The Birmingham Biceps technique for subpectoral tenodesis was developed in conjunction with Drs. Lyle Cain, Jeff Dugas and Benton Emblom from the Andrews Sports Medicine &amp; Orthopedic Center.
The technique was designed to minimize the potential for postoperative humeral fractures by placing a small 5.5 mm PEEK SwiveLock® tenodesis implant near the top of the pectoralis at a newly defined anatomical landmark, the Pallium Pectoralis. The Pallium Pectoralis is a fascial sleeve that connects from the top of the pec to the medial border of the humerus approximately 2 cm distal to the transverse humeral ligament at the metaphyseal-diaphyseal junction. All implants and disposable instrumentation required for this procedure are conveniently available in the Birmingham Biceps implant system.

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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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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.

E. Lyle Cain Jr., MD, (Birmingham, AL) details his rationale to tenodese the biceps tendon in the subpectoral region. He discusses bicipital groove pain as a main indication for a subpectoral tenodesis. Dr. Cain also addresses the argument of stress risers in the humerus, and shows how he mitigates this by using a 5.5 mm SwiveLock® anchor and drilling the tunnel 2 cm distal to the transverse humeral ligament at the metaphyseal-diaphyseal junction.

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Biceps Tenodesis: Fix it in the Subpectoral Region

Thank you, Reinhold, for inviting us here and having us all here. This is a great meeting where you can kind of talk about your techniques and debate why we're doing certain things. I'm going to show you kind of our thoughts about why we're doing mainly this, and kind of the evolution of technique. So we'll talk about the whole process. So the question is what would you do with this kid. This is a 19 year old pitcher right shoulder pain for six months. Can't pitch failed long time conservative treatment normal other structures. So rotator cuff is good. Motion is good. Had an acute pop while throwing. You know certainly this is a patient that you're less likely to tenodesis on maybe than other patients. But but still I think in today's climate this is becoming an option. And you've got this guy who's a little different. He's 47 years old, former college pitcher, right shoulder pain for the last four years, can't throw to his son's baseball team, which is a big problem. Difficulty sleeping, chronic pain and has some other problems. He has rotator cuff tendinitis. Has kind of a generally angry shoulder. So more insidious onset. So different patients, different issues. I think the question is what should we do with the proximal bicep tendon? Should we let it sit or repair the superior labrum? And I think that's somewhere where none of us really have the answer. I love hearing these talks because it really makes me think about my process that I've gone through. And I think, you know, ten years from now, maybe we'll have the correct answer. Now it's very much in motion, and I think we're still in debate. So if you look at whether the bicep tendon hurts, I think it's pretty well known now through several studies. This is a 2013 study that the long head biceps does have pain receptors. So it has both sympathetic innervation as well as alpha pain receptors. And I think we know that it causes pain. And we've known this for a long time that it causes pain. We're just not sure how to get rid of it all the time. So the question is where should we attach the bicep tendon? We've talked to a little bit about the slap repair issues, and had some good videos this morning with Neil and other people showing their technique. I think Tenotomy is still a good option in some patients. We haven't spent much time on Tenotomy obviously doesn't use any implants and it's a very easy procedure, but I think there are some downsides to tenotomy. We used to do it originally. In the rotator interval. We'd pass sutures through the interval and tie it in the interval. Some people call it the pit technique. I think the problem there is that it loses extra rotation. It's basically like doing an interval closure on these older patients. And they tend to lose extra rotation. So I don't do that much anymore. Top of the groove I think is a great option. Supermx pectoral, as Tom just mentioned I think is another good option, but we've really gravitated toward the subcortical region for several reasons. Several reasons I show. So the question in my mind really is where is the pain located and why are you doing a bicep tenodesis. Is it deep shoulder pain or is it bicipital groove pain and obviously bicep tendon pain? So I think that that when the pain is in this region, when it's in the bicipital groove, it's not deep mechanical shoulder pain like a typical slap. They may have rotator cuff disease and other issues, but when they have groove pain, when you say where do you hurt in the first place? They point is their bicipital groove. I think the Subpac region is the only place to really fix the problem, because it's the only way to get the tenant out of the groove. So I think that's the time when the indication is pretty clear. I pulled this up the other day. Just kind of I was thinking, my fellows that come in today see a lot of Bio-Tenodesis and not a lot of slap repairs. So this is my practice and Jeff Duggan's practice and Benton Emblem, one of our new partners from my beginning of practice in 2000 through 2014. And it's a little bit small, so it's hard to see. But the bottom line is our slap repairs have been pretty equal. Those are the lighter white lines primarily, and our tenodesis have really ramped up in the last four years. And if you look at the totals on the far right total tenodesis, you know, I've done about 700 Tenodesis. Jeff's done about 300 and slap repairs. I've done about 350 slap repairs. So, you know, in the last four years I've really increased the number of tenodesis I do. And the slap repairs are maintained pretty consistent levels. And I think this this all goes back to kind of figuring out where the pain is coming from and where the location of symptoms are coming from. And I think that's the key is that there are many times you have patients come back after surgery, they're still having pain, maybe a young athlete, you've done a slap I prepare terrible bicep tendon pain. They can't get through it. You know, their slap has been repaired, but their shoulder still hurts. I think that's that's the predicament we have today is how to not just the older patients but the younger athletes, how to transition into a better treatment algorithm. We do have complications and these are what we worry about. When you look at Tony Romeo's series, he had very low complication rate, only 2% of 353 patients. Not a very high number. But every once in a while we see these. We've had. This was reported in Ajsm this year. Baseball player that had a bicep tendon and sustained a fracture while throwing. We've had three proximal humerus fractures after tenodesis none in throwing athletes, but they were all very active people doing weightlifting and other other activities. And so we worry about these stress fractures. So when we started seeing these, we went to the lab and we said, you know, how do we avoid this from happening? We don't want to put hardware in a in anyone, obviously, especially if it's from an hydrogenic cause. So we did several studies looking at fracture risk. And Brian Walters, a current fellow that just finishes up in New York practicing. I did three studies looking at fracture risk and different constructs, and we looked at a lot of different potential ways to fix the biceps. And what we found essentially was that fixation size didn't really make a difference. Both 6.25 and eight millimeter screws and holes significantly lowered fracture torque. And when they did fracture in the cadaver model it happened primarily at the drill hole. We didn't look at long term results. So we don't know about bioabsorbable. But there are some reports of empty holes causing a problem. So so non absorbable is maybe better. Well how do we change this this situation. We've downsized. I used to use a eight millimeter screw initially. And now I use a 5.5mm screw. And I use a swivel lock for the overhead athletes or young patients. Sometimes I use two small labral anchors in the humerus just to decrease the stress riser. The main thing we've done is increase the tunnel height. And I think that's something I'll show you. That's very important in terms of our cadaveric studies. And we've gone to a pig screw just because of the theory that an unfilled hole is weaker than a filled hole. So increasing tunnel height, I think is a significant way to improve this. And we've done this through some AnaToemic studies. So what we found in our study was that there's some reproducible landmarks. We did all these cadavers. And as we dissected them, we started taking measurements from different points in the humerus. And we found that there was always this, this palpable landmark at the top of the pec tendon. And it's not quite super pec, and it's not, I guess, technically suspect, but it's a little fascial sleeve that connects from the pec over to the medial border of the humerus. And it's consistent. It's there on every cadaver. It's there on every case I've done since I noticed it. I always thought it was the bottom of the bicipital groove, but it's not. It's actually about two centimeters distal to the transverse ligament. So it's not the humeral ligament. It's a thin sheet of fascia, sheath of fascia. And it seems to be very, very reproducible. So one of our fellows who's into to nomenclature came up with this, this word pallium as a Latin cloak and we call it the pallium pectoralis. And I think the question was can this pallium pectoralis be a good landmark for doing this? And what we found was that over many, many anatomic models and cadaver studies, if we take about four centimeters, 3.9cm of bicep tendon above the bicipital groove, excuse me, above the muscle tendon junction. And we put it right here at this pallium hole, which is the metaphyseal junction. We've had very good length tension restoration and also had less stress risk in terms of talk to failure. So I think this may be the key to doing some apex and decreasing our rate of complications. So yes, it is a reliable landmark. So my current algorithm and the young overhead athlete activity related shoulder pain, they're pitching and they have pain that they describe as mechanical and deep. I'll still repair their superior labrum. Jim Andrews, every time I do a Bio-Tenodesis or Bio-Tenodesis, I think about him saying, you know, God put it there for a reason. You can't just cut it. So, so in these younger athletes, where I'm not 100% sure that with the long term outcomes are and they're having primarily deep pain, I think doing a slap repair is still a great option. And the younger I ever had athlete that has only groove pain and I see a lot of these, I see especially young softball players with NBA, MDI where they've had years of bicipital groove pain, not really deep shoulder pain. I think it's reasonable to do this, and we've got a series of these now where the larger athletes, the more athletic females, large boned people, we do PowerPick with a screw, the smaller bone structure. We do a tenotomy or use smaller anchors to Bio-Tenodesis in the groove. How about the failed slap repair? These you know, the bottom line is, once you do a failed slap, repair your chance of reattaching that superior labrum and having a successful outcome I think are very slim. So these are the patients that really we probably stretch the indications of tenodesis and do a lot more tenodesis again, either sub pectoral or tenotomy, depending on the size of the person. They're kind of arm anatomy, how musculature, how the musculature is and and what their requirements are. The older athletes I'm doing primarily sub tenodesis. My philosophy now is I think PowerPick is is the only certain way certain way that I feel good that I'm going to get rid of that groove pain. And then for the non-athletes or elderly patients, I think doing rotator cuff tenotomy or incorporating it in the repair is good. So the evolution of surgical techniques gone through all these different articles looking at the anatomy and tunnel location. And essentially we've found this technique. This is my quick bicep cutting slide. We have a contest amongst our fellows who can get the biceps in the fewest amount of bites. This guy was three. When you get it in one bite you've done a really good job positioning. We do everything. Lateral position. I think one of the keys to doing a tenodesis in lateral is you've got to move the arm. So you know typical lateral position you're about 30 degrees forward flexion. We take the arm and we move it about three slots back on the position to make it more extended. And that gives you a lot better view. I make an incision just medial to the biceps tendon. And right at the kind of junction of the inferior edge of the pectoralis muscle. Small incision, usually 2 to 3cm. I think the key here is that from a complication standpoint you don't want to put retractors medial. All of the all the injuries that I know of in the literature have been attributed to putting a human or some kind of retractor medial and hitting the musculocutaneous nerve. So I use my finger, I do finger retraction medial. We cut the inferior pec fascia. Once you do this you can see the humerus. And we've got a Army Navy retractor lateral. The bicep tendon is usually readily palpable in the groove. I'll uncover the bicep tendon, pull it out with an Allis clamp. And then we use this technique where we use four centimeters of whipstitch using the FiberLink FiberLink. This pre made very nice. Way to hold the tendon. So we'll look at the muscle tendon junction. We measure four centimeters. And we'll whip stitch this to get the four centimeters length which hopefully reproduces our native tension configuration. Just some technical pearls. You know I think from a visualization standpoint we're on the other side of the table. Obviously we've moved around to the anterior side of the humerus. You know, having having someone that can pull in the pec tendon allows you allows you to get up high in the groove. You don't have to be down at the bottom of the pec tendon. And with this, these measurements, we've had very good length tissue relationships even in young patients. We're using the 5.5mm SwiveLock. Now we found that this works for all tendons. We haven't had to to trim any tendons despite the fact that these are a lot of athletic, larger people. We use a 5.5mm reamer and a tap to tap the anterior cortex, and then we put a 5.5 SwiveLock in. The reason I like the SwiveLock, I think the screw does well also, but with the SwiveLock, it gives you this extra set of sutures coming through the eyelet that are attached to the bicep tendon. And so after I place my screw, I'll actually tie the two sutures together. The one that holds the SwiveLock on the suture on the anchor, and the one that holds the bicep tendon in the eyelet. And that allows you to kind of close the loop between the two devices, preventing the bicep tendon from sliding past the screw for the thing to come out. Once you tie these together, the whole construct has to come out of the hole. So much less likely, I think, to have a failure. So I'm up at the top of the groove, the pectoralis, we've named it. We're making a 5.5mm hole with a simple tap of the anterior cortex. Be sure you don't go bicortical obviously as a stress riser. And we've had very good success with this, even in very dense bone and large bicep tendon. So 5.5mm is not too small. So again finger retraction or using the suckers retractor we dunk about 19mm of tendon within the humerus and then put the SwiveLock in. So where should we attach the proximal biceps I think for those patients especially that have groove pain. And that's a large patient population in my practice I think it's important to put in the pectoral region. It's the only way to remove the offending painful structure. Thank you very much.

Birmingham Biceps Implant System (includes: 5.5 mm PEEK SwiveLock, FiberLink Plus, 5.5 mm Pilot-Headed Reamer, 5.8 mm Tap and Free Needle)

Implant System, Biceps Tenodesis 5.5 mm with PEEK SwiveLock, FiberLinkPlus, Free Needle, Tap, and Reamer

Sistema de implante, Biceps Tenodesis de 5,5 mm con SwiveLock de PEEK,

Birmingham Biceps™ Technique

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The Birmingham Biceps™ Technique For Open Subpectoral Tenodesis

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Shoulder and Elbow - Next Generation in Repair and Reconstruction 2024

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Biceps Tenodesis: Fix it in the Subpectoral Region

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