The 360 Double Lasso Loop for Biceps Tenodesis: Tips and Tricks

Abstract

The management of the intra-articular portion of the long head of the biceps tendon (LHB) is a recurring topic in every discussion about shoulder pain. In massive rotator cuff tears or in tears of the superior third of the subscapularis tendon, our approach is to systematically perform a tenodesis of the LHB. In this Technical Note, we present our arthroscopic technique for LHB tenodesis at the articular margin of the humeral head using a single anchor and a 360 double lasso loop. This technique guaranties a strong and efficient fixation of the biceps tendon and is reproducible when following the steps and tips and tricks outlined herein.

Fig 1

Position of arthroscopic portals (right shoulder). (A) Posterior portal (soft point). (B) Posterolateral. (C) Lateral portal, middle acromion. (D) Lateral portal, underneath the anterolateral angle of the acromion. (E) Anterolateral portal through the rotator interval.

Fig 2

Intra-articular arthroscopic visualization of the right shoulder from the A portal (posterior) with the patient in the beach chair position. The D portal (lateral portal) serves as the working portal. (A) Initial assessment: a large crescent-shaped SS tear is visualized. (B): Marking the level of cut of the BT with a radiofrequency ablation probe (90-S Cruise, Serfas Energy; Stryker). (C) An all-suture anchor (Iconix Speed; Stryker) is placed posterior to the biceps tendon (D) Three of the four sutures are placed in a waiting portal; the remaining strand is pushed anteriorly and medially under the biceps using a suture grasper (E) A Cleverhook (DePuy Synthes) is passed through the BT. (F) The strand is caught by the Cleverhook. (G) The suture is retrieved through the tendon, making the first loop in which the Cleverhook is passed. (H) The Cleverhook is then passed anteriorly over the BT to catch the same strand. (I) The strand is retrieved through the loop, making a second loop. (J) The Cleverhook is passed through this second loop. (K) The free strand is caught posteriorly to the biceps. (L) The suture is retrieved through the loop and out of the shoulder. (M) The biceps cut is completed, and the suture is tightened: the 360 double lasso loop is done. (N) Then, the sutures can be passed through the SS before tying a nonsliding knot allowing a tendon-to-tendon suture between the SS and the BT. (A, anchor; BT, biceps tendon; CH, Cleverhook; G, glenoid; HH, humeral head; L, labrum; RF, radiofrequency ablation probe; RI, rotator interval; SG, suture grasper; SS, supraspinatus tendon; SSc, subscapularis tendon.)

Fig 2

Intra-articular arthroscopic visualization of the right shoulder from the A portal (posterior) with the patient in the beach chair position. The D portal (lateral portal) serves as the working portal. (A) Initial assessment: a large crescent-shaped SS tear is visualized. (B): Marking the level of cut of the BT with a radiofrequency ablation probe (90-S Cruise, Serfas Energy; Stryker). (C) An all-suture anchor (Iconix Speed; Stryker) is placed posterior to the biceps tendon (D) Three of the four sutures are placed in a waiting portal; the remaining strand is pushed anteriorly and medially under the biceps using a suture grasper (E) A Cleverhook (DePuy Synthes) is passed through the BT. (F) The strand is caught by the Cleverhook. (G) The suture is retrieved through the tendon, making the first loop in which the Cleverhook is passed. (H) The Cleverhook is then passed anteriorly over the BT to catch the same strand. (I) The strand is retrieved through the loop, making a second loop. (J) The Cleverhook is passed through this second loop. (K) The free strand is caught posteriorly to the biceps. (L) The suture is retrieved through the loop and out of the shoulder. (M) The biceps cut is completed, and the suture is tightened: the 360 double lasso loop is done. (N) Then, the sutures can be passed through the SS before tying a nonsliding knot allowing a tendon-to-tendon suture between the SS and the BT. (A, anchor; BT, biceps tendon; CH, Cleverhook; G, glenoid; HH, humeral head; L, labrum; RF, radiofrequency ablation probe; RI, rotator interval; SG, suture grasper; SS, supraspinatus tendon; SSc, subscapularis tendon.)

Fig 3

Illustrations summarizing the steps required to create the 360 double lasso-loop. Posterior view of a right shoulder. Letters correspond to those in the legend of Figure 2. (B) Marking the level of cut of the biceps tendon with a radiofrequency ablation probe (90-S Cruise, Serfas Energy; Stryker). The cross in the upper left corner orients the illustration. (C) An all-suture anchor (Iconix Speed; Stryker) is placed posterior to the biceps tendon. (D) Three of the four sutures are placed in a waiting portal; the remaining strand is pushed anteriorly and medially under the biceps using a suture grasper. (F) A Cleverhook (DePuy Synthes) is passed through the biceps tendon to caught the strand. (G) The suture is retrieved through the tendon making the first loop. (H) The Cleverhook is passed through the loop and driven anteriorly over the biceps tendon to catch the same strand. (I) The strand is retrieved through the loop, making a second loop. (K) The Cleverhook is passed through this second before catching the free strand posteriorly to the biceps. (L) The suture is retrieved through the loop and out of the shoulder. (M) The biceps cut is completed and the suture is tightened: the 360 double lasso loop is done. (N) Then, the sutures can be passed through the SS before tying a nonsliding knot allowing a tendon-to-tendon suture between the SS and the biceps tendon. (A, Anchor; BT, biceps tendon; CH, Cleverhook G, glenoid; HH, humeral head; L, labrum; RF, radiofrequency ablation probe; SS, supraspinatus tendon.)

Fig 3

Illustrations summarizing the steps required to create the 360 double lasso-loop. Posterior view of a right shoulder. Letters correspond to those in the legend of Figure 2. (B) Marking the level of cut of the biceps tendon with a radiofrequency ablation probe (90-S Cruise, Serfas Energy; Stryker). The cross in the upper left corner orients the illustration. (C) An all-suture anchor (Iconix Speed; Stryker) is placed posterior to the biceps tendon. (D) Three of the four sutures are placed in a waiting portal; the remaining strand is pushed anteriorly and medially under the biceps using a suture grasper. (F) A Cleverhook (DePuy Synthes) is passed through the biceps tendon to caught the strand. (G) The suture is retrieved through the tendon making the first loop. (H) The Cleverhook is passed through the loop and driven anteriorly over the biceps tendon to catch the same strand. (I) The strand is retrieved through the loop, making a second loop. (K) The Cleverhook is passed through this second before catching the free strand posteriorly to the biceps. (L) The suture is retrieved through the loop and out of the shoulder. (M) The biceps cut is completed and the suture is tightened: the 360 double lasso loop is done. (N) Then, the sutures can be passed through the SS before tying a nonsliding knot allowing a tendon-to-tendon suture between the SS and the biceps tendon. (A, Anchor; BT, biceps tendon; CH, Cleverhook G, glenoid; HH, humeral head; L, labrum; RF, radiofrequency ablation probe; SS, supraspinatus tendon.)