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Consider open proximal biceps tenodesis with interference screw fixation
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The proximal portion of the long head of the biceps is a known cause of anterior shoulder pain.
This article will discuss the technique favored by the senior author: open biceps tenodesis with an interference screw.
After standard diagnostic arthroscopy and tenotomy of the long head of the biceps, all arthroscopic equipment is removed from the shoulder and the patient is reclined to 30° in a modified beachchair position. The operative extremity is abducted and placed on a sterile Mayo stand. The axillary crease and the inferior border of the pectoralis major tendon are palpated and marked with a sterile marking pen (Figure 1).
The incision is generally made just lateral (and parallel) to the axillary crease with one-third of the incision proximal to the inferior border of the pectoralis major tendon and two-thirds of the incision distal to it. In the majority of patients, the total length of the incision is between 3 cm and 5 cm. This is adjusted based on patient habitus and exposure requirements. In young patients, or those who have aesthetic concerns, the incision is sometimes placed in the axillary crease so as to minimize the appearance of the scar.
Figure 1. The axillary crease, inferior border of the pectoralis major tendon and the planned incision is shown.
Figure 2. The inferior border of the pectoralis major tendon is exposed.
Images: Romeo AA
After the incision has been planned and marked, the subcutaneous tissues are infused with a mixture of epinephrine and local anesthetic to both control bleeding and improve postoperative pain control. The skin incision is made with a #10 scalpel, and hemostasis is achieved with electrocautery. Sharp dissection is carried down until the fascial layer overlying the pectoralis major, coracobrachialis and biceps is visualized.
After the correct fascial plane is identified, the fascia overlying the junction of the inferior border of the pectoralis major and the biceps is incised in a proximal to distal manner. In some individuals, this fascial layer can be bluntly dissected; in others, this layer can be very stout and will require sharp incision and dissection. Once this layer is incised, the surgeon can use their finger to bluntly dissect and identify the long head of the biceps (Figure 2). Heading first medially, the smooth undersurface of the pectoralis major should be felt to ensure that the correct interval is identified. If the smooth pectoralis is not appreciated, the exposure may be in the deltopectoral interval. Once the correct interval is confirmed, the surgeon should move laterally until the anterior humerus is encountered, at which point the bicipital groove is easily palpated under the tendon of the pectoralis major. The long head of the biceps lies within this groove, immediately medial to the insertion of the pectoralis. The surgeon may need to open the biceps sheath from distal to proximal along the lateral border to mobilize the bicep tendon. Then, the tendon can easily be retrieved.
Visualization of the tendon
Some surgeons may want to efficiently extract the long head of the biceps blindly by palpation. It takes little extra time to do this under direct visualization, and until such time, that the surgeon is confident in his or her ability to identify and extract the tendon by palpation alone, we believe extraction of the tendon should only be done under direct visualization (Figure 3).
Figure 3. The extracted long head of the biceps tendon is shown.
Figure 4. Placing the Chandler and Hohmann retractors.
To visualize the tendon, we prefer the use of specific retractors including a sharp-pointed Hohmann retractor and a blunt Chandler retractor. The Hohmann is placed in a medial to lateral fashion into the pectoralis major tendon insertion and over the humerus to retract the muscle both laterally and proximally. The Hohmann should first be placed with the point facing anterior, making it easier to pierce the pectoralis insertion. Once this is accomplished, the Hohmann is rotated 180° so that the tip matches the curvature of the humerus and faces posteriorly. The blunt Chandler retractor is placed on the medial humerus to retract the short head of the biceps and the coracobrachialis (Figure 4). This retractor is critical to protecting the brachial plexus. Medial retraction should be done cautiously to avoid injury to the nearby medial neurovascular structures.
Once the tendon is identified and extracted, a hemostat is placed on the proximal end of the tendon and the musculotendinous junction is identified. The tendon is then prepared using an Arthrex 2 FiberLoop suture (Arthrex; Naples, Fla.). The loop is started just proximal the to musculotendinous junction and continues 2 cm to 2.5 cm proximally (Figure 5). The remaining proximal tendon is sharply removed. While the authors prefer the FiberLoop suture, any nonabsorbable suture should suffice using a Krackow or whipstitch to secure the tendon. The important concepts are correct identification of the musculotendinous junction and preparation of sufficient tendon to reproduce the length-tension relationship. Once the tendon is prepared, it is delivered outside of the wound and attention is turned to preparation of the humerus.
Preparation of the tendon
Using the same retractors employed to identify and isolate the tendon, the bicipital groove is identified and the periosteum is elevated 1 cm to 2 cm proximal to the inferior border of the pectoralis major tendon, in the center of the groove. Once the periosteum is elevated, a unicortical guide wire is placed perpendicular to the cortex of the humerus (Figure 6). Line-to-line reaming for the intended inference screw is planned. An 8-mm cannulated reamer is used to create a unicortical bone tunnel for the tendon and the 8-mm nonabsorbable interference screw. The reamer should not be run as it is removed from the tunnel, as this can create an asymmetric tunnel and jeopardize interference screw fixation. After the reamer and guide wire have been removed, the tunnel is freed of any surrounding tissue using electrocautery. A tap is used to prepare the hard cortical bone using the appropriate size for the selected screw. After preparation, the surgical field is thoroughly irrigated to remove bone debris.
Figure 5. Starting and advancing the FiberLoop suture.
Figure 6. Placing the guide wire.
The prepared tendon is brought back into the field and one limb of the FiberLoop is threaded through the Arthrex Bio-Tenodesis screwdriver and screw (8-mm x 12-mm PEEK Arthrex interference screw) and then wrapped around the distal end of the screwdriver to maintain tension. Keeping tension on the free end of the suture, any remaining tendon-stump is “dunked” into the tunnel and the screw is advanced over the tendon into the tunnel (Figure 7). When the screw is appropriately engaged into the humerus, it is advanced until it is slightly proud or flush with the humeral cortex. The screw should be advanced carefully as it can be easy to over-advance the screw and lose it in the medullary canal.
After the screw is appropriately seated, the screwdriver is removed and the ends of the suture loop are tied together providing secondary fixation (Figure 8). At the end of the procedure, the musculotendinous junction of the long head of the biceps tendon should rest in its native anatomic location just underneath the inferior border of the pectoralis major tendon.
Figure 7. Preparing to “dunk” the tendon and begin advancing the tenodesis screw.
Figure 8. Tying the ends of the FiberLoop to complete the tenodesis.
Closure and conclusion
After the procedure is finished, the wound is copiously irrigated and then closed in layers using a 2-0 monocryl deep dermal layer, a running 3-0 monocryl subcuticular stitch and Dermabond. Creating a seal to the wound closure with cyanoacrylate tissue adhesive helps to minimize the risk of contamination from the axilla and subsequent wound infection. Closure should be meticulous as dehiscence and wound complications in the axilla can be problematic.
There are many methods described to tenodese the long head of the biceps tendon. The goals are similar with each technique, including strong fixation, restoration of the length-tendon relationship to maintain strength and avoid cramping, and cosmesis. In our opinion, and based on more than 12 years experience documented with multiple peer-reviewed publications, this technique is safe and reliable, and can either be performed in isolation or as a part of a larger shoulder operation. We have had consistent success with this technique independent of the cause of biceps symptoms, and recommend that this option be considered when confronting long head of the biceps pathology.
For more information:
Anthony A. Romeo, MD; and Michael Khair, MD, can be reached at Midwest Orthopaedics at Rush, Rush University Medical Center, 1611 W. Harrison St., Suite 300, Chicago, IL 60612. Romeo’s email: anthony.romeo@rushortho.com. Khair’s email: mikekhair@gmail.com.
Disclosure: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed; and is Chief Medical Editor of Orthopedics Today. Khair reports no relevant financial disclosures.