Arthroscopic Biceps Tenodesis From a Superior Viewing Portal in the Shoulder Andrew A. Tarleton, M.D., Liang Zhou, M.S., Michael J. O’Brien, M.D., and Felix H. Savoie, M.D.
Abstract: The purpose of this report is to describe our modification of the Verma-Trenhaile biceps tenodesis technique using a superior viewing portal that allows placement of the tenodesis site at the top of the pectoralis major tendon with interference screw fixation. The advantages of this technique include the following: (1) There is no need to exteriorize the tendon through the skin. (2) Viewing from superiorly allows a panoramic view of the groove all the way to the pectoralis major tendon insertion. (3) This panoramic view allows a more complete view of the biceps down to the muscle-tendon junction beneath the pectoralis major tendon. (4) The improved visualization permits the drill hole to be contained within the constraints of the groove. Short-term follow-up shows favorable results clinically, and no major complications have been associated with this technique.
P
athology of the proximal portion of the biceps is commonly encountered by the physician treating shoulder diseases. Lesions of the long head of the biceps can vary in degree from tendinitis, delamination, and subluxation to frank dislocation and can be present in the tendon itself or in the pulley system of the tendon. Treatment for pathology of the proximal portion of the biceps tendon generally consists of tenotomy versus tenodesis. Tenotomy is advantageous in that the procedure takes less time operatively than tenodesis and requires no particular postoperative protection. Tenodesis was developed in response to the cosmetic deformity and biceps muscle belly weakness that came along with tenotomy, which has become generally recommended for younger patientsdthose with cosmetic concerns or those with the dominant arm involved.1-5 Open biceps tenodesis in a subpectoral fashion has a strong track record as a reliable and common procedure. The technique of tenodesis has undergone
multiple iterations and, today, can be performed in either an open or arthroscopic fashion. Boileau et al.6 initially popularized a technique of arthroscopic biceps tenodesis in 2002, and there have been multiple changes since then. The purpose of this technical note and Video 1 is to describe a modification of the arthroscopic biceps tenodesis technique that involves a superior viewing portal. The use of this portal allows direct visualization of the distal end of the bicipital groove at the level of the upper border of the pectoralis tendon. This direct visualization allows precise placement of the tendon within the ridges of the groove, preserving its normal anatomic location. Our modifications to the Verma-Trenhaile biceps tenodesis technique include using a superior viewing portal to allow placement of the graft and screw at the top of the pectoralis major tendon with interference screw fixation, containing the tenodesis tunnel within the strong bony ridge of the groove (Table 1). Our technique provides a satisfactory result in most patients.
From the Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 6, 2014; accepted March 6, 2015. Address correspondence to Felix H. Savoie, M.D., Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Ave, SL-32, New Orleans, LA 70112, U.S.A. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 2212-6287/14844/$36.00 http://dx.doi.org/10.1016/j.eats.2015.03.008
The procedure can be performed with the patient in either the beach-chair or lateral position. It is recommended that this procedure be performed in the position that is most comfortable and familiar to the surgeon. General anesthesia and an interscalene block are used for anesthesia. Patients undergo preparation and draping in a sterile fashion after all bony prominences have been padded. An arthroscopic fluid pump can be used to help maintain distension. Standard
Operative Technique
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Table 1. Advantages of Superior Viewing Portal
Table 3. Steps of Procedure
The superior portal provides a panoramic view of the entire humerus and subdeltoid space. The superior portal allows visualization of the biceps tendon from the transverse humeral ligament to the area under the pectoralis major tendon insertion. The superior portal provides a longitudinal view of the bicipital groove, including the width, so that the fixation can be kept within the walls of the groove.
1. Establish a superior viewing portal. 2. Resect the subdeltoid bursa to allow visualization of the groove. Keep the shaver facing away from deltoid to prevent axillary nerve injury. 3. Unroof the groove down to the pectoralis major tendon insertion. 4. Establish a distal anterior portal at the level of the top of the pectoralis tendon, and place an 8.5-mm clear plastic cannula into the subdeltoid space. 5. Use a locking ratchet grasper to hold the biceps out of the groove for protection and visualization. 6. Drill a Beath pin (Smith & Nephew Endoscopy) in the center of the groove just above the pectoralis tendon and over-ream with a 7-mm (female patients) or 8-mm (male patients) reamer in a unicortical manner. 7. Use the Smith & Nephew Biceptor to push the tendon into the tunnel; pin it with a wire and hold it with the cannula while the screw fixation is inserted. 8. Resect the proximal tendon just above the screw fixation site.
arthroscopic equipment is used (Table 2). The steps of the procedure are summarized in Table 3. A standard glenohumeral joint inspection is performed with a 30 arthroscope. The decision to perform the tenodesis is a preoperative decision, but it is helpful to draw the biceps into the joint during inspection so that pathology that exists in the intertubercular groove segment is not overlooked. Once the preoperative decision to perform the tenodesis has been confirmed by visual inspection, the biceps tendon is removed from its origin from the superior labrum by electrocautery, a punch, or a knife. The tendon can be marked with a No. 1 monofilament suture for place keeping if desired. Release of the tendon completes the preparation of the tendon performed during the intra-articular portion of the procedure. The subacromial space is evaluated, and any subacromial procedures are performed. A superioranterior-lateral portal, which will be used for visualization during the tenodesis, is then established just off the anterolateral corner of the acromion (Fig 1). The standard lateral portal, located approximately 3 cm distal to the anterolateral corner of the acromion, is used for debridement and, later, retraction of the deltoid muscle. Initially, the subdeltoid bursa is resected, allowing visualization of the lateral humerus. It is essential that one always keep the shaver facing toward the humerus and away from the deltoid to avoid axillary nerve injury. The bicipital groove is identified and released along the posterior aspect to expose the extra-articular portion of the biceps tendon while the surgeon is looking down the humerus from the superior-anterior-lateral portal (Fig 2). A soft-tissue shaver or electrocautery can also be used to delineate the groove and completely unroof the tissue overlying the biceps tendon in the groove. There is often quite a bit of hypervascularity and tenosynovitis
NOTE. The procedure is shown in Video 1.
in the groove that must be removed, so it is helpful to grasp the tendon with a locking ratchet grasper (Smith & Nephew Endoscopy, Andover, MA) above the eventual tenodesis fixation point and lift it up and out of the groove during debridement of the groove (Fig 3). Pulling traction on the tendon also allows the
Table 2. Basic Equipment Smith & Nephew arthroscopy equipment Clear plastic cannulas: 5 mm and 8.5 mm in diameter Locking ratchet grasper Smith & Nephew biotenodesis set Wire driver and drill
Fig 1. The patient’s anterior is on the left side of the photograph, and the top of the photograph is medial. The switching stick is above the anterosuperior portal.
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Fig 2. Top-down view from anterosuperior portal. The biceps tendon is seen emerging from underneath the falciform ligament.
Fig 4. View under pectoralis major tendon showing inflamed tissue.
tenosynovium, which is often hypertrophied, to be removed along the tendon underneath the pectoralis major insertion (Fig 4). Progressing the arthroscope under the pectoralis major tendon and concurrently pulling traction on the biceps allows the surgeon to visualize the entire distal tendon down to the muscletendon junction. Once the tendon is identified, a distal anterior portal located 4 cm distal to the standard anterior portal is established in the area just above the pectoralis tendon insertion for instrumentation. The location for this is
usually approximately 2 to 3 cm above the superior border of the axilla, and its position and angle for placement of the screw within the groove are confirmed by localization with a spinal needle before creation of the portal (Fig 5). After the site is verified, a large blunt trocar is inserted to establish the anterior axillaryefold accessory portal. The trocar is removed, and a large 8.5-mm cannula is left to maintain the portal (Fig 6). The tendon and groove are inspected again to ensure all tenosynovitis is removed (Fig 7). In many cases the ascending branch of the anterior
Fig 3. The biceps tendon is elevated out of the groove, allowing a panoramic view of the bicipital groove down to the pectoralis tendon.
Fig 5. The patient’s anterior is on the left side of the image, and the top of the image is medial. The switching stick is in the distal anterior-fold portal, which is used for instrumentation.
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Fig 8. Guide pin in center of bicipital groove.
Fig 6. The patient’s anterior is on the left side of the photograph, and the top of the photograph is medial. Tag suture is placed through the biceps and comes out of the anterior portal. An 8.5-mm green cannula is placed into the axillaryfold portal, and the arthroscope is placed into the anterosuperior portal.
circumflex vessel, which runs along the lateral edge of the groove, may require cauterization. Once the groove can be clearly visualized, the surgeon can determine the accurate placement of the tenodesis. It is helpful to use
Fig 7. View of plastic cannula over groove.
an arthroscopic retractor or switching stick in the distallateral portal to keep the deltoid elevated away from the tenodesis site. A guide pin is passed through the cannula and drilled in a unicortical manner in an anterior-to-posterior direction in the midpoint of the bicipital groove, just superior to the pectoralis major tendon (Fig 8). The width of the groove in this area is usually 8 mm in female patients and 9 mm in male patients. The guide pin is left in place in the bone, and a 7-mm (female patients) or 8-mm (male patients) cannulated acorn reamer is passed over the pin in a unicortical manner to breach the near cortex (Fig 9). After reaming, the guide pin and the reamer are withdrawn from the
Fig 9. The reamer is placed through the proximal cortex only.
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Fig 10. Biceptor placed into tunnel without tendon.
Fig 12. Fixation wire and cannula holding tendon in tunnel.
shoulder. The drill hole width should be contained within the ridges of the groove to decrease the risk of humeral shaft fracture. The next step is to place a cannulated, fork-tipped device (Biceptor; Smith & Nephew Endoscopy) into the drilled tunnel to become accustomed to the angle of insertion and actual depth of the tunnel (Fig 10). The Biceptor is then backed up and used to capture the biceps tendon and place it into the reamed cavity in the proximal humerus (Fig 11). It is important to place a locking grasper (Smith & Nephew Endoscopy) on the proximal end of the tendon at least 2.5 cm distal to the transected proximal end of the tendon to ensure that the tenodesed biceps is the proper length. Once placed into the tunnel, a wire is passed through the center of the biceps and tapped into place with a mallet in the
far cortex, thus securing the tendon in the longitudinal plane in the hole in the center of the groove. The cannula is then forcefully pushed inward, “pinning” the tendon against the bone of the humerus (Fig 12). The cannulated, fork-tipped device is removed, which could potentially allow the tendon to migrate out of the reamed hole over the thin guidewire. Holding the tendon with the cannula edges prevents this migration, allowing the tendon’s position to be maintained. The cannulated biceps tenodesis screw, which is the same size as the reamed hole, is then placed over the wire and pushed gently into the tunnel. The screw is twisted clockwise until the proximal end is flush with the ridges of the groove (Fig 13). Once the screw is placed at the desired depth, the wire is withdrawn and the fixation evaluated by pulling on the proximal end
Fig 11. (A) Biceptor device placing tendon into tunnel. (B) Tendon completely in tunnel.
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Fig 13. Screw in tunnel fixating tendon.
of the tendon, which is still held by the ratchet grasper (Fig 14). The proximal portion of the biceps tendon is now transected, and a tendon grasper is used to remove it from the shoulder (Fig 15). The repair is tested using an arthroscopic probe. Finally, the instruments are withdrawn, and a sterile dressing is applied. The patient is placed in an abduction pillow brace before awaking from anesthesia and then is awoken and taken to the recovery room. Discharge is accomplished the same day.
Postoperative Protocol The postoperative protocol for an isolated biceps tenodesis involves the use of a protective sling for 4 weeks. A home exercise program emphasizing posture and passive motion is initiated within the first week, and waist-level rotator cuff exercises with the elbow maintained at 90 of flexion are initiated at 2 weeks. The focus of rehabilitation then moves to regular physical therapy emphasizing motion and strengthening while maintaining scapular retraction at all times. Patients are generally restricted to very light use (1- to 2-lb lifting restriction) during this time. More aggressive strengthening exercises begin at 6 weeks and progress as tolerated until normal activity can be resumed, usually at 12 to 16 weeks. Table 4 shows detailed results in 41 patients treated by the described technique.
structure, it is now recognized as a part of a myriad of clinical entities involving the shoulder and plays a role in stabilization of the humeral head. The techniques to address proximal biceps disease have evolved over time as well. Tenodesis has been shown to be appropriate for biceps tendon tears, massive rotator cuff tears with biceps damage, biceps pulley lesions, and SLAP lesions. Tenodesis techniques were initially performed in an open fashion in a variety of ways using a variety of fixation strategies ranging from keyhole suture fixation to the now commonly performed mini-open subpectoral interference screw approach. The presumed advantages of the tenodesis technique versus tenotomy include better cosmetic appearance, maintenance of elbow flexion and strength, and maintenance of the length-tension relation of the biceps muscle. Trenhaile introduced the all-arthroscopic technique in the Smith & Nephew product guide for their Biceptor tenodesis system. This technique used a standard lateral arthroscopic portal for visualization. Our superior viewing portal, which is an anterior adjustment of the standard lateral arthroscopic viewing portal, provides a superior vantage point regarding the biceps tendon as it emerges from the falciform ligament of the pectoralis major. We consistently released the transverse humeral ligament as part of our procedure, and recent evidence from Sanders et al.7 suggests that release of the transverse humeral ligament is associated with lower revision rates. These data support the theory that the sheath may harbor pain-generating elements. We were fortunate not to have any noteworthy complications in our series. No fractures of the humerus
Discussion The biceps tendon has long been implicated as a pain generator in the shoulder, without a full understanding of its function. Initially described as a vestigial
Fig 14. Proximal tendon held by grasper after fixation.
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Fig 15. (A) Resection of proximal tendon. (B) Final view of fixation.
were found, and there were no incidences of fixation failure. There are many advantages to the described technique. Our modification of the Verma-Trenhaile technique with a superior visualization point allows for clear observation of the procedure arthroscopically. Placement of the fixation at the bottom of the bicipital groove removes the tendon from the groove, decreasing the potential for postoperative pain due to residual tenosynovitis within the biceps sheath.8,9 Containment of the drill hole within the wall of the groove may decrease the risk of humeral shaft fracture.10 In conclusion, our data suggest that arthroscopic biceps tenodesis from a superior visualization portal allows for predictable patient satisfaction with minor complications.
Table 4. Postoperative Data Data Age, yr BMI, kg/m2 Follow-up time, mo ASES score SSV score, % Pain rating on visual analog scale Patient satisfaction score Medical comorbidities, No. of patients Popeye deformity, No. of shoulders Cramping, No. of shoulders Arm fatigue, No. of shoulders Full grip strength postoperatively, No. of shoulders
51.7 10.4 (26-71) 28.9 4.9 (20.6-45.2) 29.3 9.1 (16-49.8) 83.9 19.7 (6.7-100) 85.3 16.0 (40-100) 1.5 2.3 (0-10) 4.64 0.76 (1-5) Present in 30/absent in 11 Present in 0/absent in 42 Present in 7/absent in 35 Present in 17/absent in 25 Present in 35/absent in 7
NOTE. Data are presented as mean standard deviation (range) unless otherwise indicated. The study population consisted of 30 male and 11 female patients (42 shoulders). ASES, American Shoulder and Elbow Surgeons; BMI, body mass index; SSV, Subjective Shoulder Value.
References 1. Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR. Biceps tenotomy versus tenodesis: A review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg 2011;20:326-332. 2. Koch BS, Burks RT. Failure of biceps tenodesis with interference screw fixation. Arthroscopy 2012;28:735-740. 3. Nho SJ, Reiff SN, Verma NN, Slabaugh MA, Mazzocca AD, Romeo AA. Complications associated with subpectoral biceps tenodesis: Low rates of incidence following surgery. J Shoulder Elbow Surg 2010;19:764-768. 4. Denard PJ, Dai X, Hanypsiak BT, Burkhart SS. Anatomy of the biceps tendon: Implications for restoring physiological length-tension relation during biceps tenodesis with interference screw fixation. Arthroscopy 2012;28: 1352-1358. 5. Shank JR, Singleton SB, Braun S, et al. A comparison of forearm supination and elbow flexion strength in patients with long head of the biceps tenotomy or tenodesis. Arthroscopy 2011;27:9-16. 6. Boileau P, Krishnan SG, Coste J-S, Walch G. Arthroscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Arthroscopy 2002;18:10021012. 7. Sanders B, Lavery KP, Pennington S, Warner JJP. Clinical success of biceps tenodesis with and without release of the transverse humeral ligament. J Shoulder Elbow Surg 2012;21:66-71. 8. Patzer T, Rundic JM, Bobrowitsch E, Olender GD, Hurschler C, Schofer MD. Biomechanical comparison of arthroscopically performable techniques for suprapectoral biceps tenodesis. Arthroscopy 2011;27:1036-1047. 9. Slabaugh MA, Frank RM, Van Thiel GS, et al. Biceps tenodesis with interference screw fixation: A biomechanical comparison of screw length and diameter. Arthroscopy 2011;27:161-166. 10. Lutton DM, Gruson KI, Harrison AK, Gladstone JN, Flatow EL. Where to tenodese the biceps: Proximal or distal? Clin Orthop Relat Res 2011;469:1050-1055.
Abstract: The purpose of this report is to describe our modification of the Verma-Trenhaile biceps tenodesis technique using a superior viewing portal that allows placement of the tenodesis site at the top of the pectoralis major tendon with interference screw fixation. The advantages of this technique include the following: (1) There is no need to exteriorize the tendon through the skin. (2) Viewing from superiorly allows a panoramic view of the groove all the way to the pectoralis major tendon insertion. (3) This panoramic view allows a more complete view of the biceps down to the muscle-tendon junction beneath the pectoralis major tendon. (4) The improved visualization permits the drill hole to be contained within the constraints of the groove. Short-term follow-up shows favorable results clinically, and no major complications have been associated with this technique.
P
athology of the proximal portion of the biceps is commonly encountered by the physician treating shoulder diseases. Lesions of the long head of the biceps can vary in degree from tendinitis, delamination, and subluxation to frank dislocation and can be present in the tendon itself or in the pulley system of the tendon. Treatment for pathology of the proximal portion of the biceps tendon generally consists of tenotomy versus tenodesis. Tenotomy is advantageous in that the procedure takes less time operatively than tenodesis and requires no particular postoperative protection. Tenodesis was developed in response to the cosmetic deformity and biceps muscle belly weakness that came along with tenotomy, which has become generally recommended for younger patientsdthose with cosmetic concerns or those with the dominant arm involved.1-5 Open biceps tenodesis in a subpectoral fashion has a strong track record as a reliable and common procedure. The technique of tenodesis has undergone
multiple iterations and, today, can be performed in either an open or arthroscopic fashion. Boileau et al.6 initially popularized a technique of arthroscopic biceps tenodesis in 2002, and there have been multiple changes since then. The purpose of this technical note and Video 1 is to describe a modification of the arthroscopic biceps tenodesis technique that involves a superior viewing portal. The use of this portal allows direct visualization of the distal end of the bicipital groove at the level of the upper border of the pectoralis tendon. This direct visualization allows precise placement of the tendon within the ridges of the groove, preserving its normal anatomic location. Our modifications to the Verma-Trenhaile biceps tenodesis technique include using a superior viewing portal to allow placement of the graft and screw at the top of the pectoralis major tendon with interference screw fixation, containing the tenodesis tunnel within the strong bony ridge of the groove (Table 1). Our technique provides a satisfactory result in most patients.
From the Department of Orthopaedic Surgery, Tulane University School of Medicine, New Orleans, Louisiana, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 6, 2014; accepted March 6, 2015. Address correspondence to Felix H. Savoie, M.D., Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Ave, SL-32, New Orleans, LA 70112, U.S.A. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 2212-6287/14844/$36.00 http://dx.doi.org/10.1016/j.eats.2015.03.008
The procedure can be performed with the patient in either the beach-chair or lateral position. It is recommended that this procedure be performed in the position that is most comfortable and familiar to the surgeon. General anesthesia and an interscalene block are used for anesthesia. Patients undergo preparation and draping in a sterile fashion after all bony prominences have been padded. An arthroscopic fluid pump can be used to help maintain distension. Standard
Operative Technique
Arthroscopy Techniques, Vol 4, No 4 (August), 2015: pp e383-e389
e383
e384
A. A. TARLETON ET AL.
Table 1. Advantages of Superior Viewing Portal
Table 3. Steps of Procedure
The superior portal provides a panoramic view of the entire humerus and subdeltoid space. The superior portal allows visualization of the biceps tendon from the transverse humeral ligament to the area under the pectoralis major tendon insertion. The superior portal provides a longitudinal view of the bicipital groove, including the width, so that the fixation can be kept within the walls of the groove.
1. Establish a superior viewing portal. 2. Resect the subdeltoid bursa to allow visualization of the groove. Keep the shaver facing away from deltoid to prevent axillary nerve injury. 3. Unroof the groove down to the pectoralis major tendon insertion. 4. Establish a distal anterior portal at the level of the top of the pectoralis tendon, and place an 8.5-mm clear plastic cannula into the subdeltoid space. 5. Use a locking ratchet grasper to hold the biceps out of the groove for protection and visualization. 6. Drill a Beath pin (Smith & Nephew Endoscopy) in the center of the groove just above the pectoralis tendon and over-ream with a 7-mm (female patients) or 8-mm (male patients) reamer in a unicortical manner. 7. Use the Smith & Nephew Biceptor to push the tendon into the tunnel; pin it with a wire and hold it with the cannula while the screw fixation is inserted. 8. Resect the proximal tendon just above the screw fixation site.
arthroscopic equipment is used (Table 2). The steps of the procedure are summarized in Table 3. A standard glenohumeral joint inspection is performed with a 30 arthroscope. The decision to perform the tenodesis is a preoperative decision, but it is helpful to draw the biceps into the joint during inspection so that pathology that exists in the intertubercular groove segment is not overlooked. Once the preoperative decision to perform the tenodesis has been confirmed by visual inspection, the biceps tendon is removed from its origin from the superior labrum by electrocautery, a punch, or a knife. The tendon can be marked with a No. 1 monofilament suture for place keeping if desired. Release of the tendon completes the preparation of the tendon performed during the intra-articular portion of the procedure. The subacromial space is evaluated, and any subacromial procedures are performed. A superioranterior-lateral portal, which will be used for visualization during the tenodesis, is then established just off the anterolateral corner of the acromion (Fig 1). The standard lateral portal, located approximately 3 cm distal to the anterolateral corner of the acromion, is used for debridement and, later, retraction of the deltoid muscle. Initially, the subdeltoid bursa is resected, allowing visualization of the lateral humerus. It is essential that one always keep the shaver facing toward the humerus and away from the deltoid to avoid axillary nerve injury. The bicipital groove is identified and released along the posterior aspect to expose the extra-articular portion of the biceps tendon while the surgeon is looking down the humerus from the superior-anterior-lateral portal (Fig 2). A soft-tissue shaver or electrocautery can also be used to delineate the groove and completely unroof the tissue overlying the biceps tendon in the groove. There is often quite a bit of hypervascularity and tenosynovitis
NOTE. The procedure is shown in Video 1.
in the groove that must be removed, so it is helpful to grasp the tendon with a locking ratchet grasper (Smith & Nephew Endoscopy, Andover, MA) above the eventual tenodesis fixation point and lift it up and out of the groove during debridement of the groove (Fig 3). Pulling traction on the tendon also allows the
Table 2. Basic Equipment Smith & Nephew arthroscopy equipment Clear plastic cannulas: 5 mm and 8.5 mm in diameter Locking ratchet grasper Smith & Nephew biotenodesis set Wire driver and drill
Fig 1. The patient’s anterior is on the left side of the photograph, and the top of the photograph is medial. The switching stick is above the anterosuperior portal.
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Fig 2. Top-down view from anterosuperior portal. The biceps tendon is seen emerging from underneath the falciform ligament.
Fig 4. View under pectoralis major tendon showing inflamed tissue.
tenosynovium, which is often hypertrophied, to be removed along the tendon underneath the pectoralis major insertion (Fig 4). Progressing the arthroscope under the pectoralis major tendon and concurrently pulling traction on the biceps allows the surgeon to visualize the entire distal tendon down to the muscletendon junction. Once the tendon is identified, a distal anterior portal located 4 cm distal to the standard anterior portal is established in the area just above the pectoralis tendon insertion for instrumentation. The location for this is
usually approximately 2 to 3 cm above the superior border of the axilla, and its position and angle for placement of the screw within the groove are confirmed by localization with a spinal needle before creation of the portal (Fig 5). After the site is verified, a large blunt trocar is inserted to establish the anterior axillaryefold accessory portal. The trocar is removed, and a large 8.5-mm cannula is left to maintain the portal (Fig 6). The tendon and groove are inspected again to ensure all tenosynovitis is removed (Fig 7). In many cases the ascending branch of the anterior
Fig 3. The biceps tendon is elevated out of the groove, allowing a panoramic view of the bicipital groove down to the pectoralis tendon.
Fig 5. The patient’s anterior is on the left side of the image, and the top of the image is medial. The switching stick is in the distal anterior-fold portal, which is used for instrumentation.
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Fig 8. Guide pin in center of bicipital groove.
Fig 6. The patient’s anterior is on the left side of the photograph, and the top of the photograph is medial. Tag suture is placed through the biceps and comes out of the anterior portal. An 8.5-mm green cannula is placed into the axillaryfold portal, and the arthroscope is placed into the anterosuperior portal.
circumflex vessel, which runs along the lateral edge of the groove, may require cauterization. Once the groove can be clearly visualized, the surgeon can determine the accurate placement of the tenodesis. It is helpful to use
Fig 7. View of plastic cannula over groove.
an arthroscopic retractor or switching stick in the distallateral portal to keep the deltoid elevated away from the tenodesis site. A guide pin is passed through the cannula and drilled in a unicortical manner in an anterior-to-posterior direction in the midpoint of the bicipital groove, just superior to the pectoralis major tendon (Fig 8). The width of the groove in this area is usually 8 mm in female patients and 9 mm in male patients. The guide pin is left in place in the bone, and a 7-mm (female patients) or 8-mm (male patients) cannulated acorn reamer is passed over the pin in a unicortical manner to breach the near cortex (Fig 9). After reaming, the guide pin and the reamer are withdrawn from the
Fig 9. The reamer is placed through the proximal cortex only.
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Fig 10. Biceptor placed into tunnel without tendon.
Fig 12. Fixation wire and cannula holding tendon in tunnel.
shoulder. The drill hole width should be contained within the ridges of the groove to decrease the risk of humeral shaft fracture. The next step is to place a cannulated, fork-tipped device (Biceptor; Smith & Nephew Endoscopy) into the drilled tunnel to become accustomed to the angle of insertion and actual depth of the tunnel (Fig 10). The Biceptor is then backed up and used to capture the biceps tendon and place it into the reamed cavity in the proximal humerus (Fig 11). It is important to place a locking grasper (Smith & Nephew Endoscopy) on the proximal end of the tendon at least 2.5 cm distal to the transected proximal end of the tendon to ensure that the tenodesed biceps is the proper length. Once placed into the tunnel, a wire is passed through the center of the biceps and tapped into place with a mallet in the
far cortex, thus securing the tendon in the longitudinal plane in the hole in the center of the groove. The cannula is then forcefully pushed inward, “pinning” the tendon against the bone of the humerus (Fig 12). The cannulated, fork-tipped device is removed, which could potentially allow the tendon to migrate out of the reamed hole over the thin guidewire. Holding the tendon with the cannula edges prevents this migration, allowing the tendon’s position to be maintained. The cannulated biceps tenodesis screw, which is the same size as the reamed hole, is then placed over the wire and pushed gently into the tunnel. The screw is twisted clockwise until the proximal end is flush with the ridges of the groove (Fig 13). Once the screw is placed at the desired depth, the wire is withdrawn and the fixation evaluated by pulling on the proximal end
Fig 11. (A) Biceptor device placing tendon into tunnel. (B) Tendon completely in tunnel.
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Fig 13. Screw in tunnel fixating tendon.
of the tendon, which is still held by the ratchet grasper (Fig 14). The proximal portion of the biceps tendon is now transected, and a tendon grasper is used to remove it from the shoulder (Fig 15). The repair is tested using an arthroscopic probe. Finally, the instruments are withdrawn, and a sterile dressing is applied. The patient is placed in an abduction pillow brace before awaking from anesthesia and then is awoken and taken to the recovery room. Discharge is accomplished the same day.
Postoperative Protocol The postoperative protocol for an isolated biceps tenodesis involves the use of a protective sling for 4 weeks. A home exercise program emphasizing posture and passive motion is initiated within the first week, and waist-level rotator cuff exercises with the elbow maintained at 90 of flexion are initiated at 2 weeks. The focus of rehabilitation then moves to regular physical therapy emphasizing motion and strengthening while maintaining scapular retraction at all times. Patients are generally restricted to very light use (1- to 2-lb lifting restriction) during this time. More aggressive strengthening exercises begin at 6 weeks and progress as tolerated until normal activity can be resumed, usually at 12 to 16 weeks. Table 4 shows detailed results in 41 patients treated by the described technique.
structure, it is now recognized as a part of a myriad of clinical entities involving the shoulder and plays a role in stabilization of the humeral head. The techniques to address proximal biceps disease have evolved over time as well. Tenodesis has been shown to be appropriate for biceps tendon tears, massive rotator cuff tears with biceps damage, biceps pulley lesions, and SLAP lesions. Tenodesis techniques were initially performed in an open fashion in a variety of ways using a variety of fixation strategies ranging from keyhole suture fixation to the now commonly performed mini-open subpectoral interference screw approach. The presumed advantages of the tenodesis technique versus tenotomy include better cosmetic appearance, maintenance of elbow flexion and strength, and maintenance of the length-tension relation of the biceps muscle. Trenhaile introduced the all-arthroscopic technique in the Smith & Nephew product guide for their Biceptor tenodesis system. This technique used a standard lateral arthroscopic portal for visualization. Our superior viewing portal, which is an anterior adjustment of the standard lateral arthroscopic viewing portal, provides a superior vantage point regarding the biceps tendon as it emerges from the falciform ligament of the pectoralis major. We consistently released the transverse humeral ligament as part of our procedure, and recent evidence from Sanders et al.7 suggests that release of the transverse humeral ligament is associated with lower revision rates. These data support the theory that the sheath may harbor pain-generating elements. We were fortunate not to have any noteworthy complications in our series. No fractures of the humerus
Discussion The biceps tendon has long been implicated as a pain generator in the shoulder, without a full understanding of its function. Initially described as a vestigial
Fig 14. Proximal tendon held by grasper after fixation.
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ARTHROSCOPIC BICEPS TENODESIS
Fig 15. (A) Resection of proximal tendon. (B) Final view of fixation.
were found, and there were no incidences of fixation failure. There are many advantages to the described technique. Our modification of the Verma-Trenhaile technique with a superior visualization point allows for clear observation of the procedure arthroscopically. Placement of the fixation at the bottom of the bicipital groove removes the tendon from the groove, decreasing the potential for postoperative pain due to residual tenosynovitis within the biceps sheath.8,9 Containment of the drill hole within the wall of the groove may decrease the risk of humeral shaft fracture.10 In conclusion, our data suggest that arthroscopic biceps tenodesis from a superior visualization portal allows for predictable patient satisfaction with minor complications.
Table 4. Postoperative Data Data Age, yr BMI, kg/m2 Follow-up time, mo ASES score SSV score, % Pain rating on visual analog scale Patient satisfaction score Medical comorbidities, No. of patients Popeye deformity, No. of shoulders Cramping, No. of shoulders Arm fatigue, No. of shoulders Full grip strength postoperatively, No. of shoulders
51.7 10.4 (26-71) 28.9 4.9 (20.6-45.2) 29.3 9.1 (16-49.8) 83.9 19.7 (6.7-100) 85.3 16.0 (40-100) 1.5 2.3 (0-10) 4.64 0.76 (1-5) Present in 30/absent in 11 Present in 0/absent in 42 Present in 7/absent in 35 Present in 17/absent in 25 Present in 35/absent in 7
NOTE. Data are presented as mean standard deviation (range) unless otherwise indicated. The study population consisted of 30 male and 11 female patients (42 shoulders). ASES, American Shoulder and Elbow Surgeons; BMI, body mass index; SSV, Subjective Shoulder Value.
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