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Biceps Tenoscopy: Arthroscopic Evaluation of the Extra-articular Portion of the Long Head of Biceps Tendon
Technical Note
Biceps Tenoscopy: Arthroscopic Evaluation of the Extra-articular Portion of the Long Head of Biceps Tendon Adnan Saithna, B.Med.Sci.(Hons), M.B.Ch.B., Dip.S.E.M., M.Sc., F.R.C.S.(Tr & Orth), Alison Longo, M.Sc., Jeff Leiter, M.Sc., Ph.D., Peter MacDonald, M.D., F.R.C.S.C., and Jason Old, M.D., F.R.C.S.C.
Abstract: The recent literature shows that imaging modalities, physical examination tests, and glenohumeral arthroscopy all have low sensitivities and specificities with respect to the diagnosis of the long head of biceps tendon pathology. Biceps tenoscopy is a strategy that aims to reduce the rate of missed diagnoses by improving visualization of the extra-articular part of the tendon. This is an area of predilection of pathology that is not adequately visualized with conventional arthroscopic techniques. This technical note presents the surgical technique for biceps tenoscopy.
P
athology of the long head of biceps (LHB) tendon is a common cause of anterior shoulder pain but diagnosis can be challenging. The reasons for this are multifactorial and include the fact that LHB pathology often occurs in conjunction with other shoulder pathologies. However, the main reason for the high rates of missed diagnoses (30% to 50%) is that imaging studies, physical examination tests, and conventional arthroscopic techniques all have poor sensitivities and specificities for this application.1 Taylor et al.2 recently published their series of 277 patients undergoing arthroscopic subdeltoid LHB to conjoint tendon transfer. They reported that the sensitivity and specificity of preoperative magnetic resonance From the Department of Orthopaedic Surgery, Pan Am Clinic (A.S., A.L., J.L., P.M., J.O.), Winnipeg, Manitoba, Canada; Department of Clinical Engineering, Institute of Ageing and Chronic Disease, University of Liverpool (A.S.), Liverpool, England; Department of Orthopaedic Surgery, Southport and Ormskirk Hospitals NHS Trust (A.S.), Southport, England; Department of Human Anatomy & Cell Science (A.L.); and Section of Orthopaedic Surgery (J.L., P.M., J.O.), College of Medicine, University of Manitoba, Manitoba, Canada. The authors report the following potential conflicts of interest or sources of funding: P.M. is an Associate Editor of the Journal of Shoulder and Elbow Surgery and has received grant from the Department of Surgery, University of Manitoba. Received May 30, 2016; accepted August 23, 2016. Address correspondence to Adnan Saithna, B.Med.Sci.(Hons), M.B.Ch.B., Dip.S.E.M., M.Sc., F.R.C.S.(Tr & Orth), Southport and Ormskirk Hospitals NHS Trust, Town Lane, Southport PR8 6PN, England. E-mail: Adnan. [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16475/$36.00 http://dx.doi.org/10.1016/j.eats.2016.08.018
Arthroscopy Techniques, Vol
-,
imaging for the diagnosis of bicipital tunnel lesions were only 50.4% and 61.4%, respectively. The literature also shows that physical examination tests and other imaging modalities are unreliable. Jordan and Saithna1 showed that published sensitivities and specificities of physical examination tests based on arthroscopic assessment as a gold standard are invalid. This is because conventional glenohumeral arthroscopy allows visualization of Denard zone A (up to 2.5 cm from the biceps anchor) and part of zone B (2.5-5.6 cm) only and does not adequately evaluate more distal parts of the tendon where the most pathology occurs.1,3,4 Moon et al.5 reported that the incidence of tendon tears distal to the subscapularis tendon (Denard zone Cddistal to 5.6 cm from the biceps anchor) was 77.8% in a cohort of patients undergoing subpectoral biceps tenodesis. A recent systematic review has shown that the standard technique of pulling the LHB into the joint at glenohumeral arthroscopy fails to provide enough excursion to visualize beyond Denard zone B (2.5-5.6 cm), and therefore it is unsurprising that several authors have reported that between 30% and 50% of macroscopic tendinopathic lesions are missed at arthroscopy when compared with an open approach.1 This has been suggested as a potential cause for suboptimal outcomes after common procedures such as cuff repair, subacromial decompression, and even biceps tenodesis if the diseased tendon is left distally in the groove (suprapectoral tenodesis).1 With such a high prevalence of missed diagnoses it is clear that alternative techniques are required to ensure more complete evaluation of the
No
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(Month), 2016: pp e1-e5
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e2
A. SAITHNA ET AL.
Fig 1. Intra-articular view of a left shoulder. Standard posterior viewing portal and 30 arthroscope used. The first image shows needle localization of the anterosuperior portal in the rotator interval immediately anterior to the leading edge of the supraspinatus. The second image shows that a correct location is confirmed by easy passage of the needle into the bicipital groove to pass anterior to the LHB tendon. (HH, humeral head; LHB, long head of biceps; RI, rotator interval; SS, supraspinatus.)
extra-articular portion of the tendon. One method of doing so would be via an open approach. Gilmer et al.6 suggested that this may be considered when there is a high clinical suspicion of LHB pathology but diagnostic
arthroscopy is considered “normal.” However, most concomitant shoulder pathologies are now treated arthroscopically, and therefore the aim of this study was to evaluate the feasibility and safety of biceps tenoscopy as a strategy directed toward reducing the rate of missed diagnoses.
Surgical Technique The surgical technique is documented in a cadaveric specimen (Video 1). Health Ethics Research Board approval was granted for this purpose. The procedure can be performed in either beach chair or lateral positions. A standard posterior viewing portal is used to perform diagnostic arthroscopy using a 30 arthroscope. However, to facilitate biceps tenoscopy, it is important to use an anterosuperior rotator interval portal rather than a standard anterior mid-glenoid portal for instrumentation. The anterosuperior rotator interval portal is located immediately anterior to the leading edge of the supraspinatus (Fig 1). Viewing externally this portal is
Fig 2. External view of a left shoulder. This shows the correct location of the anterosuperior portal in front of the acromioclavicular joint. The transverse skin marking indicates the lower border of the pectoralis major tendon, and the vertical skin marking shows a typical cosmetic incision for an open subpectoral tenodesis. The arthroscope is bought out through the skin in a 5-mm incision made in the second line. As can be seen in the image, this allows the surgeon to engage the shaver in the mouth of the arthroscope sheath to carefully guide it into the bicipital groove in a retrograde fashion.
Fig 3. Insertion of a switching stick into the bicipital groove of a left shoulder. The key point to note is insertion of the switching stick anterior to the tendon to facilitate subsequent insertion of the arthroscope anterior to the biceps muscle belly. (LHB, long head biceps tendon; SS, supraspinatus.)
BICEPS TENOSCOPY
e3
Fig 4. Biceps tenoscopy of a left shoulder viewing with a 30 arthroscope inserted through the anterosuperior portal with retrograde instrumentation. The first image shows how the view of the long head of biceps (LHB) tendon can often be initially obscured by loose connective tissue, synovitis or a degenerative lesion. The second image shows the high-quality view that can be obtained after excision of loose connective tissue, a tendinopathic lesion, and a small groove osteophyte.
located just anterior to the acromioclavicular joint (Fig 2). The adequacy of portal position can be assessed before skin incision by insertion of a spinal needle. This should be placed so that it can be directed easily into the bicipital groove (Fig 1 and Video 1). A switching stick is then inserted into the bicipital groove through the anterosuperior portal. This is performed under direct vision. The arthroscope should be positioned anteriorly in the joint with the light lead directed to face caudally toward the bicipital groove. This gives excellent visualization and allows the switching stick to be inserted into the biciptial groove so that it lies anterior to the biceps tendon (Fig 3). The arthroscope sheath is then passed over it to allow subsequent insertion of the arthroscope. It is useful to have 2 sheaths so that the second sheath can be inserted under direct vision without having to remove the camera from the posterior viewing portal. The fluid inflow is switched over to the biciptal groove sheath. The arthroscope is then passed into the sheath and advanced under direct vision. It is directed toward a line drawn on the skin indicating a typical incision for a subpectoral biceps tenodesis. A 5-mm skin incision is made in this predetermined line, directly over the tip of the arthroscope (Fig 2). The arthroscope is then disengaged from the sheath and withdrawn approximately 5 mm. The tip of a 4.2-mm Cuda shaver blade (Linvatec, Largo, FL) is inserted in a retrograde fashion through the skin incision into the mouth of the sheath and then advanced until the light source is localized, by external viewing, in the region of the bicipital groove. The arthroscope is then reinserted into the sheath and the pump switched on to a pressure of 40 mm Hg. The shaver
Fig 5. External view of a left shoulder. A pink needle has been placed approximately 1 cm above the lower border of the pectoralis major (indicated by a blue line, indicating the location of the musculotendinous junction). A cannula has been placed in the subpectoral incision to facilitate quick insertion and removal of retrograde instrumentation, although this is not essential. Viewing the needle at biceps tenoscopy gives additional feedback that the most distal zone of the long head of biceps (Denard zone C) is fully visualized.
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Table 1. Tips, Pearls, and Pitfalls of Biceps Tenoscopy Tips and Pearls The anterosuperior rotator interval portal should be needle localized to confirm that subsequent insertion of the camera will provide direct line of sight into the bicipital groove. Although it is not essential, it is helpful to have 2 camera sheaths, as the second can be inserted into the bicipital groove, under direct vision, whereas the first is used to maintain a posterior viewing portal (as seen in Fig 5). When initially inserting the camera into the groove, it is useful to place a fingertip on the arthroscope sheath 3 cm from its tip. When this subsequently comes to rest on the skin, the surgeon can be confident that the arthroscope has not gone beyond the transverse humeral ligament. Once the surgeon is oriented the arthroscope can be advanced under direct vision to the premarked skin incision distally. Three-dimensional proprioception can be improved by dimming operating lights as this allows better external visualization of the light source at the end of the camera and provides additional feedback regarding the location of instrumentation within the groove. If bleeding occurs, it can be controlled by increasing pump pressure temporarily and retrograde insertion of a radiofrequency device. Pitfalls To avoid the risk of misdirecting instruments, e.g., shaver, the camera sheath can be used as a guide for retrograde insertion (Fig 2). A cannula can also be inserted for this purpose but is not essential (Fig 5). As shown in Video 1, when bringing the arthroscope proximally, it is easy for it to fall back into the joint. This means that pathology at the entrance to the bicipital tunnel can be missed unless particular attention is paid to carefully visualizing this area. The appearance of muscle fibers within the tendon is more obvious arthroscopically than at an open approach, and this can mislead the surgeon into thinking that he or she has observed the musculotendinous junction. It is important to visualize up to this point to evaluate the full extent of the tendon. A useful tip to facilitate this is to place a needle into the bicipital groove 1 cm above the lower border of the pectoralis major to help identify this landmark (as seen in Fig 5).
is used to debride loose connective tissue to allow clear visualization of the LHB tendon up to and including the musculotendinous junction. Tendinopathic lesions and osteophytes can also be addressed in this way (Fig 4). Because muscle fibers appear variably on the anterior surface of the LHB, as one approaches the musculotendinous junction its precise definition can be rather subjective. It is helpful to localize this landmark by inserting a needle into the bicipital groove 1 cm above the lower border of pectoralis major. This can then be viewed with the arthroscope to provide additional feedback that the full length of the tendon has been visualized (Fig 5). The shaver can be exchanged for a probe using the same insertion technique and this allows manipulation of the tendon (to obtain a circumferential view) and probing and evaluation of the bicipital groove. Any further pathology that is then identified can either be addressed by reinsertion of a shaver or by prompting the decision to perform a biceps tenodesis. Table 1 provides a summary of tips, pearls, and pitfalls of this technique.
Discussion The use of an anterosuperior portal directly anterior to the biceps pulley facilitates easy insertion of the arthroscope into the bicipital groove. Excellent visualization of the full extent of the extra-articular portion of the LHB tendon can be achieved using standard arthroscopic equipment. The distal passage of the arthroscope to the predetermined location for skin incision is safe with respect to the musculocutaneous nerve because the arthroscope remains anterior to the biceps tendon and muscle belly throughout the procedure. The therapeutic use of this approach is shown by easy excision of synovitis and a tendinopathic lesion (Video 1 and Fig 4). Bhatia et al.7 were the first to describe direct arthroscopy of the bicipital groove. However, they performed this via the Neviaser portal and there are no subsequent reports of the use of this technique in the literature. This failure to gain popularity is perhaps due to a generalized acceptance of conventional techniques as a gold standard but also due to concerns regarding injury to the supraspinatus tendon and the suprascapular nerve and artery. The use of an anterosuperior portal in the current technique allows the ability to place the limb in any position due to a lack of constraint by the portal (as opposed to the need to restrict movement to minimize damage to the rotator cuff if the Neviaser portal was used). This technique also allows easy retrograde instrumentation. This facilitates therapeutic procedures (e.g., excision of groove osteophytes, debridement of tendinopathic lesions) as well as its Table 2. Advantages, Risks, and Limitations of Biceps Tenoscopy Advantages Allows visualization of the full extent of the extra-articular long head of biceps (LHB) tendon that is not seen using standard glenohumeral joint arthroscopy. Standard glenohumeral arthroscopy is reported to be associated with a 30% to 50% rate of missed diagnoses. Biceps tenoscopy has the potential to reduce this by improved visualization. This technique allows therapeutic procedures to be performed within the bicipital groove. Standard techniques do not allow intragroove procedures (e.g., excision of osteophyte and debridement of tendinopathic lesion). This technique requires no additional equipment. Risks/Limitations In addition to the risks of standard glenohumeral arthroscopy the following should be considered: The risk of compartment syndrome after established arthroscopic procedures is very low. Appropriate precautions to minimize the risk include the avoidance of high pump pressures and visual intraoperative monitoring of swelling. There is a potential risk of neurologic injury, however, by staying anterior to the LHB tendon when entering the groove and bringing the arthroscope out from the premarked skin incision; this risk is extremely low as both median and radial nerves do not lie anterior to the humerus at this level and are medial to it. The musculocutaneous nerve lies deep to the biceps muscle belly and is therefore protected by it.
BICEPS TENOSCOPY
diagnostic value. In fact, Maier et al.,8 who originally described the use of the anterosuperior portal to perform biceps tenoscopy, also reported successful removal of loose bodies, but rather than using a retrograde approach as in this technique, they used an anterior portal through the transverse humeral ligament to access the area of pathology. The use of the anterosuperior portal and retrograde instrumentation was found to be safe. The ability to needle localize the portal reduces the risk of injury to the cuff, and the passage of the arthroscope distally under direct vision with synchronous fluid distension reduces the risk of injury to muscle bellies and neurovascular structures. A summary of the advantages, risks, and limitations of biceps tenoscopy is presented in Table 2. However, the main benefit of this technique is that it addresses the limitations of standard arthroscopic techniques that, as the recent literature has shown, fail to adequately visualize the extra-articular part of the LHB tendon and lead to a high rate of missed diagnoses.
References 1. Jordan RW, Saithna A. Physical examination tests and imaging studies based on arthroscopic assessment of the long head of biceps tendon are invalid [published online November 26, 2015]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-015-3862-7.
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2. Taylor SA, Newman AM, Nguyen J, et al. Magnetic resonance imaging currently fails to fully evaluate the bicepslabrum complex and bicipital tunnel. Arthroscopy 2016;32: 238-244. 3. Denard PJ, Dai X, Hanypsiak BT, Burkhart SS. Anatomy of the biceps tendon: Implications for restoring physiological length-tension relation during biceps tenodesis with interference screw fixation. Arthroscopy 2012;28: 1352-1358. 4. Saithna A, Longo A, Leiter J, Old J, MacDonald PM. Shoulder arthroscopy does not adequately visualize pathology of the long head of biceps tendon. Orthop J Sports Med 2016;4:2325967115623944. 5. Moon SC, Cho NS, Rhee YG. Analysis of “hidden lesions” of the extra-articular biceps after subpectoral biceps tenodesis: The subpectoral portion as the optimal tenodesis site. Am J Sports Med 2015;43:63-68. 6. Gilmer BB, DeMers AM, Guerrero D, Reid JB, Lubowitz JH, Guttmann D. Arthroscopic versus open comparison of long head of biceps tendon visualization and pathology in patients requiring tenodesis. Arthroscopy 2015;31:29-34. 7. Bhatia DN, van Rooyen KS, de Beer JF. Direct arthroscopy of the bicipital groove: A new approach to evaluation and treatment of bicipital groove and biceps tendon pathology. Arthroscopy 2008;24:368.e1-368.e6. 8. Maier D, Izadpanah K, Jaeger M, Ogon P, Südkamp NP. Biceps tenoscopy in arthroscopic treatment of primary synovial chondromatosis of the shoulder. Arthrosc Tech 2014;3:e539-e545.
Biceps Tenoscopy: Arthroscopic Evaluation of the Extra-articular Portion of the Long Head of Biceps Tendon Adnan Saithna, B.Med.Sci.(Hons), M.B.Ch.B., Dip.S.E.M., M.Sc., F.R.C.S.(Tr & Orth), Alison Longo, M.Sc., Jeff Leiter, M.Sc., Ph.D., Peter MacDonald, M.D., F.R.C.S.C., and Jason Old, M.D., F.R.C.S.C.
Abstract: The recent literature shows that imaging modalities, physical examination tests, and glenohumeral arthroscopy all have low sensitivities and specificities with respect to the diagnosis of the long head of biceps tendon pathology. Biceps tenoscopy is a strategy that aims to reduce the rate of missed diagnoses by improving visualization of the extra-articular part of the tendon. This is an area of predilection of pathology that is not adequately visualized with conventional arthroscopic techniques. This technical note presents the surgical technique for biceps tenoscopy.
P
athology of the long head of biceps (LHB) tendon is a common cause of anterior shoulder pain but diagnosis can be challenging. The reasons for this are multifactorial and include the fact that LHB pathology often occurs in conjunction with other shoulder pathologies. However, the main reason for the high rates of missed diagnoses (30% to 50%) is that imaging studies, physical examination tests, and conventional arthroscopic techniques all have poor sensitivities and specificities for this application.1 Taylor et al.2 recently published their series of 277 patients undergoing arthroscopic subdeltoid LHB to conjoint tendon transfer. They reported that the sensitivity and specificity of preoperative magnetic resonance From the Department of Orthopaedic Surgery, Pan Am Clinic (A.S., A.L., J.L., P.M., J.O.), Winnipeg, Manitoba, Canada; Department of Clinical Engineering, Institute of Ageing and Chronic Disease, University of Liverpool (A.S.), Liverpool, England; Department of Orthopaedic Surgery, Southport and Ormskirk Hospitals NHS Trust (A.S.), Southport, England; Department of Human Anatomy & Cell Science (A.L.); and Section of Orthopaedic Surgery (J.L., P.M., J.O.), College of Medicine, University of Manitoba, Manitoba, Canada. The authors report the following potential conflicts of interest or sources of funding: P.M. is an Associate Editor of the Journal of Shoulder and Elbow Surgery and has received grant from the Department of Surgery, University of Manitoba. Received May 30, 2016; accepted August 23, 2016. Address correspondence to Adnan Saithna, B.Med.Sci.(Hons), M.B.Ch.B., Dip.S.E.M., M.Sc., F.R.C.S.(Tr & Orth), Southport and Ormskirk Hospitals NHS Trust, Town Lane, Southport PR8 6PN, England. E-mail: Adnan. [email protected] Ó 2016 by the Arthroscopy Association of North America 2212-6287/16475/$36.00 http://dx.doi.org/10.1016/j.eats.2016.08.018
Arthroscopy Techniques, Vol
-,
imaging for the diagnosis of bicipital tunnel lesions were only 50.4% and 61.4%, respectively. The literature also shows that physical examination tests and other imaging modalities are unreliable. Jordan and Saithna1 showed that published sensitivities and specificities of physical examination tests based on arthroscopic assessment as a gold standard are invalid. This is because conventional glenohumeral arthroscopy allows visualization of Denard zone A (up to 2.5 cm from the biceps anchor) and part of zone B (2.5-5.6 cm) only and does not adequately evaluate more distal parts of the tendon where the most pathology occurs.1,3,4 Moon et al.5 reported that the incidence of tendon tears distal to the subscapularis tendon (Denard zone Cddistal to 5.6 cm from the biceps anchor) was 77.8% in a cohort of patients undergoing subpectoral biceps tenodesis. A recent systematic review has shown that the standard technique of pulling the LHB into the joint at glenohumeral arthroscopy fails to provide enough excursion to visualize beyond Denard zone B (2.5-5.6 cm), and therefore it is unsurprising that several authors have reported that between 30% and 50% of macroscopic tendinopathic lesions are missed at arthroscopy when compared with an open approach.1 This has been suggested as a potential cause for suboptimal outcomes after common procedures such as cuff repair, subacromial decompression, and even biceps tenodesis if the diseased tendon is left distally in the groove (suprapectoral tenodesis).1 With such a high prevalence of missed diagnoses it is clear that alternative techniques are required to ensure more complete evaluation of the
No
-
(Month), 2016: pp e1-e5
e1
e2
A. SAITHNA ET AL.
Fig 1. Intra-articular view of a left shoulder. Standard posterior viewing portal and 30 arthroscope used. The first image shows needle localization of the anterosuperior portal in the rotator interval immediately anterior to the leading edge of the supraspinatus. The second image shows that a correct location is confirmed by easy passage of the needle into the bicipital groove to pass anterior to the LHB tendon. (HH, humeral head; LHB, long head of biceps; RI, rotator interval; SS, supraspinatus.)
extra-articular portion of the tendon. One method of doing so would be via an open approach. Gilmer et al.6 suggested that this may be considered when there is a high clinical suspicion of LHB pathology but diagnostic
arthroscopy is considered “normal.” However, most concomitant shoulder pathologies are now treated arthroscopically, and therefore the aim of this study was to evaluate the feasibility and safety of biceps tenoscopy as a strategy directed toward reducing the rate of missed diagnoses.
Surgical Technique The surgical technique is documented in a cadaveric specimen (Video 1). Health Ethics Research Board approval was granted for this purpose. The procedure can be performed in either beach chair or lateral positions. A standard posterior viewing portal is used to perform diagnostic arthroscopy using a 30 arthroscope. However, to facilitate biceps tenoscopy, it is important to use an anterosuperior rotator interval portal rather than a standard anterior mid-glenoid portal for instrumentation. The anterosuperior rotator interval portal is located immediately anterior to the leading edge of the supraspinatus (Fig 1). Viewing externally this portal is
Fig 2. External view of a left shoulder. This shows the correct location of the anterosuperior portal in front of the acromioclavicular joint. The transverse skin marking indicates the lower border of the pectoralis major tendon, and the vertical skin marking shows a typical cosmetic incision for an open subpectoral tenodesis. The arthroscope is bought out through the skin in a 5-mm incision made in the second line. As can be seen in the image, this allows the surgeon to engage the shaver in the mouth of the arthroscope sheath to carefully guide it into the bicipital groove in a retrograde fashion.
Fig 3. Insertion of a switching stick into the bicipital groove of a left shoulder. The key point to note is insertion of the switching stick anterior to the tendon to facilitate subsequent insertion of the arthroscope anterior to the biceps muscle belly. (LHB, long head biceps tendon; SS, supraspinatus.)
BICEPS TENOSCOPY
e3
Fig 4. Biceps tenoscopy of a left shoulder viewing with a 30 arthroscope inserted through the anterosuperior portal with retrograde instrumentation. The first image shows how the view of the long head of biceps (LHB) tendon can often be initially obscured by loose connective tissue, synovitis or a degenerative lesion. The second image shows the high-quality view that can be obtained after excision of loose connective tissue, a tendinopathic lesion, and a small groove osteophyte.
located just anterior to the acromioclavicular joint (Fig 2). The adequacy of portal position can be assessed before skin incision by insertion of a spinal needle. This should be placed so that it can be directed easily into the bicipital groove (Fig 1 and Video 1). A switching stick is then inserted into the bicipital groove through the anterosuperior portal. This is performed under direct vision. The arthroscope should be positioned anteriorly in the joint with the light lead directed to face caudally toward the bicipital groove. This gives excellent visualization and allows the switching stick to be inserted into the biciptial groove so that it lies anterior to the biceps tendon (Fig 3). The arthroscope sheath is then passed over it to allow subsequent insertion of the arthroscope. It is useful to have 2 sheaths so that the second sheath can be inserted under direct vision without having to remove the camera from the posterior viewing portal. The fluid inflow is switched over to the biciptal groove sheath. The arthroscope is then passed into the sheath and advanced under direct vision. It is directed toward a line drawn on the skin indicating a typical incision for a subpectoral biceps tenodesis. A 5-mm skin incision is made in this predetermined line, directly over the tip of the arthroscope (Fig 2). The arthroscope is then disengaged from the sheath and withdrawn approximately 5 mm. The tip of a 4.2-mm Cuda shaver blade (Linvatec, Largo, FL) is inserted in a retrograde fashion through the skin incision into the mouth of the sheath and then advanced until the light source is localized, by external viewing, in the region of the bicipital groove. The arthroscope is then reinserted into the sheath and the pump switched on to a pressure of 40 mm Hg. The shaver
Fig 5. External view of a left shoulder. A pink needle has been placed approximately 1 cm above the lower border of the pectoralis major (indicated by a blue line, indicating the location of the musculotendinous junction). A cannula has been placed in the subpectoral incision to facilitate quick insertion and removal of retrograde instrumentation, although this is not essential. Viewing the needle at biceps tenoscopy gives additional feedback that the most distal zone of the long head of biceps (Denard zone C) is fully visualized.
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Table 1. Tips, Pearls, and Pitfalls of Biceps Tenoscopy Tips and Pearls The anterosuperior rotator interval portal should be needle localized to confirm that subsequent insertion of the camera will provide direct line of sight into the bicipital groove. Although it is not essential, it is helpful to have 2 camera sheaths, as the second can be inserted into the bicipital groove, under direct vision, whereas the first is used to maintain a posterior viewing portal (as seen in Fig 5). When initially inserting the camera into the groove, it is useful to place a fingertip on the arthroscope sheath 3 cm from its tip. When this subsequently comes to rest on the skin, the surgeon can be confident that the arthroscope has not gone beyond the transverse humeral ligament. Once the surgeon is oriented the arthroscope can be advanced under direct vision to the premarked skin incision distally. Three-dimensional proprioception can be improved by dimming operating lights as this allows better external visualization of the light source at the end of the camera and provides additional feedback regarding the location of instrumentation within the groove. If bleeding occurs, it can be controlled by increasing pump pressure temporarily and retrograde insertion of a radiofrequency device. Pitfalls To avoid the risk of misdirecting instruments, e.g., shaver, the camera sheath can be used as a guide for retrograde insertion (Fig 2). A cannula can also be inserted for this purpose but is not essential (Fig 5). As shown in Video 1, when bringing the arthroscope proximally, it is easy for it to fall back into the joint. This means that pathology at the entrance to the bicipital tunnel can be missed unless particular attention is paid to carefully visualizing this area. The appearance of muscle fibers within the tendon is more obvious arthroscopically than at an open approach, and this can mislead the surgeon into thinking that he or she has observed the musculotendinous junction. It is important to visualize up to this point to evaluate the full extent of the tendon. A useful tip to facilitate this is to place a needle into the bicipital groove 1 cm above the lower border of the pectoralis major to help identify this landmark (as seen in Fig 5).
is used to debride loose connective tissue to allow clear visualization of the LHB tendon up to and including the musculotendinous junction. Tendinopathic lesions and osteophytes can also be addressed in this way (Fig 4). Because muscle fibers appear variably on the anterior surface of the LHB, as one approaches the musculotendinous junction its precise definition can be rather subjective. It is helpful to localize this landmark by inserting a needle into the bicipital groove 1 cm above the lower border of pectoralis major. This can then be viewed with the arthroscope to provide additional feedback that the full length of the tendon has been visualized (Fig 5). The shaver can be exchanged for a probe using the same insertion technique and this allows manipulation of the tendon (to obtain a circumferential view) and probing and evaluation of the bicipital groove. Any further pathology that is then identified can either be addressed by reinsertion of a shaver or by prompting the decision to perform a biceps tenodesis. Table 1 provides a summary of tips, pearls, and pitfalls of this technique.
Discussion The use of an anterosuperior portal directly anterior to the biceps pulley facilitates easy insertion of the arthroscope into the bicipital groove. Excellent visualization of the full extent of the extra-articular portion of the LHB tendon can be achieved using standard arthroscopic equipment. The distal passage of the arthroscope to the predetermined location for skin incision is safe with respect to the musculocutaneous nerve because the arthroscope remains anterior to the biceps tendon and muscle belly throughout the procedure. The therapeutic use of this approach is shown by easy excision of synovitis and a tendinopathic lesion (Video 1 and Fig 4). Bhatia et al.7 were the first to describe direct arthroscopy of the bicipital groove. However, they performed this via the Neviaser portal and there are no subsequent reports of the use of this technique in the literature. This failure to gain popularity is perhaps due to a generalized acceptance of conventional techniques as a gold standard but also due to concerns regarding injury to the supraspinatus tendon and the suprascapular nerve and artery. The use of an anterosuperior portal in the current technique allows the ability to place the limb in any position due to a lack of constraint by the portal (as opposed to the need to restrict movement to minimize damage to the rotator cuff if the Neviaser portal was used). This technique also allows easy retrograde instrumentation. This facilitates therapeutic procedures (e.g., excision of groove osteophytes, debridement of tendinopathic lesions) as well as its Table 2. Advantages, Risks, and Limitations of Biceps Tenoscopy Advantages Allows visualization of the full extent of the extra-articular long head of biceps (LHB) tendon that is not seen using standard glenohumeral joint arthroscopy. Standard glenohumeral arthroscopy is reported to be associated with a 30% to 50% rate of missed diagnoses. Biceps tenoscopy has the potential to reduce this by improved visualization. This technique allows therapeutic procedures to be performed within the bicipital groove. Standard techniques do not allow intragroove procedures (e.g., excision of osteophyte and debridement of tendinopathic lesion). This technique requires no additional equipment. Risks/Limitations In addition to the risks of standard glenohumeral arthroscopy the following should be considered: The risk of compartment syndrome after established arthroscopic procedures is very low. Appropriate precautions to minimize the risk include the avoidance of high pump pressures and visual intraoperative monitoring of swelling. There is a potential risk of neurologic injury, however, by staying anterior to the LHB tendon when entering the groove and bringing the arthroscope out from the premarked skin incision; this risk is extremely low as both median and radial nerves do not lie anterior to the humerus at this level and are medial to it. The musculocutaneous nerve lies deep to the biceps muscle belly and is therefore protected by it.
BICEPS TENOSCOPY
diagnostic value. In fact, Maier et al.,8 who originally described the use of the anterosuperior portal to perform biceps tenoscopy, also reported successful removal of loose bodies, but rather than using a retrograde approach as in this technique, they used an anterior portal through the transverse humeral ligament to access the area of pathology. The use of the anterosuperior portal and retrograde instrumentation was found to be safe. The ability to needle localize the portal reduces the risk of injury to the cuff, and the passage of the arthroscope distally under direct vision with synchronous fluid distension reduces the risk of injury to muscle bellies and neurovascular structures. A summary of the advantages, risks, and limitations of biceps tenoscopy is presented in Table 2. However, the main benefit of this technique is that it addresses the limitations of standard arthroscopic techniques that, as the recent literature has shown, fail to adequately visualize the extra-articular part of the LHB tendon and lead to a high rate of missed diagnoses.
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