Biceps Autograft Augmentation for Rotator Cuff Repair: A Systematic Review

The Arthroscopic Biceps Rerouting Technique Shows Better Early Clinical Outcomes within 1 Year Than Partial Repair in Large to Massive Rotator Cuff Tears

Background and Objectives: The arthroscopic biceps rerouting (BR) technique was introduced as a novel technique for large-to-massive rotator cuff tears (LMRCTs). This method can restore shoulder stability, and its biomechanical effect was verified in a cadaver experiment. Recent reports have shown favorable clinical outcomes. This study aimed to compare the clinical outcomes of partial repair with those of the BR technique in LMRCTs. Materials and Methods: We included 72 patients who had undergone LMRCTs. Arthroscopic partial repair was performed in 31 patients (group I), while repair with the BR technique was performed in 41 patients (group II). Functional and imaging outcomes were evaluated and compared using a visual analog scale for pain, range of motion (ROM), American Shoulder and Elbow Surgeons (ASES) score, Constant score, and Korean Shoulder Score (KSS) before the surgery and at 3, 6, and 12 months after the surgery and at the last follow-up. Tendon integrity was investigated using magnetic resonance in all the patients at 12 months postoperative. Results: The mean follow-up period was 22.11 ± 10.47 months (range, 12-53 months). Forward flexion (p = 0.02) and external rotation at the side (p = 0.04) were significantly higher in group II than in group I on postoperative day (POD) 12 months. For internal rotation, group II showed significant improvement compared to group I on POD 3 months (p = 0.002) and at 6 months postoperative (p = 0.01). On POD 12 months, the ASES (p = 0.047) and KSS (p = 0.048) were better in group II. Significant improvements in pain and clinical scores were observed in both groups at the last follow-up. However, the two groups had no significant differences in pain, clinical scores, or ROM at the last follow-up. Retear of the repaired tendon was observed in nine patients in group I (29.03%) and eight in group II (19.51%, p = 0.35). Conclusions: Partial repair and repair using the BR technique effectively improved clinical and radiologic outcomes. The BR technique revealed early recovery of ROM and better clinical results than partial repair at one year postoperative. This could be a useful method in treating LMRCTs.

Arthroscopic Superior Capsular Reconstruction Using Hybrid Autologous Fascia Lata and the Long Head of Biceps Tendon Graft: the Central Beam Concept

Superior capsular reconstruction is a joint salvage treatment option for retracted irreparable rotator cuff tears in relatively young patients. Various graft options have been described in the literature, including autologous fascia lata graft, synthetic graft, and dermal patches. Superior capsular reconstruction using long head of biceps tendon autograft alone has also been described by few authors. In this technical note, we describe a modified technique of performing arthroscopic superior capsular reconstruction using both fascia lata graft and the intra articular portion of the long head of biceps tendon. Our technique resembles central beam concept over which the fascia lata graft is anchored, providing good structural support to the graft and enabling graft healing and improved clinical outcomes.

Editorial Commentary: Shoulder Long Head of the Biceps Tendon Transposition Without Tenotomy May Be a Beneficial Augment for Massive Rotator Cuff Tear Repair

Although many surgeons discard the long head of the biceps (LHB) tendon during arthroscopic rotator cuff repairs, several authors have argued that the LHB tendon may serve as a biologic and structural augment for massive repairs. There are multiple benefits of incorporating the LHB tendon autograft in difficult-to-repair massive rotator cuff tears. First, by maintaining the glenoid origin, the tendon likely retains a significant native blood supply, as well as tenocytes, which may support the healing process. In addition, there are several biomechanical benefits. The LHB may act as a dynamic humeral head depressor since it is still attached to the muscular unit distally. The tendon could also serve as a convergence post, while proving robust tissue for the repair. Also, the LHB tendon may decrease undue tension on the repair, bringing us closer to a tension-free repair. Finally, this may be a cost-conscious technique. One concern, requiring additional investigation, is that some surgeons believe the LHB may be a pain generator in patients with rotator cuff tears. One surgeon's trash is another surgeon's treasure.

Rotator Cuff Augmentation: Its Role and Best Practices

Rotator cuff tears are a common source of pain and impairment in the shoulder. Healing of the rotator cuff tendons following repair has been associated with improved patient outcomes. While there have been many technical improvements in surgical techniques for rotator cuff repair, failure rates are still surprisingly high. Augmentation of these repairs has been shown to help with fixation biomechanics as well as healing rates. The described types of augments include autograft, allograft, xenograft, and synthetic options. This report reviews the commonly available types of augments and some of the outcomes associated with their use.

Double Attack Repair for Massive Rotator Cuff Tears: Superior Capsular Reconstruction Using the Long Head of Biceps Tendon Plus Margin Convergence Repair

Arthroscopic repair of massive retracted rotator cuff tears is very challenging with a high incidence of retears. Many techniques have been described to improve the outcomes of arthroscopic repair. In this technique, a superior capsular reconstruction using the long head of the biceps is combined with margin convergence repair aimed at improving the mechanical strength of the repair. The long head of the biceps is used as a superior capsular reconstruction to stabilize the humeral head and prevent proximal migration. Moreover, margin convergence provides an efficient gap filling between remnants of the supraspinatus and infraspinatus tendons to restore an efficient rotator repair in anatomical, biological, and tension-free fashion.

Long head of biceps tendon transposition for massive and irreparable rotator cuff tears: A systematic review and meta-analysis

BACKGROUND

Superior capsular reconstruction (SCR) with long head of biceps tendon (LHBT) transposition was developed to massive and irreparable rotator cuff tears (MIRCTs); however, the outcomes of this technique remain unclear.

AIM

To perform a systematic review of biomechanical outcomes and a meta-analysis of clinical outcomes after LHBT transposition for MIRCTs.

METHODS

We performed a systematic electronic database search on PubMed, EMBASE, and Cochrane Library. Studies of SCR with LHBT transposition were included according to the inclusion and exclusion criteria. Biomechanical studies were assessed for main results and conclusions. Included clinical studies were evaluated for quality of methodology. Data including study characteristics, cohort demographics, and outcomes were extracted. A meta-analysis was conducted of the clinical outcomes.

RESULTS

According to our inclusion and exclusion criteria, a total of six biomechanical studies were identified and reported an overall improvement in subacromial contact pressures and prevention of superior humeral migration without limiting range of motion (ROM) after LHBT transposition for MIRCTs. A total of five clinical studies were included in the meta-analysis of LHBT transposition outcomes, consisting of 253 patients. The results indicated that compared to other surgical methods for MIRCTs, LHBT transposition had advantages of more significant improvement in ROM (forward flexion mean difference [MD] = 6.54, 95% confidence interval [CI]: 3.07-10.01; external rotation [MD = 5.15, 95%CI: 1.59-8.17]; the acromiohumeral distance [AHD] [MD = 0.90, 95%CI: 0.21-1.59]) and reducing retear rate (odds ratio = 0.27, 95%CI: 0.15-0.48). No significant difference in American Shoulder and Elbow Surgeons score, visual analogue scale score, and University of California at Los Angles score was demonstrated between these two groups for MIRCTs.

CONCLUSION

In general, SCR with LHBT transposition was a reliable and economical technique for treating MIRCTs, both in terms of biomechanical and clinical outcomes, with comparable clinical outcomes, improved ROM, AHD, and reduced the retear rates compared to conventional SCR and other established techniques. More high-quality randomized controlled studies on the long-term outcomes of SCR with LHBT transposition are required to further assess.

The long head of the biceps tendon: a valuable tool in shoulder surgery

ANATOMY AND FUNCTION

The long head of the biceps tendon (LHBT) has different properties and characteristics that render it a valuable tool in the hands of shoulder surgeons. Its accessibility, biomechanical strength, regenerative capabilities, and biocompatibility allow it to be a valuable autologous graft for repairing and augmenting ligamentous and muscular structures in the glenohumeral joint.

SHOULDER SURGERY APPLICATIONS

Numerous applications of the LHBT have been described in the shoulder surgery literature, including augmentation of posterior-superior rotator cuff repair, augmentation of subscapularis peel repair, dynamic anterior stabilization, anterior capsule reconstruction, post-stroke stabilization, and superior capsular reconstruction. Some of these applications have been described meticulously in technical notes and case reports, whereas others may require additional research to confirm clinical benefit and efficacy.

CONCLUSION

This review examines the role of the LHBT as a source of local autograft, with biological and biomechanical properties, in aiding outcomes of complex primary and revision shoulder surgery procedures.

Rotator Cuff Repair with Knotless All-Suture Medial Row Anchors and Biceps Autograft Augmentation

Incomplete healing and/or functional failure following rotator cuff tear repair remains a challenging problem for both patients and surgeons. Augmentation strategies are growing to increase healing through biologic and mechanical mechanisms to improve functional results after arthroscopic rotator cuff repair. The majority of currently described augmentation techniques use allograft tissue. An alternative, low-cost, autograft option for augmentation is the use of the long head of biceps tendon autograft as a free functional graft. Here, we describe the use of autograft biceps tendon as a viable option for augmentation of double-row rotator cuff repair with knotless all-suture suture anchors.

Current Understanding and New Advances in the Surgical Management of Reparable Rotator Cuff Tears: A Scoping Review

Rotator cuff (RC) tears are among the most common musculoskeletal disorders and can be associated with pain, weakness, and shoulder dysfunction. In recent years, there have been significant advances with regard to the understanding of rotator cuff disease and its management. With technological improvements and advanced diagnostic modalities, there has been much progress as to improved understanding of the pathology. Similarly, with advanced implant designs and instrumentation, operative techniques have evolved. Furthermore, refinements in postoperative rehabilitation protocols have improved patient outcomes. In this scoping review, we aim to provide an overview of the current knowledge on the treatment of rotator cuff disorders and to highlight recent advances in its management.

Compressed Biceps Autograft Augmentation of Arthroscopic Rotator Cuff Repair

Rotator cuff repair failure rates continue to be a challenging problem. Various methods of biological and structural augmentation of the rotator cuff have been explored to improve tendon healing after repair. We describe a technique in which biceps tendon autograft is harvested after tenodesis. The biceps tendon is then compressed into a patch that is placed over the repaired rotator cuff tendon. Repurposing the portion of the tendon that is otherwise discarded offers several advantages over other augmentations that have been used, including the biological potential of live autograft tenocytes in the patch, lower cost, and no donor-site morbidity.

Partial Superior Capsular Reconstruction to Augment Arthroscopic Repair of Massive Rotator Cuff Tears Using Autogenous Biceps Tendon: Effect on Retear Rate

BACKGROUND

Massive rotator cuff tears have a high incidence of postoperative retear that can reach 90%. It is still unclear which intervention may reduce the incidence of retear and improve the functional and clinical outcomes.

PURPOSE/HYPOTHESIS

The purpose of this study was to investigate the clinical and structural outcomes at 2 years after repair of reparable massive rotator cuff tears with and without the use of partial superior capsular reconstruction (pSCR), using the autologous long head of the biceps tendon (LHBT) as a graft. It was hypothesized that augmentation with a pSCR would decrease retear rates.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

The authors compared arthroscopic repair of massive posterosuperior rotator cuff tears with and without augmentation using the LHBT for pSCR between 2015 and 2017. After applying the selection criteria, 106 patients were included in the study and distributed into 2 groups of 50 and 56 patients. Patients in the first group (50 patients) underwent arthroscopic repair without use of the LHBT (AR group), and patients in the second group (56 patients) underwent arthroscopic repair with use of the LHBT for pSCR (AR-LHBT group). The structural outcome was evaluated by ultrasound at 2 years of follow-up. Function and pain were evaluated preoperatively and at the 2-year follow-up using the American Shoulder and Elbow Surgeons (ASES) score and visual analog scale (VAS). Pre- and postoperative active range of motion, including forward elevation, external rotation, and abduction, were also documented.

RESULTS

No significant differences were found between groups regarding the baseline characteristics. After 24 months, both groups showed significant improvement from preoperative ASES scores, VAS score, and active range of motion (P < .01 for all). Patients in the AR-LHBT group showed significant improvements in postoperative functional and pain scores compared with the AR group in all measurements at the 2-year follow-up (ASES score: 77.23 ± 7.45 vs 71.04 ± 9.28, P < .01; VAS score: 1.64 ± 1.03 vs 2.12 ± 1.06, P < .01). Final range of motion was significantly increased for the AR-LHBT group for forward elevation (155 [interquartile range {IQR}, 150-160] vs 150 [IQR, 140-170]; P < .01) and abduction (150 [IQR, 140-157.5] vs 120 [IQR, 100-140]; P < .01), but external rotation was significantly greater for the AR group (54.43 ± 10.55 vs 59.5 ± 10.55; P < .01). Postoperative ultrasonography at the 2-year follow-up revealed a higher retear rate in the AR group than in the AR-LHBT group (46% vs 14%; P < .01).

CONCLUSION

Use of the LHBT for pSCR to augment massive rotator cuff tears resulted in markedly lower retear rates and modestly improved pain and function outcomes compared with repair alone.

Biceps-incorporating rotator cuff repair with footprint medialization in large-to-massive rotator cuff tears

PURPOSE

In large-to-massive rotator cuff tears (MRCTs), incorporating the long head of the biceps tendon (LHBT) with arthroscopic partial rotator cuff and margin convergence can improve clinical outcomes and preserve the acromio-humeral interval (AHI) during mid-term follow-up. The purpose of this study was to evaluate mid-term clinical and radiological outcomes of arthroscopic biceps-incorporating rotator cuff repair with partial release of the LHBT and footprint medialization through the Neviaser portal in MRCTs.

METHODS

This study enrolled 107 patients (38 males and 69 females, mean age: 64.9 ± 8.6 years) with MRCTs. A novel arthroscopic biceps-incorporating repair was performed by footprint medialization, with a partially released biceps tendon covering central defects. Clinical outcomes such as pain VAS, KSS, ASES, UCLA, SST and CS scores and ROM were evaluated at a mean follow-up time of 35 months (range 12-132 months). Serial radiographs with a mean postoperative MRI follow-up duration of 33 months were used to evaluate AHI, tendon integrity, fatty infiltration (FI) and muscle hypotrophy.

RESULTS

Postoperative pain VAS, KSS, ASES, UCLA, SST, and CS scores and ROM (except external rotation) were improved significantly. AHI also improved significantly from 8.6 to 9.3 mm. According to Sugaya's classification, type I, II, III, IV, or V healing status was found in 30 (28.0%), 29 (27.1%), 26 (24.3%), 14 (13.1%), and 8 (7.5%) patients, respectively. The retear rate was 22 (20.6%).

CONCLUSIONS

Novel biceps-incorporating cuff repair with footprint medialization yielded satisfactory outcomes in MRCT patients at the 3-year follow-up. A partially released, repaired biceps tendon provided superior stability with preserved AHI similar to that of anterior cable reconstruction.

LEVEL OF EVIDENCE

IV.

Editorial Commentary: Shoulder Superior Capsule Reconstruction Leads to Good Outcomes Despite Ambiguous Graft Healing Suggesting a Spacer Effect

Massive, retracted rotator cuff tears with poor tissue quality continue to pose a problem for the shoulder surgeon. Augmentation of such repairs with grafts, patches, spacers, or biologics is being closely investigated to help improve clinical outcomes and healing rates. Specifically, superior capsule reconstruction augmentation of such rotator cuff tears may lead to good outcomes. However, we do not truly understand how much native cuff tissue or graft healing is actually taking place. Clinically, superior capsule reconstruction augmentation of rotator cuff repair may simply be serving as a spacer.

Supraspinatus tendon reconstruction using open infraspinatus tendon shift and autologous biceps tendon interposition grafts

INTRODUCTION

Inferior tendon quality, wide retraction, and tendon stumps that cannot be mobilized define the limits of what is technically feasible for open and arthroscopic rotator cuff reconstruction. The aim of this study was to develop a procedure that enables the open reconstruction of otherwise non-reconstructable rotator cuff tears.

METHODS

From 2014 to 2018, 23 operations were performed on 21 patients (mean age 63) using open procedure involving separating the infraspinatus tendon from the point of insertion on the greater tubercle and mobilizing it proximally and ventrally into the defective area. Any remaining defects were augmented using an autologous biceps tendon interposition graft. This augmentation was performed to achieve complete closure of the defect. Furthermore, the augmentation of the rupture zone was intended to strengthen the tendon stumps of the SSP and ISP to better neutralize the initial tensile forces. After a postoperative period of 12 months-4 years, clinical examination and functional tests were carried out, the Constant score was determined, and radiological and magnetic resonance imaging check-up examinations were performed.

RESULTS

The technique resulted in a low-tension closure of an otherwise "non-repairable" superior rotator cuff defect. All patients experienced a significant functional improvement, a reduction in pain, and an increase in muscle strength. An improvement in the Constant score from 48 points preoperatively to 87 points postoperatively (p < 0.05) was observed. In 19 patients (90%), the magnetic resonance image showed an intact reconstruction. Re-rupture was seen in three patients (14%).

CONCLUSION

The surgical procedure using infraspinatus tendon shift and autologous biceps tendon interposition grafts resulted in the successful reconstruction of otherwise non-reconstructable massive rotator cuff lesions. The complete closure of the defect was observed.

Arthroscopic Superior Capsule Reconstruction Using Autologous Fascia Lata and Biceps Tendon Augmentation

Whereas arthroscopic superior capsule reconstruction has recently been introduced to treat irreparable rotator cuff tears with encouraging outcomes, graft options and fixation remain debated. The purpose of this article is to introduce a modified arthroscopic technique using the long head of the biceps tendon as augmentation for superior capsule reconstruction with fascia lata autograft.

Use of Gracile and semi-tendinosus tendons (GRAST) for the reconstruction of irreparable rotator cuff tears

Background

Irreparable rotator cuff tears are common and difficult to treat. Techniques for “filling the loss of substance” require fixation to the rotator cuff stump (tendon augmentation) or to the glenoid (superior capsular reconstruction), which are complicated by the narrow working zone of the subacromial space. The main objective of this study was to determine whether a braided graft of gracilis (GR) and semitendinosus (ST) could fill a loss of tendon substance from an irreparable rupture of the supra- and infraspinatus, by fixing the graft to the greater tuberosity and the spine of the scapula.

Methods

This was a cadaveric study with the use of ten specimens. The GRA and ST tendons were harvested, braided and reinforced with suture. An experimental tear of the supraspinatus (SS) and upper infraspinatus (IS) retracted at the glenoid was made. The GRAST transplant was positioned over the tear. The transplant was attached to the greater tuberosity by two anchors and then attached to the medial third of the scapular spine by trans-osseous stitching. The percentage of filling obtained was then measured and passive mobility of the shoulder was assessed. We proceeded to the same technique under arthroscopy for a 73 years old patient whom we treated for a painful shoulder with irreparable cuff tear. We inserted a GRAST graft using arthroscopy.

Results

The Braided-GRAST allowed a 100% filling of the loss of tendon substance. Mobility was complete in all cases.

Conclusion

This technique simplifies the medial fixation and restores the musculo-tendinous chain where current grafting techniques only fill a tendinous defect. The transplant could have a subacromial “spacer” effect and lower the humeral head. The donor site morbidity and the fate of the transplant in-vivo are two limits to be discussed. This anatomical study paves the way for clinical experimentation.

Surgical Technique for Arthroscopic Rotator Cuff Augmentation With Human Acellular Dermal Matrix

Arthroscopic repair is probably the gold standard for treating large rotator cuff tears. Although positive, the results of this type of intervention depend on many factors such as the size of the tear, the age of the patient, and the number of previous surgeries. To decrease the rate of recurrence, we propose a surgical technique for augmenting the repair using an acellular dermal matrix (ArthroFlex, LifeNet Health). Our technique allows the surgeon to initially suture the tear in a regular fashion without visual interference. Once the tear is repaired, the augmentation is performed in a simple, all-arthroscopic, reproducible, and safe way. Also, we do not use extra implants for the fixation of the graft, so it does not increase the cost of the procedure (leaving aside the cost of the matrix itself).

Superior Capsular Reconstruction of the Shoulder Using the Long Head of the Biceps Tendon: A Systematic Review of Surgical Techniques and Clinical Outcomes

Background and Objectives: Superior capsular reconstruction (SCR) with the use of a fascia lata autograft or a dermal allograft is an established treatment in treating irreparable rotator cuff (RC) tears. The long head of the biceps tendon (LHBT) has been recently proposed as an alternative graft for SCR. The purpose of this study was to present the surgical techniques and clinical studies utilizing the LHBT for SCR. Material and Methods: Medline, Scopus, and the Cochrane library were searched for relevant studies up to December 2020. The primary outcomes were pain intensity improvement and the incidence of RC and LHBT graft retears. Secondary outcomes were functional scores and acromiohumeral distance (AHD) improvements. Results: Nine studies described surgical techniques of SCR using the LHBT, and four clinical studies reported the outcomes of the technique. The mean pain intensity improved from 4.9 ± 2.3 to 1.6 ± 1.5 in terms of the visual analog scale, exceeding the minimum clinically important difference for adequate pain relief. Significant improvements were also noted in functional scores and AHD. When compared with other repair techniques for massive RC tears, i.e., the double-row repair, the transosseous-equivalent technique with absorbable patch reinforcement, and the traditional SCR with a fascia lata autograft, there were no significant differences in pain and function improvements. Conclusion: SCR using the LHBT is a useful treatment option for massive RC tears; it is equally effective with the traditional SCR and other established techniques. It presents numerous advantages being a safe, easy, time-saving, and cost-effective method. The only precondition for the technique is the presence of an intact LHBT. Additional clinical trials are necessary to determine which treatment is superior for treating massive RC tears, as well as to evaluate the long-term results of the technique.

Superiore Kapselrekonstruktion mittels langer Bizepssehne bei retrahierter Komplettruptur der Supraspinatussehne und der kranialen Infraspinatussehne

In diesem Beitrag berichten die Autoren über einen Patienten mit einer Ruptur der Rotatorenmanschette, welche sich als retrahierte Komplettruptur der Supraspinatussehne und der kranialen Infraspinatussehne präsentierte. Nach 7‑monatiger Schmerzpersistenz und anhaltendem Funktionsverlust wurde im Rahmen eines arthroskopischen Eingriffs eine Rekonstruktion der superioren Kapsel durchgeführt. Die lange Bizepssehne wurde hierzu als Autograft verwendet und mit der kranialen Infraspinatussehne verknüpft. Auf diese Weise konnte ein kompletter Verschluss des posterosuperioren Gelenkraums erreicht werden.

Effect of biceps rerouting technique to restore glenohumeral joint stability for large irreparable rotator cuff tears: a cadaveric biomechanical study

BACKGROUND

The concept of stabilizing the humerus has taken on an important role in the treatment of irreparable cuff tears, and the biceps rerouting (BR) method is considered one of the most effective treatments in this field. The study aimed to evaluate the biomechanical effects of BR for large irreparable rotator cuff tears (LICTs).

METHODS

A total of 8 cadaveric shoulders were used for testing under 5 conditions: intact shoulder, LICT, partial repair (PR), BR, and biceps rerouting with side-to-side repair (BRSS). Total rotational range of motion was measured at 40°, then 20°, and finally 0° of glenohumeral (GH) abduction. Superior humeral translation and subacromial contact pressure were measured at 0°, 30°, 60°, and 90° of external rotation at each abduction angle. Repeated-measures analyses of variance with Tukey post hoc tests were used for statistical comparisons.

RESULTS

Superior humeral translation was significantly decreased in the BR and BRSS conditions compared with the LICT and PR conditions at 0° and 20° of GH abduction (P < .001). BR and BRSS significantly reduced subacromial contact pressure compared with LICT and PR at 0° of GH abduction (P < .001). There was no significant decrease in total rotational range of motion after BR at any abduction angle.

CONCLUSION

BR biomechanically restored shoulder stability without overconstraining range of motion in an LICT model.

Hamburger Technique: Augmented Rotator Cuff Repair With Biological Superior Capsular Reconstruction

Despite profound advancements in arthroscopic rotator cuff repair (RCR) techniques, radiologic failure rates may be in excess of 60% with repairs of large and massive tears in the elderly population. One of the strategies to improve these healing rates has been "patch" augmentation of the cuff repair. At the same time, superior capsular reconstruction (SCR) has gained significant popularity as an option for irreparable rotator cuff (RC) tears. Some have also advocated performing SCR in addition to arthroscopic RCR to reinforce the repair and improve healing rates. Techniques involving the use of fascia lata, ECM patches, and long head of the biceps (LHB) for SCR to reinforce the cuff repair have all been elegantly described. In this article, we propose a technique that enables a combination of the aforementioned procedures and involves performing RCR with patch augmentation, as well as SCR using LHB. In doing so, the repaired RC is bordered by the patch over its bursal surface and the LHB on the articular surface (functioning as the superior capsule), thus giving us the name "Hamburger technique" (a 3-layered construct).

Biceps Transposition for Biological Superior Capsular Reconstruction

Reconstruction of the superior capsule is a valuable intervention for some patients in whom massive, irreparable posterosuperior rotator cuff tears are identified. Superior capsular reconstruction techniques most commonly use either tensor fascia lata autograft or dermal allograft. As an alternative to more traditional superior capsular reconstruction, we commonly transpose and incorporate the biceps tendon into the rotator cuff repair construct in such patients instead. This biological superior capsular reconstruction biceps transposition technique ("bio-SCR"), described herein, provides increased structural integrity and supplemental tendon graft using viable cells while potentially serving the role of the superior capsule. As such, transposition of the biceps tendon may offer unique and significant advantages over other techniques and can be an effective and valuable alternative in appropriate cases.

The results of using a tendon autograft as a new rotator cable for patients with a massive rotator cuff tear: a technical note and comparative outcome analysis

BACKGROUND

Several surgical reconstructive options are available to treat massive rotator cuff tears (MRCTs). The rotator cable has an important function and we evaluated the clinical result after arthroscopic reconstruction of the rotator cable with an autograft tendon.

METHODS

A prospective pilot study was performed with inclusion of four patients, average age of 64 years, with an irreparable MRCT. The patients underwent an arthroscopic reconstruction of the rotator cable with the use of the long head of biceps tendon autograft, except for one which was reconstructed with a hamstring tendon. Pre- and postsurgically, the Constant-Murley Score (CMS), Western Ontario Rotator Cuff Index (WORC), Simple Shoulder Test (SST), visual analog scale (VAS) scores, and an MRI was performed. Clinical results of the study group were compared with clinical results of comparable cohort of patients with a MRCT, treated non-operatively with physiotherapy.

RESULTS

The CMS score increased after surgery in three of the four patients. The improvement of CMS score was comparable to the improvement of the CMS score encountered in a comparable cohort. The MRI at 12 months follow-up showed that the reconstructed rotator cable was disintegrated in all patients and the rotator cuff was detached and retracted.

CONCLUSIONS

In our pilot study, arthroscopic reconstruction of the rotator cable using a tendon autograft failed over time and showed no clinical benefit in comparison to the non-operative treatment with physiotherapy.

TRIAL REGISTRATION

The regional Medical Ethical Committee (Zwolle) gave approval at 14th of October 2016 and assigned no. 16.06100.

Retears of the Rotator Cuff: An Ultrasonographic Assessment During the First Postoperative Year

Background

Surgical repair of rotator cuff (RC) tears is an effective treatment option. However, the prevalence of recurrent ruptures is high.

Hypothesis

Recurrent tears are a frequent complication of surgical repair of RC tears. Their incidence might be influenced by factors such as the patient's age and size of the initial tear.

Study Design

Case series; Level of evidence, 4.

Methods

Data from 90 adult patients who underwent arthroscopic RC repair between 2014 and 2017 and underwent an ultrasound examination 6 to 12 months after surgery were analyzed retrospectively. Massive tears were repaired using a double-row technique, and nonmassive tears were repaired with a single-row technique. Clinical records were reviewed for demographic information.

Results

All patients (57.8% women; 42.2% men) were older than 18 years (mean, 58.9 years). Of these patients, 30.0% (27/90) had massive tears, which were primarily found in patients ≥60 years (74.1%; 20/27). Complete healing was seen in 74.5% of all repairs during follow-up. A total of 23 patients (25.5%) had retears (13 complete; 10 partial), which were diagnosed by ultrasound imaging 6 to 12 months after the initial surgery. The occurrence of retears was more prevalent in patients with massive tears than in patients with nonmassive tears (40.7% vs 19.0%, respectively); the difference was statistically significant (P = .03). Reruptures occurred in 50.0% of patients older than 60 years with massive tears. Although patients older than 60 years had more recurrent tears (32.6%) compared with younger patients (18.2%), the difference was not statistically significant (P = .12).

Conclusion

One-quarter of the patients who had undergone surgical repair of an RC tear had recurrent ruptures. There was a statistically significant association between the initial massive tear and a retear. Patients older than 60 years showed a higher recurrence rate, but this difference lacked statistical significance. Reruptures occurred in 50.0% of patients older than 60 years with massive tears.

Editorial Commentary: Is the Biceps Tendon a Valid Option for Augmentation in Rotator Cuff Repair? Future Perspectives on Superior Capsule Reconstruction

Biceps autograft can be a viable option for biological augmentation of massive rotator cuff repair, albeit results of this procedure might depend on the surgical technique. In the present qualitative systematic review, 8 case series were analyzed, in which biceps autograft was used as a scaffold or tissue bridge. Indeed, leaving the proximal portion intact and fixing it onto the greater tuberosity can simulate a superior capsule reconstruction, with potentially high biologic and mechanical advantages.