February 2024 Newsletter

“Waste Not, Want Not” – Is It Time We Move the Biceps Tendon Out of the Trash and Onto the Greater Tuberosity for Massive Cuff Tears? 

By: Michael A. Zacchilli, M.D. Member, AANA Communications and Technology Committee

One hundred and fifty years after the first known rotator cuff repair, massive tears continue to present challenges to surgeons. Despite significant advances in surgical techniques and implants, modern studies continue to report retear rates well over 50% for high-risk tears. Recent efforts, such as the development of the Rotator Cuff Healing Index, have improved our ability to identify these at-risk tears in a systematic fashion.¹ Unfortunately, reproducible and cost-effective surgical solutions to prevent these failures have been more elusive. Worries over our patients’ persistent symptoms and the risk of progression to rotator cuff arthropathy persist. 

Options available to modern surgeons for high-risk or partially irreparable rotator cuff tears include partial repair, interpositional grafting, tendon transfers and reverse shoulder arthroplasty, all of which are well understood. Surgeons are similarly familiar with the unique limitations of each procedure. A persistent desire for better options has inspired recent innovation, particularly in the form of superior capsular reconstruction (SCR). Dr. Mihata’s introduction of the superior capsular reconstruction with fascia lata autograft seemed a revelation when first described.²   

More recent research has drawn the reproducibility of SCR into question, with acellular dermal allografts struggling to keep pace with the fascia lata results in some series, and midterm patient satisfaction rates lagging as follow-up periods increase. Questions regarding graft availability and cost effectiveness are an additional concern, particularly outside of the United States. Finally, some reports suggest that reverse total shoulder arthroplasties after failed SCR may produce lower functional outcomes and higher complication rates.³ These factors together have tempered surgeon enthusiasm for the procedure, opening the door for the “next big thing.”⁴  

A surprising contender for the spotlight in this new talent search is the biceps tendon – a structure many of us have spent years releasing or repositioning. Recent literature has exploded with reports of repurposing the biceps tendon, whether in situ, rerouted or modified into an autograft patch. As demonstrated by Veen et al. in their 2018 systematic review, many of these techniques share some inspiration with older descriptions.⁵ But while these techniques may not turn heads with new technologies or marketing budgets, the growing volume of research should garner interest.  

Neviaser was one of the earliest to describe use of the biceps tendon as a free graft (circa 1971), and an arthroscopic repair of the rotator cuff with margin convergence to the in situ long head of the biceps was described as early as 2004 by Richards and Burkhart.^6,7 Neither of these descriptions gained significant traction with only scattered reports of biceps augmentation prior to Mihata’s 2013 SCR description. Subsequently, the SCR procedure renewed interest in reconstructive procedures and motivated the search for alternative graft options.  

Initial iterations of biceps augmentation for rotator cuff repair included tenotomy at the glenoid, with either a broad-based tenotomy directly sutured to the cuff, or an anterior to posterior reflection of the articular segment to supplement soft tissue along the lateral edge of the cuff.^8-11 Compared to a partial repair cohort, Cho et al.’s biceps-augmented cuff repair cohort demonstrated similar functional outcomes but improved strength and higher rates of complete healing rates on MRI (58.3% vs 26.3%). In contrast, Jeon et al. (2017) and Park et al. (2018) demonstrated no statistically significant difference in clinical outcomes, strength or failure rate (approximately 40%) between groups in their series. 

Persistent interest in the symbiotic relationship between the rotator cuff and the superior capsule led to convergent evolution of the surgeries. Biceps augmentation techniques were modified to retain the glenoid origin in what some authors have now termed the “Bio-SCR."¹² A 2018 cadaveric model demonstrated that reconstruction of the anterior cable, tenodesing the biceps tendon to the greater tuberosity with an intact origin, could reliably restore humeral head depression and decrease subacromial contact pressures without restricting motion.¹³ Clinical series have subsequently explored the use of this technique to supplement large to massive tears with retraction and/or fatty infiltration.  

While current evidence is populated by short-term level IV cohorts, there is mounting research suggesting that combining the Bio-SCR with the maximum achievable repair may be a viable option for large, high-risk or irreparable rotator cuff tears. Numerous clinical series have now demonstrated good short to mid-term results in large to medium rotator cuff tears.^14-18 These cohorts have demonstrated improvements in ASES ranging from 42.7 to 61 points, reductions in VAS ranging from 2.1 to 6.91, and complete retear rates between 4.9% and 26% which compares favorably with historic results for similar populations of large to massive tears with Goutallier grade 2-3 changes. It is important to note that the only study in this group to include a comparison group (Seo et al.) had a mean follow-up of only 18.7 months for the Bio-SCR group. While improvements in acromiohumeral interval and retear rates did reach significance in this study, the differences were small, and clinical outcomes between the Bio-SCR and isolated RCR groups were equivalent.  

The most recent article by Dr. Larry Field and colleagues is highlighted in the February Arthroscopy Podcast and demonstrates some of the longest follow-up available.¹⁹ The paper analyzes the results of biceps transposition in 30 patients with massive tears (width > 5cm, ≥ 2 tendons, and area ≥ 30 cm2) to supplement partial (n=17) or complete (n=13) repair. The patients represented a broad age range (28-83 years) with 19 patients ≤ Hamada Stage 2. All patients achieved substantial clinical benefit, with mean improvements of 53.8 points on ASES and 6.2 points on VAS at 3 years. Furthermore, there were no failures. The only identified complication was a rupture of the biceps tendon in one patient at the level of the tuberosity distal to the cuff repair.  

In summary, mounting evidence is demonstrating that the Bio-SCR technique is at least equivalent to RCR alone with retear rates in cohorts lower than historical comparison for similar high-risk patterns. The procedure appears to be safe with no negative impact on range of motion. Allografts alone have been shown to add thousands to the cost of isolated partial repair, with potential for significant additional costs if extra anchors are utilized. However, given failure rates eclipsing 50% for isolated repair or partial repair in high-risk tears, a proactive approach to reducing long-term failure rates is warranted. Is it time to routinely consider Bio-SCR for these patients? The benefits of biologically active local tissue, the fiscally responsible nature of the graft, the relative ease of use and its early success in prior cohorts are tantalizing.  However, as with all technologies, we eagerly await the results of head-to-head, randomized, controlled studies comparing Bio-SCR to non-augmented repair, partial repair or other surgical options before we can endorse its routine use.