---
title: 'Transitioning to Transosseous at the ASC/hospital and Surgical Tips'
type: 'lesson'
url: 'https://doc.social/courses/transos-expertsroundtable-discussion/transitioning-to-transosseous-at-the-asc-hospital-and-surgical-tips'
course: 'TransOs ExpertsRoundtable Discussion'
course_url: 'https://doc.social/courses/transos-expertsroundtable-discussion'
position: '5 of 7'
author: 'Brett Sanders'
transcript: 'yes'
---

# Transitioning to Transosseous at the ASC/hospital and Surgical Tips

## Summary

_This lesson is a recording without a written summary._

## Transcript

2,321 words · 14 min · 4 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:00] Speaker 1: Um, that's great. Um, so, uh, well, why don't we just segue straight to Doctor Patterson then next for, I believe we're gonna talk about some techniques for biceps tenodesis, which is yet another anchor that people kind of leave out when they're talking about cuffs, but I don't know about you guys, but I'm a biceps killer and
[0:20] Speaker 1: There's, there's rarely one that survives, and, uh, so that's a, you know, that's you plus one on basically all cuff, cuff repairs.
[0:27] Speaker 1: And uh we, we studied that. I wrote up JP Warner's patients and found that the location didn't really matter, so
[0:36] Speaker 1: Super pectoral is a great place, you know, in my opinion, to, uh, to 10 of these things. And I think that's where Doctor Patterson is going to. So let's, let's see how he does it.
[0:45] Speaker 2: Um, thanks for having me. Uh, absolutely happy to be here. Um, as I kind of mentioned earlier, I've been in practice for about 9 years and basically been a, a tunneler guy, uh, transo guy ever since I came out. Um, biceps is one of those things I've gone back and forth. I've used probably most techniques that you can imagine.
[1:05] Speaker 2: Um, finally, uh, eventually came up with, uh, this, uh, uh, transosseous technique. So I, I'm not really gonna talk about indications, although, um, like Brett mentioned, uh, it's very rare that if I'm doing a cuff, um, that the biceps doesn't get anonymized or tenoded. Um,
[1:27] Speaker 2: So yeah, it, it's a pretty common indication for me that I'm doing a tenodesis.
[1:33] Speaker 2: So, um, again, just, uh, real quick about this technique in, in particular, as we've mentioned, it's clearly cheaper than using uh anchors or interference screw or whatever Other biceps, um, implant you're gonna use. It's all arthroscopic, although I do, um, spend a minute preparing the biceps outside the joint as you'll see.
[1:55] Speaker 2: Um, it opens up the groove. So people talk about groove Pain, whether it's from not opening the groove or putting an interference screw in there. This, this, uh, reduces the risk of that.
[2:06] Speaker 2: Um, you do, you tie one single knot. I, I believe it's a self-reinforcement construct, and I'll kind of show a little.
[2:14] Speaker 2: Rudimentary slide of that at the end of it.
[2:18] Speaker 2: And the thing that really sold me on this is that
[2:22] Speaker 2: Um, there is some evidence that even with an interference screw technique, the healing occurs where the biceps is contacting the humerus on, on the outside. It's not in the socket where the actual healing occurs. So, you know, then, you know, why would he even put an interference screw in there? So.
[2:40] Speaker 2: That's kind of the rationale.
[2:42] Speaker 2: Um, these are my standard portals, uh, posterior portal, uh, posterolateral for Rotator Cuff, anterolateral, anterior portal, and then the, the B is the biceps portal that usually ends up being, uh, pretty much in between anterior and anterolateral. Um, it's generally, uh, pretty much anterior with the arm and about 10 degrees of internal rotation, which, uh, puts you pretty much in line with the bicipital groove.
[3:07] Speaker 2: Um, intertraarticularly, uh, first, we localize the biceps. We're going to decide, we're going to do a, a, a tenodesis and then uh percutaneously place a spinal needle to essentially tag and immobilize the biceps. So I tagged the biceps with the spinal needle and then release it.
[3:26] Speaker 2: Um, before I do the tenodesis. So the biceps is, is tenotomized, but it's tagged with the spinal needle. Then once I'm in the subacromial space, I'll find that spinal needle. So this is with the scope and the anteterottal portal, um, viewing. So this tells me exactly where the biceps is. So, you know, for some Other techniques, um, if you're trying to find the bicipital groove once you're in the subacromial space, sometimes that's not so easy. This makes it, you know, you don't have to think about it. So what I've always said is,
[3:56] Speaker 2: The less I have to think during Surgery, uh, the better. Um, so I don't even have to think about it. That's exactly where the biceps is.
[4:03] Speaker 2: Um, then next I established the biceps portal, so that's done using an outside-in technique using the spinal needle. So this, this Other second spinal needle is, uh, you know, I'm making sure that that portal is in line with the bicipital groove.
[4:18] Speaker 2: And then, uh, basically through that biceps portal, we'll, we'll open up uh the bicipital groove and clean it out, breed it. Um, the Other thing I really like about opening up the bicipital groove is, you know, occasionally in that uh anterior bicipital groove, you'll see a little subscap split tear, and this is how I fixed the subscap too. So.
[4:38] Speaker 2: Um, it makes it very, very easy if there's that split tear, the subscap. Um, you just put a tunnel there and fix that, and then you can do your biceps tenodesis on top of it. So that, when I, when I'm doing a cuff and biceps, that's how I do it. It's subscap first, biceps tenodesis, and then posterior superior cuff repair.
[4:58] Speaker 2: Then the biceps is uh exteriorized and I remove about the proximal 1 centimeter or so and just do a quick whip stitch with whatever suture of choice, um, you, high tensile strength suture you want to use. I typically don't use tape. I'm sure you could. Um, I just have used suture.
[5:16] Speaker 2: Uh, so prepare the biceps and then put it back in the joints and bring the, the sutures out through the posterior portal.
[5:23] Speaker 2: And then I'll, I'll prepare the bone. I, I'm a big believer in preparing the bone. I, I, I really, you know, whether this is true or not, I, I was very intrigued to hear that there's Research that shows you can leave Sharpie fibers on the greater tuberosity. So maybe that's gonna change my philosophy about that a little bit. But I've been a very aggressive, uh, bone preparer. I really think you need to get it down to bleeding, um, you know, Bone Marrow elements.
[5:49] Speaker 2: So this is what it looks like after I've repaired it. So, you know, I, I want to put the biceps on there and have something for it to heal to.
[5:58] Speaker 2: Um, so punch the, the first tunnel at the superior aspect of the bicipital groove, and then it's kind of hard to see, but here's the transos.
[6:08] Speaker 2: The, the medial hook of the transos and then the lateral, uh, that's where the lateral punch goes. So the tunnel is in the bicipial groove in line with the bicipital groove. So you got the, the loop coming out medially, the, the two Other sutures coming out laterally.
[6:26] Speaker 2: And then
[6:29] Speaker 2: We'll grab the sutures that are tagging the biceps through that loop, so the
[6:36] Speaker 2: Suture grabber goes through the loop.
[6:41] Speaker 2: Grab the sutures and pull them through.
[6:46] Speaker 2: And then you use the, the lateral limbs of the shuttling suture to shuttle the biceps sutures through the tunnel.
[7:03] Speaker 2: And then this, this picture, so this is a different, this is a right Shoulder, that was a left Shoulder. So these are the sutures coming out through the biceps. That's the medial tunnel.
[7:14] Speaker 2: Out laterally, then I'll grab one around each side of the biceps and tie it down. So there's, there's two points of fixation. There's a point where the biceps is attached medially at the medial tunnel, and then it's circled around the biceps laterally.
[7:32] Speaker 2: Um, so it, it, it probably attaches about 1.5 to 2 centimeters of the biceps like onlay technique uh onto the proximal humerus.
[7:41] Speaker 2: Um, so this is kind of what it looks like at the end. That's that, that's the, the lateral tunnel, and then the biceps is fixed medially and the same thing.
[7:51] Speaker 2: Uh
[7:52] Speaker 2: Another video, I think it provides pretty stable fixation.
[7:57] Speaker 2: And kind of compression of that proximal.
[8:00] Speaker 2: You know, that good 1 centimeter, centimeter, half of the biceps onto the bone.
[8:05] Speaker 2: And, and I, I like the idea that it's out of the cuff repair. I, I, I'm a little
[8:12] Speaker 2: Ififfy about, you know, repairing the, the orinoduing the biceps kind of in the Rotator cuff repair. I, I'm, I'm not sure I want stuff in between the Rotator Cuff and the, and the tuberosity, so.
[8:23] Speaker 2: I know some really smart people do it that way. I'm just not sure that's for me.
[8:28] Speaker 2: Um, so this was my
[8:31] Speaker 2: Amazing, uh, drawing of, uh, you know, with, with this technique.
[8:38] Speaker 2: Um, if you're contracting the biceps and you're getting kind of that downward contraction of the biceps, that what's going to happen is it's, it's going to pull on these sutures, which is going to tighten that cerclage suture. So it's, that's why I call it a self-reinforcing technique.
[8:53] Speaker 2: Um,
[8:55] Speaker 2: You know, whether that's actually true or not, I haven't done a Research study on it, but I mean it's almost like a little finger trap, you know, if you pull on it, it's going to make it tighter.
[9:05] Speaker 2: Um, so then I guess the argument would be like, does that lead to failure and you know, although I'm, I've been doing this technique for a couple of years, so I mean, I don't know how many I've done a few 100 of them and
[9:16] Speaker 2: You know, I, I'm sure I've had failures, um, but I have not revised one. So if it fails, um, people here don't notice it.
[9:25] Speaker 2: Um, or maybe it just feels, you know, maybe it pulls a little and it heals. I, you know, I
[9:30] Speaker 2: When I used to use interference screws and Other various techniques, you know, I was revising a couple of them a year. Um, I have not yet revised one of these, so that's, that's my take on it.
[9:42] Speaker 2: Um, interested to hear what, what anyone else has to say about it. Maybe they think I'm crazy doing it this way, but.
[9:52] Speaker 2: Appreciate the opportunity.
[10:02] Speaker 3: Great talk. Um, I, I didn't even think about doing the tenodesis that way.
[10:10] Speaker 3: But I
[10:12] Speaker 3: I, I like the idea of it, um.
[10:16] Speaker 3: I've, I've incorporated, I do it two ways. I incorporate it into the cuff repair and I, I do it, um,
[10:24] Speaker 3: Where I'm passing um my tunnel through the, the groove but out laterally, um, through the greater tuberosity.
[10:31] Speaker 3: Um,
[10:33] Speaker 3: And I kind of leave the biceps in situ. Sometimes I still leave it attached, um, uh, to the labrum and that, those are usually cases where there's biceps instability and um I'll secure the biceps into the groove, hold it there. It'll tina de there, but that might be a patient who needs, uh, maybe a little, uh, SCR, uh, type help with uh the biceps. Uh, there might be some advantages. If they have a slap tear, I don't leave it attached.
[11:01] Speaker 3: But, um, it does give me that option, I suppose. Uh, but I like that technique. Um.
[11:08] Speaker 3: And I like staying within the groove there, so great talk, great
[11:11] Speaker 3: technique.
[11:12] Speaker 2: Thank you.
[11:13] Speaker 2: Yeah, that's the Other thing is uh the whole using the biceps as your kind of SCR. So, um, that, that's, you know, not related to this particular technique, but something that can easily be done using the uh transosseous technique as well.
[11:32] Speaker 1: Yeah, I'll keep it attached, um, and, uh,
[11:38] Speaker 1: A lot of times we'll whip stitch it in the, within the anterior tunnel adjacent to the cuff tear, uh, do a Mason Allen suture, uh, on, on it, circlage type suture, and often if there's a subscap tear, I'll tunnel and keep it, keep it inside you and spear it on purpose, you know, tunnel through it simultaneously tenodesing the, you know, the, the biceps and repairing the, uh, subscap at the same time just for time.
[12:03] Speaker 1: I tend to use the horizontally-oriented tunnels, um, but, uh, I could see how I've done your technique a couple of times where I just wanted to save time and just have two fixation points for one there by vertically orienting. So I have used that a few times, um, to save time.
[12:20] Speaker 1: So,
[12:22] Speaker 1: You taught me that.
[12:24] Speaker 1: Um, cool. Uma, how do you do it? Are you still with us?
[12:29] Speaker 4: Yeah, yeah, I'm here. That's, that was great talk, uh, well. Um, that's an interesting technique. I think that, I think you're right. It, it is a self-reinforcing, and I think that's true for the cuff tunnels as well. I mean, it's essentially, uh, uh, almost like a tension band type technique. So if you're, if you're tying your knots in a little bit of abduction, when they, when they bring their arm down, it, it should reinforce that repair.
[12:52] Speaker 4: You know, to get tighter. Uh, so I think that's a nice way of, of doing it. But I, yeah, I'll typically, if I'm doing it high, I actually prefer subpecs, so I'm just completely out of the groove here completely. But this, uh, if I do have to do it high, if there's an enchondroma or something I'm trying to avoid, um, I'll just usually bring it in, just, uh, into the high groove or next to the anterior part of the repair.
[13:15] Speaker 4: I like you, Brett.
[13:18] Speaker 1: Yeah, um, I've actually done a couple of biceps, LHB biceps, uh, autographed SCRs using a tunnel, suragging the biceps, tenodesing its pectorally, then incising it, swinging it over, and when you have that bicep, you have that, uh, you have that biceps control suture that you can pass through a tunnel.
[13:41] Speaker 1: With the two-point fixation of a tunnel, you can actually secure that quite nicely. Um, I've got some video of that I might be able to find here.
[13:50] Speaker 1: Um, but, um,
[13:52] Speaker 1: Let me see if I can uh.
[13:55] Speaker 1: Go ahead and show first what we were when I was planning on doing here.

## In this course

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- [Next: Clinical Adoption of Modern Transosseous Repair](https://doc.social/llms/courses/transos-expertsroundtable-discussion/clinical-adoption-of-modern-transosseous-repair.md)
- [All lessons: TransOs ExpertsRoundtable Discussion](https://doc.social/llms/courses/transos-expertsroundtable-discussion.md)