After completion of the diagnostic arthroscopy attention was paid to the long head of the biceps. Utilizing an arthroscopic scissors as well as an ArthroCare wand, the biceps tendon was separated from the superior labrum. The biceps tendon immediately retracted into the bicipital groove. The circumferential labrum tear was debrided with a sucker shaver and the arthrocare wand. Capsulotomy was performed with sucker shaver and electrocautery device. Attention was paid to the rotator interval which is open from the superior glenohumeral ligament to the subscapularis tendon. Capsule overlying the subscapularis tendon was then debrided and removed. Attention was then paid to the posterior capsule, extending from the 11 o’clock position to the 7 o’clock position the capsule was debrided away. At the inferior aspect of the debridement, the axillary nerve was identified. 7:00 portal was placed into the shoulder and debridement of the osteophyte was performed with sucker shaver, 4 oh bone cutter, and bur. C-arm was used to confirm location on the inferior humeral head. Neural lysis was performed to free of the nerve. *
Instruments were removed from the shoulder and the trocar was redirected into the subacromial space. The subacromial space an 18-gauge needle was placed to localize the lateral portal site and was directly visualized. An 11 blade was then used established the portal site. This was followed by insertion of the 4.5mm cannula and ArthroCare wand. Both ArthroCare wand and sucker shaver were used to debride the subacromial bursa. The coracoacromial ligament was left intact. No bursal sided tears were identified in the subacromial space. After completion of the subacromial bursectomy instruments were removed from the shoulder.**
Open subpectoral biceps tenodesis was performed. The patient’s arm was placed in an externally rotated position on a padded mayo stand. The pectoralis major tendon was identified as well as the axillary fold. An incision 1 cm lateral to the axillary fold extending 2 cm distal of the pectoralis major tendon was made with an indelible marker. The skin incision was performed with a 15 blade followed by dissection with electrocautery down to the fascia overlying the long head of the biceps. An interval between the long head of the biceps and short head of the biceps was identified and digitally dissected down to the fascia directly overlying the long head biceps tendon. The sheath was opened with Metzenbaum scissors and the long head of the biceps tendon was delivered with a right angle clamp. Marking the musculotendinous junction, a FiberWire loop on Keith needle was used to whipstitch 1.5 cm distal to the musculotendinous junction. The remaining tendon was excised. Utilizing a Chandler retractor to protect the medial structures, and a Homan retractor to expose the humerus, and an Army-Navy to expose the bicipital groove and retract the pectoralis major tendon superior, the drill guidewire for the Arthrex bio tenodesis screw and button guide was drilled through the anterior and posterior cortex of the humerus. This was followed by an 8 mm acorn reamer through the anterior cortex. Drill guide and reamer were removed from the shoulder. The strands of the biceps tendon were tied through the biceps button using a "marionette" suture technique. The biceps button was placed through the posterior cortex and flipped. The biceps tendon was brought into the tunnel using the marionette suture techniquie. An arthroscopic knot pusher was used to tie off the strands intramedullary. A single strand was passed through the arthrex screw driver and a 7x10mm PEEK screw was inserted into the anterior cortex. The remaining two sutures were tied over the top of the screw and cut. The wound was thoroughly irrigated and the wound was closed with 2-0 Vicryl deep dermal and skin staples.*
All portals were closed with 3-0 monocryl, and dressed with skin glue and steristrips, folded 4 x 4, Tegaderm. Patient was placed in a shoulder sling without abduction pillow, patient was awoken from anesthesia without complication and transferred to the PACU where he recovered without incident and was discharged home.