Abstract
Existing arthroscopic techniques of proximal biceps tenodesis may be complicated by difficulty of tendon identification, restoration of length-tension relation, cosmetic deformity, persistent biceps pain, and shoulder stiffness requiring surgical revision in a relevant proportion of cases. In this context, biceps tenoscopy, an emerging discipline of shoulder endoscopy, offers major benefits. Tenoscopy comprises endoscopic treatment of tendons and tendon sheaths. The presented technique of tenoscopic suprapectoral biceps tenodesis (TSBT) substantially facilitates tendon identification and reduces invasiveness by avoidance of unnecessary surgical involvement of the deltoid space and bursa. TSBT enables effective treatment of the biceps tendon and surrounding tissues (biceps tendon sheath, tenosynovium, transverse humeral ligament) being consistently involved in proximal biceps pathologies. The physiological length-tension relation of the musculotendinous unit is reliably maintained. Technically, the procedure of tenodesis is simplified and accelerated by redundancy of tendon exteriorization. The aforementioned benefits of TSBT may lead to superior clinical and cosmetic outcomes and lower incidences of persistent proximal biceps pain and postoperative shoulder stiffness compared with conventional techniques of arthroscopic biceps tenodesis.
Over the past few years, interest in tenodesis of the long head of the biceps tendon (LHBT) has continually increased particularly regarding minimally invasive and arthroscopic techniques.1 Unsatisfactory high rates of cosmetic deformity, muscular fatigue, and cramping after tenotomy in view of steadily increasing patient demands contribute to this still ongoing trend.
Arthroscopic biceps tenodesis (ABT) may be performed at various locations of the suprapectoral region ranging from the articular margin to the superior border of the pectoralis major tendon (PMT). However, ABT still represents a challenging procedure being associated with several unsolved issues: difficulty of LHBT identification in the suprapectoral region because of bicipital sheath coverage (particularly in rotator cuff–intact shoulders), restoration of the physiological length-tension relation, structural failure of tenodesis, persistent bicipital groove pain particularly after high tenodesis, and increased rates of shoulder stiffness compared with mini-open subpectoral tenodesis.2, 3, 4, 5
Recently, the procedure of biceps tenoscopy was introduced for the treatment of primary synovial chondromatosis involving the biceps tendon sheath (BTS).6 The authors suggested further fields of application such as use of biceps tenoscopy for suprapectoral biceps tenodesis. The presented technique of tenoscopic suprapectoral biceps tenodesis (TSBT) solves relevant problems of conventional techniques of ABT. TSBT eases LHBT identification particularly in rotator cuff–intact shoulders, reduces invasiveness by avoidance of unnecessary surgical involvement of the subdeltoid space, and enables maintenance of the physiological length-tension relation of the bicipital musculotendinous unit. Tenoscopic treatment of the biceps tendon and surrounding tissues (BTS, tenosynovium, transverse humeral ligament [THL]) being consistently involved in proximal biceps pathologies may lower the incidence of persistent proximal biceps pain. In addition, the procedure of tenodesis is technically simplified by redundancy of extracorporeal LHBT exteriorization. This technical note provides a detailed stepwise description of the operative technique of TSBT including indications and contraindications, fundamental anatomic considerations, and technical pearls and pitfalls, as well as potential risks and complications.
Surgical Technique
The indications and contraindications for TSBT are listed in Table 1.
Table 1.
Indications and Contraindications
| Indications |
| Intra-articular partial LHBT tear |
| SLAP lesion for which anatomic reconstruction is not appropriate |
| LHBT instability with tenoscopically identifiable and reducible LHBT (e.g., pulley lesion) |
| Refractory symptomatic LHBT tendinitis |
| Entrapment of LHBT (hourglass biceps) |
| Bony BG pathology (e.g., osteophyte, degenerative, post-traumatic) |
| Contraindications |
| High-grade partial tear (thinning) of LHBT at or below designated site of tenodesis |
| Complete, retracted LHBT tear |
| Severe and fixed LHBT dislocation with tenoscopically non-identifiable or non-reducible LHBT (e.g., chronic pulley lesion) |
| Previous LHBT or BTS surgery with significant scar formation impeding biceps tenoscopy |
| Anatomic variants of intra-articular LHBT (e.g., adherence or aberrance) |
BG, bicipital groove; BTS, biceps tendon sheath; LHBT, long head of the biceps tendon.
Anatomic Considerations
The choice of tenodesis site and respective anatomic conditions substantially influence potential risks, complications, and outcomes of biceps tenodesis. We recommend performing TSBT at the dia-metaphyseal junction of the proximal humerus inferior to the transverse branch of the anterior circumflex humeral artery (ACHA), crossing the bicipital groove about 3 cm inferior to the articular margin, just below the lower subscapularis (SSC) border.2, 7 The transverse branch delivers ascending branches running proximally lateral and medial to the LHBT and descending branches proceeding distally on the floor of the bicipital groove.7 Throughout the procedure, care must be taken not to injure the ACHA or its ascending branches to avoid bleeding and to prevent humeral head ischemia. Further anatomic structures at risk are the cephalic vein and the musculocutaneous nerve (Table 2). The dia-metaphyseal junction provides ideal conditions for strong but not too rigid intraosseous interference screw fixation of the LHBT. Subpectoral tenodesis with diaphyseal fixation in cortical bone may cause humeral strength reduction and biomechanical stress rising at the site of tenodesis, potentially leading to iatrogenic fracture.8 Recently, Taylor et al.9 defined 3 distinct zones of the extra-articular LHBT and bicipital tunnel: zone 1, extending from the articular margin to the inferior SSC border (i.e., bony groove); zone 2 (i.e., no man's land), extending from the inferior SSC border to the superior PMT border; and zone 3 (i.e., subpectoral region). The recommended site of tenodesis is located superiorly within zone 2, preferably at the lower extension of the bicipital groove.
Table 2.
Potential Risks and Complications
| Injury to rotator cuff (anterior supraspinatus tendon) caused by malplacement of TP |
| Insufficient tenoscopic visibility due to, for example, BTS adhesions, scarring, or bleeding (“red out”), with need for conversion to open surgery |
| Injury to ACHA or lateral ascending branch causing, for example, bleeding, hematoma, or partial humeral head ischemia |
| Injury to cephalic vein and musculocutaneous nerve |
| Primary or secondary iatrogenic fracture of proximal humerus originating from drill hole |
| Failure to remove detached proximal LHBT portion by tenoscopic or arthroscopic means |
ACHA, anterior circumflex humeral artery; BTS, biceps tendon sheath; LHBT, long head of biceps tendon; TP, tenoscopy portal.
Patient Positioning
Surgery was performed by the first author (D.M.) using a standard 4.0-mm, 30° arthroscope (Arthrex, Naples, FL). The patient was positioned in the beach-chair position with the arm preferably held by an assistant or placed in an adjustable arm holder (Trimano; Arthrex) (Fig 1). Alternatively, the patient can be placed in the lateral decubitus position. However, the surgeon has to ensure feasibility of free arm and elbow movement.
Fig 1.
Patient positioning and portal placement. A right shoulder is shown with the patient in the beach-chair position. (A) The posterior portal (PP), tenoscopy portal (TP), anterior portal (AP), high suprapectoral tenodesis portal (HTP), and low suprapectoral tenodesis portal (LTP) are marked (viewed from lateral). (B) The arthroscope is placed in the PP for glenohumeral arthroscopy, and an 8.25-mm working cannula is inserted into the AP (viewed from anterolateral). (C) Correct TP localization is verified with a K-wire before definite portal placement (viewed from posterolateral). (D) In this case, a standard 4.0-mm, 30° arthroscope is used for biceps tenoscopy (viewed from posterolateral). An additional standard arthroscopic sheath remains intra-articularly for later long head of the biceps tendon tenotomy.
Portal Placement
A posterior portal (PP) is used for standard diagnostic glenohumeral arthroscopy (Fig 1A). A standard anterior portal is created just above the SSC tendon. Hook probe examination confirms the diagnosis of a chronic type 2 SLAP lesion (Fig 2A). The tenoscopy portal (TP) is established in the rotator interval as described previously6 (Fig 1, Fig 2 C and D). The TP is located in line with and directly anterior to the LHBT, just superior to its entrance into the bicipital groove. A blunt 4.0-mm rod is inserted into the BTS medial to the LHBT, passing the THL (Fig 2D). The rod serves as a guide for insertion of the sheath of the arthroscope. Routinely, we perform biceps tenoscopy with a standard 4.0-mm, 30° arthroscope (Arthrex). Sheath passage beyond the THL may be complicated by stenosis of the bony bicipital groove or surrounding soft tissues. Therefore use of a thinner mini-arthroscope or sheathless 30° arthroscope (e.g., 2.4-, 2.7-, or 3.0-mm arthroscope; Arthrex) may be required in cases with confined anatomic conditions (e.g., small patients, narrow or constricted bicipital groove, soft-tissue adhesions).
Fig 2.
Glenohumeral arthroscopy (beach-chair position, left shoulder). (A) Hook probe evaluation shows a combined anterior and posterior SLAP lesion (G) for which anatomic reconstruction is not appropriate. (B) Rotator interval anatomy: humeral head (HH), subscapularis tendon (SSC), superior glenohumeral ligament (SGHL), and long head of biceps tendon (LHBT). The mesotenon (arrowhead) follows the LHBT into the biceps tendon sheath. If present, the mesotenon typically travels medial to the LHBT. (C) The tenoscopy portal is localized in line with and directly anterior to the LHBT shortly before its entrance into the bicipital groove. Correct localization is verified with a K-wire before definite portal placement. The mesotenon (arrowhead) follows the LHBT into the biceps tendon sheath. (D) A blunt 4.0-mm rod is inserted into the biceps tendon sheath and serves as a guide for insertion of the shaft of the arthroscope. (RI, rotator interval.)
Correct placement of the arthroscope within the BTS is verified before fluid inflow is opened (Fig 3A). At the onset of tenoscopy, pump pressure and flow are reduced to 30 mm Hg and 50% of maximum. Depending on the underlying condition, substantial tenosynovitis may exist. A mesotenon, typically being located medial to the LHBT and containing vessels for blood supply, might also be present (Fig 2, Fig 3A). The recommended site of tenodesis is located about 2 cm below the THL, just inferior to the lower SSC border centrally within the lower extension of the bicipital groove. Therefore a high suprapectoral tenodesis portal (HTP) is created directly anterior to the LHBT at a distance of approximately 6 cm to the TP using an outside-in technique (Fig 1 A and B). First, a needle is used to plan optimal HTP location and direction. Then, a longitudinal skin incision of 10 mm is performed. The subcutaneous tissue and fascia are carefully spread using a small atraumatic straight clamp. Both the musculocutaneous nerve located medial to the LHBT and the cephalic vein are at risk of iatrogenic injury (Table 2). Alternatively, low suprapectoral tenodesis can be performed just superior to the upper PMT border. For this purpose, a low tenodesis portal (LTP) can be created directly anterior to the LHBT at a distance of approximately 10 cm to the TP (Fig 1 A and B). As in subpectoral tenodesis, use of the LTP occurs in diaphyseal cortical bone exhibiting low elasticity. Therefore intraosseous interference screw implantation and tendon fixation may be complicated and may also be associated with biomechanical stress rising at the proximal humerus, potentially causing iatrogenic fracture.8 Insertion of a flexible silicone cannula (PassPort; Arthrex) might ease operation of the LTP or HTP.
Fig 3.
Tenoscopic suprapectoral biceps tenodesis (beach-chair position, left shoulder). (A) Biceps tenoscopy shows the long head of the biceps tendon (LHBT) within the biceps tendon sheath. The LHBT is accompanied by a vascularized mesotenon (arrowhead). (B) Electrosurgical release of anterior biceps tendon sheath and transverse humeral ligament. The LHBT (asterisk) is centered within the bicipital groove. (C) Temporary LHBT medialization eases exposition of the bicipital groove (BG). (D) A guidewire for cannulated drilling is placed centrally within the lower (distal) BG (arrowhead). (E) The LHBT (being held aside with a probe for demonstration purposes) is running straight across the drill hole and is ready for tenodesis. The LHBT is fixed proximal to the tenodesis site and tenotomized intra-articularly before tenodesis. (F) Completed tenodesis with forked-eyelet 7.0-mm SwiveLock Tenodesis screw (Arthrex).
Tenoscopic Preparation
Video 1 entails a step-by-step illustration and description of TSBT. Both the BTS and THL are released and tenosynovectomy is performed from distally to proximally with a 4.0-mm soft-tissue shaver (Arthrex) and an electrosurgical device (OPES Toothbrush; Arthrex) including a complete THL release (Fig 3B). We proceeded to use blunt, atraumatic electrosurgical devices (e.g., OPES Ball Electrode, 45°; Arthrex) for a more gentle tenoscopic preparation and to avoid iatrogenic bleeding. Most vessels enter the LHBT from anteriorly. At the level of the transverse branch of the ACHA (mesotenon derived), arterial vessels may exist, which need to be coagulated. Care must be taken not to injure or coagulate the ACHA or its transverse and ascending branches. In this way, the LHBT is tenoscopically released, starting along its entire course from the superior PMT border to the articular margin. TSBT enables effective treatment of the biceps tendon and surrounding tissues (BTS, tenosynovitis, THL) being consistently involved in proximal biceps pathologies. Finally, the surgeon should check for free LHBT sliding during arm movement and centered LHBT positioning within the bicipital groove (Table 3). In cases with LHBT instability (e.g., pulley lesion), the tendon should be dissected from any medialized position and repositioned into the bicipital groove prior to tenodesis to restore the physiological length-tension relation and facilitate removal of the proximal tendon portion (Table 1).
Table 3.
Technical Pearls and Pitfalls
| Pearls |
| Accurate TP placement in line with BG |
| Use of mini-arthroscope or sheathless arthroscopes in patients with tight BTS |
| Assessment for correct placement of arthroscope within BTS before opening fluid inflow |
| Planning of location of tenodesis portal with needle and performing superficial skin incision |
| Blunt “outside-in” creation of tenodesis portal |
| Removal of anterior BTS, mesotenon, and tenosynovitis from upper PMT to articular margin including THL release |
| Medialization of LHBT to enable perpendicular, central drilling within lower BG |
| Placement of horizontal tag suture at humeral drill-hole level to serve as backup fixation and tendinous mark of correct LHBT tenodesis site |
| Temporary fixation of recentered LHBT proximal to tenodesis before intra-articular tenotomy to maintain physiological length-tension relation |
| Pitfalls |
| Malplacement of TP complicating or impeding biceps tenoscopy |
| Malplacement of arthroscope outside BTS |
| Fluid extravasation, swelling, or bleeding complicating or impeding biceps tenoscopy |
| Malplacement of tenodesis portal complicating or impeding tenoscopic preparation and tenodesis |
| Neurovascular injury |
| Adherent or dislocated LHBT possibly complicating or impeding tenodesis and removal of tenotomized proximal LHBT portion |
| Eccentric drilling impairing tenodesis fixation strength and increasing risk of iatrogenic fracture |
| Tenodesis with nonanatomic length-tension relation |
BG, bicipital groove; BTS, biceps tendon sheath; LHBT, long head of biceps tendon; PMT, pectoralis major tendon; THL, transverse humeral ligament; TP, tenoscopy portal.
Biceps Tenodesis
Next, an arthroscopic grasper is used to medialize the LHBT at its designated site of tenodesis inferior to the lower SSC border. The LHBT is temporarily fixed in this medialized position using a 1.8-mm K-wire inserted medial to the tendon (Fig 3C). In this case, tenodesis is performed using a forked-eyelet 7.0-mm BioComposite SwiveLock Tenodesis screw (Arthrex). The fork of the SwiveLock Tenodesis screw has to match the tendon diameter. In case of a tendon that is too thick, the LHBT may be thinned out carefully, avoiding relevant attenuation. The drill guidewire is placed perpendicularly to the bony surface and centrally within the distal part of the bicipital groove (Fig 3D). A 7.5-mm cannulated drill is used to create a monocortical hole of 20 mm in depth. The drill hole is cleared of any soft tissue. The K-wire is removed to allow recentering of the LHBT, which should now run straight across the drill hole. Optionally, a horizontal tag suture (No. 2 FiberWire; Arthrex) can be placed through the tendon at the level of the humeral drill hole with the arm and elbow held in a neutral position. This tag suture serves as a backup fixation and as a tendinous mark for the correct site of tenodesis. Next, the centered LHBT is fixed with one or two 1.8-mm K-wires inserted percutaneously through the tendon proximal to the designated tenodesis site, keeping an adequate distance of about 2 cm (Fig 3E). The arthroscope is placed in the glenohumeral joint (PP), and intra-articular LHBT tenotomy is performed through the anterior portal (Fig 1D). Changing of the arthroscope can be simplified by use of an additional sheath remaining in the PP.
Next, biceps tenoscopy is resumed for completion of suprapectoral tenodesis. In the presence of an LHBT tag suture, a free suture end is inserted into each fork hole. Hereby, the SwiveLock Tenodesis screw is guided to the previously tagged tendon site corresponding to the correct location for LHBT tenodesis. Alternatively, the temporarily fixed tendon can be directly loaded and fixed with the forked eyelet of the SwiveLock Tenodesis screw. Before screw insertion, K-wire tendon fixation has to be removed to allow the proximal part of the tendon to slide into the drill hole during screw insertion (Fig 3F). The screw is inserted until closing up flush with the bony surface. After completed tenodesis, tenotomy is performed directly above the tenodesis site using an electrosurgical device. Care must be taken not to injure the post-tenodesis LHBT. Finally, the free proximal part of the LHBT is extracted from extra- or intra-articularly (Fig 4). Table 3 summarizes technical pearls and pitfalls of TSBT.
Fig 4.
Resected proximal portion of long head of biceps tendon (left, proximal; right, distal). The total length of the specimen is 6.0 cm. The mean length of the articular portion is about 2.5 cm, so tenodesis was performed approximately 3.5 cm distally from the articular margin.
Discussion
Existing techniques of ABT still cope with issues such as difficulty of LHBT identification, complexity and length of the procedure, maintenance and restoration of the physiological length-tension relation, structural failure, persistent biceps pain, and postoperative shoulder stiffness. Many authors have reported complaints and complications requiring surgical revision in up to 45% of cases.2, 3, 6, 10, 11
Conventional ABT requires considerable subdeltoid bursectomy and preparation for LHBT identification. Still, the LHBT does not become directly visible because of BTS and THL coverage.9 In contrast, TSBT approaches directly from the site of pathology. Performing biceps tenoscopy means that the arthroscope is placed into the anatomically closed space of the BTS, anatomically also referred to as the “bicipital tunnel.” Thus the LHBT can be easily identified, and the tenosynovium becomes visible right from the beginning of the procedure. Ease of LHBT identification substantially reduces invasiveness and avoids unnecessary surgical involvement of the deltoid space and bursa. Hereby, the procedure remains confined to the LHBT and surrounding tissues (BTS, tenosynovium, THL) being involved in proximal biceps pathologies.
Temporary LHBT fixation prior to intra-articular tenotomy preserves the physiological length-tension relation of the bicipital musculotendinous unit. Thus biceps shortening and extension potentially leading to cosmetic restrictions, muscular pain, and cramping are effectively prevented.1, 4, 10 Modern implants for intraosseous interference screw fixation such as the forked-eyelet SwiveLock Tenodesis screw enable in situ tenodesis and do not require tenotomy and Krackow suturing of the tendon stump prior to tenodesis. Redundancy of extracorporeal LHBT exteriorization considerably simplifies the procedure.
Sanders et al.11 pointed out that the outcome after biceps tenodesis is closely related to whether the BTS and THL are surgically released or not. They attributed persistent biceps pain to persistent tenosynovitis, which did not appear to resolve spontaneously after tenodesis. Biceps tenoscopy allows direct visualization and treatment of the LHBT and surrounding tissues (BTS, tenosynovium, THL) being consistently involved in proximal biceps pathologies. Tenoscopic treatment can be performed along the entire extra-articular LHBT course until tunneling under the PMT (zones 1 and 2 according to Taylor et al.9). Tenoscopic BTS and THL release as well as tenosynovectomy represent integral components of TSBT.
Werner et al.3 found a significantly increased rate of postoperative shoulder stiffness after arthroscopic suprapectoral biceps tenodesis compared with mini-open subpectoral biceps tenodesis (17.9% v 5.6%). Potential reasons were increased soft-tissue dissection, extensive subdeltoid bursectomy, increased fluid extravasation, and increased risk of bleeding. Extensive removal of the natural sliding layer of the subdeltoid bursa might contribute to formation of postoperative adhesions. In this context, TSBT considerably reduces surgical invasiveness because the procedure remains confined to the LHBT and surrounding tissues (BTS, tenosynovium, THL). At the same time, safety and efficacy are increased because relevant anatomic structures can be directly visualized.
In a recent study, Taylor et al.9 described the anatomy and histology of the bicipital tunnel as an enclosed space. They referred to zone 2, extending from the inferior SSC border to the superior PMT border, as “no man's land” because this region would remain entirely hidden and could not be accessed by means of arthroscopy. Biceps tenoscopy, an emerging discipline of shoulder arthroscopy, provides access to no man's land and enables minimally invasive diagnosis and treatment of previously inaccessible parts of the proximal biceps tendon.9, 12 It is feasible to perform tenoscopic treatment along the entire extra-articular course of the LHBT until tunneling under the PMT (zones 1 and 2 according to Taylor et al.9).
In conclusion, TSBT causatively addresses major unsolved issues of conventional ABT (Table 4). The drawbacks are passage of a learning curve related to biceps tenoscopy, potential demand for special equipment for tenoscopic procedures, and necessity of an additional rotator interval portal (Table 4). The combination of benefits may improve clinical and cosmetic outcomes and might lower the incidence of complications. Prospective clinical studies should follow.
Table 4.
Benefits and Drawbacks
| Benefits |
| Ease of LHBT identification, particularly in rotator cuff–intact shoulders |
| Preservation of subdeltoid bursa |
| Minimal invasiveness |
| Simplification of tenodesis without need for tendon exteriorization |
| Direct visualization and treatment of LHBT including surrounding tissues (BTS, THL, tenosynovitis) |
| Preservation of physiological length-tension relation |
| Potentially reduced risk of persistent biceps pain? |
| Potentially reduced risk of postoperative shoulder stiffness? |
| Drawbacks |
| Learning curve related to procedure of biceps tenoscopy |
| Special equipment recommended for tenoscopic procedure (e.g., arm holder; mini-arthroscope or sheathless arthroscope; atraumatic, frontal-working instruments) |
| Rotator interval portal required for biceps tenoscopy |
BTS, biceps tendon sheath; LHBT, long head of biceps tendon; THL, transverse humeral ligament.
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Supplementary Data
Step-by-step illustration and description of tenoscopic suprapectoral biceps tenodesis (TSBT). Surgery is performed with the patient in the beach-chair position on a left shoulder. Diagnostic arthroscopy (with the posterior portal serving as the viewing portal) shows a chronic combined anterior and posterior type 2 SLAP lesion. For TSBT, the tenoscopy portal (TP) is used as the viewing portal and the high suprapectoral tenodesis portal (HTP) is used as the working portal. Figure 1 exemplarily shows portal locations for a right shoulder.
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Supplementary Materials
Step-by-step illustration and description of tenoscopic suprapectoral biceps tenodesis (TSBT). Surgery is performed with the patient in the beach-chair position on a left shoulder. Diagnostic arthroscopy (with the posterior portal serving as the viewing portal) shows a chronic combined anterior and posterior type 2 SLAP lesion. For TSBT, the tenoscopy portal (TP) is used as the viewing portal and the high suprapectoral tenodesis portal (HTP) is used as the working portal. Figure 1 exemplarily shows portal locations for a right shoulder.