28 Transosseous Arthroscopic Biceps Tenodesis

Brett Sanders


Transosseous tendon repair techniques have been established as safe and effective in the rotator cuff. Tenodesis in the suprapectoral location is believed to yield the same pain relief as other tenodesis methods and locations, without the risk of a subpectoral wound complication. This chapter presents a fully transosseous biceps tenodesis in the suprapectoral location utilizing tendon grasping suture techniques with multi-point fixation. This technique can be used during cuff repair to perform biceps tenodesis at physiologic length and tension while decreasing hardware cost.

Keywords: biceps, tenodesis, transosseous biceps tenodesis, suprapectoral

28.1 Patient Positioning

Beach chair position with mechanical arm holder.

28.2 Portal Placement

The previously described midlateral is used for viewing and the anteroinferolateralportal is used for instrumentation.

28.3 Surgical Technique

? The biceps sheath is released with an ablator just above (? Video 28.1) the anterior circumflex humeral artery.

? A posterior grasper is introduced to bring the biceps out to the physiological length tension relationship.

? Two medial awl tunnels are made in the biceps groove in the suprapectoral location. The bone here is usually of excellent quality.

? The tunneler is used to create the inferior tunnel, leaving the suture doubled.


Video 28.1 Arthroscopic Transosseous Biceps tenodesis is demonstrated in the right shoulder in beach chair position. The biceps is secured with multi-point cerclage suture fixation in the suprapectoral location at physiologic length and tension in anchorless fashion.

? A low inferomedial and anterior portal is used to retrieve the suture through the biceps tendon in a retrograde fashion and create a locking loop, grasping the lateral limb through the loop. The sutures are then retrieved and tied through the infero anterolateral portal.

? The superior tunnel passing suture is then deployed in a similar fashion, and the same inferomedial portal is used to retrieve the double loop through the biceps tendon, leaving the loop long.

? A grasper is placed through the anterior portal, through the loop, and it is used to stabilize the biceps tendon in its physiologic location proximally. A posterior grasper is then used to bring the loop over the end of the biceps, creating a circumferential suture.

? The inferomedial portal is then used again to retropass a suture through the circumferential loop, and this suture is used to tie to the lateral post.

? The remaining biceps is then transected and the tendon ends are annealed with the ablator.

28.4 Tips and Tricks

? Forward flexing the arm aids in visualization under the deltoid.

? Internal rotation once the tunneling device is introduced allows easier tunnel creation.

? The tensor TransOs Tunneler is utilized to arthroscopically create reproducible tunnels with strong compact bone tunnels.

28.5 Pearls and Pitfalls

The anterior circumflex humeral artery is at risk for injury and can create bleeding intraoperatively. Occasionally a subchondral cyst may exist under the biceps groove; however, the tunnel can be created through it in the standard fashion.

28.6 Rehabilitation

No active elbow flexion or forearm supination is allowed for 4 weeks. Gravity extension and pendulums only.

28.7 Rationale

Multiple different biceps tenodesis techniques may be used to create the same clinical pain relief, including suprapectoral tenodesis. It has been suggested that releasing the biceps sheath is beneficial to remove the pain-generating elements of the synovium or other neural elements. The described technique avoids a separate incision in the axilla, which can be prone to infection or dehiscence, and also avoids the extra expense of another bone anchor.1 Multiple fixation points are achieved in the hardest bone of the humerus, and tendon-grasping sutures allow a high strength construct that may be tightened independently. The technique is all arthroscopic with no extra instrumentation and does allow formal release of the entire biceps sheath.


[1] Sanders B, Lavery KP, Pennington S, Warner JJP. Clinical success of biceps tenodesis with and without release of the transverse humeral ligament. J Shoulder Elbow Surg. 2012; 21(1):66?71