15.5.1 Operative Technique

The inferior rolled border of the pectoralis major is identified and demarcated at its attachment site on the lateral lip of the intertubercular groove. A 2- to 3-cm incision is marked in parallel with Langers lines near the axillary fold, allowing it to be relatively concealed upon wound healing (Fig. 15.1). After comprehensive arthroscopic evaluation and intra-articular biceps tenotomy, the planned surgical site is anesthetized using 1% lidocaine with epinephrine from proximal to distal, as standard interscalene block often spares this region. The skin is then incised starting approximately 1 cm proximal to the inferior pectoralis margin, and cutaneous bleeding vessels are cauterized with a needle point bovie. Metzenbaum scissors are utilized for sharp dissection to the overlying pectoral fascia, and the horizontal fibers of the pectoralis major are visualized. After longitudinal division of this investing fascia, gentle blunt finger dissection may be utilized to confirm the presence and location of the long head of the biceps within the intertubercular groove. To afford visualization of the biceps tendon, a small pointed Homan retractor may be placed laterally over the lateral pectoralis major footprint and a blunt Chandler retractor is placed medially and held by an assistant (Fig. 15.2). The operative surgeon utilizes the deep end of an Army Navy retractor at the apex of the incision under the rolled inferior pectoralis major musculature, and the long head of the biceps is again identified. Occasionally, the bicipital sheath may need to be divided to allow mobilization of the tendon with a right-angled clamp (or gloved finger) mobilizing underneath the tendon from medial to lateral. With gentle anterior directed traction, the proximal biceps stump is delivered into the wound and clamped with an Allis clamp. A #2 high tensile non-absorbable looped suture (Fiberloop, Arthrex, Inc; Naples, FL) is utilized to prepare approximately 15-20 mm of tendon proximal to the visualized myotendinoous junction (Fig. 15.3). The tendon is then sized circumferentially, amputated while leaving a small residual stump, and the interlocking sutures are clamped with a hemostat to the forearm bandage (Fig. 15.4).

The retractors are then repositioned to allow optimal visualization of the intertubercular groove and periosteal tissue is cleared with a bovie electrocautery or key elevator (Fig. 15.5). Greater cephalad retraction is applied to allow for proximal guidepin placement in order to restore the native length-tension relationship of the long head of the biceps, with the myotendinous junction reapproximated at the level of the inferior border of the pectoralis major (Fig. 15.6). A unicortical guidepin is then drilled centrally within the intertubercular groove and directed posterior at the equator of the humerus, The cannulated reamer, typically an 8 mm size, is then reamed over the guidepin on power, with care to stay central and unicortical, and then the reamer is removed by hand to prevent unnecessary aperture widening (Fig. 15.7). An appropriately-sized tap is routinely used, and the bony and periosteal debris are irrigated and debrided from the socket. A polyethylethylketone (PEEK) interference screw sized for line-to-line fit (e.g., 8 × 12 mm in length, headless PEEK screw) is then opened and assembled on the biotenodesis screwdriver. At this time, the #2 sutures are threaded into the central core of the screwdriver with use of a looped nitinol wire and clamped under tension. The unsutured stump is directed into the socket and the tenodesis driver is inserted and carefully advanced under direct visualization until flush with the surrounding cortical bone. The tenodesis driver is then removed, and direct palpation confirms that the screw is not proud and the myotendinous junction is at the level of the inferior pectoralis margin. the suture limbs are then tied with alternating half hitches and cut short, followed by removal of retractors (Fig. 15.8).

The wound is copiously irrigated and optional platelet rich plasma is applied at the tenodesis site. The dermal layer is reapproximated with 3-0 monocryl suture in deep interrupted fashion. Superficial subcuticular closure is performed with a 4-0 monocryl suture and reinforced with cyanoacrylate tissue adhesive. Adhesive strips may be used to hold tension on the subcuticular sutures, and a gauze dressing is applied.