APEX Shoulder Mastering Surgical Techniques for Clinical Success-Shoulder Biceps

Shoulder Biceps
Video Transcription
We've got shoulder, biceps, potpourri now. Larry and Rob, thanks for asking me to participate in this capacity.  I'm excited to be leading this panel discussion with Dan Bick, Larry Field, and David Richards. Here are my disclosures.  And like Mike just said, probably my biggest disclosure is I'm a biceps killer. And we can kind of get into this as we go.  I think some of that bias comes from the fact that I take care of a lot of military patients, and we'll unpack that. So the first case, some would say, is a vanilla case.  I'd like to call it a foundational case to set the tone here. And so 44-year-old man, active duty service member, but an active active duty service member.  Dr. Waterman took care of a lot of military guys, and he knows that military guys come in all shapes and sizes. We'd like to think that all of them are Navy SEALs.  That's not the case, especially a lot of our Army Bubbas. Nevertheless, this guy was a fast-burning fella, still very active.  He came to see me complaining of two years of atraumatic anterior shoulder pain, multiple courses of supervised physical therapy.  On physical exam, fairly benign from the standpoint of a full active unrestricted range of motion. He did have some pain through the mid-range of abduction.  But not too much going on concerning in the way of rotator cuff strength or anything like that. No apprehension. Grade one anterior load shift.  Really the most notable things are a positive O'Brien's and tenderness about the bicipital groove. Here are just some representative images here.  Nothing going on in the plain films. Just scrolling through here.  I thought that the coronal MRI nicely shows that I don't have too high of an index of suspicion about anything going on in the rotator cuff.  And these actually, these pictures came out really poorly, and I apologize for that. But what these are is this is an axial here, and then two sagittal cuts.  Because I think that in the case of these folks with atraumatic anterior shoulder pain in this age group, subscap pathology nevertheless is still on my differential.  Do you guys typically agree? I should have backed up and, you know, what's on your differential for an active guy with atraumatic anterior shoulder pain? Am I missing anything?  Yeah, so. Okay. So let me back up here a little bit. We're going to be done in six minutes, so. All right, so what do we think?  I mean, this is a surgical course, but I think, again, this is a foundational case.  So how are you guys working these patients up with a fairly benign-looking advanced imaging with respect to slap, biceps? Dr. Field, what do you think?  Yeah, I mean, honestly, I don't put a lot of stock in MR or even MR orthogram for slap lesions.  I mean, I treat these patients similarly to what I would treat any kind of biceps kind of pathology, plus or minus, as you said, upper border subscap pathology,  because those upper border subscap tears are everywhere, and this kind of guy is the kind of guy that may have one. And those symptoms overlap, subscapularis slash biceps.  I just, if I think it's within that realm of anterior shoulder pain,  then I just kind of presume that it's one or both of these things or three of these things, and I just treat them and see what happens.  Dan, what role do injections have in your practice in this case? I use them when I'm really trying to pinpoint something, such as biceps versus upper subscap.  I like to use the exam also. I think that's part of the workup, and I find that it's an interesting look at the O'Brien's exam.  If you have a negative O'Brien's, which is pain in the posterior aspect of the shoulder, thumbs down, right?  If you have pain in the anterior aspect of the shoulder, I call that an anterior O'Brien's, and that's usually biceps pathology in my hands.  The other thing is using a bear hug for superior subscap. I think that's helpful. So if I'm still not sure what's going on, then I can go to, you know,  is it someone who has referred pain from their AC joint pathology? You know, that sort of thing. So then you can use your injections.  And injecting the biceps tendon about the sheath is very useful. It will make the pain go away.  So you could define your biceps pathology there, especially if it's right at the apex as it goes over the humerus and the groove.  Dave, how often are you sending patients for an ultrasound-guided bicep tendon sheath injection?  Does that have a role in your practice and your workflow when you're trying to work these patients up? Yeah, I think it does.  We have a sports medicine guy in our office that we'll send these patients to because I think that, like Dr. Field was saying,  this is like a challenging patient when you don't have, you know, like a lot of physical findings, MRI scan.  Obviously, these ones are pretty difficult to look at, but like, you know, no obvious subscap, no obvious subcoracoid impingement, you know, no fluid around the biceps.  So if you send them for an ultrasound-guided injection, he can look at the biceps dynamically  and see if there's any irregularities of the biceps and then go ahead and inject that and see if it alleviates their pain. Larry, do you ever just inject their glenohumeral joint?  Yeah, I mean, I'll do that to differentiate different things, you know. I mean, absolutely. I mean, I'll do that depending on what I think.  I mean, I like the glenohumeral joint because it should probably help irrespective of the pathology.  If it doesn't help at all, then I start to think maybe this is something different. Maybe it's extra-articular, that type of thing. But yeah, I'll sometimes do that differentially.  Yeah, so we took him and I consented him for kind of the standard blue plate special rotator cuff repair versus debridement.  I told him, you know, I'm always suspicious about the upper board of the subscap,  which, you know, these images here just demonstrate the fact that his cuff actually looked pristine. There was obviously nothing going on there. There was nothing in his slap.  And then he's got, you know, what we oftentimes see is this erythematous changes in the biceps tendon here. On the left, looking down the groove, we went back and looked.  And you can actually – I like sticking the 70-degree scope down the groove there. I think you get a really nice perspective, an additional probably two to three centimeters of that.  And then you can pull it into the groove here, and it's just re-demonstrating all that erythema. So he was consented for a biceps tenodesis.  And so let's talk about how the panel is doing a biceps tenodesis in this situation. So we'll start. Dave, how are you going to do a biceps tenodesis in this case?  So initially I used an interference screw because that's how Dr. Burkhart taught us. And then over the years I just transitioned to an all-inside technique.  And then now recently I just use a cerclage type of technique with a suture anchor high in the groove. And generally I'll incorporate that with my subscap repair. Larry?  Yeah, you know, if I were going to do a tenodesis on a guy like this,  I mean, I think even though you can pull the biceps into the joint, you really can only see maybe half of the biceps.  I've seen a lot of evidence over the years where it looks pretty normal. But then if you split the transverse femoral ligament, you see pathology there,  and you really never know quite what's happening in the groove. So when I do these, I do an arthroscopic technique.  I do it in zone one, but I split the transverse femoral ligament completely. I look at it, and I use an anchor or anchors depending on the guy.  This guy might use two anchors because he's just a really aggressive guy. And one trick I would tell everybody that I do at least is before I get to this,  when I'm in the glenohumeral joint, I use what we call the slit technique. We published on it.  I just percutaneously bring a knife, and I split the transverse femoral ligament while I'm looking from the glenohumeral joint. It makes finding the biceps very easy.  You just find the slit, and then you just put an anchor there. And importantly, I cut the biceps but not quite completely.  And so when I go into the subacromial space, I can literally do the tenodesis before I even cut the biceps,  and then I can blindly slide my scissors approximately and cut the residual biceps. And it's tenodesed anatomically that way, and I've resected a little bit of the proximal stump.  So I can show you guys, or we can look at some video tomorrow. But that's how I do it, and it's anatomic. It's easy to find, and it's pretty quick. Dan, how do you do it?  For a guy like this, I would do something similar to what Larry's talking about, but I do it a little bit higher. I'll do it above the groove.  But as a result of COVID, my tenodesis system was taken away from me.  And one of the systems that was a major hospital that I operated in, they took Arthrex away. And none of the other companies really had a good system that I liked.  There are some other systems that are good that we just didn't use. And I started using just a simple surcoge between the supra and the subscapularis.  And putting two sutures through and around the biceps tendon and just sewing it to the local soft tissue. And I've had amazing results with that. And it's super simple, super easy.  The only guys that I don't do that for are guys like this or big-time weightlifters. And I have done it in big-time weightlifters, and I just use three sutures instead of two.  And they succeed. And I think one thing that it does do, and I'm sort of an outlier here. I think a lot of the problems with biceps tendinosis is where it makes the turn.  And if you leave it there, are you really helping the patient? You still have tendon where it makes a turn.  So I actually fenestrate the tendon in several places with a spinal needle to try to induce some sort of scarring. Because it's otherwise a synovial milieu the whole time.  And I let it shift down about half a sonometer to a sonometer. And that takes that area of the erythema down away from the turn.  And I think that's helpful in terms of controlling the inflammation. Is there anything that you would see or any situations pertaining to the quality of the tissue itself?  The picture I showed is a pretty healthy-looking tissue with some underlying erythema.  But I worry about, or I've wondered in the past about doing these all-arthroscopic tenodeses in the setting of kind of crappy-looking tissue.  Are there any instances in which you guys take the scope and you say, that needs to get out, I need to cut all that tissue off and do a sub-pec?  It's interesting that no one on the panel said that they do a sub-pec. Looking at the type of tendon you showed, I would generally not do a sub-pec.  Dr. Burkhart did publish a paper that he states that much of the inflammation and degeneration of the biceps tendon is actually intratendinous. So you don't see it.  And you won't see it. And to Larry's point, a lot of it isn't where you can pull it into the joint anyways. So that's a good point. And failures probably do occur because of that.  But most of the time where you see it, that it's completely degenerative, is visible. And you see these bad rotator cuff tears or these really degenerative biceps.  I'm wondering what you do. Do you use those for your irreparable cuffs? For what now? For the irreparable cuffs. Yeah, right. I do sometimes, yeah. Okay.  But the issue of the biceps, I mean, just to make a point here about that, is I just am not,  do I see cases where it's a horrible tendon and I think, oh, I got to do a sub-pec. Yes. For me, it's very uncommon.  If you look at the literature, it's replete with plenty of studies that show there's no difference between doing arthroscopically and doing a sub-pec.  There are cases where it's horrible. But I usually just keep going in fairly until I find good tendon and do it arthroscopically anyway.  The other thing I would say, and this is me, and probably there would be disagreement here, I just don't believe that there's an evil biceps that has to be excised.  I think the reality is when you tinnitus the biceps, you stop translation through the bicepal groove. It's no different than a decurve veins or anything else.  So the reality is I think when you open that up, and that's why I do,  J.P. Warner is showing us that if you split the transitional ligament at the time of tinnitus, they do better than if you don't.  But I think once you tinnitus it, they don't translate, and it solves the problem, in my opinion.  So initially when I used the interference screw, if I had poor quality tendon, I would really tenotomize them. It was just like the interference screw would never hold these.  And so with this new sort of interlocking type of surcloging that we do with a knotless technique with biceps tinnitus,  like the quality of the tendon can be a lot less, and you still get excellent fixation, and the patients do very well.  And to Dr. Fields' point, it's like people rupture their biceps all the time and do very, very well.  So if you have a failure of your repair, generally the patients, other than maybe some cosmetic deformity that they don't appreciate,  they don't have symptoms, so it really doesn't bother them. So to do a big complex operation when you can do a very simple operation,  and you're in an area where you're going to be taking care of the subscap and the rotator cuff, it's very straightforward, and you can do an excellent reconstruction at that point.  Rob? Yeah, I was just going to say, I like a subpec for this situation, because you know mostly right away if you made the right decision on the patient.  Because if you do a higher tinnitus, then they have pain from the anchor for a while, so then it's confusing.  But if you do a subpec, it's like they're either cured or you missed it, and they have cervical pathology or some other thing that you missed.  That's been my clinical experience taking care of these patients. My bias has been over the last six years, like I said, I joked,  we would like to say that all of our military patients are Navy SEALs, but a lot of our military patients are workman's comp patients just kind of repackaged up.  And so for me, it's nice. I do the subpec through a little small incision.  I know that there's no sort of – totally acknowledge the fact that the literature would say that the differences are negligible.  But then I can tell that person, okay, well, it's nothing in your shoulder. Lo siento, as we say in San Antonio. Okay, good. All right.  Case two, 21-year-old woman, Division II Collegiate Volleyball player. She's right-hand dominant. Six months of pain with overhead activities, worse with external rotation.  She's had reliable supervised physical therapy with team athletic trainers. She's got full unrestricted range of motion, nothing going on with her cuff, no apprehension.  She, again, has a positive O'Brien's.  She's got this positive dynamic posture instability test, and then no evidence of scapular dyskinesia. So here's this dynamic posture instability test.  Arnor asked me to make sure that he was attributed in those images, so I put that in at the last minute.  But it's this test, which I have found it to be really efficacious in a lot of these overhead athletes. And so what you do is you put the arm in abduction or external rotation.  You have them push against that hand and resist it. And the thought is that you actually get a little bit of subtle posterior translation up there at the top.  And then you repeat the test. Justin, with his left hand here, is stabilizing the humeral head, and the pain goes away.  And this is something that Dr. Bradley's talked about for a number of years. And so I think this is something that's worthwhile. But normal joint.  Is there anything else on physical exam? You know, we hit on the scapular dyskinesia already.  Is there anything else that I'm missing or is part of the kind of standard physical exam regimen that you guys are doing with these types of players? Did you discuss mobility?  She is a five out of nine. Anything else? Nothing? Okay. No passive motion loss? No. So sorry. I was on the deck of a ship, too, and these videos were being recorded earlier today.  So one thing that jumped out with me with this axial on the right was that crack in the posterior labrum as it was going all the way down. I was more  impressed with that than I was with what the the slap region looked like. So okay in summary we've got a 21 year old overhead athlete, not a thrower but still  someone that spends a lot of her competitive activities, overhead activities in that respect. We've got these scans what what's what does the  panel think? Would you send her back to physical therapy? Would you try an injection? Or is she already crossed threshold point of no return? Do you mind  doing the axial again? Yeah can we can you go back and play those again? Am I gonna short out the system if I hit the red button backwards?  What happens if I... we'll just watch this again one more time.  What about an arthrogram in this situation? Is that mandatory for you guys? Dave, you're shaking your head no.  I think it's pretty obvious in there. I think that with this individual in my hands, in fact, my daughter, a Division I college basketball player, had a posterior labral tear.  So I think the first step would be hardcore rehabilitation to see if she got better.  Now, I'm less optimistic for her being a volleyball player versus a basketball player, but I would try that first. Anybody else?  So here's what we found. This is a right shoulder lateral decubitus.  And I think that this actually nicely correlated with what we saw, that tear going from what I'd estimate probably be from the 12 o'clock position down to 9, 830 or so.  And so just, you know, it's already been talked about today, but I think that, you know, these labs are fantastic to practice, you know, making a lot of these percutaneous portals.  In this case, this is the portal made transtendent through the Port of Wilmington. But I think that, you know, to a large extent, slap repairs have gotten a bad rap over the years.  Certainly in the literature, we know that especially amongst military patients, patients over the age of 35 don't do well.  And there's a lot of ways to booger up a slap repair and a lot of ways to do the slap repair incorrectly. One of them being is that you're putting that anchor in.  I've seen people try to put them in through an advisor's portal or something like that. That portal puts you way too medial to lateral.  And so I think using this portal to set yourself up to put the anchors in, in this respect, is really a nice way to do it.  The other thing, too, that I think is important is when you go to use whatever device you're going to use, in this case, this lasso, you know, you can't get that cuff and that capsule tissue.  You really have to focus on just getting your lasso around the labrum because I think that's a lot of the issues where you can give people issues with stiffness there.  What are some of the panel's pearls as far as doing a repair in this region of the labrum? Dan. Well, I agree with everything you pointed out to begin with.  I do use the Port of Wilmington portal to set my anchor.  You also want to make sure that you do have a bleeding bony surface to repair the slap, too, as opposed to articular cartilage.  Using a mattress technique, vertical mattress technique, I think is important.  And the new knotless anchors really help in terms of rubbing against the undersurface of the supraspinatus in external rotation. Yeah, no, I'd echo just what I was going to say.  Dan said I use a mattress or a knotless. I think even the horizontal mattress can still cause trouble with the knot stack.  So I really almost always try to use knotless anchors in this area. Anything else? Yeah, I think knotless is the way to go.  And just I've found over the years that, you know, the knot stack is a real significant problem with persistent pain. So knotless.  So I think another pearl for this is I like to the way the way that I was taught to do this was was pass your sutures and then fix them after they're all passed there.  Because if you there's really not that much space to work through. And whereas if you're down, you know, doing a bank card or a posterior labrum, it's kind of a sequential process.  As you pass your you pass your suture and then you fix it and then you go up with this.  I think it's better to pass all your sutures and then one by one fix them so that you're leaving yourself with enough space there to see and to, you know, hit on some of those fundamentals that we always talked about.  Already talked about.  And then does anybody put anchors anterior to the biceps? Are there any situations in which you all would do that? Not me.  Me, not anterior to the biceps, but up in that quadrant, if you're doing a bank card to make sure you get that.  But not a slab. And so this is this picture is just showing again what we were talking about earlier, that port of Wilmington, which, again, I would practice that.  I think that's probably something that we don't typically do. Practice that in the lab tomorrow. It gives you a real nice angle of attack to put the anchors where they belong.  And then this is just the final the final repair. The schedule has us going till 535, but then nothing till 540. Do we have is there time for one more case or? Yeah. Okay. Sure.  This is that's good because I'm selfishly wanted to get y'all's opinion on this. I just did this one. So 39 year old, other active duty guy, dental technician.  So maybe not as high speed as our infantryman.  But his chief complaint was was was predominantly posterior shoulder pain and didn't actually have that many of the kind of the telltale bicep symptoms that we've talked about.  No O'Brien's, no bicipital groove tenderness.  His his kind of blinking red light from a physical exam standpoint was a grade to post your load shift and one that, you know, with all there's no medical students.  I mean, the medical student could get the post your load shift one that is not difficult to do. And so we'll blitz through these really quick. Nothing on the X rays.  And you see he's got a pan labrum tear, which is I think is nicely demonstrated there on that sagittal image up top. And then again, another tear going down in the back posteriorly.  And just for the sake of time and interest, what I'm interested in is for these big pan labral tears.  What do each of you guys do when it comes time to address the slap aspect of this? You see that obviously the anchor is is markedly unstable here. Dave.  So what what I'll do is I'll actually put my anchors in for the slap and pass the sutures first and just get that set up,  because commonly as you have to progress 300, 360 degrees, it'll become very difficult to see that portion of the labrum down the road.  So I'll start there and then I'll go anterior and move my way back. And again, and I'll put the anchors in, pass them, get them sort of primed.  But then I won't cinch them down until the very end. And I'll do it sequentially.  Yeah, similar, but in a guy like this, 40 years old, I'd probably do a tenodesis if I really felt like he had a serious, significant slap lesion.  And but but same technique, same sequence. I'd put past sutures and all. But for me, this is probably a biceps tenodesis. I agree. I'd do a tenodesis for this.  But I for pan labrals, I typically go posterior first, set my anchors. Then I do the bank card and fix the bank card and then come back and tie down the posterior.  Because I always feel that if you tie down the posterior before you do the anterior, it's more difficult to work anteriorly. I would do a biceps as well. I think that's great.  One thing I'd say about pan labrals is I really try really hard in the office to try to figure out the primary direction of instability.  Is it anterior inferior mainly? Is it posterior inferior mainly? What is it? And so the main area of instability I fix first, but don't tie. I pass, but don't tie.  So I know I've got that. I'm golden because that's my main concern. Then I go back and fix the less significant side of the labral lesion. Then I tie those at the end.  That way I feel like I've just accomplished what I set out to accomplish the best.  Robert, did you want to say something?  Larry, if you were doing a tenodesis, would you do some superior labral fixation or would you just fix anterior posterior and kind of leave superior alone after you cut the biceps?  Yeah, it's a great question. I think it depends. Nick Vermisch talked about doing both.  What I would do is do a tenodesis if I had residual instability superior labral that bothered me. It's easy. You put an anchor in it and don't worry about it.  If that solves it or seems to solve it, I might not.  Yeah, so I cut it. I cut it, and I cut it because of this guy's age and who he was, and we know what the fate of a lot of these slap repairs are in this population. So I cut it.  I fixed it. I fixed it in the front. I fixed it in the back, and then I did a subpec again.  So the subpec actually in the lateral decubitus is not as difficult as one might think it is. It's basically I just take the arm out of balance suspension, deflate the beanbag.  I have my assistant control the shoulder. I abduct and externally rotate the shoulder, and I stand in the axilla, and you can do it that way.  The one thing I found is that when I was using the first handful of them that I did, I was using the metal button.  So you can get an x-ray, and you can see where the position of your tenodesis is, and I found that standing in the axilla,  you're biased towards maybe being a little bit more proximal with your tenodesis than you are if you're in the beach chair, which is how I do probably 85% of my tenodesis.  So for those of you that are doing these in the lateral decubitus, I would just be mindful of that. Get your retractor up around the pec,  and then you really want to make sure that you're looking more kind of down the humerus as opposed to up into that wound  because I think that that can set you up to put a little bit more proximal. So, all right, that's 540. Gentlemen, thanks so much for participating. Thank you.
Asset Caption
Moderator: Andrew Sheean, M.D.
Panel: Dann Byck, M.D., Larry Field, M.D., David Richards, M.D.