Proximal biceps tenodesisArthroscopicIndicationPain associated with significant tenosynovitis of biceps tendon. Pre-rupture of the tendon. Subluxation. Dislocation.
Procedure may be undertaken: 1) In association with arthroscopic or mini-open rotator cuff repairs. 2) In cases of isolated injury of the biceps tendon with an intact cuff, especially in a young athlete, presenting as tendonitis, subluxation, pre-rupture or type 4 superior labrum anterior posterior (SLAP) lesions with large extension into the biceps anchor. 3) In cases of massive, degenerative, and irreparable cuff tears with a pathologic biceps tendon, in which a tenodesis may be preferred to a simple tenotomy, especially in the elderly but active and muscular patient.
Boileau results: The Constant score averaged 43 (13–60) before surgery and 79 (59–87) post surgery.
Anatomy
ConsiderationsTenodesis Vs Tenotomy Tenodesis of the biceps may be preferable to simple tenotomy to avoid distal retraction and bulging of the biceps muscle resulting in a cosmetic deformity (popeye) and slight decrease in supination strength. Armstrong 2004 suggested simple tenotomy should be considered in patients older than 50.
PositioningArthroscopy beach-chair position (see arthroscope positioning). Shoulder should be placed in approximately 30° of flexion, 10° to 30° of internal rotation, and 30° of abduction (arthrodesis position), allowing the anterior part of the subacromial bursa to be adequately filled with water in order to have a clear view of the superior part of the bicipital groove. Flex elbow to 90°. Use a classic U-shaped Trillat knee support with a Mayo stand to place the shoulder in the desired position. Alternatively use a sterile articulated arm holder. (eg Spider)
PortalsDraw bony landmarks Spine of the scapula Acromion Coracoid process Coracoacromial ligament.
Three portals Posterior portal 1.5 cm inferior and 1.5 cm medial to the posterolateral corner of the acromion. 2 anterior portals: Anteromedial and Anterolateral, 1.5 cm on each side of the bicipital groove with arm in slight internal rotation. Alternatively: Anterolateral portal is located approximately 2 cm distal to the anterolateral corner of the acromion, along the path of the deltoid fibres. The anteromedial portal corresponds to a low anterior portal just above the intraarticular portion of the subscapularis tendon and lateral to the coracoid process. The posterior and anterolateral
portals are viewing portals.
ProcedureSeveral steps: Glenohumeral Exploration and Tenotomy of the Long Head of the Biceps Location and Opening of the Bicipital Groove after Anterosuperior Bursectomy Biceps Exteriorization and Preparation
Glenohumeral Exploration and Tenotomy of the Long Head of the BicepsPerform Standard shoulder arthroscopy with 30° scope through the posterior portal. Establish an anteromedial portal with a cannula through the rotator interval, lateral to the coracoid process and the coracoacromial ligament, and just above the subscapularis tendon. Assess the rotator cuff and confirm biceps tendon pathology. Remeber to draw biceps tendon into joint with the probe, the pathology is very often in the intertubercular groove portion. Transfix the long head of biceps with a spinal needle at its entrance into the groove: this avoids its retraction into the groove and helps identify its location during subacromial bursoscopy. Detach the tendon from its glenoid insertion using a knife, a punch, or electrocautery.
Location and Opening of the Bicipital Groove after Anterosuperior BursectomyWithdraw, redirect and insert the posterior scope into the subacromial bursa. The same is done for the anteromedial cannula, which is placed into the anterosuperior bursa (lateral to the coracoacromial ligament). Excise bursa, and create the (third) anterolateral portal: 1.5 cm lateral to the biceps tendon, 1 cm distal to and 2 to 3 cm lateral to the anteromedial portal. A space of 2 or 3 cm between the anteromedial and anterolateral portals is necessary for triangulation. Remove the arthroscope from the posterior portal and place in the anterolateral portal while an outflow cannula is placed posteriorly using a switching stick. At this point, the anteromedial portal is the working portal, the anterolateral portal is the viewing portal, and the posterior portal is for outflow only. Instruments are placed in the anteromedial portal to continue the bursectomy and identify the bicipital groove. Shaving of the anterior part of the bursa is essential for visualization and is continued until the spinal needle is located. It is important to maintain elbow flexion during subacromial bursoscopy to prevent dislodging of the spinal needle from the cut biceps tendon. Maintain low pump pressure (40 mm Hg or less) during bursoscopy to prevent excessive soft tissue distension. The rotator cuff is evaluated and, if no tear is found, its insertion into the greater tuberosity is identified. A probe is used to palpate the “soft spot” corresponding to the bicipital groove, which is usually just medial to the lateral part of the greater tuberosity. This step is often facilitated by a rotator cuff tear. If a rotator cuff tear is encountered, the biceps tenodesis is performed as described, and the cuff is subsequently repaired by either arthroscopic or mini-open technique. The probe can be used to feel the roll of the biceps tendon in its groove. The transverse humeral ligament is now opened in a longitudinal fashion, using an electrocautery because of the leash of vessels on either border of the groove. Once the groove is open, the long head of the biceps is probed. A marker suture can be placed through the biceps tendon using any commercially available arthroscopic suturing instrument, and the corresponding position of the suture is marked in the bicipital groove with electrocautery, to locate the future position of the humeral socket and to guide in setting the tension in the tendon during implantation. (As experience is gained in this technique this step is no longer necessary to appropriately restore biceps myotension.) Lift the biceps tendon out of the groove, this step is much easier when there is a large cuff tear, with the biceps uncovered when it enters the superior part of the groove. While the surgeon is learning this technique, it can be difficult to identify the groove if there is a small cuff tear or a waterproof cuff, with the intra-articular portion of the biceps being covered by the capsule of the rotator interval.
Biceps Exteriorization and PreparationThe long head of the biceps is grasped in its groove with a forceps while the spinal needle is removed. The biceps should then be grasped by its most proximal end with an arthroscopic grasper to facilitate exteriorization. Exterriorize the tendon through the anteromedial portal while the cannula is temporarily removed. Use a vascular clamp to grasp the
tendon outside the
body more distally; this helps to avoid tendon damage and to allow tendon
preparation. About 4 to 5 cm of tendon should be exteriorized and the tendon is
prepared. Again, the tendon should be doubled and sewn to its anterior face for a length of approximately 2 cm, where a mark is made with a sterile marking pen. This mark is used to verify that the tendon is pulled sufficiently into the humeral socket. By resecting the proximal centimeter, and doubling over a length of 2 cm, appropriate muscular tension is restored with the tenodesis technique obviating the need for a marker suture as previously indicated. The diameter of the double tendon is measured using the same type of graft sizer used in the knee. The diameter of the double tendon should be 7 or 8 mm. The size of the double tendon determines the drill diameter needed to drill the humeral socket. The arthroscopic working cannula is reintroduced into the anteromedial portal while the biceps tendon remains outside the wound and outside the cannula; this is facilitated by placing the No. 5 suture under tension by attaching it to the sterile drapes with a nonpenetrating clamp.
Drilling the Humeral SocketThe bicipital groove is cleaned of all fibrous tissue with the shaver or the VAPR device. Care must be taken not to shave on the most lateral or medial parts of the groove, because this will cause the leash of several small vessels there to bleed. Socket placement is assessed with probe measurement: it is optimally placed approximately 10mm below the top of the groove entrance to prevent any anterosuperior impingement with the acromial arch. The location of the humeral socket is identified and penetrated with a sharp-tipped pick or awl, because the bone within the groove is quite hard; this prevents skivving or sliding of the guide pin along the cortical bone of the groove during drilling. A guide wire is then placed in the pilot hole and oriented strictly perpendicular to the humerus and parallel to the lateral border of the acromion, while the arm is placed next to the trunk (still in 30° of internal rotation with the elbow flexed to 90°) for the rest of the procedure. The guide wire is drilled until it just penetrates the posterior cortex of the humerus. The humeral guide pin is overdrilled with a 7- or 8-mm cannulated reamer, depending on the size of the double tendon, to a depth of 20 to 25 mm. The reamer and guide pin are then removed. Note that all of this work is done through the anteromedial (working) portal. The motorized shaver and an arthroscopic burr are placed through the same portal and into the humeral socket to chamfer smooth its entrance by removing bone debris and tissues that may contribute to tendon blocking and abrasion. Most attention should be paid to the inferior part of the humeral socket, where the tendon will enter.
Passing the Trans-humeral PinA Beath needle pull-through technique is used for tendon placement. This needle has an eyelet on its trailing end and serves as a suture passer. The Beath pin is placed through the anteromedial cannula into the humeral socket. The direction of the trans-humeral Beath pin is very important: it should be strictly perpendicular to the
humerus and parallel to the lateral border of the acromion. Both ends of the No. 5 suture are threaded
through the eyelet of the Beath pin, and the pin and
sutures are pulled through the humerus. The suture is
used to pull the biceps tendon into the humeral socket. The ink mark at the base of the doubled portion of the tendon is visualized to insert completely into the humeral socket.
Interference Screw FixationThe tendon is fixed in the hole using a bioabsorbable
interference screw, whose dimensions are 9 × 15 mm or
9 × 20 mm. As a general rule, use a 9 ×
15-mm interference screw for a 7- or 8-mm socket diameter. After complete insertion of the tendon, fixation is checked by probing the biceps tendon. After flexing and extending the elbow, fixation of the tendon is rechecked. The transverse humeral ligament may be sutured if desired using a suture hook, and the rotator cuff is repaired if a tear is present.
ModificationsWith the use of the biotenedesis set (Arthrex) its possible to insert the tendon into tunnel without drilling a beath pin through the humerus (risking injury to the axillary nerve).
Closure
Post operativelyFull passive and active elbow flexion and extension, full supination, and full pronation are allowed the day of surgery with no restriction and no immobilization. In cases of isolated biceps tenodesis, complete passive and active motion is allowed for the shoulder. In cases with associated cuff repair, only early passive motion is allowed for the shoulder. Elbow flexion and extension, supination, and pronation activities under stress are restricted for 6 weeks after the tenodesis.
ComplicationsFailure of tenodesis (2/43) Boileau et
al suggests double tendon over to increase diameter for better fit,
especially if thin frail tendon. The screw diameter should be 1 or 2 mm larger
than the socket diameter, as a rule. Because of the average size of the biceps
tendon, they usually drill a 7- or
8-mm humeral socket and systematically use a 9-mm interference screw. Axillary nerve injury Not reported but theoretical possibility where use of trans humeral beath pin. Consider use of biotenedesis set as opposed to using trans humeral beath pin. (see modifications) If not available pay careful attention during while passing the trans-humeral Pin.
References
BOILEAU, PASCAL M.D.; KRISHNAN, SUMANT G. M.D.; COSTE, JEAN-SEBASTIEN M.D.; WALCH, GILLES M.D. Arthroscopic Biceps Tenodesis: A New Technique Using Bioabsorbable Interference Screw Fixation. Techniques in Shoulder & Elbow Surgery. 2(3):153-165, September 2001.
Elkousy, Hussein A. MD; Fluhme, Derrick J. MD; O'Connor, Daniel P. PhD; Rodosky, Mark W. MD Arthroscopic Biceps Tenodesis Using the Percutaneous, Intra-articular Trans-tendon Technique: Preliminary Results. Orthopedics. 28(11):1316-1319, November 2005.
Armstrong, April D Biceps tenodesis versus tenotomy. Current Opinion in Orthopedics. 15(4):239-241, August 2004.
Edwards, T. Bradley MD *; Walch, Gilles MD + Open Biceps Tenodesis: The Interference Screw Technique. Techniques in Shoulder & Elbow Surgery. 4(4):195-198, December 2003. Page created by: Lee Van RensburgLast updated 11/09/2015 |