Modified Long Head of Biceps Tendon Rerouting and Fixation as Partial Capsular Reconstruction for Massive Irreparable Rotator Cuff Tears

Summary

We propose a technical modification for capsular reconstruction that utilizes arthroscopic rerouting and fixation of the long head of the biceps tendon to enhance the repair of massive irreparable rotator cuff tears.

Abstract

Massive irreparable rotator cuff tears (MIRCTs) present a particularly complex and difficult challenge for the orthopedic surgeon. Fatty infiltration of muscles, chronic excessive retraction of tendons, and overall tissue degeneration predispose these cases to high failure rates following surgical treatment. Several approaches have been introduced for transferring the long head of the biceps tendon (LHBT) to help stabilize the humeral head and reestablish shoulder muscle strength. This article proposes a technical modification of capsular reconstruction using arthroscopic LHBT rerouting and fixation, which can enhance the repair of MIRCTs. The essential steps of this procedure involve exposing the native bicipital groove following full release of the rotator cuff, forming a new groove in the greater tuberosity, redirecting the LHBT into this newly created channel with secure fixation, and completing a side-to-side rotator cuff repair over the tendon, making the method suitable for most patients. Our clinical experience suggests this technique can be safely implemented following specific guidelines. We believe that the introduction of this technique offers new insights into reducing sharp graft angulation ("killer turn"), such as the sharp angulation seen in modified "Chinese Way" techniques, where the graft is positioned in the bicipital groove, thereby reducing graft wear caused by this acute angulation. This modification reduces graft wear caused by this acute angulation and provides better humeral head-depression effects. Additionally, the newly created groove facilitates healing between the LHBT and the greater tuberosity, lowering the risk of retear after rotator cuff repair.

Introduction

Massive irreparable rotator cuff tears (MIRCTs) account for 10-40%^1,2,3 among all rotator cuff tears, and their incidence increases with age⁴. Repairing these tears remains a surgical challenge⁵. The management of MIRCTs poses a significant challenge for orthopedic surgeons, primarily attributed to the concurrent presence of fatty infiltration and tendon retraction, which further complicates the treatment approach⁶. Several studies have reported significant initial functional recovery and patient satisfaction following arthroscopic repair, even in cases with Grade 3 fatty infiltration⁷. However, maximal repair being considered the gold standard treatment for MIRCTs, the rate of retear after repair remains high, ranging from 40% to 90%^8,9. Thus, it is essential to explore ways to reduce the retear rate and improve the quality of life for patients.

In cases of MIRCTs, the long head of the biceps tendon (LHBT) is often forced to take on an excessive depressive function of the humeral head. This can lead to secondary degenerative and inflammatory changes, causing pain and functional loss^10,11. Many surgeons frequently perform tenotomy or tenodesis during surgery to repair massive tears¹², viewing the LHBT primarily as a source of pain rather than utilizing it for structural support in the repair process. However, preserving the LHBT and using it as an autograft can help alleviate pain while enhancing rotator cuff repair by incorporating it into a partial superior capsular reconstruction¹³. Several studies have demonstrated the feasibility of using the LHBT to support rotator cuff repair^14,15,16.

One notable technique, described by Boutsiadis et al.⁶, is a modified autograft technique called the "Chinese Way." In this approach, the LHBT's supraglenoid insertion is left intact while the tendon is anatomized distally and fixed with a suture anchor onto the humeral greater tuberosity. As a result, this technique loses the depressing effect of the LHBT on the humeral head. Additionally, a "tension-free" repair of the retracted rotator cuff tendons can be achieved by integrating the LHBT¹⁷. The modified "Chinese Way" technique builds upon the traditional method by creating a new bicipital groove to facilitate the rerouting of the LHBT. All these methods aim to connect the rotator cuff or the glenoid with the humeral head.

More recently, Kim et al.¹⁸ reported a technique advocating for neither harvesting nor trimming the LHBT, but instead rerouting it posteriorly to the greater tuberosity of the humeral head. This rerouting involves altering the pathway of the LHBT without fixation, while maintaining its proximal attachment to the glenoid and distal muscle connection. To treat posterosuperior rotator cuff tears, Tang et al.¹⁹ modified this rerouting technique by pulling the LHBT out of its natural groove and relocating it posteriorly and laterally to a new groove over the greater tuberosity without fixation.

Theoretically, rerouting the LHBT without fixation may offer advantages over transferring it as a free graft after tenotomy. The rerouted LHBT can provide optimal humeral head-depression effects through muscle contraction and tendon micromotion, achieving a tenodesis effect while also reducing surgical time¹⁹. However, this technique may lead to early postoperative biceps pain or even fracture of the greater tuberosity between the two grooves^18,19. In our early clinical practice, we observed that postoperative LHBT rupture could occur with the modified "Chinese Way" technique due to inadequate healing and prolonged stress concentration caused by the sharp angulation between the graft and the greater tuberosity or the bicipital groove, known as the "killer turn"^20,21(Figure 1). This "killer turn" has been reported to elevate tensile stress on the graft, resulting in elongation, tunnel widening, and, in some cases, eventual failure^21,22.

This article aims to propose a technical modification for capsular reconstruction using arthroscopic LHBT rerouting and fixation. The key stages of this method consist of debriding and releasing the rotator cuff, exposing the native bicipital groove, forming a new groove across the greater tuberosity, transferring the LHBT into this channel with fixation, and completing rotator cuff repair over the rerouted tendon. Our clinical experience suggests this technique can be safely implemented following specific guidelines. We believe that the introduction of this technique offers new insights into reducing the "killer turn" effect, providing better humeral head-depression effects, minimizing the risk of Popeye deformity, promoting healing between the LHBT and the bicipital groove, and lowering the risk of retear in cases of tendon transfer.

Protocol

The procedure described herein was conducted in compliance with the guidelines set out by the Ethics Committee of West China Hospital, including regulations on research activity (IRB No. 2020-934). Written informed consent was obtained from the patient for participation and for publication of anonymized clinical data, images, and surgical video. The study was conducted in accordance with the Declaration of Helsinki.

1. Preoperative preparation

1. Patient selection
   1. Inclusion criteria: Ensure patients have a confirmed diagnosis of massive rotator cuff tear via shoulder X-ray and magnetic resonance imaging (MRI). Include patients with significant shoulder pain, restricted range of motion, or joint stiffness that may be associated with the rotator cuff tear, and who may require arthroscopic treatment.
      NOTE: LHBT is acceptable for use even with partial degeneration, as long as the tendon wear does not exceed 50% of its thickness, with a Goutallier grade of ≤3 and a Hamada classification of <3 (Figure 2).
   2. Exclusion criteria: Exclude patients with severe comorbidities that preclude them from tolerating surgery and who decline surgical treatment. Exclude patients with a completely torn LHBT or complete dislocation medial to the lesser tuberosity of the humerus.
2. Provide standard presurgical preparation. Position the patient in the contralateral lateral decubitus position, left lateral for right shoulder pathology and right lateral for left shoulder pathology. Administer general endotracheal anesthesia. Place the operative arm in 30° of abduction and 20° of forward flexion.
3. Administer prophylactic antibiotics in accordance with established guidelines to reduce the risk of postoperative infections.

2. Examination of the glenohumeral joint and subacromial space

1. Use the standard posterior and anterior portals as viewing and working portals. Perform arthroscopic examination to evaluate the subscapularis tear pattern, the intra-articular quality of the LHBT, and the overall condition of the shoulder joint. With a tendon grasper, evaluate rotator cuff retraction at this stage (see also step 3.7).
2. Classify injured LHBTs during preoperative arthroscopic assessment by the extent of the tear as follows: Type I, intact tendon; Type II, hourglass-shaped hypertrophic tendon with fraying extending into the bicipital groove; Type III, partial tear involving less than 50% of tendon width at the intra-articular region without fraying in the groove; Type IV, partial tear affecting more than 50% of tendon width and extending into the groove; and Type V, complete rupture of the tendon²³. Consider Type IV and V as severely damaged and unsuitable for this technique.
3. Advance the arthroscope into the subacromial space through the posterior portal. Examine the subacromial space to evaluate any associated pathology.

3. Intra-articular and subacromial debridement and rotator cuff release

1. Move the arthroscope into the subacromial space and use a motorized shaverand a radiofrequency electrocautery device to perform extensive bursectomy.
2. Create a standard lateral portal along the posterior extension of the clavicle, approximately 5 cm from the lateral edge of the acromion. Use this lateral portal as the primary viewing portal. Identify extensive osteophyte formation at the anterolateral aspect of the acromion with narrowing of the subacromial space.
   NOTE: Place the lateral portal under arthroscopic guidance by introducing a spinal needle through the tear just superior to the greater tuberosity.
3. Under arthroscopic visualization, create a standard anterolateral working portal approximately 3-5 cm anterior to the viewing portal.
4. Use a radiofrequency electrocautery device to debride the hypertrophic tissue and soft tissue at the anterolateral subacromial region through the anterolateral portal. Perform acromioplasty using a burr to thoroughly recontour the acromion, remove the osteophytes, and freshen the footprint on the greater tuberosity.
5. Begin rotator cuff release with the anterior tissues, including the coracohumeral ligament. Perform coracoplasty if the distance between the coracoid and the subscapularis tendon is <5 mm²⁴.
6. Use a shaver and radiofrequency device to remove all inflammatory or hypertrophied synovial tissues around the joint capsule and both the bursal and articular surfaces of the rotator cuff.
7. With a tendon grasper, an evaluation of rotator cuff retraction and degeneration is also performed. Assess the tension and elasticity of the released rotator cuff to determine the feasibility of arthroscopic rotator cuff repair.

4. Fabricating New LHBT Groove and Rerouting LHBT

1. Position the arthroscope through the lateral portal. Introduce a radiofrequency device or shaver through the anterolateral portal. Release the transverse humeral ligament to expose the LHBT beneath it. Release approximately 5 cm of the biceps sheath to facilitate posterolateral transfer of the LHBT.
2. Create a longitudinal groove on the greater tuberosity with an arthroscopic burr, positioning it about 1-1.5 cm posterior to the native LHBT groove, and ensure it remains within the lateral half of the tuberosity (Figure 3). Extend this groove from the cartilage margin of the humeral head across the greater tuberosity to a point roughly 3-5 cm distal to its tip, angling slightly anteriorly at the distal end (Figure 4).
3. Insert an anchor at the most proximal part of the new LHBT groove (Figure 4). Use a 2-0 absorbable suture (see the Table of Materials) to wrap circumferentially around the LHBT, followed by a secure knot tying to ensure firm fixation of the tendon. Pass the second suture through the body of the LHBT to create a secure fixation by tying a knot (Figure 3). Tie the opposite part of the suture using an SMC knot, followed by an additional knot to secure the LHBT; place one knot anteriorly, and the other posteriorly (Figure 4).
4. Leave all suture strands uncut for subsequent suturing of the rotator cuff (Figure 3).

5. Rotator cuff repair

1. Use the sutures from the previously inserted anchors securing the LHBT to assist in the repair of either the anterior edge of the supraspinatus tendon or the superior border of the subscapularis tendon. Place an additional anchor in the posterolateral aspect of the greater tuberosity of the humeral head, at a distance of 1-1.5 cm posterior to the LHBT, to repair a posterior rotator cuff tear (Figure 3).
   NOTE: If the subscapularis tendon is classified as Lafosse Type 1 or 2, use the sutures securing the anterior portion of the LHBT directly to repair the subscapularis tendon. If classified as Lafosse Type 3 or higher, place an anchor on the lesser tuberosity of the humerus to repair the subscapularis tendon.
2. Perform a side-to-side marginal repair over the LHBT (Figure 4). Use the suture bridge technique to repair the rotator cuff. Insert two knotless anchors in the anterior and posterior regions, 1.5-3 cm from the edge of the greater tuberosity, following the suture bridge technique. Cross the sutures over the top of the new bicipital groove to firmly compress the lateral edge of the rotator cuff and the rerouted LHBT within the groove (Figure 4).
3. Irrigate the joint cavity and achieve hemostasis. Suture the incision using No. 3-0 silk thread.

6. Postoperative rehabilitation and follow-up

1. Obtain an immediate postoperative X-ray (Figure 2). Instruct the patient to undergo suture removal at a local clinic 2 weeks after surgery. Schedule follow-up visits at 3, 8, and 12 weeks, 6 months, and 12 months postoperatively, and annually thereafter.
2. Apply an abduction brace immediately postoperatively to maintain a limited and protected motion of the shoulder (Figure 5).
   NOTE: Passive and mild active motion are allowed postoperatively at 3 weeks postoperatively, but forceful activity and weight-bearing should be avoided. Perform an MRI at 3-6 weeks to evaluate early rotator cuff repair outcomes.
3. Begin full-range rehabilitation activities and active motion exercises once the brace has been removed. Initiate pendulum and pulley exercises immediately following brace removal, normally within 6-8 weeks after surgery.
4. Begin active range of motion exercises at 8-10 weeks postoperatively. Start internal rotation strengthening exercises after 12 weeks. Delay resisted strengthening exercises until 6 months postoperatively.
   NOTE: The primary goals of rehabilitation are to improve active shoulder mobility and preserve glenohumeral joint biomechanics.
5. Conduct a follow-up MRI at 1 month and 2 years postoperatively to assess the retear rate (Figure 2).

Results

A patient who met the above inclusion criteria underwent minimally invasive techniques to treat a massive irreparable rotator cuff tear (MIRCT). The patient was a 60-year-old, right-hand-dominant female with a body mass index (BMI) of 24 and a 20-month duration of symptoms. She had no history of diabetes, hypertension, or other systemic diseases. The patient presented with significant pain and a limited range of motion in the right shoulder. The patient's drop arm test was positive. Preop...

Discussion

In this study, we propose a technical modification of capsular reconstruction that involves arthroscopic LHBT rerouting and fixation. This approach aims to enhance the repair of MIRCTs. Compared to the method described by Tang et al.¹⁹, the main principles remain the same. After forming a new bicipital groove in the greater tuberosity and rerouting the LHBT into it, the LHBT is secured within the new groove using anchors. The anterior and posterior shoulder force couples are then restored by repai...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Arthroscopic sheath	smith&nephew	72200829	6 mm
Arthroscopy	smith&nephew	72202087	30 mm x 4 mm
Beam guide	smith&nephew	72204925	5 mm x 3.6 m
Beam guide-arthroscopy end connector	smith&nephew	2143
Beam guide-panel connector	smith&nephew	2147
Blunt puncture cone	smith&nephew	4356	4 mm
Camera	smith&nephew	72200561	NTSC/PAL
Clear-Trac Complete Threaded Cannula Obturator	smith&nephew	72200905	7 x 72 mm
Coupler	smith&nephew	72200315
Disposable radiofrequency plasma surgical electrodes	MeChan	MC407
DYONICS POWER II	smith&nephew	72200873	100-24VAC, 50/60 Hz
DYONICS POWERMAX ELITE	smith&nephew	72200616
Endoscopic camera system	smith&nephew	72201919	560P NTSC/PAL
FOOTPRINT Ultra	smith&nephew	72202901
HD monitor	smith&nephew	LB500031	27 inch
Hook probe	smith&nephew	3312
Incisor plus platinum shaver	smith&nephew	72202531	4.5 mm
Micropunch,teardrop,left	smith&nephew	7207602
Micropunch,teardrop,right	smith&nephew	7207601
Micropunch,teardrop,straight	smith&nephew	7207600
PDS II (polydioxanone) Suture	Ethicon	W9236T	absorbable suture
Pitbull Jr. Grasper	smith&nephew	14845
TWINFIX ULTRA HA	smith&nephew	72202597