Arthroscopic Management of Massive Irreparable Rotator Cuff Tears: Whole Rotator Cable Reconstruction Using Proximal Biceps Tendon Autograft

Summary

Massive irreparable rotator cuff tears (MIRCTs) pose significant clinical challenges due to their complex pathology and limited treatment options. This study introduces whole rotator cable reconstruction (WRCR) using proximal biceps tendon autograft as a novel surgical technique for MIRCTs.

Abstract

Massive irreparable rotator cuff tears (MIRCTs) are not uncommon in clinical practice, significantly impacting shoulder function and daily activities. Extensive tear size, tendon contracture, and fat infiltration within the rotator cuff pose significant challenges for both patients and clinicians. This type of tear is a key area of interest and a challenge in research and treatments. Current treatment options include conservative management, debridement, partial repair, superior capsule reconstruction (SCR), tendon transfers, and reverse total shoulder arthroplasty (RTSA). However, clinical outcomes vary widely.

The rotator cable (RC) exhibits a perpendicular orientation with respect to the superior rotator cuffs, thereby forming an arc-shaped attachment to the proximal humerus, and it plays an essential role in maintaining the rotator cuff's force couple. The attachments of both anterior and posterior RC play a crucial role in facilitating overhead movements. When complete tension-free coverage of the footprint cannot be attained, whole rotator cable reconstruction (WRCR) presents as an alternative approach for MIRCTs. We utilized autologous tendon harvested from the proximal biceps tendon for arthroscopic WRCR. The proposed technique offers distinct advantages: autologous tissue utilization eliminates immunogenicity; simplified harvesting reduces operative complexity; and minimized anchor usage enhances cost-effectiveness. In this study, 12 patients underwent WRCR, with significant improvements in shoulder function and pain relief observed during a 1 year follow-up.

Introduction

Massive rotator cuff tears (MRCTs) are defined as tears involving at least two tendons or tears wider than 5 cm. Approximately 20% of primary rotator cuff tears and 80% of recurrent tears fall into this category^1,2. The documented rate of treatment failure for MRCTs is approximately 40%³. In some cases, MRCTs are deemed irreparable due to muscle atrophy, fat infiltration, and severe tendon contracture, making low-tension anatomical repair impossible^4,5. Some investigators have reported the incidence of MIRCTs up to 30%^6,7. Due to the increasing prevalence of shoulder pain among elderly patients and the escalating demands of daily activities and exercise, as well as the unique characteristics of MIRCTs, its treatment necessitates a highly intricate and crucial decision-making process.

Current therapeutic strategies for MIRCTs encompass a spectrum of interventions ranging from conservative management to advanced surgical techniques such as superior capsular reconstruction (SCR) and reverse total shoulder arthroplasty (RTSA) ⁸. The appropriate treatment depends on a comprehensive evaluation of various factors. Reconstructing the rotator cuff is considered the primary treatment for elderly patients with low demand and non-shoulder osteoarthritis⁹.

The rotator cable (RC), spanning from the supraspinatus anterior margin to the infraspinatus posterior border, functions as a biomechanical suspension system that preserves coronal plane force equilibrium within the rotator cuff complex¹⁰. Evidence indicates that the combined technique of rotator cuff repair and anterior cable reconstruction utilizing the proximal biceps tendon achieves satisfactory functional and anatomical outcomes in patients with massive retracted anterosuperior L-shaped rotator cuff tears¹¹. In a previous study, anterior rotator cable reconstruction was successfully achieved using a V-shaped hamstring allograft for the management of MIRCTs, demonstrating favorable biomechanical functionality¹².

Posterior cable insertion has been reported to play a crucial role as a connecting structure among the Teres minor (TM), infraspinatus (ISP), and supraspinatus (SSP). As a result, complete rupture of the entire cable can lead to significant impairment of shoulder function in patients¹³. Previous study was conducted to investigate the efficacy of suture-based cable reconstruction in partially repairing the rotator cuff¹⁴. Drawing on prior research, we adopt the whole rotator cable reconstruction (WRCR) technique to treat MIRCTs.Theoretically, this technique offers greater potential to restore optimal coronal plane equilibrium and is more likely to enhance the patient's shoulder function when the rotator cuff cannot be completely repaired without applying tension.

Protocol

This study adhered to the guidelines set by the Ethics Committee of the 909th Hospital, Xiamen University School of Medicine. Informed consent was obtained from all participants. The study included 12 patients (7 females and 5 males) aged 50 to 70 years.

1. Preoperative preparation

1. Set the following inclusion criteria: patients with a preliminary diagnosis of MIRCT by magnetic resonance imaging (MRI) and Hamada type 2 or type 1 MIRCT¹⁵, aged between 50 and 70, and those with treatment failure after standard conservative treatment.
   NOTE: Confirm MIRCT under arthroscopy if tension-free sutures cannot adequately cover the footprint.
2. Set the following exclusion criteria: patients with a history of previous shoulder surgery; those with grade 4 fatty infiltration¹⁶; injury involving more than half of the tendon of the long head of the biceps brachii or absence of the tendon; patients with intolerance to general anesthesia; and those with irreparable anterior or posterior rotator cuff tears that could not restore the horizontal force couple balance.

2. Arthroscopy surgical procedures

1.  Anesthesia and patient positioning
   1. Perform the surgery under general anesthesia with a brachial plexus block. Place the patient on their side. Cushion all bony prominences with sponge pads to prevent pressure ulcers. Assess the degree of adhesion in the shoulder joint and manually release the joint.
   2. Immobilize the operative arm using a foam traction sleeve. Apply a 3-6 kg traction force using a simple traction frame. Tilt the torso back at an angle of 30°, maintain the abduction of the operative arm at 60°, and set flexion at 30°. Mark anatomical landmarks and portal positions prior to disinfection using iodine tincture and alcohol (Figure 1).
2. Establishing the arthroscopic approaches
   1. Create a standard posterior portal. Make a 0.5 cm skin incision using an 11 G blade.
   2. Insert a 30° arthroscope toward the rotator interval. Target the anterior light spot through an incision along the lateral coracoid process. Observe the shoulder cavity contents, evaluate the biceps long head tendon, and release the rotator interval if adherent.
   3. Enter the subacromial space via the posterior arthroscopic approach. Establish anterolateral and lateral approaches 4 cm beyond the lateral acromion border (Figure 2).
3. Evaluation of the subacromial space
   1. Observe the subacromial space from the posterior portal and insert a shaver through the anterolateral approach to debride thickened bursa and adhesive tissues. Use a radiofrequency probe for hemostasis and mark the anterolateral acromion if hyperplasia or impingement is observed. Debride subacromial soft tissues with hyperplasia using an arthroscopic shaver, and remove subacromial spurs with a Burr.
   2. Reassess rotator cuff tears from the lateral portal, including tear pattern, extension, fatty atrophy, retraction, and location. Evaluate the biceps long head tendon. Proceed with WRCR if MIRCTs cannot be restored to the footprint without tension after release (Figure 3).
4. Preparation of the long head tendon of the biceps
   1. Use a radiofrequency probe to meticulously dissect and fully expose the distal end of the long head of the biceps tendon, ensuring clear visualization of the surrounding structures. Carefully transect the tendon at the insertion using a Basket Punch, and maintain 6-7 cm tendon length throughout (Figure 4).
   2. Braid the long head tendon using four No. 2 Orthocord braided composite sutures at both ends and the center (Figure 5).
5. Release of the rotator cuff and preparation of the footprint
   1. Carefully freshen the footprint on the bone surface using a burr. Create a 'U'-shaped groove extending from the cartilage margin to the distal end of the greater tubercle, positioned at the original anterior and posterior cable locations (Figure 6).
      NOTE: Retracted rotator cuff tissues should be thoroughly released to prevent suprascapular nerve injury. If present, torn subscapular tendons should be repaired using anchor sutures.
6. Whole rotator cable reconstruction
   1. Place two 4.5 mm anchors (each loaded with two #2 sutures). Position the first anchor at the anterior edge of the 'U'-shaped groove along the cartilage rim; then, place the second anchor at the posterior edge of the groove. Carefully pull the woven long head tendon into the subacromial space, and secure the tendon at the distal end of the 'U'-shaped groove using two footprint anchors. Ensure both ends of the long head of the biceps tendon are securely anchored within the distal portion of the 'U'-shaped groove (Figure 7).
   2. Select the white suture from the cartilage margin anchor and pass the white suture through the long head tendon to ensure a secure hold. Tie the white suture using an SMC knot to firmly secure the tendon within the bone groove. Ensure even tension and proper seating of the tendon in the groove. Do not cut the sutured tail, leave it for the subsequent suturing of the retracted rotator cuff.
   3. Using a suture shuttle, sequentially pass the sutures from the cartilage margin anchor and the braided sutures at the center of the long head of the biceps tendon through the retracted rotator cuff tissue. With the assistance of a full-loop knot manipulator, secure the repair with an SMC knot. Utilize a cannula to manage the sutures and prevent tangling throughout the procedure. (Figure 8).
   4. Assess suturing with an arthroscopic probe hook. Add anchors or composite sutures for reinforcement to close the glenohumeral joint and subacromial space, if needed.
      NOTE:The number of anchors or composite sutures required to reinforce the suture should be determined based on the intraoperative situation. This is illustrated in the case presented in the video.
7. Suture of the incision
   1. Perform radiofrequency ablation for hemostasis. Drain fluid from the subacromial space. Suture the incision with a 3-0 silk braided suture.

3. Rehabilitation and follow-up

1. Instruct patients to wear an abduction brace for six weeks postoperatively. Allow wrist and elbow movement starting postoperative day 1. Initiate passive shoulder movements at 3 weeks, active movements at 6 weeks, and muscle strength training at 12 weeks. Permit full activity, including contact sports at 6 months.
2. Encourage patients to ambulate on postoperative day 2.
3. Change dressings every 3 days. Remove stitches 14 days postoperatively.
4. Perform shoulder radiography (AP and supraspinatus outlet views) prior to discharge.
5. Discharge patients once pain decreases (VAS ≤ 4).
6. Schedule follow-up visits at 3 and 6 weeks, 3 and 6 months, and 1 year postoperatively.
7. Assess VAS score, shoulder ROM, ASES score, X-ray, and MRI at 6 months, 12 months, and annually thereafter.

Results

WRCR using the proximal biceps tendon autograft was performed in 12 patients between February 2021 and March 2023, with suture repair in four cases of subscapular muscle partial tear; 7 out of 12 patients had adhesions of varying degrees, and all of them underwent manual release after anesthesia. Postoperative complications were not observed. The one-year follow-up revealed significant improvement in shoulder function (P < 0.05) and pain relief (P < 0.05) as compar...

Discussion

The management of MIRCTs remains a critical challenge in orthopedic surgery, necessitating continued exploration of biomechanically sound reconstruction techniques. The tension-free anatomical restoration of the torn rotator cuff represents the optimal therapeutic approach in our clinical practice. The presence of extensive tears and severe tendon contracture in patients with MIRCTs adversely affects the achievement of tension-free anatomical repair. The available treatments for these patients are limited in their effica...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
ACCU-PASS Suture Shuttle	smith&nephew	7210423	45°, left
ACCU-PASS Suture Shuttle	smith&nephew	7210424	45°, right
Basket Punch	smith&nephew	7207057	3.5 mm
Blade	smith&nephew	72202534	4.5 mm
Burr	smith&nephew	7205668	Straight
Camera Control Unit	smith&nephew	72202334	NTSC/PAL
Camera Head	smith&nephew	72200561	NTSC/PAL
Diagnostic Cannula	smith&nephew	72200829
Diagnostic Cannula Obturator	smith&nephew	4356	100-240 VAC, 50/60 Hz
Direct-View Arthroscopes	smith&nephew	72202087
DYONICS POWER Footswitch	smith&nephew	7205399
DYONICS POWER II Shaver System	smith&nephew	72200873	6.0 mm, double-valve
DYONICS RF System	smith&nephew	72202149	conical tip
DYONICS Shaver Handpiece	smith&nephew	72200616	4.0 mm, 30°
Fiber Optic Light Cables and Adaptors	smith&nephew	7205180	4.5 mm
FOOTPRINT Ultra PK Suture Anchor	smith&nephew	72202901	4.5mm
Full Loop Knot Manipulator	smith&nephew	72201213	4.0 mm x 10 ft
Healix advance BR anchor	DePuy Mitek	222295	4.5 mm
Light Source	smith&nephew	72200588	500XL
ORTHOCORD Violet Braided composite suture	DePuy Mitek	223104	#2
Spade Tip Drill	smith&nephew	72202116	3.5 mm
Suture Cutter	smith&nephew	7209492
Suture Loop Horizontal Grasper	smith&nephew	72201179
Suture Loop Vertical Grasper	smith&nephew	7209494
Threaded Cannula	smith&nephew	72200905	7.0 mm x 72 mm