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Técnica de tenodesis para bíceps FiberTak®

El sistema de implante para el tendón del bíceps FiberTak, proporciona un anclaje de sutura total diseñado para su utilización en procedimientos abiertos de fijación de tejido sobrepuesto (onlay), particularmente en reparaciones de los tendones proximales y distales del bíceps. El implante tiene doble carga de suturas deslizantes SutureTape e incluye 4 agujas unidas. El sistema incluye un implante para el tendón del bíceps FiberTak, guía de perforación, broca de 1.9 mm y una aguja curva.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

Nikhil N. Verma, MD (Chicago, IL), discusses applications and treatment options for arthroscopic proximal biceps tenodesis. He presents a case in which he used a suprapectoral onlay technique with a knotted and knotless FiberTak® suture anchor. The anchors were inserted through small drill holes, which can help reduce the risk of fracture, while the 2-anchor repair can help with cosmesis, particularly in younger more active patients.

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Arthroscopic Biceps Tenodesis: Applications and Technique

My name is Doctor Nikhil Verma. I'm the director of sports medicine at Rush University Medical Center in Chicago. And I'd like to share with you my thoughts on arthroscopic biceps tenodesis indications and a surgical technique. The patient that we'll be presenting today came to the office with right shoulder pain. He was a 26 year old, right hand dominant male who worked as a baggage handler and reported an injury about two months prior when he was lifting a bag and felt pain in the anterior aspect of the shoulder. Since that time, he'd had persistent activity related pain. He reported pain over the anterior and lateral aspect of the arm, with some radiation into the biceps itself, associated with weakness and nighttime discomfort. The patient had undergone physical therapy, as well as a trial of non-steroidal anti-inflammatory medications without significant benefit. His examination demonstrated that he had full, painless cervical range of motion with a negative Spurling sign and no reproduction of his shoulder symptoms. He was tender to palpation directly over the biceps in the anterior aspect of the shoulder. He had full range of motion, although pain with terminal elevation and abduction, mildly positive impingement signs, as well as positive cross-body adduction, O'Brien signs speed and Jurgensen maneuvers. His strength was generally maintained in all planes, with no evidence of rotator cuff tear. His diagnostic imaging included an MRI scan, as you can see here. One can appreciate that there was some inflammation and edema surrounding the AC joint, a mild amount of subacromial fluid, a small amount of glenohumeral effusion, an intact rotator cuff, and fluid surrounding the biceps, particularly in its distal portion just below the bicipital groove. Here you can see an axial view where we can actually look at the tendon itself, and one can appreciate a small split within the tendon, resulting in two separate fascicles. Now, when considering biceps related surgery, it's important that we understand the anatomy of the biceps itself, and the biceps consists of two portions a smaller intra-articular portion and a larger or longer extra articular portion. The intra-articular portion is about two centimeters in length compared to the extra articular portion, which is about 5 to 6cm in length, and only the intra-articular portion is visualized during an arthroscopic procedure. This is important as we start to consider indications for surgery, and the fact that 1st May not be able to identify biceps pathology during direct visualization at the time of arthroscopy. And so, in my opinion, this is a diagnosis that is made most often in the preoperative setting. In terms of functional considerations, we need to consider how does removing the biceps from the shoulder joint affect our patients? And a quick summary would be that the comparative anatomy and EMG data suggest a minimal role for biceps and shoulder activity. But biomechanical data does suggest a secondary but possibly important role at extremes of range of motion, so this may indicate that we should use caution in selecting a biceps, tenotomy or tenodesis for our overhead athletes, or for our patients that are experiencing shoulder instability. The diagnosis of a symptomatic biceps can be somewhat difficult, particularly in that biceps related conditions are often associated with other painful, dysfunctional shoulder conditions such as rotator cuff. Tears, slap lesions, arthritis, or other forms of intra-articular. Pathology. We use as our primary identification of biceps pathology. Number one palpation of the biceps directly in the groove, with reproduction of symptoms and pain over the anterior aspect of the shoulder, as well as selective ultrasound guided injections into the biceps sheath, where a positive response and reduction of pain can indicate that the biceps is a source of the patient's pathologic condition. The plan for this patient was to in fact undertake an ultrasound guided biceps sheath injection, which was done and resulted in about ten days of improvement, indicating that the biceps was a source of pathology within this patient's shoulder. Therefore, a surgical plan was initiated, including a right shoulder arthroscopy, a rotator cuff evaluation and treatment, subacromial decompression, arthroscopic biceps tenodesis, as we'll demonstrate. And finally, a distal clavicle excision given pain over the clavicle associated with AC joint edema. On the preoperative MRI scan, our positioning for this procedure is done in a beach chair position. We use standard portals, including a posterior portal, which is used primarily for visualization. A lateral portal, which is used for visualization during the tenodesis portion of the procedure. A standard anterior portal that can be used as a working portal, as well as an accessory. Anterolateral portal, which is created about two centimeters distal and two centimeters lateral to our standard anterior portal. And it's the primary portal using which we introduce anchors and or manipulate sutures for the actual tenodesis. The procedure begins with a standard diagnostic arthroscopy. This is a right shoulder in a beach chair position. You can see that we have the scope posteriorly, and we've established an anterior portal. And we're now using a simple basket in order to displace the biceps in order to visualize the grooved portion. And here you can see a positive lipstick sign or tenosynovitis of the biceps as it enters the groove, which is consistent with our preoperative diagnosis and Gnosis in imaging, and we begin by releasing the biceps or performing a tenotomy using a basket forceps for later tenodesis. We then move into the subacromial space. In this case, we've already completed a Bursectomy. We now have the camera in the lateral portal, and we've established using spinal localization, our accessory anterolateral portal. And in this case, I'm actually opening the roof of the biceps groove or the transverse ligament using an 11 blade which allows me to remove the tendon. And you see the significant amount of disease that exists within the groove portion of the tendon, including thickening of the tendon and tenosynovitis. Now, an important part of the procedure is then to use a grasping device, such as a KingFisher, from a posterior portal, which allows you to maintain control of the biceps, to tension the biceps, and to maneuver the biceps. In order for you to access different areas of the bone and or passing suture around the tendon during the tenodesis itself. We then use a radiofrequency one, which will allow us to expose proximally the biceps groove and more distally, the bone just below the groove in the area between the groove and the pectoralis major tendon. Here you can see a release of the soft tissue, and you can appreciate the fact that the groove actually has a fibrocartilage type appearance at its base. And here you can see the top border of the pectoralis major reflected edge defining the supra pectoral space. The tenodesis occurs between the pectoralis major and the base of the bicipital groove, and therefore is known as a supra pectoral tenodesis, which we can compare to a sub pectoral tenodesis, which is often undertaken using an open approach with an incision in the axilla, and my preference is to use an all suture anchor because of its limited cortical perforation, which limits the risk of fracture associated with the cortical defect. This is a standard all suture single loaded anchor, and we're essentially going to pass the sutures in a cinch configuration. We're going to pass one loop around the tendon and retrieve the same loop of suture through our loop to create a luggage tag type configuration. And then we're going to come distal to that loop with a Penetrator and retrieve the second limb of the suture in order to perform a somewhat of a mason Allen type configuration that may prevent suture slippage or slippage of the tendon through the suture construct. The second limb is retrieved as you see here. We can then adjust the tension of the biceps, bringing the biceps into its normal position and estimating the length that would be necessary to reach the supraglenoid tubercle in order to restore the normal length tension relationship. And then we simply tie using an arthroscopic knot tying technique. My preference is to use arthroscopic half hitches, generally five in alternating directions, in order to create a strong construct. The sutures are then transected, leaving about a 1 to 2 millimeter suture limb in order to prevent the knot from untying. Now, we have looked at this in our clinical experience and found that two anchors result in a lower failure rate in comparison to one anchor. And so my preference is to use a double anchor construct. The second anchor is placed about one centimeter proximal directly at the base of the bicipital groove. And in this case we're going to demonstrate the use of a knotless all suture anchor for the second most proximal aspect of our reconstruction. Again, we use a standard guide which is placed percutaneously. The pilot hole is prepared and the anchor is impacted into position. And in this case we have a working suture which is the blue suture as well as the passing suture which is the striped black suture that need to be manipulated throughout the tenodesis. We use the working suture to again prepare a cinch configuration. So a loop of the suture is brought out around the biceps, and the same suture is retrieved through the loop. This creates our cinch which is then adjusted in height. And then we then pass the working suture back through the anchor. Using the passing suture, the appropriate passing suture is selected. It's brought out an accessory cannula. The passing suture has a loop at one end that allows for passage of the working suture, as you see here. There's also a mark on the working suture, which allows us to estimate the amount of suture that actually should be placed through the loop to allow for smooth suture passage. We then use the second limb of the passing suture to pass the working suture back through the anchor body itself. Once the tenodesis is completed, the more proximal portion of the tendon is resected using a cautery device about 5 to 7mm proximal to the proximal anchor, and then removed using a KingFisher from the posterior portal. That completes the arthroscopic tenodesis. The post-operative rehabilitation is often dictated based on other procedures, such as slap repair or rotator cuff repair. But in the setting of an isolated biceps tenodesis, we use a sling for comfort for about four weeks. We allow early passive and active assisted range of motion of both the shoulder and the elbow, but we avoid any resisted elbow activity until about eight weeks after surgery. Between 4 to 8 weeks, the sling is discontinued. We progress active range of motion in all planes and we begin light isometrics and between 8 to 12 weeks, we initiate the strengthening phase of rehab with the goal of returning our patients to full unrestricted activity, including sports. By 12 weeks Post-operatively, we've looked at our experience in both the one anchor and two anchor construct and found that in a single anchor group, the macro failure rates are about 10% compared to a two anchor group where failure rates are less than 2%. Although this difference is not statistically significant, it certainly would indicate to me that a two anchor construct may be preferred, particularly in our younger, more active patients, where Cosmesis is of significant concern in terms of return to work. For our single anchor group, we averaged 88% of patients returning to their normal work. You can see this broken down into light duty, moderate duty and heavy duty, and there was no difference between the two anchor and single anchor constructs with regard to ability to return to preoperative work levels. And finally, if we look at patient reported outcome measures such as an Ace score, a Sain same score or an SF 12 quality of life measures. Both the single anchor group and the two anchor group showed statistically significant improvements from preoperative to ultimate post-operative recovery. So why an arthroscopic technique? Well, I think there are several advantages when undertaking a biceps tenodesis using an arthroscopic procedure. Number one patient preference. Patients like the fact that they don't require an altered incision. It significantly improves cosmesis with only an additional one centimeter portal in the anterior aspect of the shoulder. And from a surgeon perspective, it's a very simplified technique that avoids an axillary wound that can be complicated by surgical dehiscence and or post-operative wound complication. And finally, it uses a very small cortical hole when using all suture anchors. And I think this is important to reduce or minimize fracture risk, particularly in our younger patients who may be returning to contact or collision sports. Thanks very much for your attention.

Kelechi R. Okoroha, MD (Detroit, MI), demonstrates distal biceps repair using two FiberTak® biceps anchors. Dr. Okoroha places the anchors near the native tendon insertion through 1.9 mm unicortical drill holes to help recreate the footprint. The anchors are double-loaded with SutureTape with needles to allow for various whipstitching techniques.

A video recording of a surgical technique on a live patient in an operating room setting or a cadaveric demonstration.

Eine Videoaufnahme einer Operationsanleitung an einem lebenden Patienten oder Patientin in einem Operationssaal oder eine Demonstration an einem Humanpräparat.

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Gravação em vídeo de uma técnica cirúrgica em um paciente em uma sala de cirurgia ou uma demonstração cadavérica.

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Grabación en vídeo de una técnica quirúrgica de un paciente en un quirófano o una demostración cadavérica.

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Distal Biceps Repair Using the FiberTak® Biceps Implant System

This is Colette from Detroit, Michigan, and we're going to be demonstrating an anatomic distal biceps repair using a 1.9mm FiberTak suture anchor. This is the FiberTak biceps kit. It comes with a 1.9mm anchor. It comes with two suture tapes with needles wedged on the end. It also comes with a 1.9mm drill and a slotted cannula, which allows those sutures to come through. We start by using a two by one small L-shaped incision. We prefer this incision as it allows greater exposure and really allows you to identify that posterior medial footprint. And we will make this a little bit bigger where I mark is where I usually make it. But we'll make it a little bit bigger for this demonstration here. Then you're going to dissect through the subcutaneous tissue using the Metzenbaum scissors here. You want to be careful of the lateral antebrachial cutaneous nerve to avoid any nerve related complications. So then usually the biceps tendon is more superficial. And you can just use your finger to kind of pull that out there. So you're going to grab the tendon with a clamp, and then you're going to free the tendon from any devitalized structures and trim the ends a little bit here. Then we're going to place a traction stitch through the tendon. I'm just going to allow you to free any adhesions from the biceps tendon. Circumferentially. So after we identify our biceps tendon, we're going to proceed with dissection to the radial tuberosity. We're putting two Bennett retractors on either side of the radial tuberosity. And you want to note that you want to have minimal retraction on the Bennett's to decrease any chance of nerve related issues. Postoperatively. Once we've identified the radial tuberosity, we want to clear it from any soft tissue. We usually do this with a bovie electrocautery. So once we identify our radial tuberosity we have Bennett retractors on each side. You want to remove any soft tissue from the tuberosity. And you can gently supinate and pronate. And you see that radial tuberosity. And that insertion is more posterior. Traditionally when we do our button and screw fixation we put our insertion point anteriorly. But as you see, the tendon inserts more posteriorly. And if we recreate that anatomical repair we get increased supination. So after you after you identify your tuberosity, you're going to want to use a small bur or a rasp to decorticate that surface to give you a nice bleeding, bony bed for your repair. So traditionally, we placed two suture anchors, one at the more proximal footprint and then one at the distal footprint. And we want to try to get as posterior as we can on that radial tuberosity to recreate that natural footprint. So I'm going to try to cheat it back a little bit here. And see about this procedure is it allows you to do uni cortical drill. When you're not going through that second cortex. You don't have to worry about any nerve related issues with piercing the cortices. Mount. That in and remove our tab here. And switch this out. And slide a guide allows you to bring your sutures out. And then you want to tension it with your tension. Just not pulling out. Don't place one more. So we're going to put our second anchor distally. Again uni cortical drilling don't violate that second cortex. You don't have to worry about the nerve Posteriorly. We're going to tension it here. Great. So we have pretty two strong. Fixation points. So again these suture anchors are going to allow you to get that more. Posterior footprint on the radial tuberosity. That's going to help with your supination as you see. Put them in pretty posterior here. All right. So next we're going to go to passing the needles through the tendon. So if you look at the tendon the tendon kind of inserts in a vertical fashion on the posterior radial tuberosity. So what you want your first anchor to do is come from the back side to lay it. So lay flat proximally. And then our distal anchor will do on this side to give us that flat configuration. We'll do a crack out here. So we just have one set pass. And then we're going to use the distal anchor to pass our second set. So you can cut your suture ends off with the extra suture depending on the patient. Their muscular anatomy, their activity level. You can pull that suture, or you can pass that second suture for some increased strength. In this case, we'll just pull them. Now we're going to cut any bulbous tissue from the tendon. We'll remove our tack stitch here. So you have your two sets of sutures passed. And you're going to pull on the free end. And that's going to bring the tendon down to the bone and tension slide technique. I have the free end right here that was passed through the tendon. When I pull that it's going to slide that tendon back down. We'll do the same thing with the blue side here. Pull that free tendon. It's going to pull that right down the bone. When you're doing this you want to flex the arm. It's going to allow that nice insertion. Now what I like to do is have somebody hold one of the sutures and I'll tie the other side. So, as you see, I'm going to turn the arm a little bit. That allows it to get real posterior instead of anterior on that cortex. And do your knot tying. I. Just want to make sure you switch your post here just so you have a nice knot. And cut this with a fresh knife. Tie your second set here. And that's your distal biceps repair using a 1.9mm FiberTak we see that rotation, we're getting real superior instead of more anterior. And that's going to give them some great supination postoperatively. So then we'll close the skin incision. Post-operatively. He'll be put in a posterior mold splint which will be at 90 degrees of flexion. He'll then follow up at two weeks. We'll do a dressing change. And we'll be put in a hinge brace which will block extension at 90 degrees. He'll then start physical therapy. And brace is usually discontinued at 6 to 8 weeks.

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Biceps Tenodesis: Options for Fixation Scientific Update

The FiberTak® Biceps Implant System delivers an all-suture anchor optimized for use in open tissue-fixation procedures, particularly subpectoral biceps tenodesis. The implant, which is placed through a 1.9 mm unicortical drill hole, is double-loaded with sliding 1.3 mm SutureTape and includes 4 attached needles.

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Visão geral incluindo as etapas relevantes de uma técnica cirúrgica Arthrex. Essas animações sempre incluem uma narração explicando o processo.

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Subpectoral Biceps Tenodesis Using the FiberTak® Biceps Implant System

Sub pectoral biceps tenodesis using the FiberTak biceps implant system. Make a 2 to 3 centimeter incision in the axilla at the inferior border of the pectoralis major. Bluntly dissect to identify the pectoralis major and the long head of the biceps tendon. Retrieve the previously anatomized biceps tendon through the incision. Place the FiberTak biceps drill guide at the desired location on the bony surface of the proximal humerus, and drill a bicortical hole with the 1.9mm FiberTak biceps. Drill. Keep the drill guide in place and insert the FiberTak biceps implant through the guide. Lightly tap on the inserter handle to advance the implant into bone. The implant is fully inserted once the inserter handle is flush with the drill guide. The needle guard contains the four pre-attached needles to remove the sutures. First, remove the suture release tab and then free the needle guard and the sutures from the inserter handle. Remove the inserter from the drill guide. The drill guide slot will allow the sutures to become free from the guide, and the guide is removed. Pull back on the sutures with a slow, continuous pull to set the implant. Remove the four needles from the needle guard. This implant supports multiple stitching techniques to accommodate surgeon preference and tendon morphology. Pass one or both of the sutures through the tendon. Cut the needles from the suture. Limbs. Pull on the opposing free suture. Limbs to reduce the tendon down to the bone. Securely tie the sutures and cut the remaining tails to complete the repair.

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FiberTak® Biceps Implant System

Brian J. Cole, MD, MBA, (Chicago, IL) demonstrates an open subpectoral biceps tenodesis using a 1.9 mm FiberTak® anchor with needles.

Subpectoral Biceps Tenodesis Using a 1.9 mm FiberTak® Anchor With Needles

What we're looking at here is the FiberTak biceps anchor. And what you'll notice are a couple of changes from the initial FiberTak. One is its working length is more appropriate for open procedures, but still could be used arthroscopically. It essentially has a sheath that will interface with the cortical bone and the near cortex. It's a very small 1.9mm drill bit. It's 1.9 from the beginning to the end. So the opposite cortex, for example, in the proximal humerus is irrelevant. You just got to get to the first cortex. The suture tapes have swaged on needles for convenience. And the overall length of the tape is much shorter to improve its flexibility in handling properties. Because we're advocating doing this in a single step, we now have a slotted guide that we will drill through, insert the anchor and extract the guide, and then be able to work with the sutures that have needles wedged on. So for a sub pectoral, biceps tenodesis, ultimately we want to still be above the latissimus, but some of your landmarks are the axillary crease. The anterior border of the Aboard the deltoid comes across here. The pec comes across here. And you can make this incision very cosmetic so that it's more towards the inner side of the arm. And you would only see it in high degrees of external rotation. So it doesn't require a very long incision in line with the biceps. So you know that we're going to have to be sort of under the pec, under the medial border of the deltoid to get access to the biceps tendon as it runs longitudinally up the arm. So a lot of this dissection can be done bluntly, just spreading gently. You'll come down on the biceps, short head and long head, and you get this confluence of the pec and the deltoid. And if you just pop through laterally, you can use your finger for blunt dissection. And that will allow you to get a pointed home in lateral to the biceps around the humerus. We have one retractor underneath the deltoid, where at the confluence of the pec which is coming across underneath the deltoid. Here, you know that if the pec insertion is here and you're medial to it, That just along the length of the humerus will be the biceps. Medially we take great care with the pointed or blunt retractor along the humerus, just to hold things just above the latissimus, out of the way, always keeping it perpendicular. And then we can just take a curved snap to retrieve the biceps from distal to proximal, where it's been synonymized. Just place a snap on the tendon. So typically we would prepare the proximal humerus of soft tissue in a footprint maybe one by two centimeters. Oftentimes what I'll do is I'll fish scale the humerus just to create some bleeding. You can also use your arthroscopic bone cutter open with irrigation just to denude the surface for preparation, basically trying to create a biologic landing strip for for healing. Another option for humeral preparation. What we designed is a serrated tip on the guide. It'll it'll act to hold the guide onto the bony surface, but you can actually use it. Instead of opening up a set of osteotomies, you can use it to prepare the proximal humerus. And then at the upper end of the prepared area, we drill the hole. So it's a slotted drill guide. Anchors inserted. Easily impacted. Then the needle casing is removed from the proximal end of the handle with all. It has all four needles neatly packaged. And then the anchor is. The insert is removed, the sutures are removed from the slotted guide, and the guide is removed and the anchor is in position and tugged to verify that the anchor is holding. So we have two suture tapes of different colors, which makes it very easy to manage. We remove the plastic covering of the sutures. We'll do some type of modified Kessler Krakow or Mason Allen suture on the tendon, you know, several passes. Through the tendon. In this case I'll typically it's a very small tendon. So we'll work with one limb. Through the tendon. So really, you could think of the post limb as the limb that's not passed through the tendon. And we'll snap that and keep that out of the way. Grab the other limb. Again these will slide through the base of the anchor. So it's a sliding stitch. We then hold the biceps proximally. I pull the one limb and that will actually juxtapose the the tendon to the bone, and then just tie accordingly. And always remember to at some point reverse your post so you get better internal friction and locking of the knot. So I pull the post limb, which is the limb that's not going through the tissue. That pulls the the tendon to the bone. And then we suture it down. And I always leave a little bit of a stump of tendon when I'm done. And that's it. That's an open pec tenodesis using the FiberTak biceps anchor.

Técnica de tenodesis para bíceps FiberTak^®

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Biceps Tenodesis: Options for Fixation Scientific Update

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Subpectoral Biceps Tenodesis Using the FiberTak® Biceps Implant System

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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FiberTak® Biceps Implant System

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Arthroscopic Biceps Tenodesis: Applications and Technique

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Distal Biceps Repair Using the FiberTak® Biceps Implant System

Subpectoral Biceps Tenodesis Using a 1.9 mm FiberTak® Anchor With Needles

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