Surgical Technique Biceps Tenodesis

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Several techniques for tenodesis of the biceps have been described that range from all open to arthroscopically assisted to all arthroscopic. Many of these techniques require expensive implants or involve creating large drill holes in bone. Presented in this chapter is a simple all-arthroscopic percutaneous intra-articular transtendon (PITT) technique.26 This technique requires no specialized hardware and can be performed with a spinal needle, suture material, and standard arthroscopic equipment. The design of the percutaneous intra-articular transtendon technique is based on the premise of tenotomy with scarring in the bici-pital groove that occurs in cases of trauma or degeneration.

The patient is placed in the beach chair position, a standard posterior portal is established, and the arthroscope is placed into the glenohumeral joint. The anterior portal is made under direct visualization in the rotator interval just above the superior glenohumeral ligament. It is helpful to locate this entrance point initially with a spinal needle prior to the introduction of a blunt trochar. A completed diagnostic arthroscopy is performed to rule out any associated shoulder pathology prior to evaluation of biceps tendon pathology. The extra-articular portion of the biceps can be visualized by placing a probe in the anterior portal and pulling the biceps into the glenohumeral joint. Additional tendon excursion can be obtained by elevating the arm forward with the elbow flexed.

Once biceps tendon pathology is confirmed, a spinal needle is placed from the anterior aspect of the shoulder through the deltoid and the transverse humeral ligament into the bicipital groove. Under direct visualization, the spinal needle is then placed through the biceps tendon (Fig. 24-3), and a no. 1 poly-diaxone monofilament suture (PDS; Ethicon, Cornelia, GA) is threaded into the glenohumeral joint and pulled out the anterior portal with a grasper. A second spinal needle is then placed in the same location piercing the biceps tendon near the first suture. The second PDS is then pulled out the anterior portal with a grasper (Fig. 24-4). A no. 2 braided, nonabsorbable polyester suture (Surgidac, United States Surgical, Norwalk, CT) is tied to one strand of the PDS and pulled through the puncture wound in the front of the shoulder through the biceps tendon and out the anterior portal (Fig. 24-5). The end of the Surgidac that is out the anterior portal is tied to the remaining PDS, and the PDS is pulled back into the anterior portal through the biceps tendon and then out the puncture site on the anterior aspect of the shoulder. This creates a mattress type suture that attaches the biceps to the transverse humeral ligament (Fig. 246). This process is completed a second time, providing extra fixation to the transverse humeral ligament. Using different colored sutures can be helpful to simplify suture management.

The biceps can then be cut proximal to the sutures with arthroscopic scissors or a narrow biter, and the remaining stump

Figure 24-4 Photograph of two polydiaxone monofilament sutures passed through the diseased tendon. Both strands have been retrieved and pulled out the anterior cannula. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-4 Photograph of two polydiaxone monofilament sutures passed through the diseased tendon. Both strands have been retrieved and pulled out the anterior cannula. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

is debrided with a motorized shaver back to a stable rim on the superior labrum (Fig. 24-7). The arthroscope is then removed from the posterior portal and directed into the subacromial space through the same skin incision. A lateral acromial working portal is localized first with a spinal needle and then established under direct visualization. The subacromial space is evaluated, and, if needed, a decompression or rotator cuff repair can be performed. Care must be taken to avoid cutting the previously placed sutures transfixing the biceps tendon. The biceps sutures

Figure 24-3 Arthroscopic photograph showing a spinal needle piercing the biceps tendon. A polydiaxone monofilament suture is threaded through the needle and a grasper is used to bring the suture out the anterior cannula. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-3 Arthroscopic photograph showing a spinal needle piercing the biceps tendon. A polydiaxone monofilament suture is threaded through the needle and a grasper is used to bring the suture out the anterior cannula. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-5 The polydiaxone monofilament suture is tied to the nonabsorbable polyester braided suture as it is being shuttled through the biceps tendon. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-5 The polydiaxone monofilament suture is tied to the nonabsorbable polyester braided suture as it is being shuttled through the biceps tendon. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-8 Loose sutures are shown in the subacromial space. A suture grasper is being used to pull the sutures out of the lateral cannula. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-6 Arthroscopic photograph showing the mattress pattern of braided nonabsorbable sutures passed through the biceps tendon. Tendon is now sutured to the transverse humeral ligament. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-6 Arthroscopic photograph showing the mattress pattern of braided nonabsorbable sutures passed through the biceps tendon. Tendon is now sutured to the transverse humeral ligament. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-8 Loose sutures are shown in the subacromial space. A suture grasper is being used to pull the sutures out of the lateral cannula. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-7 A, Biceps tendon being cut with arthroscopic scissors. B, The remaining stump of the biceps tendon attached to the superior labrum. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

Figure 24-7 A, Biceps tendon being cut with arthroscopic scissors. B, The remaining stump of the biceps tendon attached to the superior labrum. (From Sekiya LC, Elkousy HA, Rodosky MW: Arthroscopic biceps tenodesis using the percutaneous intra-articular transtendon technique. Arthroscopy 2003;19:1137-1141.)

are located in the subacromial space (Fig. 24-8) and subsequently retrieved through the lateral portal. They are then sequentially tied using standard arthroscopic knot-tying techniques, thereby completing the soft-tissue tenodesis (Fig. 24-9).

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