13.1 Goals of Procedure

A new arthroscopic technique with Cobra guide ( Fig. 13.1 ) was developed to enable fast, controlled, and strong intraosseous biceps tenodesis using bone tunnels and sutures without implants.

13.2 Advantages

Because it is an implant-free technique, there are no complications related to the device, either mechanical or biological failure such as implant fracture or migration, synovitis from implant degradation, and osteolysis. ¹ This implant-free fixation technique has superior biomechanical properties compared to other suturing methods, including interference screw type of fixation. Proposed tenodesis of the long head of the biceps (LHB) can be performed safely even in the presence of swelling during rotator cuff repair, as it is the last step of the shoulder procedure.

13.3 Indications

This technique can be used for all kinds of symptomatic pathological conditions of the LHB that require surgical resort. Tenodesis, in general, might be preferred over tenotomy for several reasons, including improved cosmetic appearance, maintenance of elbow supination and flexion strength, and maintenance of the biceps muscle length–tension relation. Further, bony fixation techniques have shown better results than soft-tissue fixation. ²

13.4 Contraindications

This technique is not recommended for chronic ruptures of the LHB with muscle retraction. It is also not recommended in acute ruptures with short muscle-tendon stump, because biceps muscle length–tension relation cannot be controlled.

13.5 Preoperative Preparation/Positioning

This procedure can be done in a beach-chair or in a lateral decubitus position under general anesthesia or scalene block only.

13.6 Operative Technique

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  Step 1: Standard anteroinferior portal formation. After insertion of the scope through standard posterior portal and inspection of glenohumeral (GH) joint, the standard outside-in anteroinferior portal is made. This portal is used for later suprapectoral suture management and the LHB tenotomy.

  
  
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  Step 2: Standard lateral subacromial (SA) portal formation. With the scope switched into the SA space, the standard lateral portal is made. This viewing portal is used for suprapectoral visualization and later knot tying.

  
  
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  Step 3: Visualization of the suprapectoral space. With the trocar through lateral portal in the SA space, the downward shift is sited toward the superior pectoralis major insertion with the tip of trocar touching the anterolateral humeral cortical edge at the same time. Usually, there is some bursal tissue, which is removed with the electrode through the anteroinferior portal. The LHB is most frequently covered by the falciparum ligament, which is the proximal extension of the pectoralis major tendon insertion. This ligament has to be removed in order to expose the LHB.

  
  
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  Step 4: Suprapectoral portal formation. This portal is performed with a spinal needle from outside-in, with an angle of approximately 45 degrees, against the humeral cortex toward cranial direction. Through this portal, the bony tunnel will be drilled later on.

  
  
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  Step 5: The marking stitch passage. The marking stitch passes through the LHB at the level of the future entrance of the bony tunnel. This important step controls and prevents the final overtension of the tenodized tendon.

  
  
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  Step 6: Tenotomy of the LHB. Classical tenotomy of the LHB at its base is done with the scope through the posterior portal inside the GH joint, and biceps scissors from the anteroinferior portal.

  
  
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  Step 7: The proximal biceps is pulled out through the suprapectoral portal. The scope switched back to the suprapectoral space; with the grasper through the suprapectoral portal, the proximal part of the LHB is pulled out through the skin.

  
  
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  Step 8: Holding the suture passage. The proximal part of the LHB is pulled out as much as it goes and a mosquito clamp is placed at the level of the skin to prevent slippage of the tendon back inside. A modified Kessler holding stitch is passed in order to form a distance between both strands (entry and exit) of approximately 1 cm.

  
  
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  Step 9: K-wire introduction. The K-wire (motorized) introduced through the suprapectoral portal to the anterior humeral cortex with an angle of less than 45 degrees and pointed toward the humeral head and slightly medial. The aim is to get enough bone length to drill a 30-mm-deep bony tunnel. The entry point is at the level of the marking stitch placement.

  
  
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  Step 10: First (primary) bony tunnel drilling. Cannulated drill over the K-wire is used to make a primary bony tunnel for the LHB ( Fig. 13.2 ). The size of the drill depends on the size of the biceps tendon, but it should not be less than 6 mm. The lower part of the tunnel entrance is smoothened with the shaver blade to avoid conflict of the LHB tendon with a sharp bony edge after tenodesis.

  
  
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  Step 11: Cobra guide positioning. The Cobra guide is introduced inside the primary bonny tunnel ( Fig. 13.3 ). The depth of insertion is controlled by the scope, and it must be ensured that both holes at the end of the primary cannulated stick are inside the tunnel.

  
  
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  Step 12: Drill guides insertion. Once the Cobra guide is placed inside the primary bony tunnel, the C-frame is rotated to the desired level to avoid axillary nerve injury. Both drill guides are then inserted through the skin incisions (“Cobra bites”) to the lateral humeral cortex and tapped slightly ( Fig. 13.4 ).

  
  
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  Step 13: Two parallel bony tunnels drilling. With the drill guides in place, two parallel bony tunnels are made using 3-mm-sized drills with stoppers ( Fig. 13.5 ).

  
  
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  Step 14: Insertion of the double suture loop inserter. The double suture loop inserter is loaded with two sutures (of different colors). Then, it will be inserted through the drill guides down to the end ( Fig. 13.6 ).

  
  
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  Step 15: Insertion of the locking needle and passing the suture loops (shuttles). The locking needle is then inserted through the primary cannulated stick. The Cobra guide will be removed; finally, the two suture shuttle loops will have a common exit through the suprapectoral portal in the front and two separate exits through each of the two “Cobra bite” holes ( Fig. 13.7 ).

  
  
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  Step 16: Holding suture strands shuttling. Under the scope of control through the lateral portal, each of the holding suture strands are passed through one of the shuttle loops with the suture retriever through the anteroinferior portal. Both strands are then shuttled out from the lateral “Cobra bite” incisions.

  
  
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  Step 17: Pulling the LHB inside the primary bony tunnel. With pulling on both strands of the holding suture, the proximal part of the LHB is inserted into the primary bony tunnel up to the level of marking stitch.

  
  
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  Step 18: Final fixation with six half hitches. Before the final knot tying, both strands should be taken out through the posterior of the two “Cobra bite” incisions. Then, six half hitches are made, the first three in the same direction and the other three in the opposite direction. Note, the scope must be in the lateral portal at all times.

  
  
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  Step 19: Removing of the marking stitch. Finally, the scope in the lateral portal is shifted toward the suprapectoral space and pulling on the marking stitch checks biceps fixation. At the end, the marking stitch is removed and the procedure is concluded ( Fig. 13.8 ).