proximal biceps tenodesis surgical techniques

Proximal Biceps Tenodesis Surgical TechniquesSuprapec and Subpec Approaches

Biceps Tenodesis System

Procedural Efficiency and

Versatility with the Industry

Leading Biocomposite1,2

The MILAGRO BR Biceps Tenodesis System enables subpectoral and suprapectoral

biceps tenodesis in one easy-to-use system. The tendon fork simplifies the procedure

and offers controlled delivery of the tendon to the bone socket. Once the tendon is

in position, a trocar-tipped guidewire is placed, the fork is removed, and the screw

is inserted. The MILAGRO BR System offers surgeons versatility and procedural

efficiency to address each patient's unique needs.

MILAGRO® BR Biceps Tenodesis System

MILAGRO BR Biceps Tenodesis System 2

Features and Benefits 3

Surgical Techniques

– Screw and Socket Sizing Guidelines 4

– Suprapectoral Biceps Tenodesis Technique 5–8

– Subpectoral Biceps Tenodesis Technique 9–10

– Alternative Subpectoral Technique 11

Ordering Information 12

2.

3.

7 x 15 mm 8 x 15 mm 7 x 23 mm 8 x 23 mm 9 x 23 mm

• Clinically Proven MILAGRO BR

Interference Screws1, 2

• Trocar-Tipped 1.6 mm Guidewire

• Tapered Tendon Fork

• 15 mm Modular Tenodesis Driver

• 23 mm Modular Tenodesis Driver

• Guidewire Cap

• Low-Profile Graft Sizer

Features and Benefits

Long fork tines provide tendon control

Tapered tip enables tendon insertion

Forked end estimates tendon size

Fork functions as a drill-pin guide

Depth markings indicate when tendon is fully inserted

4.

Screw and Socket Sizing Guidelines

The MILAGRO BR Biceps Tenodesis System enables secure fixation of the biceps tendon when used with the appropriate socket-to-screw sizing. If performing an arthrosopic tenodesis, the forked end of the tendon fork can be used to estimate the tendon size. If performing the procedure open, the tendon fork or optional tendon and graft sizer can be used to assess the tendon size.

Table 1. Condition: Tendon down and up the socket

Table 2. Condition: Tendon on one side of socket ONLY

Approximate Tendon Size

Approximate Tendon Size

Socket Diameter

Socket Diameter

Screw Size

Screw Size

Tendon Width = Fork Slot

Width (Approximately 3.5 mm)

Tendon Width = Fork Width

(Approximately 5.5 mm)

Tendon Width > Fork Width

(Greater than 5.5 mm)

Tendon Width = Fork Slot

Width (Approximately 3.5 mm)

Tendon Width = Fork Width

(Approximately 5.5 mm)

Tendon Width > Fork Width

(Greater than 5.5 mm)

8 mm

9 mm

10 mm

7 mm

8 mm

9 mm

7 mm

8 mm

9 mm

7 mm

8 mm

9 mm

5.

Suprapectoral Biceps Tenodesis TechniqueScrew and Socket Sizing Guidelines

A suture grasper is inserted through the anterior portal to retrieve the suture.

2. 1.

4. 3.

Arthroscopy confirms the need for a biceps tenodesis. With the arthroscope in the posterior portal, a spinal needle is inserted from an anterolateral location through the skin and through the biceps tendon. A suture is then passed through the needle and through the tendon.

While visualizing from the lateral portal and working through the anterior portal, a VAPR® electrode is used to debride tissue anterior to the tendon. Care should be taken not to damage the underlying biceps tendon.

The tendon is tenotomized from its origin and an anterolateral viewing portal is established. Ideally, the portal will be placed anterior to the midline of the acromion since this portal will be used for visualization during the tenodesis.

6.

Suprapectoral Biceps Tenodesis Technique

A drill pin is inserted through the anteroinferior portal. Drill to a depth that will accommodate the tendon and screw length.

7.

Assess the size of the biceps tendon with the proximal end of the tendon fork. This assessment will be used with Table 1 guidelines to select reamer and screw sizing. Retract the biceps tendon medially using a switching stick.

6.

5.

A spinal needle is inserted superior and lateral to the axillary fold. It should be in direct line with the biceps tendon, perpendicular to the humerus, approximately 1 to 2 cm above the pectoralis major tendon. This establishes an accessory anteroinferior portal location.

Technical note: The accessory anteroinferior portal enables an arthroscopic approach to the biceps tenodesis. Before creating the portal, the tendon should be exposed distally until the upper border of the pectoralis major tendon is visible.

7.


The socket is reamed to a depth that will accommodate the tendon and screw length.

8.

Select an acorn reamer using Table 1. Insert the reamer over the drill pin.

9.

10.

The tendon fork is used to insert the tendon into the socket. If the tendon does not slide into the socket easily, apply pressure to the tendon, remove the fork from the socket, and then reapply pressure. Use the depth indicator to determine when the tendon has been fully seated.

Technical note: Ensure the arm is in the proper position before inserting the tendon in the bone socket. Flexing the elbow after tendon insertion will cause tendon migration in the socket. If the tendon migrates you may encounter difficulty seating the screw. Always ensure the tendon is fully seated and utilitze the depth indicators on the distal end of the tendon fork.

An optional 8.5 mm cannula is also available. The cannula may be used to apply counter-pressure to the proximal end of the socket and tendon during fork removal. This will help ensure the tendon remains at the bottom of the socket.

8.


Insert the screw until it is flush with the bone surface. Maintain visualization of the proximal end of the screw to prevent over-insertion.

13.

The guidewire is removed and any remaining tendon is trimmed.

14.

The tendon fork is removed. A screw is selected using the guidelines in Table 1. The screw is then inserted over the guidewire.

12. 11.

A 1.6 mm guidewire is placed through the cannulation in the fork and through the tendon. The guidewire is tapped into place with the guidewire cap to secure the tendon to the base of the socket. The cap has a positive stop, which prevents the guidewire from being tapped more than 10 mm beyond the base of the socket.

9.

Tenotomize the biceps tendon from its origin on the superior labrum. Make a 2 cm incision near the axillary fold just below the most inferior border of the pectoralis major.

The size of the biceps tendon is assessed with the tendon fork or tendon and graft sizer. Once the tendon is moved medially, the drill pin is inserted and drilled to a depth that will accommodate the tendon and screw length.

1. 2.

Subpectoral Biceps Tenodesis Technique

Select an acorn reamer using Table 1. Insert the reamer over the drill pin and ream to a depth that will accommodate the tendon and screw.

The tendon fork is used to insert the tendon into the socket. If the tendon does not slide into the socket easily, apply pressure to the tendon, remove the fork from the socket, and then reapply pressure. Use the depth indicator to determine when the tendon has been fully seated. Never flex the elbow or apply tension to the tendon once it is seated fully in the socket. Tendon migration in the socket will lead to difficulty advancing the screw.

3. 4.

10.

Subpectoral Biceps Tenodesis Technique

A 1.6 mm guidewire is placed through the cannulation in the fork and through the tendon. The guidewire is tapped into place with the guidewire cap to secure the tendon to the base of the socket. The cap has a positive stop, which prevents the guidewire from being tapped more than 10 mm beyond the base of the socket.

5.

The tendon fork is removed, leaving the tendon at the base of the socket. A screw is selected using the guidelines in Table 1. The screw is then inserted over the guidewire.

6.

7.

Insert the screw until it is flush with the bone surface. Maintain visualization of the proximal end of the screw to prevent over-insertion.

The guidewire is removed and any remaining tendon is trimmed.

8.

11.

Select a screw using Table 2. Insert the screw over the 1.6 mm guidewire until it is flush with the bone surface. Maintain visualization of the proximal end of the screw to prevent over-insertion.

3.

Externalize, whipstitch, and size the tendon. The free end of the tendon can be doubled over, or a loop can be tied off for capture in the fork.

1.

Create a bone socket using the sizing guidelines in Table 2. Utilize the fork to deliver the tendon to the socket.

2.

Alternate Subpectoral Technique

The proximal biceps tenodesis instrumentation is versatile and offers a number of options for performing a biceps tenodesis. Surgeons who prefer to whipstitch the biceps tendon may follow these steps. Refer to the sizing guidelines in Table 2.

Biceps Tenodesis System

DePuy Mitek Inc.325 Paramount DriveRaynham, MA 02767USATel: +1 (800) 382-4682

www.depuy.com

Printed in USA

©DePuy Mitek, Inc. 2012. All Rights Reserved.

P/N 901175 08/12 RDDB/LP

CA #8436

References: 1. “Industry-Leading” claim based on sales of BIOCRYL® RAPIDE™ anchors compared with other second-generation biocomposites. Data on file. DePuy Mitek 3/2012. 2. CT Imaging study of MILAGRO BR Screws: Barber FA, Dockery WD, Hrnack SA. Long-term degradation of a poly-lactide co-glycolide/ß-tricalcium phosphate biocomposite interference screw. Arthroscopy. 2011;27(5):637-643.

Ordering Information

Catalog Number MILAGRO BR Screws

231811 7 x 15 mm Screw

231812 8 x 15 mm Screw

231800 7 x 23 mm Screw

231810 8 x 23 mm Screw

231820 9 x 23 mm Screw

Catalog Number Instrumentation

211321 1.6 mm Guidewire (5/box)

214152 Sterile 1.6 mm Guidewire (1/box)

254729 Calibrated Drill Pin, 2.4 mm x 15 in

219445 Tendon and Graft Sizer, 4–9 mm

219970 Quick-Connect Ratcheting Handle

219971 Guidewire Cap

219447 15 mm Modular Tenodesis Driver

219973 23 mm Modular Tenodesis Driver

219974 Tendon Fork

232402 Sterile Acorn Reamer, 7 mm




219337 Acorn Reamer, 7 mm




proximal biceps tenodesis surgical techniques

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