Labral Repair Augmentation by Labroplasty and Simultaneous Trans-Subscapular Transposition of the Long Head of the Biceps

Biceps tendon autograft augmentation for rotator cuff and instability procedures: a narrative review

Rotator cuff tears (RCT) and instability are the most common surgically treated shoulder pathologies. The concept of augmentation using the long head of the biceps tendon (LHBT) autograft was created to improve the results of surgical treatment of these pathologies, especially in cases of chronic and massive injuries. The popularity of using the LHBT for augmentation is evidenced by the significant number of publications on this topic published in the last 3 years; however, only one systematic review has been published regarding only LHBT augmentation for massive RCTs. Several studies comparing partial repair with partial repair and additional LHBT augmentation for RCT showed superior clinical outcomes and lower re-tear rates when LHBT augmentation was performed. There is a rising popularity of using LHBT as an autograft to perform superior capsule reconstruction (SCR) in case of irreparable rotator cuff tears. In recent years, shoulder stabilization by arthroscopic Bankart repair with biceps augmentation has been promoted with very promising short-term results. The evidence provided by studies appears to be sufficient to recommend the use of LHBT for augmentation whenever necessary; however, larger studies with long-term follow-up are needed.

Anchorless Onlay Dynamic Anterior Stabilization of the Shoulder Using a Guided Posterior Double Endobutton Fixation

The treatment of shoulder instability in the presence of a subcritical glenoid defect poses challenges, as simple Bankart seems insufficient, and the Latarjet procedure may be excessive. Recently, a dynamic anterior stabilization technique involving anterior transposition of the long head of the biceps (LHB) through a subscapularis split was described for that purpose. Previously published results demonstrated good short-term results, but several technical pitfalls have also been mentioned. We describe an onlay, anchorless, and intra-articular knotless method of fixing the LHB into the anterior glenoid that provides the important stabilizing "sling effect" of the dynamic anterior stabilization while avoiding some of the pitfalls described by other techniques.

Modified Dynamic Anterior Stabilization and Labroplasty for Anterior Shoulder Instability With Concomitant SLAP Lesion

Several arthroscopic techniques to treat anterior shoulder instability have been described. Bankart repair may be insufficient in cases with some degree of bone loss, and arthroscopic Latarjet is technically challenging. It is not rare to find at the time of surgery a more extensive labral tear (SLAP lesion) or an insufficient anterior capsulolabral tissue. We describe for those cases a dynamic anterior stabilization where using the long head of the biceps we are treating the SLAP lesion and at the same time it provides the "sling effect" of a Latarjet procedure for the anterior instability.

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.

Dynamic Anterior Stabilization of the Shoulder: Onlay Biceps Transfer to the Anterior Glenoid Using the Double Double-Pulley Technique

The treatment of anterior glenohumeral instability includes several surgical options, ranging from soft tissue to bony procedures-open or arthroscopic. In arthroscopic dynamic anterior stabilization (DAS) of the shoulder, the long head of the biceps is transferred to the anterior glenoid through a subscapularis tendon split. The biceps may be fixed either in an inlay or in an onlay position. Inlay DAS theoretically increases anterior glenohumeral stability through 3 different effects: the hammock effect, sling effect, and the tensioning effect. Onlay DAS may additionally increase stability through a labroplasty effect, produced by the onlay positioning of the biceps on the anterior glenoid rim. The current technical note presents tips and tricks, and pearls and pitfalls, to reproducibly perform onlay DAS using all-suture anchors and the double double-pulley technique.

Onlay Dynamic Anterior Stabilization With Biceps Transfer for the Treatment of Anterior Glenohumeral Instability Produces Good Clinical Outcomes and Successful Healing at a Minimum 1 Year of Follow-Up

Purpose

To report the results of the onlay dynamic anterior stabilization (DAS) using the long head of biceps (LHB) and the double double-pulley technique for the treatment of anterior glenohumeral instability (AGI) with ≤20% glenoid bone loss (GBL).

Methods

From September 2018 to December 2021, patients with AGI and ≤20% GBL were enrolled in a prospective study on DAS and followed for a minimum of 1 year. The primary outcomes were Western Ontario Shoulder Instability Index, Rowe score, range of motion, and strength. The secondary outcomes were ability to return to play (RTP), RTP at same level, lack of recurrence of instability, successful LHB healing, and lack of complications. Magnetic resonance imaging was used to measure GBL, Hill-Sachs interval, glenoid track, and assess LHB integrity.

Results

Eighteen consecutive patients underwent DAS. Fifteen patients had a minimum follow-up of 12 months (mean, 23.93 ± 13.67 months). In total, 12 were male and 3 female patients; 73.3% practiced recreational sports; mean age at surgery was 23.40 ± 6.53 years; mean number of dislocation episodes were 10.13 ± 8.42; mean GBL was 8.21 ± 7.39% (range, 0-20.24%); mean Hill-Sachs interval was 15.00 ± 2.96 mm; and mean glenoid track was 18.87 ± 2.57mm. The mean improvement in the Western Ontario Shoulder Instability Index and Rowe score (959.27 ± 386.70 and 74.00 ± 22.22 points) was significant (P < .001 and P < .001) and more than 6 times greater than the minimum clinically important difference. The mean improvement in active elevation, abduction, and external and internal rotation (23.00 ± 27.76°, 33.33 ± 43.78°, 8.33 ± 13.58°, and 0.73 ± 1.28 points) was significant (P = .006, P = .011, P = .032, and P = .044). RTP rate was 93.33%. RTP at same level was 60.00%. One patient with hyperlaxity had a redislocation (6.7% recurrence). No complications were reported. Each magnetic resonance imaging scan showed successful LHB healing to the anterior glenoid.

Conclusions

At a minimum of 1-year follow-up, DAS produces significant and clinically important improvements in shoulder function, successful LHB healing, and is safe for the treatment of AGI with ≤20% GBL without severe hyperlaxity.

Level of Evidence

IV, therapeutic case series.

Editorial Commentary: The Long Head of the Biceps Tendon Is Useful for Shoulder Reconstruction Including Glenohumeral Stabilization: From Biceps Killers to Biceps Users

Historically, it was believed that the shoulder long head of the biceps tendon (LHBT) was a pain generator and had to be routinely sacrificed. Recently, it has become apparent that the LHBT is useful as an autograft for various types of surgical reconstruction, including superior capsular reconstruction for irreparable rotator cuff tears, and augmentation for poor soft-tissue quality during rotator cuff repair or shoulder arthroplasty. In cases of shoulder instability, the biceps can reinforce the capsule or reconstruct a missing labrum for glenohumeral stabilization. Dynamic anterior stabilization transfers the LHBT through the subscapularis to the anterior glenoid margin, creating "sling" and "hammock" effects. Various labral augmentation techniques also have been described. In a paradigm shift, shoulder surgeons may become LHBT users instead of LHBT "killers."

Modified Dynamic Anterior Stabilization (DAS) and Hill-Sachs Remplissage for the Treatment of Recurrent Anterior Shoulder Dislocation

The optimal treatment for recurrent glenohumeral instability is a subject under debate. The recently described arthroscopic technique for dynamic anterior stabilization (DAS) fills the treatment indication gap between reconstructive bony procedures and soft tissue stabilization. However, indications for DAS are considered limited or not appropriate for patients with recurrent shoulder dislocations caused by severe bone defects. In this Technical Note, we present a modified all-arthroscopic DAS technique with added infraspinatus and posterior capsule remplissage to correct the extra-articular Hill-Sachs defect in a patient with recurrent dislocations and off-track bony lesions. The patient requested an alternative treatment option, other than the complication-prone Latarjet procedure.

Extra-articular Soft Arthroscopic Latarjet Technique: More Versatility and Closer Reproducibility of Classic Latarjet Procedure than Its Intra-articular Counterpart

The recent innovative concept of dynamic anterior stabilization of the shoulder by long head of biceps tendon for anterior gleno-humeral instability management has gained growing popularity among shoulder surgeons. Different techniques using this concept have been reported. Nevertheless, these techniques share common steps of tenotomy, re-routing, trans-subscapularis transfer and bony glenoid fixation of long head of biceps. Lately, a simplified procedure of intra-articular soft arthroscopic Latarjet technique has been introduced to refer to soft tissue tenodesis of long head of biceps to subscapularis tendon by 2 simple stitches of nonabsorbable sutures following Bankart repair. For more technical simplicity and closer reproducibility of gleno-humeral restabilization mechanisms of Latarjet procedure; the current Technical Note describes the extra-articular soft arthroscopic Latarjet technique, whereby long head of biceps is retrieved to the subpectoral region following intra-articular tenotomy; whip-stitched; rerouted deep to pectoralis major; and passed within subscapularis window into the gleno-humeral joint, where it is sutured over itself around upper subscapularis tendon. The currently reported technique offers potential advantages of versatility, steep learning curve, low cost (no hardware), feasibility of concurrent gleno-humeral restabilization procedures, and technical easiness of revision management; however; it is nonanatomic and should be biomechanically and clinically investigated to validate its long-term versatile utility.

Soft Arthroscopic Latarjet Procedure: Technical Note on Biceps Tendon as a Modified Sling for Restoration of Glenohumeral Stability

As an alternate to sling glenohumeral restabilization mechanism of Latarjet procedure, recent different arthroscopic soft-tissue reconstructive techniques have been described for the management of glenohumeral instability. One of these techniques is trans-subscapularis bony tenodesis of long head of biceps (instead of coracoid graft transfer) to the anteroinferior glenoid. For simplification of the latter technique, the current article reports an alternative arthroscopic technique for management of glenohumeral instability in patients with type V SLAP lesion or poor soft-tissue quality of the anterior capsulolabral complex. In this technique, Bankart repair is followed by soft-tissue tenodesis of long head of biceps to upper border of subscapularis tendon by 2 simple stitches of non-absorbable sutures. Compared with previous ones, the currently reported technique is versatile, quick, technically simple, entirely intra-articular, and cost-saving; however, it is nonanatomic and should be investigated in biomechanical and cohort clinical studies to clarify its long-term validity.

All-Suture Anchor Dynamic Anterior Stabilization Produced Successful Healing of the Biceps Tendon: A Report of 3 Cases

CASES

Three patients (age, 15-34 years) who had a history of chronic traumatic anteroinferior glenohumeral instability (2-10 dislocations) and preoperatively documented Bankart and Hill-Sachs lesions underwent all-arthroscopic trans-subscapular transposition of the long head of the biceps that was fixed on the anteroinferior glenoid using a novel double double-pulley all-suture anchor method that has not been reported previously.

CONCLUSION

Excellent 12-month clinical and imaging outcomes, with substantial improvements in the Western Ontario Shoulder Index and the Rowe score in the first consecutive patients who underwent this original technical variant of dynamic anterior stabilization and the surgical pearls and pitfalls are described in detail.

A Novel Technique for Labral Reconstruction Using Long Head of Biceps Tendon: Duru Technique

Arthroscopic capsulolabral repair is a well-established surgical treatment for traumatic anterior shoulder instability. When there is insufficient labral tissue during arthroscopic primary or revision Bankart repairs, various soft tissue procedures have been recommended. All these procedures aim to reattach glenohumeral ligaments to the glenoid rim and regain the tight anterior structures to prevent re-dislocation or subluxation. Some authors recommend the Latarjet procedure, even in the absence of critical bone loss in this patient group. The labrum increases the depth of the glenoid cavity, thereby, increasing the glenoid track. It behaves like a block for the humeral head. Reconstruction of the labral tissue may strongly contribute to shoulder joint stability when it is totally absent. In this article, we describe a novel labral reconstruction technique (Duru technique) using the long head of the biceps tendon in two patients without an existing labral tissue.

Lateral Meniscus Replacement Using Peroneus Longus Tendon Autograft

Nowadays, several techniques are available for preserving the lateral aspect of the knee after meniscectomy; meniscus transplantation is the gold standard, and meniscus scaffold implantation is an effective alternative. However, meniscus transplantation is technically difficult and has many potential complications, whereas scaffolds resorb over time. Autografts are commonly used for labroplasty in shoulder and hip surgeries. We attempted to adapt this technique to the knee, using autografts for meniscus replacement. In this report, we describe a meniscus-replacement technique, using a peroneus longus autograft, for lateral meniscus deficits. This technique significantly simplifies the procedure and is cost effective, and thus can be considered as an alternative technique for preventing osteoarthritis of the lateral aspect of the knee.