Abstract
Background:
Massive rotator cuff tears (MRCTs) involving the rotator cable are associated with increased tendon retraction, fatty infiltration, and high retear rates after repair. Biceps anterior cable reconstruction (ACR) is a surgical technique that augments rotator cuff repair by reconstructing the anterior cable with the long head of the biceps tendon (LHBT), improving greater tuberosity coverage and biomechanical stability.
Indications:
Biceps ACR is indicated for full-thickness MRCTs with anterior cable involvement in patients with an intact LHBT and no advanced glenohumeral arthritis. Risk factors for repair failure, including the full-thickness retracted pattern of a tear, patient age, and activity level, are considered when deciding to add a concomitant ACR.
Technique Description:
A knotless repair stitch from an anchor at the anteromedial footprint of the greater tuberosity is passed circumferentially around the proximal LHBT. The biceps is left attached to the glenoid, and the repair stitch is tightened, which reduces the biceps tendon to the anterior aspect of the greater tuberosity. This allows the biceps tendon to slide and find its optimal tension, tenodeses the biceps tendon to the greater tuberosity, and reconstructs the anterior cable. This provides greater tuberosity coverage and reduces the tear distance. The remaining sutures from the anteromedial anchor can be passed through the rotator cuff. The remaining rotator cuff can be repaired using a variety of standard techniques. Simple side-to-side stitches can be placed in the biceps tendon and rotator cuff as needed.
Results:
Biceps ACR improves greater tuberosity coverage and enhances biomechanical stability by decreasing superior translation and subacromial contact pressure. Clinical studies have demonstrated excellent patient-reported outcomes and lower retear rates when biceps ACR is added to arthroscopic rotator cuff repair.
Discussion/Conclusion:
Biceps ACR is a viable option for MRCTs with anterior cable involvement and a high risk for failure.
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.
This is a visual representation of the abstract.
Video Transcript
For this video, we are presenting a biceps anterior cable reconstruction (ACR) for a massive rotator cuff tear (MRCT). All author disclosures are listed here.
Background
MRCTs may involve the rotator cable, a thick bundle of fibers that runs perpendicular to the supraspinatus and infraspinatus. 7 Tears involving the rotator cable have an increased risk of accelerated tendon retraction and fatty infiltration, as well as increased rates of retear after primary repair. 4 Biceps ACR is a surgical option for MRCTs with anterior cable involvement and can help cover the greater tuberosity in difficult repairs.1-3,5,6,8
Indications
Indications for biceps ACR include full-thickness MRCTs involving the anterior cable with an intact biceps tendon in patients who are otherwise indicated for cuff repair. Contraindications include advanced glenohumeral arthritis, absent long head of the biceps tendon (LHBT) proximal attachment, and extreme deficiencies of the superior rotator cuff.
In this video, we present the case of a 75-year-old male cyclist who had a rotator cuff tear that was managed nonoperatively 6 years ago. Six weeks prior to presentation in our clinic, he had an acute decrease in his shoulder function and an increase in pain while working out. On examination, he had no obvious deformity or atrophy, well-preserved motion with a painful flexion arc, and supraspinatus weakness. Special tests were positive for impingement, and he had bicipital groove tenderness. Plain radiographs demonstrated no glenohumeral arthritis and a normal acromiohumeral interval. Magnetic resonance imaging (MRI) demonstrated an MRCT involving the supraspinatus and infraspinatus with retraction to the glenohumeral joint. Sagittal MRI demonstrated only Goutallier grade 1 fatty infiltration.
This patient elected to proceed with rotator cuff repair. Risk factors for repair failure, including the full-thickness retracted pattern of the tear, patient age, and activity level, are considered when deciding to add a concomitant ACR. It is important to assess the muscle quality and LHBT integrity on preoperative MRI as well and be prepared with a graft or patch backup option if needed.
Technique Description
The patient is placed in the beach-chair position. A standard posterior viewing portal and anterior portal are used for any intra-articular work as needed. Most of the case is performed in the subacromial space, viewing from a posterolateral viewing portal just off the corner of the acromion and instrumenting through a standard lateral portal that is placed appropriately low and anterior.
The rotator cuff is evaluated with a cuff grasper through the lateral working portal to assess repairability and mobility. The arthroscopic view is through the posterolateral viewing portal. The biceps tendon is assessed and found to be intact. The biceps tendon is mobilized using a radiofrequency probe to remove fibers of the transverse ligament. The greater tuberosity is prepared in a standard fashion using a shaver and burr. Care is taken not to violate the cortical bone, which can lead to anchor pullout. Anchor trajectory is planned with a spinal needle. Due to the large tear size but maintained mobility and reducibility, a double-row repair is planned.
The first anchor is placed in the medial and posterior aspect of the greater tuberosity footprint, and these sutures are passed through the posterior aspect of the tear. The next anchor, which will be used for the ACR, is placed at the anterior and medial aspect of the greater tuberosity. We prefer an anchor with a knotless repair mechanism and suture tapes, but this technique is possible with any anchor with multiple sutures. The knotless repair stitch is passed circumferentially around the biceps tendon with a self-retrieving labral passer, taking care not to pierce the tendon, so it will slide within the repair stitch loop that is created. This allows the tendon to slide and find the optimal tension when it is reduced down to the anchor. The knotless mechanism is then used to reduce the biceps tendon to the anchor at the anterior aspect of the greater tuberosity, reconstructing the anterior cable. This provides excellent greater tuberosity coverage and reduces the tear distance nicely.
The remaining sutures from the medial anterior anchor are then passed through the rotator cuff in standard fashion. A simple repair stitch can be placed from the edge of the rotator cuff tendon to the biceps tendon, in a side-to-side, marginal convergence fashion as needed. The tapes that were passed through the rotator cuff are then retrieved to finish the lateral row portion of the repair. This demonstrates good reduction of the rotator cuff over the greater tuberosity footprint, with the biceps tendon augmenting the repair and reconstructing the anterior cable. A second lateral row anchor is then placed in a standard fashion. Any gaps or dog ears in the reconstruction can be tied down with an additional side-to-side simple stitch. This view demonstrates complete coverage of the greater tuberosity with a complete repair and ACR using the biceps tendon.
We demonstrate the critical portion of this technique once more on the right shoulder of a different patient. The cuff grasper shows a frayed but intact and mobile biceps tendon and the delaminated, articular portion of this MRCT, which is reducible to the articular margin. An anchor is placed in the anterior aspect of the articular margin, and the repair stitch is passed circumferentially around the biceps tendon only. In this case, the same repair stitch is then passed through the delaminated, undersurface portion of the tear. Tensioning this stitch simultaneously reconstructs the anterior cable and starts to reduce the rotator cuff for a more anatomic repair.
Complications include postoperative stiffness and pain, LHBT failure, and incomplete healing or retear of the rotator cuff. Technical pearls include mobilizing the tendon out of the sheath, placing a suture around the biceps rather than through the biceps to prevent over- or undertensioning, and using the biceps for side-to-side suture repair. Being prepared with another graft or augmentation source is recommended in case the biceps is not present or of poor quality.
Results
Postoperative rehabilitation is similar to standard rotator cuff repair protocols. The shoulder is immobilized in a sling for the first 6 weeks, and progressive range of motion is initiated at 4 weeks. Formal strengthening with physical therapy begins at 12 weeks. Typical return to work or strenuous activities occurs around 6 months, depending on progress with therapy.
Discussion/Conclusion
Early studies have shown promising clinical outcomes. One cadaveric study demonstrated that ACR decreases superior translation and subacromial contact pressure. 5 A prospective comparative study demonstrated a significantly lower retear rate when biceps rerouting was added to arthroscopic rotator cuff repair, and a small case series demonstrated excellent patient-reported outcomes after rotator cuff repair with biceps ACR with a similarly low retear rate.6,8
Thank you.
Footnotes
Submitted April 8, 2025; accepted August 28, 2025.
Winner of the Bronze Medal Prize at the 2025 VJSM Fellows Video Technique Challenge.
One or more of the authors has declared the following potential conflict of interest or source of funding: A.L. is a paid consultant for Arthrex and Stryker/Tornier and serves on the advisory board for Restor3d. 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.
