Applications for the Biceps Tendon in Rotator Cuff Repair

The long head of the biceps has traditionally been ignored, tenodesed, or tenotomized during shoulder arthroscopy. However, more recently, it has been recognized as robust autograft tissue that may be mobilized or harvested to aid in a range of augmentation and reconstructive procedures. Several applications are included in this infographic. An intertendinous augmentation (biologic superior capsular reconstruction) technique is indicated in massive tears that are either partially or completely reparable. The intact biceps tendon is mobilized from the groove, transposed and secured to the greater tuberosity, and used as a convergence post to augment the repair. Anterior cable reconstruction is indicated in supraspinatus tears with a deficient anterior cable. The intact biceps tendon is tenotomized in the groove and its most proximal portion is used to reconstruct and incorporate the deficient anterior cable. The insertional augmentation ("sandwich") technique is indicated in tears with inadequate lateral mobility. The biceps tendon is released from its proximal insertion, redirected along the greater tuberosity, and incorporated into the lateral rotator cuff margin to augment and offload the repair. The biceps autograft superior capsular reconstruction ("snake") technique is indicated in massive irreparable tears. The intact biceps tendon is released as distally as possible to maximize autograft and arthroscopically routed back and forth between the glenoid and greater tuberosity to fashion an autograft superior capsular reconstruction. The autograft patch ("biceps smash") technique offers an alternative to biologic patches. The patch can augment partial rotator cuff tears without repair or reinforce cuff repairs with compromised, degenerative tissue. The proximal biceps tendon is harvested, processed extracorporeally, and reintroduced to the shoulder. Finally, in upper border subscapularis repairs with excessive tension or poor tissue quality, the biceps can be released at its proximal insertion and secured to the subscapularis tendon to supplement and offload the repair. Although far from an exhaustive list of all biceps tendon applications, these techniques are useful additions for the toolbox of a shoulder arthroscopist.