Table 2.

Technical Pearls for Key Steps of Procedure

Step	Pearls
Portals and visualization	The parabiceps portal is placed with a 3-mm sheath, and a gentle insertion technique is necessary to prevent damage to the radial vessels. Inferior angulation is crucial, and any resistance to insertion should caution the surgeon against deeper penetration.
Initial viewing through the parabiceps portal should be performed with air insufflation. This provides excellent views of the pathoanatomy and prevents soft-tissue swelling.
The distal anterior portal should be placed directly above the tuberosity. Sonographic marking and digital palpation while viewing from the parabiceps portal are necessary for precise placement.
A 2.9-mm 30° arthroscope is preferred for ease of placement and provides good visualization. A 70° arthroscope provides excellent views and is beneficial in partial tears for visualization of the posteromedial aspect of the radial tuberosity.
Cannula placement	The cannula is placed in the working distal anterior portal by gently retracting tissue with a retractor to protect the soft tissues. Usually, a short cannula is useful (Twist-In cannula, 6 mm × 7 mm, or Caps-Lock cannula [ArthroCare, Sunnyvale, CA], 8.2 mm × 35 mm).
A good alternative to the regular cannula is the disposable sheath of a Bio-Interference screw (6 mm × 23 mm; Arthrex). The distal hood of the sheath is useful for protection of surrounding soft tissues. The sheath may be sectioned externally to a shorter length for use of small-joint instruments (shown in Fig 4).
Radial tuberosity preparation	Tuberosity preparation is performed with a 3.5-mm shaver and burr (Sabre; Arthrex) through the cannula (Twist-In cannula, 6 mm × 7 mm).
A small-joint 3-mm shaver and burr (Arthrex) are useful, and their application is less aggressive; however, these cannot be passed through a cannula of regular length. Hence, a short cannula should be used (Caps-Lock cannula, 8.2 mm × 35 mm).
The shaver and burr are placed with the hood facing the soft tissues to prevent any neurovascular injury.
Radiofrequency may be used for debridement; however, this is best avoided to protect the neurovascular structures in a limited potential space.
Anchor placement and tendon stitching	A titanium screw-in–type anchor (2.8-mm FasTak) provides good purchase into the tuberosity. The anchor eyelet must be subcortical, and this is ensured under endoscopic vision.
Two anchors provide an optimal repair strength. The whipstitch is placed at 2 levels to ensure a 10- to 15-mm contact area between the tendon and bone.
The anchors are placed in the ulnar aspect of the radial tuberosity to re-create the original footprint.
An image intensifier is used to confirm anchor position and depth.
Tendon docking and final assessment	The sliding mechanism of the suture anchors is used for tendon docking. The free suture of each anchor is pulled, and the whipstitched sutures and the tendon are drawn onto the tuberosity.
Endoscopic viewing through the parabiceps portal is necessary to confirm the adequacy of tendon approximation to the tuberosity.
Both portals are used for viewing to confirm correct tensioning of the tendon. The parabiceps portal gives an end-on view of the tendon-bone construct, whereas the direct anterior portal provides a panoramic view of the tendon (Fig 9).