SCOI Technique for Biceps Tenodesis Using the C.W. Sub-Pectoralis Approach

Stephen J. Snyder, MD

 

At our institute, we use a simple technique to perform a mini-open biceps tenodesis which allows firm fixation of the injured biceps tendon into a drill hole in the proximal humerus using a one to two-inch anterior axillary incision. The technique requires that the surgeon have excellent shoulder arthroscopic skills, in addition to experience with open surgical exposure in the anterior aspect of the shoulder. The technique is performed in two steps: (I) Arthroscopic; (2) Open.

 

Arthroscopic Portion

*     A complete videorecorded arthroscopic exam is performed of the shoulder and the bursa, and any debridement or decompression is performed as needed.

*     The subacromial electrode is used on the electrocautery tool through an insulated anterior cannula to transect the biceps tendon just above the labrum. (Figure I)

 

Open Procedure

*     The arm is removed from the traction device and covered with a sterile stockinette. The table is tilted posteriorly about 3Qo and the axilla is re-prepped with Betadine.

*     A 1-2 inch incision is made in the anterior axilla centered on and perpendicular to the lower border of the pectoralis tendon. The areolar tissue covering the tendon is carefully dissected in a lateral direction up to its insertion point on the humerus.

*     A pointed tip Hohmann or similar retractor placed around the humerus medially to retract the conjoined tendon. Another Hohmann retractor, preferably with a 90-degree bend in its handle, is placed around the lateral humerus to retract the pectoralis proximally. The biceps tendon groove is palpated and the sheath opened to expose the tendon. (Figure 2)

*     A marker suture is placed through the biceps tendon at the upper portion of the exposed field (near the bottom of the biceps groove). The electrosurgical tool is used to mark a spot in the biceps groove which corresponds Figure 3 to the position of the marker suture. (Figure 2) This mark serves as a guide in setting the tension in the tendon during implantation.

*     The biceps tendon is removed from the groove and the frayed ends excised, removing about 4-5cm so that 2cm of tendon remain proximal to the marker suture.

*     A double-whip stitch of #2 non-absorbable braided suture is placed beginning in the free end of the biceps tendon and extending down to the level of the marker suture and back up again to the free end. This suture will serve as the lead suture during the tenodesis.

*     A central hole is drilled in the lower end of the biceps groove at the area previously marked with the electrosurgery. The diameter of the hole is similar to that of the biceps tendon. The direction of the burr is then changed to angle distally into the hollow medullary canal. (Figure 3) The hole is smoothed with a curette.

*     Two holes are drilled using a 7/64-inch drill, one anterior and one posterior to the biceps, approximately 2cm distal from the central hole. (Figure 4)

*     A Shuttle RelayTM is passed into one of the distal holes using a crescent-shaped or 9Q0 suture hook, and retrieved out the center hole. One suture is loaded into the Shuttle eyelet and carried down through the central hole and anterior drill hole. (Figure 5) The second suture is passed using the Shuttle RelayTM through the other drill hole.

*     With both sutures pulling distally, the biceps stump is directed into the central hole and advanced distally into the medullary canal. (Figure 6)

*     With the patient’s elbow in full extension, the end of one limb of the lead suture is passed with a free needle through the overlying biceps tendon and tied to the other strand, locking the tendon in position. (Figure 7)

*     The fixation is tested by pulling distally on the biceps tendon. It should be noted that, with proper tension, the marker suture placed in the tendon should be at the level of the central hole in the upper portion of the groove. This ensures that the resting length of the biceps tendon remains physiologic.

*     The subcuticular tissue (if available) is closed with interrupted 3-0 absorbable sutures and steri-strips are applied and a Xeroform dressing is placed in the axilla to help protect against bacterial contamination.

 

Postop Care

*     The arm is placed in a neutral rotation sling immobilizer (UltraSlingllTM, Donjoy Inc.) and gentle biceps exercises are begun immediately postop. A Shoulder Therapy Kit (STK, Breg, Inc.) is used to start forward elevation and gentle internal and external rotation strengthening exercises a few days postop. Full activity is delayed for three months to allow for the tenodesis to mature.

*     The suture Shuttle Relaytm consists of a twisted wire core 30 inches long with a nylon coating. It is the size and stiffness of a # I monofilament suture. There is a I cm eyelet in the center of the Shuttle formed by removing a segment of the nylon covering and spreading the wire core. The Shuttle Relay allows the surgeon to pass any type of suture material using any of the conventional arthroscopic suture passing instruments, such as the slotted-jaw suture punch or suture hook, which previously only allowed use of monofilament sutures. Using the Shuttle Relay, the surgeon may employ any suture if desired in a single stitch, running suture, mattress stitch, or figure-of-eight fashion. Besides allowing repair of torn shoulder labrum and capsule, the Shuttle also facilitates repair of avulsed anterior cruciate ligaments in the knee and plication procedures for the unstable patellofemoral joint or the subluxation shoulder with a patulous anterior and/or posterior capsule.