Anterior Capsular Reconstruction With Proximal Biceps Tendon for Large to Massive Rotator Cuff Tears

Massive rotator cuff tears (RCT) have traditionally been a challenging clinical problem for shoulder surgeons. A broad variety of treatment options have been proposed to address this problem, but outcomes have been as variable as the techniques themselves. Superior capsular reconstruction has been presented as a way to restore the restraining effect of the superior joint capsule and balanced force couples in massive tears of the superior rotator cuff. The purpose of this article is to propose a technical modification of the superior capsular reconstruction in large to massive RCT, and, especially in anterior L-shaped RCT, using the long head of the biceps tendon autograft to reinforce the weakest area of the anterior capsule, not as an augmentation of the rotator cuff, but as a static stabilizer of the humeral head, allowing the rotator cuff repair to heal without tension.
Technique Video Video 1 With the patient in the beach chair position and into the subacromial space, a bony trough is created from the anterolateral portal in line with the bicipital groove and the mobility of the biceps tendon is checked. After medial anchor insertion a double lasso loop is made to the biceps with the first strand to facilitate the transfer to its new location. Next the suture retriever is passed under the biceps tendon to grasp the second strand for atraumatic suture. After placing the second anchor, the same process is carried out as with the medial implant, but this time we take the first strand with a simple lasso loop. Next, the sutures are tied at 30° of abduction and the stability of the biceps is checked. Finally, the tendon tenotomy is performed in the bicipital groove. Once the anterior capsular reconstruction is finished, attention is paid to the rotator cuff, and its mobility is verified; in this case we have a delaminated tear. After placing the posterior anchor of the medial row, placement of a lasso loop was performed around the free edge of the deep layer. The free end of this lasso loop suture was then passed at the muscle-tendon junction through the superficial layer. The second free end of the suture is subsequently passed through both the deep and superficial layers of the cuff. Later, the most anterior anchor of the medial row is placed, and the same procedure is carried out as with the posterior anchor. Finally, a double row repair is performed with the suture limbs of the medial row and the integrity of the repair is checked.