Arthroscopic Biological Augmentation for Massive Rotator Cuff Tears: The Biceps-Cuff-Bursa Composite Repair

Abstract

Surgical repair of massive and chronic rotator cuff tears is difficult due to tendon retraction and severe atrophy, and the resultant retear rate in the structurally weak tendons is high. Commercially available patches and bioinductive scaffolds have been used to provide strength and superior healing environment in partial and complete rotator cuff tears. Biological biceps autograft has been used for superior capsular reconstruction, and the subacromial bursa has been shown to have significant pluripotent stem cell potency for tendon healing. We describe our technique for combined use of the long biceps tendon (LBT) and vasculature-preserved subacromial bursa as autografts in rotator cuff repair augmentation. The technique involves obtaining a LBT graft of sufficient length using a "traction and tenodesis" technique. The subacromial bursa is mobilized as a continuous layer (vascular bursal duvet) by maintaining its medial and lateral vascularity. All-suture anchors are used to minimize the insertion apertures (3 mm) in tuberosity. The bursa is advanced laterally, and the mobilized cuff is repaired together as a biceps-cuff-bursa composite unit. Combined use of the biceps and bursa as biological autografts has the advantage of structural and regenerative augmentation, and the autografts are easily accessible without added cost.

Fig 1

Magnetic resonance image and arthroscopic view (posterior portal) of a massive rotator cuff tear (arrow) in a right shoulder is shown. The torn tendon (C) is atrophic and retracted and the bare tuberosity (T) can be visualized.

Fig 2

Long biceps tendon (LBT) autograft harvest technique is demonstrated (right shoulder, posterior viewing, lateral working portal). Subscapularis (SC) repair sutures (arrow) are retrieved via lateral cannula and passed around LBT. Nonsliding knots are used to tenodesis the biceps after pulling it out of the groove (top images). LBT is detached proximal to tenodesis sutures (arrow) and this results in adequate tendon length for augmentation (bottom images). H denotes humeral head; T denotes tuberosity.

Fig 3

Subacromial bursa (B) harvest technique is demonstrated (right shoulder, high posterolateral High posterolateral portal viewing, lateral working portal). B is released from the deltoid adhesions and sufficiently mobilized for anterolateral advancement (arrows). C, rotator cuff tendons; RF, radiofrequency probe; SH: shaver.

Fig 4

The tuberosity (T) is debrided (top left image) and 3 all-suture anchors (AN1, AN2, and AN3) are passed along the medial aspect of the tuberosity in a single row configuration (top right and bottom images). C, torn cuff tendon, H, humeral head, right shoulder, high posterolateral portal view; SH, shaver.

Fig 5

Sutures are seen passing through the biceps graft (LBT), cuff tendon (C) and bursa (B) together as a composite unit. The anterior-most suture (AN1) passes through the supraspinatus only (C, top left image), and the next 2 sutures are passed through all 3 structures (top images). Thereafter, sutures are passed through C and B (bottom images, right shoulder, high posterolateral portal view).

Fig 6

Arthroscopic view prior to knot tying shows the distribution of sutures through the long biceps tendon (LBT)-C-B complex (left image). Sliding knots are used to advance the bursa (B) laterally over the repaired tendon (C) at its edge (middle image). The LBT is covered by the supraspinatus (arrow, right image) as the sutures are knotted. HPL portal view; T, tuberosity, right shoulder.

Fig 7

Final view shows the bursal (left and middle images) and articular aspects (right image) of the repaired and augmented cuff tendons. The “vascular bursal duvet” (B) is seen adequately covering the repaired tendons (C). The long biceps tendon (LBT) is seen securely fixed to the tuberosity (T) in conjunction with the repaired tendon (C). H, humeral head, right shoulder, high posterolateral portal view.