Arthroscopic Biceps Tenodesis

Jason P. Rogers

W. Stephen Choate

John M. Tokish

Sterile Instruments/Equipment

• Standard arthroscopic shoulder set, including a SutureLasso (Arthrex, Naples, FL) or equivalent and an arthroscopic grasper with ability to lock

• 30-degree arthroscope

• Bipolar radiofrequency (RF) thermal ablation device. Our preference is the 90-degree wand.

• Two clear, plastic cannulas: one 7-mm Twist-In and one 8-mm Twist-In (Arthrex, Naples, FL)

• Power drill for anchor placement

• Free no. 2 nonabsorbable sutures

• SwiveLock (Arthrex, Naples, FL), 4.75-× 19.1-mm biocomposite knotless anchor. We use a largerdiameter anchor in poor-quality bone.

Positioning

• The patient is positioned in the lateral decubitus position (Fig. 17-1).

• All bony prominences are carefully padded, including the contralateral elbow (radial and ulnar nerves), greater trochanter, fibular head (peroneal nerve), and ankle malleoli.

• See Chapter 1 for full description.

Surgical Approach

• Accurate identification and marking of bony anatomy prior to starting the case is paramount for success in establishing portals.

• Important landmarks include the posterolateral acromion edge, acromioclavicular joint, coracoid tip, scapular spine, clavicle (posterior border specifically), and lateral midacromion.

• Standard posterior, anterior interval (midglenoid), and lateral portals are used. An accessory “falciform” portal can be used for direct access to the bicipital groove.

• The posterior viewing portal is positioned 2-3 cm inferior from and just medial to the posterolateral corner of the acromion.

• The anterior interval portal is established lateral to the coracoid tip (never medial to avoid neurovascular structures) and halfway between acromioclavicular joint and anterolateral border of the acromion.

▪ An “outside-in” technique with a spinal needle under direct visualization from posterior portal is used.

▪ The anterior capsule is dilated with a hemostat to facilitate access in and out of the joint.

Figure 17-1 | Patient positioned in left lateral decubitus with lateral arm holder in place. White axillary straps provide lateral force, distracting the glenohumeral joint. Longitudinal traction is applied with weights off the end. Moving the weights to the middle pulley will provide abduction of the glenohumeral joint.

• The lateral portal is placed 3 cm off the lateral border of the acromion and exactly halfway between the anterior and posterior corners of the lateral acromion for a true “50-yard line” position.

▪ The portal typically is established after the intra-articular portion of case is complete, and the arthroscope is in the subacromial space (Fig. 17-2).

Figure 17-2 | The patient is in lateral decubitus position with sterile drapes in place and bony anatomy with all working portals marked. The typical portals used for shoulder arthroscopy include posterior (1), anterior central (may move distal for true midglenoid portal) (2), anterolateral (3), anterosuperior (4), anterosuperior-lateral (5), posterolateral (6), posterior 7 o’clock (7), Wilmington (8), and Neviaser (9).

• Glenohumeral joint

• Following portal placement, intra-articular evaluation is performed in a systematic manner.

• In the absence of instability or planned labral repair, the standard anterior interval portal is established and a probe is introduced into the joint (Fig. 17-3).

Figure 17-3 | Rotator interval. HH, humeral head; star, subscapularis; asterisk, LHBT.

• Diagnostic evaluation of the long head of the biceps tendon (LHBT) should assess for tearing, subluxation, tenosynovitis, and/or superior labral pathology. All such findings are indications to perform a biceps tenodesis (Figs. 17-4, 17-5 and 17-6).

Figure 17-4 | Biceps sling. HH, humeral head; asterisk, LHBT.

Figure 17-5 | Long head biceps tendon tearing intra-articularly without associated rotator cuff tear. HH, humeral head; asterisk, LHBT.

Figure 17-6 | Intra-articular long head biceps tendon tear with flattening in setting of concomitant massive, retracted rotator cuff tear. Triangle, subscapularis tendon; HH, humeral head; asterisk, LHBT.

▪ The intertubercular portion of the tendon is pulled into the joint for inspection. The anchor attachment at the superior labrum is probed for signs of instability and trauma (>5 mm of separation from the articular glenoid margin, detachment with positive peel back, local synovitis, or chondral damage) (Figs. 17-7 and 17-8).

Figure 17-7 | Long head biceps tendon is delivered into the joint, using a probe or shaver, for further evaluation during the diagnostic portion of the case. HH, humeral head; asterisk, LHBT.