Incidence of avascular necrosis following biceps tenodesis during proximal humerus open reduction and internal fixation


proximal humerus ; open reduction internal fixation ; avascular necrosis ; biceps ; tenodesis ; delto-pectoral

Published online: Sep 14 2021

Kunal Mohan, Justin Matthias Hintze, David Morrissey, Diarmuid Molony

From the Department of Trauma & Orthopaedics, Tallaght University Hospital, Dublin D24NROA, Ireland


Avascular necrosis (AVN) may occur in up to 77% of proximal humeral fractures and can cause fixation failure. Risk factors include fracture position, calcar length and medial hinge integrity. We routinely perform intra-articular biceps tenotomy with tenodesis at the level of pectoralis major to facilitate fragment identification and potentially ameliorate post-operative pain relief. Concern exists that tenotomising the biceps damages the adjacent arcuate artery, potentially increasing the rate of AVN. The purpose of this study was to evaluate whether biceps tenodesis is associated with an increased risk of radiographically evident humeral head AVN.

61 fractures surgically treated over a 52-month period were retrospectively reviewed and radiographically assessed in accordance with Neer’s classification, calcar-length and medial hinge integrity.

40, 20 and 1 were four-, three- and two-part fractures respectively. 37 had a calcar-length less than 8mm and 26 suffered loss of the medial hinge. The median radiographic follow-up was 23 months. There was radiographic evidence of humeral head AVN in only one case, comparing favourably to rates quoted in current literature.

In our experience, intra-articular biceps tenotomy with the deltopectoral approach was thus not associated with a significantly increased risk of humeral head AVN, even in complex four-part fractures.