Arthroscopic Inlay Biceps Tenodesis Using a Tendon-Docking Anchor

Abstract

Pathology of the long head of the biceps tendon can be treated surgically with a multitude of tenodesis techniques; however, there is a lack of consensus on which technique provides the most optimal outcomes. Commonly used methods include inlay tenodesis with a bone tunnel and interference screw construct and onlay tenodesis with anchors or unicortical buttons. Although current methods typically provide satisfactory outcomes, many surgeons believe complications and failure rates remain suboptimal across techniques. In this article, we present an arthroscopic suprapectoral biceps tenodesis technique using an anchor device that was developed to address the shortcomings of current techniques, optimize outcomes, and minimize risk.

Fig 1

Arthroscopic view from posterior portal with 70° scope in right shoulder. The unsheathed long head of the biceps tendon (arrow) is mobilized into the subacromial space with a grasper. Any remaining tissue in the groove is debrided with a radiofrequency ablation device and/or shaver.

Fig 2

The accessory biceps portal can be located with the triangle method (A) or by use of the sizing guide (B). (A) Exterior view of right anterolateral shoulder in beach-chair position. The triangle method is used to locate the accessory biceps portal by visualizing an isosceles triangle with the anterior portal and lateral portal (red triangle). The tip of the triangle (green circle) indicates the location of the accessory biceps portal. A spinal needle is first inserted and visualized to confirm optimal portal placement. (B) Exterior view of right anterolateral shoulder in lateral decubitus position. The edge of the sizer is aligned with the anterior portal and lateral portal as closely as possible with the same corresponding size lines on either side of the device. The corresponding line length, or position between lines, on the arm of the device indicates the accessory portal location (green circle). In the case shown, the anterior and lateral portals align most closely with the middle lines on the device; therefore, the middle line is marked as the location of the accessory portal. A spinal needle is inserted and visualized to confirm optimal portal placement.

Fig 3

Arthroscopic view from posterior portal with 70° scope in right shoulder. The anterior humeral circumflex vessels (red arrow) traversing the distal bicipital groove can be used as a landmark for the tunnel location. We typically place the bone tunnel approximately 1 cm proximal to these vessels (green circle) in the bicipital groove.

Fig 4

Exterior view of right anterolateral shoulder and extremity. The shoulder and elbow are flexed to aid with exteriorizing a sufficient length of the proximal biceps tendon (arrow) through the accessory biceps portal with a grasper.

Fig 5

Exterior view of right anterolateral shoulder. The exteriorized biceps tendon (red arrow) is marked in a female patient. This is marked approximately 2 to 2.5 cm from the proximal end in female patients and 3 to 3.5 cm in male patients. A second mark (green arrow) is made 2 cm distal to the initial mark.

Fig 6

Exterior view of right anterolateral shoulder. The exteriorized tendon is whipstitched from the distal mark to the proximal mark, and the excess proximal tendon is removed with a No. 11 blade.

Fig 7

Exterior view of right anterolateral shoulder and TIGHT-N sizing guide. The sutured biceps tendon is sized to find the appropriate anchor and reamer. Options include small (5.5 mm), medium (7.0 mm), and large (8.5 mm). In this case, a medium-sized implant (yellow circle) was selected.

Fig 8

Exterior view of accessory biceps portal in right anterolateral shoulder. A malleable sled retractor is placed in the accessory biceps portal (asterisk) as an alternative to a cannula for reaming. The exteriorized tendon (arrow) is pulled to the side and kept under tension during reaming in cases in which the tendon is sutured and sized first.

Fig 9

Exterior view of anterolateral shoulder with prepared implant-tendon construct. The distal portion of the tendon is clamped at the skin to allow for easier management and docking of the tendon to the TIGHT-N device.

Fig 10

Arthroscopic images obtained with 70° scope from posterior portal in right shoulder. (A) Proximal view of loaded TIGHT-N anchor prior to insertion into bone tunnel in the distal bicipital groove. The handle of the inserter is tapped very lightly with a mallet until the implant-tendon construct is inserted to the level of the black line (22-mm mark). (B) View of black line on inserter that is flush with cortical bone surface (yellow star), indicating optimal implant depth. (C) View of completed biceps tenodesis using TIGHT-N implant. (D) View of tunnel aperture filled with marrow elements and blood clot from the tunnel minutes after the tenodesis is completed.