Mini-open Subpectoral Biceps Tenodesis Using a Suture Anchor

Abstract

The long head of the biceps (LHB) tendon is a potential source of shoulder pain encountered by orthopaedic surgeons. A multitude of approaches to addressing LHB tendinopathy have been described. These include various surgical techniques such as tenodesis versus tenotomy, an arthroscopic versus an open approach, and differing methods of tenodesis fixation. Our preferred approach to addressing LHB tendinopathy is through a mini-open approach using a double-loaded 4.5-mm suture anchor. This Technical Note with accompanying video describes our technique for performing this procedure, as well as supporting clinical evidence and technical pearls.

Figures

Fig 1

The patient is in the beach-chair position with the operative extremity secured distally in a sterile limb-positioning device. The left anterior shoulder is depicted and relevant surface anatomy highlighted. A 3-cm longitudinal incision is made over the anterior arm at the level of the pectoralis major tendon.

Fig 2

The left anterior shoulder is depicted with the patient in the beach chair position. The fascia immediately inferior to the pectoralis major (PM) tendon is incised 2 cm proximally and distally. The PM tendon is bluntly separated from the biceps brachii and retracted superiorly. Next, the tenotomized long head of the biceps (LHB) tendon is retrieved from the incision as shown.

Fig 3

The left anterior shoulder is depicted with the patient in the beach chair position. Two double-bent Homan retractors are placed both laterally and medially across the humerus subperiosteally. A long head of the biceps tendon docking point is selected over the midline anterior humerus 2 cm distal to the pectoralis major tendon along the bicipital groove. A 3.5-mm drill is used to make a unicortical pilot hole in the anterior humerus, followed by a 4.5-mm tap and hand placement of a 4.5-mm Healicoil open-architecture PEEK (polyether ether ketone) double-loaded suture anchor.

Fig 4

The long head of the biceps tendon retrieved from the wound of the anterior shoulder (left is depicted) is evaluated and marked at the proximal and distal borders of the musculotendinous junction (MTJ) with a sterile marking pen.

Fig 5

Intraoperative and artist depictions of a left anterior shoulder. The previously marked borders of the long head of the biceps (LHB) tendon musculotendinous junction (MTJ) serve as the boundaries for suture location. A free needle is used to pass 3 running Krackow stitches of suture A through the lateral aspect of the LHB tendon from the anatomic anterior-to-posterior direction, progressing from proximally to distally. Suture B is passed in a similar locking Krackow fashion over the medial LHB tendon, thus securing both strands of the double-loaded suture anchor to the MTJ of the LHB tendon.

Fig 6

The ends of sutures A and B are tied together and cut after both Krackow stitches are completed to form knot 1, as shown at the anatomic posterior and distal portion of the long head of the biceps (LHB) tendon musculotendinous junction. The remaining ends of the corresponding suture strands of sutures A and B of the double-loaded suture anchor are passed through the Krackow running stitches from the anatomic posterior-to-anterior direction in the LHB tendon.

Fig 7

The left anterior shoulder is depicted with the patient in the beach chair position. The diseased proximal portion of the long head of the biceps (LHB) tendon is excised with scissors at the proximal aspect of the musculotendinous junction border.

Fig 8

The left anterior shoulder is depicted with the patient in the beach chair position. The remaining suture ends of sutures A and B are used to parachute the long head of the biceps (LHB) tendon into the wound back into the anatomic position and secured to the suture anchor docking site by tying the previously passed sutures on the anterior surface of the LHB tendon, creating knot 2.