Biceps Anterior Cable Reconstruction for Massive Rotator Cuff Tears

Massive rotator cuff tears (MRCTs) involving the rotator cable are associated with increased tendon retraction, fatty infiltration, and high retear rates after repair. Biceps anterior cable reconstruction (ACR) is a surgical technique that augments rotator cuff repair by reconstructing the anterior cable with the long head of the biceps tendon (LHBT), improving greater tuberosity coverage and biomechanical stability.

Biceps ACR is indicated for full-thickness MRCTs with anterior cable involvement in patients with an intact LHBT and no advanced glenohumeral arthritis. Risk factors for repair failure, including the full-thickness retracted pattern of a tear, patient age, and activity level, are considered when deciding to add a concomitant ACR.

A knotless repair stitch from an anchor at the anteromedial footprint of the greater tuberosity is passed circumferentially around the proximal LHBT. The biceps is left attached to the glenoid, and the repair stitch is tightened, which reduces the biceps tendon to the anterior aspect of the greater tuberosity. This allows the biceps tendon to slide and find its optimal tension, tenodeses the biceps tendon to the greater tuberosity, and reconstructs the anterior cable. This provides greater tuberosity coverage and reduces the tear distance. The remaining sutures from the anteromedial anchor can be passed through the rotator cuff. The remaining rotator cuff can be repaired using a variety of standard techniques. Simple side-to-side stitches can be placed in the biceps tendon and rotator cuff as needed.

Biceps ACR improves greater tuberosity coverage and enhances biomechanical stability by decreasing superior translation and subacromial contact pressure. Clinical studies have demonstrated excellent patient-reported outcomes and lower retear rates when biceps ACR is added to arthroscopic rotator cuff repair.

Biceps ACR is a viable option for MRCTs with anterior cable involvement and a high risk for failure.

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