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With a range of tear characteristics such as chronicity, degree of fatty atrophy, and number of tendons involved as well as varying patient-specific characteristics including age, injury mechanism, and expectations after treatment to consider, proper and successful treatment of a rotator cuff tear is multifactorial and, consequently, challenging. Although conservative management of a rotator cuff tear may be successful, a more severe tear with involvement of more tendons may warrant surgical intervention. Furthermore, additional pathology including biceps tendinopathy may result in greater patient morbidity and an even more complex treatment decision-making process and surgical technique. The purpose of this Technical Note is to describe our preferred surgical technique for the treatment of a rotator cuff tear involving 2 rotator cuff tendons in conjunction with a lesion of the long head of the biceps tendon.
See video under supplementary data.
Rotator cuff tears (RCTs) are common and limiting injuries of the shoulder
that result in pain, stiffness, weakness, and loss of proper range of motion. Although many patients can present as asymptomatic in the setting of an RCT, this condition can lead to a disabling and painful condition, especially in elderly patients.
Because of the cost of surgical management and comparable outcomes to conservative management in certain RCT cases, it is imperative to properly choose surgical candidates based on both their symptoms and ultimate functional goals. Surgical treatment is usually recommended for chronic symptomatic tears with previously failed conservative management and as a primary treatment option in young patients with high functional demands.
Aside from the patient's symptoms and postoperative demands as well as the condition of the rotator cuff, concomitant pathology must also factor into the ultimate treatment to be undertaken. Often seen in association with RCTs, tendinopathy of the long head of the biceps (LHB) is a limiting pathology reportedly seen in 30% to 69% of RCTs.
In particular, surgical treatment for biceps tendinopathy is advised in the setting of a medial tendon subluxation, partial thickness tears ≥25% to 50% in size of the tendon of the LHB, and/or failed conservative treatment.
(Video 1). We feel that this position allows for anatomic orientation of the torn rotator cuff and facilitates greater arm range of motion during the surgical case, thereby facilitating access to the LHB for eventual subpectoral biceps tenodesis. Before surgical intervention, many of our patients elect to undergo peripheral regional nerve blockade to aide in postoperative pain control.
After induction of general anesthesia, the patient, who is supine on a beach chair operating table, has his head secured and padded to the table using foam beach chair head restraint. The legs are slightly flexed at the knee with the use of a foam pad. Afterward, the bony prominences are well padded. Sequential compression devices are placed on bilateral lower extremities. Before raising the head of the patient's bed, blood pressure is checked and the patient is confirmed to be safe for elevation with anesthesia. Occasionally, the patient can suffer from hypotension, and a cerebrovascular incident is possible if the patient is raised to the beach chair position under general anesthesia.
The neck is then checked, with the patient in the upright position, to ensure that it remains in the neutral position. A safety strap secures the patient to the operative table. The nonoperative arm is held in the neutral position with an Allen Arm Positioner (Allen Medical Systems, Acton, MA) with care to ensure that the ulnar nerve is not compressed. The back of the beach chair table is then slid toward the contralateral side, clearing room for operative intervention. A “kidney rest” is tightened in order for the patient to remain secured to the operative table during the entirety of the procedure. The operative arm is then sterilely prepped and draped in a standard manner. We use a SPIDER2 (Smith & Nephew, Andover, MA) to hold the arm in position during arthroscopic and open surgery. Before incision, a surgical time-out is performed to confirm the correct patient, extremity, and surgical procedure.
Diagnostic Arthroscopy and Biceps Tenotomy
A standard posterior arthroscopic shoulder portal is made approximately 2 cm distal and 2 cm posterior to the posterior tip of the acromion. This portal is placed in line with the axillary crease and Neviaser portal soft spot. The arthroscope is introduced into the joint, and then under direct visualization, a 5-mm Arthrex cannula is used to establish an anterior mid-glenoid portal, which is in close proximity to the coracoid process, into the rotator interval. Pump pressure is typically around 40 mm Hg, and visualization is further aided by hypotensive anesthesia with a systolic blood pressure goal of 90 mm Hg.
A diagnostic arthroscopy of the joint is initially performed with particular attention paid to the status of the biceps tendon, joint synovium, glenohumeral ligaments, subscapularis and supraspinatus tendons, cartilage, and labrum. In our case example, synovitis is debrided with an arthroscopic shaver (Arthrex, Naples, FL) (Fig 1A). Then, further inspection reveals tenosynovitis and fraying of the LHB. The LHB is then tenotomized through the use of a combination of basket-style arthroscopic scissors and arthroscopic shaver (Fig 1B). Once the tenotomy is complete, a retraction of the biceps tendon is performed (Fig 1C). In this case example, tears of the supraspinatus and subscapularis tendons are identified. Once identified, a No. 1 polydioxanone stay suture (Ethicon, Somerville, NJ) is passed via a spinal needle.
Subacromial Decompression and Bursectomy With Associated Acromioplasty
After completion of the initial arthroscopy, the arthroscope is repositioned through the posterior portal into the subacromial space. We then establish a “50-yard line” style portal off the lateral border of the acromion. A thorough bursectomy is then performed using an arthroscopic shaver and a radiofrequency device (Arthrex) (Fig 2). We perform most of our bursectomy using the arthroscopic shaver, whereas the radiofrequency wand is mostly used for hemostasis. Bursal tissue in this space often appears bruised, thickened, and scarred in association with the RCT. We focus on both the subacromial space and lateral gutter to better visualize the tear. The tears are readily identified by the stay suture that was placed previously while in the intra-articular glenohumeral joint. The tears are then sufficiently mobilized during the bursectomy with nearly a 360° release. At this point, it is crucial to identify tear type to plan for surgical repair of the tendons that is guided by the tear pattern.
The subacromial decompression is then performed. The acromial spurring is addressed with an arthroscopic burr after soft tissue is cleared from the bone with the arthroscopic shaver. Concurrently, hemostasis is maintained with the radiofrequency device. Several millimeters of the spurring are resected allowing for more space to accommodate the supraspinatus tendon repair.
Arthroscopic Rotator Cuff Repair of the Subscapularis and Supraspinatus
In our case example, the tears of the subscapularis and supraspinatus are reconfirmed and evaluated to fully understand the tear pattern. Afterward, a FiberWire suture (Arthrex) is first passed through the torn subscapularis tendon using a FastPass Scorpion Suture Passer (Arthrex) through the anterior portal. After this, the footprint of the rotator cuff is prepared with an arthroscopic bone-cutting shaver (Arthrex) in shaver mode, radiofrequency wand, and rasp (Fig 3). A 4.75-mm SwiveLock Suture Anchor (Arthrex) is used. First, a Punch/Tap for the 4.75-mm SwiveLock (Arthrex) is used through the accessory portal to create the hole necessary for suture anchor insertion. Then, the anchor is loaded with the previously passed FiberWire suture. Afterward, the anchor is placed into the lesser tuberosity and then the repair is properly tensioned. A mallet may be used to appropriately insert the anchor to adequate depth. In this case example, the size of the tear found in the subscapularis tendon is small; therefore, 1 anchor is allowed for a sufficient repair. Once the repair is appropriately tensioned, the shoulder is taken through normal range of motion in internal and external rotation while the repair is arthroscopically visualized to ensure adequate fixation. Visualization of the subscapularis tear is sometimes aided by a 70° arthroscope.
Once the subscapularis tear has been repaired, the supraspinatus tear is re-evaluated. In this case example, the tear of the supraspinatus is identified as a “u-shaped” pattern that easily mobilizes back to the greater tuberosity footprint for anatomic repair. The arm is typically positioned to the side, in no more than 10° to 15° of abduction and neutral rotation. Similar to preparation before repair of the subscapularis, the supraspinatus footprint on the greater tuberosity is prepared using an arthroscopic bone-cutting shaver in shaver mode to remove the residual torn tendon stump. Debridement is accomplished with the arthroscope in the posterior portal and with instrumentation through the lateral “50-yard line” portal. After the bony bed has been sufficiently prepared, the FiberWire suture is then passed through the torn tendon, whereas the FastPass Scorpion Suture Passer is used to retrieve the suture through the lateral portal. After passing the sutures in a horizontal mattress configuration, the free ends are retrieved (Fig 4).
Similar to the subscapularis tear repair, a 4.75-mm SwiveLock is used. This is accomplished by first punching a hole with the Punch/Tap for the 4.75-mm SwiveLock in the lateral aspect of the rotator cuff footprint under arthroscopic visualization. A separate accessory portal is often made to get an ideal angle for anchor insertion after first localizing the trajectory and placement of this anchor with a spinal needle. Then, the sutures that were previously passed through the tendon are retrieved and loaded into the 4.75-mm SwiveLock anchor (Fig 5). The anchor is then inserted through the accessory portal by first dunking the anchor approximately 25% into the previously established pilot hole and, afterward, pulling the sutures until they are taut. Again, a mallet may be used to insert the anchor into its proper place. In this case example, these steps are repeated for a second 4.75-mm SwiveLock anchor because of the size of the tear. In total, 3 anchors, 1 for the subscapularis and 2 for the supraspinatus, are used to reach an adequate repair.
Mini-open Subpectoral Biceps Tenodesis
Using a surgical pen, the path of the pectoralis major tendon is marked (Fig 6A). A small 2.5-cm incision is then made just inferior to the pectoralis major tendon, lateral to the axillary fold (Fig 6B). Hemostasis is achieved with bovie electrocautery while dissecting through the subcutaneous tissue. Metzenbaum scissors are then used to dissect through 2 layers of fascia. We are then able to readily identify the previously arthroscopically tenotomized LHB just medial to the pectoralis major tendon (Fig 7A). The tendon is then retracted from the joint (Fig 7B). Typically, the proximal extent of the tendon has significant synovitis and tearing, which is cleaned off and all adhesions are removed (Fig 7C). In most cases, this occurs in the proximal 4 to 5 cm of the tendon. The FiberWire suture is then whipstitched into the proximal end of the remaining tendon approximately 2 cm proximal to the muscle-tendon junction (Fig 8). The diseased tendon end is then resected. A 7 × 7 mm unicortical tunnel is then drilled over a guidewire in the biceps groove approximately 2 cm superior and proximal to the pectoralis major tendon insertion. Afterward, the biceps tendon is loaded into a 7 × 10 mm PEEK (polyether ether ketone) biceps tenodesis screw (Arthrex) by passing the whipstitched end through the eyelet and up the screw and screwdriver. The screw is then secured into the drilled tunnel (Fig 9). After screw insertion, the handle is removed to ensure that the screw is flush with the humeral cortex. Lastly, the screw is shuck once the repair is complete to ensure adequate fixation.
Copious irrigation of the subpectoral biceps tenodesis incision is then completed after completion of the tenodesis. A layered closure is performed with 2-0 monocryl and 3-0 monocryl subcuticular stitch, dermabond, and steristrips. The incisions are then dressed. Afterward, the shoulder is placed in an abduction sling. The pearls and pitfalls associated with this technique are listed in Table 1.
Table 1Pearls and Pitfalls
To ensure adequate interference fixation within bone and proper tensioning of the muscle-tendon unit, enough of the tendon must be secured before the fixation
Inadequate interference fixation may result from poor securement of the tendon for fixation
The arm is externally rotated approximately 10° while the drill is aimed directly anterior to posterior to ensure drilling and reaming in the center of the humerus
If the arm is improperly positioned during drilling, eccentric drilling may result and lead to inadequate fixation
A separate accessory portal can be made to get an ideal angle for anchor insertion after first localizing the trajectory and placement of this anchor with a spinal needle
After subacromial decompression and bursectomy, it is crucial to identify tear type to plan for surgical repair of the tendons that is guided by the tear pattern
For this particular repair, we advise a postoperative rehabilitation program lasting a total of 16 to 22 weeks. The initial 6 weeks should be centered on the goal of maintaining and protecting the repair. Therefore, the shoulder will be largely immobilized during this portion of the rehabilitation with no active range of motion and a restriction to only pendulum exercises and passive range of motion. At week 6, active range of motion is allowed with periscapular and stretching exercises. At week 10, early strengthening exercises including external and internal rotation with thera bands, elbow flexion and extension, and lateral raises are encouraged. During weeks 16 to 22, advanced strengthening exercises are suggested to capture the strength of the shoulder before injury. Moreover, self-capsular stretching is encouraged to maintain full range of motion. The return to sport is at the discretion of the patient.
Moreover, given the biceps tenodesis performed as part of this particular repair, the postoperative protocol should also consist of no active biceps activation of more than 10 lbs of lifting for the initial 6 weeks. However, we encourage passive elbow range of motion in flexion, extension, and pronation, supination in the scapular plane of motion with low scapular engagement.
RCTs with associated biceps tendinopathy are a common cause of debilitating shoulder pain that is challenging to treat due to the variety of factors in consideration. This Technical Note describes our preferred surgical technique for addressing this particular injury pattern. We recommend using this technique both in the setting of failed conservative management and in the acute setting with a symptomatic patient with high functional demand and high expectations after treatment.
There remains debate regarding the ideal treatment protocol, whether conservative or surgical, for RCTs. Many randomized control trials have shown that conservative management of rotator cuff repairs yields very similar objective outcomes when compared with surgical intervention.
showed that 4 specific factors affected outcomes after conservative treatment and the need for subsequent surgery: integrity of intramuscular supraspinatus tendon, supraspinatus muscle atrophy, impingement sign, and significantly decreased external rotation range of motion.
As previously stated, biceps tendinopathy is a common injury typically associated with RCTs. Surgical treatment is the preferred method when significant instability or pain is present, or when conservative management has failed. The 2 main categories of treatment for biceps tendinopathy are tenodesis versus tenotomy. Numerous studies have been performed comparing the 2 procedures, and most have shown no clinically significant difference in subjective or objective outcomes.
Both options have been shown to be viable options for the treatment of tendinopathy. One advantage to tenotomy is a faster postoperative rehabilitation with an earlier return to sport compared with tenodesis. Tenodesis, on the other hand, usually results in inactivity for the initial 4 weeks after surgery with no active range of motion.
With this in mind, tenotomy may be a more favorable treatment option for an athlete or active patient looking for a quicker return to play or work; however, tenodesis may be preferable when long-term strength and stability are the top priority.
In conclusion, we recommend our described technique for the treatment of RCTs with associated biceps tendinopathy. We feel that our technique is easily replicable and ultimately leads to a resolution of symptoms regardless of the patient's particular functional demands. Nevertheless, further studies are needed to explore differences in long-term outcomes between different operative techniques, such as tenotomy versus tenodesis, performed concurrently with rotator cuff repair. These studies will further confirm the validity of the described technique.
A diagnostic arthroscopy of the left shoulder is initially performed. The long head of the biceps tendon is inspected and then tenotomized using a combination of basket-style arthroscopic scissors and arthroscopic shaver. Tears of the subscapularis and supraspinatus are identified, and then a No. 1 PDS stay suture is used. An arthroscopic shaver and radiofrequency device are used to perform the bursectomy. The subscapularis tear is evaluated and noted to be small in this case example. Afterward, a FiberWire suture is first passed through the torn subscapularis tendon using a FastPass Scorpion Suture Passer through the anterior portal. Then, the footprint of the rotator cuff is prepared with an arthroscopic bone-cutting shaver in shaver mode, radiofrequency wand, and rasp. A 4.75-mm SwiveLock Suture Anchor is used for fixation of the tendon. In this case example, the size of the tear found in the subscapularis tendon is small; therefore, 1 anchor is allowed for a sufficient repair. Once the repair is appropriately tensioned, the shoulder is taken through normal range of motion in internal and external rotation, while the repair is arthroscopically visualized to ensure adequate fixation. After this, the supraspinatus tear pattern is identified as a “u-shaped” pattern. The greater tuberosity footprint of the supraspinatus is debrided using an arthroscopic bone-cutting shaver; then a combination of a rasp and high-speed cutting shaver is used to create a bleeding bony surface. Next, the rotator cuff tendon is secured and the free ends of the sutures are retrieved. Two 4.75-mm SwiveLock anchors are used to repair the tendon in the anatomic position, similar to the subscapularis tendon. After completion of the rotator cuff repair, attention is turned to the biceps tenodesis. A 2.5-cm incision is made just inferior to the pectoralis major tendon, lateral to the axillary fold. The tendon is whipstitched with the FiberWire suture approximately 2 cm proximal to the muscle-tendon junction. Then, the diseased end of the tendon is resected. After this, a 7 × 7 mm unicortical tunnel is drilled over a guidewire in the biceps groove approximately 2 cm superior and proximal to the pectoralis major tendon insertion. The biceps tendon is then loaded into a 7 × 10 mm PEEK (polyether ether ketone) biceps tenodesis screw by passing the whipstitched end through the eyelet and up the screw and screwdriver. The screw is inserted into the drilled tunnel. After screw insertion, the handle is removed to ensure that the screw is flush with the humeral cortex. Once the tenodesis is complete, a standard, layered closure is performed.
The authors report the following potential conflicts of interest or sources of funding: M.T.P. is the consultant for Arthrex and JRF Ortho; has patent numbers (issued) 9226743, 20150164498, 20150150594, 20110040339; and receives publishing royalties from Arthrex and SLACK. Full ICMJE author disclosure forms are available for this article online, as supplementary material.