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Arthroscopic biceps tenodesis
Technical Note
Arthroscopic Biceps Tenodesis Steven Klepps, M.D., Yassamin Hazrati, M.D., and Evan Flatow, M.D.
Abstract: Surgical treatment of symptomatic pathology of the long head of the biceps tendon generally consists of either biceps tenotomy or tenodesis. Biceps tenodesis is generally recommended for younger patients and has been well described using open techniques. With advancements in arthroscopic ability and equipment, new arthroscopic techniques have recently been reported. These techniques can be especially useful when used in conjunction with other arthroscopic procedures such as distal clavicle resection, rotator cuff repair, and subacromial decompression. We present a modification of the techniques suggested by other researchers. In this technique, a bone anchor is used as a pulley at the bottom of the tunnel to pull the tendon into position. This is followed by interference screw fixation. To our knowledge, this technique has not been previously described. Key Words: Biceps—Tenodesis—Arthroscopy—Suture anchors—Shoulder—Technique.
S
urgical options for treating symptomatic pathology of the long head of the biceps tendon have been limited. Biceps tenodesis is generally recommended for younger patients and has been well described using open techniques.1-9 However, with advancements in arthroscopic ability and equipment, new arthroscopic techniques have recently been reported. These techniques can be especially useful for treating symptomatic pathology of the long head of the biceps tendon when used in conjunction with other arthroscopic procedures such as distal clavicle resection, rotator cuff repair, and subacromial decompression. Gartsman and Hammerman10 described an arthroscopic technique employing suture anchors, and Boileau et al.11 presented a technique using interference screw fixation with the guide pin drilled through the humerus, pulling the biceps into position. We
From the Department of Orthopaedics, Mount Sinai Hospital, New York, New York, U.S.A. Address correspondence and reprint requests to Evan Flatow, M.D., Chief, Shoulder Service, Deptartment of Orthopedic Surgery, Mount Sinai Hospital, 5 East 98th St, 9th Flr, Box 1188, New York, NY 10029, U.S.A. © 2002 by the Arthroscopy Association of North America 0749-8063/02/1809-3067$35.00/0 doi:10.1053/jars.2002.36467
present a modification of these techniques, in which a bone anchor is used as a pulley at the bottom of the tunnel to pull the tendon into position. This is followed by interference screw fixation.
OPERATIVE TECHNIQUE Although recent reports have described performing isolated biceps tenodesis with positive results,12 in general, surgical treatment of the biceps is performed in patients with concomitant lesions. When performing biceps tenotomy, this is done as an initial step because it often improves visualization. Conversely, when performing biceps tenodesis, we prefer to treat associated lesions by performing both the subacromial decompression and distal clavicle resection, if necessary, before the biceps tenodesis. However, the biceps tenodesis is performed before the rotator cuff repair, so that every effort is made to protect the repaired rotator cuff. We use interscalene anesthesia, the beach chair position, and standard arthroscopic equipment. Standard posterior and anterior portals are created, and the intra-articular portion of the biceps tendon is visualized. The biceps tendon is pulled into the joint using a probe to evaluate the portion of the biceps that lies
1040 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 9 (November-December), 2002: pp 1040-1045
ARTHROSCOPIC BICEPS TENODESIS
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FIGURE 1. The biceps tendon is noted to have a significant amount of hyperemic changes including erythema and swelling. Both are consistent with biceps tendonitis.
within the groove. If significant tearing (⬎25%), subluxation, or severe tendonitis (with hemorragic inflammation) is seen (Fig 1), then the decision to address the biceps surgically is made. Biceps tenotomy is strongly considered for elderly patients, revision cases, or shoulders with reduced range of motion to avoid postoperative stiffness. Biceps tenodesis is preferred in patients younger than 45 years of age with medium to thin body habitus.7 After the decision to perform a tenodesis has been made, a spinal needle is used to pass 2 No. 0 PDS sutures through the proximal biceps to control the tendon after the tenotomy is performed (Fig 2). These sutures are retrieved through the anterior cannula. The scope is tilted to look down the groove, and a guide wire from the cannulated bioabsorbable screw set (Bioscrew, ref c8011; Linvatec, Largo, FL) is percutaneously drilled into the humerus for several milli-
meters, piercing the biceps tendon. The origin of the biceps is then detached from the glenoid, and its labral base origin is smoothed with a 5.5-mm shaver. The arthroscope is removed from the glenohumeral joint. The arthroscope is redirected into the subacromial bursa though the posterior portal, and an anterolateral portal is created. The biceps sheath is identified and subsequently transected using an arthroscopic blade (Fig 3). The arthroscope is now placed into the anterolateral portal, the wire is removed, and the tendon is lifted out of the groove (Fig 4). The arthroscope is now returned to the subacromial space through the posterior portal and the PDS sutures and the biceps are retrieved out of the anterolateral portal (Fig 5). Depending on where the biceps was tenotomized, a small portion may be excised to place the sutures at the end
FIGURE 2. The intraarticular portion of the biceps is shown with No. 0 PDS sutures placed for control of the biceps once it is detached.
FIGURE 3. With the biceps tendon held in position, an arthroscopic blade is used to incise the sheath, exposing the underlying biceps tendon.
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S. KLEPPS ET AL.
FIGURE 4. After the unroofing is completed, the biceps tendon is removed from its groove and retrieved out the anterolateral portal. FIGURE 6. A second lateral portal is created, and an 8-mm drill is placed into the biceps groove.
of the tenotomized tendon to ensure repair at the appropriate tension. A second lateral portal is made to drill an 8-mm hole into the upper part of the biceps groove (Fig 6). A 3.5-mm Bi-Roc EZ anchor (Innovasive Devices, Marlborough, MA) is placed at the base of the drill hole (Fig 7). These sutures are retrieved out of the same hole as the biceps. One suture end is passed through the proximal portion of the tendon multiple
FIGURE 5. The biceps tendon is pulled through the anterolateral border to allow suture placement.
times using a free needle and securely tied (Fig 8). The biceps tendon is returned to the bursal space and directed to the previously drilled hole. Oftentimes, a grasper from the second portal can be used to guide the tip of the biceps into the hole as the other end of the suture is pulled. This pulls the biceps tendon to the bottom of the tunnel (Fig 9). Next, the previously used guide wire is placed down
FIGURE 7. A 3.5-mm Bio-Roc EZ (Innovasive Devices) anchor is placed into the base of the drill hole created by the 8-mm drill.
ARTHROSCOPIC BICEPS TENODESIS
FIGURE 8. The Bio-Roc sutures are retrieved through the same anterolateral portal as the biceps tendon. One limb of the sutures is now placed within the end of the tendon.
the 8-mm hole along the edge of the biceps tendon through the lateral portal (Fig 10). A 9-mm resorbable interference screw is placed over the guide wire and
FIGURE 9. The other end of the Bio-Roc suture is pulled to position the biceps tendon into the base of the drill hole with the suture anchor acting as a pulley.
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FIGURE 10. A guide wire is placed along the edge of the biceps tendon with a 9-mm bioabsorbable interference screw positioned for final placement.
tightened until fixation is secure and the screw is flush with the humeral cortex (Fig 11). The suture is cut using arthroscopic scissors, and the rotator cuff repair is now performed, if necessary. The wounds are closed using absorbable sutures (Fig 12), sterile dressing is applied, and the arm is placed in a standard sling.
FIGURE 11. The interference screw is tightened into position, ensuring that it is flush along the groove to avoid mechanical symptoms.
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S. KLEPPS ET AL.
FIGURE 12. Clinical photos of a patient 3 months after biceps tenodesis. (A) The patient has minimal wounds over the lateral deltoid and (B) a well-functioning biceps tendon.
POSTOPERATIVE PROTOCOL For patients undergoing both rotator cuff repair and biceps tenodesis, postoperative rehabilitation is focused on protecting the rotator cuff repair. Full passive shoulder and elbow motion is performed during the first 6 weeks with avoidance of shoulder extension and internal rotation. Active shoulder motion begins at 6 weeks and is continued for 3 months when resistive exercises begin. For patients undergoing isolated tenodesis, full passive and activeassisted shoulder motion exercises are begun immediately. Active biceps flexion, however, is avoided for 6 weeks. At 6 weeks, full unlimited active elbow motion and resistive exercises are begun. DISCUSSION A description of a new technique for performing an all-arthroscopic biceps tenodesis is presented. Although several different methods of open biceps tenodesis have been previously reported,1-9 all-arthroscopic techniques have been rarely described. The open technique uses a separate deltopectoral incision, which probably increases postoperative pain and is cosmetically less appealing. However, the open technique has produced excellent outcomes, and any new arthroscopic technique should not sacrifice fixation while creating a procedure with potentially less perioperative morbidity. To our knowledge, only 2 other descriptions of all-arthroscopic biceps tenodesis have been reported.10,11 Unlike the technique described by
Gartsman and Hammerman,10 which uses the bone anchor for definitive fixation, our technique uses the bone anchor for temporarily holding the biceps into the bone tunnel while the interference screw is placed. Using 2 different types of fixation probably results in a more stable construct. As opposed to Boileau et al.’s11 technique, our method avoids the anterior to posterior transhumeral passage of a guide-wire. That technique does put the neurovascular structures at risk of injury, although slight; this risk is avoided with our technique. However, our method is technically challenging, and further investigation and follow-up is warranted to assess the efficacy of this technique. Thus far, we have performed this technique in 5 patients, with positive results and no complications. A new screwdriver designed for holding the biceps in the drill-hole while placing the interference screw has been designed (Arthrex). We have begun using this system in an effort to reduce the technical difficulty of performing this procedure.
REFERENCES 1. Dines D, Warren RF, Inglis AE. Surgical treatment of lesions of the long head of the biceps. Clin Orthop 1982;164:165-171. 2. Hitchcock HH, Bechtol CO. Painful shoulder: observations on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am 1948;30:263-273. 3. O’Donoghue DH. Subluxing biceps tendon in the athlete: Transosseous osteosynthesis in treating fracture-dislocations of the shoulder. Clin Orthop 1982;164:26-29. 4. Crenshaw A, Kilgore W. Surgical treatment of bicipital tenosynovitis. J Bone Joint Surg Am 1966;48:1496-1498.
ARTHROSCOPIC BICEPS TENODESIS 5. Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8: 644-654. 6. Froimson AJ, Oh I. Keyhold tenodesis of biceps origin at the shoulder. Clin Orthop 1975;112:245-249. 7. Ball C, Galatz L, Yamaguchi K. Tenodesis or tenotomy of the biceps tendon: Why and when to do it. Tech Shoulder Elbow Surg 2001;2:140-152. 8. Becker DA, Cofield RH. Tenodesis of the long head of the biceps brachii for chronic bicipital tendinitis. Long-term results. J Bone Joint Surg Am 1989;71:376-381.
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9. Berlemann U, Bayley I. Tenodesis of the long head of biceps brachii in the painful shoulder: Improving results in the long term. J Shoulder Elbow Surg 1995;4:429-435. 10. Gartsman GM, Hammerman SM. Arthroscopic biceps tenodesis: Operative technique. Arthroscopy 2000;16:550-552. 11. Boileau P, Krishnan SG, Coste JS. Arthoscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Tech Shoulder Elbow Surg 2001;2:153-165. 12. Gill TJ, McIrvin E, Mair SD. Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder Elbow Surg 2001;10:247-249.
Arthroscopic Biceps Tenodesis Steven Klepps, M.D., Yassamin Hazrati, M.D., and Evan Flatow, M.D.
Abstract: Surgical treatment of symptomatic pathology of the long head of the biceps tendon generally consists of either biceps tenotomy or tenodesis. Biceps tenodesis is generally recommended for younger patients and has been well described using open techniques. With advancements in arthroscopic ability and equipment, new arthroscopic techniques have recently been reported. These techniques can be especially useful when used in conjunction with other arthroscopic procedures such as distal clavicle resection, rotator cuff repair, and subacromial decompression. We present a modification of the techniques suggested by other researchers. In this technique, a bone anchor is used as a pulley at the bottom of the tunnel to pull the tendon into position. This is followed by interference screw fixation. To our knowledge, this technique has not been previously described. Key Words: Biceps—Tenodesis—Arthroscopy—Suture anchors—Shoulder—Technique.
S
urgical options for treating symptomatic pathology of the long head of the biceps tendon have been limited. Biceps tenodesis is generally recommended for younger patients and has been well described using open techniques.1-9 However, with advancements in arthroscopic ability and equipment, new arthroscopic techniques have recently been reported. These techniques can be especially useful for treating symptomatic pathology of the long head of the biceps tendon when used in conjunction with other arthroscopic procedures such as distal clavicle resection, rotator cuff repair, and subacromial decompression. Gartsman and Hammerman10 described an arthroscopic technique employing suture anchors, and Boileau et al.11 presented a technique using interference screw fixation with the guide pin drilled through the humerus, pulling the biceps into position. We
From the Department of Orthopaedics, Mount Sinai Hospital, New York, New York, U.S.A. Address correspondence and reprint requests to Evan Flatow, M.D., Chief, Shoulder Service, Deptartment of Orthopedic Surgery, Mount Sinai Hospital, 5 East 98th St, 9th Flr, Box 1188, New York, NY 10029, U.S.A. © 2002 by the Arthroscopy Association of North America 0749-8063/02/1809-3067$35.00/0 doi:10.1053/jars.2002.36467
present a modification of these techniques, in which a bone anchor is used as a pulley at the bottom of the tunnel to pull the tendon into position. This is followed by interference screw fixation.
OPERATIVE TECHNIQUE Although recent reports have described performing isolated biceps tenodesis with positive results,12 in general, surgical treatment of the biceps is performed in patients with concomitant lesions. When performing biceps tenotomy, this is done as an initial step because it often improves visualization. Conversely, when performing biceps tenodesis, we prefer to treat associated lesions by performing both the subacromial decompression and distal clavicle resection, if necessary, before the biceps tenodesis. However, the biceps tenodesis is performed before the rotator cuff repair, so that every effort is made to protect the repaired rotator cuff. We use interscalene anesthesia, the beach chair position, and standard arthroscopic equipment. Standard posterior and anterior portals are created, and the intra-articular portion of the biceps tendon is visualized. The biceps tendon is pulled into the joint using a probe to evaluate the portion of the biceps that lies
1040 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 9 (November-December), 2002: pp 1040-1045
ARTHROSCOPIC BICEPS TENODESIS
1041
FIGURE 1. The biceps tendon is noted to have a significant amount of hyperemic changes including erythema and swelling. Both are consistent with biceps tendonitis.
within the groove. If significant tearing (⬎25%), subluxation, or severe tendonitis (with hemorragic inflammation) is seen (Fig 1), then the decision to address the biceps surgically is made. Biceps tenotomy is strongly considered for elderly patients, revision cases, or shoulders with reduced range of motion to avoid postoperative stiffness. Biceps tenodesis is preferred in patients younger than 45 years of age with medium to thin body habitus.7 After the decision to perform a tenodesis has been made, a spinal needle is used to pass 2 No. 0 PDS sutures through the proximal biceps to control the tendon after the tenotomy is performed (Fig 2). These sutures are retrieved through the anterior cannula. The scope is tilted to look down the groove, and a guide wire from the cannulated bioabsorbable screw set (Bioscrew, ref c8011; Linvatec, Largo, FL) is percutaneously drilled into the humerus for several milli-
meters, piercing the biceps tendon. The origin of the biceps is then detached from the glenoid, and its labral base origin is smoothed with a 5.5-mm shaver. The arthroscope is removed from the glenohumeral joint. The arthroscope is redirected into the subacromial bursa though the posterior portal, and an anterolateral portal is created. The biceps sheath is identified and subsequently transected using an arthroscopic blade (Fig 3). The arthroscope is now placed into the anterolateral portal, the wire is removed, and the tendon is lifted out of the groove (Fig 4). The arthroscope is now returned to the subacromial space through the posterior portal and the PDS sutures and the biceps are retrieved out of the anterolateral portal (Fig 5). Depending on where the biceps was tenotomized, a small portion may be excised to place the sutures at the end
FIGURE 2. The intraarticular portion of the biceps is shown with No. 0 PDS sutures placed for control of the biceps once it is detached.
FIGURE 3. With the biceps tendon held in position, an arthroscopic blade is used to incise the sheath, exposing the underlying biceps tendon.
1042
S. KLEPPS ET AL.
FIGURE 4. After the unroofing is completed, the biceps tendon is removed from its groove and retrieved out the anterolateral portal. FIGURE 6. A second lateral portal is created, and an 8-mm drill is placed into the biceps groove.
of the tenotomized tendon to ensure repair at the appropriate tension. A second lateral portal is made to drill an 8-mm hole into the upper part of the biceps groove (Fig 6). A 3.5-mm Bi-Roc EZ anchor (Innovasive Devices, Marlborough, MA) is placed at the base of the drill hole (Fig 7). These sutures are retrieved out of the same hole as the biceps. One suture end is passed through the proximal portion of the tendon multiple
FIGURE 5. The biceps tendon is pulled through the anterolateral border to allow suture placement.
times using a free needle and securely tied (Fig 8). The biceps tendon is returned to the bursal space and directed to the previously drilled hole. Oftentimes, a grasper from the second portal can be used to guide the tip of the biceps into the hole as the other end of the suture is pulled. This pulls the biceps tendon to the bottom of the tunnel (Fig 9). Next, the previously used guide wire is placed down
FIGURE 7. A 3.5-mm Bio-Roc EZ (Innovasive Devices) anchor is placed into the base of the drill hole created by the 8-mm drill.
ARTHROSCOPIC BICEPS TENODESIS
FIGURE 8. The Bio-Roc sutures are retrieved through the same anterolateral portal as the biceps tendon. One limb of the sutures is now placed within the end of the tendon.
the 8-mm hole along the edge of the biceps tendon through the lateral portal (Fig 10). A 9-mm resorbable interference screw is placed over the guide wire and
FIGURE 9. The other end of the Bio-Roc suture is pulled to position the biceps tendon into the base of the drill hole with the suture anchor acting as a pulley.
1043
FIGURE 10. A guide wire is placed along the edge of the biceps tendon with a 9-mm bioabsorbable interference screw positioned for final placement.
tightened until fixation is secure and the screw is flush with the humeral cortex (Fig 11). The suture is cut using arthroscopic scissors, and the rotator cuff repair is now performed, if necessary. The wounds are closed using absorbable sutures (Fig 12), sterile dressing is applied, and the arm is placed in a standard sling.
FIGURE 11. The interference screw is tightened into position, ensuring that it is flush along the groove to avoid mechanical symptoms.
1044
S. KLEPPS ET AL.
FIGURE 12. Clinical photos of a patient 3 months after biceps tenodesis. (A) The patient has minimal wounds over the lateral deltoid and (B) a well-functioning biceps tendon.
POSTOPERATIVE PROTOCOL For patients undergoing both rotator cuff repair and biceps tenodesis, postoperative rehabilitation is focused on protecting the rotator cuff repair. Full passive shoulder and elbow motion is performed during the first 6 weeks with avoidance of shoulder extension and internal rotation. Active shoulder motion begins at 6 weeks and is continued for 3 months when resistive exercises begin. For patients undergoing isolated tenodesis, full passive and activeassisted shoulder motion exercises are begun immediately. Active biceps flexion, however, is avoided for 6 weeks. At 6 weeks, full unlimited active elbow motion and resistive exercises are begun. DISCUSSION A description of a new technique for performing an all-arthroscopic biceps tenodesis is presented. Although several different methods of open biceps tenodesis have been previously reported,1-9 all-arthroscopic techniques have been rarely described. The open technique uses a separate deltopectoral incision, which probably increases postoperative pain and is cosmetically less appealing. However, the open technique has produced excellent outcomes, and any new arthroscopic technique should not sacrifice fixation while creating a procedure with potentially less perioperative morbidity. To our knowledge, only 2 other descriptions of all-arthroscopic biceps tenodesis have been reported.10,11 Unlike the technique described by
Gartsman and Hammerman,10 which uses the bone anchor for definitive fixation, our technique uses the bone anchor for temporarily holding the biceps into the bone tunnel while the interference screw is placed. Using 2 different types of fixation probably results in a more stable construct. As opposed to Boileau et al.’s11 technique, our method avoids the anterior to posterior transhumeral passage of a guide-wire. That technique does put the neurovascular structures at risk of injury, although slight; this risk is avoided with our technique. However, our method is technically challenging, and further investigation and follow-up is warranted to assess the efficacy of this technique. Thus far, we have performed this technique in 5 patients, with positive results and no complications. A new screwdriver designed for holding the biceps in the drill-hole while placing the interference screw has been designed (Arthrex). We have begun using this system in an effort to reduce the technical difficulty of performing this procedure.
REFERENCES 1. Dines D, Warren RF, Inglis AE. Surgical treatment of lesions of the long head of the biceps. Clin Orthop 1982;164:165-171. 2. Hitchcock HH, Bechtol CO. Painful shoulder: observations on the role of the tendon of the long head of the biceps brachii in its causation. J Bone Joint Surg Am 1948;30:263-273. 3. O’Donoghue DH. Subluxing biceps tendon in the athlete: Transosseous osteosynthesis in treating fracture-dislocations of the shoulder. Clin Orthop 1982;164:26-29. 4. Crenshaw A, Kilgore W. Surgical treatment of bicipital tenosynovitis. J Bone Joint Surg Am 1966;48:1496-1498.
ARTHROSCOPIC BICEPS TENODESIS 5. Sethi N, Wright R, Yamaguchi K. Disorders of the long head of the biceps tendon. J Shoulder Elbow Surg 1999;8: 644-654. 6. Froimson AJ, Oh I. Keyhold tenodesis of biceps origin at the shoulder. Clin Orthop 1975;112:245-249. 7. Ball C, Galatz L, Yamaguchi K. Tenodesis or tenotomy of the biceps tendon: Why and when to do it. Tech Shoulder Elbow Surg 2001;2:140-152. 8. Becker DA, Cofield RH. Tenodesis of the long head of the biceps brachii for chronic bicipital tendinitis. Long-term results. J Bone Joint Surg Am 1989;71:376-381.
1045
9. Berlemann U, Bayley I. Tenodesis of the long head of biceps brachii in the painful shoulder: Improving results in the long term. J Shoulder Elbow Surg 1995;4:429-435. 10. Gartsman GM, Hammerman SM. Arthroscopic biceps tenodesis: Operative technique. Arthroscopy 2000;16:550-552. 11. Boileau P, Krishnan SG, Coste JS. Arthoscopic biceps tenodesis: A new technique using bioabsorbable interference screw fixation. Tech Shoulder Elbow Surg 2001;2:153-165. 12. Gill TJ, McIrvin E, Mair SD. Results of biceps tenotomy for treatment of pathology of the long head of the biceps brachii. J Shoulder Elbow Surg 2001;10:247-249.