Arthroscopic suprapectoral biceps tenodesis is a good option for surgeons that are looking for a minimally invasive alternative to open tenodesis. To prevent postoperative bicipital groove pain, the entire groove needs to be released. The below technique provides surgeons a reproducible method to achieve this.
Keywords: Biceps tenodesis, biceps, shoulder pain, biceps tendonitis
? Beach chair.
? Standard posterior viewing portal and anterior working portal. Lateral and anterolateral (AL) portals made under direct visualization.
Diagnostic scope with posterior portal and created anterior portal:
Step 1: Interval exposure: Probe through anterior portal and hook overtop of the biceps and pull it inferiorly toward the subscapularis. This tensions the biceps pully and allows access toward the groove.
Step 2: AL portal: Needle localization through the interval (most AL position) directly onto biceps. Use coablation through this portal to tease the biceps out and resect the interval. Proceed until subacromial space is exposed including the coracoacromial ligament.
Step 3: Tag biceps with suture: Clever hook (R for left shoulder; L for right shoulder) to pierce biceps. Retrieve out anterior portal.
Step 4: Subacromial exposure. Posterior portal with trochar through to anterior portal and back to central. Use (or create) lateral portal and resect bursa with coablation. Switch to lateral viewing portal when biceps are clearly visible and ready to complete preparation.
Step 5: Finish biceps preparation. Identify tag suture. Pull up externally and tease remaining tissue off biceps and expose the groove. Shaver to stimulate bleeding in the groove.
Step 6: Helicoil anchor placement. Pull biceps out of groove with traction stitch and punch/tap/anchor. Retrieve all four sutures out of the posterior portal.
Step 7: Biceps suturing. Retriever to take one limb (blue) and advance inline with the biceps into the glenohumeral joint. Clever hook: to pierce biceps, grab suture, pull just out of biceps remaining intraarticular. Now release suture and pass through the loop created and grab the same suture from below the tendon. Repeat with white suture. Next take the second limb of each suture and pierce biceps with the clever hook and grab both.
Step 8: Tenotomy. Retrieve all sutures through AL portal, then ablate the tendon 1 cm proximal to most proximal suture.
Step 9: Prepare for tying (cannula to avoid soft tissue bridging). Retrieve all four limbs through the posterior portal. Remove cannula from the anterior portal and place in the AL portal directly over the tenodesis site. Retrieve two like sutures at a time.
Step 10: Tie down and pull on each suture limb. One will tighten in cinch fashion. The other will loosen the construct. Use the tightening limb as the post (two same-direction half-hitches; three alternating). Repeat for the second suture.
? Clever hook is useful for shuttling sutures through the biceps.
? Make sure to ?park? the sutures intraarticularly when performing the lasso loop to make them easier to grab.
? Can externally rotate arm to allow better visualization of the groove.
? Must make sure the entire groove is released to prevent post-op pain in the bicipital groove.
? Phase 1: Passive range of motion (about 4 weeks).
? Phase 2: Active range of motion (starts about 4 weeks post-op).
? Phase 3: Strengthening (starts between 6 and 8 weeks post-op).
? See Sanders et al1 and Millet et al (? Video 27.1).2
 Sanders B, Lavery KP, Pennington S, Warner JJ. Clinical success of biceps tenodesis with and without release of the transverse humeral ligament. J Shoulder Elbow Surg. 2012; 21(1):66?71
 Millett PJ, Sanders B, Gobezie R, Braun S, Warner JJ. Interference screw vs. suture anchor fixation for open subpectoral biceps tenodesis: does it matter? BMC Musculoskelet Disord. 2008; 9:121