or how do we use the biceps potentially as a graph to augment patients that have these massive rotator cuff tears. I'd like to acknowledge Paul Sethi and Larry Field. Paul was supposed to be here today to give this talk and he asked me to fill in, but both he and Dr. Field have contributed significant content to this talk itself. My disclosures are available through the Academy's online disclosure program. So I think we know that there's a variety of treatment options that are available for these complicated patients that have massive rotator cuff pathology. The problem is we don't have a lot of evidence to guide us in terms of which procedure is appropriate to which patient. And as we've already started to talk about, the problem with many of these procedures are number one, they're very complex and technically challenging, and number two, they're expensive. And so we need to know when options, which options are available and how to decide. I think if you take away anything from this talk, what you should take away is that when you're thinking about soft tissue procedure, and that probably includes any of the talks today, we should think about patients that have primary or revision surgery without arthritis. Patients that have some form of elevation, generally above 90, do better. Patients that prioritize pain over function will improve because we won't get strength back for many of these procedures. And we've got to keep in mind the age of the patient, the cost, the complication rate, and what is the patient looking for. The Hamada classification has been very helpful here in helping us to identify that it's really ones and twos that we want to be operating on. Threes are a yellow light in special circumstances, and anybody above that really should be getting an arthroplasty type procedure. We know that the risk of failure for these tears is related to a number of factors, including chronicity, the retraction, the tissue quality, the muscle quality. And when we see these situations, we clearly have defined that the repair failure rates go up. They can be anywhere as high as 50 to 70%, depending on what study you look at. And the reality is that the reason they go up is because we're not dealing with normal tendon tissue, and we're dealing with a poor biologic environment. Having said that, there are a number of studies that show that when we can achieve a structurally intact repair, that these patients do reasonably well. And so we shouldn't throw the baby out with the bathwater, and a repair is preferred when possible. The integrity of the repair does improve functional outcomes if you look across a spectrum of studies, particularly with regard to functional recovery and strength, as well as potentially reducing the risk of progression of functional deficit or progression of rotator cuff arthropathy. We should try to achieve a structurally intact repair when possible. So what about graft augmentation? Well, obviously, it's of interest to all of us. It helps with an anatomic reconstruction. We know that the biomechanical data is clear, that we can improve time equals zero, pull out strength of the repair itself, and we know that the clinical outcomes are better. But the reality is it's technically challenging. How do we get the graft in place? How do we manage our sutures? How do we fixate it? And cost is a real concern, as we've already started to talk about. So the question is, is there other ways that we consider using grafts or graft augmentation, and potentially there's an autologous solution. So what is anterior cable reconstruction? Well, it's essentially taking the biceps, moving it out of the groove, centering it over the humeral head to potentially act as a static and dynamic humeral head depressor, and integrating it into our repair to use the collagen to augment the repair itself. The reconstruction of the anterior cable adds biomechanical strength due to an overlapping repair construct, and it also acts as a scaffolding. So potentially a repair that was only partially repairable is now completely repairable when we augment with the biceps itself. Now, this is not a new concept. These are two studies, one all the way back from 75, a second from 2001, where they described using the biceps as some form of interposition graft in managing patients with these massive rotator cuff tears, and at least in small cases series have demonstrated that the results can be very good. And there is cadaveric data to support this as well. This was a study where they looked at using the biceps and different types of configurations of the biceps, V configurations or box configurations or straight configurations. But what they showed is that you can reduce superior migration of the humeral head. We can increase the abduction angle, and we can also decrease the subacromial contact pressure. This is not unlike the data that we see with superior capsule reconstruction or the balloon in terms of trying to recenter the humeral head to improve elevation and allow patients to restore function. And in terms of the clinical data, it's starting to trickle out. We've seen a number of case series now that report on using the biceps for this type of an augmentation procedure. This is Larry Field's data. He now has, I think, over 45 cases where he's done this. It's essentially a bio-SCR type technique when he transposes the biceps to center over the humeral head integrates it into the repair construct. And he feels that this can provide both a static and a dynamic humeral head depressor, as well as allowing some collagen into the area to facilitate healing. And we'll show you how we do this in just a second. This is another study that came from Korea, looked at patients undergoing this type of procedure. 77% displayed improvement. The acromial humeral distance was decreased and there was no graft hair or re-tear detected in about 85% of patients. So very positive results given a challenging patient population. And then finally, a study that compared those with biceps transposition to those that did not have a transposition and showed that both the patient reported, excuse me, the strength reported outcomes and the healing rate was better. But as is a challenge with any of these techniques, trying to show improvements in patient reported outcomes between one technique and another is difficult to do. So how do we do these procedures? Well, here's an example from Dr. Field, 55 year old, two year history of shoulder pain after a fall. He's got decent motion, but not normal. Strength is deficient as you would expect and neurovascularly normal. Again, as we talked about earlier, he's a MATA 1. So his humeral head is centered. There's no arthritis, no proximal migration. So very good candidate for any of the soft tissue solutions you're hearing about. The MRI shows a large retracted supraspinatus tear. The muscle quality is reasonable, but based on the tendon quality, one would argue whether this is biomechanically and certainly biologically repairable. So maybe we need to do something else to help with our repair construct. Here's what it looks like. You can see that the biceps is intact as we see in many of these cases, the biceps is kind of thickened and flattened in nature. The tendon quality is reasonable, but it's very retracted and the tendon has become stiff due to the delay from his injury until the surgery. Now, of course, our first goal is to repair this. So we would perform all of the normal releases we would do underneath the cuff, on the top of the cuff, as well as an anterior superior release. But if that's not successful, then we can start to think about augmentation with the biceps for the repair itself. So here's what it looks like. The first thing you need to do is release the transverse humeral ligament. And then it's important to recognize that we actually move this biceps into a more centered position over the humeral head. So in this case, Dr. Field has placed his anchors both anteriorly and posteriorly, and these will be the same anchors that are gonna be used ultimately for the rotator cuff repair surgery. Now we take one limb of each of the anchors, one from the back, one from the front, and you can kind of choose your suture configuration that you prefer. You can use mattress sutures, simple sutures. In these situations, he's kind of using, incorporating half the tendon with the front, half the tendon with the back, and using a cinch type configuration. And this allows you to stabilize the biceps in place in order to then perform your repair. So once these sutures are tied, the biceps is now transposed into its new position. We do this with the arm in about 30 degrees of forward flexion, 20 degrees of abduction to try to set the tension. And then we're gonna repair the tendon around the biceps, incorporating the biceps into the repair construct, as you see here. And so we're using the biceps in two fashions. One is to help augment our repair to provide some biology, and two is to help potentially provide a humeral depression role to augment our repair itself. So why should we choose the biceps? Well, we know that Mihata has showed extremely positive results with his experience in using the TFL. But the reality is that that's not the procedure that we do here in the United States. And we haven't been able to duplicate his results when using these dermal allografts, not to mention the cost and the complexity of the procedure itself. So maybe the biceps is a good option because it's vascularized, because we can actually get some static and potentially dynamic humeral head depression, and because at least the preliminary results show us that it's a positive improvement for our patients and a very cost-effective technique. What are some of the remaining questions? Well, there is some controversy. Do you use this as an SCR, meaning you release the tendon distally and then somehow weave it over the top of the humeral head a la an SCR, or do we leave it intact the way that Dr. Fields does? Of course, the first thing we hear about or think about when we decide to leave it intact is is it gonna be a pain generator for the shoulder moving forward? And that just hasn't been the experience, at least in the limited case series to date. Do we need an intact subscap? Or can we ditch that if patients have good range of motion? What about the muscle quality and how does that matter? Does it matter how we fixate the biceps? And what about these diseased biceps? Are they still applicable for this technique? I think all of those questions will be answered in the coming years, but I think this is something that you should keep in mind in the armamentarium because it's a very on-the-fly, effective solution for managing these complex patients. Thanks very much for your attention. Nick, where are your current thoughts about cut the biceps, not cut the biceps? Yeah, as you know, JT, from Rush, we're a biceps cutter. I mean, I think in most of these patients, the French data, you hooked that up, right? The French data has suggested that just cutting the biceps alone may be important. I think when you look at these patients, the vast majority have, quote, unquote, diseased biceps, and I've always assumed that it's part of the pain-generating process. But if you go back to some of the research that we've done in the past, it's part of the pain-generating process. But if you go back to some of JP's work, what he shows is that as long as you unroof the groove or get the biceps out of the groove, that that may solve your problem. And so I think what Larry's doing in this situation is he's taking away the disease generator, which is the rubbing that occurs through the groove, so we get rid of the pain from the biceps, but still keeping it to preserve some functional utility in the setting of these massive rotator cuff repairs. So I'm not sure that it matters if you move it, if you tenotomize it, if you tenodes it, if you just unroof it, but I think the disease process is that kind of constriction that happens within the groove itself, and as long as we address that, we probably are successful. Can you comment real quick on your release of the transition? Yeah, so there's a couple videos that I have on SportsMed Innovate and VJSM that show this, but there's a couple of real good pearls for this. Number one is I work in the beach chair position. So the first thing I do is I bring the arm into about 60 degrees of forward elevation, external rotation, and that really opens up that front space of the shoulder for you, and then I make a portal that's essentially triangular between a standard anterior portal and a lateral portal. So it's basically right off the anterolateral edge of the acromion about three to four centimeters down, and that gives you a direct working area to the transverse humeral ligament itself. It's a fairly vascularized area, so using the RF is really helpful, and what I've found is that it's really challenging to find the tendon up top where it sits between the two borosities. It's very difficult to palpate in that area. So if you just come a little bit more distal, you can actually feel the tendon readily, and I start from distal and release proximal, and in that way, I've found it very reproducible to be able to find the tendon, and I do that after I release it in the joint. I've really never seen a situation where it retracts to the point that you're not able to recover it when you go to that position. Is memory and slap play into your decision at all, all the patients, honestly? So memory and slap play? Yeah, it's a great question, right, because I think it goes back to whether you believe that this actually performs some form of a humoral depression role. So I think if you ask Larry, and he's probably got the biggest experience in this, what he would tell you is he has to feel like the biceps has a functional, stable fixation on the glenoid itself. So in many cases, the labrum can be debrided, but the actual attachment of the biceps onto the bone is pretty stable, but I think if it was flapping into the joint or it was clearly unstable, that would probably be a situation where maybe you would release it and then use it in some other fashion to try to augment your repair itself. But the answer is we don't know. All right. Thanks, Dave.

treatment options

massive rotator cuff tears

biceps augmentation

structural integrity

functional outcomes