Arthroscopic Rotator Cuff Repair Reinforced With Proximal Biceps Rerouting

Abstract

Background:

Massive rotator cuff tears (RCTs) with significant retraction are challenging due to the high retear rates and limitations associated with existing repair techniques. Biceps tendon rerouting has recently emerged as an effective reinforcement technique for massive RCTs, particularly in achieving low retear rates.

Indications:

Arthroscopic RCT repair with proximal biceps tendon rerouting is a viable option for nonarthritic, active patients with massive, retracted RCTs for whom nonoperative treatment has failed and the long head of the biceps tendon is intact.

Technique Description:

The patient was placed in a lateral decubitus position with the arm in 10 lbs of traction. A diagnostic arthroscopy demonstrated a complete supraspinatus and infraspinatus tear with retraction to the glenoid, along with a frayed long head of the biceps tendon with an intact subscapularis tendon. The transverse humeral ligament was released to reroute the biceps tendon and anchor it 10 mm posterior to the bicipital groove. The rotator cuff was mobilized and sequentially repaired with medial-to-lateral advancement using 3 separate suture tapes passed through the supraspinatus, biceps tendon, and back through the supraspinatus to create a linked, reinforced construct. A horizontal mattress suture was placed posteriorly to reduce a posterior dog-ear soft tissue corner. The sutures were then tensioned and anchored on the greater tuberosity using 3 anchors.

Results:

Arthroscopic massive RCT repair with biceps tendon rerouting has shown favorable clinical outcomes. Significantly lower retear rates compared with arthroscopic repair alone, and clinical outcomes equivalent to those of superior capsular reconstruction with autograft have been demonstrated in the literature for this technique.

In this technical report, our patient experienced complete pain relief and regained full strength, along with near-complete range of motion, within 6 months after surgery.

Discussion/Conclusion:

Biceps tendon rerouting in the setting of arthroscopic massive RCT repair is an effective surgical option in active individuals with an intact or minimally degenerated biceps tendon. This technique provides a cost-effective solution that offers additional mechanical support and supplies a rich autologous source of collagen to strengthen the repair.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

This video describes our technique for an arthroscopic rotator cuff repair reinforced by a rerouted long head of the biceps tendon.

Background

Massive rotator cuff tears (RCTs) have been defined as a tear with >67% of the greater tuberosity exposed or retraction of the rotator cuff to the glenoid. ¹³ Studies have shown that 15% of massive RCTs are irreparable, and this number rises to nearly 50% in cases with stage 3 or 4 fatty infiltration.^2,15 Irreparable tears, a tear in which tendon-to-bone healing is not feasible, pose a significant challenge for surgeons, particularly in younger patients without advanced osteoarthritis. When possible, joint-preserving options are generally favored. These include partial repair with footprint medialization, tendon transfer, superior capsular reconstruction, and cable reconstruction. However, all these procedures have potential drawbacks—including increased complexity, invasiveness, concerns about allograft cost, and variable short- and mid-term clinical outcomes. ⁶ This ongoing challenge with massive RCT repair has led to the utilization of the intra-articular portion of the long head of the biceps tendon as an autologous augment for rotator cuff repair.

The long head of the biceps tendon typically measures approximately 9 cm in length and 5 to 6 mm in diameter, with its intra-articular portion averaging 3 to 4 cm in length. ¹⁴ Notably, the biceps tendon has been identified as a source of multipotent stem cells, even in the presence of inflammation. ¹²

Over the years, various techniques emerged and evolved to utilize the biceps tendon to augment a rotator cuff repair. In 1971, Neviaser ⁸ described harvesting the long head of the biceps and using it as a split graft to cover defects in irreparable RCTs. ⁸ More recently, this concept has evolved to include flattening of the biceps tendon to create a broader surface area graft for implantation. ³

Anterior cable reconstruction has also been described, involving tenotomizing the distal end of the intra-articular portion of the biceps while preserving its glenoid attachment, then fixing the remaining intra-articular portion to the greater tuberosity. ¹ More recently, biceps tendon rerouting has gained attention as a reinforcement technique that involves cutting the transverse humeral ligament to transpose the biceps tendon posteriorly on the greater tuberosity while maintaining its proximal and distal attachments.^4,11

The purpose of the present article is to describe a technique that builds upon this biceps rerouting approach by incorporating the rotator cuff repair sutures through the biceps tendon to create a linked construct. This technique provides mechanical support and a rich autologous collagen source to reinforce the rotator cuff repair and reconstruct the anterior cable, while also achieving the tenodesis effect to address any concomitant biceps tendon pathology.

Indications

Our case illustrates a 58-year-old male laborer who reported acute left shoulder pain after falling during an altercation. Before presenting to our office, the patient completed 2 months of physical therapy and received a corticosteroid injection without any relief in symptoms. He continued to report pain at night while sleeping and sharp pain and clicking when lifting his arm. Physical examination revealed 3/5 strength to the supraspinatus, 4/5 to the infraspinatus, and 5/5 to the subscapularis. Range of motion was limited to 100° of active forward flexion and 35° of external rotation. Lastly, the patient had a positive Jobe, Speeds, and O’Brien tests.

Radiographic imaging demonstrated minimal humeral head migration with an acromial-humeral distance of 9.3 mm (Hamada grade 1). Magnetic resonance imaging (MRI) revealed a full-thickness tear of the supraspinatus and infraspinatus, with retraction into the glenoid, without significant muscle belly atrophy. The subscapularis/biceps tendon relationship was intact without tendinosis or medial subluxation on preoperative MRI.

The patient's history, physical examination, and imaging studies reflect an acute-on-chronic massive retracted RCT with limitations in motion and recalcitrant pain in the setting of an active middle-aged man. The patient was counseled on the possibility of continued nonoperative treatment versus rotator cuff repair with possible biceps reinforcement, and salvage treatment options—including anterior cable reconstruction using an allograft. The patient expressed understanding and chose the surgical option.

Technique Description

The patient underwent a preoperative regional shoulder peripheral nerve block. After general anesthesia was administered, the patient was placed in the lateral decubitus position on a bean bag with the operative arm placed in 10 pounds of traction. A standard posterior portal was utilized to conduct a diagnostic arthroscopy of the glenohumeral joint, which demonstrated a complete supraspinatus and infraspinatus tear with retraction to the glenoid. The long head of the biceps tendon at the insertion on the superior labrum demonstrated mild fraying without separation, and the subscapularis tendon was intact. No significant focal articular cartilage damage was seen on the glenoid or humeral head.

The rotator cuff was mobilized to the medial articular margin of the footprint. Due to significant tension in the tissue, a biceps-reinforced rotator cuff repair with biceps rerouting was pursued to provide additional repair security.

The transverse humeral ligament was released, and the biceps tendon was mobilized from the bicipital groove. Two 1.3-mm tape sutures were looped around the biceps tendon, and tension was applied to the tape sutures to translate the biceps tendon posteriorly. Next, the tape sutures were secured with a 4.75-mm anchor in the greater tuberosity approximately 10 mm posterior to the bicipital groove, which also secured the biceps tendon. The biceps tendon was not released proximally or distally, serving as an anterior cable and strut for the RCT repair.

Using a cuff grasper, rotator cuff mobilization was assessed and noted to reach just medial to the footprint on the greater tuberosity. A black traction suture was placed in a horizontal mattress configuration to aid in mobilization during suture passage.

Next, starting medially, a 1.7-mm tape suture was placed—first, through the supraspinatus; second, through the anchored biceps tendon; and third, through the supraspinatus more posteriorly. The sutures were tied arthroscopically and kept for fixation in a lateral row. These steps were repeated twice for 2 additional tape sutures, with the sutures placed progressively more laterally on the cuff tendon and biceps tendon. The sutures were tied arthroscopically and kept for fixation in a lateral row.

An additional tape suture was placed posteriorly in a horizontal mattress configuration to reduce and secure a potential posterior dog-ear soft tissue corner prominence, and then fixed first laterally on the most posterior aspect of the medial footprint of the greater tuberosity. Subsequently, 1 strand from each of the 3 more anterior tape sutures was tensioned and placed anterior to the medial footprint of the greater tuberosity. To complete the repair, the remaining sutures from the anterior tape sutures were placed in another anchor posteriorly on the medial footprint of the greater tuberosity.

Results

Postoperative rehabilitation consisted of 6 weeks of passive-only movement and pendulum exercises, followed by 6 weeks of active-assisted range of motion. Isometric and isokinetic strengthening started at 3 months, with a goal of full strength and motion by 6 months.

Discussion/Conclusion

In biomechanical studies, capsular reconstruction with proximal biceps tendon rerouting demonstrated an equivalent reduction in superior humeral head migration to dermal allograft reconstruction in massive RTC tears, without decreasing motion.^7,10

Additionally, Paccot et al ⁹ suggested positioning the shoulder in 30° of abduction and attaching the tendon to the middle to posterior aspect of the greater tuberosity to maximize humeral head kinematic restoration.

Regarding biceps rerouting, Kim et al ⁴ compared this technique with subpectoral tenodesis as a treatment option for biceps tendinopathy. Their findings showed a significantly lower biceps retear rate in the rerouting group, with clinical outcomes comparable to those of subpectoral tenodesis, even in cases with a pathologic biceps tendon or a type 2 superior labrum anterior and posterior (SLAP) lesion. Rhee et al ¹¹ evaluated rotator cuff repair with and without biceps rerouting in patients with large-to-massive RCTs. The authors demonstrated a significantly higher retear rate in the RCT repair-only group; however, if >50% of the biceps tendon was affected, the risk of retear increased.

In addition, Kocaoglu et al ⁵ found that outcomes of partial rotator cuff repair and biceps rerouting capsular reconstruction were as effective as harvesting and using autograft tensor fascia lata. This finding may boost our collective confidence in addressing massive RCTs all arthroscopically.

Further clinical research is still needed to better define the optimal indications for biceps rerouting and determine the most effective surgical technique.

The following is a list of key pearls and pitfalls to consider:

• The biceps tendon is a strong, cost-effective source of collagen that can enhance the reinforcement of large, retracted rotator cuff repairs.

• The biceps can be adapted in various ways to reconstruct the anterior cable of the rotator cuff without the need for an allograft.

• The biceps tendon and superior labrum should be carefully inspected; however, minor to moderate tendinopathy or type 2 SLAP is not a contraindication to biceps utilization. ⁴

• Incorporating repair sutures through the anchored biceps tendon helps create a unified and stable repair construct.

• Sequentially tying the repair sutures from proximal to distal allows the cuff tendon to undergo stress relaxation as it is gradually reduced to its footprint.

Biceps rerouting is a technically simple, cost-effective, and all-arthroscopic technique that enhances the success rate of massive rotator cuff repairs.