All Arthroscopic Suprapectoral Biceps Tenodesis

Abstract

Background:

Biceps tendinopathy can have significant clinical manifestations in active patients. Failure to achieve resolution of symptoms through nonsurgical modalities oftentimes results in surgical intervention. The 2 most common surgical treatment options for tendinopathy of the long head of the biceps tendon (LHBT) are tenotomy and tenodesis. Both modalities have shown efficacy within the literature; however, tenodesis of the LHBT has many advantages to tenotomy.

Indications:

Subgroove tenodesis eliminates the potential pain generation within the bicipital groove. Despite recent proof of clinical equivalence in open versus arthroscopic tenodesis, there has been increasing interest in all-arthroscopic biceps tenodesis techniques in hopes of minimizing surgical exposure, decreasing the rate of potential neurovascular compromise, and decreasing the time to recovery.

Technique:

We present an all-arthroscopic technique for a subgroove biceps tenodesis using a unicortical tensionable button. The proximal biceps anchor is held in place at its insertion site with a spinal needle to prevent retraction. The lateral portal is redirected into the subdeltoid space. A novel suprapectoral biceps portal, called the Willingboro portal, is placed percutaneously 2 cm above the pectoralis tendon. Onlay fixation of the LHBT is performed proximal to the pectoralis major muscle insertion using a unicortical button. Postoperative protocol is similar to other fixation constructs.

Results:

Numerous arthroscopic biceps tenodesis techniques have been described with good success; however, an all-arthroscopic suprapectoral tenodesis is attractive to many reasons. The unicortical button construct shows similar load to failure strength as the bicortical button construct, both of which are greater than all other constructs described in the literature.

Discussion/Conclusion:

Arthroscopic subgroove biceps tenodesis using a unicortical button technique is a viable option that avoids the complications associated with an open axillary incision as well as persistent groove pain. Anchoring the biceps tendon prior to tenotomy allows for preservation of tendon length, limiting the complications associated with tendon retraction with anticipated improvement in patient-reported outcomes. The unicortical button is known to have a similar strength profile as the bicortical button technique, which is greater than other techniques described in the literature. Future studies should be aimed at assessing long-term patient-reported outcomes.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

The following video demonstrates our preferred technique for an all arthroscopic suprapectoral biceps tenodesis using a tensionable button.

There are no relevant disclosures to this talk.

We plan to review over the next several minutes our preoperative planning, patient positioning, and preferred technique for performing the all arthroscopic suprapectoral biceps tenodesis. Our case is a 50-year-old man who has 6 months of right anterior shoulder pain. He is a right-hand dominant firefighter and has pain with overhead activity. He reports loss of strength and discomfort when sleeping and has failed to respond to a home strengthening program. He has received and responded positively to interval biceps injections. On physical examination, he has tenderness over the bicipital groove. He has active range of motion to 150° with loss of internal rotation. He has a positive O’Briens Test and has loss of strength with provocative testing.

Imaging of the right shoulder demonstrates subacromial impingement without glenohumeral osteoarthritis. Magnetic resonance imaging has been reviewed. In these 2 images selected, there is evidence of acromioclavicular (AC) joint arthrosis with a Type 2 slap tear noted. Our diagnosis upon further query of the patient is biceps tendonitis secondary to a slap tear with subacromial impingement and AC joint arthrosis. Our recommended procedure is an extraarticular biceps tenodesis with decompression and Mumford procedure.

The management of the biceps tendon has been widely discussed over the last decade. Surgical treatments include tenotomy, tenodesis of an open or arthroscopic nature, and different placements of the biceps including intraarticular, extra articular, and subgroove fixation. ¹ Numerous articles and techniques have been written. The placement of the biceps below the bicipital groove has been shown to have less pain associated and less need for revision surgery.^2,3 Indications for a biceps tenodesis below the bicipital groove include a failed slap repair, medial subluxation of the long head of the biceps outside of the groove, subscapularis tendon, tears Type 2 and Type 4 slap tears, arthrofibrosis of the glenohumeral joint with biceps inflammation visualized during arthroscopy, and tearing the biceps tendon intraarticularly, extending up over top of the groove.^4,5

Patient positioning is important. I prefer to perform the procedure in the lateral decubitus position using an interscalene block for blood pressure control. The arm is suspended with 10 pounds of traction in a lateral distracter. Portals are used of routine nature, including standard, posterior, lateral, and anterior portals, and then 2 accessory portals are also used. The “D” portal is a portal used for visualization into the subdeltoid space. It is created about 2 centimeters inferior and lateral to the lateral border of the acromion. The working portal, known as the “E” portal, is described as the portal of Willingboro. This portal is used over top of the bicipital groove for direct access to the biceps as well as for the tenodesis. This is created typically on a 45° angle, 3 fingerbreadths away from the “B” portal, which is your standard anterior. After diagnostic evaluation, a spinal needle is placed percutaneously. This will ensure the biceps does not retract after being released from the superior culinary tubercle. Once the biceps has been released, we can then turn our attention to identifying the biceps in the subdeltoid space.

Viewing through the modified lateral portal and working through the portal of Willingboro, we were able to use electrocautery and shaver to remove adhesions, as well as lysis of all adhesions within the area. As the biceps tendon is released, we prefer to denude any soft tissue around the biceps to remove pain generators. Electric cautery is preferred in this area.

A high-speed burr is then introduced, and we decorticate the humerus. This will maintain a bed for our biceps to heal during our on lay procedure. Next, using a tissue penetrator, a #5 suture is passed through the biceps. The tale of the suture is then captured and brought back out through the working portal. The tail is passed through the loop on the end of the suture to create a cinch stitch, and then the steps are repeated.

Once the biceps has been captured and secured, a drill bit can be inserted into the working portal. This is typically a 2.9 millimeter drill tip. The drill is placed unicortical and then removed to allow for visualization of our insertion hole. Next the tail is placed through the button. This self-tensioning button has a preloading device which allows for this feature to be placed. It is then reintroduced into the body through the working portal. Once the button has been delivered into the humerus, we can then remove the locking mechanism on the back of the button and remove it. We could then gently tension down the suture into the button. Tension can be dialed in as a surgeon sees fit. We then remove the free ends of the suture to complete this portion of the tenodesis.

The arthroscopic scissor is inserted, and the remaining portion of the proximal biceps is released. A grasper is inserted to remove the biceps and the spinal needle, which was previously placed at the start of the case, is removed prior to extraction. At this point, electrocautery is then returned into the body and we remove any remaining pain generators from within the bicipital groove. Finally, a survey is performed to ensure that the biceps is stable.

Postoperatively, our patient is placed into a sling for a period of 4 weeks. We try to stress nonweight bearing if at all possible. Passive range of motion of the elbow, wrists and shoulder are allowed in the form of pendulums, as well as range of motion with flexion/extension of the elbow and wrist. We ask the patient to avoid active flexion and supination of the elbow. At week 4, formal physical therapy is begun and progressive strengthening is started.

Complications do exist with this procedure. ⁶ Postoperative humoral fracture, while low given the fact that we are drilling such a small hole, does exist. It is important to also drill the pin unicortically and not bicortically to avoid the risk of neurovascular injury. Respect and understanding of the neurovascular structures within this area is important. Finally, failure of the tenodesis may occur, and as such, it is imperative that the patient follow the postoperative protocol and avoid lifting >5 pounds if at all possible during their first 4 to 6 weeks.