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

The research investigates treatment strategies for massive irreparable rotator tears, aiming to evaluate outcomes and identify optimal evidence-based approaches in an area lacking standardized clinical consensus. This technique requires proficient arthroscopic shoulder skills and suture management techniques. The video clearly demonstrates the procedural steps of this technique.

This technique utilizes the autologous proximal biceps tendon for whole rotator cable reconstruction, making it suitable for middle-aged and elderly patients with low functional demands who desire shoulder preservation. The main advantages of this technique include facile tissue harvesting, a straightforward surgical procedure, the absence of immune response, and cost-effectiveness. To begin, place the anesthetized patient in the lateral decubitus position, pad all bony prominences with sponge supports, and gently mobilize the shoulder to release joint adhesions.

Immobilize the operative arm using a foam traction sleeve. Apply a traction force of three to six kilograms using a simple traction frame. Tilt the torso back by 30 degrees, maintain the operative arm in 60 degrees abduction, and set flexion at 30 degrees.

After marking the anatomical landmarks and portal positions, disinfect the area with iodine tincture followed by alcohol. Next, create a standard posterior portal and make a 0.5 centimeter skin incision using an 11-gauge blade. Insert a 30-degree arthroscope toward the rotator interval.

Target the anterior light spot via 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.

Now enter the subacromial space using a posterior arthroscopic approach. Establish anterolateral and lateral approaches at four centimeters beyond the lateral acromion border. Observe the subacromial space from the posterior portal and insert a shaver through the anterolateral approach to debride the thickened bursa and adhesive tissues.

Use a radiofrequency probe for hemostasis and mark the anterolateral acromion if hyperplasia or impingement is noted. Debride soft tissues with hyperplasia using an arthroscopic shaver and remove subacromial spurs with a burr. Next, 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 massive irreparable rotator cuff tears cannot be restored to the footprint without tension after release. Use a radiofrequency probe to dissect and fully expose the distal end of the long head of the biceps tendon.

Transect the tendon at its insertion using a basket punch, maintaining a length of six to seven centimeters. Braid the long head tendon using four No.2 OrthoCord braided composite sutures at both ends and the center. 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 at original cable locations. Position a 4.5-millimeter anchor at the anterior edge of the U-shaped groove and another at the posterior edge. Pull the woven biceps tendon into the subacromial space and secure it at the groove's distal end with two footprint anchors.

Ensure both ends of the tendon are anchored within the distal groove. Select the white suture from the cartilage margin anchor, and pass it through the biceps tendon. Tie the suture using an SMC knot to firmly secure the tendon, and leave the tail for rotator cuff suturing.

Using a suture shuttle, sequentially pass sutures from the anchor and tendon center through retracted cuff tissue. With a full-loop knot manipulator, secure the repair using an SMC knot, and manage sutures with a cannula. Assess suturing with an arthroscopic probe hook.

Add anchors or sutures if needed to close the glenohumeral joint and subacromial space. Perform radiofrequency ablation for hemostasis, drain fluid from the subacromial space, and suture the incision with 3-0 silk braided suture. The one-year follow-up of the patients revealed significant improvement in shoulder function and pain relief as compared to those before surgery.

The patient's VAS score significantly decreased from 4.58 plus or minus 1.17 preoperatively to 0.67 plus or minus 0.78 postoperatively. While the ASES score increased significantly from 43.30 plus or minus 6.0 to 84.43 plus or minus 4.73, the postoperative active range of motion significantly increased throughout the follow-up period. The patient's forward flexion significantly improved from 101.33 plus or minus 27.77 degrees preoperatively to 154.08 plus or minus 13.58 degrees postoperatively.

Similarly, lateral external rotation increased from 34.83 plus or minus 10.55 degrees to 41.42 plus or minus 10.29 degrees, and internal rotation also showed improvement, rising from 7.0 plus or minus 4.0 degrees to 8.83 plus or minus 3.0 degrees.