One-Step Release Technique for Tendon Extraction During Biceps Tenodesis

All biceps tenodesis techniques involving extra-articular tendon preparation consist of 2 distinct steps for tenotomy and tendon grasping. These 2 maneuvers are performed by different instruments. A single-step tendon release technique is described for both arthroscopic and open shoulder surgery. This technique finds application in arthroscopic proximal suprapectoral tenodesis, open treatment of proximal humerus fractures, and suprapectoral mini-open tenodesis. Herein, we describe an arthroscopic biceps tenodesis technique that combines the actions of cutting and gripping the tendon in a single step.

there is not a singular instrument that completes 1 task.This reduces clinical efficiency and increases procedural time.The BITER (BIceps TEndon Releaser; KARL STORZ SE & Co. KG) is an instrument specifically designed for cutting and grasping, which allows in 1 step to tenotomize and pull extra-articularly the LHBT.
Herein, we report the technique as previously published, 6 describing simultaneous resection and grip of the biceps (Video 1).The intent is to describe a technique that simplifies a central step in LHBT tenodesis, providing a more effective and rapid procedure.

Subtotal tears or tears with loss of substance Subpectoral tenodesis
The patient is placed in the beach-chair position and the surgical arm is secured in an arm-holding device.The entire scapula and arm are prepared and draped, and bony landmarks are drawn on the shoulder.This surgical technique for arthroscopic proximal suprapectoral tenodesis with knotless anchor fixation requires 4 steps.

Step 1: Glenohumeral Exploration
The 4-mm 30 scope is introduced in the standard posterior viewing portal, and the glenohumeral joint is explored.The LHBT is evaluated from its glenoid origin medially and followed into the bicipital groove laterally.Pathology of the biceps tendon is confirmed: instability, inflammation, degeneration, and tears are noted.

Step 3: Tendon Preparation
The biceps is secured to a Kocher clamp so not to lose it.The proximal part of the tendon is resected and evened to approximately 1.5 cm (Fig 2A).The stump is reinforced with a No. 2 FiberWire suture (Arthrex) using the baseball stitch technique (Fig 2B).
Step 4: Knotless Anchor Fixation A debridement of the reinsertion zone at the sulcus entry is made.The area is prepared with a motorized shaver.
An onlay anchor tenodesis using a self-punching knotless anchor (ReelX STT; Stryker Corp) is performed.The PEEK anchor is loaded with the 2 tails of

Discussion
Surgical treatment for pathologies of the LHBT is limited to removal of the intra-articular portion of the tendon, with either tenotomy or tenodesis.Both procedures have advantages and disadvantages.7,8 Tenodesis of the LHBT is technically more challenging than simple tenotomy.In LHBT tenodesis, there is a differentiation between an open, a mini-open, and an arthroscopic procedure in the type of fixation and in the choice of fixation implants.Whatever technique is adopted, so far there are 2 distinct steps to tenotomize and exteriorize the LHBT.
This article describes an arthroscopic tenodesis in the proximal-suprapectoral position that combines the actions of cutting and grasping the tendon in a single step.Typically, there are 2 distinct steps for tenotomy and tendon gripping.In fact, these 2 maneuvers are performed by different instruments.Usually, a preliminary first step is intra-articular transfission of the LHBT at its entrance into the groove using a spinal needle.This will prevent the tendon from retracting into the groove in the transition between tenotomy and tendon grasping.Tenotomy can be performed with a knife, an arthroscopic scissor, a punch, or electrocautery.After being cut, the tendon is grasped firmly at the proximal part while the spinal needle is removed.The task can be accomplished with a clamp or an arthroscopic grasper.At this point, the LHBT can be exteriorized to continue with the next steps.The key goal achieved using this technique is a simplification of this stage of the surgery.The BITER was developed as an alternative to conventional instrumentation.Combining the action of cutting and grasping, this device provides the function of several other standard instruments.In 1 step, the LHBT can be resected, gripped, and pulled out, without the need for temporary fixation with a spinal needle and without the need to change instruments.There is a model of this instrument designed for the right shoulder and one for the left shoulder, so that the tendon is engaged by making a rotation.Listed in Table 1 are some of the pearls and pitfalls.
In addition to this simplification of the procedure, the proposed technique has other advantages (Table 2).This technique is suitable for both arthroscopic and open shoulder surgery: in particular, it can be applied to the osteosynthesis of the proximal humerus fracture.In this situation, the LHBT tendon is at risk of injury because of its proximity to fracture fragments and to the osteosynthesis plate.In case of doubt, a tenotomy of the intra-articular portion of the LHBT and, if necessary, a soft tissue tenodesis distal to the intertubercular sulcus should be performed. 2It may happen that the rotator interval is intact, and access to the supraglenoid tubercle may not be easy.The BITER makes it easier to reach the LHBT in such cases.
Finally, an additional advantage of this arthroscopic technique, in comparison with mini-open techniques, is less soft tissue damage.
However, there are situations in which this technique cannot be applied.First, it is not indicated in the case of subtotal tears or tears with loss of substance.Under such conditions, the BITER in grasping the tendon could tear it; moreover, given the poor quality of the tendon, proximal fixation does not provide an adequate strength.In addition, the technique is not indicated in the case of subpectoral tenodesis, where the LHBT stump is exteriorized more distally.
The disadvantage of proximal suprapectoral tenodesis is that the intratubercular part of the LHBT, which often has synovitic changes, is not resected.To date, however, it has not been possible to prove or definitively rule out that this portion continues to cause symptoms after static fixation by tenodesis.
For the procedures in which this technique finds application, results have already been published.Scheibel et al. 6 compared the clinical and structural outcome after arthroscopic soft tissue tenodesis vs an arthroscopic bony fixation anchor tenodesis.The bony fixation tenodesis was performed with a suture anchor or a knotless anchor; in the latter case, the technique used is similar to that described in this article.The results showed that anchor fixation provides significant advantages concerning the clinical and structural  In conclusion, the BITER can be a useful device for both arthroscopic and open shoulder surgery.The technique described, by performing a single-step LHBT release, results in a faster and more efficient procedure.

Step 2 :
Tenotomy and Exteriorization of the LHBT If the LHBT is determined to require tenodesis, an anterolateral portal is established with an outside-in technique using a spinal needle.The BITER is introduced by the anterolateral portal (Fig 1A).By turning the instrument, the tendon engages in the housing (Fig 1B).By tightening it, a spike transfixes the tendon holding it in place while a blade precisely cuts the end (Fig 1C).The biceps tendon is tenotomized close to its origin, pulled extra-articularly, and exteriorized (Fig 1D).The penetration of the LHBT by the spike of the BITER allows the tendon to be pulled out directly without any additional steps.

Fig 1 .
Fig 1.Right shoulder.Beach-chair position.Posterior view.(A) Introduction of an instrument designed for cutting and grasping (BITER) into the glenohumeral joint by the anterolateral portal.(B) Twisting of the LHBT around the instrument and engagement.(C) Tenotomy: the BITER's blade cuts the tendon and the tip pierces it, keeping its grip.(D) The BITER extracted from the joint still attached to the biceps.(HH, humeral head; LHBT, long head of the biceps tendon.)

Fig 2 .
Fig 2. Right shoulder.Beach-chair position.(A) Exteriorization and resection of the proximal part of the tendon.The LHBT is secured to a clamp so not to lose it.(B) Tendon stump suture with the baseball suture technique using a No. 2 FiberWire suture.(C) The knotless PEEK anchor loaded with the 2 tails of No. 2 FiberWire before being pushed into the bone at the sulcus entry.(D) Fixation of the LHBT at the insertion site with the knotless anchor.(LHBT, long head of the biceps tendon.) From the Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Piazza del Mercato, Brescia, Italy (E.M.); Department of Shoulder and Elbow Surgery, Schulthess Clinic, Zürich, Switzerland (E.M., M.S.); and Center for Musculoskeletal Surgery, Campus Virchow, Charité-Universitaetsmedizin Berlin, Berlin, Germany (M.S.).The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: M.S. reports personal fees from Stryker, outside the submitted work.E.M. declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

TABLE I .
Pearls and Pitfalls for the 1-Step Release Technique for Tendon Extraction During Biceps Tenodesis

TABLE II .
Advantages, Disadvantages, and Limitations of the 1-Step Release Technique for Tendon Extraction During Biceps Tenodesis Advantages Disadvantages and Limitations Eliminates additional steps and tools, speeding and simplifying the procedure Not indicated in the case of subtotal LHBT tears or tears with loss of substance Suitable for both arthroscopic and open shoulder surgery Not indicated in the case of subpectoral tenodesis Minor soft tissue damage The intratubercular LHBT segment is not resected LHBT, long head of the biceps tendon.e4 outcome.Kerschbaum et al. 9 evaluated the clinical results of a simultaneous biceps tendon treatment (tenotomy or tenodesis) during plate osteosynthesis of proximal humerus fractures.They found that the simultaneous surgical treatment of the LHBT during plate osteosynthesis of proximal humeral fractures brings good clinical and cosmetic results.