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Arthroscopic biceps tenodesis: Indications and technique
ARTHROSCOPIC BICEPS TENODESIS: INDICATIONS AND TECHNIQUE IAN K.Y. LO, MD, and STEPHEN S. BURKHART, MD
Biceps tendon pathology commonly occurs in combination with other shoulder disorders, such as subacromial impingement and rotator cuff tears. Although the arthroscopic treatment of impingement and rotator cuff tears has previously been reported, arthroscopic biceps tenodesis has rarely been described. In this article, we present our technique of arthroscopic biceps tenodesis, which uses a uniquely designed Bio-Tenodesis screw system. This system allows intra-articular manipulation of the biceps tendon, ensures placement of the tendon into the base of the bone socket, allows insertion of the screw while maintaining the position and tension in the tendon, and ensures an adequate screw-tendon-bone interface. KEY WORDS: arthroscopic biceps tenodesis, screw system, shoulder, shoulder arthroscopy
Copyright 2002, Elsevier Science (USA). All rights reserved.
Disorders of the long head of the biceps may occur in isolation or in association with rotator cuff tears and subacromial impingementJ -6 Although controversy continues as to the existence of isolated biceps tendinitis and its etiology (eg, primary or secondary to impingement), 3 there is without a doubt a significant number of patients who require concomitant treatment of their biceps pathology. Routine exploration of the long head of the biceps during open surgery and arthroscopy has greatly enhanced our understanding and diagnosis of biceps tendon disorders. 1,7-11 Several pathologies may exist, including biceps tendinitis, biceps subluxation or dislocation, and partial or complete biceps tears. Although techniques of open biceps tenodesis have been reported previously, 12-15 we have been able to find only one report of arthroscopic biceps tenodesis. 16 The purpose of this article is to describe our indications for and technique of arthroscopic biceps tenodesis.
PATIENT SELECTION As stated previously, biceps tendon disorders commonly occur in association with other disorders of the shoulder (eg, rotator cuff tea~'). Thus, the indication for surgery is usually failure of conservative management of the associated shoulder disorder (eg, failure of nonoperative treatment for rotator cuff tear). Indeed, many biceps conditions are diagnosed or confirmed on arthroscopic evaluation (eg, isolated tendinitis, subluxation), and in some cases the diagnosis is serendipitously made. Our most common indications for arthroscopic biceps tenodesis are (1) biceps tears involving >50% of the ten-
From The San Antonio Orthopaedic Group, San Antonio, TX. Address reprint requests to Stephen S. Burkhart, MD, 540 Madison Oak Drive, Suite 620, San Antonio, TX 78258. E-mail: [email protected]. Copyright 2002, Elsevier Science (USA). All rights reserved. 1060-1872/02/1002-0006535.00/0
doi:10.1053/otsm.2002.30651
don, (2) medial subluxation of the biceps tendon, and (3) combined subscapularis tears and biceps subluxation, in which biceps tenodesis is done to protect the arthroscopic subscapularis repair. Complete tears of the biceps tendon are rarely an indication for tenodesis, unless there is chronic cramping in the biceps muscle belly with activity. In addition, retraction of the tendon into the arm can preclude arthroscopic tenodesis. Although our first two indications are commonly cited in the reported literature, the third indication is not. However, biceps tendon pathology is commonly associated with a torn subscapularis tendon. In the senior author's (S.S.B.) experience of repairing subscapularis tears (both open and arthroscopic) with associated biceps instability, attempts to preserve and relocate the biceps by stabilizing it within the bicipital groove commonly fail secondary to redislocation of the biceps. This can lead to persistent symptoms and can cause disruption of the s-ubscapularis repair. Therefore, we now routinely perform arthroscopic biceps tenodesis during arthroscopic subscapularis repairs when subluxation or dislocation has been confirmed. We have no strict age criteria for performing arthroscopic biceps tenodesis versus tenotomy. However, in sedentary patients physiologically older than 65 years of age, we more commonly perform biceps tenotomy.
ARTHROSCOPIC PRINCIPLES A number of technical principles must be followed for successful arthroscopic biceps tenodesis, as follows: (1) obtain and maintain as much biceps tendon length as possible; (2) obtain secure traction sutures into the biceps tendon; (3) obtain and maintain adequate visualization in the subacromial space by performing a careful bursectomy, using 30 ° and 70 ° arthroscopes and multiple viewing portals as required; and (4) obtain adequate length and fixation of the biceps tendon within the bone socket by using the Bio-Tenodesis screw system (Arthrex Inc, Naples, FL).
Operative Techniques in Sports Medicine, Vol 10, No 2 (April), 2002: pp 105-112
1 05
Fig 1. Bio-Tenodesis cannulated screwdriver with driver handle (H), reverse-threaded sleeve and thumb piece (T), bioabsorbable Bio-Tenodesis screw (S), and a loop of suture (L) loaded through the cannulated tip. Turning the handle (H) and holding thumb piece (T) advances the screw (S), while the driver end (E) remains stationary at the base of the bone socket.
It should be noted that arthroscopic biceps tenodesis in the presence of an intact rotator cuff is more difficult than when a torn rotator cuff is present. However, the technique and principles are essentially the same.
THE BIO-TENODESIS SCREW SYSTEM Special mention must be made of the system incorporated into our technique. The system uses bioabsorbable PLLA
(poly-L-lactic acid) cannulated screws and a uniquely designed Bio-Tenodesis screwdriver. Screws for biceps tenodesis are available in three sizes (7 to 9 ram) and are 23 mm in length. The cannulated screwdriver (Fig 1) is specially designed with a reverse-threaded sleeve and a thumb piece on the driver shaft. This design allows the biceps tendon to be maintained at the bottom of the bone socket under tension as the Bio-Tenodesis screw is advanced in the bone socket by the hex driver and the reverse-thread pitch of the thumb sleeve. Reduction of the biceps tendon at the base of the bone socket is obtained by first whipstitching the tendon and passing the suture ends through a loop of suture at the end of the cannulated screwdriver (Fig 2A) (alternatively, the suture ends may be passed directly through the cannulated screwdriver). Pulling the suture ends advances the biceps tendon to the end of the cannulated driver, and thus the biceps tendon can be manipulated and controlled by the cannulated screwdriver tip. The screwdriver (along with the biceps tendon) is then inserted into the bone socket (Fig 2B) and the screw is advanced. Turning the blue driver handle while holding the reverse-threaded thumb piece advances the screw and maintains pressure on the head of the screw during insertion, while the tendon is maintained in a stationary position at the base of the bone socket (Fig 2C). This guarantees an adequate screw-
Fig 2. Simulated depiction of Bio-Tenodesis screw insertion: (A) The biceps tendon (BT) is whipstitched and the ends of the suture (W) are passed through the suture loop (L) at the end of the Bio-Tenodesis screwdriver tip. The sutures are then pulled, drawing the biceps tendon to the tip of the Bio-Tenodesis screwdriver. Thus, the biceps tendon can be manipulated using the end of the driver tip; (B) The Bio-Tenodesis screwdriver tip is then inserted into a previously drilled bone (B) socket, thus guiding the tendon into the base of the bone socket; (C) The driver handle is then turned while holding the thumb piece (T), which advances the screw while the driver tip holds the biceps tendon stationary at the base of the bone socket. This maintains the tendon within the bone socket under appropriate tension; (D) The screw is inserted until flush with the overlying bone.
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Fig 3. Posterior arthroscopic view of a left shoulder, demonstrating partial tearing of the biceps tendon involving approximately 50% of the tendon.
Fig 4. Arthroscopic view of a left shoulder from a posterior portal with a 70° arthroscope demonstrating a degenerative and subluxed biceps tendon (BT), an attenuated medial sling (M), and a degenerative subscapularis tendon (SSc). Note how the proximal biceps tendon appears to be situated posterior to the projected fibers of the subscapularis tendon, suggestive of medial subluxation.
Fig 5. Establishment of the anterolateral portal, placement of traction sutures, and release of the biceps tendon: (A) An 18-gauge needle is used to guide placement of the anterolateral portal which is directed through the bicipital sheath parallel to the biceps tendon; (B) The 18-gauge needle is then replaced with a 7-mm clear fish-bowl cannula (Arthrex Inc, Naples, FL); (C) Two or 3 traction sutures are placed through the biceps tendon by advancing no. 2 nylon suture through an 18-gauge needle piercing the biceps tendon. These are retrieved through the anterolateral portal; (D) A 90° hooked electrocautery bovie (Linvatec, Largo, FL) is introduced through the anterolateral portal and the biceps tendon is then released close to its insertion on the superior labrum. 107 ARTHROSCOPIC BICEPS TENODESIS
Fig 6. Pulling the biceps tendon out through the skin: (A) Pulling on the traction sutures draws the biceps tendon (BT) into the anterolateral cannula; (B) The traction sutures and cannula are then pulled out of the skin drawing the tendon (BT) through the bicipital sheath (BS); (C) Continued traction pulls the biceps tendon (BT) through the subacromial space; (D) Finally, the biceps tendon (BT) is pulled through the deltoid, subcutaneous tissue and emerges through the skin.
tendon-bone interface within the bone socket (Fig 2D) and eliminates the need for transosseous drilling. TECHNIQUE
We perform all arthroscopic shoulder procedures in the lateral decubitis position. General anesthesia is administered and a warming blanket is applied to prevent hypothermia. Five to 10 lb of balanced suspension is used, with
Fig 7. The exposed biceps tendon is whipstitched and contoured to a uniform shape. 108
the arm in 20 ° to 30 ° of abduction and 20 ° of forward flexion (Star Sleeve Traction System, Arthrex Inc). Diagnostic glenohumeral arthroscopy is performed through a standard posterior portal with an arthroscopic pump maintaining pressure at 60 mm Hg. A midlateral anterior portal is created just superior to the lateral half of the subscapularis tendon. The biceps/labrum complex and the long head of the biceps are assessed, and the amount of degeneration and partial tearing is estimated (Fig 3). Complete assessment of the biceps tendon is performed by pulling the intertubercular portion of the biceps tendon intra-articularly. 17 Particular attention is also paid to the medial sling, the subscapularis tendon, and the posterior rotator cuff, which are also commonly involved in biceps disorders (Fig 4). Visualization of the subscapularis and particularly its footprint on the lesser tuberosity is best performed through a posterior viewing portal with the arm in abduction and internal rotation. Occasionally, a 70 ° arthroscope is necessary to visualize the entire subscapularis insertion. The treatment of other concomitant pathologies in the shoulder is common during arthroscopic biceps tenodesis. In the case of a torn rotator cuff, we initially secure the biceps tendon with traction sutures and then tenotomize it before performing subscapularis repair or other rotator cuff repair. Arthroscopic subscapularis 18 and rotator cuff repair 19-21 are then performed, followed by arthroscopic biceps tenodesis. In the rare case of concomitant arthroscopic superior labrum anterior posterior (SLAP) repair Lo AND BURKHART
Fig 8. Arthroscopic views from the lateral portal demonstrating exposure and drilling of the bicipital groove: (A) The bicipital sheath and rotator interval are debrided, exposing the underlying biceps tendon (BT) and bicipital groove (BG); (B) A 2.4-mm guide pin is placed in the center of the bicipital groove perpendicular to the bone; (C) A cannulated headed reamer is inserted over the guide wire and drill hole placement is assessed; (D) A hole is then reamed to approximately 25 mm in depth to accommodate a 23-mm screw.
Fig 9. Extracorporeally, the traction sutures and whipstitch (W) are passed through the suture loop (L) at the end of the driver and pulled. The end of the biceps tendon can now be controlled by the screwdriver tip. ARTHROSCOPIC BICI-PSTENODESIS
and biceps tenodesis, the tendon is initially tagged and released and the superior labrum is then reassessed. If the superior labrum is of adequate consistency and size to act as a superior restraint to translation, then the SLAP lesion is repaired 22-24 before biceps tenodesis. After diagnostic arthroscopy, any tendon degeneration is debrided. If the rotator cuff is intact, an anterolateral portal is created approximately 2 to 3 cm anterior and lateral to the anterolateral corner of the acromion entering the glenohumeral joint through the biceps sheath just above and parallel with the long head of the biceps. We use an 18-gauge needle to act as a guide for portal placement (Fig 5A). This is then replaced with a 7-mm clear fish-bowl cannula (Arthrex Inc) (Fig 5B). If a concomitant rotator cuff tear is present, the anterolateral portal may be established directly through the torn rotator cuff. Two or three traction sutures are then placed through the biceps tendon by percutaneously introducing an 18gauge needle near the anterolateral corner of the acromion and piercing the biceps tendon approximately i to 1.5 cm distal to its insertion onto the superior labrum. Nylon suture (no. 2 Ethilon; Ethicon, Somerville, NJ) is then advanced through the needle and retrieved through the 109
Fig 10. Arthroscopic view from the lateral portal demonstrating screw insertion and closure of the residual defect through the rotator interval: (A) Following seating of the driver tip and biceps tendon (BT) into the base of the bone socket, the screw is advanced until flush with the bone; (B) The biceps tendon (BT)-screw-bone interface can be assessed by visualizing the tendon through the transparent cannulated portion of the Bio-Tenodesis screw; (C) Arthroscopic view demonstrating the screw (S) and the residual defect (RD) in the rotator cuff through the bicipital sheath and rotator interval; (D) Closure of the cuff defect is performed using a suture passing device (Penetrator; Arthrex Inc, Naples, FL) to pass one limb of the FiberWire from the whipstitch, followed by standard knot tying.
anterolateral portal (Fig 5C). Care is taken to place the traction sutures at different angles and lengths along the tendon to minimize the risk of suture pull-out, particularly in degenerative tendons. A 90 ° hooked electrocautery bovie (Acromioplasty Electrode; Linvatec, Largo, FL) is introduced through the anterolateral portal, and the biceps tendon is then released close to its insertion on the superior labrum (Fig 5D). The residual stump on the superior labrum is debrided to a stable and smooth margin. Traction is then applied to the sutures, pulling the biceps tendon into the cannula (Fig 6A). The traction sutures and cannula are then pulled from the skin and the tendon is drawn out through the biceps sheath (Fig 6B), through the subacromial space (Fig 6C), through the deltoid, and out through the skin (Fig 6D). If there is adequate length, the tendon is pulled through the skin and the traction sutures are augmented with a whip-stitch of no. 2 Ethibond (Ethicon, Somerville, NJ) or no. 2 FiberWire (Arthrex Inc) (Fig 7). Placing the shoulder and elbow in flexion may decrease the tension on the long head of the biceps and increase the exposed tendon length. The biceps tendon is
110
then contoured to a uniform shape (removing the bulbous tip) and sized using anterior cruciate ligament (ACL) sizing guides. Subacromial bursoscopy is then performed using a posterior viewing portal. A standard lateral portal is created 2 to 3 cm lateral to the acromion and in-line with the posterior border of the clavicle. Bursectomy is then performed, clearing the anterior and lateral gutters of the subacromial space and exposing the "shoulder" of the greater tuberosity. Care is taken to avoid damaging the biceps tendon. In the subsequent steps, when working in the subacromial space, it is common to use both the 30 ° and 70 ° arthroscopes and to view not only from the posterior portal but also from the lateral and anterolateral portals. The biceps tendon is then identified and the overlying rotator interval and bicipital sheath are debrided exposing the bicipital groove (Fig 8A). A clear space of approximately 1.0 cm is necessary to accommodate the headed reamers. A 2.4-mm guide wire is placed in the center of the bicipital groove perpendicular to the surface of the bone (Fig 8B) and followed by a cannulated headed reamer LO AND BURKHART
Fig 11. Arthroscopic view from the lateral portal demonstrating the final result with closure of the residual defect (RD). S = screw, BT = biceps tendon.
(Arthrex Inc) (Fig 8C). The hole is reamed to the size of the biceps tendon previously measured (usually 8 or 9 mm in diameter) and to a depth of 25 mm (Fig 8D). In most cases, the anterolateral portal may be used for guide wire placement and reaming; however, a separate portal may be necessary to ensure an appropriate angle to the bicipital groove. The Bio-Tenodesis screwdriver is then loaded with a Bio-Tenodesis screw (Arthrex Inc) 1 mm smaller than the reamed hole, and a loop of no. 2 Ethibond or no. 2 FiberWire is fed through the end of the driver tip. Extracorporeally, the biceps tendon traction sutures and whipstitch are then advanced through this loop at the end of the screwdriver and the loop is tightened (Fig 9). This gives the screwdriver control of the biceps tendon. The biceps tendon/Bio-Tenodesis screwdriver is then introduced through the anterolateral portal and the biceps tendon is directed to the bottom of the bone socket by manipulating the end of the screwdriver. While maintaining the screwdriver and thus the biceps tendon at the bottom of the hole, the screw is then advanced until it is flush with the surface of the bicipital groove (Fig IOA). Visualization through the head of the transparent cannulated screw can confirm screw placement, and the length of the screw-tendon-bone interface can be assessed by direct visualization of the tendon within the bone socket (Fig lOB). Traction and loop sutures may then be cut or incorporated during rotator cuff repair. We commonly use 1 suture to close the residual defect in the rotator interval (Figs 10C, D and 11).
POSTOPERATIVE MANAGEMENT Postoperatively, the arm is placed at the side in a sling with a small pillow. All procedures are performed on an ARTHROSCOPIC BICEPS TENODESIS
outpatient basis, even in cases combined with rotator cuff or subscapularis repair. Postoperative rehabilitation is guided by the rehabilitation of other concomitant disorders.18-24 In general, patients perform passive external rotation exercises immediately, restricting maximal external rotation for the first 6 weeks to 0 ° (ie, straight ahead) if an arthroscopic subscapularis repair is performed. If there is no subscapularis tear, passive external rotation is performed maximally as tolerated. Overhead stretching is avoided until 6 weeks postoperatively to avoid stressh~g the repair. Active elbow flexion and extension is performed with the arm at the side, restricting terminal extension by 20 °. However, we have been impressed that full extension of the elbow does not cause any discomfort. At 6 weeks, the sling is discontinued and overhead stretches with a rope and pulley and internal rotation stretching are commenced. Isotonic strengthening is not begun until 12 weeks after arthroscopic biceps tenodesis, at which point we begin rehabilitation of the rotator cuff, deltoid, and scapular stabilizers. Progressive activities are incorporated as strength allows, and unrestricted activities are usually resumed 6 months after surgery.
DISCUSSION AND CONCLUSIONS The advent of arthroscopy has advanced both our understanding and treatment of disorders of the shoulder. Arthroscopic treatment of infection, osteoarthritis, glenohumeral instability, rotator cuff tears (both posterosuperior and anterosuperior tears), adhesive capsulitis, calcific tendinitis, and some fractures can be performed. Arthroscopic biceps tenodesis expands the arthroscopist's role in the treatment of shoulder pathology. Although arthroscopic biceps tenodesis has previously been reported using suture anchors, x6 our technique involves "interference" fixation of the tendon to bone, allowing early active elbow flexion and extension. The development of the Bio-Tenodesis screw system has simplified arthroscopic biceps tenodesis. This system allows intra-articular manipulation of the biceps tendon, ensures placement of the tendon into the base of the bone socket, allows insertion of the screw while maintaining the position and tension of the tendon, and ensures an adequate screw-tendon-bone interface with excellent fixation strength. Using this technique, we have not noted any failures of fixation or residual biceps discomfort. Adherence to the arthroscopic principles outlined above will routinely lead to good results after arthroscopic biceps tenodesis.
REFERENCES 1. Habermeyer P, Walch G: The biceps tendon and rotator cuff disease, in Burkhead WZ Jr (ed): Rotator Cuff Disorders. Baltimore, MD, Williams & Wilkins, 1996, pp 142-159 2. Yamaguchi K, Bindra R: Disorders of the biceps tendon, in Ianno~ti JP, Williams GR (eds): Disorders of the Shoulder: Diagnosis and Management. Philadelphia, PA, Lippincott Williams & Wilkins, 1999, pp 159-190
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3. Burkhead WZ Jr, Arcand MA, Zeman C, et al: The biceps tendon, In Rockwood CA Jr, Matsen FA (eds): The Shoulder (ed 2). Philadelphia, PA, Saunders, 1998, pp 1009-1063 4. Dines DM, Warren RF, Inglis AE: Surgical treatment of lesions of the long head of biceps. Clin Orthop 164:165-171, 1982 5. Post M: Proximal tendonitis of the long head of the biceps. Clin Orthop 246:117-124, 1988 6. Neer CS: Anterior acromioplasty for the chronic impingement syndrome in the shoulder: A preliminary report. J Bone Joint Surg Am 54:41-50, 1972 7. Bennett WF: Visualization of the anatomy of the rotator interval and bicipital sheath. Arthroscopy 17:107-111, 2001 8. Teefey SA, Hasan SA, Middleton WD, et al: Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. J Bone Joint Surg Am 82:498-504, 2000 9. Bennett WF: Specificity of the Speed's test: Arthroscopic technique for evaluating the biceps tendon at the level of the bicipital groove. Arthroscopy 14:789-796, 1998 10. Gartsman GM, Taverna E: The incidence of glenohumeral joint abnormalities associated with full-thickness, reparable rotator cuff tears. Arthroscopy 13:450-455, 1997 11. Curtis AS, Snyder SJ: Evaluation and treatment of biceps tendon pathology. Orthop Clin North Am 24:33-43, 1993 12. DePalma AF, Callery GE: Bicipital tenosynovitis. Clin Orthop 3:69-85, 1954 13. Froimson AI, Oh I: Keyhole tenodesis of biceps origin at the shoulder. Clin Orthop 112:245-249, 1974
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14. 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 30:263-273, 1948 15. Lippmann RK: Bicipital tenosynovilis. N Y State J Med 44:2235-2240, 1944 16. Gartsman GM, Hammerman SM: Arthroscopic biceps tenodesis: Operative technique. Arthroscopy 16:550-552, 2000 17. Favorito PJ, Harding WG III, Heidt RS Jr: Complete arthroscopic examination of the long head of the biceps tendon. Arthroscopy 17:430-432, 2001 18. Burkhart SS, Tehrany AM: Arthroscopic subscapularis repair: Technique and preliminary results. Arthroscopy (in press) 19. Burkhart SS: Arthroscopic repair of massive rotator cuff tears: Concept of margin convergence. Techniques Shoulder Elbow Surg 1:232239, 2000 20. Burkhart SS: Current concepts: A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy 16:82-90, 2000 21. Burkhart SS: Arthroscopic treatment of massive rotator cuff tears. Clin Orthop 390:107-118, 2001 22. Burkhart SS, Morgan CD, Kibler WB: Shoulder injuries in overhead athletes. The "dead arm" revisited. Clin Sports Med 19:125-158, 2000 23. Morgan CD, Burkhart SS, Palmeri M, et al: Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 14:553-565, 1998 24. Burkhart SS, Parten PM: Dead arm syndrome: Torsional SLAP lesions versus internal impingement. Techniques Shoulder Elbow Surg 2:74-84, 2001
LO AND BURKHART
Biceps tendon pathology commonly occurs in combination with other shoulder disorders, such as subacromial impingement and rotator cuff tears. Although the arthroscopic treatment of impingement and rotator cuff tears has previously been reported, arthroscopic biceps tenodesis has rarely been described. In this article, we present our technique of arthroscopic biceps tenodesis, which uses a uniquely designed Bio-Tenodesis screw system. This system allows intra-articular manipulation of the biceps tendon, ensures placement of the tendon into the base of the bone socket, allows insertion of the screw while maintaining the position and tension in the tendon, and ensures an adequate screw-tendon-bone interface. KEY WORDS: arthroscopic biceps tenodesis, screw system, shoulder, shoulder arthroscopy
Copyright 2002, Elsevier Science (USA). All rights reserved.
Disorders of the long head of the biceps may occur in isolation or in association with rotator cuff tears and subacromial impingementJ -6 Although controversy continues as to the existence of isolated biceps tendinitis and its etiology (eg, primary or secondary to impingement), 3 there is without a doubt a significant number of patients who require concomitant treatment of their biceps pathology. Routine exploration of the long head of the biceps during open surgery and arthroscopy has greatly enhanced our understanding and diagnosis of biceps tendon disorders. 1,7-11 Several pathologies may exist, including biceps tendinitis, biceps subluxation or dislocation, and partial or complete biceps tears. Although techniques of open biceps tenodesis have been reported previously, 12-15 we have been able to find only one report of arthroscopic biceps tenodesis. 16 The purpose of this article is to describe our indications for and technique of arthroscopic biceps tenodesis.
PATIENT SELECTION As stated previously, biceps tendon disorders commonly occur in association with other disorders of the shoulder (eg, rotator cuff tea~'). Thus, the indication for surgery is usually failure of conservative management of the associated shoulder disorder (eg, failure of nonoperative treatment for rotator cuff tear). Indeed, many biceps conditions are diagnosed or confirmed on arthroscopic evaluation (eg, isolated tendinitis, subluxation), and in some cases the diagnosis is serendipitously made. Our most common indications for arthroscopic biceps tenodesis are (1) biceps tears involving >50% of the ten-
From The San Antonio Orthopaedic Group, San Antonio, TX. Address reprint requests to Stephen S. Burkhart, MD, 540 Madison Oak Drive, Suite 620, San Antonio, TX 78258. E-mail: [email protected]. Copyright 2002, Elsevier Science (USA). All rights reserved. 1060-1872/02/1002-0006535.00/0
doi:10.1053/otsm.2002.30651
don, (2) medial subluxation of the biceps tendon, and (3) combined subscapularis tears and biceps subluxation, in which biceps tenodesis is done to protect the arthroscopic subscapularis repair. Complete tears of the biceps tendon are rarely an indication for tenodesis, unless there is chronic cramping in the biceps muscle belly with activity. In addition, retraction of the tendon into the arm can preclude arthroscopic tenodesis. Although our first two indications are commonly cited in the reported literature, the third indication is not. However, biceps tendon pathology is commonly associated with a torn subscapularis tendon. In the senior author's (S.S.B.) experience of repairing subscapularis tears (both open and arthroscopic) with associated biceps instability, attempts to preserve and relocate the biceps by stabilizing it within the bicipital groove commonly fail secondary to redislocation of the biceps. This can lead to persistent symptoms and can cause disruption of the s-ubscapularis repair. Therefore, we now routinely perform arthroscopic biceps tenodesis during arthroscopic subscapularis repairs when subluxation or dislocation has been confirmed. We have no strict age criteria for performing arthroscopic biceps tenodesis versus tenotomy. However, in sedentary patients physiologically older than 65 years of age, we more commonly perform biceps tenotomy.
ARTHROSCOPIC PRINCIPLES A number of technical principles must be followed for successful arthroscopic biceps tenodesis, as follows: (1) obtain and maintain as much biceps tendon length as possible; (2) obtain secure traction sutures into the biceps tendon; (3) obtain and maintain adequate visualization in the subacromial space by performing a careful bursectomy, using 30 ° and 70 ° arthroscopes and multiple viewing portals as required; and (4) obtain adequate length and fixation of the biceps tendon within the bone socket by using the Bio-Tenodesis screw system (Arthrex Inc, Naples, FL).
Operative Techniques in Sports Medicine, Vol 10, No 2 (April), 2002: pp 105-112
1 05
Fig 1. Bio-Tenodesis cannulated screwdriver with driver handle (H), reverse-threaded sleeve and thumb piece (T), bioabsorbable Bio-Tenodesis screw (S), and a loop of suture (L) loaded through the cannulated tip. Turning the handle (H) and holding thumb piece (T) advances the screw (S), while the driver end (E) remains stationary at the base of the bone socket.
It should be noted that arthroscopic biceps tenodesis in the presence of an intact rotator cuff is more difficult than when a torn rotator cuff is present. However, the technique and principles are essentially the same.
THE BIO-TENODESIS SCREW SYSTEM Special mention must be made of the system incorporated into our technique. The system uses bioabsorbable PLLA
(poly-L-lactic acid) cannulated screws and a uniquely designed Bio-Tenodesis screwdriver. Screws for biceps tenodesis are available in three sizes (7 to 9 ram) and are 23 mm in length. The cannulated screwdriver (Fig 1) is specially designed with a reverse-threaded sleeve and a thumb piece on the driver shaft. This design allows the biceps tendon to be maintained at the bottom of the bone socket under tension as the Bio-Tenodesis screw is advanced in the bone socket by the hex driver and the reverse-thread pitch of the thumb sleeve. Reduction of the biceps tendon at the base of the bone socket is obtained by first whipstitching the tendon and passing the suture ends through a loop of suture at the end of the cannulated screwdriver (Fig 2A) (alternatively, the suture ends may be passed directly through the cannulated screwdriver). Pulling the suture ends advances the biceps tendon to the end of the cannulated driver, and thus the biceps tendon can be manipulated and controlled by the cannulated screwdriver tip. The screwdriver (along with the biceps tendon) is then inserted into the bone socket (Fig 2B) and the screw is advanced. Turning the blue driver handle while holding the reverse-threaded thumb piece advances the screw and maintains pressure on the head of the screw during insertion, while the tendon is maintained in a stationary position at the base of the bone socket (Fig 2C). This guarantees an adequate screw-
Fig 2. Simulated depiction of Bio-Tenodesis screw insertion: (A) The biceps tendon (BT) is whipstitched and the ends of the suture (W) are passed through the suture loop (L) at the end of the Bio-Tenodesis screwdriver tip. The sutures are then pulled, drawing the biceps tendon to the tip of the Bio-Tenodesis screwdriver. Thus, the biceps tendon can be manipulated using the end of the driver tip; (B) The Bio-Tenodesis screwdriver tip is then inserted into a previously drilled bone (B) socket, thus guiding the tendon into the base of the bone socket; (C) The driver handle is then turned while holding the thumb piece (T), which advances the screw while the driver tip holds the biceps tendon stationary at the base of the bone socket. This maintains the tendon within the bone socket under appropriate tension; (D) The screw is inserted until flush with the overlying bone.
106
LO AND BURKHART
Fig 3. Posterior arthroscopic view of a left shoulder, demonstrating partial tearing of the biceps tendon involving approximately 50% of the tendon.
Fig 4. Arthroscopic view of a left shoulder from a posterior portal with a 70° arthroscope demonstrating a degenerative and subluxed biceps tendon (BT), an attenuated medial sling (M), and a degenerative subscapularis tendon (SSc). Note how the proximal biceps tendon appears to be situated posterior to the projected fibers of the subscapularis tendon, suggestive of medial subluxation.
Fig 5. Establishment of the anterolateral portal, placement of traction sutures, and release of the biceps tendon: (A) An 18-gauge needle is used to guide placement of the anterolateral portal which is directed through the bicipital sheath parallel to the biceps tendon; (B) The 18-gauge needle is then replaced with a 7-mm clear fish-bowl cannula (Arthrex Inc, Naples, FL); (C) Two or 3 traction sutures are placed through the biceps tendon by advancing no. 2 nylon suture through an 18-gauge needle piercing the biceps tendon. These are retrieved through the anterolateral portal; (D) A 90° hooked electrocautery bovie (Linvatec, Largo, FL) is introduced through the anterolateral portal and the biceps tendon is then released close to its insertion on the superior labrum. 107 ARTHROSCOPIC BICEPS TENODESIS
Fig 6. Pulling the biceps tendon out through the skin: (A) Pulling on the traction sutures draws the biceps tendon (BT) into the anterolateral cannula; (B) The traction sutures and cannula are then pulled out of the skin drawing the tendon (BT) through the bicipital sheath (BS); (C) Continued traction pulls the biceps tendon (BT) through the subacromial space; (D) Finally, the biceps tendon (BT) is pulled through the deltoid, subcutaneous tissue and emerges through the skin.
tendon-bone interface within the bone socket (Fig 2D) and eliminates the need for transosseous drilling. TECHNIQUE
We perform all arthroscopic shoulder procedures in the lateral decubitis position. General anesthesia is administered and a warming blanket is applied to prevent hypothermia. Five to 10 lb of balanced suspension is used, with
Fig 7. The exposed biceps tendon is whipstitched and contoured to a uniform shape. 108
the arm in 20 ° to 30 ° of abduction and 20 ° of forward flexion (Star Sleeve Traction System, Arthrex Inc). Diagnostic glenohumeral arthroscopy is performed through a standard posterior portal with an arthroscopic pump maintaining pressure at 60 mm Hg. A midlateral anterior portal is created just superior to the lateral half of the subscapularis tendon. The biceps/labrum complex and the long head of the biceps are assessed, and the amount of degeneration and partial tearing is estimated (Fig 3). Complete assessment of the biceps tendon is performed by pulling the intertubercular portion of the biceps tendon intra-articularly. 17 Particular attention is also paid to the medial sling, the subscapularis tendon, and the posterior rotator cuff, which are also commonly involved in biceps disorders (Fig 4). Visualization of the subscapularis and particularly its footprint on the lesser tuberosity is best performed through a posterior viewing portal with the arm in abduction and internal rotation. Occasionally, a 70 ° arthroscope is necessary to visualize the entire subscapularis insertion. The treatment of other concomitant pathologies in the shoulder is common during arthroscopic biceps tenodesis. In the case of a torn rotator cuff, we initially secure the biceps tendon with traction sutures and then tenotomize it before performing subscapularis repair or other rotator cuff repair. Arthroscopic subscapularis 18 and rotator cuff repair 19-21 are then performed, followed by arthroscopic biceps tenodesis. In the rare case of concomitant arthroscopic superior labrum anterior posterior (SLAP) repair Lo AND BURKHART
Fig 8. Arthroscopic views from the lateral portal demonstrating exposure and drilling of the bicipital groove: (A) The bicipital sheath and rotator interval are debrided, exposing the underlying biceps tendon (BT) and bicipital groove (BG); (B) A 2.4-mm guide pin is placed in the center of the bicipital groove perpendicular to the bone; (C) A cannulated headed reamer is inserted over the guide wire and drill hole placement is assessed; (D) A hole is then reamed to approximately 25 mm in depth to accommodate a 23-mm screw.
Fig 9. Extracorporeally, the traction sutures and whipstitch (W) are passed through the suture loop (L) at the end of the driver and pulled. The end of the biceps tendon can now be controlled by the screwdriver tip. ARTHROSCOPIC BICI-PSTENODESIS
and biceps tenodesis, the tendon is initially tagged and released and the superior labrum is then reassessed. If the superior labrum is of adequate consistency and size to act as a superior restraint to translation, then the SLAP lesion is repaired 22-24 before biceps tenodesis. After diagnostic arthroscopy, any tendon degeneration is debrided. If the rotator cuff is intact, an anterolateral portal is created approximately 2 to 3 cm anterior and lateral to the anterolateral corner of the acromion entering the glenohumeral joint through the biceps sheath just above and parallel with the long head of the biceps. We use an 18-gauge needle to act as a guide for portal placement (Fig 5A). This is then replaced with a 7-mm clear fish-bowl cannula (Arthrex Inc) (Fig 5B). If a concomitant rotator cuff tear is present, the anterolateral portal may be established directly through the torn rotator cuff. Two or three traction sutures are then placed through the biceps tendon by percutaneously introducing an 18gauge needle near the anterolateral corner of the acromion and piercing the biceps tendon approximately i to 1.5 cm distal to its insertion onto the superior labrum. Nylon suture (no. 2 Ethilon; Ethicon, Somerville, NJ) is then advanced through the needle and retrieved through the 109
Fig 10. Arthroscopic view from the lateral portal demonstrating screw insertion and closure of the residual defect through the rotator interval: (A) Following seating of the driver tip and biceps tendon (BT) into the base of the bone socket, the screw is advanced until flush with the bone; (B) The biceps tendon (BT)-screw-bone interface can be assessed by visualizing the tendon through the transparent cannulated portion of the Bio-Tenodesis screw; (C) Arthroscopic view demonstrating the screw (S) and the residual defect (RD) in the rotator cuff through the bicipital sheath and rotator interval; (D) Closure of the cuff defect is performed using a suture passing device (Penetrator; Arthrex Inc, Naples, FL) to pass one limb of the FiberWire from the whipstitch, followed by standard knot tying.
anterolateral portal (Fig 5C). Care is taken to place the traction sutures at different angles and lengths along the tendon to minimize the risk of suture pull-out, particularly in degenerative tendons. A 90 ° hooked electrocautery bovie (Acromioplasty Electrode; Linvatec, Largo, FL) is introduced through the anterolateral portal, and the biceps tendon is then released close to its insertion on the superior labrum (Fig 5D). The residual stump on the superior labrum is debrided to a stable and smooth margin. Traction is then applied to the sutures, pulling the biceps tendon into the cannula (Fig 6A). The traction sutures and cannula are then pulled from the skin and the tendon is drawn out through the biceps sheath (Fig 6B), through the subacromial space (Fig 6C), through the deltoid, and out through the skin (Fig 6D). If there is adequate length, the tendon is pulled through the skin and the traction sutures are augmented with a whip-stitch of no. 2 Ethibond (Ethicon, Somerville, NJ) or no. 2 FiberWire (Arthrex Inc) (Fig 7). Placing the shoulder and elbow in flexion may decrease the tension on the long head of the biceps and increase the exposed tendon length. The biceps tendon is
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then contoured to a uniform shape (removing the bulbous tip) and sized using anterior cruciate ligament (ACL) sizing guides. Subacromial bursoscopy is then performed using a posterior viewing portal. A standard lateral portal is created 2 to 3 cm lateral to the acromion and in-line with the posterior border of the clavicle. Bursectomy is then performed, clearing the anterior and lateral gutters of the subacromial space and exposing the "shoulder" of the greater tuberosity. Care is taken to avoid damaging the biceps tendon. In the subsequent steps, when working in the subacromial space, it is common to use both the 30 ° and 70 ° arthroscopes and to view not only from the posterior portal but also from the lateral and anterolateral portals. The biceps tendon is then identified and the overlying rotator interval and bicipital sheath are debrided exposing the bicipital groove (Fig 8A). A clear space of approximately 1.0 cm is necessary to accommodate the headed reamers. A 2.4-mm guide wire is placed in the center of the bicipital groove perpendicular to the surface of the bone (Fig 8B) and followed by a cannulated headed reamer LO AND BURKHART
Fig 11. Arthroscopic view from the lateral portal demonstrating the final result with closure of the residual defect (RD). S = screw, BT = biceps tendon.
(Arthrex Inc) (Fig 8C). The hole is reamed to the size of the biceps tendon previously measured (usually 8 or 9 mm in diameter) and to a depth of 25 mm (Fig 8D). In most cases, the anterolateral portal may be used for guide wire placement and reaming; however, a separate portal may be necessary to ensure an appropriate angle to the bicipital groove. The Bio-Tenodesis screwdriver is then loaded with a Bio-Tenodesis screw (Arthrex Inc) 1 mm smaller than the reamed hole, and a loop of no. 2 Ethibond or no. 2 FiberWire is fed through the end of the driver tip. Extracorporeally, the biceps tendon traction sutures and whipstitch are then advanced through this loop at the end of the screwdriver and the loop is tightened (Fig 9). This gives the screwdriver control of the biceps tendon. The biceps tendon/Bio-Tenodesis screwdriver is then introduced through the anterolateral portal and the biceps tendon is directed to the bottom of the bone socket by manipulating the end of the screwdriver. While maintaining the screwdriver and thus the biceps tendon at the bottom of the hole, the screw is then advanced until it is flush with the surface of the bicipital groove (Fig IOA). Visualization through the head of the transparent cannulated screw can confirm screw placement, and the length of the screw-tendon-bone interface can be assessed by direct visualization of the tendon within the bone socket (Fig lOB). Traction and loop sutures may then be cut or incorporated during rotator cuff repair. We commonly use 1 suture to close the residual defect in the rotator interval (Figs 10C, D and 11).
POSTOPERATIVE MANAGEMENT Postoperatively, the arm is placed at the side in a sling with a small pillow. All procedures are performed on an ARTHROSCOPIC BICEPS TENODESIS
outpatient basis, even in cases combined with rotator cuff or subscapularis repair. Postoperative rehabilitation is guided by the rehabilitation of other concomitant disorders.18-24 In general, patients perform passive external rotation exercises immediately, restricting maximal external rotation for the first 6 weeks to 0 ° (ie, straight ahead) if an arthroscopic subscapularis repair is performed. If there is no subscapularis tear, passive external rotation is performed maximally as tolerated. Overhead stretching is avoided until 6 weeks postoperatively to avoid stressh~g the repair. Active elbow flexion and extension is performed with the arm at the side, restricting terminal extension by 20 °. However, we have been impressed that full extension of the elbow does not cause any discomfort. At 6 weeks, the sling is discontinued and overhead stretches with a rope and pulley and internal rotation stretching are commenced. Isotonic strengthening is not begun until 12 weeks after arthroscopic biceps tenodesis, at which point we begin rehabilitation of the rotator cuff, deltoid, and scapular stabilizers. Progressive activities are incorporated as strength allows, and unrestricted activities are usually resumed 6 months after surgery.
DISCUSSION AND CONCLUSIONS The advent of arthroscopy has advanced both our understanding and treatment of disorders of the shoulder. Arthroscopic treatment of infection, osteoarthritis, glenohumeral instability, rotator cuff tears (both posterosuperior and anterosuperior tears), adhesive capsulitis, calcific tendinitis, and some fractures can be performed. Arthroscopic biceps tenodesis expands the arthroscopist's role in the treatment of shoulder pathology. Although arthroscopic biceps tenodesis has previously been reported using suture anchors, x6 our technique involves "interference" fixation of the tendon to bone, allowing early active elbow flexion and extension. The development of the Bio-Tenodesis screw system has simplified arthroscopic biceps tenodesis. This system allows intra-articular manipulation of the biceps tendon, ensures placement of the tendon into the base of the bone socket, allows insertion of the screw while maintaining the position and tension of the tendon, and ensures an adequate screw-tendon-bone interface with excellent fixation strength. Using this technique, we have not noted any failures of fixation or residual biceps discomfort. Adherence to the arthroscopic principles outlined above will routinely lead to good results after arthroscopic biceps tenodesis.
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14. 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 30:263-273, 1948 15. Lippmann RK: Bicipital tenosynovilis. N Y State J Med 44:2235-2240, 1944 16. Gartsman GM, Hammerman SM: Arthroscopic biceps tenodesis: Operative technique. Arthroscopy 16:550-552, 2000 17. Favorito PJ, Harding WG III, Heidt RS Jr: Complete arthroscopic examination of the long head of the biceps tendon. Arthroscopy 17:430-432, 2001 18. Burkhart SS, Tehrany AM: Arthroscopic subscapularis repair: Technique and preliminary results. Arthroscopy (in press) 19. Burkhart SS: Arthroscopic repair of massive rotator cuff tears: Concept of margin convergence. Techniques Shoulder Elbow Surg 1:232239, 2000 20. Burkhart SS: Current concepts: A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy 16:82-90, 2000 21. Burkhart SS: Arthroscopic treatment of massive rotator cuff tears. Clin Orthop 390:107-118, 2001 22. Burkhart SS, Morgan CD, Kibler WB: Shoulder injuries in overhead athletes. The "dead arm" revisited. Clin Sports Med 19:125-158, 2000 23. Morgan CD, Burkhart SS, Palmeri M, et al: Type II SLAP lesions: Three subtypes and their relationships to superior instability and rotator cuff tears. Arthroscopy 14:553-565, 1998 24. Burkhart SS, Parten PM: Dead arm syndrome: Torsional SLAP lesions versus internal impingement. Techniques Shoulder Elbow Surg 2:74-84, 2001
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