Long Head Biceps
Arthroscopic SLAP Repair
Technique
1. Establish portals
A. Posterior portal for viewing
B. Anterior portal
- need to keep low and away from biceps, otherwise difficult to get around biceps
- for suture passage, if in combination with bankart repair often use AI portal instead of AS
C. Anterosuperolateral portal / Wilminton for insertion of anchors
- insert spinal needle first
- anterolateral border acromion
- needs to be close to acromion to get angle over humeral head
- check with needle
- need best angle to insert anchors to anterior and posterior aspect of biceps
- passes through supraspinatous
- use knife to cut in line with fibres
- insert portal
2. Prepare insertion
- shaver via anterior portal
- debride frayed labrum
- mobilise biceps tendon
- debride bony base to create ledge and bleeding bone
3. Anchors
Drill and insert via Wilminton portal
Usually 3 anchors is a minimum
Technique
- insert anchor
- suture through each cannula
- limb through W portal will be the suture limb that is passed
- suture passer through anterior portal (right angled for left shoulder)
Anterior anchor
- best to pass the suture passer above the biceps to get good bite
- retrieve sutures and tie from port of Wilmington
Posterior 2 anchors
- pass suture passer under biceps
Can suture Portal of Wilminton if desired
4. Dfficult posterior anchors
Camera through anterior / anterosuperiorlateral portal
A. Place anchor through posterior portal
- does not always give good angle
B. Trans infraspinatous Portal
Biceps Tenodesis
Options
Arthroscopic
- intra-articular
- suprapectoral
Open
- suprapectoral
- subpectoral
A. Arthroscopic Intra-articular
Concept
- suture biceps to superior capsule using figure 8 no 2 non absorbable
Technique
- anterior portal + portal of Wilmington
- debride capsule and biceps with shaver so will heal
- use curved suture passer with no 1 PDS
- suture shuttle no 2 fibre wire
- divide 90% biceps insertion so will rupture in time
- allows healing of biceps to capsule
Attempt Figure 8 Suture Configuration
B. Arthroscopic Suprapectoral Technique
1. Secure Biceps Tendon - allows tensioning and prevents losing tendon
A. Birds Beak Passer with 2 ethibond loop
- pass loop through intact tendon at entry through RC interval
- retrieve loop out through portal and lock
- this gives strong hold on tendon
B. Pass 18 G spinal needle through biceps tendon
- thread 1 PDS or nylon
- retrieve both suture ends via portal in rotator interval
- secure with half hitches
- pass 1 loop of PDS about entire tendon and tie again
2. Resect tendon with electrocautery at insertion
3. Make portal over biceps interval into subacromial space
- release biceps tendon with electrocautery or arthroscopic scissors
4. Secure tendon
- make drill hole
- insert tendon
- secure with biotenodesis screw
- multiple techniques with specifically designed equipment
C. Open Technique for Intact Biceps
1. Divide biceps arthroscopically
- may wish to place stay suture first to avoid retraction
- biceps normally has vinculae preventing complete retraction into arm
2. Suprapectoral
- deltoid split
- between anterior and middle parts
- find biceps in groove
- pull out of wound and whip stitch with heavy suture
- drill appropriate size tunnel for fixation screw
- multiple biceps tenodesis devices
- push the tendon into the hole, then fixate with screw
3. Subpectoral
- medial incision in arm
- below inferior edge of pectoralis major
- find biceps tendon
- whip stitch
- pass through drill holes / secure with screw / secure with anchor
D. Open Technique for Ruptured LHB / Popeye in young patient
1. Locate biceps
Options
A. Suprapectoral
- best to make deltopectoral approach
- biceps may be futher retracted
B. Subpectoral approach
2. Fixation
SLAP lesion
Definition
Superior labrum anterior & posterior
Injury to superior part of glenoid labrum involving region of biceps tendon insertion
Epidemiology
2 groups
1. Young patients
- most common in young males
- fall / trauma
- also associated with glenohumeral instability
2. Older patients
- have rotator cuff tear or other pathology
- don't repair in this group
- tenotomy / tenodesis
Aetiology
Three mechanisms
1. Compression force applied to GHJ
- FOOSH
- commonest
- arm in abduction & forward flexion
- head subluxes superiorly over glenoid edge & detaches labrum by shear & compression
2. Traction on Arm
- sudden pull on arm
- grab while falling
3. Overhead motion
- throwing thlete
- repetitive microtrauma due to eccentric loading
History
Pain with overhead activities
Catching or popping with overhead activities
Acute trauma
Mimics impingement
Examination
Speed's Test
Yergason's Test
O'Brien's test
Causes impingement of biceps on anterosuperior labrum
1. Shoulder flexed 90o in plane of scapula
- adducted 30-45o / max IR
- i.e. thumb down
- resisted elevation produces pain
2. Relieved when same again but with ER
- i.e. no pain with thumbs up
McMurray's Shoulder test
Compression-Rotation test
- patient supine
- shoulder abducted 90°, elbow flexed 90°
- compression force to humerus and humerus rotated
- attempt to trap torn labrum
- positive if pain & click
MRA
See fluid up under biceps insertion
- note: difficult to distinguish pathological v normal variant
Supralabral ganglion cyst
- associated with posterior SLAP tears
Normal Arthroscopy
Arthroscopic Classification Snyder
Type 1 (10%)
- fraying & degeneration of the edge of superior labrum
- firmly attached labrum and biceps anchor
Type 2 (40%)
- Superior labrum + Biceps tendon stripped off glenoid
Subtypes
- anterior
- posterior
- anterior and posterior
Type 3 (30%)
- bucket handle tear of superior labrum
- displacement of labrum into joint
- biceps tendon attached to glenoid
Type 4
- bucket handle tear of superior labrum with part of biceps
- extension into biceps tendon which remains attached but with partial tear
Type 5 - 7 added by Gartsman
Type 5
- SLAP 2 with anterior bankart extension
Type 6
- SLAP 2 with free flap of meniscal tissue
Type 7
- Slap 2 with anterior bankart extension and into MGHL
Normal Variations of the Superior Labrum
The superior labrum can be mobile
- normal cartilage extending over the tubercle
- no evidence of trauma
- the labrum and biceps is firmly attached to the tubercle
- this is not pathological
- do not repair
Davidson et al Am J Sports Medicine 2004
- described normal variations
1. Triangular
2. Bumper
- lump of fibrous tissue
3. Meniscoid
- labrum extends down over glenoid face
Management
Non Operative
Trial
- physio
- HCLA
Operative
Arthroscopic diagnosis
- high level of pre-operative suspicion
- must establish is pathological
- treated at time of arthroscopy
Options
1. Debridement of frayed labrum / Type 1 & 3
2. Repair superior labrum and biceps / Type 2
3. Biceps tenodesis
4. Tenotomy
Issues
1. Older patient with RC tear and SLAP
Francheschi Am J Sports Med April 2008
- RCT patients with SLAP and RC > 50
- tenotomy v SLAP repair in setting RC tear
- improved ROM and functional scores in tenotomy group
2. Repair v Tenodesis Type II SLAP
Boileau et al Am J Sports Med May 2009
- compared cohort arthroscopic repair v arthroscopic tenodesis in overhead athletes (Level 3 evidence)
- repair group 40% satisified, 20% returned to previous level of sport
- tenodesis patients 93% satisified, 87% return to previous level of sport
Altcheck et al JBJS Am 2009
- case series of 37 athletes with SLAP 2 repair
- 87% rated outcome as good or excellent
- 75% able to return to previous level of sport
- this was higher (92%) if athlete described a discrete traumatic event
3. SLAP and instability in young patient
- SLAP lesions can cause instability
- a SLAP lesion can contribute to inferior instability
- a SLAP and a Bankart can co-exist
Management Algorithm
Type 1
Debride labrum
Type 2
A. Arthroscopic repair
B. Tenotomy / tenodesis
Type 3
Debride bucket handle labrum
Type 4
Remove labral flap
Repair / debride / tenodesis biceps
- may be evidence that do better with tenodesis
Types 5 - 7
- associated with instability
- repair as per treatment of instability
Tendinosis / Rupture / Subluxation / Hypertrophy
Function
LHB primary function is humeral head depressor
Also accelerate / decelerate arm in overhead sports
Problems
Biceps problems usually occur with other pathology
- rotator cuff / instability
3 main problems
1. Degeneration
- "Tendinosis"
- usually associated with impingement
- can lead to rupture
Rupture
- rarely associated with weakness
- 80% flexion strength from brachialis and short head biceps
2. Instability
Stability contributed by
- transverse humeral ligament
- coracohumeral ligament
- superior GH ligament
Almost always associated with cuff tears
- SS tears
- medial subluxation with SSC tear
Lafosse et al Arthroscopy 2007
- biceps can be unstable anteriorly or posteriorly
- anterior with SSC tears
- posterior with SS tears
3. Disorders of the origin (SLAP)
4. Hourglass Biceps
Wiley etal J Shoulder Hand Surg 2004
- thickened intra-articular portion biceps
- unable to travel in groove
- with forward flexion of arm, arthroscopically see bunching of biceps
- requires double release / tenotomy / tenodesis
Anatomy
Origin
- from postero-superior labrum and supraglenoid tubercule
Tendon is intra-articular
- passes deep to CH ligament, through rotator interval
- enters bicipital groove, beneath transverse humeral ligament
Examination
Tenderness over biceps tendon crucial
Rupture
- Popeye appearance
Speed's
- forward flexed shoulder against resistance
- elbow kept extended and supinated
- feel pain or palpate tenderness
Yergason's
- elbow flexed and pronated
- resist supination
- pain over LHB
O'Brien's / SLAP
- arm forward flexed and adducted in plane of scapula
- point thumb down and resist downwards force
- this generates pain
- no / less pain with thumb up
MRI
Normal
Tendonitis
Tendonosis / thickening
Medial Subluxation
Arthroscopy
Normal
Mild Tendonopathy
Moderate Tendonopathy
Severe Tendonopathy
Dislocated Biceps in Presence of complete SSC Rupture
Management
1. Tendonitis
Non Operative
As per rotator cuff / impingement
- HCLA
- physio
Surgical Options
1. SAD
2. Manage rotator cuff pathology
3. Consider for inflamed but intact LHB
- release THL
- spare CH ligament
2. Tendon Fraying / Tendinosis / Rupture
Grade tendon integrity
I Minor fraying <25%
II Fraying 25-50%
III Fraying >50%
IV Complete rupture
Management Strategy
I & II
- SAD & debride tendon
III & IV
- SAD & biceps tenodesis / tenotomy
Tenotomy v Tenodesis
Frost et al Am J Sports Medicine April 2009
- reviewed all articles on tenotomy / tenodesis
- concluded that there is no evidence for superiority of one over another
Koh et al Am J Sports Med 2010
- tenotomy v tenodesis in setting RC tears
- 9% popeye in tenodesis (suture anchor) and 27% in tenotomy
- no other difference in terms elbow flexion power / shoulder scores
Tenotomy
Popeye deformity
Lim et al Am J Sports Med 2011
- incidence of pop-eye of 45% post tenotomy
- more common in men
Cosmetic deformity acceptable in elderly
- not in young
- avoided by tenodesis
Strength
Shank et al Arthroscopy 2011
- no evidence of decreased elbow flexion or supination strength
Tenodesis
Indications
- young patient grade II, III, IV
- slim arm (where popeye would cause significant cosmetic problem)
Issues
- screw prominence / pain
- failure of fixation
Options
- arthroscopic
- open
- see techniques
Arthroscopic
Soft tissue or bony fixation
- in inter-tubercular groove
- suprapectoral
Sheibel Am J Sports Med 2011
- soft tissue v bony anchor fixation
- superior cosmetic and functional outcome with bony
Open
Suprapectoral or subpectoral
Nho et al J Should Elbow Surgery 2010
- 353 patients treated with subpectoral bioabsorbable tenodesis screw
- 2% complication rate
- 2 patients with popeye
- 2 with tenderness over screw
- 1 deep infection
- 1 MCN injury
3. Subluxation
Issues
Usually medial from SSC tear
- must manage LHB or SSC repair will fail
Options
1. Tenodesis / Tenotomy + SSC repair
2. Stabilisation + SSC repair
Issue
- can get stenosed painful tendon
Maler et al JBJS Am 2007
- 21 patients with traumatic tear of SSC treated within 6 weeks
- open SSC repair and LHB stabilisation
- 7 had symptoms of mild tenodinopathy
- 2 recurrent instability and 1 rupture on US