’s osteopenic, it’s osteoporotic, it doesn’t heal terribly well. And the tendon-to-tendon healing is better. And I’ve not ever had to revise a rheumatoid because of a late rupture of the subscapularis. Is part of my problem the fact that I do mostly rheumatoids?
Dr. Galatz: Those are not normal tendons and perhaps they don’t scar like somebody with osteoarthritis. I don’t know. I just think that when you think about it anatomically the course of the biceps and where it lays in the surgery that you’re doing, you’re leaving it susceptible to scarring. It’s not going to glide normally, especially if you do a tuberosity osteotomy, which is something that’s gaining favor.
Moderator Thornhill: If you do a total knee and you don’t resurface the patella and somebody complains of anterior knee pain, or somebody does a uni and they complain of some pain, you have another operation you can do. You can do a total or you can resurface the patella. If you leave the biceps tendon and they have some pain, is sometimes just taking the long head of the biceps the solution because it’s there? How do you know that’s the cause of the pain?
Dr. Crosby: Well, you don’t, but physical exam certainly can help you. Arthroscopy can also be a powerful tool. You can look inside the joint. You can make sure the glenoid is not loose. You can exam the biceps if it was left behind, like the Dineses (NOTE: Dines is the last name that needs to be plural to capture father and son) reported, and you can release it. You can do a tenotomy or you can release it and then do a tenodesis later if it is a problem. Those two articles I think are what forced most of us to go ahead and do a tenotomy or tenodesis at the time of total shoulder and those were both retrospective type reports.
Moderator Thornhill: Great discussion both of you.
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