Transitioning to Transosseous at the ASC/hospital and Surgical Tips

Speaker 1Um, that's great. Um, so, uh, well, why don't we just segue straight to Doctor Patterson then next for, I believe we're gonna talk about some techniques for biceps tenodesis, which is yet another anchor that people kind of leave out when they're talking about cuffs, but I don't know about you guys, but I'm a biceps killer and

Speaker 1There's, there's rarely one that survives, and, uh, so that's a, you know, that's you plus one on basically all cuff, cuff repairs.

Speaker 1And uh we, we studied that. I wrote up JP Warner's patients and found that the location didn't really matter, so

Speaker 1Super pectoral is a great place, you know, in my opinion, to, uh, to 10 of these things. And I think that's where Doctor Patterson is going to. So let's, let's see how he does it.

Speaker 2Um, thanks for having me. Uh, absolutely happy to be here. Um, as I kind of mentioned earlier, I've been in practice for about 9 years and basically been a, a tunneler guy, uh, transo guy ever since I came out. Um, biceps is one of those things I've gone back and forth. I've used probably most techniques that you can imagine.

Speaker 2Um, finally, uh, eventually came up with, uh, this, uh, uh, transosseous technique. So I, I'm not really gonna talk about indications, although, um, like Brett mentioned, uh, it's very rare that if I'm doing a cuff, um, that the biceps doesn't get anonymized or tenoded. Um,

Speaker 2So yeah, it, it's a pretty common indication for me that I'm doing a tenodesis.

Speaker 2So, um, again, just, uh, real quick about this technique in, in particular, as we've mentioned, it's clearly cheaper than using uh anchors or interference screw or whatever Other biceps, um, implant you're gonna use. It's all arthroscopic, although I do, um, spend a minute preparing the biceps outside the joint as you'll see.

Speaker 2Um, it opens up the groove. So people talk about groove Pain, whether it's from not opening the groove or putting an interference screw in there. This, this, uh, reduces the risk of that.

Speaker 2Um, you do, you tie one single knot. I, I believe it's a self-reinforcement construct, and I'll kind of show a little.

Speaker 2Rudimentary slide of that at the end of it.

Speaker 2And the thing that really sold me on this is that

Speaker 2Um, there is some evidence that even with an interference screw technique, the healing occurs where the biceps is contacting the humerus on, on the outside. It's not in the socket where the actual healing occurs. So, you know, then, you know, why would he even put an interference screw in there? So.

Speaker 2That's kind of the rationale.

Speaker 2Um, these are my standard portals, uh, posterior portal, uh, posterolateral for Rotator Cuff, anterolateral, anterior portal, and then the, the B is the biceps portal that usually ends up being, uh, pretty much in between anterior and anterolateral. Um, it's generally, uh, pretty much anterior with the arm and about 10 degrees of internal rotation, which, uh, puts you pretty much in line with the bicipital groove.

Speaker 2Um, intertraarticularly, uh, first, we localize the biceps. We're going to decide, we're going to do a, a, a tenodesis and then uh percutaneously place a spinal needle to essentially tag and immobilize the biceps. So I tagged the biceps with the spinal needle and then release it.

Speaker 2Um, before I do the tenodesis. So the biceps is, is tenotomized, but it's tagged with the spinal needle. Then once I'm in the subacromial space, I'll find that spinal needle. So this is with the scope and the anteterottal portal, um, viewing. So this tells me exactly where the biceps is. So, you know, for some Other techniques, um, if you're trying to find the bicipital groove once you're in the subacromial space, sometimes that's not so easy. This makes it, you know, you don't have to think about it. So what I've always said is,

Speaker 2The less I have to think during Surgery, uh, the better. Um, so I don't even have to think about it. That's exactly where the biceps is.

Speaker 2Um, then next I established the biceps portal, so that's done using an outside-in technique using the spinal needle. So this, this Other second spinal needle is, uh, you know, I'm making sure that that portal is in line with the bicipital groove.

Speaker 2And then, uh, basically through that biceps portal, we'll, we'll open up uh the bicipital groove and clean it out, breed it. Um, the Other thing I really like about opening up the bicipital groove is, you know, occasionally in that uh anterior bicipital groove, you'll see a little subscap split tear, and this is how I fixed the subscap too. So.

Speaker 2Um, it makes it very, very easy if there's that split tear, the subscap. Um, you just put a tunnel there and fix that, and then you can do your biceps tenodesis on top of it. So that, when I, when I'm doing a cuff and biceps, that's how I do it. It's subscap first, biceps tenodesis, and then posterior superior cuff repair.

Speaker 2Then the biceps is uh exteriorized and I remove about the proximal 1 centimeter or so and just do a quick whip stitch with whatever suture of choice, um, you, high tensile strength suture you want to use. I typically don't use tape. I'm sure you could. Um, I just have used suture.

Speaker 2Uh, so prepare the biceps and then put it back in the joints and bring the, the sutures out through the posterior portal.

Speaker 2And then I'll, I'll prepare the bone. I, I'm a big believer in preparing the bone. I, I, I really, you know, whether this is true or not, I, I was very intrigued to hear that there's Research that shows you can leave Sharpie fibers on the greater tuberosity. So maybe that's gonna change my philosophy about that a little bit. But I've been a very aggressive, uh, bone preparer. I really think you need to get it down to bleeding, um, you know, Bone Marrow elements.

Speaker 2So this is what it looks like after I've repaired it. So, you know, I, I want to put the biceps on there and have something for it to heal to.

Speaker 2Um, so punch the, the first tunnel at the superior aspect of the bicipital groove, and then it's kind of hard to see, but here's the transos.

Speaker 2The, the medial hook of the transos and then the lateral, uh, that's where the lateral punch goes. So the tunnel is in the bicipial groove in line with the bicipital groove. So you got the, the loop coming out medially, the, the two Other sutures coming out laterally.

Speaker 2And then

Speaker 2We'll grab the sutures that are tagging the biceps through that loop, so the

Speaker 2Suture grabber goes through the loop.

Speaker 2Grab the sutures and pull them through.

Speaker 2And then you use the, the lateral limbs of the shuttling suture to shuttle the biceps sutures through the tunnel.

Speaker 2And then this, this picture, so this is a different, this is a right Shoulder, that was a left Shoulder. So these are the sutures coming out through the biceps. That's the medial tunnel.

Speaker 2Out laterally, then I'll grab one around each side of the biceps and tie it down. So there's, there's two points of fixation. There's a point where the biceps is attached medially at the medial tunnel, and then it's circled around the biceps laterally.

Speaker 2Um, so it, it, it probably attaches about 1.5 to 2 centimeters of the biceps like onlay technique uh onto the proximal humerus.

Speaker 2Um, so this is kind of what it looks like at the end. That's that, that's the, the lateral tunnel, and then the biceps is fixed medially and the same thing.

Speaker 2Uh

Speaker 2Another video, I think it provides pretty stable fixation.

Speaker 2And kind of compression of that proximal.

Speaker 2You know, that good 1 centimeter, centimeter, half of the biceps onto the bone.

Speaker 2And, and I, I like the idea that it's out of the cuff repair. I, I, I'm a little

Speaker 2Ififfy about, you know, repairing the, the orinoduing the biceps kind of in the Rotator cuff repair. I, I'm, I'm not sure I want stuff in between the Rotator Cuff and the, and the tuberosity, so.

Speaker 2I know some really smart people do it that way. I'm just not sure that's for me.

Speaker 2Um, so this was my

Speaker 2Amazing, uh, drawing of, uh, you know, with, with this technique.

Speaker 2Um, if you're contracting the biceps and you're getting kind of that downward contraction of the biceps, that what's going to happen is it's, it's going to pull on these sutures, which is going to tighten that cerclage suture. So it's, that's why I call it a self-reinforcing technique.

Speaker 2Um,

Speaker 2You know, whether that's actually true or not, I haven't done a Research study on it, but I mean it's almost like a little finger trap, you know, if you pull on it, it's going to make it tighter.

Speaker 2Um, so then I guess the argument would be like, does that lead to failure and you know, although I'm, I've been doing this technique for a couple of years, so I mean, I don't know how many I've done a few 100 of them and

Speaker 2You know, I, I'm sure I've had failures, um, but I have not revised one. So if it fails, um, people here don't notice it.

Speaker 2Um, or maybe it just feels, you know, maybe it pulls a little and it heals. I, you know, I

Speaker 2When I used to use interference screws and Other various techniques, you know, I was revising a couple of them a year. Um, I have not yet revised one of these, so that's, that's my take on it.

Speaker 2Um, interested to hear what, what anyone else has to say about it. Maybe they think I'm crazy doing it this way, but.

Speaker 2Appreciate the opportunity.

Speaker 3Great talk. Um, I, I didn't even think about doing the tenodesis that way.

Speaker 3But I

Speaker 3I, I like the idea of it, um.

Speaker 3I've, I've incorporated, I do it two ways. I incorporate it into the cuff repair and I, I do it, um,

Speaker 3Where I'm passing um my tunnel through the, the groove but out laterally, um, through the greater tuberosity.

Speaker 3Um,

Speaker 3And I kind of leave the biceps in situ. Sometimes I still leave it attached, um, uh, to the labrum and that, those are usually cases where there's biceps instability and um I'll secure the biceps into the groove, hold it there. It'll tina de there, but that might be a patient who needs, uh, maybe a little, uh, SCR, uh, type help with uh the biceps. Uh, there might be some advantages. If they have a slap tear, I don't leave it attached.

Speaker 3But, um, it does give me that option, I suppose. Uh, but I like that technique. Um.

Speaker 3And I like staying within the groove there, so great talk, great

Speaker 3technique.

Speaker 2Thank you.

Speaker 2Yeah, that's the Other thing is uh the whole using the biceps as your kind of SCR. So, um, that, that's, you know, not related to this particular technique, but something that can easily be done using the uh transosseous technique as well.

Speaker 1Yeah, I'll keep it attached, um, and, uh,

Speaker 1A lot of times we'll whip stitch it in the, within the anterior tunnel adjacent to the cuff tear, uh, do a Mason Allen suture, uh, on, on it, circlage type suture, and often if there's a subscap tear, I'll tunnel and keep it, keep it inside you and spear it on purpose, you know, tunnel through it simultaneously tenodesing the, you know, the, the biceps and repairing the, uh, subscap at the same time just for time.

Speaker 1I tend to use the horizontally-oriented tunnels, um, but, uh, I could see how I've done your technique a couple of times where I just wanted to save time and just have two fixation points for one there by vertically orienting. So I have used that a few times, um, to save time.

Speaker 1So,

Speaker 1You taught me that.

Speaker 1Um, cool. Uma, how do you do it? Are you still with us?

Speaker 4Yeah, yeah, I'm here. That's, that was great talk, uh, well. Um, that's an interesting technique. I think that, I think you're right. It, it is a self-reinforcing, and I think that's true for the cuff tunnels as well. I mean, it's essentially, uh, uh, almost like a tension band type technique. So if you're, if you're tying your knots in a little bit of abduction, when they, when they bring their arm down, it, it should reinforce that repair.

Speaker 4You know, to get tighter. Uh, so I think that's a nice way of, of doing it. But I, yeah, I'll typically, if I'm doing it high, I actually prefer subpecs, so I'm just completely out of the groove here completely. But this, uh, if I do have to do it high, if there's an enchondroma or something I'm trying to avoid, um, I'll just usually bring it in, just, uh, into the high groove or next to the anterior part of the repair.

Speaker 4I like you, Brett.

Speaker 1Yeah, um, I've actually done a couple of biceps, LHB biceps, uh, autographed SCRs using a tunnel, suragging the biceps, tenodesing its pectorally, then incising it, swinging it over, and when you have that bicep, you have that, uh, you have that biceps control suture that you can pass through a tunnel.

Speaker 1With the two-point fixation of a tunnel, you can actually secure that quite nicely. Um, I've got some video of that I might be able to find here.

Speaker 1Um, but, um,

Speaker 1Let me see if I can uh.

Speaker 1Go ahead and show first what we were when I was planning on doing here.