Name: Proximal Biceps Tenodesis
Uploaded: 2014-08-04T00:00:00Z
Channel: Arthrex

Paul Sethi, MD, (Greenwich, CT) discusses the issues regarding the diagnosis and treatment of proximal biceps pathology.
<ul>
 <li>What is normal tissue appearance on arthroscopic examination?</li>
 <li>Is tenotomy alone good enough?</li>
 <li>Is there a role for limited debridement?</li>
 <li>Who is a candidate for tenodesis?</li>
</ul>
 He also discusses the best location options relative to safety and efficacy; high bicepital groove, suprapec, subpec. In addition, Dr. Sethi explains the best fixation options; soft tissue, anchors, interference screws, buttons, or a combination. Dr. Sethi thoroughly demonstrates his preferred arthroscopic technique with the SwiveLock® Tenodesis Implant and open subpec biceps tenodesis using the Arthrex FiberLoop®, Biceps Button, and Tenodesis Screw, with associated pearls.

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VPT1-00257-EN | A | Proximal Biceps Tenodesis

Paul Sethi

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Proximal Biceps Tenodesis

When it comes to the proximal biceps, I'm a hater and I will take that proximal biceps more often than not. Take it. Going through this, really the first challenge with the biceps is to understand what's normal. When you sit there and you stare at that intra-articular biceps. What is a carpet synovitis? What is a normal appearance? What's a normal tissue? I don't think that this is clear to anybody in this room, and I can get significant debate about that. So I find that challenging in looking at the biceps before we get into this anatomy alone. Good enough. And I think that in the right select group of patients who are a lower demand and not not going to mind the risk of cosmetic deformity, it is a very viable option. And it would be irresponsible, not to mention tenotomy limited debridement. Bob taught me long ago that you either have a normal biceps or you don't. So I don't really have a role for for 25 or 30% debridement. If you have a bad biceps, it's going to go. If you have a good biceps, you get to keep it. In that case in 2014. And this this list is always changing. Who is a candidate for biceps tenodesis. Well, those who have significant fraying fraying of any any 10% or more an hourglass, which is a very clinical diagnosis. It's very hard to know which which which biceps are actually hourglass. Sometimes you can see that intra-articular a lot of times you can't see a sublux or a pulley lesion. Real slap tears, you know, maybe even 30 year olds. Now, going forward, when I do it, whenever I do a subscapularis, the biceps is going to go because it can become a standard lesion. And then in any irreparable or revision rotator cuff surgery, the biceps is going to go from me. So a lot. And really what we're understanding more and more is that even in a morphologically normal looking biceps, we know that histologically the biceps is very abnormal and that that histological abnormality progresses as the severity of rotator cuff disease progresses. And this has been shown in a number of different studies. So it's not new or, or or fascinating news that the biceps can be a real pain and a real bad actor. Tenodesis options are a lot of places you can be above the groove Intra-articular you can be sub deltoid, you can be in the groove, the very vogue supra pectoral location and sub pectoral. And I'll try and go through each through each of these a little bit, understanding what we have here. The first thing to understand is that, look, this is a fibro osseous tunnel. The biceps has about three centimeters intra-articular and it has about another three centimeters in the groove. So you've got about 6cm or 8cm of tendon until you get to that musculotendinous junction. And the pec that you can see, you can see this long pec tendon. So when you're coming in in the sub pectoral location, you're coming up over here. I like this image a lot. I'll come back to it. This is a patient that had a proximal tenodesis that was later revised to a distal tenodesis. And you can see the locations and how distinct they are on on an individual humerus when you look at where tenodesis occurs. The proximal tenodesis is occurring in metaphyseal bone. So this is amenable to screw fixation. The distal tenodesis in contrast, or the sub pectoral, is occurring in this bone here, which has got a four millimeter on the average cortical rim. So it's a very different type of fixation. So getting a screw approximately is very different than trying to get a screw in distally. The techniques for getting into this look there's you can use anchors. You can use buttons. You can use a screw as Doctor Burkhart will do it. You can actually look at intra-articular or rerouting procedures that that Sam Akhavan and Jim Pacey have really made popular. You can switch it over to the conjoint tendon like doctor O'Brien has suggested when you when you're looking at a high groove suture anchor, I think it's important to get that biceps out of the way of the of the rotator cuff. And, you know, I think that the anchor technique proximally is probably less perfect in the shoulder and elbow. This this last year, Lee Lee published his excellent results 12.9% clinical biceps, 25% MRI, MRI based biceps and 7% cramping. So I you know, I wasn't thrilled with that. And I don't think I would be that happy in my own patient group pit technique. I don't know if there's any pit fellows in the room. It is simple. It is inexpensive. It's a little harder to do with a significant cuff tear. There's a question of groove pain. And in this year, Gary Glassman presented a over 20% failure rate with the with the pit technique here, however, is a proximal tenodesis technique using a screw. This is Doctor Burkhart's technique using two racking sutures. The biceps is exteriorized sized up here through a cannula high in the groove. Guide pin is placed. Appropriate sized anchor is in place. Hand hand reaming of this and then inserting a biocomposite anchor. To get this back down, flush and you can see a nice solid strong tenodesis. And I'll comment a little more on this. There are a lot of ways to skin this cat, and I don't think there's one right, right or wrong way. And there's there's there's plenty of debate. This debate started with doctor with Doctor Warner at Harvard. And he looked at his biceps. And the revision rate for his proximal versus distal tenodesis was about three fold higher. So in his series, he had to revise three times as many proximal tenodesis as he did distally. So this really got to the idea of sub factorial or distal fixation or decompression. Sam Taylor and Steve O'Brien looked again at this and looked at looked at the lesions that are hidden in the biceps, and 47% of patients undergoing surgery in their hands had hidden lesions. 45% who had abnormal intra-articular also had concomitant distal lesions. And and you know, this led led them to conclude that look above tenodesis may be fine for patients except when it doesn't really work. So you have to be wary of distal disease. That said, you know there is some significant data. To the contrary. Doctor Burkhart in the brass study group has an over 1000 case follow up with proximal tenodesis. And Sam and Jim Pasi feel that when you place the teen to proximal, you've eliminated the motion between the biceps and the and the humerus. So look, there is role. And it's not just a one sided argument entirely. So above, below or above or below the groove. Now we're starting to get into my opinion. I think there's a lower incidence of of pain at the bicipital groove when I go sub pectoral, I think you can address the lesions that are not seen in arthroscopy. And this is supported by by Sam Taylor and Burke and O'Brien. You can use a smaller hole in the humerus, and fractures can and indeed occur. When I'm doing a subtextual thesis, I'm looking at a five or A55 hole. And I think this is an easier, more predictable recovery. Looking at super Pectoral tenodesis super Pectoral again. So we're going below groove. So now we've switched from above groove to below groove. And here Arthroscopically looking at the transverse ligament, you can come down, you can use an Arthroman Ablator and identify the biceps here down below the groove. And then in many different ways here is here's a technique that Bill Banovich showed a cartoon of. I've got these two spinal needles in place, and the two spinal needles are my goalposts. They're also going to hold the biceps in place and protect it from retracting. Or me losing, losing any of my my length. Once it's released, I can come into the subacromial space and these are my goalposts. Now I can identify where the medial and lateral biceps border is and looking in from a From a mid-lateral portal. I'll insert a spinal needle. And I'll identify the biceps. And you can see just by pushing on it, I can show where the biceps is. Then I'll open up and I'll decompress the sheath. There's always a small little vessel you'll get to when you get to the superior border of the pectoralis tendon. This has been characterized by the guys at Mount Sinai. And this is not. This is not the ascending branch. And I don't think this gives you a osteonecrosis of your head, but there's that little vessel right there demarcates the superior aspect of the pectoralis. So you now you know you're low enough in getting a Bio-Tenodesis. And I'll twang on the pec in a second. I'll go on the other side and try and get that vessel on its partner on the other side. There's often a thick synovitis. There's the pec right there. That little vessel is bleeding on me a little bit. Let me get control of it. Then I'll pull the biceps over and out of the way. I'll use this nipple tip drill so I don't need a guide pin. In its line to line. Or you can go a half millimeter above it goes in 18mm. I'll probably go to about 20 on clean out the hole just a little bit. So now you've got a nice round hole. Your biceps are subluxed out of the way. I've not had to worry about the length at all, because I've got it pinned in place with the spine a little more proximally. I'll insert the fork tip swivel. Grab hold of this biceps. Now that I've got it right at the right there, I'll stop for a second. I'll release the spinal needles. So now I've got my my length maintained and I'll dunk it in. Once I dunk it in I can then screw down. And this is a very, very simple, straightforward arthroscopic technique for being below groove. Super pectoral open pectoral surgery. This is this is probably my mainstay coming through. I'll make a small incision. This is going to be between the. The biceps will be released. And you really you know, if you are not comfortable with this, this is something you should get in the lab because it's such a straightforward, elegant dissection coming between the inferior border of the pectoralis and the and the and the short head biceps. It's always nice. Once you leave the joint to return back to a prep. You should not in general go from extra articular. Or when you finish arthroscopy, you should not go back in and out of the joint. You can introduce bacteria that's been shown in the lab making this making this approach. And this is a bigger, wider approach for the sake of seeing things pull the biceps out. You can deliver it right here a little pull. Sometimes it slides through the tunnel and you can see it thickened with a little bit of abnormality. Here, a lot of people have popularized or taken credit for the sub pectoral button technique. Here's the same approach. Sub pectoral approach. Biceps will get pulled out. Those of you who don't know, this is Tom Hackett from Steadman. Hawkins in that bottom corner. Biceps is pulled out. Same way you might do a distal biceps repair. You're going to start at the Musculotendinous junction. Whip it up for about two centimeters. So this is this is a way to recapitulate length. The buttons on there. Now this is a zip line of a button. You're going to drill Bicortical hole a bicortical hole across the ream line to line. Here you have your choice. If you use a screw or not to use a screw on bigger versus smaller, the buttons placed on the button pass or pass on the on the far cortex and then tension slotted or docked into place tied over itself right over here. So again, I think this is an attractive option. I don't I don't place these people in a sling for more than two days. I let them move right away after this repair. Is this safe? That's the question that everyone asks me. They say, look, you know, I'm a little nervous drilling across that far. Cortex. Is that is that a safe thing? And what we did is we we took a look from around the country, four different sites and said, where does this tenodesis occur? And we found out where it occurred. And we went into the lab and looked at it. And this is going to be in shoulder and elbow. But here you can see here is anterior looking at the, at the latissimus. That's the axillary nerve right there. There's the biceps. You'll flip it over. Here's where the button is going to pass for a sub pectoral approach. Here's your axillary nerve. And in the specimens we looked at on the average of four centimeters 123 four centimeters away. So it's very, very safe away from the axillary nerve. The radial nerve is in front of that trampoline of latissimus and very safe as well. So, you know, we were able to nicely show that going bicortical here is indeed pretty safe. The biomechanics of whether you use Bicortical button, whether you use a screw, or whether you use a Bicortical button, I think is supported by many studies, and you can have enough evidence to feel that whatever you choose to do is most right for your patients, is supported in the lab. Revision Tenodesis. You know, you actually do have to go in and revise tenodesis. And the only study written on this is by Doctor Romeo. And all the revision tenodesis were revised to a sub pectoral with reasonable with reasonable results. Certainly there's risks. You have the risk of nerve and vascular injury and fracture. It's pretty darn small. And what we know is, at least in the sub factorial approach, you should look at smaller holes. And you should avoid being eccentric, because those are the sort of things that are going to get you into more trouble. So, you know, at the end of the day, for me below, groove is my preferred technique. I don't think every tenodesis needs to be above groove proximal, below the groove has good bone. You can consider a screw here. Super pectoral I think you can consider using the 4K indicis and for the sub, pectoral humeral shaft is hollow, so I'd have you consider using a button. And I think that's all I have for the biceps on this morning.

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