Name: Proximal Biceps Tenodesis
Uploaded: 2012-09-27T00:00:00Z
Channel: Arthrex

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VID1-003548-en-US | A | Proximal Biceps Tenodesis

Paul Sethi

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Proximal Biceps Tenodesis

Thank you very much, Reinhold and Arthrex and Brian for putting this together. I think this is an amazing forum and I feel quite, quite honored to be amongst the faculty here. I'm going to talk about the biceps tendon. I have a love hate relationship with the with the biceps tendon. I like that distal biceps. I'm not such a big fan of the proximal biceps when it when it has failed conservative management and about a decade ago. Neal, it's been ten years since you since you've had me in your tutelage. A decade ago, you taught me to really examine that, examine that proximal biceps, and really know what I'm getting into before I approach any patient surgically. So not just to look at the appearance of the biceps, but to understand what it's doing. I think any discussion of the proximal biceps, we have to include the concept of tenotomy and the tenotomy alone. Good enough. And certainly in certain patients it is, and probably in a younger group of patients it's not. And this is something that we'll reserve in our armamentarium. Bob Arciero has taught me about the biceps tendon. He says, look, for me, it's all or none. You either have a good tenant or a bad tenant, and the role of limited debridement has really fallen out of favor for me, at least, in finding these hidden lesions in the biceps and and partially breeding them. I found that I've come back where patients have come back to me with a painful biceps, and both the patient and I hope that the biceps auto ruptures. 2012 biceps. Who for me will certainly most degenerative slaps and hourglass or a subluxed biceps pulley lesions. Any fraying, any real slap tears in the non-throwing athletes. So so a slap tear in a 30 year, a 35 year old male who's a tennis pro in my in my community is going to frequently get a get a biceps all rotator cuff tears. I'm not quite there yet, but certainly in my irreparable cuffs I will. And and I guess this is really the French experience is really catching on or exposing more influence in this country. The role of Odysseus in a throwing athlete. I think maybe at the question and answer session, I'd like to ask doctor, doctor, Romeo and Trish for their thoughts on this. Where does Tenodesis occur? It occurs at a number of different locations. It can occur high in the groove, actually in the bicipital groove, in the supra pectoral location, which is an arthroscopically identifiable location and the spectral location. And I started to really think about this a lot and dissecting out these, these proximal humeri the pec tendon is Doctor Romeo showed in the earlier presentation. It's actually a pretty long tendon. And where we're going super pec or sub pec or arthroscopically is a very wide variation. If you start here up at the top of the in the groove, at the bottom of the groove, at the super Pac, or down at the Sub Pac location where you're coming to the Musculotendinous junction. My $0.02 on this. You know, I still can't quite understand what's normal and who should be east. I think there is some amount of synovium and some amount of vasculature that exists on the superior aspect of the biceps tendon. That's variable. And not everyone has this lipstick synovium where we say, gosh, there's no tear, but there's an inflamed biceps, should I indeed Tenodesis should I do a JT type synovectomy on this biceps? I'd like to better understand that in my hands the tenotomy is going to be less common. You're going to be a larger arm, less active. I have, I've tried and I've tried many of the all arthroscopic techniques in the pit essentially was a tenotomy to me. Anchors. Well, you know, I was concerned about using anchors in the in the proximal biceps, because this is poor quality tissue in the beginning and above, the groove may be fine, but to me it can interfere with my leading edge. Supraspinatus repair and I found a lot of high deltoid and high deltoid incisions cause adhesion to the adhesion there. And I found that I've gone in and rereleased this tissue to the patient's relief. So it's brought me over to the to the distal distal biceps tenodesis or the sub pectoral. And Doctor Warner and I think Peter Millet was involved in this study, looked at the rate of revision surgery after proximal versus distal biceps tenodesis. And the revision rate was much higher when when you had an above groove above groove Tenodesis performed. So I've really gone on to this sub pectoral. I went on to the sub pectoral approach as described by Doctor Romeo and Maisaka, and here, here I sort of modified it a little bit. I use the the Arthrex BicepsButton because I want to really dial in the length. Ruben, you wrote this up in the cortical way in not too long ago, so it's a small two centimeter incision. Right? Right. Just above the musculotendinous junction. I'm going to use a FiberLoop. Take about two centimeters of tendon to anatomize the residual part. I'll load a I'll load this into a button. Once I load it into a button, I'll use the 3.2mm guide pin and drill. And I'll drill bicortical I know Ruben likes to go uni cortical, I like bicortical, I want to dock this tendon into the bone and really dial in the length you can over drill, and you really have the option if you want to use a screw in this situation, you can drill a 7 or 8, but if you have a small tendon or a small purse, you can go as small as a five. The button flips on the back cortex, and as you pull on your sutures, you can really dock this this biceps into into into the tendon. And it's very rewarding to sort of dial in the exact length that you want. It is important to place a suture through through the tendon and lock it into place. In this case, using a screw to fix it is useful. And and and I'll talk later about the biomechanics here. The screw actually I think is somewhat important. The question that many people have asked me, is this a safe location? Can I drill bicortical through the humerus in this location here on the right, you can see an x ray of where the button ends up. You say, my gosh, that's a lot farther distal than I than I think. And I would I would submit to most of you that your sub pectoral tenodesis does occur, especially depending on a muscular person. It occurs a little further down the humerus than than you may expect. And perhaps you can X-ray 1 or 2 of your patients. But is this a safe location? Tom Hackett in Colorado has looked at it this year, and some data that will be released, I think, in the upcoming meeting shows us that a a Bicortical a Bicortical button here is about 30mm from any of the dangerous neurovascular structures there. So this is indeed a safe approach. And probably when I do a pectoral, my preferred approach, I started to question, why do I have to do this? Why do I have to do this in an open fashion? Can I do this arthroscopically and then cuff tears? You can really see very nicely the transverse ligament. And as you start to clear this out, you can actually identify the biceps tendon pretty clearly and you can identify it below the groove. So I was satisfying I was satisfying the idea of Above Groove. Above groove disease by able to identify that biceps down below the groove and Arthrex finally came out with the SwiveLock and I waited with with bated breath for this, because for so long I would have to exteriorize the tendon here. And this was a little bit of a struggle. So I was doing this arthroscopically, but nonetheless, I'd have to exteriorize the tendon, place a Kelly clamp on it, try and determine the exact right length, and then recapitulate that length when I got back into the. When I got back into the shoulder. So Bill Bainovic showed this video earlier before. So I think I'll skip over it in the interest of time, and I'll just show you what I'm doing. Arthroscopically currently and here you can see a shoulder. I've got a spinal needle placed into the, into the biceps tendon and that's going to hold my length. So there's no marking suture, no tendon, no grasp or anything like that. I'll release the biceps from its location. And these are what I call my goalposts. I can see my goalposts. I'm in the mid lateral portal, as you can see in the top left. I'm going to look down. This is a patient who does not have a rotator cuff tear, just a painful proximal biceps. I'll use a spinal needle localization where I identify that area. Looking at my goalpost and as I insert an ablation wand there, you can see as I push on the edge of the bottom of the groove, you can see where the biceps actually is. You can release the tissue on the lateral side of the groove. Invariably there's a small vessel that likes to bleed. You can see it's starting to bleed right there. And I'll show it to you a little more clearly. Here you can see that as I've come further down, I continue to release. There's that vessel that really lets me know I'm at the super practical lesion. It's a pretty consistent location. And Brad Edwards has written it up the vascularity to suggest that this is a consistent finding right there. I'll release it on both sides and I'll size this intellectually. It's usually a seven or an eight, I think a very, very. And there's the pec tendon right there. So you can see you're really at that super pectoral location by by landing on the pec. And there's the other side of that bleeder, which I'll ablate. Now you have your choice. I'm going to use a probe. Pull the pull the tendon out of the way, right in that flat below the groove. I'm going to use this this nipple tip drill, which does not require a guide wire. I drill a half a millimeter above. So this is a typically I'm going to use a seven millimeter implant and I'll use a 7.5 reamer. You can go line to line. But I think that does run the risk of rupturing. I'm going to clean the aperture of the hole up. Remove any soft tissue debris. The biceps is still being held out of the way. Again I'm looking from a mid lateral and I'm working from just a low anterolateral portal. You can see it up on the top right. I'll release the biceps width from my probe and then I'll grab the biceps. Right now as I just start to push I'll release the spinal needle. So now my length has never been changed significantly. No suture, nothing. That is an option for this. The tent has never been exteriorized and I'll insert this device. You can see it's a smooth a smooth tip. So I don't want to put this deep in to flush to the bone. I think it's probably better to leave it, you know, a millimeter proud. And I think I go a little deeper than I need to here. The the proximal tip which has gotten pulled down because you're putting you're putting 20mm or so of biceps into this hole. Comes out, I'll debride away this residual edge of tissue. And you can see right below me once I debris this way. There's the pec. There's there's the biceps right there fixed in nicely. And right below me is the is the slip of the pec. And I found this to be very rewarding and super strong. So I've been thinking about where this happens and where my proximal versus my distal tenodesis occurs. When I do this proximal tenodesis I'm in metaphyseal bone. I feel good about putting a screw in that bone. And I feel good about the quality of the purchase when I'm more distal in the sub pectoral location, I think that the bone is more hollow, and this is why I prefer to use the button here, because your screw purchase relies only on four millimeters of cortical bone. So that's that's the logic. And then in the lab at UConn with Doctor Mazaki and myself. We've been looking at this and and what I found. And what's very interesting is you cyclically load these different types of repairs, just like Doctor Roman suggested. It's really an issue of the tendon quality. And there are times when this is super strong and it does fantastic. And there's times when it's just not as predictable. So in an article we'll have coming out in the next couple months, we're going to show you that it's not necessarily the button that makes this stronger. It's the nature of the proximal biceps tissue. And on the right you see it's just going to fail to tendon. On the left you can see it just pulling through. So the biomechanics I think are going to continue to be very, very interesting as we as we go forward. And in summary, the biceps is is a persistent source of pain. It's not enough maybe alone. And there are various techniques below. Groove fixation is my is my preferred technique. It may not be that all tenodesis need to be below the groove and you may be able to be successful, but it's hard to predict who's going to fail. Above. Above the groove, proximal bone below the groove is good and the humeral shaft is hollow. So that's that's my $0.02 on this.

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