4 Double-Row Repair with Biceps Tendon Augmentation

Jeffrey S. Abrams and Tertuliano Vieira


Double-row repair techniques to address rotator cuff tears have increased the healing rate to the greater tuberosity. The biceps tendon is considered a pain generator when rotator cuff tears extend toward the rotator interval, and tenodesis or tenotomy has been popularized. Attempts at improving greater tuberosity coverage are often made at the expense of muscular tendinous tension, placing this functional unit at risk. Incorporating the long head of the biceps into the repair can graft the injured tendon with autogenous tissue, and reduce risk of postoperative pain emanating from the biceps because of tenodesis. The authors will demonstrate a technique that will assist the biological healing of the rotator cuff retracted tear and combine biceps tenodesis to augment the cuff repair.

Keywords: biceps augmentation cuff repair, biceps tenodesis, grafts, rotator cuff tears

4.1 Examination under Anesthesia

? Supine patient with passive shoulder motion evaluated in flexion, abducted external rotation, and abducted internal rotation.

? Any restriction as a result of soft tissue adhesions is gently manipulated to create a full range of motion prior to surgical repair.

4.2 Positioning

? Can be performed in lateral decubitus or beach chair.

? Appropriate padding of pelvis and lower extremities.

? Protective support to head and neck to neutralize cervical positioning.

4.3 Portal Placement

? Standard posterior viewing portal, 2 cm lateral to the junction of the spine of the scapula and posterior acromion edge.

? Anterior portal inferior to the acromioclavicular joint.

? Lateral portal 3 cm lateral to the edge of the acromion.

? Accessory portals for suture anchor placement along the margin of the anterior acromion and midlateral margin.

4.4 Surgical Technique

? Articular exam, debridement, and capsulotomy of posterior and inferior capsule adjacent to the labrum.

? Evaluate tear margins and delaminations using anterior and posterior articular viewing portals.1,2

? Bursectomy to develop anterior, lateral, and posterior margins, and define margins of the rotator cuff tear.

? Subacromial decompression using both posterior and lateral viewing portals. Additional clavicle spur excision is performed when prominent.

? Prepare greater tuberosity with soft tissue debridement.

? Suture anchor placement. Triple-loaded anchor placed approximately 1 cm posterior to the biceps tendon, adjacent to the medial margin of the greater tuberosity (? Fig. 4.1).3

? Suture the leading margin of the supraspinatus with a mattress suture. Followed by a more medial simple suture (? Fig. 4.1).

? Coracohumeral ligament release to lateral margin of the coracoid provides additional flexibility in mobilizing the anterior retracted tear.

? Posterior suture anchor placed on the greater tuberosity adjacent to the posterior tear margin (? Fig. 4.2).4,5

? Posterior sutures retrieved through the posterior cuff as mattress sutures repairing delaminations and reconstructing the posterior cable (? Fig. 4.2).

? Posterior mattress sutures are tied first but are not cut and are retrieved out of the insertion portal to help manage sutures.

? Biceps tendon is viewed from the posterior articular portal.

? The rotator interval is opened lateral to the coracoacromial ligament and a suture is placed through biceps and retrieved out through the anterior portal. The biceps are tenotomized adjacent to the labrum junction and retrieved through the anterior window (? Fig. 4.3).

? Remove bursal tissue to permit a clear pathway for the biceps.

? Tie anterior rotator cuff sutures, mattress first, then simple suture.

? Use the third stitch from the anchor and place one arm through the biceps stump approximately 2 cm from the cut edge.


Fig. 4.1 Anterior suture anchor and suture placement. Anchor is located 1 cm posterior to the biceps tendon and sutures passed with mattress and crossing simple suture configuration.


Fig. 4.2 Posterior suture anchor is placed at the supraspinatus?infraspinatus junction. Sutures retrieved as mattress sutures to allow repositioning of the multiple layers of tendon.


Fig. 4.3 The tenotomized biceps tendon is retrieved through an opening in the rotator interval and pulled into the subdeltoid space. A traction stitch is clamped to avoid retraction. (a) Articular view of divided biceps exiting through the opened interval. (b) Bursal view of biceps positioned and retracted with subdeltoid bursae.

? As the biceps suture is tied, gentle partial release of traction suture will permit biceps to wrap over the anterior supraspinatus margin (? Fig. 4.4).

? The free edge of the biceps can be directed posterior, medial, or obliquely to reinforce thin tissue. The previously placed biceps suture is used to pierce the posterior cuff, and the suture is retrieved and tied (? Fig. 4.5).

? If the supraspinatus stump is unable to reach greater tuberosity, it can be sewn to the traversing biceps tendon.

? A set of posterior mattress sutures, combined with supraspinatus biceps sutures, can be combined to a knotless anchor for additional reinforcement (? Fig. 4.6, ? Video 4.1).


Fig. 4.4 The biceps are fixed to the anterior suture anchor, overlapping the anterior repair.