Tenodesis screws are used in techniques and procedures of the shoulder and elbow and provide the most technologically advanced interference fixation. With a comprehensive product line including BioComposite, PLLA, PEEK and titanium, the Tenodesis™ Screw System provides superior and immediate fixation for shoulder and elbow procedures.

Shoulder

Product

Developed in conjunction with Sam Akhavan, MD (Pittsburgh, PA), and James M. Paci, MD (Long Island, NY), this knotless biceps tenodesis technique is a simple approach to top-of-the-groove arthroscopic biceps tenodesis using the Loop 'N' Tack stitch configuration. For surgeons who want to transition from tenotomy to a quick arthroscopic technique, it is an excellent option for using existing portal placement while viewing familiar anatomy. This straightforward surgical approach helps minimize the potential for cramping or cosmetic "Popeye" deformity, which is often associated with tenotomy.1
The implant system provides everything required to perform a Loop 'N' Tack biceps tenodesis in a simple, convenient kit.
Reference
1. Mirzayan R, McCrum C, Butler RK, Alluri RK. Risk factors and complications following arthroscopic tenotomy of the long head of the biceps tendon. Orthop J Sports Med. 2020;8(2):2325967120904361. doi:10.1177/2325967120904361

Sam Akhavan, MD (Pittsburgh, PA), demonstrates the all-arthroscopic Loop 'N' Tack™ biceps tenodesis technique using FiberLink™ SutureTape and a SwiveLock® anchor to tenodese the biceps intra-articularly at the top of the bicipital groove.

Not Hidden

English  - en

video

Human

Loop 'N' Tack™ Biceps Tenodesis

Hello, this is Sam Ackerman from Pittsburgh, Pennsylvania. Today we're going to be talking about the loop and tack procedure. This is a procedure we've been doing for about eight years now down in Pittsburgh. We've done several studies on it, which I'm going to talk a little bit about. We are going to demonstrate the SutureTape link suture for use with the loop and tack stitch. We have a bovine tendon here that we're going to use for this. Some of the key features of this stitch is that it has a 2.5in, or about a 50 to 60 millimeter loop that is ideal for going around tissues. So the key aspect to this stitch is the first part, which is just a standard loop. So you essentially intra-articular will pass this the suture around the tendon and then pass the suture through its its loop. So you're going to see that here. Once this is tightened, what we're going to do here is we're going to use the Penetrator to pierce through the tendon and then grasp the suture on the other side. One of the key aspects of this procedure is where you make your anterior portal as it will be. Make the procedure significantly simpler. It is key to place the portal in a position where you can easily access, below and above the biceps, to be able to easily be able to pass sutures above and below. The other key to this portal is you have to be able to access the top portion of the Intra-articular groove. We are going to be placing our anchor at the top portion, right above the subscapularis tendon, at the most distally visualized portion of the intra-articular groove, and placing your portal medial and medial enough will allow you to have access to that top portion of the intra-articular portion of the biceps. Once we have verified that that's where we want to make our portal, we're going to go ahead and come in with a switching stick in order to still make sure that we are piercing the shoulder at the spot where we want to be again, checking to make sure that I can easily access above below the biceps and reach the top portion of the intra-articular groove. We are then going to come in with a purple cannula. One of the key reasons I like this purple cannula is it allows for mobility. For most of my shoulders I will use a Gemini cannula. However, in this case the Gemini cannula can decrease your mobility to be able to reach the top of the groove. With this seven by seven purple cannula allows us easy access above and below and allows for increased mobility. In order to provide us access to the top of the subscapularis tendon at the most distally visualized portion of the intra-articular groove, we are going to go ahead and create our loop intact, not using this grasping BirdBeak. The great aspect of this BirdBeak is it has teeth at the end that will allow you to easily grasp the suture. I have put the loop over the shaft of the BirdBeak, and now I'm going to grab the tail end using the the tooth portion of this BirdBeak. We are now going to re-introduce the suture over the top of the biceps. And come underneath and grab any part of the suture that is exposed to create our luggage tag. Because we have the loop over the top of the shaft, the luggage tag is going to be created at this point. This is actually the key portion of the case, as the tension on the biceps is determined at this point. If you are trying to put less tension on the biceps, you are going to try to put this loop closer to the insertion at the top of the superior labrum. If you want to replicate the tension closer to what the native tension of the biceps is, you are actually going to put the loop further down. The one thing about putting it further down that may complicate it is you will have less biceps left distally. In order to create your tack. But this is where you will determine the tension of your biceps. I prefer to take the biceps slightly off tension, so I'm going to use this cannula as a suture, as a kind of a knot pusher, to push my knot closer to the insertion of the biceps. And this is where my luggage tag is going to be created at this stage. We're going to reintroduce the suture from the SutureTape FiberLink by grasping it with the BirdBeak and reinserting it below the biceps. This time, once the suture has been dropped, we can use the tip of our BirdBeak to pierce through the center of the biceps, where we're going to go ahead and grasp any part of the suture and finish up our loop intact. Not. At this stage you can use these curved cutters that are available both in left as well as right. One of the great advantages of this is it allows you to cut the biceps while staying away from the tip of your suture. One of the key ways that this knot can actually fail is if you cut the biceps too close to the suture, the the looped end, the luggage tag end can actually slip over the top of the biceps. So you want to make sure that you have you leave yourself enough biceps stump. So that does not happen at this stage. I'm going to go ahead and cut this biceps as close to the top of the superior labrum as possible. You can see the top end of the scissor over the top of the biceps to make sure that you're not cutting any other tissue. Once the biceps is cut, we are now ready to fix it. Where you fix the biceps is actually very important. I like to do it just anterior to the supraspinatus tendon and just superior to the subscapularis tendon. In essence, it's at the most distally visualized portion of the intra-articular groove. Coming in here with our punch, we're going to come right above the top of the subscapularis tendon right here. And we're going to go ahead and mallet this in. At this stage you want to make sure that your SwiveLock anchor is loaded with your suture prior to removing your punch. [00:06:21] Came up ready. At this stage we're going to insert our SwiveLock anchor into place. And bring it right above the top where our hole is. We're going to go ahead and pull a little tension on the suture to kind of tension our biceps in place, and then mallet the anchor down. If you were to do this as part of a subscapularis tendon, we would go ahead and incorporate both sets of sutures into the eyelet prior to tightening this down. We're going to go ahead and pull our sutures, and we'll go ahead and cut our suture with the arthroscopic scissors. At this point, I'd like to insert my Apollo RF probe to actually mushroom the tip of the biceps and take the very top of the biceps back so that very little stump is left. You can then look at the top of the of the superior labrum and resect the excess biceps from that end as well. And this will be your loop and tack tenodesis.

Alan M. Hirahara, MD (Sacramento, CA), combines a Loop 'N' Tack™ biceps tenodesis with an upper border subscapularis repair using a single Knotless SwiveLock® anchor from the Loop 'N' Tack implant system.

Combined Loop ‘N’ Tack™ Biceps Tenodesis and Upper Border Subscapularis Repair

My name is Alan Hirahara from Sacramento, California, will be working today on the shoulder arthroscopy, doing a subscapular repair with a loop and tac biceps. And what I'll do is I'm going to pass my instrument through the loop to prepare it. I'm then going to grab the end of it with my grasping portion like this. So now I'm all set up to go. This will create the loop around the biceps automatically, as I'm able to pass it around it and pull it back through automatically in one pull. So we're going to come in. I'm going to leave the suture there. I'm going to release the suture. Come up over the biceps. We grab my suture. And basically pull that out. And then pulling that out you'll see the loop automatically feed directly onto the suture. So that when I pull the suture now, the loop goes in and immediately wraps around the biceps tendon perfectly. So all in one motion. We're going to repeat the process now with the same instrument grabbing the end of our suture. And I find personally that the best way to do this is just go ahead and do it the same way. Pass the suture in, leave it in place, let it go, then skewer my biceps. At this point, back here behind, try going through the middle. Once I've gone through the middle, I can just rotate, release my grasping portion, grab the suture and pull it through. And now you've got your loop intact, ready to go. So now we're going to attach a 4.75 SwiveLock anchor with Knotless mechanism. Attach it onto the biceps loop Tenodesis that's intact. And we're going to go ahead and just attach this on. It on and we're going to snap and hold the side for now. Now, the reason why I'm doing this is that if you weren't going to do knotless, this is the point. I would leave this here and I would pass my FiberTape through the SpeedScap if I was going to do this all in one motion. If I was going to use this all in one suture anchor, you don't cut the biceps because it turns out that gets in the way. So I leave the biceps until I'm ready to tack it in. So if you have other things to do, do it now. Leave the biceps. Leave the suture there. You can externalize the suture outside and it's just ready to go. So what I want to do is I want to get my my scissors up to this area here. And I'm going to be cutting this direction that way. Then I don't have to make any modification on my, on my labrum. So you are going to cut kind of backwards towards it's going to asymmetrically cut the biceps. Some people want to come perpendicular. I don't I won't actually cut it off right here. And you can see where the biceps attaches and where the labrum is. And so that's the line you want to follow. Following it back posteriorly to cut it so that the biceps is cut off and the labrum is flush. Now, you don't have to do anything more. To your labrum. There. Now it's off fully. You can see now the labrum is pretty good. You see that there's nothing else can be done. And if you're going to do a repair on this labrum, this can be done easily because you have plenty of tissue to work with. But you also don't really need to do any modifications to take any more stump off. So you're going to follow that posterior along its line. So now we're going to do is we're going to go ahead and punch our socket. Okay. That's perfect right there. That's where we want to be. Perfect. Now at this point again we're just going to attention I'm in this I'm in the hole. I've tensioned the biceps up against it. And now I'm pretty much ready to just go ahead and tamp that in. Yep. Okay. Now we're going to go ahead and cut off the biceps portion. And just make sure that you don't capture the other sutures. We left a knotless mechanism in place. And now we're good to go. And we're ready to go ahead and start passing this. I'm going to go ahead and attach again my suture. We'll go down. We're going to place that really low for us to use and grab. We're going to release that and hold it down and position down there. We're going to go ahead and grab our sub GAP pass it through where we want to be. Grab our suture again. And pull that through. Okay. At this point now keeping everything separated, we're going to now separate out the suture passer. So now we're going to take our repair suture and pass it to the looped end of our passing suture. And pull it back to the purple mark. We're ready to pass it now. We'll simply pull on our passing suture. And now we simply just tighten because it's now tensioned on appropriately. And the contention as much as we want. And once it's tension to the appropriate one, if you if you don't like it, you want to tension more, you just simply pull more. But once it's down and ready to go, all we have to do is cut off the end and we're finished. And from this end, you can see the biceps is attached. You can see the subs GAP attached as well.

Paul M. Sethi, MD (Greenwich, CT), demonstrates an all-arthroscopic Loop 'N' Tack™ biceps tenodesis using FiberLink™ SutureTape and a SwiveLock® anchor to tenodese the biceps intra-articularly at the top of the bicipital groove. Dr. Sethi uses the SwiftStitch™ suture passer to create the cinch loop and to penetrate the biceps tendon to complete the Loop 'N' Tack stitch.

Today I'm going to demonstrate a loop and tack biceps tenodesis. I'll do that using the new Loop and Tack kit. That kit includes the loop and tack SwiftStitch, a SutureTape FiberLink a 4.75 SwiveLock, and the punch associated with that. The loop intact SwiftStitch is a single pass device. Here you can see this handle and you can deploy the jaws. These jaws will reach in and grab suture and help you to retrieve it in a single step fashion. You can perform a biceps codicis in the beach chair or the lateral position. It's really how you're trained and what your preference is. I think one of the important things to remember is that the decision for biceps synthesis is often made before you get to the operating room, and we want to emphasize that examining the biceps is so important. The portal approaches. Here I am looking through a posterior portal in the shoulder. There's a there's an abnormal superior labrum. Right. This is not something that you're going to want to do a superior labral repair on and a partial thickness rotator cuff tear. It's very important to me, at least, to think about where this portal is going to go. And I'm going to stay in the lateral aspect of the rotator interval. And what I want to do is I want to use my spinal needle To imagine the trajectory of where my suture anchor will go. So here I can access the very front edge of the subscapularis. And once we get in here to clean this up, I'll remove some of the biceps sling and you'll see a nice bony landmark, some forward flexion on the arm, and a little bit of internal rotation, at least in the beach chair position, can allow you to see this even more clearly. But once again, the spinal needle is my test for my trajectory of my suture anchor, which will allow this to work in a facile fashion. As I create my anterior portal, I'm going to see that I've got a torn labrum. I want to make sure that that my anterior portal is going to allow me the appropriate trajectory, so I can get a suture anchor in and be able to reach over and underneath the biceps. So making sure this portal is appropriate, that it's far lateral enough in the rotator interval can make this procedure even easier. I have my anterior portal created, and I think it's important to examine the biceps to draw the biceps into the joint, recognizing, of course, that not all of the biceps is going to be viewed intra-articular. But if there's going to be some pathology, this is one important way to look at it. The other thing is that it's very important to examine the leading edge of the edge of the subscapularis. Somewhere between 30 and 50% of rotator cuff tears are going to have abnormal subscapularis tendons, and it's important to recognize the leading edge tear. The lever push maneuver can really help you recognize this. And if you need to do a concomitant subscapularis repair, it's very easy to place a stitch through the subscapularis and incorporate it into your biceps repair. So to start off, I'm going to load the SwiftStitch and the SutureTape FiberLink. So I'll put the loop around the shaft. And then I'll take the tape and I'll fold it up about five times so that I may reach into the joint and retrieve it easily. I'll grab it in the jaws. Secure it. Enter into the biceps. The suture is introduced into the joint, and I'll park it in the back of the joint. The jaw is closed as I pull it out. Now I've deployed this. I'm going to come over the top of the biceps. Open my device. Capture my suture. And pull it out. As you can see, the loop is all set, so I don't need to pass or twist anything. I just execute through. And before I fully synch, I want to make sure I'm not too close to the labrum, but I also want to make sure I'm not too distal down the biceps so that I won't be able to pass through. But here you go. Now it's passed through and cinched into place. I have enough biceps so that I'm not going to slide off the tendon approximately, and I'll have enough room to work distally. The luggage tag has been placed around the biceps, and now I need to penetrate distally to complete the loop and tack suture. So I'm going to go ahead and once again in a similar fashion, bring the material back into the joint deploy release. And I don't need to come fully out of the joint here. And I'll just simply come back a little bit. Identify my biceps. Ups. Penetrate distally. Come through. And this is the beauty here. It's right there. I've got it grabbed. I'll pull it out. There we go. So now I've got my loop and tack stitch passed around. You can see right where I'm going to want to go ahead and deploy it into place. Before you deploy it, I want to release the biceps tendon. I like to do this with an arthroscopic scissor. I'd use that arthroscopic scissor to release the biceps from its origin. I think you can use the electrocautery just the same. And now I'm going to come in with the punch and identify where on the on the leading edge of the subscapularis I want to be. And I'm going to go ahead and put it right. Right over here. And what this is going to go to the SwiveLock line. I'm buried good here. You typically don't need to tap this bone. And once again you're going to have different anchor choices here. If I wanted to address the subscapularis, I would put stitches in the subscapularis right now to share the space. In a standard way, we'll load the SwiveLock up. Sutures brought through the eyelet on the SwiveLock. Hold a little tension on the suture. Now I've come down, I identify where my biceps belongs. I'll put it in. Probably give it 1 or 2 taps. Good. And then thread down the SwiveLock. I could use the additional safety stitch for the subscapularis. I could do more work on the biceps. If I felt that I didn't get the tenodesis that I wanted to, but I feel like I have an adequate purchase here. I'll go ahead and cut this stitch. I'll slide down. I like to keep this nice and flush. I'll cut it. I have plenty of biceps there. I don't think it's a problem to leave some behind, but I may just make this a little. A little less pronounced. I don't want to go to too far and compromise my fixation, but I think just. We can trim it up just a little bit. And there's my fixation in there. Nice and secure. The biceps is now into place. Subscapularis is good. And the superior labral lesion is treated.

This knotless technique is a simple approach to top-of-the-groove, arthroscopic biceps tenodesis using the Loop ‘N’ Tack™ stitch configuration. For surgeons who want to transition from tenotomy to a quick arthroscopic technique, it is an excellent option for using existing portal placement while viewing familiar anatomy.

Loop ‘N’ Tack™ Biceps Tenodesis

The loop intact. Biceps tenodesis technique allows for an arthroscopic knotless repair at the top of the bicipital groove, eliminating the need to externalize the tendon for preparation. This repair can be incorporated with a medial row anchor in a knotless rotator cuff repair using the loop intact SwiftStitch suture passer. Introduce the tail end of the SutureTape FiberLink suture over the top of the biceps tendon, and retrieve from below the biceps tendon through the cannula. Insert the free end through the loop to create a cinch. Stitch with the FiberLink suture and advance around the biceps tendon. Complete the loop intact configuration by advancing a portion of the tail end of the suture under the biceps tendon. Insert the loop intact SwiftStitch suture. Passer through the biceps tendon and retrieve the tail. Resect the biceps tendon with a curved scissor at its insertion on the superior labrum. Create a socket with a punch and fixate the tail end of the SutureTape FiberLink suture with a SwiveLock suture anchor to complete the repair.

Hussein Saad, MD (Dearborn, MI), discusses his transition from performing biceps tenotomy to biceps tenodesis using the Loop 'N' Tack™ tenodesis system.

Biceps Tenodesis Using the Loop 'N' Tack™ System

Hello everyone. My name is Doctor Hussein Saad. I'm a board certified orthopedic surgeon and sports medicine specialist. I'm in a private practice orthopedic setting in my beautiful hometown of Dearborn, Michigan. To date, I have performed close to 200 loop and tech biceps Tenodesis cases. The title of this talk is going to be My journey to the Arthrex loop and Tech technique. In general, biceps tendon pathology sees us more than we see it. The prevalence of labral biceps complex conditions may be as high as 93% in the presence of rotator cuff pathology. We see it more common in men than women as well as the aging population. So I'd like to tell you about what I did then when I first started practice and what I currently do, and this is my journey to the Lupine TAC team. I initially started with the open technique, and I did this because I learned it in fellowship, and this was what I was comfortable doing when I first started out my practice. The outcomes were good. However, I felt patients had a lot more post-operative pain than I expected to treat. I needed something less invasive. I felt like I was doing two doing two surgical techniques to this patient. At that point, I reviewed the literature and I was also preparing for my board collections. The literature at that point showed there was really no significant differences between tenotomy and or tenodesis. So I started discussing this with patients, and I had a lot more patients telling me to perform the tenotomy on them. Overall, their pain was well controlled afterwards, but I was not happy with the amount of Popeye deformity and cramping seen with these patients. So I needed something different again. I went to my partners. They taught me this percutaneous spinal needle technique. This was well supported and documented into the literature, but again, I was not happy with the results. I was seeing a lot more stiffness, a lot more Popeye deformity, and a lot more cramping. I was taken to Arthrex where I was introduced to this lupine Tenodesis kit. In fact, I did the first one in the lab in under five minutes. My initial observations included. This percutaneous technique allows for less likely neurovascular injury and fracture associated with the open techniques, and this is documented in the literature. The knotless technique allows for more reproducible tension on the on the biceps tendon than in the percutaneous technique, and overall it reduces the operative time. I've looked at the studies over and over, and they found equal outcomes with that quote unquote high in the groove tenodesis when compared to the subacromial technique. The kit itself was very well designed, and this allows for simplification of the technique. It's very convenient your operative staff as well. Everything was available in a single use pill pack kit. This avoids opening several trays. At the end of the day, believe me, your staff will appreciate this. The technique is very well discussed and demonstrated in several online videos which I watched when I first started, but I will tell you a few of my surgical pearls that will help you. In this case, portal placement is key. I always use a spinal needle to first determine my quote unquote spot for my portal. I always pass the loop on to the FiberLink SutureTape first, and I pass this around the biceps tendon, as I feel this allows for better control of the anatomized tendon. I prefer to use an RF wand over the arthroscopic scissors because it allows for quote unquote mushrooming of the tendon stump, which minimizes the risk of tendon retraction into the groove. I also use this kit when I'm repairing an upper border subscapularis tendon tear. This goes along and in conjunction with my biceps tenodesis and the tension again is readily reproducible. In practice, I've used self-directed patient reported outcomes. I found an extremely low failure rate. We've had two Popeye deformities reported and one of them was after a traumatic fall. In general, my patients report significantly less bicipital groove pain. In summary, my journey from tenotomy to tenodesis was an easy transition made possible by a very well designed loop and tack tenodesis kit. The technique is very easy to do, readily reproducible and will change your practice as it has done mine. The end result for any surgeon is excellent patient care and excellent patient outcomes, and thus far this technique has accomplished both. Thank you for your time.

application/pdf

Biceps Tenodesis: When and Where Scientific Update

Elbow

Biceps Tenodesis: Options for Fixation Scientific Update

Biceps Tenotomy Versus Tenodesis Scientific Update

Loop 'N' Tack™ Tenodesis Implant System

Child (D)

Procedure

The Knotless FiberTak® biceps implant system offers a knotless, all-suture anchor solution to perform an onlay proximal biceps tenodesis at any location. The implant uniquely integrates two individual tensionable knotless mechanisms within a single FiberTak sheath. The blue FiberWire® repair suture passes around the biceps tendon, while the white suture loop is retrieved through the tendon. The blue repair suture is retrieved through the loop, and both are tensioned to complete the tenodesis.

Knotless FiberTak® Biceps Implant System for Proximal Biceps Tenodesis

In the subacromial space. Insert a cannula in line with the intended anchor insertion site. Place the drill guide on the bony surface of the proximal humerus at the desired tenodesis location. Drill a pilot hole using the 3.0mm. Drill until the positive stop on the drill guide is reached. Keep the drill guide in place and insert the Knotless FiberTak implant through the guide. Lightly tap on the inserter handle until it is flush with the drill guide. Remove the black suture release tab to remove the sutures from the inserter handle. Lightly pull evenly on the suture limbs to set the anchor in the bone. Using a suture retriever, shuttle the solid blue FiberWire. Repair suture under and around the biceps tendon to the opposite side of the white suture loop. Insert the loop and tack SwiftStitch. Suture passer and penetrate the biceps tendon at the desired tenodesis location. Retrieve and shuttle the shuttle the white tensioning suture loop through the tendon. Using a suture retriever. Retrieve the solid blue FiberWire. Repair suture through the white TensionLoc suture loop. Load the blue FiberWire. Repair suture through the shuttle link suture loop and fold the repair suture limb at the purple indicator mark. Pull the tape end of the shuttling suture to shuttle the repair suture through the knotless mechanism and tension the repair suture around the biceps tendon. Tension the white suture limb to lock the tendon to the blue circumferential stitch. Pull each suture limb sequentially to ensure adequate tension and a secure tendon reduction. Cut the suture. Limbs. Excise the biceps tendon 5 to 10mm proximal to the repair, and remove the remaining tendon stump from its attachment to complete the repair.

Stephen Brockmeier, MD (Charlottesville, VA), demonstrates an arthroscopic suprapectoral onlay biceps tenodesis using the Knotless FiberTak® biceps implant system.

Suprapectoral Onlay Biceps Tenodesis Using the Knotless FiberTak® Biceps Implant System

This is Stephen Brockmeier from the University of Virginia. And the implant we're going to be looking at today is the Knotless FiberTak biceps. So this is a knotless biceps implant can be used in all locations for biceps tenodesis procedures. In this particular case, I'm going to demonstrate my technique doing a Super Pectoral arthroscopic tenodesis. As you can see, the superior labrum biceps tendon, you can see the upper pack, you can see the biceps. And then we're going to go ahead and do our tenodesis. There's our tendon right there. You can figure out what your native tension is. I normally like to tension this pretty much right where it sits. So we haven't detached it. So you can kind of tension it kind of right where it was before detaching it. So next we're going to deploy our implant. All right. So now we have our biceps tendon all set up for the tenodesis. So you can see I have my guide in place. There's the groove for this implant. I find it easier to place the guide more medially, just medial to the tendon, but right in that bicipital groove. So once the guide's in place, we'll drill our pilot hole. Okay. So now we're going to place our our anchor in place. You'll see it come down. All right. All right. Now the anchor is deployed. All right. So we'll take the guide out and then we'll secure. We'll make sure that the implant is secure here. We'll test it. Pull it up against the cortex. You can see it here on the medial side. Nice and secure. So now the rest of this is suture passage. We're going to come in and we're going to locate our blue repair stitch which is here. So you can see our collection of sutures. So repair stitch. And we're going to slide this out around the tendon. All right. So now that is brought from medial to lateral in position. And a second step that I find helpful. And you'll see why in a second is I'm going to then localize my white loop. And I'm going to pull that lateral as well. In a second. We're going to take this loop and we're going to pull to pull it through the tendon itself. I find it easier to grasp the loop and retrieve it if I bring it out laterally. So that loop is positioned now with the repair stitch. So now we're going to we're going to pierce through the tendon itself. So this is called the SwiftStitch suture passer. So we'll bring this through the same cannula. Notice we're working through the same cannula the whole time. And so now we're going to figure out where we want our tenodesis to occur. And we pierce through the tissue. You'll see I'm going to go through the biceps entirely. All right. So now you get your jaws around the loop. And you got to have enough space to pull the loop through the tendon. So now we have our loop through the tendon itself. And so next step is to come back through the loop itself and secure. So you'll see in a second I'm going to come through the loop and I'll grab the repair stitch. And we're going to pull that through the loop and back out exteriorly. So now I'm going to pull down the loop just a little bit just to cinch it down so you can see what's actually happening here. So now we're gonna pull this to here. All right. Now you can see the loop with the with the repair stitch through it. All right. So next we're going to take our repair stitch and we're going to link it through. Here. Our passing stitch. And this is going to load our anchor and set up our knotless mechanism. So now we'll shorten the loop. Bring it through load it through the anchor. And back up and out. So now that's out of our way. And now you'll see outside I'm cycling through the suture here. And I'm doing this slowly, just so everybody in the video can see kind of the different components of this. So now we'll shorten this loop and bring the tendon down to the bone. You can see like that. And then we'll reciprocally tension the blue stitch and the white stitch. And you can see I'm pulling really hard here, which certainly is reassuring from the standpoint of your purchase of the tendon here. And that thing is revered. Now that we've cut our sutures, we have a nice knotless biceps tenodesis construct. You'll see here I'm going to pull real hard. And this thing is snug as can be down on the humerus on the bottom part here too. All right. Let's say an RF now and we'll kind of cut the remaining tendon out. So next what I would typically do is I would release the tendon here. And then I would go up and remove it from inside the joint. And we'll take a final look at this here. Again you can see we're right above that pec major. Right. You can see the pec much better now where it's inserting you can see our biceps nicely secured in the bicipital groove. And so you can see it nicely from this perspective. And then an additional view that I find sometimes kind of helpful to see. As you can see right here, you see the upper border of the pec biceps nice and secured with our knotless implant. Super pectoral Tenodesis a few easy steps Knotless fixation nice and secure on late technique.

Michael Huang, MD (Colorado Springs, CO), demonstrates a subpectoral biceps tenodesis using the Knotless FiberTak® biceps implant system.

Subpectoral Biceps Tenodesis Using the Knotless FiberTak® Biceps Implant System

This is a demonstration of the Knotless FiberTak biceps implant and kit for pectoral biceps Tenodesis. On the left side you'll see the drill guide followed by a drill bit, which is a three millimeter diameter. There is a SwiftStitch suture passer, and then we have the anchor that's currently on the shaft, and then an anchor that has been unloaded. So you can see the different strands in the middle. You'll see a small closed loop at the very base of the anchor or implant. On the left side you'll see a number two solid white that has a slight coloration to it. That's to be identifiable in arthroscopic type techniques, but in open fashion you can also identify it. In the middle will be a solid blue number five FiberWire. And then the two strands on the right will be the suture shuttling mechanism to create the knotless construct. The advantage of this device is that the blue number five suture, once you've converted, it goes over the top of the tendon. But in addition to that, the number two white suture, the closed loop that's passed through the tendon gives us tendon purchase. And then once both loops are converted, we have an interlocking knotless tension device. What we've done here is we've went ahead and simulated the arthroscopic release at the superior labrum. And so this is the stump of the biceps here. In addition to that, we've exposed the distal aspect of the bicipital groove. So this is our planned anchor position right here. Next step is we're going to be placing the drill guide in the distal aspect of the bicipital groove. One key to this procedure is to try to be as central as possible. In order to increase the intramedullary distance. We are dropping our hand down slightly, so we're drilling from distal to proximal. We have drilled our cortical hole slightly distal to proximal. And now the anchor is going through the drill guide. We're going to give it a slight tug just to make sure it's seated. And it is. The next step is to separate the sutures. We have two shuttling limbs that are striped. And then we have a closed loop in the middle. And then we have the rest of the white suture that is contiguous with the closed loop. And then we have the number five FiberWire which is solid blue. One technique, pearl is in the open fashion is to elongate the loop. This loop was designed to be used arthroscopically as well. So one side you can pull and one side you cannot. That makes it easier to work with. Might even take a little bit more of that. The next step is to pass the loop using the SwiftStitch suture passer. The closed loop. We're going to pass that through the tendon. The solid sutures are on one side of the tendon and the shuttling sutures. The striped will be on the other side of the tendon. So here's the tendon. And what we want to do is anticipate our tenodesis to occur right about here. We're going to puncture through. And we'll use the SwiftStitch device to grab the lengthen closed loop to pass it right through. The next step is to grab the number five blue suture through the closed loop. And so I'm using the SwiftStitch to also help me do that. And then the last portion of the blue side of the construct is to complete the Knotless Tensional construct. Now we're passing the number five FiberWire blue suture through the closed loop of the suture shuttle. And then there is a mark that tells you where to stop. While that is under tension, we're pulling on the non looped end of the suture shuttle. And this will complete the Knotless TensionLoc construct for the blue number five suture. So now the suture shuttle is removed and all we have left is the number five blue on one side and the number two white on the other. We recommend completing the blue 100% or completing it all the way. So we're going to pull it all the way down. You'll see the tendon advance to bone. And once that's seated then you complete the white number two. Fiberwire. And this is the second knotless tensioning bolt in the implant. At the end you can certainly go back and retention each side just to make sure that all the slack is removed on either side. Okay. So this is what it looks like at the very end. Again we have the long head of the biceps right here. The Knotless FiberTak is holding the tendon down. You see the blue on one side, the white on the other. It's completed nice and tight. The last step is just to cut the suture. And there's nothing proud. No, no. Not stack. And that's the final construct. Very tight. Very secure.

Suprapectoral Biceps Tenodesis With the Knotless FiberTak®  Biceps Anchor

Justin W. Griffin, MD (Virginia Beach, VA), presents a case and details a technique for suprapectoral biceps tenodesis using the Knotless FiberTak® Biceps anchor.

Case Presentation: Suprapectoral Biceps Tenodesis Using the Knotless FiberTak® Biceps Anchor

I'm Justin Griffin from Virginia. I'm excited to share with you a new development in my management of the biceps tendon for my patients, the Knotless FiberTak biceps. First, I'd like to share with you a case of a patient that I chose to manage the biceps in a particular way. This is a 68 year old active female with right shoulder pain. She had pain for several years, had failed conservative treatment. She was very active with different activities including gardening. She started to lose sleep and then she started to have problems with her functional activities due to pain on her exam. She had a difficulty with range of motion. She also had a positive O'Brien's with some biceps groove tenderness, a little bit of weakness in her rotator cuff and also some limitations with range of motion. Here's your MRI. You can see on the MRI that she has not only a rotator cuff problem, but also at her superior labral attachment. We can notice that she has a tear. She could, of course, have a superior label repair, but this would not be my choice for her. A debridement alone could be considered, but I don't think it would completely manage her pain. And then we could of course, consider a tenodesis, which is what we chose in this patient. The knotless FiberTak biceps offers a number of advantages. First, it creates a very small drill hole. Second, it's very simple and efficient, and it creates a strong repair through an interlinked double loaded knotless mechanism. So the way to perform this is first I pin the biceps through a spinal needle in an intra-articular manner. Then I release the biceps with arthroscopic scissors. You can also release the biceps with your Apollo, which creates perhaps less bleeding. And you can see that we can do this very efficiently here in the joint. Next I'll bring the shoulder into forward elevation. I'll really identify in the sub deltoid space where my portal should be. We create an inverted triangle between our anterior or lateral and our anterior inferior biceps portal. We'll create this and then place a passport cannula for efficient suture management. Once we have our passport in place, we can identify the biceps and really skeletonize it in the groove. We can see that we're working medially and laterally here. We have to pay careful attention to the little things. We don't want to get a great deal of bleeding, which makes the procedure more difficult. And we want to avoid violating the sub deltoid fascia. That's where the passport really I find helpful. Once we have our space managed quite well, we can then sweep the biceps more laterally, place our drill guide into the biceps groove, and we can feel the guide falling directly into that biceps groove. Then my assistant will efficiently place this anchor in a cortical manner. Once she enters through that one cortex, you can see that we place the anchor directly into the bone, and then we're ready to manage our sutures. The next step, as you can see, is we go ahead and grab the white suture directly around the biceps. This is going to serve as our loop. We can then take our passing device. Pass this directly through the biceps and retrieve it on the other side. We want to take a really good bite of the biceps. I try to enter directly through the central portion of the biceps, and then pull the suture up. And then we're ready to manage this. Sometimes I'll pull the loop down just a little bit to allow me to be able to see the loop better, to manage it on the other side of the biceps. Our next step is we're going to grab our other suture, which goes into the other Knotless Knotless mechanism. As we know, this is a double loaded knotless anchor. We can then retrieve our blue suture through the white loop. As you can see here. This is then loaded onto the passing suture. And we can then tension this down to obtain stout fixation in an interlinked way. I always like to look at my repairs. When I'm complete, I'll move my scope to anteriorly. As you can see here, we're going to move the scope anteriorly. And we'll be able to see that this is a very stout repair in an orderly fashion, and all we have left to do is remove the proximal unhealthy biceps. I typically will take a KingFisher and grab the biceps, elevate it up because it was moved in an anatomic fashion. And then subsequently I'll take that portion of the biceps out and we're completed with our biceps. Tenodesis Postoperatively I keep all of my patients in a sling for four weeks. We begin active range of motion at that point, but we're not starting any strengthening until six weeks. In this case, we've highlighted the fact that there is an easy and efficient way to manage the biceps in an interlinked knotless way. We've created an on lay biceps tenodesis and takes advantage of the optimal length tension relationship. This is also a knotless repair, which makes it efficient, smooth, and seamless in your operating room. Thank you for your attention.

Knotless FiberTak® Biceps Tenodesis

The FiberTak biceps implant system delivers an all-suture anchor designed for use in open, onlay-tissue fixation procedures, particularly proximal and distal biceps repairs. The implant is double-loaded with sliding SutureTape and includes 4 attached needles. The system includes a FiberTak biceps implant, drill guide, 1.9 mm drill, and a free curved needle.

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.

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.

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.

FiberTak® Biceps Implant System

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.

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.

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.

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.

FiberTak® Biceps Tenodesis

The family of SwiveLock tenodesis implants is designed to support a multitude of proximal biceps tenodesis techniques and maximize OR efficiency. Implants are available with suture eyelets or closed eyelets for surgeons who prefer a whipstitching technique, and forked eyelet versions are offered for an all-arthroscopic approach. There is no need to predetermine tendon length, as position and tension can easily be set and visualized prior to final implant insertion. Obtain strong fixation by simply advancing the preloaded SwiveLock tenodesis screw. The system also features piloted headed reamers with built-in guide tips that eliminate the need to ream over a guide pin.

SwiveLock® Tenodesis

Tenodesis Screws™&nbsp;may be used in conjunction with #2 or 2-0 FiberWire®&nbsp;to facilitate intraoperative tissue tensioning and fixation in a predrilled socket. The predrilled socket minimizes incision length, dissection, and overall morbidity. BioComposite, PLLA, vented PEEK or titanium Tenodesis Screw insertion provides superior and immediate fixation for foot and ankle indications such as Achilles repair, FDL, FHL tendon transfers and lateral ligament stabilization. The system can also be used for applications in the hand and elbow (UCL, LRTI, distal biceps), shoulder (rotator cuff repair, proximal biceps), as well as collateral ligament repair, reconstruction and secondary graft or suture fixation for ACL, PCL reconstruction. This construct allows for direct tendon-to-bone healing, without hardware prominence. &nbsp;
The Tenodesis Screws are part of the Bio-Tenodesis Screw System which eliminates transosseous tunnels in tendon repairs and ligament reconstructions by simplifying tissue fixation in a bone socket while maintaining tension of the tissue throughout fixation.&nbsp; A specially designed, retracting screwdriver with extended tip tensions the graft near the base of the socket while a unique outer sleeve delivers the Tenodesis Screw as the extended driver retracts. This technique is ideally applicable for biceps tendon and collateral ligament repairs. The graft passing sutures through the screw cannulation can be used to provide backup fixation by incorporating anti-slippage mulberry knots at the distal end of the screw. The suture ends can be tied over the screw at the completion of the procedure as additional backup fixation, if desired.

Tenodesis

Loop 'N' Tack™ Tenodesis Implant System

Knotless FiberTak® Biceps Tenodesis

FiberTak^® Biceps Tenodesis

SwiveLock^® Tenodesis

Tenodesis Screw™