Arthroscopic Transtendinous Biceps Tenodesis With All-Suture Anchor Chien-An Shih, M.D., Florence L. Chiang, M.D., Chih-Kai Hong, M.D., Cheng-Wei Lin, M.D., Ping-Hui Wang, M.D., I-Ming Jou, M.D., Ph.D., and Wei-Ren Su, M.D., M.Sc.
Abstract: There are several methods for long head of the biceps (LHB) tenodesis, yet the optimal option is still debatable. Here we introduce a technique for arthroscopic suprapectoral biceps tenodesis with an all-suture anchor, the transtendinous biceps tenodesis technique. The LHB tenodesis is performed by using the Y-Knot anchor (1.3-mm). A standard suprapectoral approach is used for the tenodesis. A 1.3-mm drill bit is used to drill through the midportion of the biceps tendon and underlying bone to make a pilot hole. Next, the Y-Knot anchor is passed through the tendon and anchored on the underlying bone. A wrapping suture technique is then used to wrap around, tension, and secure the LHB tendon with the aid of a shuttling polydioxanone suture. The construct is fixed by tying down both suture limbs in a nonsliding fashion. This Technical Note describes an alternative method for all-arthroscopic suprapectoral biceps tenodesis using an all-suture anchor with a small diameter to minimize trauma to the tendon.
P
athologic changes of the long head of the biceps brachii (LHB) tendon are a well-known cause of shoulder pain that are frequently associated with chronic rotator cuff tears or anterosuperior impingement syndromes.1-4 The biceps tenodesis procedure has been used in the treatment of partial tears, instability, tenosynovitis, and SLAP tears.1,2,4,5 Surgical options for the LHB itself include tenotomy and tenodesis. Tenotomy is generally reserved for older, less-active patients, and tenodesis is typically used for younger, more active patients and has the advantage of improved cosmesis and strength compared with tenotomy.1,2,4 There have been multiple arthroscopic techniques
From the Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University (C-A.S., C-K.H., C-W.L., I-M.J., W-R.S.), Tainan, Taiwan; University of Texas Health Science Center at San Antonio School of Medicine (F.L.C.), San Antonio, Texas, U.S.A.; Department of Orthopedics, Chi-Mei Medical Center (P-H.W.), and Medical Device Innovation Center, National Cheng Kung University (I-M.J., W-R.S.), Tainan, Taiwan. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 28, 2016; accepted January 30, 2017. Address correspondence to Wei-Ren Su, M.D., M.Sc., Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng Li Road, Tainan 704, Taiwan. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/161056/$36.00 http://dx.doi.org/10.1016/j.eats.2017.01.018
developed for biceps tenodesis.6-10 The fixation technique can be performed using suture anchors, interference screws, cortical buttons, and soft tissue tenodesis.11-15 Yet, optimal treatment is still debatable. The all-suture anchor (ASA), composed of ultrahigh-molecular-weight polyethylene sutures that pass through a flexible tube of braided material, has been developed as new technology to reduce the biological impact on the patient in labral repair and rotator cuff repair.16,17 Recently, the ASA has been employed in the transtendinous repair of partial articular supraspinatus tendon avulsion (PASTA) type lesions and is advantageous because of the small size and soft texture, which may cause less damage to tendon tissue. We describe a technique of arthroscopically assisted suprapectoral biceps tenodesis, the transtendinous biceps tenodesis technique, which uses an ASA to efficiently perform a suture wrap and provide secure fixation of the biceps tendon.
Technical Note All surgical procedures are performed with the patient in the lateral decubitus position under general anesthesia; traction is applied on the affected limb with an adjunctive interscalene block (see Video 1). Standard posterior and anterior portals are made for glenohumeral joint exploration. An arthroscope is placed into the subacromial space through the posterolateral portal at 1 cm lateral and anterior to the posterolateral
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edge of the acromion. Subsequently, a bursectomy is performed to expose the LHB tendon, especially in the anterolateral aspect near the bicipital groove area through the lateral portal. The routine arthroscopic anatomic points are examined through the posterolateral and anterior portals. In cases with a concomitant rotator cuff tear, the LHB tendon is easily identified in the subacromial space through the posterolateral portal. However, if the supraspinatus were intact, especially the anterior portion of the supraspinatus tendon, exploration of the bicipital groove is necessary to expose the LHB tendon. It should be noted that the tenodesis is performed in full before cutting the intraarticular portion of the LHB tendon. The attachment of the LHB tendon may maintain physiologic length and tension of the LHB tendon and facilitate passing a Y-Knot anchor (ConMed, Utica, NY) through the tendon. After the LHB tendon in the bicipital groove is identified, the biceps sheath and upper portion of the transverse humeral ligament are released with a radiofrequency device. The biceps tendon is retracted from the bicipital groove near the articular entrance and suspended with a probe introduced from the anterior portal. This step helps facilitate the subsequent debridement of the groove surface and placement of the polydioxanone (PDS) suture. As the bicipital groove is exposed, a suture hook (Suture Hook, Spectrum II; Linvatec, Largo, FL) loaded with a PDS suture is placed through the anterior portal and passed under the LHB tendon (Fig 1). A suture retriever (Suture Retriever; Arthrex, Naples, FL) introduced through the lateral portal is used to grasp and pull out one limb of the PDS suture. Then, to aid in suture management, a switching stick is placed through the anterior cannula, after which the cannula is removed. The limb of the PDS suture in the anterior cannula is then pulled out of the cannula. Subsequently, the cannula is placed back over the stitching stick into the subacromial space, rendering the anterior cannula empty to facilitate the placement of the Y-Knot anchor. Arthroscopic Transtendinous Biceps Tenodesis With ASA The most common placement site for tenodesis is in the bicipital groove, approximately 1 cm distal to the starting point of the groove. A 1.3-mm drill bit is used to drill through the LHB tendon and underlying bone by using a drill guide placed on the midportion of the LHB tendon via the cannula (Threaded Cannula, 7 mm 72 mm; Smith & Nephew, Andover, MA) that was placed in the anterior portal to allow for passage of the Y-Knot anchor. Subsequently, the Y-Knot anchor is inserted through the drill guide and into the 1.3-mm pilot hole underlying the tendon by knocking at the anchor inserter handle (Fig 2). The suture is released from the handle by unscrewing the suture retention
Fig 1. Arthroscopic image of a right shoulder in the lateral decubitus position from the posterolateral viewing portal. A suture hook loaded with a PDS suture (arrow) is placed through the anterior portal and passed under the LHB tendon. (LHB, long head of biceps; PDS, polydioxanone.)
feature. Next, the anchor inserter handle is pulled back directly from the drill guide. Both sutures are lightly pulled to set the anchor until fully seated and abutting the cortex. One suture limb of the Y-Knot in the anterior portal is retrieved through the lateral portal by using the suture retriever and tied to the limb of PDS suture in the lateral cannula outside the lateral portal. Subsequently, the limb of PDS suture located outside the anterior cannula is retrieved back into the anterior cannula. By pulling the limb of PDS suture in the anterior cannula, the permanent suture is pulled retrograde, over, and under the tendon to wrap around the tendon (Fig 3). Then the same process is repeated for the other limb of the Y-Knot suture by using the same PDS shuttle suture to pull the permanent suture retrograde, over, and under the tendon to wrap around the tendon through the lateral cannula. Both limbs of the permanent suture are then retrieved back into the anterior cannula (Fig 4). After wrapping around the tendon, the suture limbs are tied together in a nonsliding fashion. Once the transtendinous tenodesis procedure is completed, secure fixation is confirmed with a probe, and the intra-articular portion of the LHB tendon is then excised. Postoperative rehabilitation after biceps tenodesis includes immobilization for 4 weeks in a sling at 90 of elbow flexion and neutral rotation, followed by gentle active elbow range of motion exercises, which can be adjusted according to the combined pathology.
Discussion This Technical Note describes a technique for arthroscopic suprapectoral biceps tenodesis with an ASA. In this transtendinous tenodesis procedure, a small perforation is made with a drill bit followed by the Y-Knot anchor insertion through the tendon and into
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Fig 2. Arthroscopic image of a right shoulder from the posterolateral viewing portal. The Y-Knot anchor (arrow) is inserted through the drill guide at the midportion of the tendon into the 1.3-mm pilot hole underlying the tendon via the anterior portal.
the underlying bone. The suture attached to the Y-Knot anchor is used to wrap the tendon. The Y-Knot anchor, with a smaller diameter and consisting of only soft components, has the benefit of causing less damage to tendon tissue, which may lead to improved mechanical strength of the tenodesis construct. ASAs have recently been introduced for use in arthroscopic PASTA repairs and are advantageous in causing less damage to tendon, preserving native tissue, and re-establishing the normal footprint of the rotator cuff. Given the common practice of ASA fixation in the shoulder, the transition to biceps tenodesis seems like a logical progression. The proposed technique offers some advantages. First, trauma of the Y-Knot anchor to the tendon fibers at the time of insertion is likely to be reduced compared with the ordinary threaded anchor. Zhang et al.4 compared the damage to the rotator cuff
Fig 4. Arthroscopic image of a right shoulder in the lateral decubitus position from the posterolateral viewing portal. Both limbs of the Y-Knot suture are wrapped securely around the tendon through the anterior cannula.
tendons caused by 4 different anchor systems in a cadaver transtendon rotator cuff repair model and found that smaller anchors caused less damage to the tendon tissue. They concluded that smaller anchors should be considered when performing transtendon procedures to repair partial rotator cuff tears. We speculate that the Y-Knot anchor may cause less disruption of surrounding tissue given its smaller diameter (1.3 mm) and smooth surface; also, given the mechanism of the Y-Knot insertion, the tendon tissue is not screwed and crushed under the threads of the more commonly used anchors. Second, this wrapping suture technique, similar to other lasso-loop stitch techniques,18-20 could increase the fixation strength by incorporating the entire circumference of the tendon instead of only grasping a fraction of the thickness of the biceps tendon,21,22 which may decrease the risk of suture slippage. Third, placement of the wrapping sutures with the aid of a PDS shuttle suture is a more Table 1. Advantages and Disadvantages of Arthroscopic Transtendinous Biceps Tenodesis With All-Suture Anchor Advantages 1. Relatively safe, and reproducible 2. Minimal LHB tendon injury
Fig 3. Arthroscopic image of a right shoulder from the posterolateral viewing portal. One limb of the Y-Knot suture is shuttled retrograde and wrapped around the tendon by pulling the limb of the PDS suture in the anterior cannula. (PDS, polydioxanone.)
3. Small pilot hole in cortical bone drilling 4. Better fixation with wrapping suture technique 5. Placement of the wrapping sutures with the aid of only 1 PDS shuttle suture is an efficient method 6. Fewer operative steps and less surgical time
Disadvantages 1. Arthroscopic tenodesis can be technically challenging 2. Knots tied over the LHB tendon may cause irritation under the coracoid process 3. Epiosseous tenodesis may reduce tendon healing potential
LHB, long head of biceps; PDS, polydioxanone.
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Table 2. Pearls and Pitfalls of Arthroscopic Transtendinous Biceps Tenodesis With All-Suture Anchor Pearls
Pitfalls
1. Maintain the drill guide positioned and oriented correctly to allow for passage of the Y-Knot anchor through the drill guide and into the 1.3-mm pilot hole underlying the LHB tendon 2. The PDS shuttle suture should be tied around the permanent suture limb by a simple half-hitch located in proximity to the middle of the PDS suture to avoid the PDS suture escaping from the cannula while pulling the other limb of the PDS suture in the opposite cannula
1. Dislocated LHB tendon possibly impeding tenodesis and removal of tenotomized proximal LHB tendon portion
2. Eccentric drilling impairing tenodesis fixation strength and increasing risk of iatrogenic tendon damage
LHB, long head of biceps; PDS, polydioxanone.
efficient and reproducible method compared with other lasso-loop stitch techniques. Thus, lessening the technically demanding portions of the procedure is a significant positive when evaluating various techniques for the same indication. Additional advantages and disadvantages, as well as the pearls and pitfalls of this technique, are detailed in Tables 1 and 2. Although the ASA may cause less damage to surrounding structures given its less intrusive anchor size, one logical question to ask is whether or not the smaller Y-Knot anchor will provide adequate fixation strength for biceps tenodesis. Dwyer et al.23 reported that the Y-Knot anchor revealed a median force to failure of 145 N (range 125-165 N) in human cadaver glenoid models. Su et al.15 described a new technique for open subpectoral biceps tenodesis using a 1.3-mm Y-Knot fixation that provided ultimate failure load and stiffness comparable to those with the interference screw technique. Our mechanical strength pilot study revealed an ultimate failure load of 166 25 N for the transtendinous Y-Knot anchor fixation construct. The threshold for sufficient pullout strength was approximately 112 N when holding a 1 kg weight at 90 of elbow flexion, which is defined as the threshold that the biceps tenodesis construct should achieve.19 Therefore, during early motion rehabilitation programs without heavy weight-bearing after biceps tenodesis surgery, the transtendinous Y-Knot anchor fixation should provide sufficient biomechanical strength. Further biomechanical studies should be completed to prove the security of the fixation construct. This technique has some potential limitations. First, tendon damage may occur at the perforated site during the transtendinous procedure regardless of the smaller
diameter and softer texture of the Y-Knot although the adverse effects of tendon damage on the healing and mechanical strength of the transtendinous tenodesis construct are unclear. Second, this technique employs suture wrapping around the LHB tendon, which is knotted over the tendon; the knots tied over the tendon may cause irritation under the coracoid process and coracoacromial ligament. Third, the LHB tendon is fixed on the surface of the humeral cortex, with partial contact of the tendon with the bone. Thus, there is a possibility of reduced healing compared with intramedullary canal fixation in interference screw tenodesis. However, tenodesis with the loop-suture technique has had good to excellent results with both suprapectoral and subpectoral approaches in the literature.2 Therefore, this application of the ASA for transtendinous fixation may serve as a reliable, easily reproducible, and efficient method for arthroscopic suprapectoral biceps tenodesis.
References 1. De Carli A, Vadala A, Zanzotto E, et al. Reparable rotator cuff tears with concomitant long-head biceps lesions: Tenotomy or tenotomy/tenodesis? Knee Surg Sports Traumatol Arthrosc 2012;20:2553-2558. 2. Koh KH, Ahn JH, Kim SM, Yoo JC. Treatment of biceps tendon lesions in the setting of rotator cuff tears: Prospective cohort study of tenotomy versus tenodesis. Am J Sports Med 2010;38:1584-1590. 3. Wu PT, Jou IM, Yang CC, et al. The severity of the long head biceps tendinopathy in patients with chronic rotator cuff tears: Macroscopic versus microscopic results. J Shoulder Elbow Surg 2014;23:1099-1106. 4. Zhang Q, Zhou J, Ge H, Cheng B. Tenotomy or tenodesis for long head biceps lesions in shoulders with reparable rotator cuff tears: A prospective randomised trial. Knee Surg Sports Traumatol Arthrosc 2015;23:464-469. 5. Creech MJ, Yeung M, Denkers M, Simunovic N, Athwal GS, Ayeni OR. Surgical indications for long head biceps tenodesis: A systematic review. Knee Surg Sports Traumatol Arthrosc 2016;24:2156-2166. 6. Gombera MM, Kahlenberg CA, Nair R, Saltzman MD, Terry MA. All-arthroscopic suprapectoral versus open subpectoral tenodesis of the long head of the biceps brachii. Am J Sports Med 2015;43:1077-1083. 7. Sampatacos N, Getelman MH, Henninger HB. Biomechanical comparison of two techniques for arthroscopic suprapectoral biceps tenodesis: interference screw versus implant-free intraosseous tendon fixation. J Shoulder Elbow Surg 2014;23:1731-1739. 8. Su WR, Ling FY, Hong CK, Chang CH, Chung KC, Jou IM. An arthroscopic technique for long head of biceps tenodesis with double knotless screw. Arthrosc Tech 2015;4:e375-e378. 9. Su WR, Budoff JE, Chiang CH, Lee CJ, Lin CL. Biomechanical study comparing biceps wedge tenodesis with other proximal long head of the biceps tenodesis techniques. Arthroscopy 2013;29:1498-1505.
ARTHROSCOPIC TRANSTENDINOUS BICEPS TENODESIS 10. Yi Y, Lee JM, Kwon SH, Kim JW. Arthroscopic proximal versus open subpectoral biceps tenodesis with arthroscopic repair of small- or medium-sized rotator cuff tears. Knee Surg Sports Traumatol Arthrosc 2016;24:3772-3778. 11. Buchholz A, Martetschlager F, Siebenlist S, et al. Biomechanical comparison of intramedullary cortical button fixation and interference screw technique for subpectoral biceps tenodesis. Arthroscopy 2013;29:845-853. 12. Franceschi F, Longo UG, Ruzzini L, Rizzello G, Maffulli N, Denaro V. Soft tissue tenodesis of the long head of the biceps tendon associated to the Roman Bridge repair. BMC Musculoskelet Disord 2008;9:78. 13. Mazzocca AD, Cote MP, Arciero CL, Romeo AA, Arciero RA. Clinical outcomes after subpectoral biceps tenodesis with an interference screw. Am J Sports Med 2008;36:1922-1929. 14. Snir N, Hamula M, Wolfson T, Laible C, Sherman O. Long head of the biceps tenodesis with cortical button technique. Arthrosc Tech 2013;2:e95-e97. 15. Su WR, Ling FY, Hong CK, Chang CH, Lin CL, Jou IM. Subpectoral biceps tenodesis: A new technique using an all-suture anchor fixation. Knee Surg Sports Traumatol Arthrosc 2015;23:596-599. 16. Barber FA, Herbert MA. Cyclic loading biomechanical analysis of the pullout strengths of rotator cuff and glenoid anchors: 2013 update. Arthroscopy 2013;29:832-844.
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17. Mazzocca AD, Chowaniec D, Cote MP, et al. Biomechanical evaluation of classic solid and novel all-soft suture anchors for glenoid labral repair. Arthroscopy 2012;28: 642-648. 18. Lafosse L, Van Raebroeckx A, Brzoska R. A new technique to improve tissue grip: “The lasso-loop stitch”. Arthroscopy 2006;22:1246.e1-1246.e3. 19. 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. 20. Shon MS, Koh KH, Lim TK, Lee SW, Park YE, Yoo JC. Arthroscopic suture anchor tenodesis: Loop-suture technique. Arthrosc Tech 2013;2:e105-e110. 21. Kusma M, Dienst M, Eckert J, Steimer O, Kohn D. Tenodesis of the long head of biceps brachii: Cyclic testing of five methods of fixation in a porcine model. J Shoulder Elbow Surg 2008;17:967-973. 22. Mazzocca AD, Bicos J, Santangelo S, Romeo AA, Arciero RA. The biomechanical evaluation of four fixation techniques for proximal biceps tenodesis. Arthroscopy 2005;21:1296-1306. 23. Dwyer T, Willett TL, Dold AP, et al. Maximum load to failure and tensile displacement of an all-suture glenoid anchor compared with a screw-in glenoid anchor. Knee Surg Sports Traumatol Arthrosc 2013;24:357-364.
Abstract: There are several methods for long head of the biceps (LHB) tenodesis, yet the optimal option is still debatable. Here we introduce a technique for arthroscopic suprapectoral biceps tenodesis with an all-suture anchor, the transtendinous biceps tenodesis technique. The LHB tenodesis is performed by using the Y-Knot anchor (1.3-mm). A standard suprapectoral approach is used for the tenodesis. A 1.3-mm drill bit is used to drill through the midportion of the biceps tendon and underlying bone to make a pilot hole. Next, the Y-Knot anchor is passed through the tendon and anchored on the underlying bone. A wrapping suture technique is then used to wrap around, tension, and secure the LHB tendon with the aid of a shuttling polydioxanone suture. The construct is fixed by tying down both suture limbs in a nonsliding fashion. This Technical Note describes an alternative method for all-arthroscopic suprapectoral biceps tenodesis using an all-suture anchor with a small diameter to minimize trauma to the tendon.
P
athologic changes of the long head of the biceps brachii (LHB) tendon are a well-known cause of shoulder pain that are frequently associated with chronic rotator cuff tears or anterosuperior impingement syndromes.1-4 The biceps tenodesis procedure has been used in the treatment of partial tears, instability, tenosynovitis, and SLAP tears.1,2,4,5 Surgical options for the LHB itself include tenotomy and tenodesis. Tenotomy is generally reserved for older, less-active patients, and tenodesis is typically used for younger, more active patients and has the advantage of improved cosmesis and strength compared with tenotomy.1,2,4 There have been multiple arthroscopic techniques
From the Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University (C-A.S., C-K.H., C-W.L., I-M.J., W-R.S.), Tainan, Taiwan; University of Texas Health Science Center at San Antonio School of Medicine (F.L.C.), San Antonio, Texas, U.S.A.; Department of Orthopedics, Chi-Mei Medical Center (P-H.W.), and Medical Device Innovation Center, National Cheng Kung University (I-M.J., W-R.S.), Tainan, Taiwan. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received October 28, 2016; accepted January 30, 2017. Address correspondence to Wei-Ren Su, M.D., M.Sc., Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, 138 Sheng Li Road, Tainan 704, Taiwan. E-mail: [email protected] Ó 2017 by the Arthroscopy Association of North America 2212-6287/161056/$36.00 http://dx.doi.org/10.1016/j.eats.2017.01.018
developed for biceps tenodesis.6-10 The fixation technique can be performed using suture anchors, interference screws, cortical buttons, and soft tissue tenodesis.11-15 Yet, optimal treatment is still debatable. The all-suture anchor (ASA), composed of ultrahigh-molecular-weight polyethylene sutures that pass through a flexible tube of braided material, has been developed as new technology to reduce the biological impact on the patient in labral repair and rotator cuff repair.16,17 Recently, the ASA has been employed in the transtendinous repair of partial articular supraspinatus tendon avulsion (PASTA) type lesions and is advantageous because of the small size and soft texture, which may cause less damage to tendon tissue. We describe a technique of arthroscopically assisted suprapectoral biceps tenodesis, the transtendinous biceps tenodesis technique, which uses an ASA to efficiently perform a suture wrap and provide secure fixation of the biceps tendon.
Technical Note All surgical procedures are performed with the patient in the lateral decubitus position under general anesthesia; traction is applied on the affected limb with an adjunctive interscalene block (see Video 1). Standard posterior and anterior portals are made for glenohumeral joint exploration. An arthroscope is placed into the subacromial space through the posterolateral portal at 1 cm lateral and anterior to the posterolateral
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edge of the acromion. Subsequently, a bursectomy is performed to expose the LHB tendon, especially in the anterolateral aspect near the bicipital groove area through the lateral portal. The routine arthroscopic anatomic points are examined through the posterolateral and anterior portals. In cases with a concomitant rotator cuff tear, the LHB tendon is easily identified in the subacromial space through the posterolateral portal. However, if the supraspinatus were intact, especially the anterior portion of the supraspinatus tendon, exploration of the bicipital groove is necessary to expose the LHB tendon. It should be noted that the tenodesis is performed in full before cutting the intraarticular portion of the LHB tendon. The attachment of the LHB tendon may maintain physiologic length and tension of the LHB tendon and facilitate passing a Y-Knot anchor (ConMed, Utica, NY) through the tendon. After the LHB tendon in the bicipital groove is identified, the biceps sheath and upper portion of the transverse humeral ligament are released with a radiofrequency device. The biceps tendon is retracted from the bicipital groove near the articular entrance and suspended with a probe introduced from the anterior portal. This step helps facilitate the subsequent debridement of the groove surface and placement of the polydioxanone (PDS) suture. As the bicipital groove is exposed, a suture hook (Suture Hook, Spectrum II; Linvatec, Largo, FL) loaded with a PDS suture is placed through the anterior portal and passed under the LHB tendon (Fig 1). A suture retriever (Suture Retriever; Arthrex, Naples, FL) introduced through the lateral portal is used to grasp and pull out one limb of the PDS suture. Then, to aid in suture management, a switching stick is placed through the anterior cannula, after which the cannula is removed. The limb of the PDS suture in the anterior cannula is then pulled out of the cannula. Subsequently, the cannula is placed back over the stitching stick into the subacromial space, rendering the anterior cannula empty to facilitate the placement of the Y-Knot anchor. Arthroscopic Transtendinous Biceps Tenodesis With ASA The most common placement site for tenodesis is in the bicipital groove, approximately 1 cm distal to the starting point of the groove. A 1.3-mm drill bit is used to drill through the LHB tendon and underlying bone by using a drill guide placed on the midportion of the LHB tendon via the cannula (Threaded Cannula, 7 mm 72 mm; Smith & Nephew, Andover, MA) that was placed in the anterior portal to allow for passage of the Y-Knot anchor. Subsequently, the Y-Knot anchor is inserted through the drill guide and into the 1.3-mm pilot hole underlying the tendon by knocking at the anchor inserter handle (Fig 2). The suture is released from the handle by unscrewing the suture retention
Fig 1. Arthroscopic image of a right shoulder in the lateral decubitus position from the posterolateral viewing portal. A suture hook loaded with a PDS suture (arrow) is placed through the anterior portal and passed under the LHB tendon. (LHB, long head of biceps; PDS, polydioxanone.)
feature. Next, the anchor inserter handle is pulled back directly from the drill guide. Both sutures are lightly pulled to set the anchor until fully seated and abutting the cortex. One suture limb of the Y-Knot in the anterior portal is retrieved through the lateral portal by using the suture retriever and tied to the limb of PDS suture in the lateral cannula outside the lateral portal. Subsequently, the limb of PDS suture located outside the anterior cannula is retrieved back into the anterior cannula. By pulling the limb of PDS suture in the anterior cannula, the permanent suture is pulled retrograde, over, and under the tendon to wrap around the tendon (Fig 3). Then the same process is repeated for the other limb of the Y-Knot suture by using the same PDS shuttle suture to pull the permanent suture retrograde, over, and under the tendon to wrap around the tendon through the lateral cannula. Both limbs of the permanent suture are then retrieved back into the anterior cannula (Fig 4). After wrapping around the tendon, the suture limbs are tied together in a nonsliding fashion. Once the transtendinous tenodesis procedure is completed, secure fixation is confirmed with a probe, and the intra-articular portion of the LHB tendon is then excised. Postoperative rehabilitation after biceps tenodesis includes immobilization for 4 weeks in a sling at 90 of elbow flexion and neutral rotation, followed by gentle active elbow range of motion exercises, which can be adjusted according to the combined pathology.
Discussion This Technical Note describes a technique for arthroscopic suprapectoral biceps tenodesis with an ASA. In this transtendinous tenodesis procedure, a small perforation is made with a drill bit followed by the Y-Knot anchor insertion through the tendon and into
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Fig 2. Arthroscopic image of a right shoulder from the posterolateral viewing portal. The Y-Knot anchor (arrow) is inserted through the drill guide at the midportion of the tendon into the 1.3-mm pilot hole underlying the tendon via the anterior portal.
the underlying bone. The suture attached to the Y-Knot anchor is used to wrap the tendon. The Y-Knot anchor, with a smaller diameter and consisting of only soft components, has the benefit of causing less damage to tendon tissue, which may lead to improved mechanical strength of the tenodesis construct. ASAs have recently been introduced for use in arthroscopic PASTA repairs and are advantageous in causing less damage to tendon, preserving native tissue, and re-establishing the normal footprint of the rotator cuff. Given the common practice of ASA fixation in the shoulder, the transition to biceps tenodesis seems like a logical progression. The proposed technique offers some advantages. First, trauma of the Y-Knot anchor to the tendon fibers at the time of insertion is likely to be reduced compared with the ordinary threaded anchor. Zhang et al.4 compared the damage to the rotator cuff
Fig 4. Arthroscopic image of a right shoulder in the lateral decubitus position from the posterolateral viewing portal. Both limbs of the Y-Knot suture are wrapped securely around the tendon through the anterior cannula.
tendons caused by 4 different anchor systems in a cadaver transtendon rotator cuff repair model and found that smaller anchors caused less damage to the tendon tissue. They concluded that smaller anchors should be considered when performing transtendon procedures to repair partial rotator cuff tears. We speculate that the Y-Knot anchor may cause less disruption of surrounding tissue given its smaller diameter (1.3 mm) and smooth surface; also, given the mechanism of the Y-Knot insertion, the tendon tissue is not screwed and crushed under the threads of the more commonly used anchors. Second, this wrapping suture technique, similar to other lasso-loop stitch techniques,18-20 could increase the fixation strength by incorporating the entire circumference of the tendon instead of only grasping a fraction of the thickness of the biceps tendon,21,22 which may decrease the risk of suture slippage. Third, placement of the wrapping sutures with the aid of a PDS shuttle suture is a more Table 1. Advantages and Disadvantages of Arthroscopic Transtendinous Biceps Tenodesis With All-Suture Anchor Advantages 1. Relatively safe, and reproducible 2. Minimal LHB tendon injury
Fig 3. Arthroscopic image of a right shoulder from the posterolateral viewing portal. One limb of the Y-Knot suture is shuttled retrograde and wrapped around the tendon by pulling the limb of the PDS suture in the anterior cannula. (PDS, polydioxanone.)
3. Small pilot hole in cortical bone drilling 4. Better fixation with wrapping suture technique 5. Placement of the wrapping sutures with the aid of only 1 PDS shuttle suture is an efficient method 6. Fewer operative steps and less surgical time
Disadvantages 1. Arthroscopic tenodesis can be technically challenging 2. Knots tied over the LHB tendon may cause irritation under the coracoid process 3. Epiosseous tenodesis may reduce tendon healing potential
LHB, long head of biceps; PDS, polydioxanone.
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Table 2. Pearls and Pitfalls of Arthroscopic Transtendinous Biceps Tenodesis With All-Suture Anchor Pearls
Pitfalls
1. Maintain the drill guide positioned and oriented correctly to allow for passage of the Y-Knot anchor through the drill guide and into the 1.3-mm pilot hole underlying the LHB tendon 2. The PDS shuttle suture should be tied around the permanent suture limb by a simple half-hitch located in proximity to the middle of the PDS suture to avoid the PDS suture escaping from the cannula while pulling the other limb of the PDS suture in the opposite cannula
1. Dislocated LHB tendon possibly impeding tenodesis and removal of tenotomized proximal LHB tendon portion
2. Eccentric drilling impairing tenodesis fixation strength and increasing risk of iatrogenic tendon damage
LHB, long head of biceps; PDS, polydioxanone.
efficient and reproducible method compared with other lasso-loop stitch techniques. Thus, lessening the technically demanding portions of the procedure is a significant positive when evaluating various techniques for the same indication. Additional advantages and disadvantages, as well as the pearls and pitfalls of this technique, are detailed in Tables 1 and 2. Although the ASA may cause less damage to surrounding structures given its less intrusive anchor size, one logical question to ask is whether or not the smaller Y-Knot anchor will provide adequate fixation strength for biceps tenodesis. Dwyer et al.23 reported that the Y-Knot anchor revealed a median force to failure of 145 N (range 125-165 N) in human cadaver glenoid models. Su et al.15 described a new technique for open subpectoral biceps tenodesis using a 1.3-mm Y-Knot fixation that provided ultimate failure load and stiffness comparable to those with the interference screw technique. Our mechanical strength pilot study revealed an ultimate failure load of 166 25 N for the transtendinous Y-Knot anchor fixation construct. The threshold for sufficient pullout strength was approximately 112 N when holding a 1 kg weight at 90 of elbow flexion, which is defined as the threshold that the biceps tenodesis construct should achieve.19 Therefore, during early motion rehabilitation programs without heavy weight-bearing after biceps tenodesis surgery, the transtendinous Y-Knot anchor fixation should provide sufficient biomechanical strength. Further biomechanical studies should be completed to prove the security of the fixation construct. This technique has some potential limitations. First, tendon damage may occur at the perforated site during the transtendinous procedure regardless of the smaller
diameter and softer texture of the Y-Knot although the adverse effects of tendon damage on the healing and mechanical strength of the transtendinous tenodesis construct are unclear. Second, this technique employs suture wrapping around the LHB tendon, which is knotted over the tendon; the knots tied over the tendon may cause irritation under the coracoid process and coracoacromial ligament. Third, the LHB tendon is fixed on the surface of the humeral cortex, with partial contact of the tendon with the bone. Thus, there is a possibility of reduced healing compared with intramedullary canal fixation in interference screw tenodesis. However, tenodesis with the loop-suture technique has had good to excellent results with both suprapectoral and subpectoral approaches in the literature.2 Therefore, this application of the ASA for transtendinous fixation may serve as a reliable, easily reproducible, and efficient method for arthroscopic suprapectoral biceps tenodesis.
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