Name: The Birmingham Biceps™ Technique For Open Subpectoral Tenodesis
Uploaded: 2015-08-29T00:00:00Z
Channel: Arthrex

E. Lyle Cain Jr., MD, (Birmingham, AL) demonstrates biceps tenodesis in the subpectoral region using the Birmingham Biceps™ Implant System. He describes the Pallium Pectoralis as a new anatomic marker to help place his 5.5 mm SwiveLock® Tenodesis anchor 2 cm distal to the transverse humeral ligament at the metaphyseal-diaphyseal junction. He explains that this tenodesis location helps mitigate concerns about a subpectoral tenodesis potentially creating humeral stress risers. Dr. Cain also demonstrates the use of the new FiberLink™ Plus for quickly whipstitching the tendon. The Birmingham Biceps Implant System contains the FiberLink Plus, 5.5 mm PEEK SwiveLock® Tenodesis Screw™, reamer, tap and free needle in one convenient and sterile package.

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VID1-00554-EN | B | The Birmingham Biceps™ Technique For Open Subpectoral Tenodesis

E. Lyle Cain Jr.

Human

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.

Operationstechnikvideos

Surgical Technique Videos

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

Vídeos de técnicas cirúrgicas

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

Videos de técnicas quirúrgicas

The Birmingham Biceps™ Technique For Open Subpectoral Tenodesis

These are the components of the Birmingham Bicep Tenodesis kit. Kind of an order of use. This is a FiberLink plus, which is a FiberLink suture with a needle attached. That's what we use to grab our bicep tendon stump. We then have a pilot headed 5.5mm reamer to make our entry hole. We have a 5.8mm tap to prepare for the SwiveLock. We have a 5.5mm peak SwiveLock with a suture threader that allows you to pull the suture through the tip of the SwiveLock. And then the last thing at the end of the case is we have a free needle with a loop on the end, so that you can take the sutures from the bicep tendon, pass it through itself, and lock it to form a locking construct. So this is a left shoulder. We have the patient in lateral decubitus position. The arm is in an arm holder. Typically we finish the arthroscopic portion of the case and we've moved around to the front of the shoulder. So we actually walk around the bed to the front of the patient. We've taken the arm and we've shifted the arm holder to place it in a more extended position. So instead of instead of being about 20 degrees forward flexed, the arm is now in a neutral position at about 40 to 50 degrees of abduction. We're looking at the inferior border of the pectoralis major muscle. So this is the pec coming across here attaching to the humerus. Then you have the bicep muscle coming up the edge here where it meets the undersurface of the pec. We're going to make our incision just medial to this, which allows us to reach up under the pectoralis major and find the biceps long head. Typically in surgery our incision would be somewhere around three centimeters. So we would start about the inferior border of the pec, go about three centimeters down the arm, just lateral to the axilla. For this particular case I'm going to make a larger incision just so we can see in this cadaver. The key to the beginning of the dissection is not getting too far into the muscle laterally. The way we do this is we start off by pulling the skin medial, and we work medially to stay subcutaneous. If we get into muscle at this point, we're probably too far into the pectoralis muscle in the wrong plane. So we're going to start off on the medial side, develop this plane medial to the pectoralis muscle. And we're going to put an Army-Navy retractor in for visualization. So we're working along the medial edge of the pectoralis major muscle. Once we get under the medial edge, we're able to cut the fascia over the pectoralis. And we put the army navy underneath the pec. And we're able to pull the pec cephalad. There should be a nice plane underneath the pec muscle where you're on the anterior humerus, and there's no muscle medial to you. At this point, we're looking at the anterior humerus. The pectoralis muscle is pulled up cephalad and lateral, and the biceps tendon is sitting right here in the groove. So we're gonna split open the biceps sheath. So we've uncovered the bicep tendon. Here's the bicep tendon. And its groove. The pectoralis is pulled lateral. The conjoint tendon is medial. The musculocutaneous nerve is the only really important structure in this area. And it's a couple of centimeters medial to us. So typically I don't use a retractor like a Army Navy lateral on the medial side. I use my finger and I'll just pull down with my finger so I can see the bicep tendon. And I'll pull up with the army Navy. So it gives me a good me a good visualization of the bicep tendon within its groove. So the synovium has been removed from the top of the biceps. We just have the bicep tendon itself. We've basically dissected off this synovial sheath and we're looking at the bicep tendon, which makes it where you can pull the bicep tendon out much easier and pull it out of the incision. So this is the bicep tendon. We've released the sheath. So we have the bicipital groove that's very obvious at the base of the humerus here. So I think the most important part of Bicep tenodesis in my mind is proper tensioning and maintaining the length tension relationship. That's always been a little bit difficult to get the same length tension relationship on all people. What we found in our studies that are in publication now is that there's a pretty unique landmark at the top of the pectoralis muscle insertion. We've called it the pallium pectoralis. And this fold of fascia is present in all people. When you run your finger up the bicipital groove, you hit this transverse crossing fascia. It is not the bicipital groove, it's not the transverse ligament. It's about two centimeters distal, but it's a consistent fold of fascia that basically acts as the roof of the pectoralis attachment to the humerus. That area is pretty consistent in all cadaveric specimens that we've measured. And what we found is if you start with the muscle tendon junction of the biceps tendon here and you go about 3.9cm, so just about four centimeters from the muscle tendon junction, using a 5.5mm screw for fixation, using a swivel lock that gives you the proper length tension relationship at the top of this pectoralis. So we go to the top of the pectoralis muscle. This also represents the metaphyseal diaphyseal junction of the humerus, which makes it much less likely to be a stress riser for future humeral fracture. So the first part of the procedure is to prepare the biceps tendon. And to do that we're going to use a FiberLink plus, which is essentially a FiberLink loop that has a suture on the end with a swaged needle. So we're going to start out right at the muscle tendon junction. We're going to pass the first stitch right at the muscle tendon junction. And it's important with this FiberLink plus to make sure the two limbs are even. So we're going to tighten this up until it's completely even on both sides. And we have good tension. If you use the FiberLoop or the FiberLink before you know that at this point you just pass the graft in between the two limbs and you continue to pass sutures, running baseball, stitch up the tendon to pass another stitch through, pull all the tension out. Typically for four centimeters, it's somewhere around 5 or 6 passes for me. I pass them close to a little less than a centimeter apart. So I know that after a certain number of passes, I'm just about four centimeters. Then I'll check it and measure it before I finish. And that's where I'm going to stop my preparation of tendon. So I've got another couple of throws probably. At the very end, I like to take my last throw at a different angle to try to keep the tendon from unraveling. So I'll come through and lock behind my previous throw, and then we'll excise the excess tendon right at the four centimeter mark. So from a technique standpoint, the difference with this technique compared to the way I was initially taught, is that I was taught that you went essentially 2 to 3cm up from the muscle tendon junction and put the bicep tendon right at the inferior border of the pectoralis muscle. The problem with that is that we've shown in several cadaveric studies that the diaphyseal area with a humeral hole increases the stress distribution and may cause a pathologic fracture. When we get up to the top where this pallium is, this little sheath of tissue that signifies the metaphyseal diaphyseal junction, which is much less likely to cause a stress riser. And our study is much less likely to cause a stress fracture of the proximal humerus. So the next part is we cut the needle off of the FiberLink plus, and we're going to load our sutures into our SwiveLock. So SwiveLock comes with a suture retriever. Put the suture through the suture retriever and pull it through the SwiveLock base. And the base of the handle. So the next part of the procedure is to find the location of our tenodesis site. So if we look at the bicipital groove at the top of the groove, there's this transverse fascia very palpable. You can see it right here. It's called the pallium pectoralis that is the metaphyseal junction of the humerus. Typically we'll clean that off with electrocautery or with an elevator. In this case you can see pretty well right at the top of the groove. This pallium pectoralis. We're then going to use our 5.5 reamer. We're going to apply it to the humerus. And we're going to drill just uni cortical. Next we're going to tap with a 5.8mm tap just to start the thread for the screw. We just have to tap the anterior cortex. Once we've tapped we're going to place the tendon and the SwiveLock into the hole. Seat it up against the distal cortex and screw the SwiveLock in place. I like to leave the last thread of the SwiveLock visible, so I have good cortical fixation rather than going completely into the cancellous bone. We'll loosen this suture, pull my handle back, make sure that the screw is seated. So at this point I have two sutures. I have one suture in my left hand which is the bicep whip stitch, the FiberLink plus that runs next to the SwiveLock. And then I have this pair of sutures that goes through the center of the SwiveLock and connects the SwiveLock tip to the SwiveLock anchor. The two options at this point, to make a continuous loop, I'll either tie these together, which makes the bicep tendon and anchor all one all one continuous piece, or you can take the suture from the biceps itself using this free needle and the FiberLink, plus pass it back through the bicep tendon. And then tie this to the other suture that comes out of the anchor, which results in backup fixation and a continuous loop that holds the bicep to the screw. And we'll cut our sutures there we have our final reconstruction. So we have the SwiveLock screw the bicep tendon. And then this continuous loop FiberLink that comes back and attaches to the bicep tendon again. To make one continuous construct for closure, I typically leave the pectoralis fascia alone. The pectoralis muscle falls back into place, and we'll typically just do a subcuticular stitches with absorbable suture. And then we do a running subcuticular pullout suture or a subcuticular with skin glue.

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