Free Biceps Tendon Autograft to Augment Arthroscopic Rotator Cuff Repair Padraic R. Obma, M.D.
Abstract: Arthroscopic rotator cuff repairs have become the standard of treatment for all sizes of tears over the past several years. Current healing rates reported in the literature are quite good, but improving the healing potential of rotator cuff repairs remains a challenging problem. There has been an increase recently in the use of augmentation of rotator cuff repairs with xenografts or synthetics for large and massive tears. Biceps tenodesis is often indicated as part of the treatment plan while one is performing rotator cuff surgery. A subpectoral biceps tenodesis provides a source of autograft to augment rotator cuff repairs of all sizes. Two techniques are presented to augment rotator cuff repairs with a free biceps tendon autograft. This is a novel idea in an attempt to improve healing rates and long-term results of rotator cuff repairs of all sizes.
S
houlder pain and weakness are problems for patients with rotator cuff tears. After nonsurgical management fails, patients frequently elect to undergo surgical repair of the torn rotator cuff tendon or tendons. Healing rates for small- to medium-sized tears have been reported in the literature to be around 90% for double-row repair techniques.1,2 Large and massive tears of the rotator cuff have a much lower healing rate after surgery.3,4 Better clinical outcomes have been associated with a healed rotator cuff repair,2,5 making it very important to achieve healing of the repair. Augmentation of large and massive rotator cuff repairs has been described with a biceps tendon that has undergone tenotomy,6,7 left attached distally to the muscle, or using a patch8,9 to augment the repair. Allograft reconstruction has also been described in the literature with poor reported results.10 The previously mentioned studies on rotator cuff augmentation tended to focus on augmentation for large and massive tears. The long head of the biceps tendon is another source of pain and disability in the shoulder. On physical
From the Department of Sports Medicine, Prevea Health, Green Bay, Wisconsin, U.S.A. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received May 1, 2013; accepted July 10, 2013. Address correspondence to Padraic R. Obma, M.D., Department of Sports Medicine, Prevea Health, 2502 S Ashland Ave, Green Bay, WI 54307-9070, U.S.A. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/13283/$36.00 http://dx.doi.org/10.1016/j.eats.2013.07.002
examination and during arthroscopic surgical evaluation, the long head of the biceps can be assessed for pathology. One of the many techniques described to address pathology of the biceps tendon is a subpectoral biceps tenodesis with an interference screw.11 This procedure is not without risks because a recent study has shown the potential at-risk structures including the musculocutaneous nerve, radial nerve, and deep brachial artery all within 1 cm of the standard medial retractor.12 When tenodesis of the long head of the biceps is indicated and the subpectoral tenodesis technique is chosen to address the biceps pathology, there is a source of autograft tissue that can be incorporated into rotator cuff repairs of all sizes.
Technique When nonsurgical management is unsuccessful, the patient is taken to the operating room for arthroscopic surgery. After examination under anesthesia, the patient is placed in the lateral decubitus position and routine arthroscopic evaluation of the shoulder joint is undertaken (Video 1). Frequently, preoperative planning will alert us whether the long head of the biceps tendon is going to be addressed. It is also visualized surgically before we make a final decision about biceps tenodesis. When indicated, the biceps tendon is tagged and undergoes tenotomy. The subpectoral biceps tenodesis has been described in previous literature.11 We prefer to perform the subpectoral biceps tenodesis before subacromial arthroscopy so that the tissue planes are not altered by fluid extravasation. After biceps tenodesis, there is a free autograft of biceps tendon that
Arthroscopy Techniques, Vol 2, No 4 (November), 2013: pp e441-e445
e441
e442
P. R. OBMA
Table 1. Indications for Biceps Weave Technique Patients with small to large rotator cuff tears requiring biceps tenodesis Repairable rotator cuff tear that is mobile Quality rotator cuff tissue able to be dilated to 3 mm Lack of footprint coverage
is available for rotator cuff augmentation. The biceps autograft generally ranges from 4 to 8 cm in length and from 3 to 6 mm in diameter. We place the autograft on the back table under saline solutionesoaked gauze and proceed with subacromial arthroscopy to assess the rotator cuff and determine whether an autograft augmentation is possible. These augmentations can be used for all sizes of tears from small to massive depending on the quality of rotator cuff tissue and level of retraction. We have developed a weave technique and an onlay technique for free biceps tendon autograft augmentation. We currently use the weave technique more frequently than the onlay technique. Weave Technique After determining that an augmentation is possible, the graft is prepared (Table 1). We take a 6- to 8-cm strip of tendon and cut it in half longitudinally to provide us 2 strips of graft that are 6 to 8 cm in length and have a diameter of 2 to 3 mm. On 2 cm of each end of the graft, we use a FiberLoop (Arthrex, Naples, FL) to prepare the graft with a running-locking stitch (Fig 1). After graft preparation, we use a posterior viewing portal and create a lateral working portal. The rotator cuff tear is then mobilized, and medial-row anchors (5.5-mm Biocomposite CorkScrew; Arthrex) are placed. The medial-row stitches are passed with a MultiFire Scorpion (Arthrex). We try to obtain about a 1-cm bite of tissue with each stitch and space the stitches 5 to 7 mm apart to avoid dog ears. After the medial-row
Figure 1. Biceps tendon autograft preparation for weave technique.
Figure 2. View from the posterior portal of a left shoulder as the biceps autograft is weaved through the posterior edge of the torn rotator cuff just lateral to the medial-row stitches and pulled out the anterior portal. (BT, biceps tendon; HH, humeral head; RC, rotator cuff.)
stitches are passed, a 2-mm FiberTape (Arthrex) is used to pass the graft from the lateral portal. We place a single knot in the thick part of the FiberTape and then place a double knot 1 cm behind the first knot, followed by a triple knot 1 cm behind the double knot. This allows us to dilate the rotator cuff just enough to pass the graft. The FiberTape is passed retrograde in the posterior portion of the tear just lateral to the medial-row stitches and pulled out the anterior portal just past the triple knot. The graft is passed from the lateral portal, through the rotator cuff, and the leading-edge stitches are then pulled out the anterior portal by use of the FiberTape as a dilating and passing stitch (Fig 2). We pass the same FiberTape retrograde from the lateral portal through the
Figure 3. View from the posterior portal of a left shoulder as the anterior limb of the autograft has been weaved back through the anterior edge of the rotator cuff repair. (BT, biceps tendon; RC, rotator cuff.)
FREE BICEPS TENDON AUTOGRAFT
e443
Table 3. Indications for Biceps Onlay Technique Medium to large tears requiring biceps tenodesis Incomplete footprint coverage Biceps autograft length
Abstract: Arthroscopic rotator cuff repairs have become the standard of treatment for all sizes of tears over the past several years. Current healing rates reported in the literature are quite good, but improving the healing potential of rotator cuff repairs remains a challenging problem. There has been an increase recently in the use of augmentation of rotator cuff repairs with xenografts or synthetics for large and massive tears. Biceps tenodesis is often indicated as part of the treatment plan while one is performing rotator cuff surgery. A subpectoral biceps tenodesis provides a source of autograft to augment rotator cuff repairs of all sizes. Two techniques are presented to augment rotator cuff repairs with a free biceps tendon autograft. This is a novel idea in an attempt to improve healing rates and long-term results of rotator cuff repairs of all sizes.
S
houlder pain and weakness are problems for patients with rotator cuff tears. After nonsurgical management fails, patients frequently elect to undergo surgical repair of the torn rotator cuff tendon or tendons. Healing rates for small- to medium-sized tears have been reported in the literature to be around 90% for double-row repair techniques.1,2 Large and massive tears of the rotator cuff have a much lower healing rate after surgery.3,4 Better clinical outcomes have been associated with a healed rotator cuff repair,2,5 making it very important to achieve healing of the repair. Augmentation of large and massive rotator cuff repairs has been described with a biceps tendon that has undergone tenotomy,6,7 left attached distally to the muscle, or using a patch8,9 to augment the repair. Allograft reconstruction has also been described in the literature with poor reported results.10 The previously mentioned studies on rotator cuff augmentation tended to focus on augmentation for large and massive tears. The long head of the biceps tendon is another source of pain and disability in the shoulder. On physical
From the Department of Sports Medicine, Prevea Health, Green Bay, Wisconsin, U.S.A. The author reports that he has no conflicts of interest in the authorship and publication of this article. Received May 1, 2013; accepted July 10, 2013. Address correspondence to Padraic R. Obma, M.D., Department of Sports Medicine, Prevea Health, 2502 S Ashland Ave, Green Bay, WI 54307-9070, U.S.A. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/13283/$36.00 http://dx.doi.org/10.1016/j.eats.2013.07.002
examination and during arthroscopic surgical evaluation, the long head of the biceps can be assessed for pathology. One of the many techniques described to address pathology of the biceps tendon is a subpectoral biceps tenodesis with an interference screw.11 This procedure is not without risks because a recent study has shown the potential at-risk structures including the musculocutaneous nerve, radial nerve, and deep brachial artery all within 1 cm of the standard medial retractor.12 When tenodesis of the long head of the biceps is indicated and the subpectoral tenodesis technique is chosen to address the biceps pathology, there is a source of autograft tissue that can be incorporated into rotator cuff repairs of all sizes.
Technique When nonsurgical management is unsuccessful, the patient is taken to the operating room for arthroscopic surgery. After examination under anesthesia, the patient is placed in the lateral decubitus position and routine arthroscopic evaluation of the shoulder joint is undertaken (Video 1). Frequently, preoperative planning will alert us whether the long head of the biceps tendon is going to be addressed. It is also visualized surgically before we make a final decision about biceps tenodesis. When indicated, the biceps tendon is tagged and undergoes tenotomy. The subpectoral biceps tenodesis has been described in previous literature.11 We prefer to perform the subpectoral biceps tenodesis before subacromial arthroscopy so that the tissue planes are not altered by fluid extravasation. After biceps tenodesis, there is a free autograft of biceps tendon that
Arthroscopy Techniques, Vol 2, No 4 (November), 2013: pp e441-e445
e441
e442
P. R. OBMA
Table 1. Indications for Biceps Weave Technique Patients with small to large rotator cuff tears requiring biceps tenodesis Repairable rotator cuff tear that is mobile Quality rotator cuff tissue able to be dilated to 3 mm Lack of footprint coverage
is available for rotator cuff augmentation. The biceps autograft generally ranges from 4 to 8 cm in length and from 3 to 6 mm in diameter. We place the autograft on the back table under saline solutionesoaked gauze and proceed with subacromial arthroscopy to assess the rotator cuff and determine whether an autograft augmentation is possible. These augmentations can be used for all sizes of tears from small to massive depending on the quality of rotator cuff tissue and level of retraction. We have developed a weave technique and an onlay technique for free biceps tendon autograft augmentation. We currently use the weave technique more frequently than the onlay technique. Weave Technique After determining that an augmentation is possible, the graft is prepared (Table 1). We take a 6- to 8-cm strip of tendon and cut it in half longitudinally to provide us 2 strips of graft that are 6 to 8 cm in length and have a diameter of 2 to 3 mm. On 2 cm of each end of the graft, we use a FiberLoop (Arthrex, Naples, FL) to prepare the graft with a running-locking stitch (Fig 1). After graft preparation, we use a posterior viewing portal and create a lateral working portal. The rotator cuff tear is then mobilized, and medial-row anchors (5.5-mm Biocomposite CorkScrew; Arthrex) are placed. The medial-row stitches are passed with a MultiFire Scorpion (Arthrex). We try to obtain about a 1-cm bite of tissue with each stitch and space the stitches 5 to 7 mm apart to avoid dog ears. After the medial-row
Figure 1. Biceps tendon autograft preparation for weave technique.
Figure 2. View from the posterior portal of a left shoulder as the biceps autograft is weaved through the posterior edge of the torn rotator cuff just lateral to the medial-row stitches and pulled out the anterior portal. (BT, biceps tendon; HH, humeral head; RC, rotator cuff.)
stitches are passed, a 2-mm FiberTape (Arthrex) is used to pass the graft from the lateral portal. We place a single knot in the thick part of the FiberTape and then place a double knot 1 cm behind the first knot, followed by a triple knot 1 cm behind the double knot. This allows us to dilate the rotator cuff just enough to pass the graft. The FiberTape is passed retrograde in the posterior portion of the tear just lateral to the medial-row stitches and pulled out the anterior portal just past the triple knot. The graft is passed from the lateral portal, through the rotator cuff, and the leading-edge stitches are then pulled out the anterior portal by use of the FiberTape as a dilating and passing stitch (Fig 2). We pass the same FiberTape retrograde from the lateral portal through the
Figure 3. View from the posterior portal of a left shoulder as the anterior limb of the autograft has been weaved back through the anterior edge of the rotator cuff repair. (BT, biceps tendon; RC, rotator cuff.)
FREE BICEPS TENDON AUTOGRAFT
e443
Table 3. Indications for Biceps Onlay Technique Medium to large tears requiring biceps tenodesis Incomplete footprint coverage Biceps autograft length
![[Functional outcome of arthroscopic rotator cuff repair].](/assets/img/hold.png)
