Long Head Biceps

Arthroscopic SLAP Repair

Shoulder Scope SLAP 2

 

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

 

SLAP repair anterior portal

 

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

 

SLAP Repair Port WilmingtonShoulder Portal WilmingtonShoulder SLAP Repair Portals

 

2.  Prepare insertion

- shaver via anterior portal

- debride frayed labrum

- mobilise biceps tendon

- debride bony base to create ledge and bleeding bone

 

Shoulder SLAP Preparation Base

 

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)

 

SLAP Anchor InsertionShoulder SLAP Repair Suture Management

 

Anterior anchor

- best to pass the suture passer above the biceps to get good bite

- retrieve sutures and tie from port of Wilmington

 

SLAP Repair Suture PasserSLAP repair Anterior AnchorSLAP Repair anterior anchor 2

 

SLAP Anchor 1SLAP Tie anterior anchor

 

Posterior 2 anchors

- pass suture passer under biceps

 

SLAP Vertical MattressSLAP Second Anchor

 

SLAP third anchorSLAP 3 anchor repair

 

Can suture Portal of Wilminton if desired

 

Portal WilmingtonWilminton Repair 1Wilminton Repair 3

 

4.  Dfficult posterior anchors

 

Camera through anterior / anterosuperiorlateral portal

 

A.  Place anchor through posterior portal

- does not always give good angle

 

SLAP repair posterior portal

 

B.  Trans infraspinatous Portal

 

SLAP Insertion Posterior AnchorsSLAP Posterior SuturesSLAP Posterior Repair

 

Biceps Tenodesis

Options

 

Arthroscopic

- intra-articular

- suprapectoral

 

Open

- suprapectoral

- subpectoral

 

A.  Arthroscopic Intra-articular

 

Biceps Tenodesis 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

 

Biceps Tenodesis First PassBiceps Tenodesis PDSBiceps Tenodesis First Suture

 

Biceps Tenodesis Second PassBiceps Tenodesis CompletedBiceps Tendon Insertion Cut

 

Attempt Figure 8 Suture Configuration

 

Biceps Tenodesis Step 1Biceps Tenodesis Step 2

 

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

 

Arthroscopy Tagging Biceps TendonArthroscopy Secured Biceps Tendon

 

2.  Resect tendon with electrocautery at insertion

 

Arthroscopy Biceps Tenotomy

 

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

 

Biceps Subpectoral TenodesisSubpectoral Biceps Tenodesis

 

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

DefinitionMRI SLAP Tear

 

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

 

MRI Slap with SS tearMRI Anterior Bankart

 

Supralabral ganglion cyst

- associated with posterior SLAP tears

 

Normal Arthroscopy

 

Normal Biceps Insertion

 

Arthroscopic Classification Snyder

 

Type 1 (10%)

- fraying & degeneration of the edge of superior labrum

- firmly attached labrum and biceps anchor 

 

Arthroscopy Meniscoid Biceps Insertion

 

Type 2 (40%)

- Superior labrum + Biceps tendon stripped off glenoid   

 

Subtypes

- anterior

- posterior

- anterior and posterior

 

SLAP arthroscopyShoulder Scope SLAP Type 2

 

Type 3 (30%)

- bucket handle tear of superior labrum

- displacement of labrum into joint

- biceps tendon attached to glenoid

 

Shoulder Scope Type 3 SLAP

 

Type 4

- bucket handle tear of superior labrum with part of biceps

- extension into biceps tendon which remains attached but with partial tear

 

Type 4 SLAP Tear extends partially into bicepsSLAP Type 4

 

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

 

Arthroscopy Normal Cartilage under Biceps LabrumArthroscopy Stable Biceps Insertion

 

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

 

MRI SLAPMRI Anterior Bankart

 

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

FunctionNormal Biceps

 

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

 

Popeye Sign BicepsPopeye Biceps

 

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

 

MRI Enlocated Biceps Tendon

 

Tendonitis

 

Biceps Tendonitis MRI

 

Tendonosis / thickening

 

Biceps Tendinosis MRI

 

Medial Subluxation

 

Biceps Tendon Medially DislocatedMedially Dislocated Biceps Tendon with Torn SubscapularisBiceps Medially Dislocated and Torn SSC

 

Arthroscopy 

 

Normal

 

Arthroscopy Normal Biceps Tendon Arthroscopy Normal Biceps Exit

 

Mild Tendonopathy

 

Biceps Tendonopathy Grade 2 Arthroscopy

 

Moderate Tendonopathy

 

Shoulder Biceps Moderate Tendonopathy

 

Severe Tendonopathy

 

Biceps Tendonopathy ArhroscopyBiceps Tear near complete

 

Dislocated Biceps in Presence of complete SSC Rupture

 

Shoulder Scope Dislocated Biceps TendonMedially Subluxed Biceps Tendon

 

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