Abstract
Background:
Chronic rotator cuff tears (RCTs) are common and are often only partially repairable. Surgical treatment is challenging in younger patients. Surgical options include partial repair, tendon transfer, subacromial spacer, superior capsular reconstruction (SCR), and reverse shoulder arthroplasty. The use of SCR has been expanded and commercialized. The proposed techniques are complex using free avascular grafts and up to 7 anchors with associated increase in theater time and nonrefunded cost. Biceps SCR has shown promising biomechanical resistance and seems to offer a simple and cost-effective alternative.
Indications:
Patients with RCTs (Goutallier stage ≥3, Patte 3) without arthritis that are at least partially repairable (infraspinatus and subscapularis) are candidates. Patients with mechanically intact long head of biceps (LHB) and superior labrum anterior to posterior (SLAP) anchor (minimal fraying of <10% and fraying of SLAP without full-thickness tears acceptable) are also candidates.
Technique:
Key steps include arthroscopic release/lateral opening of the bicipital grove (15-20 mm) and placement of a first footprint anchor 8 to 10 mm posterior to the anatomical sulcus. Use of a 5-mm burr to create a new rerouting groove obliquely from the first anchor to the original groove, 15 to 20 mm caudal to the summit of the tubercle. Lasso-loop translation and tenodesis of the LHB to the first anchor. Use of a second caudal biceps tenodesis anchor with lasso-loops at the caudal end of the new groove. These 2 anchors create a rerouting bipedicle tenodesis performing the function of both an SCR and biceps tenodesis. Single-row, tension-free over-the-top repair of infraspinatus and the bursal layer of supraspinatus is completed with a third anchor on the rerouted biceps which remains in continuity.
Results:
The pilot series (n = 10) with a mean follow-up of 12 months (9-18 months) shows satisfactory outcomes. One patient developed a postoperative frozen shoulder and one a secondary Popeye deformity. Functional scores and patient satisfaction improved in all cases. The subjective shoulder value improved from a mean of 30% (10%-40%) preoperatively to 75% (60%-80%) postoperatively and the constant score from 30 points (20-40) to 68 points (60-71).
Conclusion:
As long as LHB and its SLAP anchor are adequate, biceps rerouting in combination with partial rotator cuff repair is a safe alternative to time-consuming and expensive commercialized SCR techniques.
This is a visual representation of the abstract.
Keywords
Video Transcript
Superior capsular reconstruction (SCR) is one of the treatment options for irreparable rotator cuff tears. The SCR has been shown to restore vertical stability. The use of the long head of biceps for SCR has been described in recent years with various techniques. Long head of biceps (LHB) rerouting with 2 fixation points is new and may improve healing with mechanical advantages.
Biological SCR (bio-SCR) with rerouting of the biceps requires LHB to be 90% intact, with a tubular morphology and no full-thickness superior labrum anterior to posterior (SLAP) tear. Selection criteria and contraindications are listed for your reference.
In our experience, biceps is not suitable in 20% to 30% of younger patients below the age of 65 years and in more than 50% of older patients above the age of 70 years.
The LHB has been shown to provide good biomechanical properties. Shortening of no more than 10 mm by rerouting is recommended. Two-point fixation prevents dynamic kinking, “windscreen wiping,” and fraying. Continuity of the tendon preserves its blood supply for ingrowth and remodeling.
We present a 63-year-old patient with failure of nonoperative management. Physical examination should include testing for horizontal and vertical pseudoparesis. Radiographs show no arthritis and a Hamada stage 2 cuff-tear arthropathy. Arthrogram shows a supraspinatus tear, Patte 3, Goutallier II-III, and a partial infraspinatus tear. Integrity of the biceps tendon is also shown.
Important equipment is listed on this slide for your reference.
We prefer a standard beach chair positioning with the use of an arm holder.
The biceps is assessed for any SLAP tears. It is lifted with a blunt suture grasper to assess its tubular structure and to exclude partial notching tears frequently located at the entrance of the pulley. Minor fraying like in this case is acceptable, but biceps integrity of about 90% is recommended. The subacromial space is debrided. Changing to a lateral portal for viewing, an anterolateral portal is created. An anterolateral portal is established in outside-in technique with a 60° to 90° viewing to working angle.
The LHB is again assessed for integrity and mobility. The bursal layer of the supraspinatus is reducible to the medial footprint with adequate tension. The capsular layer is further retracted underneath the bursal layer and is not visible.
This sketch shows the initial superior capsular and cuff deficiency and the location of the biceps before rerouting.
First, the biceps pulley is released from proximal to distal over 15 mm with the radiofrequency ablator keeping the dissection cranially and posterolaterally in relation to the sulcus and tendon. This prevents bleeding and arthroscopic “red-out” from the vessels ascending in the sulcus.
A 5-mm burr is used to create a cancellous groove for posterior rerouting of the biceps. Cortical bone islands for anchor placement must be planned and maintained to prevent failure of anchor fixation. We aim for 5 to 10 mm of posterior translation of the biceps.
A first 2.8-mm suture anchor is inserted 5 to 10 mm posterior to the biceps tendon at the medial border of the footprint.
With a retrograde suture passer, double lasso-loops are set up and classic half-hitches, so-called Lafosse easy knots, are tied inverting post-tension to fix the biceps as a superior capsular reconstruction. A simple additional circumferential anchor-based suture tied around the biceps, not shown in this video, is recommended to prevent splitting of the tendon. It is important not to overtension the biceps, limiting its posterior translation to maximum 5 to 10 mm in 30° abduction.
All suture ends are passed under the bursal layer into the joint to be picked up with a retrograde suture passer until all suture ends are passed through the anterior part of the bursal layer of the supraspinatus. It needs to be mentioned that a limited release of supraspinatus of 2 to 3 mm with the radiofrequency device was undertaken, which is not shown in this video.
It is important to point out as highlighted under indications that this technique is contraindicated in cases with simultaneous irreparable subscapularis or infraspinatus tears, which may require tendon transfers.
A second 2.8-mm suture anchor is placed posterior to the first anchor between biceps and infraspinatus at the medial border of the footprint.
The footprint is further freshened up with a 5-mm burr.
As for the anterior part of the bursal layer of the supraspinatus, sutures are passed through the posterior part of the supraspinatus and anterior part of the infraspinatus with a retrograde suture passer before arthroscopic easy knots are tied again.
While maintaining lateral viewing, sutures are organized through anterolateral and posterolateral portals.
The anterior bursal layer of the supraspinatus is tied to the biceps reconstruction on the first anchor as a single row over the top repair without tension. The posterior part of the supraspinatus as well as the anterior part of the infraspinatus are repaired in the same way as a single-row technique. The quality of the suture fixation is tested with an arthroscopic probe.
Next, the second biceps tenodesis anchor is inserted about 15 mm distal to the first anchor just posterior to the anatomical bicipital groove. As for the proximal tenodesis, a double lasso-loop technique is used for the distal tenodesis.
The 2 sketches show the initial and final position of the biceps after rerouting with a posterior translation and double tenodesis.
The final repair and reconstruction are probed and tested.
Do not overtension the retracted supraspinatus. The repair should just reach the medial footprint. The biceps tendon should also not be overtensioned and posterior translation should be limited to 5 to 10 mm.
We recommend an abduction orthosis with passive exercises to 90° for 6 weeks with progressive active-assisted mobilization from week 7. Return to appropriate sports is allowed after 6 months.
This pilot series of biceps rerouting shows encouraging preliminary results at 1 year, comparable to SCR with dermal allografts. Radiographs at 1 year demonstrate no arthritis and maintenance of the acromiohumeral distance.
Potential advantages of biceps rerouting include both biomechanical and biological benefits. It is a simple procedure that is time-saving compared with alternatives, with low infection risk and reduced cost.
The main limitations are preliminary results at 1 year and lack of magnetic resonance imaging controls.
Biceps rerouting is a safe alternative to expensive, time-consuming SCR techniques. Comparative studies with objective investigations are needed.
Footnotes
Submitted January 27, 2021; accepted April 19, 2021.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
