26 Identifying and Exposing the Proximal Biceps in Its Groove: The ?Slit? Technique

Mark R. Wilson, Eric D. Field, and Larry D. Field

Summary

Proximal biceps tendon pathology is a common source of shoulder symptoms. Thus, visualization of the entire extent of the biceps tendon is often required for both diagnostic and therapeutic purposes. Accurately recognizing the presence and extent of biceps pathology intraoperatively is made more difficult, however, due to the extraarticular location of a significant portion of the biceps tendon as it courses within the bicipital groove. Unfortunately, identification of the biceps groove in the subacromial space is often challenging due to the lack of visual and tactile landmarks. A technique coined the ?slit? technique that facilitates efficient and reliable bicipital groove identification and biceps tendon visualization along its entire course within the groove is presented.

Keywords: biceps exposure, biceps tendonitis, biceps tenodesis, slit technique, SLAP tear

26.1 Patient Positioning

Both beach chair and lateral decubitus positions are acceptable.

26.2 Portal Placement

? Standard posterior portal placed initially for diagnostic arthroscopic evaluation.

? Anterosuperior glenohumeral portal and subsequently a subacromial lateral portal is created.

? Anterior and posterior subacromial accessory portals are created as needed.

26.3 Surgical Technique

? The patient is positioned in the beach chair position and prepped and draped in usual sterile fashion.

? A standard posterior glenohumeral joint?viewing portal is created initially, and a 30� arthroscope is used.

? Next, a standard anterosuperior working portal that is centered within the rotator interval is made. A thorough diagnostic arthroscopy is then completed.

? The biceps tendon is carefully evaluated by probing the superior labrum and proximal origin of the biceps tendon and by palpating the biceps tendon.1 Also, as much of the biceps tendon as possible is pulled into the glenohumeral joint using this probe in an effort to assess the tendon for fraying, tearing, synovial reaction, and instability.1

? If the entire proximal biceps tendon requires visualization, either because of concern about pathology within the more distal portion of the biceps tendon that cannot be visualized by pulling the tendon into the glenohumeral joint or when a suprapectoral tenodesis is planned, the authors? ?slit? technique is routinely employed.2

? This technique simply and reliably exposes the location and vertical orientation of the bicipital groove while still allowing the arthroscope to remain within the glenohumeral joint using standard arthroscopic equipment.

? First, an 18-gauge spinal needle is inserted into the anterior shoulder approximately 3 cm lateral to the previously placed anterosuperior portal cannula and advanced until the spinal needle is arthroscopically identified within the bicipital groove at the location where the biceps exits the glenohumeral joint (? Fig. 26.1).

? This spinal needle location and trajectory are then used as a guide to allow the surgeon to direct a percutaneously placed standard knife handle loaded with a #11 scalpel blade through the skin. It then advances through the anterior soft tissues in a parallel path until the tip of the scalpel blade is identified as it perforates the proximal aspect of the transverse humeral ligament overlying the bicipital groove (? Fig. 26.2).

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Fig. 26.1 An 18-gauge spinal needle (white arrow) is seen percutaneously localizing the biceps tendon(BT) in this left shoulder in the beach chair position as viewed from the posterior portal. This spinal needle penetrates the most proximal aspect of the tissue overlying tendon as it enters the bicipital groove. SS, supraspinatus; HH, humeral head; SubS, subscapularis; white arrow, 18-gauge spinal needle.

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Fig. 26.2 The tip of the #11 scalpel blade (white arrow) is advanced through the tissue overlying the proximal aspect of the bicipital groove in a left shoulder in the beach chair position as viewed from the posterior portal. SS, supraspinatus; HH, humeral head; BT, biceps tendon; white arrow, #11 scalpel blade.

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Fig. 26.3 The incised tissue or ?slit? (white arrow) in the proximal aspect of the transverse humeral ligament overlying the bicipital groove is seen in a left shoulder in the beach chair position as viewed from the posterior portal. RC, rotator cuff; BT, biceps tendon; white arrow, slit in the transverse humeral ligament overlying the biceps.

? This scalpel blade is then directed distally, while viewing arthroscopically from the posterior portal, following the course of the biceps tendon to create a split or ?slit? in the transverse humeral ligament. Also, care is taken to avoid damage to the biceps tendon as this slit is created and enlarged. Slight forward flexion of the shoulder can sometimes improve visualization within the biceps groove as the incision proceeds more distally.

? Typically, 2?3 cm of the overlying transverse humeral ligament is easily incised (? Fig. 26.3). Care should be taken to minimize iatrogenic damage to the underlying biceps tendon as the slit is extended.3,4

? This incision in the transverse humeral ligament will then be easily and reliably identified arthroscopically once the arthroscope is subsequently redirected into the subacromial space.

? When arthroscopic suprapectoral biceps tenodesis is to be carried out, the authors generally employ suture anchor fixation by impacting a suture anchor into the abraded bicipital groove while viewing from the subacromial space. However, prior to transferring the arthroscope to the subacromial space, the most proximal aspect of the biceps tendon is released from its origin at the superior glenoid except for a very small, residual portion of the biceps tendon that is left intact (? Fig. 26.4) until the suture anchor sutures are passed through the biceps tendon and tied.

? Following arthroscopic knot tying, detachment of this small residual intact portion of the biceps tendon is completed, often with a gentle distal tug on the tendon using a standard arthroscopic grasper. These few fibers of the proximal biceps are intentionally left intact by the authors so as to preserve anatomic biceps length until the tenodesis is completed.

? Following completing this partial release of the proximal biceps tendon, the arthroscope is then transferred to the standard posterior subacromial portal site.

? Next, a lateral subacromial working portal is created and used to accomplish a thorough subacromial bursectomy. The arthroscope is then moved to this lateral subacromial portal site and, with slight external rotation of the glenohumeral joint, the previously placed ?slit? incision in the transverse humeral ligament along with the exposed biceps tendon can be clearly visualized (? Fig. 26.5).

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Fig. 26.4 The proximal biceps tendon(BT) is nearly, but not completely, released prior to biceps tenodesis as seen in a left shoulder in the beach chair position viewing from the posterior portal. Leaving a very limited amount of residual tendinous tissue intact (white arrow) ensures that the anatomic length of the biceps is preserved during tenodesis using a suture anchor technique at the bicipital groove. Following completion of the tenodesis, the remaining tendon is then freed usually by simply tugging on the biceps. GL, glenoid/labrum; HH, humeral head; *arthroscopic suture scissors.

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Fig. 26.5 The slit (black arrow) is easily located while viewing from the lateral portal in the subacromial space after a standard bursectomy is performed in a left shoulder in the beach chair position. SS, supraspinatus; DF, deltoid fascia; black arrow, slit created over the biceps tendon.

? The #11 blade scalpel (? Fig. 26.6) or an arthroscopic shaver blade can then be used to incise the more distal portion of the transverse humeral ligament and other tissue overlying the biceps tendon so as to expose them along the length of the biceps.

? A probe can then be used to manipulate the biceps and further assess it for synovial reaction, fraying, or partial tearing (? Fig. 26.7).

? Once the biceps tendon has been thoroughly evaluated, the surgeon can then proceed with suprapectoral tenodesis, if indicated, using the fixation method of choice.

? Again, the authors? preferred tenodesis technique usually utilizes a double- or triple-loaded suture anchor(Healicoil Regenesorb 4.5 mm, Smith & Nephew) inserted into the bicipital groove followed by passage of these sutures through the biceps tendon using a locking-loop construct (? Fig. 26.8, ? Video 26.1).

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Fig. 26.6 While viewing from the lateral portal in the subacromial space in a left shoulder in the beach chair position, the #11 blade(white arrow) is used to incise the more distal tissue overlying the biceps(*) until the tendon is completely unroofed and exposed. SS, supraspinatus; DF, deltoid fascia; white arrow, #11 scalpel blade; *biceps tendon below the slit.

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Fig. 26.7 Visualizing and probing (*) the entire biceps tendon (BT) is carried out after the incision of the tissue overlying the biceps is completed. Note the significant fraying (white arrow) of the very distal aspect of the biceps tendon that was not able to be identified when visualized intraarticular. This image is taken of a left shoulder in the beach chair position while viewing from the lateral portal in the subacromial space. DF, deltoid fascia, *arthroscopic probe; white arrow, frayed/degenerative biceps tendon.

26.4 Surgeon Tips and Tricks

? Near complete, but not complete, sectioning of the biceps from its attachment on the superior labrum helps keep accurate tension when performing tenodesis.

? Accurate trajectory of the spinal needle in all planes is key for both creating a good ?slit? and for creating an accessory portal that provides maximum access to the biceps groove.

? Slight forward flexion of the arm can help visualization while extending the slit distally when viewing from the joint in the posterior portal.