The Hosentraeger Technique: An Arthroscopic Tendon-in-Tendon Interposition Approach Using the Long Head of the Biceps for Irreparable Rotator Cuff Tears

Abstract

Massive and irreparable rotator cuff tears (MIRCTs) represent a challenging clinical problem, particularly in younger patients in whom joint-preserving strategies are preferred. Although a range of surgical techniques exist-including partial repair, superior capsular reconstruction, and tendon transfer-none have shown clear superiority, and failure rates remain high. Autologous grafts such as long head of the biceps tendon (LHBT) grafts have gained attention because of their biological compatibility and accessibility. In this technical note, we present an arthroscopic tendon-in-tendon interposition technique-the "Hosentraeger technique"-that uses the LHBT to reconstruct the rotator cable in MIRCTs. After subpectoral tenodesis and glenoid tenotomy, the LHBT is passed through the remaining resistant portion of the rotator cuff and anchored laterally using knotless fixation. This technique aims to achieve stable biological integration by creating a direct tendon-to-tendon interface while restoring dynamic force transmission across the superior cuff. By avoiding the need for allografts or excessive tension on degenerated tendon remnants, this approach offers a reproducible, biologically favorable, and mechanically robust solution for MIRCTs in selected patients.

Fig 1

Preoperative magnetic resonance imaging (MRI) of the right shoulder of a 65-year-old male patient. (A) In the coronal view, a large posterosuperior rotator cuff tear is observed, with stage III retraction of the supraspinatus tendon (white arrow) according to the Patte classification. (B) In the axial view, tendinopathy of the long head of the biceps is noticeable (black arrow); however, the tendon remains intact. (C) The parasagittal view reveals muscle atrophy and grade 2 fatty infiltration according to Goutallier et al. The asterisk indicates the supraspinatus muscle.

Fig 2

Biceps tenodesis and graft preparation. After the long head of the biceps tendon is exposed (A) and secured with nonabsorbable sutures using Krackow stitches (B), the tendon is fixed in a unicortical manner using a BicepsButton (C). (D) Subsequently, the tendon is cut just above the tenodesis site. (E, F) After arthroscopic tenotomy, the approximately 70-mm biceps autograft is sutured at both ends with FiberWire by the Krackow stitch technique for further use. The asterisks indicate the long head of the biceps tendon. (C, caudal; Cr, cranial.)

Fig 3

With the patient placed in the beach-chair position, anatomic landmarks and portal sites are marked on the right shoulder, viewed from the lateral aspect. (A, acromion; C, clavicle; 1, anterior portal; 2, lateral portal; 3, posterolateral portal; 4, posterior portal; 5, Neviaser portal.)

Fig 4

Arthroscopic visualization of a right shoulder with the patient in the beach-chair position. (A) The interval region is visualized using a scope in the posterior portal, showing an intact long head of the biceps tendon (LHB) on the superior rim of the glenoid (G). (B) After debridement and partial resection of the bursa, a complete supraspinatus (SSP) lesion extending to the glenoid rim is observed. After transection of the LHB at the level of the labrum (C), the supraspinatus tendon is released as much as possible, and a suture is placed through the tendon to facilitate its mobilization toward the footprint (D).

Fig 5

Arthroscopic visualization in a right shoulder with the patient in the beach-chair position. After penetration of the rotator cuff cable from the Neviaser portal (A), a grasper is used to shuttle the reinforced long head of the biceps graft (LHBG) through the lateral portal and then through the retracted tendon (B-E). After fixation of the 2 limbs of the graft at the footprint (FP) with 2 ReelX knotless anchors (Stryker, Kalamazoo, MI) (F-H), the cable is restored and repositioned (I). (J) From the intra-articular view, the defect is closed. (G, glenoid; HH, humeral head; SSP, supraspinatus tendon.)

Fig 6

Positioning of the long head of the biceps tendon graft. For isolated retracted supraspinatus ruptures, a C-configuration may be suitable (type I). If the harvested graft is long enough, a U-configuration can be formed through the rotator cuff cable (type II). For more extensively retracted ruptures, if 2 C-configurations are planned, allografts can be used to shape 2 separate C-configurations (type III). If an additional tendon is ruptured and retracted, a U-configuration with a long head of the biceps autograft can be formed through both the supraspinatus (SSP) and infraspinatus (ISP) tendons (type IV).