Summary

Method that aims to preserve bone stock and allows a strong fixation with a minimal approach, using a device originally developed for another purpose. MRI showed safe distance between the implant and important vasculonervous structures. When subpectoral fixation is chosen, this method seems to offer additional safety due to the minimal amount of bone removed and the very small size of the implant.

Abstract

Introduction

Tenodesis of the long head of the biceps tendon (LHB) has long been recognized as a valid alternative to address pathological conditions of this tendon and various techniques for that purpose have been proposed. However, the location and type of fixation is still a matter of discussion, since common complications associated to this procedure include failure of the repair, persistent pain, reaction to the fixation device, cosmetic deformity and fracture.

Aim

To describe a new method of subpectoral LHB tenodesis that aims to preserve bone stock and allows a strong, easy and reproducible type of fixation with a minimal approach, using a knotless suspensory button with an appropriate pusher originally developed for another purpose.

Methods

LHB tenotomy is performed arthroscopically in a standard fashion.
Surgical approach to the subpectoral region of the LHB is performed in a classical way through a 3 cm approach on the anterior aspect of the axilla, perpendicular to the inferior border of the pectoralis major.
Roughly 2 cm of the LHB are tagstitched using No. 2 ExpressBraid suture (Zimmer Biomet, Warsaw, IN, USA). The most distal 5-10 mm of the stitches should incorporate the loop strands of the suspensory button construct (ToggleLoc, ZimmerBiomet, Warsaw, IN, USA). The ToggleLoc implant is inserted in the bone tunnel using the ToggleLoc pusher and then by pulling on the remaining free loop of the implant, the so-called ziploop, the tendon end will migrate into the bone tunnel until it’s locked.
An anatomical study using MRI cuts from 10 random shoulders was done to ensure the safety of the procedure in terms of vasculonervous iatrogenic injuries.

Results

This is a reproducible technique that allows a strong fixation of the LHB with a minimal approach.
An orthogonal placement of the bone tunnel in the humerus at 1 cm proximal to the inferior border of the pectoralis major will place the titanium button of the implant at a safe distance from important vasculonervous structures.

Conclusion

This is a quick, easy and safe type of LHB fixation that may be used as an alternative to the several types of LHB tenodesis described until today. In those patients where a subpectoral tenodesis is chosen, this method seems to offer additional safety considering the minimal amount of bone that is removed and the very small size of the implant.