Research Article| Volume 50, ISSUE 3, P681-685, March 2019

Prospective outcome analysis following tenodesis of the long head of the biceps tendon along with locking plate osteosynthesis for proximal humerus fractures

Published:February 09, 2019DOI:


      • We evaluated the outcome after ORIF and biceps tenodesis for treating proximal humerus fractures.
      • 56 patients were enrolled(Tenodesis group: 26 patients; Control group: 30 patients).
      • Tenodesis revealed superior MSQ-, SPADI- and DASH-score. Especially throwing motion was significantly enhanced.
      • There was no significant difference regarding anatomic deformity including the Popeye sign.
      • We regard tenodesis as a promising adjunct to ORIF of proximal humerus fractures.



      Fractures of the proximal humerus are often associated with lesions of the long head of the biceps (LHB) tendon. This often leads to prolonged shoulder pain. Hence, many surgeons decide to perform a tenodesis of the LHB tendon simultaneous to ORIF. The purpose of this study was to evaluate the postoperative outcome after interlocking plate fixation and biceps tenodesis for treating proximal humerus fractures.


      56 patients (38 females, 18 male) suffering from proximal humerus fractures who underwent surgery were retrospectively included. 26 of these 56 patients (19% Neer II, 38% Neer III, 43% Neer IV) were treated with simultaneous tenodesis of the LHB tendon when ORIF using interlocking plate fixation was performed. 30 patients (17% Neer II, 40% Neer III, 43% Neer IV) served as control group receiving only interlocking plate fixation. The patients were asked to complete the Munich Shoulder Questionnaire (MSQ) for evaluation of postoperative shoulder function. Results of the Disabilities of the Arm, Shoulder and Hand (DASH) Score and Shoulder Pain and Disability Index (SPADI) were calculated from the MSQ. Patients were clinically evaluated for a positive O’Brien test and Popeye sign.


      The tenodesis group demonstrated significant superior outcome regarding the MSQ (mean 90.47 points vs. 79.41 points, p = 0.006), DASH Score (mean 4.2 points vs. 16.81 points, p = 0.017) and SPADI (mean 94.59 points vs. 83.56, p = 0.045). Flexion, external rotation and the capability of throwing a soft ball were significantly improved in the tenodesis group compared to the control group. The O’Brien test as indicator for lesions of the LHB was positive in fewer patients of the tenodesis group (2/26, vs. 21/30, p = 0.001). There was no significant difference of a positive Popeye Sign.


      Our results show evidence of an improved shoulder function when a simultaneous tenodesis of the LHB tendon is performed during treatment of proximal humerus fractures using interlocking plate fixation.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Neer 2nd, C.S.
        Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report.
        J Bone Joint Surg Am. 1972; 54 (volume): 41-50
        • Tosounidis T.
        • Hadjileontis C.
        • Georgiadis M.
        • Kafanas A.
        • Kontakis G.
        The tendon of the long head of the biceps in complex proximal humerus fractures: a histological perspective.
        Injury. 2010; 41: 273-278
        • Schai P.A.
        • Hintermann B.
        • Koris M.J.
        Preoperative arthroscopic assessment of fractures about the shoulder.
        Arthroscopy. 1999; 15: 827-835
        • Kim J.M.
        • Jupiter J.B.
        Traumatic laceration of the long head of the biceps brachii from a displaced surgical neck fracture of the humerus: case report.
        J Surg Orthop Adv. 2011; 20: 252-254
        • Cheng N.M.
        • Pan W.R.
        • Vally F.
        • Le Roux C.M.
        • Richardson M.D.
        The arterial supply of the long head of biceps tendon: anatomical study with implications for tendon rupture.
        Clin Anat. 2010; 23: 683-692
        • Sethi N.
        • Wright R.
        • Yamaguchi K.
        Disorders of the long head of the biceps tendon.
        J Shoulder Elbow Surg. 1999; 8: 644-654
        • Scheibel M.
        [Humeral head fracture and cuff].
        Der Unfallchirurg. 2011; 114: 81-82
        • Osbahr D.C.
        • Diamond A.B.
        • Speer K.P.
        The cosmetic appearance of the biceps muscle after long-head tenotomy versus tenodesis.
        Arthroscopy. 2002; 18: 483-487
        • Slenker N.R.
        • Lawson K.
        • Ciccotti M.G.
        • Dodson C.C.
        • Cohen S.B.
        Biceps tenotomy versus tenodesis: clinical outcomes.
        Arthroscopy. 2012; 28: 576-582
        • O’Brien S.J.
        • Pagnani M.J.
        • Fealy S.
        • McGlynn S.R.
        • Wilson J.B.
        The active compression test: a new and effective test for diagnosing labral tears and acromioclavicular joint abnormality.
        Am J Sports Med. 1998; 26: 610-613
        • Gill T.J.
        • McIrvin E.
        • Mair S.D.
        • Hawkins R.J.
        Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii.
        J Shoulder Elbow Surg. 2001; 10: 247-249
        • 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
        • Soliman O.A.
        • Koptan W.M.
        Proximal humeral fractures treated with hemiarthroplasty: does tenodesis of the long head of the biceps improve results?.
        Injury. 2013; 44: 461-464
        • Kerschbaum M.
        • Werth M.
        • Gerhardt C.
        • Scheibel M.
        [Simultaneous surgical treatment of the long head of the biceps tendon during operative treatment of proximal humeral fractures].
        Unfallchirurg. 2017; 120: 865-872
        • Neer C.S.
        2nd. Displaced proximal humeral fractures: part I. Classification and evaluation.
        Clin Orthop Relat Res. 1970; 2006: 77-82
        • Owen J.M.
        • Boulter T.
        • Walton M.
        • Funk L.
        • Mackenzie T.A.
        Reinterpretation of O’Brien test in posterior labral tears of the shoulder.
        Int J Shoulder Surg. 2015; 9: 6-8
        • Schmidutz F.
        • Beirer M.
        • Braunstein V.
        • Bogner V.
        • Wiedemann E.
        • Biberthaler P.
        The Munich Shoulder Questionnaire (MSQ): development and validation of an effective patient-reported tool for outcome measurement and patient safety in shoulder surgery.
        Patient Saf Surg. 2012; 6: 9
        • Beirer M.
        • Cronlein M.
        • Venjakob A.J.
        • Saier T.
        • Schmitt-Sody M.
        • et al.
        Additional calcar support using a blade device reduces secondary varus displacement following reconstruction of the proximal humerus: a prospective study.
        Eur J Med Res. 2015; 20: 82
        • Biberthaler P.
        • Beirer M.
        • Kirchhoff S.
        • Braunstein V.
        • Wiedemann E.
        • Kirchhoff C.
        Significant benefit for older patients after arthroscopic subacromial decompression: a long-term follow-up study.
        Int Orthop. 2013; 37: 457-462
        • Beirer M.
        • Siebenlist S.
        • Cronlein M.
        • Postl L.
        • Huber-Wagner S.
        • Biberthaler P.
        • et al.
        Clinical and radiological outcome following treatment of displaced lateral clavicle fractures using a locking compression plate with lateral extension: a prospective study.
        BMC Musculoskelet Disord. 2014; 15: 380
        • Adolfsson L.
        • Lysholm J.
        Arthroscopy for the diagnosis of shoulder pain.
        Int Orthop. 1991; 15: 275-278
        • Suder P.A.H.K.
        • Frich L.H.
        • Rasmussen O.S.
        • Lundorf E.
        Intraarticular findings in the chronically painful shoulder. A study of 32 posttraumatic cases.
        Acta Orthop Scand. 1994; 65: 339-343
        • Katthagen J.C.
        • Hennecke D.
        • Jensen G.
        • Ellwein A.
        • Voigt C.
        • Lill H.
        Arthroscopy after locked plating of proximal humeral fractures: implant removal, capsular release, and intra-articular findings.
        Arthroscopy. 2014; 30: 1061-1067
        • Hitchcock H.H.
        • Bechtol C.O.
        Painful shoulder; observations on the role of the tendon of the long head of the biceps brachii in its causation.
        J Bone Joint Surg Am. 1948; 30A (volume): 263-273
        • Furlani J.
        Electromyographic study of the m. biceps brachii in movements at the glenohumeral joint.
        Acta Anat (Basel). 1976; 96: 270-284
        • Rodosky M.W.
        • Harner C.D.
        • Fu F.H.
        The role of the long head of the biceps muscle and superior glenoid labrum in anterior stability of the shoulder.
        Am J Sports Med. 1994; 22: 121-130
        • Warner J.J.
        • McMahon P.J.
        The role of the long head of the biceps brachii in superior stability of the glenohumeral joint.
        J Bone Joint Surg Am. 1995; 77 (volume): 366-372
        • Yamaguchi K.
        • Riew K.D.
        • Galatz L.M.
        • Syme J.A.
        • Neviaser R.J.
        Biceps activity during shoulder motion: an electromyographic analysis.
        Clin Orthop Relat Res. 1997; : 122-129
        • Walch G.
        • Edwards T.B.
        • Boulahia A.
        • Nove-Josserand L.
        • Neyton L.
        • et al.
        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
        • Ahrens P.M.
        • Boileau P.
        The long head of biceps and associated tendinopathy.
        J Bone Joint Surg Br. 2007; 89 (volume): 1001-1009

      Linked Article