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VID1-003520-en-US | A | Arthroscopic Biceps Tenodesis Using the BioComposite Tenodesis Screw

Stephen S. Burkhart

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Arthroscopic Biceps Tenodesis Using the BioComposite Tenodesis Screw

Okay, so this is a 42 year old man. He injured his left shoulder initially. 18 years ago, we had an a c separation. He had a reconstruction of that in 1992. And then he's had this continual pain since then. But it's been gradually progressive, and the weakness has increased over the last couple of years. So what I like to do is in a case like this, he has an MRI scan, a supraspinatus tear, probably part of the infraspinatus. It's hard to tell if it is upper SpeedScap, because the quality of the MRI scan is not so good. My posterior portal, I tend to make fairly low, about four centimeters below the back of the acromion. And I like to come in at about the midpoint of the humeral head, about the equator of the humeral head. This man is quite muscular, and so you have the deltoid thickness to contend with a little bit there. So you see the depth I am in. Plus I tend to be 2 or 3cm medial to the corner of the acromion. And then I'll come through the deltoid so that I'm just up against posterior capsule and feel the posterior glenoid rim. Now internally rotate. If there's any question where that is internal rotation can help. And then we'll just go into the joint. Okay. So now we have a 70 degree scope. And you can see how we're looking down what we call an aerial view. As if we're looking from 30,000ft in an airplane. And we can see the SpeedScap much better now. And we can also look down into the top of the bicipital groove. And you see, we can see a couple of centimeters down. So we have that view there. Okay. Now. Now we're going to do a posterior lever. Push. Tom. Tom is our expert on the posterior lever. Push! Give me a poster lever. Push now and see what he's doing is stabilizing the elbow and then pushing posteriorly on the upper humerus. And you see, now we've got this great view of the footprint of the SpeedScap. There is typically a bare strip of a footprint just medial to the insertion. But, you see, it looks like there has been some disruption of these upper fibers of the sub scap. And I think we're probably going to want to put one anchor there. And very likely we'll need usually when we have that disruption of upper subscapular. It's in my opinion secondary to subcoracoid impingement. So we'll probably want to do a coracoid plasty. And then you see how we, in my view, have some incompetency to the medial sling. So we're going to want to do a biceps. Tenodesis. Now, the other reason to do Bio-Tenodesis is that I think that the biceps root has some damage to it. We're going to to probe that in a minute. I need to make an antero-superolateral portal just off of the anterolateral corner of the acromion. That's where that's our starting point, anyway. You see where there's sort of a ridge here where the lateral sling of the biceps is here. Now, that right there where my needle came through, is the anterior margin of the supraspinatus tendon. So we want to come in right about that area. Because we don't want to cut any of the supraspinatus tendon doing this. Then we also the ideal orientation of this portal is at about a 45 degree angle to the superior margin of the glenoid. 30 to 45 degree angle. That's pretty good. That's going to be about a 45 degree angle there, very close to it. So that's going to be where we want to place our Antero-superolateral portal. And we use the 8.25mm cannula here. What I'm doing these BicepsButton GAP combinations I like to use a rigid cannula. The other thing about this particular angle is you want to come in so that you're roughly at right angles to the top of the bicipital groove, and you can do your biceps tenodesis through this same portal. So you see how we can come in right over the top of the biceps, right at the very top of bicipital groove, and do our tenodesis through this same portal. Okay, so the next thing we're going to do is we're going to put a couple of cinch loop stitches or half rack half racking stitches in our biceps tendon. We'll have to have half the suture on one side of the slot, half on the other. That is, we grasp it right in the middle of the suture. And then what I'll do is just pass that through the biceps tendon to get a sort of a strangulation stitch. We call it a half racking stitch. So we'll pass the loop through the tendon. And we'll just drop the loop. And then we'll come back posterior to the biceps. We'll grab the loop. And then come out through. So the first thing we do is we even it up. So the limbs are about equal. And then we have this loop from the one end. And then we'll pass the two free ends of the suture through the loop, and then we sort of reciprocally cinch that down. So you'll see the knot coming down. And with a reciprocal tightening you get sort of a strangulation stitch that has a tight circle at right angles to the fibers of the tendon. Now we'll do one of each color, we'll do a TigerWire and we'll also do a blue FiberWire. We'll do the same thing with our blue. So now we have just kind of a double grip on the tendon. Okay. Next thing I want to do is do a biceps tenotomy in preparation for tenodesis. So we're going to use these curved scissors. These are very nice curved arthroscopic dissecting scissors. I want to come in at a bit of an angle. And get a view. Of the two tips basically on each side of our of our tent, and this is quite a large tendon, but still you can see that. And typically it takes one bite, sometimes two to do that. And so now what we're going to do is exteriorize. The biceps. So to optimize our visualization of the biceps we we flex our elbow. We'll forward flex the shoulder. And this is actually quite a bit that we can bring out here. Now generally we'll use a seven millimeter but interference screw for the females and eight on the males. His actually is a little smaller than I might have expected for a man his size. He's a very big man. Now, I like to start the the whip stitch on the superior aspect of the biceps. So I know that I've intentionally passed these loops over the posterior aspect of the biceps, so I know this is This is post your. Then this aspect has to be superior right here. And I like to start out about five millimeters from the end of the tendon so that I can. Use my tenodesis driver to push the tendon down into the bone socket. Typically I'll go 3 or 4 whip stitches on each side of the tendon. Now, if you do your tenodesis at the top of the bicipital groove it gives you a very cosmetic appearance. If you just use the natural length of your biceps tendon, that is, if you don't shorten it down any, because the intra-articular length of the biceps is usually in the range of 22 to 26mm or so, and your by your interference screw is 23mm in length, so you end up being within a couple of millimeters of anatomic length. And then I want to trim this end a little bit. And I want to trim any dog ears off the edge so that it will fit very easily down into our bone socket. When we make that, I want to get rid of the other blue stitch because I want to have two suture pairs. I'm going to have a blue suture pair from my whip stitch, and then I'll have the TigerWire pair. And then this other blue pair I'm going to get rid of. Okay. So he's got a smaller tendon than usual. It fits easily through a seven. So we'll probably use a seven millimeter interference screw. So our workhorse cannula for doing biceps tenodesis at the top of the bicipital groove. Is this antero-superolateral cannula. So let's externally rotate a little bit now. Now what you want to do is have your assistant pull up. You want to have them pull on the tendon so those sutures aren't visible. Okay. So pull up on the tendon, and then then you know that you're not going to cut your sutures while you're preparing things at the top of bicipital groove. So here's the very top of Bicipital groove. Now, Tom, you internally and externally rotate. If you haven't got your angle just right, you can change it by having your assistant internally or externally rotate the arm and you want to come in perpendicular to the top of the bicipital groove. So there we are right there. The other thing is I'm using the 70 degree scope so I can look kind of around the corner. And and that gives me that perfect view right there. That's what I want to do. I want to just have that sitting down like a little bell on top of the table there. Okay. So we'll put our guide pin in first for making our hole. Go ahead. And we've measured seven millimeters. So that's what we're going to use. So what we do now is to go only through the cortex, and then we hand spin it to go the rest of the way, and we go down 25mm, and we'll work inside this clear cannula. So we go down to 25. And now we'll back that all out. And now we've got a clear the mouth of that bone socket. We've got to get that soft tissue out because that can prevent you from pushing the tendon down into it. So we have several different options on how to clear that out. We'll start out with a shaver. We can use cautery. And we can also use those ring curettes. Those three instruments are the workhorses for clearing the soft tissue from the mouth of that bone socket. You have to be a little careful when you use the cautery that you don't. Actually cut some of your biceps tendon. So you have you have to know where that is. Obviously here we're working away from it so it's not in danger. But when you come back this way, you have to know where your biceps is. And we're far enough away from our the anchor that we used, the SwiveLock anchor that we used to fix the sub scalp. Okay. So the next thing we're going to do, we'll take out this cannula and we're going to thread our blue sutures, which are the ones from our whipstitch. We'll thread those through the cannulation of our Bio-Tenodesis driver. And I prefer that rather than to use an extra suture to kind of lasso it, because this way I have a direct contact between the tendon and the inserter. I'm not. I don't have an interposed passing lasso type of a suture there. So then we bring that down. We use a poster lever. Push. Now this is where it can be a little bit tight and you've got to be able to to see. This is where a 70 degree scope really helps you see that I'm at the mouth of that bone socket. You see it right there as our bone socket. And then we use our driver just to push that in the same line okay. So hold the camera okay. So you push it down until the threads hit the bone. So I'll hold the thumb pad while an assistant turns the handle. Okay. And once again I can back the sleeve off if I want to. And I can see I'd like to maybe go another half turn. We'll put the sleeve back down. Now turn again. Okay, good. So now we're slightly countersunk. That's exactly where I want to be. We'll take our driver out, and we've got two sets of sutures we can use to use in our rotator cuff repair if we want, or if we're not going to do that, we can just tie a blue to a tiger twice, so that the sutures completely encircle the anchor to help further reinforce the construct.

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Tenodesetechnik

Arthroscopic Biceps Tenodesis Using the BioComposite Tenodesis Screw

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