Intra-articular Double-Anchor Double-Loop Figure-of-Eight Transtendon Long Head of the Biceps Tendon Tenodesis

Abstract

Tenodesis emerges as the gold standard for pathologic lesions of the long head of the biceps tendon. Various arthroscopic or open techniques have been described and intra-articular single-anchor methods may penetrate the tendon aggressively and decrease fixation strength. We describe an all-arthroscopic intra-articular double-anchor double-loop figure-of-eight transtendon tenodesis technique using all-suture anchors. This technique may balance tendon preservation with biomechanical stability—a critical trade-off in current surgical strategies.

Pathologic lesions of the long head of the biceps tendon (LHBT) often are responsible for anterior shoulder pain,^1,2 with tenodesis emerging as the gold standard for refractory conditions including partial tears, instability, and labrum lesions.^1,3 Although traditional tenotomy demonstrates pain relief, it carries a 20% risk of Popeye deformity^4,5 and 10% strength deficit in supination,⁶ driving the evolution toward tendon-preserving fixation techniques.

Current intra-articular tenodesis methods using single-anchor fixation face 2 critical limitations: decrease in strength under cyclic loading,⁷ and aggressive tendon penetration during suture passage compromises vascularity.⁸ Recent innovations in all-suture anchors and minimally invasive tendon handling have yet to address the fundamental conflict between fixation strength and tissue preservation.^9,10

We present the intra-articular double-anchor double-loop figure-of-eight transtendon biceps tenodesis (DADL-8T), a technique that integrates 3 biomechanical principles: transtendon-sparing with fish-mouth dilation technique, dual fixation matrix with double anchor and double loop, and stress distribution with figure-of-eight suture configuration. This procedure was completed through intra-articular portals only. V-lock all-suture anchors were used for the tenodesis procedures.

Surgical Technique

Positioning and Portal Establishment

The patient is placed in the standard lateral decubitus position with the affected shoulder positioned upward. The torso is stabilized using a beanbag positioning system, and the head is supported with padding to maintain neutral alignment. The operative arm is placed in 30° of abduction and 15° of forward flexion using a balanced suspension system with 5 to 10 lbs of traction to optimize intra-articular visualization.¹¹

A diagnostic arthroscopy is initiated via the posterior portal, established 2 cm inferior and 1 cm medial to the posterolateral acromial border. A 30° arthroscope is introduced into the glenohumeral joint to evaluate the biceps tendon, rotator cuff, and labral structures. The anterior portal is then created under direct visualization using an outside-in technique, positioned midway between the coracoid process and the anterolateral acromion. This portal serves as the primary working channel for intra-articular instrumentation, including probes and biters. For the biceps tenodesis, an anterolateral portal is established 1 cm lateral to the anterolateral acromion edge, angled toward the bicipital groove.¹² This portal facilitates access to the subdeltoid space and distal biceps sheath. Before portal placement, spinal needle localization is used to confirm trajectory and avoid neurovascular structures.

Tendon Preparation

The pathologic long head of biceps tendon (LHBT) is identified through the posterior portal. The LHBT tendon is thoroughly released from the bicipital sheath through the anterolateral portal. After the position of the anchor is confirmed, the bone bed is prepared using a planer. A fish-mouth dilation technique is performed using a curved guide device (Delta Medical, Beijing, China) inserted via the anterolateral portal. The guide device is used to make a controlled longitudinal splitting in the midportion of LHBT at the proximal inlet of the groove. This preserves 80% to 90% of the native tendon architecture.

Proximal and Distal Anchor Fixation

A 1.6-mm transtendinous pilot hole is drilled using the guided cannula system (Delta Medical), followed by insertion of a 1.8-mm V-lock all-suture anchor (Delta Medical). After anchor insertion, a limb is passed beneath the tendon to loop the LHBT from the posterior to the anterior, and another limb is passed in the opposite direction. Both suture limbs are retrieved through the anterolateral portal, creating a circumferential double-loop around the LHBT (Fig 1).

Fig 1.

Tendon preparation and proximal anchor fixation for the LHBT in right shoulder. (A) Tendinopathy of LHBT viewed from posterior portal of shoulder. (B) The bone bed is prepared using a planer after confirming the targeted position of proximal anchor on humeral head (HH). (C) Fish-mouth tendon dilation technique (black arrow) is used for controlled longitudinal splitting in the midportion of LHBT at the proximal groove inlet. (D) A 1.6-mm V-lock all-suture anchor is placed through the transtendinous pilot hole from the ASL portal. (E) A limb is passed beneath the tendon to loop LHBT from posterior to anterior, another limb was passed in opposite direction. (F) First double-loop (black arrow) demonstrating tendon-bone compression. Patient is placed in lateral decubitus position and posterior portal serves for observation and ASL portal serves for operation. (ASL, anterosuperalateral; HH, humeral head; LHBT, long head of the biceps tendon.)

A second all-suture anchor is placed 1 cm distal to the first using identical technique. Suture limbs are similarly passed around the tendon to form a second independent loop (Fig 2).

Fig 2.

Distal anchor fixation and final knotting for the LHBT in right shoulder. (A) Fish-mouth tendon dilation technique (black arrow) is used for distal anchor fixation. (B) A 1.6-mm V-lock all-suture anchor is placed through the transtendinous pilot hole, the first loop (black arrow) is also demonstrated. (C) A limb is passed beneath the tendon to loop the LHBT from posterior to anterior, and another limb is passed in opposite direction. (D) Another double-loop demonstrating tendon-bone compression (black arrow). (E) Figure-of-eight suture configuration is shown. (F) Configuration after final knotting and fixation. The patient is placed in the lateral decubitus position and posterior portal serves for observation and ASL portal serves for operation. (ASL, anterosuperalateral; LHBT, long head of the biceps tendon.)

Knotting and Final Fixation

The proximal loop suture limbs are tied with simple knots using a sliding knot pusher to complete the preliminary tenodesis construct. This completes a point fixation achieving anchor-tendon-bone stability. Subsequently, both pairs of suture limbs (from proximal and distal anchors) are combined and tied with figure-of-eight knot over the tendon surface, achieving double surface fixation. The cross-linked suture matrix compresses the tendon-to-bone interface. After tenodesis, biceps tenotomy is performed at the insertion site of the LHBT, preserving at least 0.5 cm of biceps-tendon stump proximal to the tenodesis site (Figs 2 and 3).

Fig 3.

The schematic diagram of double-anchor double-loop figure-of-eight trans-tendon LHBT tenodesis (right side). (A) The proximal and distal all-suture anchor is placed through the transtendinous pilot hole using the fish-mouth tendon dilation technique. (B) The limb is passed beneath the tendon to loop the LHBT from the posterior to the anterior, another limb was passed in the opposite direction. (D) Double loop is completed. (D) Figure-of-eight suture configuration after final knotting and fixation. (HH, humeral head; LHBT, long head of the biceps tendon.)

Postoperative Care

Immediate passive range of motion is permitted with elbow flexion restricted to <1 kg resistance for 6 weeks. Progressive strengthening commences at 8 weeks, guided by our institution's biceps preservation rehabilitation pathway.

Discussion

We present an all-arthroscopic intra-articular DADL-8T LHBT tenodesis technique using all-suture anchors. This technique introduces several technique innovations by combining the fish-mouth dilation technique with a dual-anchor fixation. This method aims to balance tendon preservation with biomechanical stability—a critical trade-off in current surgical strategies.

The fish-mouth dilation technique represents a deliberate shift from complete tenotomy or aggressive tendon splitting. By creating controlled longitudinal splitting, this approach preserves the continuity of the LHBT's collagen framework while allowing sufficient exposure for anchor placement. This may theoretically maintain the tendon's proprioceptive function and vascular supply, factors known to influence postoperative healing.¹³

All-suture suture anchor is a viable fixation method for LHBT in comparison with conventional interference screws and suture anchors in terms of biomechanical properties.¹⁴ However, the fixation strength of different configurations is not consistent. Transtendinous LHBT tenodesis have been promoted as attractive alternatives because the suture-wrapping techniques are simplified and can be easily performed.^15,16 Neither the simple stitch nor the mattress suture method is enough to securely fix the LHBT with a significantly lower mechanical strength. However, the 2 simple stitches method show similar initial fixation strength as the lasso-loop technique,⁷ and the double-lasso loop technique has lower displacement after cyclic loading compared with interference screw fixation.¹⁷ Our dual-loop design serves 2 primary functions: first, it creates a circumferential "cradle" effect around the tendon, distributing tensile loads more evenly than linear suture patterns; second, the crossed suture limbs may act as internal splints, resisting rotational forces during arm movement. This geometric advantage becomes particularly relevant in cases requiring multiplanar stability, such as overhead athletes with combined rotator cuff and biceps pathology (Table 1).

Table 1.

Advantages and Disadvantages

Advantages

The technique is entirely performed within the glenohumeral joint.

Fish-mouth transtendinous dilation technique minimizes iatrogenic tendon damage.

Combined point-surface fixation increases load-sharing capacity owing to more suture fixation point and the risk of Popeye deformity is reduced.

Disadvantages

Finding the anchor’s pilot hole can be challenging for less-experienced surgeons.

All-arthroscopic multiple limb passings may be challenging for less-experienced surgeons.

There is a risk of anchor-related morbidity and insertion pain.

The figure-of-eight suture configuration complements this design by creating multidirectional compression forces across the tendon-bone interface,¹⁸ potentially reducing the risk of stress concentration at single fixation points—a common failure mechanism observed in simple stitch configurations.¹⁹

This technique allows for tailored applications across diverse clinical scenarios. In patients with osteoporosis, the dual-anchor system provides redundancy against potential anchor migration. For revision cases, the minimal bone removal characteristic of all-suture anchors preserves options for subsequent procedures. As with any surgical technique, the major disadvantage of this technique is that there is a learning curve, especially because of the all-arthroscopic intra-articular line-crossing procedure. However, this technique is basically a combination of basic arthroscopic procedures. We believe that with proper surgical preparation and training, this technique may provide excellent outcomes.

In conclusion, DADL-8T is an all-arthroscopic intra-articular double-anchor double-loop figure-of-eight trans-tendon LHBT tenodesis technique using all-suture anchors. This technique is a viable option for the arthroscopic management of LHBT tenodesis.

Disclosures

All authors (J.S., T.L., Z.J., L.F.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

The patient is positioned in lateral decubitus position. Three portals, namely the posterior viewing portal, anterior working portal, and anterolateral portal, are established. The anterior and anterolateral portal are created under direct visualization via an outside-in technique. The pathologic long head of the biceps tendon is identified through the posterior portal, and the tendon is fully released from the bicipital sheath through the anterolateral portal. After confirming the position of the anchor, the bone bed is prepared using a planer, and a fish-mouth dilation technique is carried out with a curved guide device inserted. A 1.6-mm transtendinous pilot hole is drilled with the guided cannula system, followed by the insertion of a 1.8-mm V-lock all-suture anchor. Once the anchor is inserted, a limb is passed beneath the tendon to loop the LHBT from the posterior to the anterior, and another limb is passed in the opposite direction. Both suture limbs are retrieved through the anterolateral portal, creating a circumferential double-loop around the LHBT. A second all-suture anchor is placed 1 cm distal to the first using the same technique, and suture limbs are similarly passed around the tendon to form a second independent loop. The proximal loop suture limbs are tied with a sliding knot pusher to complete the preliminary tenodesis construct, thus achieving anchor-tendon-bone stability. Subsequently, both pairs of suture limbs from the proximal and distal anchors are combined and tied with a figure-of-eight knot over the tendon surface, achieving double surface fixation. The cross-linked suture matrix presses the tendon to the bone interface, and finally, scissors are used to remove the excess sutures. (LHBT, long head of the biceps tendon.)