Transillumination of the bicipital groove: a novel technique for localization of the long head of biceps tendon in the subacromial space

L ocalization of the long head of biceps tendon from within the subacromial space during an arthroscopic tenodesis procedure can be technically challenging. Even in experienced hands the variable anatomy of the bicipital groove and the degree of synovitis, bursal scarring and investing adventitial tissue can impede visualization and require the surgeon to spend a great deal of time excising this tissue to achieve an adequate view. Several authors have described techniques to facilitate localization. Boileau et al. recommended placing the shoulder in approximately 30 degrees of flexion, 10--30 degrees of internal rotation, and 30 degrees of abduction. Positioning in a standard way helps the surgeon to gain familiarity with the expected location of the tendon. Furthermore, doing so allows the anterior part of the subacromial bursa to be adequately distended by fluid, allowing a clear view of the superior part of the bicipital groove. However, extensive shaving of the anterior part of the bursa often is still required before the groove can be identified. This can be difficult, and an additional useful landmark is the falciform ligament of the pectoralis tendon. This ligamentous structure can be identified by the intersection of the transverse fibers of the pectoralis fascia with the longitudinal fibers of the biceps sheath. Once identified, the ligament is divided revealing the long head of the biceps tendon. However, this landmark also can be difficult to distinguish from thickened and scarred bursal tissue and so other techniques, such as placing a needle into the intraarticular part of the tendon and then locating it from the subacromial space, also have been described. Although these ‘‘surgical pearls’’ help guide localization of the tendon, none of these techniques avoid the requirement for some degree of ‘‘searching,’’ and it is that process that can lead to iatrogenic injuries of the adjacent subscapularis and supraspinatus tendons, which may be a cause of persistent pain after surgery. The technique described below uses transillumination of the bicipital groove to rapidly localize the tendon and reduce the risk of iatrogenic injury that can occur when searching for it using conventional techniques. The surgical technique was documented in a single freshfrozen forequarter cadaver specimen (age 85) with an intact distal extremity. The study was awarded health research ethics board approval. The specimen was thawed for a minimum of 24 hr before assessment. The surgical technique was recorded by photography.