Iatrogenic Brachial Plexus Injuries Associated With Open Subpectoral Biceps Tenodesis

Open subpectoral biceps tenodesis (OSPBT) is performed with increasing frequency as a treatment for instability of the long head of the biceps tendon (LHBT) or tendinosis. The technique was first described in 2005 as an efficient and reproducible technique, afforded by the clearly identifiable surgical anatomy. Advocates stressed that OSPBT does not violate muscle-tendon units, can re-create the length-tension relationship of the LHBT, provides stable initial fixation, and removes the tendon from the intertubercular groove, which may be a source of persistent tenosynovitis and pain. In this same report, the clinical results of 41 patients who underwent OSPBT were presented, and no complications were described at a mean follow-up of 29 months. Although OSPBT has been recommended as a safe and technically straightforward procedure, rare iatrogenic brachial plexus injuries (BPIs) can occur. Nho et al noted 1 patient with musculocutaneous nerve palsy 10 days after OSPBT who underwent surgical exploration at 6 weeks postoperatively without evidence of nerve discontinuity and subsequent resolution of symptoms by 6 months postoperatively. Similarly, Ma et al reported on a patient with musculocutaneous nerve palsy after OSPBT that was caused by malpositioning of the LHBT deep into the musculocutaneous nerve with consequent entrapment of the nerve. The patient had full resolution of symptoms after revision OSPBT (with the LHBT in an anatomic position) and neurolysis at 3 months postoperatively. To our knowledge, no other nerve injuries have been reported after OSPBT. The purpose of this case series is to illustrate a variety of iatrogenic BPIs sustained at the time of OSPBT that were evaluated and treated at a national, referral, multidisciplinary brachial plexus center. In addition, a review of the potential causes of BPIs that can occur during OSPBT is presented with perioperative measures that may prevent the occurrence of these iatrogenic injuries. The patients described in this case series underwent their index OSPBT at various outside medical facilities. Their clinical history and operative details were obtained from transferred medical records and in communication with the primary surgeon when available.