PMC5420177_01
Clinical picture showing - rupture of the LHB, denoted by a typical 'popeye sign' with a dropped biceps muscle.
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F1
He presented to the emergency department with severe pain in the anterior compartment of his right arm and a "Popeye" deformity, with clear rupture of the long head of the biceps (Figs. 1A, 1B).
Line drawing showing the preferred location for tenodesis of the long head of the biceps (LHB) tendon at the distal bicipital groove (DBG) with an open supra-pectoral technique. SC: Subscapularis; PM: Pectoralis Major.
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F2
The site for drilling is identified at the distal-most aspect of the biceps groove (Fig. 2).
Intraoperative photographs of the Tension-slide technique of proximal biceps tendodesis using an EndoButton reproducing anatomical length-tension relationship. A, The proximal end of the biceps tendon is retrieved through second subpectoral incision; B, Guide wire passed through the distal bicipital groove (DBG); C, making a drill hole with cannulated reamer over the guide wire; D, proximal end of biceps tendon sutured by Krachow suturing technique using No.5 synthetic polyester suture (Ethibond); E, getting sutured biceps tendon through delto-pectoral incision using smallest size foley's catheter; F, passing suture limbs through 4 holed EndoButton; G,The EndoButton is loaded onto the Button deployment device and passed through bone tunnel; H, Pulling on the sutures shuttles the LHB tendon into the humerus; I, end of the procedure showing proximal biceps tenodesis at distal bicipital groove.
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F3
The longitudinal, white tendon of the biceps tendon is identified and pulled out of the incision (Fig. 3A). Care should be taken to avoid skydiving off the edge of the humeral shaft (Fig. 3B). This is followed by drilling the anterior cortex over the guide wire with a calibrated cannulated drill, the size of which is the same as the measured diameter of the tendon (in our case, a 7-mm drill for a 7-mm tendon) (Figs. 3C, 4B). A number-5 synthetic polyester suture (Ethibond Excel, Ethicon Inc; Johnson and Johnson, USA) is woven into the proximal biceps tendon using the Krackow technique or whipstitch suture technique (Fig. 3D). The tendon end to the DBG is retrieved again using the smallest size Foleys catheter (Fig. 3E). The other suture end from the tendon was passed through the terminal two holes of the Endo Button in a reverse manner i.e. from outside in - inside out (Figs. 4D, 7, 3F). The Endo Button is loaded onto the Button deployment device and passed through bone tunnel (Figs. 4E, 3G). The sutures are tensioned until the tendon is in contact with the posterior cortex (Fig. 3H). Finally, we advocate using a free needle to pass one suture through the tendon and tie down to the second suture to reinforce the fixation (Figs. 4F, 3I).
Illustrations of the surgical steps in the Tension-slide technique of proximal biceps tendodesis using an EndoButton reproducing anatomical length-tension relationship A, Passing the guide wire through distal bicipital groove (DBG) B, Reaming the anterior cortex and the intramedullary canal over the guide wire using a calibrated cannulated drill. C, Drilling the posterior cortex over the guide wire using an EndoButton drill. D, Passing suture thread limbs through the 4-holed EndoButton. E, Inserting a threaded EndoButton through the bone tunnel. F, Tightening the suture threads and flushing the EndoButton on the posterior cortex and tying the knot under tension after passing the suture ends through the proximal end of the long head biceps tendon, once it is shuttled through the bone tunnel to reinforce the fixation.
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F4
The guide wire should be stopped as soon as the pin penetrates the posterior cortex (Fig. 4A). This is followed by drilling the anterior cortex over the guide wire with a calibrated cannulated drill, the size of which is the same as the measured diameter of the tendon (in our case, a 7-mm drill for a 7-mm tendon) (Figs. 3C, 4B). Finally, the posterior cortex is drilled through with a 4.5-mm drill to allow for the passage of the cortical button (Fig. 4C). The other suture end from the tendon was passed through the terminal two holes of the Endo Button in a reverse manner i.e. from outside in - inside out (Figs. 4D, 7, 3F). The Endo Button is loaded onto the Button deployment device and passed through bone tunnel (Figs. 4E, 3G). Finally, we advocate using a free needle to pass one suture through the tendon and tie down to the second suture to reinforce the fixation (Figs. 4F, 3I).
Schematic drawing showing location of landmarks in relation to the long head of the biceps. (A) Labral origin; (B) Superior bicipital groove; (C) Distal bicipital groove (DBG); (D) Superior border of pectoralis tendon; (E) Musculotendinous junction (14); and (F) Inferior border of the pectoralis tendon.
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Hereby, we describe a novel technique to estimate the required tendon length and calculate the tendon resection length (Figs. 5, 6, 7).
Illustrations showing method of calculating the required tendon length to reproducing anatomical length-tension relationship. (A) Marking musculotendinous junction; (B) 22mm proximal to mark A; a simple stay suture knot applied at this location with superior border of pectoralis tendon; (C) mark on biceps tendon at DBG level; (D) mark proximal to mark C, at a distance equal to tunnel depth (TD) i.e if TD is 25mm, then mark D is 25mm proximal to mark C; (E) Proximal end of biceps tendon. D-E: is the segment of tendon to be resected. Tendon suturing should be started from mark D and then two suture limbs from tendon passed through the 4 holed EndoButton, as explained above.
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F6
Hereby, we describe a novel technique to estimate the required tendon length and calculate the tendon resection length (Figs. 5, 6, 7). The MTJ is identified and marked (A) (Fig. 6). Another point (marked B) Fig. (6) lies 22mm above the MTJ. Keep the tendon over the tunnel, without any kinking, and mark (C) on the tendon at DBG (Fig. 6). Make another mark (D) on the tendon at a distance equal to measured tunnel depth (TD) (Fig. 6). Hence, the required tendon length for this procedure is A-D (Fig. 6).
Illustrations showing method of calculating the required tendon length to reproducing anatomical length-tension relationship. (A) Marking musculotendinous junction; (B) 22mm proximal to mark A; a simple stay suture knot applied at this location with superior border of pectoralis tendon; (C) mark on biceps tendon at DBG level; (D) mark proximal to mark C, at a distance equal to tunnel depth (TD) i.e if TD is 25mm, then mark D is 25mm proximal to mark C; (E) Proximal end of biceps tendon. D-E: is the segment of tendon to be resected. Tendon suturing should be started from mark D and then two suture limbs from tendon passed through the 4 holed EndoButton, as explained above.
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Hereby, we describe a novel technique to estimate the required tendon length and calculate the tendon resection length (Figs. 5, 6, 7). The other suture end from the tendon was passed through the terminal two holes of the Endo Button in a reverse manner i.e. from outside in - inside out (Figs. 4D, 7, 3F).
(A) Post-operative anterolateral radiograph showing the ideal position of the EndoButton at the posterior cortex of the proximal humerus, in line with the DBG. Clinical images (B) and (C) taken 1-year post biceps tenodesis showing a well healed surgical scar as well as symmetrical muscle bulk.
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Postoperative radiographs were obtained to assess the tenodesis location (Fig. 8A).