Updated: 1/13/2020
CPT Codes: 29828 Arthroscopy, shoulder, surgical; biceps tenodesis

Arthroscopic Biceps Tenodesis

TECHNIQUE STEPS
Preoperative Patient Care
Operative Techniques
D

Simulation

1

Cadaveric demonstration of surgical approach and therapeutic skill

2

Sawbones demonstration of proper instrumentation

E

Preoperative Plan

1

Evaluate radiographs and MRI

  • Biceps tendon or labral pathology (SLAP tear) that indicates a tenodesis procedure.

2

Perform exam under anesthesia

3

Execute surgical walkthrough

  • describe steps of the procedure verbally to the attending prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Make sure tower working

  • 30° arthroscope
  • fluid pump system
  • standard arthroscopic instruments
  • suture passing devices
  • suture retrieving devices
  • knot tying devices
  • arthroscopic shavers and burrs
  • radiofrequency (RF) ablation wand
  • suture anchors

2

Room setup and Equipment

  • standard OR table for lateral decubitus position

3

Patient Positioning
(lateral)

  • place patient in the lateral decubitus position
  • pad any prominences of the extremities
  • position the head and neck in neutral alignment
  • support the head with a foam head cradle
  • protect the eyes with tape
  • place an axillary role under the upper chest to protect the lower shoulder and axilla
  • ensure the entire scapula is free from the edge of the table
  • support the arm with the Meisel mitten in the arthroscopy position with 10 pounds of traction
  • prep and drape the arm in the usual fashion for shoulder arthroscopy
G

Scope Insertion

1

Outline landmarks

  • Outline the acromion, distal clavicle, coracoid process and biceps tendon

2

Place posterior portal

  • Mark portal 2 to 3 cm distal and 1 to 2 cm medial to the posterior lateral tip of the acromion
  • Make 4mm skin incision
  • Place scope cannula with a blunt trocar into the incision and enter the joint.
  • use lateral traction to avoid damage to the articular surface
  • Place the 30° arthroscope.

3

Place anterior portal

  • Halfway between acromioclavicular joint and the lateral aspect of the coracoid
  • Pierce the anterior fibers of the deltoid and enter the joint in the interval between the supraspinatus and subscapularis
H

Diagnostic Arthroscopy

1

Perform diagnostic arthroscopy

  • 1. Biceps tendon and biceps anchor
  • 2. Posterior labrum and posterior capsular pouch
  • 3. Inferior capsular pouch and inferior aspect of the humeral head (? osteophyte)
  • 4. Glenoid articular cartilage
  • 5. Articular surface of the rotator cuff and rotator cuff crescent
  • 6. Posterior rotator cuff attachment and bare area of the humeral head (?Hill-Sachs lesion)
  • 7. Biceps Tendon
  • 8. Anterior superior labrum and rotator interval
  • 9. Subscapularis tendon and Middle Gleno-Humeral ligament
  • 10. Anterior-Inferior labrum and ligaments

2

Insert the scope in the anterior portal and perform the final 5 points of the 15-point exam

  • 11. Posterior labrum and posterior inferior capsule
  • 12. Posterior superior capsule and posterior rotator cuff tendon
  • 13. Anterior inferior labrum and ligaments
  • 14. Subscapularis tendon and subscapularis recess medial to the glenoid
  • 15. Anterior surface of the humeral head and subscapularis attachment

3

Debride tissues

  • Debride synovitis and cartilage lesions
I

Intra-Articular Biceps Management

1

Start tenodesis in glenohumeral compartment

  • pierce biceps tendon with spinal needle coming into the joint from the anterior lateral acromial border, though the rotator cuff interval, and through the biceps tendon
  • after pierced and held, cut tendon at anchor with curved scissors.
  • leave spinal needle in place to the end of the procedure to hold and anchor the tendon
  • debride tendon stump and labrum with shaver
J

Subacromial Space Management

1

Perform subacromial bursectomy

  • Move trocar into SAS
  • slide the trocar under the acromiom over the posterior rotator cuff
  • sweep under the acromiom through the lateral gutter to break up adhesions

2

Identify the CC ligament

  • found on the anterior aspect of the subacromial space

3

Reposition the anterior cannula

  • Push the trochar through the anterior portal, slide anterior cannula over, insert camera, now camera and ant trochar in subacromial space.

4

Perform a Bursectomy

  • Use the shaver to perform a lateral and anterior bursectomy through anterior portal
K

Tendon Preparation

1

Move camera to posterior lateral portal

  • Use spinal needle to make a posterior lateral portal just off the acromion.
  • this allows for visualization down into the bicipital groove in the humerus

2

Make stab incision

  • use switching sticks to place camera into posterior lateral portal, place canula into the original posterior portal

3

Localize biceps tendon in groove and create a portal over tendon

  • use pre-operative biceps marking as guide
  • make stab incision approximatly 1/2 down to axilla

4

Insert shaver for further bursectomy

5

Measure for passport cannula

  • Measure and place passport cannula centered over tendon in groove

6

Release the roof of the bicipital grove

  • Use shaver or RF to feel the tendon, and start by releasing lateral
  • careful to not cut tendon itself

7

Size the tendon

  • Use tendon sizer
  • most common size is 7mm & 8mm

8

Isolate tendon medially

  • Use tendon sizer to push tendon medial and place a spinal needle into it to hold position
L

Implant Fixation

1

Drill Potting hole

  • Use a piloted reamer that is 5mm larger than the selected implant

2

Remove spinal needle holding tendon medially

  • Tendon will return to position above the hole

3

Implant biceps specific forked screw and tendon

  • Push forked screw implant into passport and down onto tendon above the hole
  • Place tension with forked implant
  • Implant until screw is flush with cortex
  • will have tension via proximal spinal needle holding it
  • Remove the proximal spinal needle
  • Screw down implant and fix tendon

4

Debride the remaining tendon

  • Use curved scissors to cut remaining tendon and remove with grasper through passport
  • Use shaver or RF to debride down remaining stump
N

Wound Closure

1

Closing the portals and dressing the incisions

  • withdraw the instruments

2

Close the incisions with a single subcuticular stitch

  • use 4-0 monocryl suture

3

Apply steristrips

4

Place dressings

  • place Prowicks sponges that are primed with liquid betadine solution over the incisions
  • place and wrap Prowick dressings over the incision
  • cut the arm portion of the wrap to relieve pressure around the axilla and upper humerus.

5

Place sling

  • support the patients arm in an regular sling.
Postoperative Patient Care
 

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