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%

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....

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