Nerve Injury with Long Head of the Biceps Tenodesis

Abstract

Objectives:Surgical treatment of long head of the biceps tendon (LHBT) lesions is controversial. Nerve injury is a potentially devastating complication following tenodesis of the LHBT, particularly with regard to tenodesis distal to the biceps groove. The axillary, musculocutaneous, ulnar, radial, and median nerves are all within close proximity of the tenodesis site and are susceptible to injury via retraction of the soft tissues or drilling. The purpose of this study is to characterize the rate of nerve injury during tenodesis of the LHBT, specifically with regard to subpectoral tenodesis.Methods:Following IRB approval, the records of patients who underwent a LHBT tenotomy +/- tenodesis at an integrated health care system by 84 surgeons, from 2006 to 2014, were retrospectively analyzed. Inclusion criteria were patients who underwent a shoulder arthroscopy where the LHBT underwent tenodesis. Exclusion criteria included revision tenodesis, arthroplasty, neoplastic, or fracture surgery, age below 18, or indata. Fixation methods, location of tenodesis were recorded. Descriptive statistics were employed, and odds ratios with 95% confidence intervals were calculated to evaluate the association between variables, with significance evaluated with chi-square for categorical variables.Results:A total of 1524 patients were included in this study. The average patient age was 53.7 ± 10.2 years, which was not significantly different between patients who did and did not experience a nerve complication (p=0.97). There were 1076 males and 445 females included. Subpectoral techniques were performed on 997 cases, while the tendon was tenodesed in the groove on 527 cases. Of the subpectoral LHBT tenodesis, 103 were drilled bicorically, while 682 were drilled unicortically. A total of 16 nerve injuries were encountered, and all nerve injuries were neuropraxias and recovered at terminal follow up. The musculocutaneous nerve was most often injured during subpectoral tenodesis (0.6% of cases), followed by the axillary nerve (0.3% of cases), and finally the radial, median, and ulnar nerves (0.2% of cases each). Significantly more nerve injuries were encountered for subpectoral techniques (15 of 982 cases, 1.53%) than suprapectoral techniques (1 of 526 cases, 0.19%) (OR 8.03, 95% CI 1.06-61, p=0.02). There was no difference between drilling unicortically versus bicortically with regard to nerve injury (OR 1.43, 95% CI 0.40-5.07, p=0.57). There was no difference in nerve injury between males and females (p=0.85).Conclusion:Both suprapectoral and subpectoral LHBT are safe procedures, although nerve injury is a rarely encountered. Nerve injury occurred at a significantly higher rate for subpectoral LHBT tenodesis and tenodesis within the bicipital groove, although all nerve function did recover. However, neither number of cortices drilled nor patient gender influenced nerve injury frequencies. This data suggests that care should be taken while drilling and placing and holding retractors, especially during subpectoral tenodesis.