1. A New Technique of Minimally Invasive Biceps Tenodesis in Conjunction with Shoulder Arthroscopy Eric R. McMillan, MD, Richard B. Caspari, MD Orthopaedic Research of Virginia Richmond, Virginia, USA.

3. I. INTRODUCTION Mechanisms of Biceps Tendon Pain Common Tendinitis as a component of classic impingement syndrome Rupture associated with impingement syndrome

4. Uncommon Rupture secondary to acute shoulder trauma in the younger patient Instability associated with acute trauma in the younger patient Instability associated with large rotator cuff tears Tendinitis secondary to direct injury to the biceps groove

5. Treatment of biceps tendon pathology has been controversial, but in some cases tenodesis may be indicated. We present a new mini-open technique of biceps tenodesis that is easy to perform, safe, and minimally invasive. Patient satisfaction is high because the incision leaves a small and well-hidden scar.

7. II. MATERIALS AND METHODS A. Decision-Making Criteria 1. Biceps Tendinitis Associated with Impingement Initial conservative treatment Modification of activity Oral anti-inflammatory medication Rotator cuff strengthening program

8. Next step is injection of local anesthetic and steroid if conservative treatment unsuccessful Injection is repeated once if patient got good relief from first injection or if there is question about whether the injection was truly placed into the subacromial space If symptoms persist, surgical treatment

9. 2. Proximal Biceps Tendon Rupture a. Acute rupture in a young patient Typically relatively high-energy trauma We believe repair is indicated We repair the biceps tendon through a small anterior open exposure after arthroscopy of the glenohumeral joint and subacromial bursa

10. b. Acute rupture in an older patient i. High demand (heavy laborer or strenuous sporting activity with the affected extremity) Initially, conservative treatment If symptoms persist, surgical treatment ii. Low demand Conservative treatment

11. 3. Biceps Tendon Instability and Injury to the Biceps Groove Initially, conservative treatment If symptoms persist, surgical treatment

13. B. Arthroscopic Evaluation of the Shoulder 1. Arthroscopy of the Glenohumeral Joint Our first step in surgical treatment of all biceps tendon pathology The articular surfaces, labrum, capsule, rotator cuff, and biceps tendon are all carefully inspected The biceps tendon is drawn into the glenohumeral joint using the probe and inspected for any tendinitis

14. If the tendon is frayed but at least 50% of the cross-sectional area is preserved, the frayed portion is debrided and the remainder is left undisturbed If the tendon is frayed and less than 50% of the cross-sectional area is preserved, we feel that tenodesis is indicated

15. 2. Arthroscopy of the Subacromial Bursa The undersurface of the acromion, the rotator cuff, the coracoacromial ligament, and the undersurface of the acromioclavicular joint are examined If there is abrasion on the coracoacromial ligament or the rotator cuff, an arthroscopic subacromial decompression is carried out

17. C. Mini-Open Biceps Tenodesis 1. The biceps tendon is detached and any remaining attachment is debrided. 2. The arm is removed from traction, abducted, and externally rotated to expose the pectoralis major insertion. 3. A 3 – 4 centimeter incision is centered over the long head of the biceps, parallel to the pectoralis major tendon at the lateral border of the axilla.

19. 4. Dissection is carried down parallel to the pectoralis major tendon until the short and long heads of the biceps are encountered. Using finger dissection, the lesser tuberosity can be palpated proximally for orientation. 5. Pectoralis major is retracted anteriorly and proximally, revealing the musculotendinous junction of the long head of the biceps. A portion of the inferior insertion of the pectoralis major can be detached for visualization.

21. 6. The tendon should be in the desired “anatomic” tenodesis position already due to soft tissue tethering. 7. A site in the distal portion of the biceps tendon is chosen for placement of fixation. The anterior cortex of the humerus at the anchoring site is drilled for a cancellous screw or a suture anchor. The axillary nerve can be damaged here by penetration of the posterior cortex. 8. If a screw and washer construct is chosen, the screw is placed through a split in the tendon.

22. 9. If a suture anchor is chosen, the tendon is moved aside and the anchor placed. The anchor’s sutures are woven through the tendon and tied securely. 10. Redundant tendon proximal to the fixation is debrided. 11. Muscles displaced for the approach are allowed to fall back into position. It is not necessary to repair detachment of the inferior pectoralis major attachment. 12. Skin is closed in a standard fashion.

23. III. DISCUSSION A. Biceps tendinitis 1. Biceps Tendinitis as a Component of Subacromial Impingement Like Neer and other authors, we believe that the vast majority of biceps tendinitis occurs as a component of impingement syndrome Not all investigators have noted this association between biceps tendinitis and impingement syndrome

24. Most of the variance of results in studies can be attributed to differences in procedures performed with biceps tenodesis Investigators who have noted the relationship between biceps tendinitis and impingement have performed other procedures with biceps tenodesis and had better patient outcomes Investigators who have not noted the association between biceps tendinitis and impingement and have performed isolated biceps tenodesis and had poorer patient outcomes

25. Becker and Cofield concluded that neglect of the associated pathology of subacromial impingement contributed to poor long-term results in their review of isolated biceps tenodeses, as did Dines, Warren, and Inglis

26. Some authors have noted the association between biceps tendinitis and impingement but recommended treatment only of the other components of impingement with neglect of the biceps. This has been shown by Berlemann and Bayley to be unsuccessful.

27. We feel that it is important to look for and address any of the components of impingement that may be present, including Tendinitis of the biceps Abrasion of the coracoacromial ligament Degenerative change of the acromioclavicular joint, and Encroachment of the anterolateral acromion on the rotator cuff

28. 2. True Isolated Biceps Tendinitis Probably does occur, but is thought to occur only with traumatic injury to the biceps groove We feel that isolated biceps tenodesis does have a role, but these injuries are exceedingly rare in our experience

29. A. Rupture of the Biceps Tendon at the Shoulder 1. Rupture Associated with Subacromial Impingement An end-stage manifestation of biceps tendinitis Several authors favor tenodesis for this condition while others have recommended against tenodesis Warren has discussed the indications for tenodesis of old biceps tendon ruptures, supporting tenodesis in the unusual case of pain over the biceps muscle belly

30. We feel that tenodesis is indicated with high work or sporting demands or with pain localized to the biceps muscle belly. With low functional demands, we feel biceps rupture should be treated conservatively.

31. 2. Traumatic Rupture of the Biceps Tendon in a Young Individual Can occur in association with high-energy trauma, but is very unusual in our experience We feel that repair of the long head of the biceps should be undertaken through an open surgical approach

33. B. Biceps Tendon Instability Biceps tendon instability is usually associated with tearing of the rotator cuff Tearing of the rotator cuff leading to instability may occur as a high-energy traumatic event in the younger patient or with a degenerative rotator cuff tear in the older patient

34. Burkhead advocates reduction of the tendon and reconstruction of the fibrous roof of the biceps tunnel in the patient less than 50 years of age. In patients older than 65, Burkhead recommends conservative treatment. Other authors have recommended tenodesis for biceps tendon instability in cases refractory to conservative treatment

35. We feel that tenodesis is indicated in the patient with symptomatic biceps instability who has significant attenuation or low functional demands. With high work or sporting demands, we believe that reconstruction of the fibrous roof is a good option.

37. C. Proximal Migration of the Humeral Head After Biceps Tenodesis Demonstrated by several authors Thought to occur due to loss of the depressor effect of the long head of the biceps on the humeral head

38. Thought to be responsible for deterioration of results of isolated biceps tenodesis over time through secondary impingement of the rotator cuff on the undersurface of the acromion, as proposed by Kumar and Satku Although this association between proximal migration and secondary impingement seems intuitive, no definite association has been proven

39. Berlemann and Bayley series Series of biceps tenodeses in which subacromial decompressions were carried out with biceps tenodesis for biceps tendinitis and/or impingement Authors documented proximal migration of the humeral head using radiographic methods No late symptoms of impingement during their average 7 year follow up

40. Indicates that factors other than proximal migration contribute to late secondary impingement Lends support to treatment of the entire spectrum of impingement initially We feel that the humeral head depressor effect of the biceps is important and that tenodesis should not be undertaken without consideration of possible sequelae

41. D. Comparison of Tenodesis Techniques Previously published techniques of biceps tenodesis have been traditional open procedures, arthroscopic variations of traditional open procedures, or all- arthroscopic procedures

42. The technique presented here has several advantages The small incision and limited dissection avoid the morbidity associated with traditional open approaches The small size and medial location of the incision produce a very cosmetic scar This procedure is significantly easier to perform than all-arthroscopic techniques and less time- consuming than all-open or all-arthroscopic approaches

43. Nervous structures at risk The musculocutaneous nerve can be damaged by overzealous retraction medially or inadvertent medial dissection The axillary nerve can be injured by penetration of the posterior humeral cortex with the drill None of the significant vascular structures about the shoulder are at particular risk

45. IV. SUMMARY This mini-open technique is easy to perform, safe, and minimally invasive. Patient satisfaction is high because of the small and well-hidden scar.

46. Thank You!