Biceps tendon autograft augmentation for rotator cuff and instability procedures: a narrative review

in EFORT Open Reviews
Authors:
Hubert Laprus St Luke’s Hospital, Bielsko-Biala, Poland
Dworska Hospital, Kraków, Poland
Hospital in Proszowice, Poland

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https://orcid.org/0000-0001-9438-2297
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Bartłomiej Juszczak University Children’s Hospital in Kraków, Poland

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Roman Brzóska St Luke’s Hospital, Bielsko-Biala, Poland

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Adrian Błasiak St Luke’s Hospital, Bielsko-Biala, Poland

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Ion-Andrei Popescu Romanian Shoulder Institute -ORTOPEDICUM, Bucharest, Romania

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Przemysław Lubiatowski Rehasport Clinic, Poznań, Poland

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Correspondence should be addressed to H Laprus; Email: Hubert.laprus@gmail.com
Open access

  • Rotator cuff tears (RCT) and instability are the most common surgically treated shoulder pathologies.

  • The concept of augmentation using the long head of the biceps tendon (LHBT) autograft was created to improve the results of surgical treatment of these pathologies, especially in cases of chronic and massive injuries.

  • The popularity of using the LHBT for augmentation is evidenced by the significant number of publications on this topic published in the last 3 years; however, only one systematic review has been published regarding only LHBT augmentation for massive RCTs.

  • Several studies comparing partial repair with partial repair and additional LHBT augmentation for RCT showed superior clinical outcomes and lower re-tear rates when LHBT augmentation was performed.

  • There is a rising popularity of using LHBT as an autograft to perform superior capsule reconstruction (SCR) in case of irreparable rotator cuff tears.

  • In recent years, shoulder stabilization by arthroscopic Bankart repair with biceps augmentation has been promoted with very promising short-term results.

  • The evidence provided by studies appears to be sufficient to recommend the use of LHBT for augmentation whenever necessary; however, larger studies with long-term follow-up are needed.

Abstract

  • Rotator cuff tears (RCT) and instability are the most common surgically treated shoulder pathologies.

  • The concept of augmentation using the long head of the biceps tendon (LHBT) autograft was created to improve the results of surgical treatment of these pathologies, especially in cases of chronic and massive injuries.

  • The popularity of using the LHBT for augmentation is evidenced by the significant number of publications on this topic published in the last 3 years; however, only one systematic review has been published regarding only LHBT augmentation for massive RCTs.

  • Several studies comparing partial repair with partial repair and additional LHBT augmentation for RCT showed superior clinical outcomes and lower re-tear rates when LHBT augmentation was performed.

  • There is a rising popularity of using LHBT as an autograft to perform superior capsule reconstruction (SCR) in case of irreparable rotator cuff tears.

  • In recent years, shoulder stabilization by arthroscopic Bankart repair with biceps augmentation has been promoted with very promising short-term results.

  • The evidence provided by studies appears to be sufficient to recommend the use of LHBT for augmentation whenever necessary; however, larger studies with long-term follow-up are needed.

Introduction

The long head of the biceps (LHB) typically originates from the supraglenoid tubercle and postero-superior labrum. The tendon initially travels downward through the rotator cuff interval, where it is enclosed by the biceps pulley and resides within the bicipital groove.

The structure and accessibility of the biceps tendon (LHBT) during shoulder arthroscopic surgery make it an attractive option for augmentation in challenging rotator cuff reconstructions or in recurrent glenohumeral instability treatment. So far, several applications and modifications of the techniques have been described in various clinical scenarios. Therefore, this review aims to summarize the use of LHBT as an augmentative material in rotator cuff repair, superior capsular reconstruction, and anterior shoulder instability treatment.

LHBT’s role in shoulder

There is a paucity of data regarding the LHBT’s role in intact shoulders; however, it is essential to consider its anatomical variations as well as their potential impact on shoulder function. Studies using surface electromyography in healthy shoulders suggest the LHBT’s involvement in shoulder flexion, abduction (1, 2), and pitching activities (highest activity during cocking and between 9:00 h and follow-through face) (3, 4). On the other hand, there are similar studies suggesting a minimal role of the tendon in shoulder function (5, 6). Moreover, conflicting findings question the relevance of LHBT, especially considering studies that do not immobilize elbow movements, making it unclear if LHBT activity is solely attributed to shoulder function. Furthermore, there is limited data on the stabilizing function of the biceps in healthy individuals, with only one study presented by Sakurai et al.(7) proposing the concept of stabilizing the humeral head in superior and anterior directions (7) .

Anatomical variations of LHBT, affecting approximately 6–10% of the studied population (8), typically encompass aberrant tendon origin, supernumerary accessory heads, intra-articular tendon mobility, and tendon absence. The association between these variations and patient-related shoulder manifestations such as instability, pain, or diminished shoulder function is rather uncertain due to the predominance of case studies in current literature (9, 10). There is only one study with a larger population that identified a correlation between proximal LHBT tendon anatomical variations (sublabral foramen, cord-like middle glenohumeral ligament, or Buford complex) and an increase in passive internal rotation at a 90° abduction (P = 0.046), leading to anterosuperior labral fraying (P = 0.000) (11). Additionally, a systematic review reported that the absence of the LHBT is frequently linked with shoulder pain (85.7%) and instability (37.1%). However, the authors remained inconclusive about whether the absence of the LHBT should be perceived as a predisposing factor for rotator cuff or labral pathology or if it remains incidental and lacks clinical relevance (12).

LHBT’s role in shoulder pathologies

The majority of biomechanical studies on the function of the LHBT often use cadaveric models, posing challenges in translating in vitro findings to the physiological load experienced by the LHBT in vivo (13). In understanding of many, the LHBT is believed to act as a supporting structure, resembling a hammock, between the supraglenoid tubercle and the biceps pulley, inhibiting superior and anterior migration of the humeral head during shoulder movement. In the case of concomitant rotator cuff tears, the LHBT experiences greater tension, requiring hyperactivation for uncoupled superior humeral head shift (14). Some studies suggest that LHBT plays a supplementary role in shoulders with rotator cuff tears (15) or in patients with multidirectional instability (16). Others, on the contrary, indicate a minimal role of LHBT in glenohumeral joint stability (17), grip test strength (18), or biceps activity with elbow immobilization brace (19). Radiological studies presented by Kido and McMahon advocate the concept of LHBT acting as an active humeral head depressor during shoulder elevation (20). Furthermore, a study comparing clinical and radiological outcomes after the repair of massive and irreparable rotator cuff tears showed that partial repair with biceps augmentation increased the acromio-humeral distance (AHI) more significantly than partial repair alone (21). This finding supports the theory that LHBT augmentation helps to depress the humeral head in case of insufficient cuff balance. However, it is still unknown if this is accomplished by providing mechanical and vascular support for the repaired cuff construct or by mimicking the function of the native rotator cable described by Burkhart in 1993 (22).

On the other hand, the potential role of the tendon is limited in the case of LHBT tendinitis, which is typically secondary to other shoulder pathologies such as rotator cuff tears or impingement syndrome. In the course of the inflammatory process, the tendon increases in diameter and finally becomes mechanically constricted due to scarring and adhesions within the bicipital groove. Progressive friction of an inflamed tendon during shoulder movements may lead to tendon rupture, typically occurring at the proximal attachment or at the musculotendinous junction. Ruptures are often associated with symptomatic relief and a deformity of the distal humerus called the Popeye sign (23). These ruptures are more frequently observed in individuals over the age of 50, with an incidence rate of over 95%, surpassing that of the short head portion or the distal biceps (24).

LHBT’s role in rotator cuff tears

The LHBT is frequently involved in rotator cuff tears and may be the source of anterior shoulder pain. Tendon hypertrophy, delamination, tear, hourglass contracture, and tendon instability within the bicipital groove are common findings accompanying rotator cuff tears during shoulder arthroscopy. Candela et al. conclude that the bigger the rotator cuff tear is, the more often concomitant LHBT pathology occurs (25). Failure to address LHBT disorders in the setting of rotator cuff tears may result in persistent shoulder pain and poor satisfaction following rotator cuff repair (26). In the recent years, there has been a heated debate regarding techniques addressing the aforementioned biceps injuries. There were many proofs that both biceps tenodesis and tenotomy are efficient techniques for addressing biceps during rotator cuff reconstruction, even in cases with no visible signs of biceps pathology (27). However, the impact of routine and adjunctive LHBT surgery in the case of rotator cuff-related pain and its longer-term implications on shoulder function remains unknown. Possible proprioceptive and stabilizing functions of the LHB are desirable, yet not always worth retaining (28). Per the senior author’s protocol, there is a low threshold for inclusion of biceps management in the case of cuff reconstruction. By and large, any pathologic abnormalities of the tendon lead to concomitant treatment of the biceps during first-time shoulder surgeries, and the preserved biceps are treated almost routinely during revision surgeries, especially when used as an augmentation. In our preference, biceps tenodesis is performed in young and active patients, especially in patients with thin arms. Biceps tenotomy is reserved for older patients with lower physical demands, but also in patients for whom cosmesis and potential pope-eye deformity are not a concern.

LHBT as a viable material for shoulder augmentations

The success of rotator cuff reconstruction is influenced by both the size of the contact surface between bone and the repaired tendon as well as the biological quality of the construct (29). Hypovascularity and oligocellularity of the tendon diminish healing potential, and tendon retraction often observed in chronic cases increases tension of newly repaired structures, substantially raisinge the risk of tendon retearing. The particular mechanism and biological role of LHBT augmentation are not fully expanded. The use of LHBT as an augmentation during rotator cuff reconstruction facilitates tendon healing by stiffening the reconstruction and reducing tension at the tendon–bone junction, as suggested by Cho et al. (30) Moreover, LHBT provides a source of fibroblasts producing collagen and additional vascularization at the healing site, which influences the remodeling of the construct (31). Lubiatowski et al. (29) proved that the recurrence of rotator cuff tears after reconstruction was associated with a decrease in the isokinetic strength of the shoulder. Given that, the better the quality of the reconstructed tendons, the lower postoperative re-tear rate and the better postoperative functional outcome. Furthermore, LHBT augmentation may play a role as a mechanical bumper, protecting the reconstruction (32), which may be visualized by an increase in AHD in patients with biceps augmentation (21). LHBT pathology is often associated with rotator cuff tears and maybe a source of anterior shoulder pain, prompting the intraoperative decision of tendon debridement, tenotomy, or tenodesis (29). By using the LHBT as a part of the augmentation for rotator cuff repair, we simultaneously aid both the repair and healing of the construct and by tenodesis, we effectively manage LHBT pathology (30).

The main disadvantage of using LHBT for augmentations more widely is the lack of the tendon in cases of previous tendon rupture, anatomical anomalies, or poor quality and degeneration of the tissue. In any other case, when the LHBT is preserved in good quality, the use of this tendon as an augmentation should be considered as a viable option.

LHBT for augmentation in repair of massive and irreparable rotator cuff tears

There is a significant array of diverse applications for LHBT in procedures to treat patients with extensive rotator cuff tears. ‘The giant’ of shoulder surgery – Dr Neviaser was the first to use LHBT as an augmentation in rotator cuff reconstruction in 1971 (33). However, it was only recently that the popularization of the LHBT use as an augment source in arthroscopic repairs of massive rotator cuff tears caused shoulder surgeons to gradually change their approach and attitude so that many of them have turned from ‘biceps killers’ to ‘biceps lovers’ (21, 30, 34, 35, 36). Several techniques have been described so far in which LHBT augmentation has proven useful. LHBT augmentation in the reconstruction of massive rotator cuff tears has been proposed and published in a clinical study by Rhee et al. (37), who was the first to use an intra-articular fragment of the LHBT after tenotomy. He stretched the tendon between the greater tubercle and rotator cuff in case of irreparable tears. In the group of 16 patients, the average CM score was 83.5 points, and healing of the lesion on follow-up MRI was observed in 64.3% of patients. Sano et al. (38) used a free LHBT fragment for augmentation in open surgeries and reported a recurrence rate of 7% in a group of 14 patients with massive lesions.

This technique became more popular after being adopted arthroscopically. Cho et al. (30) and later other authors (21, 34, 35, 36) used LHBT for augmentation in arthroscopic partial rotator cuff reconstructions in patients with massive and irreparable tears. These authors used the proximal part of the LHBT to cover the greater tubercle of the humerus, attaching the proximal end of the LHBT to the tendon of the ISP muscle (Fig. 1). Several studies comparing partial repair with partial repair and additional LHBT augmentation showed superior clinical outcomes and lower re-tear rates when LHBT augmentation was performed (21, 30, 34). Results published by Laprus (21) are in line with the one published by Cho (30); the re-tear rate was 40% when LHBT augmentation was used for partial RCT repair and over 70% without such augmentation, which was statistically significant in both studies. Not all studies confirmed the high effectiveness of LHBT augmentation in improving postoperative results in the treatment of massive RCTs, especially when assessing postoperative functional outcomes (35, 36).

Figure 1
Figure 1

Diagram showing biceps augmentation for irreparable rotator cuff surgery. On the left, before and on the right, after reconstruction.

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-24-0011

A systematic review published by Veen et al. (39) looked at LHBT autograft used both as an augment and a bridge in massive rotator cuff repairs. The review highlights different techniques of utilizing LHBT autograft as well as comparisons between clinical, function, and re-tear rates pre- and postoperatively. Significant improvement in clinical outcomes was noted in all studies comprising this review, with 82% of cases demonstrating an intact graft reconstruct at 2 years follow-up. A recent systematic review presented during BSES at PTA Congresses in 2023, which included only comparative studies performed by Green et al., proved a lower re-tear rate in the LHBT autograft group compared to the control group. In this review, when comparing bridging and augmentation LHBT autograft techniques, the mean re-tear rate was lower in the augmentation group (31.4%) compared to the bridging group (49.5%). However, considerable heterogeneity is noted between the studies. In conclusion, the author of this study advocated cuff augmentation rather than SCR or bridging of biceps in order to facilitate a more anatomic reconstruction in cases of low-quality rotator cuff tendons or muscle retraction (Fig. 2).

Figure 2
Figure 2

Intraoperative photo showing augmentation with LHBT. On the left, the connection of the LHBT with the deep layer of the infraspinatus tendon. On the right, the final postoperative view.

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-24-0011

Lately, there have been some reports regarding the use of compressed biceps as a biological patch covering the rotator cuff after reconstruction (40, 41). This concept aims to improve biological healing capabilities and, consequently, reduce re-tearing rate. A flattened biceps does not have sufficient mechanical resistance, so the augmentation in this case should be conceived rather as biological than biomechanical. At present, current literature is not unequivocal about which augmentation strategy is superior to another. We still lack scientifically sound prospective comparative studies or randomized trials to determine which technique of LHBT augmentation of massive and irreparable cuff is the most efficient.

LHBT for superior capsular reconstruction

There is a rising popularity in using LHBT as an autograft to perform superior capsule reconstruction (SCR) in cases of irreparable rotator cuff tears, observed in recent years (32, 41, 42, 43, 44, 45, 46). This procedure relies on leaving the proximal insertion of the LHBT on the superior glenoid tubercle and transposing of the intra-articular part of the tendon to the greater tubercle of the humerus. Unfortunately, unlike the use of LHBT for augmentation of massive cuff reconstruction, in order to perform SCR only with LHBT, the quality of the biceps tendon must be very good, which may limit the use of this technique. Barth et al. (32) proposed SCR by LHBT along with tenotomy of the distal part of the tendon, which is a feasible procedure and may reduce pain generated by distal LHBT. They compared this technique with double-row reconstruction and reconstruction with an additional patch. In the results, they did not find any significant clinical differences, and according to the healing assessment, the infraspinatus tendon was healed in 100% of patients operated by SCR-LHBT compared to 76.5% in the patch group and 75% in the double row group (P = 0.006). Unfortunately, posterior transposition of LHBT may pose a risk of internal rotation limitation (47). Moreover, leaving the poorly vascularized proximal part of the tendon, along with tenotomy of the remaining part, limits biological potential of LHBT and may result in rapid recurrence of the injury or biceps tear. Some authors proposed V-shape or double bundle (four corners) SCR by LHBT (44, 45), which relies on folding the proximal portion of the biceps tendon and fixing it in three or four different points – two on the glenoid and one/two on the greater tubercle. In principle, this modification should increase strength and stiffness; however, it requires more implants and a longer portion of the tendon. Unfortunately, folding the biceps in the subacromial space may also be a source of postoperative pain and crepitations.

The advantage of using LHBT as a tissue for SCR is the reduction of costs and harvesting-related morbidity. Moreover, the results of using LHBT as a material for SCR in many studies were encouraging and proved the effectiveness of the technique in protecting the ISP from re-rupturing (32, 44). The procedure has some limitations. One is the necessity of the presence of LHBT of good quality for technique aspects, but also the need for thick and durable material as pointed out by Mihata (48).

LHBT augmentations for glenohumeral instability

In addition to the wide use of LHBT as an autograft for the augmentation of massive rotator cuff tear repairs, in recent years there have been papers regarding the use of this tendon in the treatment of glenohumeral joint instability. The first mention of this technique was in 2017 during the ESSKA Biennial Congress in Kraków by Milenin, which was published 2 years later (49). This technique is based on a dynamic stabilization effect, which is achieved by trans-subscapular tenodesis with simultaneous reconstruction of the anterior segment of the labrum. Subsequent resuspension of the glenohumeral ligaments is performed using the same anchors. Given that, the transpositioned LHBT tendon, just like in the Latarjet procedure, provides triple mechanism of sling effect stabilization.

In recent years, shoulder stabilization by arthroscopic Bankart repair with biceps augmentation has been promoted by Collin et al. (50), defining the principles of using LHBT as augmentation for the anterior labrum complex and popularizing this technique, calling it dynamic anterior stabilization (DAS). Subsequent significant modifications were introduced by other authors, along with the development of the onlay fixation method (51) (Fig. 3). The results reported by most of the aforementioned authors are statistically better than results of classic Bankart repair and comparable to other stabilization techniques with capsulolabral complex augmentation (52, 53). Not long ago, the results of simplified inlay DAS procedure with additional remplissage procedure were published and shed light on the possibility of new, bilateral soft tissue shoulder joint stabilization (54), (Fig. 4). Because of LHBT, there is a possibility to stabilize the shoulder with the use of soft tissues even in case of poor quality of the capsulolabral complex, which is often observed in chronic anterior shoulder instabilities and is a considerable factor of surgical treatment failure (55). DAS seems to be a significant adjunct in arthroscopic soft tissue repair in so-called borderline cases with poor labral quality and minimal bone deficiency. The alternative would be a bone procedures including coracoid transfer or bone block. Such techniques have proven their effectiveness but come with the price of higher complications. DAS, proposed as a minimally invasive surgical option, is technically less demanding than arthroscopic bone procedures and may offer a more favorable safety profile. Certainly, longer studies are needed to prove its clinal value.

Figure 3
Figure 3

Arthroscopic view of the onlay dynamic anterior stabilization with biceps transfer using all-suture anchors and the double double-pulley technique. Copyright of the image: ‘Clara de Campos Azevedo, MD, PhD and Ana Catarina Ângelo, MD’ with permission.

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-24-0011

Figure 4
Figure 4

Arthroscopic view of the dynamic anterior stabilization with remplissage. Final view. Copyright of the image: ‘Ion-Andrei Popescu MD’ with permission.

Citation: EFORT Open Reviews 9, 6; 10.1530/EOR-24-0011

Conclusion and future perspective

Over the past 20 years, there has been significant progress in the quality of surgical treatment of shoulder pathologies, with the outspring of new techniques and dedicated implants. Unfortunately, the abundance of new technical possibilities has not entirely followed by such improvement in clinical results, especially regarding rotator cuff tears and shoulder joint instability management. This fact may suggest that apart from improving surgical techniques and implants, we should also focus on improving biological healing capabilities to treat patients more effectively. That is why the use of autografts and local grafts in cases of tissue degeneration or rotator cuff tendon retraction should be considered as a preferential treatment with clinically promising results. In shoulder joint reconstructive surgery, the most obvious choice of autograft is the local graft of the long head of the biceps tendon, as it is often feasible and easy to implement without the need for any additional implants. However, it should be mentioned that all techniques using LHBT for augmentation are relatively new, and at present, we lack convincing data from longer-term follow-up studies.

Furthermore, there is currently a lack of good comparative studies juxtaposing the results of different LHBT augmentation techniques.

To summarize, LHBT is a local and viable tissue for augmentations during reconstruction procedures in shoulder joints. A major advantage compared to the other augmentation solutions is the absence of extra costs (implants) or donor site morbidity (autografts). The evidence provided by studies appears to be sufficient to recommend the use of LHBT for augmentation whenever necessary. Yet the lack of larger studies with long-term follow-up means its real clinical value is yet to be proven, and its use should be considered individually.

ICMJE Conflict of Interest Statement

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the study reported.

Funding Statement

This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

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    Carter AN, & Erickson SM. Proximal biceps tendon rupture: primarily an injury of middle age. Physician and Sportsmedicine 1999 27 95101. (https://doi.org/10.3810/psm.1999.06.888)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Candela V, Preziosi Standoli J, Carbone S, Rionero M, & Gumina S. Shoulder long head biceps tendon pathology is associated with increasing rotator cuff tear size. Arthroscopy, Sports Medicine, and Rehabilitation 2021 3 e1517e1523. (https://doi.org/10.1016/j.asmr.2021.07.013)

    • PubMed
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    • Export Citation
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    Virk MS, & Cole BJ. Proximal biceps tendon and rotator cuff tears. Clinics in Sports Medicine 2016 35 153161. (https://doi.org/10.1016/j.csm.2015.08.010)

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    Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, & Trojani C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. Journal of Bone and Joint Surgery 2007 89 747757. (https://doi.org/10.2106/JBJS.E.01097)

    • PubMed
    • Search Google Scholar
    • Export Citation
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    Lephart SM, & Jari R. The role of proprioception in shoulder instability. Operative Techniques in Sports Medicine 2002 10 24. (https://doi.org/10.1053/otsm.2002.29169)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Lubiatowski P, Kaczmarek P, Dzianach M, Ogrodowicz P, Bręborowicz M, Długosz J, Lisiewicz E, & Romanowski L. Clinical and biomechanical performance of patients with failed rotator cuff repair. International Orthopaedics 2013 37 23952401. (https://doi.org/10.1007/s00264-013-2024-0)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Cho NS, Yi JW, & Rhee YG. Arthroscopic biceps augmentation for avoiding undue tension in repair of massive rotator cuff tears. Arthroscopy 2009 25 183191. (https://doi.org/10.1016/j.arthro.2008.09.012)

    • PubMed
    • Search Google Scholar
    • Export Citation
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    Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. Journal of Bone and Joint Surgery 1974 56 1426. (https://doi.org/10.2106/00004623-197456010-00002)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Barth J, Olmos MI, Swan J, Barthelemy R, Delsol P, & Boutsiadis A. Superior capsular reconstruction with the long head of the biceps autograft prevents infraspinatus retear in massive posterosuperior retracted rotator cuff tears. American Journal of Sports Medicine 2020 48 14301438. (https://doi.org/10.1177/0363546520912220)

    • PubMed
    • Search Google Scholar
    • Export Citation
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    Neviaser JS. Ruptures of the rotator cuff of the shoulder: new concepts in the diagnosis and operative treatment of chronic ruptures. Archives of Surgery 1971 102 483485. (https://doi.org/10.1001/archsurg.1971.01350050049015)

    • PubMed
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  • 34

    Chiang CH, Shaw L, Chih WH, Yeh ML, Ting HH, Lin CH, Chen CP, & Su WR. Modified superior capsule reconstruction using the long head of the biceps tendon as reinforcement to rotator cuff repair lowers retear rate in large to massive reparable rotator cuff tears. Arthroscopy 2021 37 24202431. (https://doi.org/10.1016/j.arthro.2021.04.003)

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    Park SR, Sun DH, Kim J, Lee HJ, Kim JB, & Kim YS. Is augmentation with the long head of the biceps tendon helpful in arthroscopic treatment of irreparable rotator cuff tears? Journal of Shoulder and Elbow Surgery 2018 27 19691977. (https://doi.org/10.1016/j.jse.2018.04.022)

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    Jeon YS, Lee J, Kim RG, Ko YW, & Shin SJ. Does additional biceps augmentation improve rotator cuff healing and clinical outcomes in anterior L-shaped rotator cuff tears? Clinical comparisons with arthroscopic partial repair. American Journal of Sports Medicine 2017 45 29822988. (https://doi.org/10.1177/0363546517720198)

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    Rhee YG, Cho NS, Lim CT, Yi JW, & Vishvanathan T. Bridging the gap in immobile massive rotator cuff tears: augmentation using the tenotomized biceps. American Journal of Sports Medicine 2008 36 15111518. (https://doi.org/10.1177/0363546508316020)

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    Sano H, Mineta M, Kita A, & Itoi E. Tendon patch grafting using the long head of the biceps for irreparable massive rotator cuff tears. Journal of Orthopaedic Science 2010 15 310316. (https://doi.org/10.1007/s00776-010-1453-5)

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    • Export Citation
  • 39

    Veen EJD, Stevens M, & Diercks RL. Biceps autograft augmentation for rotator cuff repair: a systematic review. Arthroscopy 2018 34 12971305. (https://doi.org/10.1016/j.arthro.2017.10.044)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Tokish JM, Shaha JS, Denard PJ, Mercuri JJ, & Colbath G. Compressed biceps autograft augmentation of arthroscopic rotator cuff repair. Arthroscopy Techniques 2022 11 e2113e2118. (https://doi.org/10.1016/j.eats.2022.08.011)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Endell D, Rüttershoff K, & Scheibel M. Biceps smash technique: biceps tendon autograft augmentation for arthroscopic rotator cuff reconstruction. Arthroscopy Techniques 2023 12 e383e386. (https://doi.org/10.1016/j.eats.2022.11.020)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Adrian SC, & Field LD. Biceps transposition for biological superior capsular reconstruction. Arthroscopy Techniques 2020 9 e841e846. (https://doi.org/10.1016/j.eats.2020.02.020)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Kim D, Jang Y, Park J, & On M. Arthroscopic superior capsular reconstruction with biceps autograft: snake technique. Arthroscopy Techniques 2019 8 e1085e1092. (https://doi.org/10.1016/j.eats.2019.05.023)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Fandridis E, & Zampeli F. Superior capsular reconstruction with double bundle of long head biceps tendon autograft: the “box” technique. Arthroscopy Techniques 2020 9 e1747e1757. (https://doi.org/10.1016/j.eats.2020.07.017)

    • PubMed
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    • Export Citation
  • 45

    Kitridis D, Yiannakopoulos C, Sinopidis C, Givissis P, & Galanis N. Superior capsular reconstruction of the shoulder using the long head of the biceps tendon: a systematic review of surgical techniques and clinical outcomes. Medicina 2021 57 57229. (https://doi.org/10.3390/medicina57030229)

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    Milenin O, & Toussaint B. Labral repair augmentation by labroplasty and simultaneous trans-subscapular transposition of the long head of the biceps. Arthroscopy Techniques 2019 8 e507e512. (https://doi.org/10.1016/j.eats.2019.01.010)

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    Collin P, Nabergoj M, Denard PJ, Wang S, Bothorel H, & Lädermann A. Arthroscopic biceps transfer to the glenoid with Bankart repair grants satisfactory 2-year results for recurrent anteroinferior glenohumeral instability in subcritical bone loss. Arthroscopy 2022 38 17661771. (https://doi.org/10.1016/j.arthro.2021.11.043)

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    de Campos Azevedo C, & Ângelo AC. Onlay dynamic anterior stabilization with biceps transfer for the treatment of anterior glenohumeral instability produces good clinical outcomes and successful healing at a minimum 1 year of follow-up. Arthroscopy, Sports Medicine, and Rehabilitation 2023 5 e445e457. (https://doi.org/10.1016/j.asmr.2023.01.012)

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    Brzóska R, Laprus H, Michniowski P, Solecki W, Klon W, & Błasiak A. Novel and effective arthroscopic extracapsular stabilization technique for anterior shoulder instability-BLS. Knee Surgery, Sports Traumatology, Arthroscopy 2019 27 38973904. (https://doi.org/10.1007/s00167-019-05496-1)

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    Popescu IA, Neculau DC, Simion C, & Popescu D. Modified dynamic anterior stabilization (DAS) and Hill-Sachs remplissage for the treatment of recurrent anterior shoulder dislocation. Arthroscopy Techniques 2022 11 e147e152. (https://doi.org/10.1016/j.eats.2021.10.004)

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    Loppini M, Delle Rose G, Borroni M, Morenghi E, Pitino D, Domínguez Zamora C, & Castagna A. Is the instability severity index score a valid tool for predicting failure after primary arthroscopic stabilization for anterior glenohumeral instability? Arthroscopy 2019 35 361366. (https://doi.org/10.1016/j.arthro.2018.09.027)

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  • Figure 1

    Diagram showing biceps augmentation for irreparable rotator cuff surgery. On the left, before and on the right, after reconstruction.

  • Figure 2

    Intraoperative photo showing augmentation with LHBT. On the left, the connection of the LHBT with the deep layer of the infraspinatus tendon. On the right, the final postoperative view.

  • Figure 3

    Arthroscopic view of the onlay dynamic anterior stabilization with biceps transfer using all-suture anchors and the double double-pulley technique. Copyright of the image: ‘Clara de Campos Azevedo, MD, PhD and Ana Catarina Ângelo, MD’ with permission.

  • Figure 4

    Arthroscopic view of the dynamic anterior stabilization with remplissage. Final view. Copyright of the image: ‘Ion-Andrei Popescu MD’ with permission.

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    Carter AN, & Erickson SM. Proximal biceps tendon rupture: primarily an injury of middle age. Physician and Sportsmedicine 1999 27 95101. (https://doi.org/10.3810/psm.1999.06.888)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Candela V, Preziosi Standoli J, Carbone S, Rionero M, & Gumina S. Shoulder long head biceps tendon pathology is associated with increasing rotator cuff tear size. Arthroscopy, Sports Medicine, and Rehabilitation 2021 3 e1517e1523. (https://doi.org/10.1016/j.asmr.2021.07.013)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26

    Virk MS, & Cole BJ. Proximal biceps tendon and rotator cuff tears. Clinics in Sports Medicine 2016 35 153161. (https://doi.org/10.1016/j.csm.2015.08.010)

  • 27

    Boileau P, Baque F, Valerio L, Ahrens P, Chuinard C, & Trojani C. Isolated arthroscopic biceps tenotomy or tenodesis improves symptoms in patients with massive irreparable rotator cuff tears. Journal of Bone and Joint Surgery 2007 89 747757. (https://doi.org/10.2106/JBJS.E.01097)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Lephart SM, & Jari R. The role of proprioception in shoulder instability. Operative Techniques in Sports Medicine 2002 10 24. (https://doi.org/10.1053/otsm.2002.29169)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Lubiatowski P, Kaczmarek P, Dzianach M, Ogrodowicz P, Bręborowicz M, Długosz J, Lisiewicz E, & Romanowski L. Clinical and biomechanical performance of patients with failed rotator cuff repair. International Orthopaedics 2013 37 23952401. (https://doi.org/10.1007/s00264-013-2024-0)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 30

    Cho NS, Yi JW, & Rhee YG. Arthroscopic biceps augmentation for avoiding undue tension in repair of massive rotator cuff tears. Arthroscopy 2009 25 183191. (https://doi.org/10.1016/j.arthro.2008.09.012)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31

    Wolfgang GL. Surgical repair of tears of the rotator cuff of the shoulder. Factors influencing the result. Journal of Bone and Joint Surgery 1974 56 1426. (https://doi.org/10.2106/00004623-197456010-00002)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32

    Barth J, Olmos MI, Swan J, Barthelemy R, Delsol P, & Boutsiadis A. Superior capsular reconstruction with the long head of the biceps autograft prevents infraspinatus retear in massive posterosuperior retracted rotator cuff tears. American Journal of Sports Medicine 2020 48 14301438. (https://doi.org/10.1177/0363546520912220)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 33

    Neviaser JS. Ruptures of the rotator cuff of the shoulder: new concepts in the diagnosis and operative treatment of chronic ruptures. Archives of Surgery 1971 102 483485. (https://doi.org/10.1001/archsurg.1971.01350050049015)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34

    Chiang CH, Shaw L, Chih WH, Yeh ML, Ting HH, Lin CH, Chen CP, & Su WR. Modified superior capsule reconstruction using the long head of the biceps tendon as reinforcement to rotator cuff repair lowers retear rate in large to massive reparable rotator cuff tears. Arthroscopy 2021 37 24202431. (https://doi.org/10.1016/j.arthro.2021.04.003)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35

    Park SR, Sun DH, Kim J, Lee HJ, Kim JB, & Kim YS. Is augmentation with the long head of the biceps tendon helpful in arthroscopic treatment of irreparable rotator cuff tears? Journal of Shoulder and Elbow Surgery 2018 27 19691977. (https://doi.org/10.1016/j.jse.2018.04.022)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 36

    Jeon YS, Lee J, Kim RG, Ko YW, & Shin SJ. Does additional biceps augmentation improve rotator cuff healing and clinical outcomes in anterior L-shaped rotator cuff tears? Clinical comparisons with arthroscopic partial repair. American Journal of Sports Medicine 2017 45 29822988. (https://doi.org/10.1177/0363546517720198)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37

    Rhee YG, Cho NS, Lim CT, Yi JW, & Vishvanathan T. Bridging the gap in immobile massive rotator cuff tears: augmentation using the tenotomized biceps. American Journal of Sports Medicine 2008 36 15111518. (https://doi.org/10.1177/0363546508316020)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 38

    Sano H, Mineta M, Kita A, & Itoi E. Tendon patch grafting using the long head of the biceps for irreparable massive rotator cuff tears. Journal of Orthopaedic Science 2010 15 310316. (https://doi.org/10.1007/s00776-010-1453-5)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39

    Veen EJD, Stevens M, & Diercks RL. Biceps autograft augmentation for rotator cuff repair: a systematic review. Arthroscopy 2018 34 12971305. (https://doi.org/10.1016/j.arthro.2017.10.044)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 40

    Tokish JM, Shaha JS, Denard PJ, Mercuri JJ, & Colbath G. Compressed biceps autograft augmentation of arthroscopic rotator cuff repair. Arthroscopy Techniques 2022 11 e2113e2118. (https://doi.org/10.1016/j.eats.2022.08.011)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 41

    Endell D, Rüttershoff K, & Scheibel M. Biceps smash technique: biceps tendon autograft augmentation for arthroscopic rotator cuff reconstruction. Arthroscopy Techniques 2023 12 e383e386. (https://doi.org/10.1016/j.eats.2022.11.020)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42

    Adrian SC, & Field LD. Biceps transposition for biological superior capsular reconstruction. Arthroscopy Techniques 2020 9 e841e846. (https://doi.org/10.1016/j.eats.2020.02.020)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 43

    Kim D, Jang Y, Park J, & On M. Arthroscopic superior capsular reconstruction with biceps autograft: snake technique. Arthroscopy Techniques 2019 8 e1085e1092. (https://doi.org/10.1016/j.eats.2019.05.023)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 44

    Fandridis E, & Zampeli F. Superior capsular reconstruction with double bundle of long head biceps tendon autograft: the “box” technique. Arthroscopy Techniques 2020 9 e1747e1757. (https://doi.org/10.1016/j.eats.2020.07.017)

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 45

    Kitridis D, Yiannakopoulos C, Sinopidis C, Givissis P, & Galanis N. Superior capsular reconstruction of the shoulder using the long head of the biceps tendon: a systematic review of surgical techniques and clinical outcomes. Medicina 2021 57 57229. (https://doi.org/10.3390/medicina57030229)

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