Position the patient supine on the operating table with an attached hand-table or in a beach-chair position with a small bolster under the scapula. Supine positioning allows for easier glenohumeral reduction, eliminating the weight of the arm and the influence of gravity on glenohumeral subluxation.

Make an anterior deltopectoral incision from the coracoid process extending distally for 10 cm (Fig. 1). Split the subcutaneous tissues and develop the plane between the deltoid and pectoralis major muscles, preserving the cephalic vein. Dissect through the clavipectoral fascia and identify the bicipital groove. Sharply incise the biceps tendon sheath and expose the long head of the biceps tendon (Fig. 2). Use electrocautery to expose the proximal part of the humerus subperiosteally over the bicipital groove.

Make two unicortical 5-mm drill holes into the humerus within the bicipital groove (Fig. 3). Make the proximal drill hole at the level of the superior aspect of the lesser tuberosity and the more distal drill hole at the inferior aspect of the lesser tuberosity. Use a curet to connect these holes, creating a tunnel.

Carefully dissect the tendon of the long head of the biceps free from the muscle while leaving the proximal origin of the tendon intact.

Take care to preserve as much length of the biceps tendon as possible by incising the tendon at the musculotendinous junction. The location of the musculotendinous junction is variable but is generally near the pectoralis major insertion on the humerus.

If you dissect the biceps tendon free of its attachments within the biceps groove, cephalad traction can be placed on the tendon and the musculotendinous junction can be easily identified and incised.

In general, you do not have to release the pectoralis major insertion to identify the musculotendinous junction of the biceps tendon; however, this is an option if you cannot safely identify the junction with cephalad traction on the tendon.

Once the tendon is incised, place a heavy nonabsorbable suture in the distal end of the tendon using a Krackow technique (Fig. 3).

Pass the biceps tendon through the tunnel in the humerus from proximal to distal using a suture passer (Fig. 4). Place cephalad traction on the tendon to reduce the inferior subluxation of the humerus and to remove any slack in the tendon. Pull the distal end of the tendon proximally to create a loop and suture the distal end of the biceps tendon to the proximal end with multiple sutures of heavy nonabsorbable suture, creating a suspension sling (Fig. 5). Inspect the shoulder to ensure reduction of the subluxation. Since the shoulder is visible, neither radiographs nor fluoroscopy is needed.

Protect the repair in a sling for three months to allow bone-to-tendon healing to occur. Patients perform passive range-of-motion shoulder exercises during this three-month period. If patients have motor function, they begin active range-of-motion after three months. We encourage patients to use a different sling for showering and bathing; however, we allow them to remove the sling and maintain an “arm at the side” position if this is not acceptable to them.

Patients with upper motor neuron injury with inferior glenohumeral subluxation

Pain that is worse with sitting or standing, or at any time that the arm is unsupported, and pain relief with trial reduction of the glenohumeral subluxation in the physician's office

The patient must find it acceptable that the procedure is expected to provide pain relief but not improve active function.

We do not recommend this surgical procedure during the initial period of flaccid paralysis (six to nine months) after upper motor neuron injury; we instead focus on nonoperative measures of reducing the subluxated shoulder prior to the period of spasticity that follows.

Patients with severe degenerative glenohumeral joint disease are unlikely to benefit from biceps suspension alone.

Patients with a ruptured or degenerated long head of the biceps tendon are not good candidates for this surgery. We do not have experience with the use of allografts instead of the native biceps tendon.

Patients with glenohumeral subluxation after upper motor neuron injury often have substantial shoulder contractures and/or spasticity. Conducting a biceps suspension procedure in this setting without addressing the underlying spasticity or contractures is likely to be unsuccessful as spasticity can compromise the maintenance of joint reduction and can continue to cause pain.

Compliance with postoperative sling wear is critical to the success of this procedure. If the weight of the arm is allowed to hang unsupported perioperatively, patients are at risk for failure of suture fixation as well as stretching of the biceps tendon and persistent glenohumeral subluxation. It is critical to evaluate patients preoperatively for their ability to comply with postoperative restrictions, either on their own or with the assistance of a caregiver.

While patients with isolated glenohumeral subluxation after upper motor neuron injury can experience substantial pain, it is important to rule out other potential causes of the pain before creating a treatment plan. In the spastic shoulder, pain can result from several variables, including rotator cuff tears, decreased range of motion of the shoulder, capsulitis, spasticity of the shoulder musculature, brachial plexus and peripheral nerve injuries, and glenohumeral joint arthritis.

How do you decide what shoulder tendon lengthening procedures or releases a patient might require in addition to a biceps suspension procedure?

What is the role of injections and bracing in providing pain relief and improved function in patients with inferior glenohumeral subluxation after upper motor neuron injury?