BICEPTOR^◊ Tenodesis System Offers All-Inside Option to Biceps Tendon Repair

The BICEPTOR^◊ Tenodesis System was designed to bring an updated approach to repairing the biceps tendon. The BICEPTOR^◊ Tenodesis System does not require whip stitching the tendon which means fewer steps for an all-arthroscopic repair. The technique allows for increased soft-tissue to bone surface area and avoids the need for tendon resection prior to fixation. The system is designed to be both simple and adaptable to the surgeon’s preference for either a fully arthroscopic or mini-open procedure.

Scoping out Developing the System

In order to better understand both the system and the thought process behind it, Joint Intelligence met with Dr. Scott Trenhaile, MD, (one of the pioneering surgeons for the System) for a quick interview.

JI: What difficulties led you to experiment with a new technique or system for proximal biceps repairs?

Dr. T: Previously, when a tenodesis was needed, I found that soft tissue procedures such as sewing the tendon into the rotator interval or reattaching the tendon with anchors allowed for an arthroscopic approach; however, postoperative protocols did not allow aggressive motion.  Soft tissue-to-bone techniques such as bone tunnels or bone sockets with screws were more effective with immediate fixation to allow motion, but did not allow an all-arthroscopic approach. 

JI: How did you develop the current technique you use with the BICEPTOR^◊ Tenodesis System?

Dr. T: I was looking for a way to get the long head of the biceps into a bone tunnel and fixate it securely without the need to open the shoulder. I also wanted to increase the tendon-to-bone surface area to improve healing and possibly improve fixation as well. I began unroofing the long head of biceps more distally using the arthroscope in the subacromial space and realized that an all-arthroscopic approach may be possible with some specialized instruments.

JI: How has this new technique and BICEPTOR^◊ System helped to alleviate the challenges associated with previous techniques?

Dr. T: Using the BICEPTOR^◊ instrumentation, I am now able to rigidly fixate the tendon to bone using an all-arthroscopic approach without the need to open the shoulder or deliver the tendon out of the body for whip stitching.  The system has eliminated the problem of performing a tenodesis on patients with significant soft tissue mass in the shoulder or intra-operative soft tissue swelling.  Furthermore, the BICEPTOR^◊ tendon fork allows me to adjust the tension on the tendon prior to fixation using the interference screw.  The screw provides rigid fixation while maximizing the amount of tendon-to-bone surface area. The last step in the process is to resect the excess tendon.

JI: What is the learning curve expectation when transitioning to the BICEPTOR^◊ Tenodesis System using an arthroscopic approach?

Dr. T: Performing arthroscopy in the anterior-most aspect of the shoulder can be quite unfamiliar.  When first performing an all-endoscopic tenodesis, I found the most difficult part of the procedure was locating the biceps tendon in the intertubercular groove.  A systematic bursectomy working from superior to inferior through the anterior accessory portal proved most successful.   In addition, incising the transverse ligament is best done from inferior to superior while staying lateral to the biceps tendon.  This step ensures that the dissection is a safe distance from the subscapularis insertion site.  Once the tendon and groove are exposed, the remaining tenodesis steps are very straight forward after one or two cases using the Biceptor^◊ Tenodesis System.

JI: Thank you, Dr. Trenhaile, for taking the time to share this information with us. Continue reading for technique information related to best use of the BICEPTOR^◊ Tenedosis System.

Using the BICEPTOR^◊ Tenodesis System

As described by:
Scott W. Trenhaile, M.D.
Clinical Assistant Professor
Orthopedic Surgery
University of Illinois College of Medicine
Rockford, Illinois

How to complete a successful Biceps Tenodesis Repair using the BICEPTOR^◊ Tenodesis System:

Patient Positioning:
Place the patient in either the lateral decubitus or beach chair position for an all arthroscopic procedure. If an open biceps tenodesis procedure is chosen to be performed place the patient in a modified beach chair position with the head of the bed elevated approximately 30 degrees. Take care to appropriately position the neck and avoid extremes of flexion and extension. Prep the arm and shoulder to allow changes in arm position during the procedure. Alternatively, if the initial arthroscopy is performed in a lateral position, the patient can be turned slightly supine to the operative side to allow access to the operative site.

Portal Placements for diagnostic arthroscopy:
Create standard arthroscopic portals in which a diagnostic arthroscopy may be performed. These portals include a posterior soft spot portal, a rotator interval anterior portal, and possibly an anterior accessory portal. Address glenohumeral joint pathology prior to long head of biceps tenotomy.

Portal placement for arthroscopic biceps tenodesis repair:
A standard lateral portal is established to clear bursal tissue from the joint space and visualize the biceps tenodesis repair. When the biceps is tenodesed and the bursal tissue has been cleared a portal will be established perpendicular to the bicipital grove and biceps tendon to complete the biceps tenodesis repair arthroscopically.  Introduce a spinal needle into the skin until the humerus is engaged. March the needle laterally off the humerus and then back again medially to confirm the intertubercular bicipital groove location.  Introduce an additional cannula and direct it superiorly after encountering the humerus so as to be visualized in the subacromial space.

Portal establishment for a sub-pectoral biceps tenodesis repair:
Make a 4 cm incision beginning at the superior aspect of the axillary fold and running laterally along the medial edge of the biceps muscle.  Carry the incision through the subcutaneous tissue and expose the inferior muscular border of the pectoralis major muscle. Just deep and inferior to the pectoralis, identify the short head biceps muscle belly.  Develop the plane between the pectoralis and short head biceps muscle. Use blunt finger dissection to develop this plane laterally, allowing elevation of the pectoralis muscle. The humeral shaft and bicipital groove can now be palpated. Place a pointed Homan retractor under the pectoralis muscle and over the lateral border of the humerus, providing superior and lateral retraction of the pectoralis muscle. Facilitate this by placing the arm in slight flexion and internal rotation.  Place a small homan retractor along the medial aspect of the humerus to define the medial edge of the bone and to protect the medial structures. Take care to avoid excessive medial retraction which may place the musculocutaneous nerve at risk. At this point, the long head biceps tendon can be palpated just medial to the pectoralis tendon insertion on the humeral shaft.  Use a curved hemostat to open the tendon sheath.  Remove the tendon from the sheath and bring it out into the wound to allow access to the underlying humeral bone.

Below are the six steps required for a successful repair utilizing the BICEPTOR^◊ Tenodesis System:

	Step 1 Arthroscopically place “tagging” suture through tendon. Release biceps tendon from insertion site on glenoid.
	Step 2 Use the tendon forks to estimate the size diameter drill and interference screw to be used for the biceps repair. Drill pilot hole with 2.4 guide wire using tendon fork as drill guide. Remove tendon fork. Ream over guide wire with appropriately-sized reamer (use line-to-line sizing).
	Step 3 Clean up soft tissue around drilled hole. Insert tendon into prepared hole with tendon fork.
	Step 4 Place 1.5 mm tendon pin through tendon fork. Insert bi-grip pin puller on tendon pin and hammer with mallet, pinning tendon in place.
	Step 5 Remove bi-grip pin puller. Remove tendon fork and insert screw over 1.5 mm tendon pin.
	Step 6 If necessary, place bi-grip puller on 1.5 mm tendon pin to assist with pin removal. Trim Tendon.