Abstract
Biceps tendinopathy and superior labrum anterior posterior lesions are a common source of shoulder pain and disability and can be effectively treated with biceps tenodesis. There are a variety of open and arthroscopic tenodesis techniques, but no one technique has demonstrated superiority. Arthroscopic techniques often disregard the extra-articular portions of the biceps tendon as a potential source of pain. Open techniques address this concern; however, they can be associated with wound complications, increased blood loss, nerve injury, and disruptions to surgical workflow. Here, we describe an all arthroscopic tenodesis technique at the suprapectoral zone of the tendon. This method addresses extra-articular sources of pain, while limiting the potential pitfalls of open surgery.
Technique Video
Narrated technique video. Standard posterior, anterior, lateral, and low anterior portals are used during the technique. Viewing from the posterior portal in a right shoulder the biceps anchor is debrided to a stable base. A BirdBeak device is inserted through the standard anterior portal and pierces the biceps tendon as laterally as possible, and an 18-gauge spinal needle is used to tease the suture from the BirdBeak device. After a standard subacromial decompression is performed the camera is inserted into the standard lateral portal, and an anterior subdeltoid bursectomy is performed to provide adequate visualization of the tenodesis site. An accessory low anterior portal is created about 1.5 cm proximal to the pectoralis major tendon insertion. The pectoralis major insertion site is used to aid in localization of the tendon just proximal to the subdeltoid portion of the tendon. An 11-blade is inserted through the low anterior portal and used to incise the transverse humeral ligament; the biceps tendon will often bulge from beneath the ligament at this step, confirming appropriate position. The bicep tendon is retracted with the probe, and a noncannulated 8-mm reamer is inserted into the low anterior portal and used to produce a unicortical tunnel. The tunnel’s edges are debrided using an arthroscopic shaver and the arthroscopic electrocautery device; the inferior portion of the tunnel must be smooth to prevent fraying of the tendon. The biceps tendon is then tensioned appropriately via tension pulled through the previously placed suture. A fork-tipped interference screw is then introduced through the low anterior portal to introduce the biceps tendon into the tenodesis site. The interference screw is then inserted and left 1 mm proud. The residual proximal bicep tendon is then amputated using an arthroscopic biter and removed through the lateral portal. The finished tenodesis site is probed and inspected, and a standard postoperative protocol is used.
Introduction
Long head of the biceps tendinopathy (LHBT) is a well-known cause of anterior shoulder pain. Although simple tenotomy is effective in reducing pain, it can lead to cosmetic deformity, muscle cramping, and decreased supination strength.1, 2, 3, 4 Tenodesis has been shown to decrease anterior shoulder pain in patients with bicipital tendinopathy, while avoiding several complications associated with tenotomy.3, 4, 5 Taylor et al. described the anatomy of the bicipital tunnel as having three distinct zones.6 Zone 1 extends from the articular margin to the distal subscapularis tendon. Zone 2 extends from the distal subscapularis tendon to the proximal border of the pectoralis major tendon. Zone 3 is the subpectoral region. Zones 1 and 2 are enclosed by a dense connective tissue sheath and synovium, while Zone 3 is not. Arthroscopic tenodesis techniques are most commonly performed in Zone 1, and may disregard the distal segments of the pathologic tendon.7, 8, 9 This may lead to the higher reported revision rate with proximal tenodesis.10 Open tenodesis techniques address this concern; however, they may result in additional blood loss, wound complications, nerve injuries, undesirable cosmetic appearance, and disruptions to surgical workflow.7,11 This Technical Note describes an all-arthroscopic distal tenodesis technique at the suprapectoral zone of the tendon. This method addresses extra-articular sources of pain, while limiting the potential pitfalls of open surgery.
Surgical Technique
The patient is in a beach-chair position with the operative extremity prepped and draped in a sterile fashion. A standard posterior portal is used as the initial primary viewing portal (Fig 1). A standard 30° arthroscope (Arthrex, Naples, FL) is inserted, and a diagnostic arthroscopy is performed. An anterior portal is established by outside-in technique, and a 5.5-mm cannula (Arthrex) is inserted and directed superior to the biceps tendon. Once the diagnostic arthroscopy confirms the surgical indication for biceps tenodesis, a BirdBeak device (Arthrex) is loaded with #2 FiberWire suture (Arthrex) and is inserted through the anterior cannula. The BirdBeak pierces the biceps tendon as laterally as possible. The BirdBeak is then withdrawn from the tendon anteriorly, but it remains within the anterior cannula before passing superiorly over the tendon to retrieve the suture. A percutaneous spinal needle can temporarily hold the loop of the stitch to facilitate the passage (Table 1). The suture is then retrieved from the anterior cannula, and the single end is passed through the looped end to complete a luggage tag of the biceps tendon. An arthroscopic biter is introduced from the anterior portal, and a tenotomy is performed as medially as possible. A shaver is used to debride any remaining tendon stump from the anchor at the superior labrum. The tagged biceps tendon is clamped from the anterior portal to maintain tension.
Fig 1.
Landmarks and portal placement. The right shoulder is draped, while the patient is in the standard beach chair position. A standard accessory lateral portal is established 2 to 3 fingerbreadths from the lateral border of the acromion, at ∼25% of the anterior to posterior distance in line with the acromio-clavicular joint. A standard posterior portal is used as the initial primary viewing portal. The ◼ overlies the area marked out to represent the scapular spine. The ★ overlies the area marked out to represent the clavicle. The ⬤ overlies the area marked out to represent the coracoid.
Table 1.
Pearls and Pitfalls
| Pearls |
| An accessory spinal needle may be used to help remove the FiberWire tag stitch from the BirdBeak device. |
| Identification of the biceps tendon in Zone 2 of the groove may be facilitated by visualization of a white fascial band of the pectoralis tendon as it crosses the bicipital groove. |
| A probe is used to retract the tendon medially during drilling to prevent damaging tendon. |
| A grasper may be used to prevent the tendon from rotating in the tunnel during insertion of the interference screw. |
| Pitfalls |
| Failure to perform a thorough subdeltoid bursectomy can lead to difficulty identifying the biceps tendon and lead to increased operative time. Bicortical drilling should be avoided as it may lead to a stress riser. |
From the previously established posterior portal, the scope is introduced into the subacromial space. A standard accessory lateral portal is established 2 to 3 fingerbreadths from the lateral border of the acromion, at approximately 25% of the anterior to posterior distance in line with the acromio-clavicular joint (Fig 1). An additional 5.5-mm cannula is introduced through the lateral portal. A standard subacromial bursectomy is performed with a shaver and radiofrequency probe. The camera is switched to the lateral portal and an extensive anterior subdeltoid bursectomy is performed with the arm in abduction and forward flexion. It is critical that a thorough anterior bursectomy is performed for proper visualization of the biceps within the groove.
After the subacromial and subdeltoid bursectomies are complete, the camera is positioned in the lateral portal looking distally and anteriorly with the shoulder positioned in ∼75° of forward flexion and neutral rotation. An accessory low anterior portal is created via the outside-in technique using an 18-gauge spinal needle ∼1.5 cm proximal to the pectoralis major tendon insertion. A radio frequency probe is introduced and used to dissect along the delto-pectoral interval to visualize the pectoralis major tendon insertion lateral to the bicipital groove. Identification of the proper interval can be facilitated by visualization of a white fascial band along the anterior humerus (Fig 2). The biceps tendon can be identified by rolling over the tendon with a probe, while the first assistant tensions the stump using the tagged suture from the anterior portal. An 11-blade is introduced through the accessory low anterior portal and used to release the biceps tendon sheath (Fig 3). A probe is introduced by the first assistant through the traditional anterior portal and used to retract the biceps tendon anteriorly. An 8-mm cannula is placed into the low anterior portal, and a radio frequency probe is introduced to debride the tissue overlying the bicipital groove until the bleeding bone is present. An 8-mm noncannulated reamer is then introduced into the low anterior portal, and a unicortical hole is reamed within the bicipital groove. During removal, it is important to keep the reamer centralized to prevent oblique enlargement of the tunnel. Once drilled, the tunnel is debrided with use of the shaver and/or radio frequency probe until the inferior border of the tunnel is smooth in order to prevent fraying of the tendon (Fig 4). The biceps is tensioned by the first assistant with a mild superior force to represent physiological tension. A fork-tipped 8 × 23 mm interference screw is used to straddle the tendon and introduce it into the tenodesis site (Fig 5). During insertion of the screw, the proximal tendon is held with a grasper to prevent the tendon from twisting. Our preference is to leave the screw 1 mm proud (Fig 6). The residual tendon proximally can be tenotomized with use of a biter or burner.
Fig 2.
Interval identification. Viewing from the lateral portal in a right shoulder in standard beach chair position, a radio frequency probe via the standard anterior portal is used to dissect along the delto-pectoral interval to visualize the pectoralis major tendon insertion lateral to the bicipital groove. Identification of the proper interval can be facilitated by visualization of a white fascial band ★ along the anterior humerus.
Fig 3.
Biceps tendon sheath release. Viewing from the lateral portal of the right shoulder of the patient while in standard beach chair position, an 11-blade is inserted through the low anterior portal and is used to release the THL. THL, transverse humeral ligament.
Fig 4.
Tunnel preparation. Viewing from the lateral portal in the right shoulder of the patient while in the standard beach chair position, an 8-mm noncannulated reamer is introduced via the low anterior portal, and a unicortical hole is reamed within the groove. Once drilled, the tunnel is debrided with use of the shaver and/or radio frequency probe to ensure a smooth inferior border to prevent fraying of the tenodesis site. The ★ overlies the smooth inferior border of the tenodesis site.
Fig 5.
Interference screw insertion. Viewing from the lateral portal in the right shoulder of the patient while in the standard beach chair position, a fork-tipped 8 × 23 mm interference screw is inserted through the low anterior portal and is used to introduce the tendon into the tenodesis site. The ★ overlies the area of the tendon distal to the tenodesis site. The ◾ overlies the drill hole for the tenodesis site.
Fig 6.
Tenodesis. Viewing from the lateral portal in the right shoulder of the patient while in the standard beach chair position, the interference screw is tightened such that it is left 1 mm proud. The residual proximal tendon is then amputated after the tenodesis and is removed through the proximal lateral portal. The ★ overlies the biceps tendon distal to the tenodesis site. The ◾ overlies the arthroscopic probe.
Postoperatively, the patient is placed in a sling for comfort only. Passive range of motion exercises are permitted immediately, and active range of motion is encouraged after 1 week. Formal physical therapy begins around 6 weeks after surgery, with light resistance exercises permitted. Weight training may start at 8 weeks postoperatively, and return to sports is permitted at 12 weeks.
Discussion
Several authors have reported that LHBT pathology within the bicipital groove is common.2,4,5,10,12,13 This region is both a vascular watershed area and prone to frictional attrition.13,14 Although the ideal location and technique of tenodesis remains controversial, proximal tenodesis may be a cause of increased rate of revision surgery.10 Alpantaki et al. identified a large neuronal network in the distal tendon zones and transverse humeral ligament, which may act as a pain generator following proximal tenodesis.15 In addition, Moon et al. reported that 80% of interstitial tendon tears propagated into the extra-articular zones and described these “hidden lesions” commonly extending to the distal aspects of Zone 2.8 For these reasons, we believe the ideal tenodesis location is at the distal extent of the bicipital groove.
We also believe the ideal technique for proximal biceps tenodesis should be arthroscopic. Arthroscopic management reduces the risks of open treatment, including infection, blood loss, and nerve damage. Arthroscopic tenodesis can be performed in combination with other arthroscopic procedures, such as rotator cuff or labral repair. Additionally, the use of open tenodesis in an otherwise all-arthroscopic procedure would require additional surgical trays, disruptions to surgical workflow, and increases in surgical time for closure of the incision.7,11 However, several authors have presented concerns regarding the ability to adequately visualize the distal tendon segments arthroscopically.16, 17, 18 Murthi et al. reported a 50% rate of missed pathology during arthroscopy due to the inability to visualize distal tendon segments.19 Festa et al. demonstrated that only 30.8% of the extra-articular tendon could be visualized with the commonly performed arthroscopic pull-down maneuver from the anterior portal.16 Similarly, Taylor et al. reported that only 55% of Zones 1 and 2 could be visualized arthroscopically.18 The authors termed Zone 2 as “no man’s land” due to the inability to visualize this zone from either arthroscopic or open subpectoral methods.7,18 However, it should be noted that the above authors did not use a subdeltoid bursectomy and extensive arthroscopic debridement. Other authors have described improved arthroscopic visualization with the use of a 70° arthroscope and an accessory Navaiser portal.20,21 Although these techniques may prove useful for some authors, we prefer to avoid additional instrument trays and the potential for suprascapular nerve injury.
We describe a technique to perform an all arthroscopic suprapectoral LHBT tenodesis at the distal bicipital groove. For the described technique, the surgeon uses a standard 30° arthroscope from the lateral portal and performs a thorough bursectomy, which allows for extensile exposure of Zones 1 and 2 of the LHBT. At this location the LHBT lies within the distal groove, and the degree of residual distal pathology is minimal.8,22 Screws placed distal within the groove may additionally avoid previously described pain secondary to biologic screw reaction.9 This technique presents a reliable and reproducible surgical treatment for patients with symptomatic biceps tenodesis and can be used for both proximal and distal biceps pathology. Other advantages of this technique include the ease of use during concomitant arthroscopic procedures. No additional instrumentation or trays are needed, and there is no disruption to surgical workflow. Limitations of this technique include possible increased swelling and fluid extravasation in the arm, the presence of a surgeon learning curve, and the possibility that the pathology of the subpectoral zone of the tendon is not addressed (Table 2).
Table 2.
Advantages and Disadvantages
| Advantages |
| Addresses pathology in Zones 1 and 2 of the bicipital groove. |
| Improved cosmesis |
| Unicortical fixation |
| Reduced blood loss and risk of neurovascular injury |
| All-arthroscopic procedure resulting in less disruption of workflow |
| Disadvantages |
| Requires extensive subacromial and subdeltoid bursectomies. |
| May lead to increased fluid extravasation and swelling |
| Requires a learning curve regarding dissection and recognition of the anatomy |
| Large 8-mm tunnel |
| Does not allow for visualization of the bicep musculotendinous junction to assist in determining muscle length and tension |
Conclusion
This Technical Note describes an all-arthroscopic distal tenodesis technique at the suprapectoral zone of the tendon. Utilization of this method addresses extra-articular sources of pain, while limiting the potential pitfalls of open surgery.
Supplementary Data
Narrated technique video. Standard posterior, anterior, lateral, and low anterior portals are used during the technique. Viewing from the posterior portal in a right shoulder the biceps anchor is debrided to a stable base. A BirdBeak device is inserted through the standard anterior portal and pierces the biceps tendon as laterally as possible, and an 18-gauge spinal needle is used to tease the suture from the BirdBeak device. After a standard subacromial decompression is performed the camera is inserted into the standard lateral portal, and an anterior subdeltoid bursectomy is performed to provide adequate visualization of the tenodesis site. An accessory low anterior portal is created about 1.5 cm proximal to the pectoralis major tendon insertion. The pectoralis major insertion site is used to aid in localization of the tendon just proximal to the subdeltoid portion of the tendon. An 11-blade is inserted through the low anterior portal and used to incise the transverse humeral ligament; the biceps tendon will often bulge from beneath the ligament at this step, confirming appropriate position. The bicep tendon is retracted with the probe, and a noncannulated 8-mm reamer is inserted into the low anterior portal and used to produce a unicortical tunnel. The tunnel’s edges are debrided using an arthroscopic shaver and the arthroscopic electrocautery device; the inferior portion of the tunnel must be smooth to prevent fraying of the tendon. The biceps tendon is then tensioned appropriately via tension pulled through the previously placed suture. A fork-tipped interference screw is then introduced through the low anterior portal to introduce the biceps tendon into the tenodesis site. The interference screw is then inserted and left 1 mm proud. The residual proximal bicep tendon is then amputated using an arthroscopic biter and removed through the lateral portal. The finished tenodesis site is probed and inspected, and a standard postoperative protocol is used.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Narrated technique video. Standard posterior, anterior, lateral, and low anterior portals are used during the technique. Viewing from the posterior portal in a right shoulder the biceps anchor is debrided to a stable base. A BirdBeak device is inserted through the standard anterior portal and pierces the biceps tendon as laterally as possible, and an 18-gauge spinal needle is used to tease the suture from the BirdBeak device. After a standard subacromial decompression is performed the camera is inserted into the standard lateral portal, and an anterior subdeltoid bursectomy is performed to provide adequate visualization of the tenodesis site. An accessory low anterior portal is created about 1.5 cm proximal to the pectoralis major tendon insertion. The pectoralis major insertion site is used to aid in localization of the tendon just proximal to the subdeltoid portion of the tendon. An 11-blade is inserted through the low anterior portal and used to incise the transverse humeral ligament; the biceps tendon will often bulge from beneath the ligament at this step, confirming appropriate position. The bicep tendon is retracted with the probe, and a noncannulated 8-mm reamer is inserted into the low anterior portal and used to produce a unicortical tunnel. The tunnel’s edges are debrided using an arthroscopic shaver and the arthroscopic electrocautery device; the inferior portion of the tunnel must be smooth to prevent fraying of the tendon. The biceps tendon is then tensioned appropriately via tension pulled through the previously placed suture. A fork-tipped interference screw is then introduced through the low anterior portal to introduce the biceps tendon into the tenodesis site. The interference screw is then inserted and left 1 mm proud. The residual proximal bicep tendon is then amputated using an arthroscopic biter and removed through the lateral portal. The finished tenodesis site is probed and inspected, and a standard postoperative protocol is used.
Narrated technique video. Standard posterior, anterior, lateral, and low anterior portals are used during the technique. Viewing from the posterior portal in a right shoulder the biceps anchor is debrided to a stable base. A BirdBeak device is inserted through the standard anterior portal and pierces the biceps tendon as laterally as possible, and an 18-gauge spinal needle is used to tease the suture from the BirdBeak device. After a standard subacromial decompression is performed the camera is inserted into the standard lateral portal, and an anterior subdeltoid bursectomy is performed to provide adequate visualization of the tenodesis site. An accessory low anterior portal is created about 1.5 cm proximal to the pectoralis major tendon insertion. The pectoralis major insertion site is used to aid in localization of the tendon just proximal to the subdeltoid portion of the tendon. An 11-blade is inserted through the low anterior portal and used to incise the transverse humeral ligament; the biceps tendon will often bulge from beneath the ligament at this step, confirming appropriate position. The bicep tendon is retracted with the probe, and a noncannulated 8-mm reamer is inserted into the low anterior portal and used to produce a unicortical tunnel. The tunnel’s edges are debrided using an arthroscopic shaver and the arthroscopic electrocautery device; the inferior portion of the tunnel must be smooth to prevent fraying of the tendon. The biceps tendon is then tensioned appropriately via tension pulled through the previously placed suture. A fork-tipped interference screw is then introduced through the low anterior portal to introduce the biceps tendon into the tenodesis site. The interference screw is then inserted and left 1 mm proud. The residual proximal bicep tendon is then amputated using an arthroscopic biter and removed through the lateral portal. The finished tenodesis site is probed and inspected, and a standard postoperative protocol is used.