Safety of the “Inside-out” Radiofrequency Ablation Technique for Rapid Localization of

the Biceps Tendon in the Subacromial SpaceAdnan Saithna1,2 , Alison Longo1,3, Jeff Leiter1,3, Peter MacDonald1,3, Jason Old1,3

1Pan Am Clinic Foundation, Winnipeg, MB; 2Ormskirk Hospital,UK; 3Faculty of Medicine, University of Manitoba.

Study Methodology, Surgical Technique and Results

Introduction

Discussion

Conclusion

References

The study was awarded health research ethics board approval. A single forequarter amputation specimen (age 73) was evaluated. The surgical technique was recorded by video [1] and a subsequent open dissection was performed to evaluate whether any injury had occurred to the rotator cuff. After performing a diagnostic arthroscopy of the glenohumeral joint an antero-superior rotator interval portal was created. This was localized with an 18 gauge spinal needle whilst viewing intra-articularly through a standard posterior portal. The optimum needle position was located immediately adjacent to the leading edge of supraspinatus and in front of the biceps pulley with direct “line of sight” from the portal into the bicipital groove (Fig 1). A number 11 blade was used to create the portal and a radiofrequency device (both 9700 series radiofrequency ablation device, Arthrex, Naples, Florida and Turbovac 90, ArthroCare, Austin, Texas have been previously used) was then inserted into the bicipital groove (Fig 2.). This was left in-situ while the arthroscope was transferred into the subacromial space via the lateral portal. The electocautery device was then located distal to the transverse humeral ligament and rotated to face away from the biceps tendon (Fig 3) and then used to divide the THL from distal to proximal, under direct vision, thus releasing the LHB tendon (Fig 4). At open dissection it could clearly be seen that no iatrogenic injury occurred to either subscapularis or supraspinatus tendons and that only the transverse humeral ligament had been divided

This technique minimizes the need for an aggressive bursectomy and reduces the risk of iatrogenic injury that may occur to the rotator cuff when searching for the LHBT when using a standard technique. “Inside-Out” division of the THL also has the major advantage of offering a rapid method of tendon localization, which can potentially reduce the overall duration of surgery.

Arthroscopic biceps tenodesis requires localization of the long head of biceps tendon (LHBT) within the subacromial space. Even in experienced hands variable amounts of synovitis and bursal scarring can impede visualization and require the surgeon to spend a great deal of time excising this tissue in order to achieve an adequate view.

The inside-out radiofrequency ablation technique is a novel procedure that was devised to allow rapid LHBT localization. Although numerous techniques for localization are previously reported, none of these avoid the requirement for some degree of “searching” for the tendon. It is that process that can lead to iatrogenic injuries of the adjacent rotator cuff tendons which may then be a cause of persistent post-operative anterior shoulder pain. The aim of this study was to evaluate the safety of this novel and rapid technique with regard to the risk of iatrogenic injury to the rotator cuff in a cadaveric specimen.

This procedure is easy to perform in both beach chair and lateral decubitus positions. It allows rapid localization of the biceps tendon and minimizes the risk of injury to the adjacent rotator cuff tendons. This is demonstrated by the cadaveric dissection performed to assess the safety of this technique (Fig 5), which shows no evidence of injury to the cuff. We postulate that iatrogenic injury may be one of the causes of ongoing anterior shoulder pain after surgery. The rate of anterior shoulder pain after biceps tenodesis is variably reported. Heckman, et al. stated that excellent pain relief was consistently achieved in greater than 90% of patients in a number of recent studies [2]. However, several authors have reported a significantly higher revision rate of between 21-36% for proximal tenodeses and less than 3-7% for open subpectoral tenodeses [3,4]. They suggested that the difference may be due to residual pain generating elements in the groove and other authors have reported similar findings. However, it is apparent that persistent anterior shoulder pain is not clearly understood and that it is of multifactorial etiology. To our knowledge the role that iatrogenic injury to the rotator cuff has to play in persistent post-operative pain has not previously been considered in the literature.

Fig 1. Left shoulder: Needle localisation of the anterosuperior rotator interval (RI) portal immediately anterior to the leading edge of supraspinatus (SS) with direct “line of sight” into the bicipital groove

Fig 2. Radiofrequency device being inserted into bicipital groove whilst viewing from standard posterior portal

Fig 3The radiofrequency device is located distal to the THL whilst viewing from a lateral subacromial space portal. As can be seen in the picture an extensive bursectomy is not needed

Fig 4. The transverse humeral ligament is then released from distal to proximal – a process that allows quick and easy localization of the LHBT

SS

RI

LHBT

LHBT

Fig 5. Left shoulder viewed from anteriorly after excision of deltoid from acromion (A). LHBT removed (for separate study) allowing visualisation of bicipital groove (BG). Lesser Tuberosity (LT) and Greater tuberosity (GT) identified. No injury to adjacent rotator cuff tendons

GT

LT

BG

A

Study supported by the Pan Am Foundation

1. Saithna A, et al. Safety of the “Inside-Out” Radiofrequency Ablation Technique for Rapid Localization of the Biceps Tendon in the Subacromial Space. TSES 2016;7(2):98-992. Heckman DS, et al. Management of failed biceps tenodesis or tenotomy: causation and treatment. Sports Med. Arthrosc. Rev 2010;18:173–180 3. Friedman DJ, et al. Proximal biceps tendon: injuries and management. Sports Med. Arthrosc. Rev 2008;16:162–169 4. Sanders B, et al. Clinical success of biceps tenodesis with and without release of the transverse humeral ligament. JSES 2012;21:66–71