Biceps repair: Open approaches

Proximal biceps tendon ruptures are most common in individuals 40 to 60 years of age and often are due to impingement or chronic microtrauma on the tendon. These injuries also may occur in younger individuals during heavy weightlifting or other sports activities (e.g., football, rugby, soccer, snowboarding) or in a traumatic fall. Tenodesis techniques range from open to mini-open to all-arthroscopic. Fixation can be done with suture anchors, interference screws, or bone tunnels.

Subpectoral biceps tenodesis

With the patient in the beach chair position, perform a standard diagnostic arthroscopic examination.
Identify the rotator interval between the supraspinatus and subscapularis tendons and make a standard anterior portal from inside-out or outside-in.
With a probe in the anterior portal, pull the biceps tendon into the glenohumeral joint to evaluate its mobility and any structural lesions. Because pathologic processes of the biceps tendon are most often in the intertubercular groove portion, it is critical that this part be drawn into the joint.
Evaluate the coracohumeral ligament and supraspinatus and subscapular tendons for any pathologic process.
With an arthroscopic cutting instrument or thermal ablator through the anterior portal, tenotomize the biceps tendon at its base. A shaver can be used to debride the proximal portion for a stable base.
With the arm abducted and internally rotated, palpate the inferior border of the pectoralis major tendon. On the medial aspect of the arm, make an incision 1 cm superior to this inferior border and continue it to 3 cm below the inferior border ( Fig. 22.1 ).
Inject the incision site with a local anesthetic plus epinephrine for subcutaneous hemostasis and perioperative analgesia.
Dissect through the subcuticular tissue, using electrocautery to control bleeding, and clear the overlying fatty tissue until the fascia overlying the pectoralis major, coracobrachialis, and biceps is identified. If these anatomic landmarks are not seen, the dissection may be too lateral. If the cephalic vein is seen in the deltopectoral groove, the dissection is too proximal and too lateral.
Once the inferior border of the pectoralis major has been identified, incise the fascia over the coracobrachialis and biceps in a proximal to distal direction. It is important to see the horizontal fibers of the pectoralis muscle and dissect below this level.
Use blunt finger dissection under the inferior edge of the pectoralis muscle, palpating up the anteromedial humerus, to identify the longitudinal, fusiform structure of the biceps tendon.
Place a pointed Hohmann retractor into the pectoralis major tendon and on the proximal humerus to retract the muscle proximally and laterally ( Fig. 22.2 ).
Position a blunt Chandler retractor on the medial aspect of the humerus and gently retract the coracobrachialis and short head of the biceps tendon. Avoid vigorous medial retraction to prevent injury to the musculocutaneous nerve.
Once the biceps tendon is identified, place a right-angle clamp deep to it and pull the tendon into the wound ( Fig. 22.3 ).
One centimeter proximal to the pectoralis major tendon reflect the periosteum in a rectangle roughly 2 × 1 cm.
To ensure appropriate tensioning of the biceps tendon, resect the proximal portion to leave 20 to 25 mm of tendon proximal to the musculotendinous portion of the biceps.
Using a Krackow or whip stitch, weave a no. 2 nonabsorbable suture into the proximal 15 mm of the tendon. Secure enough of the tendon to ensure adequate interference fixation within bone and to position the musculotendinous portion of the biceps muscle beneath the inferior border of the pectoralis major tendon. This is critical for proper tensioning of the muscle-tendon unit as well as for cosmesis ( Fig. 22.4 ).
Use a guidewire and an 8-mm reamer to make a 15-mm deep bone tunnel at the junction of the middle and distal thirds of the intertubercular groove between the lesser and greater tuberosities ( Fig. 22.5 ).
Clear all debris from the field with irrigation.
Thread one limb of the suture through a biotenodesis screwdriver and screw (8 × 12 mm) and wrap the end of the suture into the screw cleat.
Place the tenodesis screwdriver into the bone tunnel and advance the screw over the tendon. When the screw is flush with the bone tunnel, remove the screwdriver.
Tie the limb of the suture next to the tendon and screw to the limb of the suture through the screw to provide both an interference fit and suture anchor stability ( Fig. 22.6 ).
When the fixation is completed, the musculotendinous junction should rest in its exact anatomic location underneath the inferior border of the pectoralis major tendon.
Complete the procedure with standard wound closure.