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The Nord Technique

Glenohumeral arthroscopy is performed in the lateral decubitus position under 10 lbs. of traction as described in the preceding paragraphs. The arm is suspended at approximately a 45-degree angle of abduction and 10 degree forward flexion and distraction of the shoulder joint is accomplished with 10 lbs. of traction. This allows for external and internal rotation of the shoulder while distracted. This technique can be performed in the beach chair position if the surgeon desires.

Four to six portals are utilized during the procedure. The anterosuperior, posterior, and lateral portals are made to obtain visualization of anatomical structures and defects. These portals are also used as working portals and cannulas are utilized. When a rotator cuff repair is necessary, the subclavian, anterolateral and modified Neviaser portals are utilized as necessary for passing suture through the tendon. Anchors for rotator cuff repair are typically inserted through an anterolateral portal without a cannula.

To facilitate biceps tenodesis, the subclavian portal is used for anchor insertion. The subclavian portal is located 1 to 2 cm medial to the AC joint, above and slightly medial to the coracoid, and directly inferior to the clavicle . A cannula is not needed or recommended for this portal. Instruments or anchors are passed inferior and anterior to the AC joint before entering the subacromial bursa. Subacromial decompression optimizes the use of the subclavian portal.

The scope is introduced into the glenohumeral joint through a standard posterior portal. An anterosuperolateral portal is made following the path of a spinal needle. The anatomical structures are visualized and any abnormalities are assessed. Treatment of other pathology is performed as indicated.

The shoulder is evaluated for rotator cuff tears. If present, the rotator cuff defect facilitates access to the biceps tendon. A lateral portal is created and subacromial decompression is performed, which relieves shoulder impingement and facilitates the use of the subclavian portal. The scope is utilized through the posterior portal below the rotator cuff to gain visualization of the biceps tendon. Using a burr through the lateral portal, a small area of the articular and bony surface is abraded under the biceps tendon, just proximal to the bicipital groove.

A spinal needle is inserted through the subclavian portal in order to identify the tract through the CHL to the biceps tendon. A 3 mm incision is made for the subclavian portal and no cannula is used. A suture anchor, 5 mm (preferred) or 3.5 mm, is passed through the subclavian portal entering the joint through the rotator interval.

The suture anchor is then placed through the biceps tendon slightly proximal to the bicipital groove. Lifting the biceps tendon with a probe will help facilitate visualization of the anchor through the biceps tendon and embedding into bo.

The subclavian approach allows fixation of the tendon “in-situ” just proximal to the point at which the tendon enters the bicipital groove. The anchor can be placed directly through the biceps or adjacent to it. Sutures are passed with a penetrating suture grasper such as the Penetrator or Bird Beak (Arthrex, Inc. Naples, FL) or with suture passers such as the Viper or Scorpion (Arthrex, Inc. Naples, FL).

The sutures can be passed via the subclavian or anterosuperolateral portal—whichever provides a better angle. The biceps is left attached while the suture anchor is inserted through the tendon. If a rotator cuff tear is present, the sutures through the biceps may be tied through the lateral portal; however, if a rotator cuff tear is not present, sutures are tied through the anterior portal.

One limb of the suture is pulled underneath and over the biceps tendon, and then out the appropriate portal with a crochet hook. The sutures are each tied. Knot security and loop security are assessed. A second suture anchor is introduced into the subclavian portal, passed through the biceps tendon slightly proximal to the other suture anchor, and sutures retrieved. The biceps tendon is found to be firmly attached by testing the tenodesis with a hook probe.

The residual intra-articular biceps tendon is released from a site just proximal to the sutures using a basket cutter and the remaining stump is excised at the point of attachment at the superior glenoid labrum utilizing a basket cutter and shaver. Arthroscopic rotator cuff repair is performed as necessary after the completion of the biceps tenodesis.

The tenodesis will not add any significant bulk beneath the rotator cuff repair and allows for normal shoulder motion. During range of motion testing of the shoulder and elbow, stability of the biceps tenodesis is arthroscopically assessed.

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