Preface

*Arthroscopic Surgery – New Perspectives* provides current information on the cutting edge of arthroscopic surgical techniques for the shoulder and knee. The book addresses controversial topics in arthroscopy, presents the latest perspectives, and discusses how to deal with challenges. For the shoulder, chapters discuss the controversial topic of superior labrum anterior to posterior (SLAP) lesions and the latest arthroscopic techniques to address them. For rotator cuff tears, chapters examine the use of new biologics, augmentation with patches, tendon transfers, and balloon spacers.

I would like to thank all my co-authors who so generously donated their time and energy to this project and our editors and publishers at IntechOpen who kept us all on task and who were instrumental throughout the publication process.

> **William B. Stetson, M.D.** Associate Clinical Professor of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles, California, USA

> > Stetson Lee Orthopaedics and Sports Medicine, CA, USA

**1**

Section 1

Shoulder

Section 1 Shoulder

#### **Chapter 1**

## Failure of SLAP Tear Repair and the Management of Long Head of Biceps Pathology

*William Wardell, Margaret Jonas and Joesph Choi*

#### **Abstract**

SLAP (superior labrum anterior-posterior) tears are a source of shoulder pain encountered by the orthopedic surgeon. These injuries are most frequently seen in young patients, notably overhead throwing athletes, in addition to older patients, commonly degenerative tears. Treatment of SLAP lesions initially consists of conservative measures including throwing rest, and physical therapy, especially in younger overhead throwing athletes. Operative treatment interventions include arthroscopic labral debridement alone, arthroscopic debridement with bicep anchor/labral repair, or arthroscopic debridement with biceps tenotomy or tenodesis. Patients over 40 years old are often treated with biceps tenotomy compared to tenodesis alone. Younger patients, especially overhead athletes less than 40 are typically treated with SLAP repair. Debate remains between the use of long head of biceps tenotomy compared to biceps tenodesis, either mini open (subpectoral) or arthroscopic (suprapectoral) tenodesis. This chapter will focus on the failure of SLAP repair and subsequent management, in addition to the role of biceps tenotomy versus tenodesis in the role of management of this pathology, either as the primary procedure or as an adjunct to repair.

**Keywords:** SLAP tear, biceps tenotomy, biceps tenodesis, SLAP repair, SLAP failure, superior labrum anterior posterior

#### **1. Introduction**

SLAP (superior labrum anterior-posterior) tears are a source of shoulder pain most frequently seen in young, overhead throwing athletes, as well as older patients, often seen as degenerative tears. These injuries are initially managed conservatively with rest, symptomatic treatment, and physical therapy. However, when conservative measures fail, operative treatment may be indicated. This chapter will focus on the failure of SLAP repairs as well as discuss the role of biceps tenotomy and tenodesis in the management of SLAP tears and long head of the biceps tendon pathology. Biceps tenotomy or tenodesis can be utilized either as the primary procedure or as an adjunct to SLAP repair.

#### **2. SLAP (superior labrum anterior-posterior) tears**

SLAP tears of the glenohumeral labrum are uncommon injuries most often seen in overhead throwing athletes. In the initial description by Andrews, it was found that most tears occur at the anterior-superior portion of the labrum in close proximity to the biceps insertion, and the long head of the biceps tendon is under increased stress in the throwing motion [1]. SLAP pathology is also associated with glenohumeral internal rotation deficit (GIRD), internal impingement, scapular dyskinesis and articular sided rotator cuff tears. Patient presentation is often delayed, with complaints of vague, nonspecific, deep shoulder pain. Throwing athletes will complain of decreased effectiveness and early fatigue [2, 3]. SLAP tears were initially classified by Snyder, which is the most commonly used classification system. The most common tear type, as defined by Snyder, was Type II, defined as fraying of the labrum with associated detachment of the biceps anchor [3]. The superior glenoid serves as the attachment point for the long head of the biceps, with insertion commonly occurring on the glenoid labrum. The biceps tendon anchor is the weakest point, leading to SLAP pathology [1]. The anatomy of this attachment is important in consideration of both the surgical treatment of SLAP lesions, and the post operative complications, including SLAP repair failure.

The diagnosis of a SLAP tear can be made with a combination of provocative physical examination maneuvers and imaging modalities. One option for advanced imaging is the magnetic resonance imaging (MRI) or magnetic resonance arthrogram (MRA). Studies have shown that MRA is better utilized for diagnosis of SLAP tear, as it can also be diagnostic for associated injuries including rotator cuff tear [4]. However, it is important to correlate imaging findings with patient history and clinical examination, as not all SLAP tears are symptomatic, or even require operative treatment. There are multiple studies that have evaluated the correlation of SLAP tear on MRI and impact on athletes, when they were asymptomatic. One such study found that there was no relationship between findings on imaging and likelihood of future symptoms in Major League Baseball players. However, this study did demonstrate that MRI findings were more common in players who pitched more innings, suggesting that these injuries are attributable to overuse and overhead throwing motion [5]. Additional studies suggest that there is a significant number of overhead athletes who have SLAP tears found on MRI but remain asymptomatic. For example, Stetson et al. published their MRI review of U.S. Olympic volleyball athletes, 46% of asymptomatic elite volleyball players had MRI evidence of SLAP tears or fraying but no history or complaints of shoulder problems. This suggests that non operative management can be a successful mainstay in these patients [6, 7]. This is extremely important to note due to the significantly poor outcomes with competitive overhead throwers who undergo surgical fixation of SLAP tears. Return to play in baseball players ranges from 7 to 62% [8–12].

Treatment of SLAP lesions initially consists of conservative measures including throwing rest and physical therapy. However increased level of overhead throwing may predispose athletes to failure of conservative treatment and physical therapy [13, 14]. A physical therapy regimen focuses to address underlying associated pathology including glenohumeral internal rotation deficit (GIRD) and internal impingement by addressing rotator cuff strengthening, posterior capsular stretching, and scapular stability. Operative treatment interventions include arthroscopic debridement alone, arthroscopic debridement with bicep anchor/labral repair, or arthroscopic debridement with biceps tenotomy or tenodesis.

#### *Failure of SLAP Tear Repair and the Management of Long Head of Biceps Pathology DOI: http://dx.doi.org/10.5772/intechopen.114163*

The treatment algorithm for operative management of SLAP tears involves the patient's age, activity level, body habitus, and cosmetic expectations. Patients over age 40 are best treated with tenotomy of the long head of the biceps versus biceps tenodesis alone [6]. Younger patients, especially overhead-throwing athletes, are typically treated with SLAP repair and do not tolerate non operative treatment well [13, 15]. Surgical technique involves the use of suture anchors placed in the glenoid rim and configured optimally based on arthroscopic observation of labral tear [11, 16]. The most common adverse outcomes associated with SLAP repair are decreased rate of return to competitive sport and shoulder stiffness [2–4, 11, 13–16]. Shoulder stiffness is the most common complication following SLAP repair. Therefore, differentiating a type II SLAP tear from a meniscoid type of labrum, a normal sublabral foramen or variant is also critical to the success of the operation. Gobezie et al. showed that even among expert shoulder surgeons, interobserver and intraobserver reliability is poor (48%) in differentiating type II SLAP tears from normal variants or degenerative type I SLAP lesions. Arthroscopic repair of a normal variant can lead to loss of external rotation and alter normal throwing mechanics [17, 18]. SLAP repair failure is an additional complication seen.

#### **3. SLAP tears repair failure**

SLAP repair failure is defined as persistent shoulder pain with or without mechanical symptoms requiring additional treatment. SLAP repair failure is seen following arthroscopic repair with multiple potential etiologies. Common etiologies for SLAP repair failure include failure of the repair (which can be secondary to hardware failure of the suture anchors) or articular cartilage damage. SLAP repair is more often utilized and has shown to have greater effectiveness in patients who are younger than thirty-six years old [19]. Research shows that there are less complications and reported failures in patients who undergo tenodesis of the long head of the biceps and arthroscopic debridement, instead of repair [20–22]. Patients undergoing primary tenotomy or tenodesis of the long head of the biceps are typically older patients, however more recent studies suggest this as a viable treatment method in younger patients [15].

Complications and failure of SLAP repair are not infrequent and can cause significant exacerbation of symptoms in patients. SLAP repair failure is managed with either nonoperative management, revision SLAP repair, or repair revision to long head of the biceps tenodesis. Literature suggests that revision repair is well tolerated, however biceps tenodesis is better tolerated. Biceps tenodesis also demonstrates higher return to functional activity level [22]. The most prevalent complication following SLAP repair is post operative stiffness. In review of cases from the American Board of Orthopedic Surgery (ABOS) part II cases, it was noted that only 26.3% of patients reported absence of pain and only 13.1% of patients reported function as normal [23]. These findings help illustrate the impact of SLAP repair failure and the importance of preventing this complication. Numerous biomechanical studies have been performed with the goal of evaluating methods of SLAP repair. These studies address topics such as the number and location of suture anchors on the glenoid. A cadaveric study by Lehtinen found the optimal anchor position was found to be approximately a thirtydegree angle in relation to the articular surface, the anchor in this position provides the greatest glenoid bone stock to complete the repair [24]. In another cadaveric study focused on the configuration of suture anchors, they found that there is no

biomechanical advantage to the placement of suture anchor anterior to the biceps anchor [25]. Prior studies have suggested that suture anchor placement anterior to the biceps anchor can lead to increased stiffness post operatively in SLAP repair [26].

The reason for SLAP repair failure is poorly understood, however there are multiple reasons hypothesized in the literature. One theory is that concomitant injuries lead to poor outcomes and the inability to return to sport, including rotator cuff tears. Ability to return to sport is also dependent upon position played, as there is significant evidence suggesting worse outcomes in baseball pitchers [9, 27, 28]. Additionally, SLAP repair has been shown to change pitching mechanics and yield diminished throwing performance highlighted by decreased velocity and inability to maintain command of their pitches. These altered mechanics were highlighted in a study by McLaughlin who found that pitchers who had undergone SLAP repair had decreased abduction, decreased external rotation, and forward trunk tilt [29]. In addition to patient factors, technical factors from surgery may also play a role in SLAP repair failure and poor patient outcomes. Review of the literature suggests that use of the trans-rotator cuff portal may lead to damage of the musculotendinous portion of the supraspinatus, which predisposes patients to decreased return to play and poor outcomes [17]. Using the trans rotator cuff portal, O'Brien et al. [30] reported a 44% return-to-sport rate and Cohen et al. [12] reported a 38% rate whereas Neri et al. [9] reported a 13% rate. Therefore, using a single anchor placed via a cannula through the rotator interval is recommended.

Studies also indicate that anchor location in SLAP repair can impact patient outcomes and may explain some of the biomechanical alterations seen including decreased external rotation. If the SLAP repair anchor is placed anteriorly, this can lead to loss of external rotation [27, 31] due to entrapment of the superior glenohumeral ligament and middle glenohumeral ligament causing an inadvertent small but statistically significant loss of external rotation [11, 32]. Furthermore, a biomechanical study of the peel-back mechanism of failure has shown no advantage to the placement of an anterior anchor [25].

Associated shoulder pathology may be another reason SLAP repairs fare so poorly. For example, baseball pitchers with partial rotator cuff tears at the time of SLAP repair have shown a lower rate of return to baseball. Neri et al. [9] reported that only 13% were able to return to base- ball, whereas Brockmeier et al. reported that 64% were able to return [11]. Partial articular-sided rotator cuff tears present a challenge to the surgeon. These need to be addressed with either debridement (<50% of the tendon involved) or repair (>50% of the tendon involved) either using a PASTA (partial articular supraspinatus tendon avulsion) repair technique, which is preferred in younger overhead athletes, or completing the tear and repairing it in older athletes [17].

The final technical point that may impact patient outcomes is the type of suture used to repair. Studies have demonstrated that mattress suture is able to better recreate the native labrum/glenoid interface, as well as provide a more robust fixation method when compared to a simple suture [33, 34]. Because of the prevalence of SLAP repair failure, additional research has been performed to evaluate the use of biceps tenodesis or tenotomy as primary treatment of SLAP repair.

#### **4. Biceps tenodesis vs. biceps tenotomy**

In addition to SLAP repair, SLAP pathology can be managed with long head of the biceps tenotomy or tenodesis. The clinical indications of long head of biceps tenotomy

#### *Failure of SLAP Tear Repair and the Management of Long Head of Biceps Pathology DOI: http://dx.doi.org/10.5772/intechopen.114163*

compared to biceps tenodesis are not universally agreed upon. Multiple techniques have been described for biceps tenodesis, and multiple studies have been performed to determine the clinical indications and utilization of tenodesis or tenotomy. Biceps tenodesis can be performed through an open or an arthroscopic approach, and the tendon may be anchored in a proximal suprapectoral (above the groove), suprapectoral (below the groove), or distal subpectoral position [1, 23, 24].

One popular method of all arthroscopic tenodesis is the "loop 'N' tack biceps tenodesis". This technique is a knotless, intra-articular, arthroscopy only technique [35]. The loop and tack technique involves standard arthroscopy positioning in either the lateral decubitus or beach chair position. A diagnostic arthroscopy is performed utilizing a standard posterior viewing portal and a standard anterior working portal is then made under direct visualization. Then, the surgeon passes a looped suture around the proximal portion of the long head of the biceps tendon and retrieves the loop through the anterior canula. The free end of the suture is placed through the loop to complete a luggage tag stitch (**Figure 1**). Utilizing a sharp arthroscopic tool, like the Bird Beak (Arthrex), the surgeon passes the free end of the suture through the biceps tendon to anchor to the humeral head. Then the proximal portion of the long head of the biceps is cut using either arthroscopic scissors, shaver, or radiofrequency device near the attachment point of the superior labrum. The free end of the suture is then anchored to the humerus at the superior border of the subscapularis and the most distal portion of the bicipital groove visualized (**Figure 2**). This can be done with the surgical anchor of the surgeon's preference [35].

Another option for repair is a mini-open subpectoral technique for biceps tenodesis utilizing all suture technique [36]. This subpectoral technique can utilize different fixation methods including a tenodesis screw, an all-suture anchor, or a cortical button for fixation of the biceps. The surgeon begins this technique by starting the patient in the beach chair position, utilizing a mechanical arm holder of the surgeon's choice for positioning of the operative extremity. Standard diagnostic arthroscopy is

#### **Figure 1.**

*Arthroscopic image of long head of the biceps tendon. Patient positioned in beach chair position, viewing from standard posterior shoulder portal. Loop suture has been secured around the biceps tendon. Suture is anchored to the humerus at the superior border of the subscapularis and the most distal portion of the bicipital groove.*

**Figure 2.**

*Arthroscopic image of long head of the biceps tendon after completion of biceps tenodesis with tenotomy utilizing arthroscopic scissor. Patient positioned in beach chair position, viewing from standard posterior shoulder portal.*

performed with a standard posterior viewing portal and a standard anterior working portal, made under direct visualization. Tenotomy of the pathologic long head of the biceps is performed using either arthroscopic scissors, radiofrequency device, or shaver. Attention is then turned distally to the subpectoral bicipital groove. The arm is abducted and externally rotated to expose the pectoralis major tendon; a longitudinal skin incision is made distal to this. The coracobrachialis, biceps and pectoralis are identified. The long head of the biceps is palpated after retraction of the pectoralis major tendon. A clamp is then placed around the long head of the biceps tendon and the free end of the tendon is then delivered through the skin incision [36]. At this point multiple different fixation devices have been described including the all-suture anchor technique, tenodesis interference screw, and cortical button [36, 37]. There is no generalized consensus as to which of these techniques yields the best results.

Research on this topic comparing the use of the interference screw versus all suture anchor showed that the two options were equivalent in both ultimate failure load and stiffness [38]. There is no general consensus regarding which tenodesis technique leads to the best outcomes; both all-arthroscopic biceps tenodesis and open subpectoral biceps tenodesis are viable treatment methods for management of pathology of the long head of the biceps [9].

Conversely, biceps tenotomy is also an option in management of long head of the biceps pathology. The patient is positioned in either the beach chair or lateral decubitus position, based on surgeon comfort and preference. Pathologic long head of the biceps tendon is visualized through the standard posterior portal (**Figure 3**). Tenotomy is best achieved using arthroscopic scissors, shaver, or radiofrequency device near the attachment point of the superior labrum, depending on surgeon preference (**Figure 4**). Meeks reported high patient satisfaction with reported 13% rate of cosmetic deformity in patients who underwent biceps tenotomy. These results suggest that tenotomy alone is a viable alternative surgical management [39]. Other

#### *Failure of SLAP Tear Repair and the Management of Long Head of Biceps Pathology DOI: http://dx.doi.org/10.5772/intechopen.114163*

concerns with biceps tenotomy include decreased supination function and muscle cramping. This study demonstrates similar results regarding biceps cramping, 20%, when compared to other tenotomy evaluations [39]. With this alternative in treatment, multiple studies exist comparing biceps tenotomy and tenodesis.

Biceps tenotomy compared to tenodesis has been a frequently studied topic. According to multiple review articles and meta-analysis, tenotomy is more likely to result in cosmetic deformity, Popeye deformity, and muscle cramping (although cramping is not obviated by performing tenodesis). Additionally, tenotomy has also shown decreased functional scores and diminished supination strength [40, 41]. Additional meta-analysis demonstrates there is increased incidence of cosmetic deformity and post operative cramping with tenotomy, however there are no functional differences noted between tenotomy and tenodesis of the long head of the biceps [42]. Tenotomy is best utilized in older, overweight patients, with less functional demand, and less concern for cosmesis [41]. Tenodesis is often reserved for younger, higher functional demand, and less likely to tolerate Popeye deformity [41]. Tenodesis can be performed in patients best suited for tenotomy, however there may be no clinical benefit in this patient population.

As discussed above, tenodesis can be performed all arthroscopically, using the loop and tack technique, or using a mini open technique using a tenodesis interference screw, tightrope with cortical button, or suture/suture anchor utilizing an onlay technique. These techniques have been studied, with no general consensus. Studies demonstrate favorable results with use of these tenodesis techniques, especially in management of SLAP repairs, however there is no general consensus.

Newer research advocates for the use of tenodesis in the treatment of SLAP repairs in younger patients, especially those who participate in overhead throwing activities. The study by Pogorzelski evaluated the use of biceps tenodesis utilizing biceps

#### **Figure 3.**

*Arthroscopic image of diseased long head of the biceps tendon with probe placed around tendon. Patient positioned in lateral decubitus position, viewing from standard posterior shoulder portal.*

#### **Figure 4.**

*Arthroscopic image of long head of the superior glenoid labrum and biceps anchor after completion of biceps tenotomy with arthroscopic shave. Patient positioned in lateral decubitus position, viewing from standard posterior shoulder portal.*

tenotomy with radiofrequency device followed by mini open subpectoral biceps tenodesis with utilization of tenodesis screw. Results demonstrated patients had significant improvement in American Shoulder Elbow Society Scores (ASES) and a 90% rate of return to preoperative level of function, including return to sports and overhead activities [15]. Additional review demonstrates comparable return to sport in patients undergoing SLAP repair compared to biceps tenodesis, although these results do not account for activity, including overhead throwing versus non overhead throwing athletes [43]. Other attempted treatment modalities in this population includes repair of the SLAP tear with concomitant biceps tenodesis, however these results show that these patients experience worse outcomes in comparison to patients undergoing primary repair or biceps tenodesis in isolation [44]. This may demonstrate the role of biceps tenodesis in younger, overhead throwing athletes. Given the complication rates and failures noted in SLAP repair, more studies are necessary to evaluate the role of biceps tenodesis compared to SLAP repair.

### **5. Conclusions**

SLAP (superior labrum anterior-posterior) tears are a source of shoulder pain most frequently seen in young, overhead throwing, patients, as well as older patients, degenerative tears. SLAP lesions and concomitant shoulder pathology is best diagnosed using advanced imaging including magnetic resonance imaging (MRI) and magnetic resonance arthrogram (MRA). Treatment of SLAP lesions initially consists of conservative measures including throwing rest, in younger, overhead throwing athletes and physical therapy. Operative treatment interventions include arthroscopic debridement alone, arthroscopic debridement with bicep anchor/labral repair, or

*Failure of SLAP Tear Repair and the Management of Long Head of Biceps Pathology DOI: http://dx.doi.org/10.5772/intechopen.114163*

arthroscopic debridement with biceps tenotomy or tenodesis. Patients over 40 are best treated with biceps tenotomy vs. tenodesis alone. Younger patients, especially overhead athletes less than 40 are typically treated with SLAP repair. There is a high incidence of SLAP repair failure in competitive overhead athletes that is multifactorial in nature, secondary to patient characteristics and surgical technique. There remains debate between the use of long head of biceps tenotomy compared to biceps tenodesis, either mini open (subpectoral) or arthroscopic tenodesis. Tenotomy is best utilized in older, overweight patients, with less functional demand, and less concern for cosmesis. Tenodesis is often reserved for younger, higher functional demand, and less likely to tolerate Popeye deformity.

#### **Conflict of interest**

The authors declare no conflict of interest.

#### **Author details**

William Wardell1 , Margaret Jonas2 \* and Joesph Choi1

1 Guthrie/Robert Packer Hospital, Sayre, PA, United States of America

2 Christus Health, Corpus Christi, TX, United States of America

\*Address all correspondence to<EMAIL_ADDRESS>
© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Andrews JR, Carson WG Jr, McLeod WD. Glenoid labrum tears related to the long head of the biceps. The American Journal of Sports Medicine. 1985;**13**(5):337-341. DOI: 10.1177/036354658501300508

[2] Kim TK, Queale WS, Cosgarea AJ, McFarland EG. Clinical features of the different types of SLAP lesions: An analysis of one hundred and thirty-nine cases. The Journal of Bone and Joint Surgery. American Volume. 2003;**85**(1):66-71

[3] Snyder SJ, Banas MP, Karzel RP. An analysis of 140 injuries to the superior glenoid labrum. Journal of Shoulder and Elbow Surgery. 1995;**4**(4):243-248. DOI: 10.1016/s1058-2746(05)80015-1

[4] Stetson WB, Templin K. The crank test, the O'Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. The American Journal of Sports Medicine. 2002;**30**(6):806-809

[5] Lesniak BP, Baraga MG, Jose J, Smith MK, Cunningham S, Kaplan LD. Glenohumeral findings on magnetic resonance imaging correlate with innings pitched in asymptomatic pitchers. The American Journal of Sports Medicine. 2013;**41**(9):2022-2027

[6] Connor PM, Banks DM, Tyson AB, Coumas JS, D'Alessandro DF. Magnetic resonance imaging of the asymptomatic shoulder of overhead athletes: A 5-year follow-up study. The American Journal of Sports Medicine. 2003;**31**(5):724-727

[7] Stetson WB, Goldhaber NH, Powell SE, Lee CS. Magnetic resonance imaging findings in asymptomatic elite overhead athletes. Arthroscopy. 2017;**33**:58-59

[8] Fedoriw WW, Ramkumar P, McCulloch PC, Lintner DM. Return to play after treatment of superior labral tears in professional baseball players. The American Journal of Sports Medicine. 2014;**42**(5):1155-1160

[9] Neri BR, ElAttrache NS, Owsley KC, Mohr K, Yocum LA. Outcome of type II superior labral anterior posterior repairs in elite overhead athletes: Effect of concomitant partial-thickness rotator cuff tears. The American Journal of Sports Medicine. 2011;**39**(1):114-120

[10] Gilliam BD, Douglas L, Fleisig GS, Aune KT, Mason KA, Dugas JR, et al. Return to play and outcomes in baseball players after superior labral anteriorposterior repairs. The American Journal of Sports Medicine. 2018;**46**(1):109-115

[11] Brockmeier SF, Voos JE, Williams RJ 3rd, Altchek DW, Cordasco FA, Allen AA. Hospital for special surgery sports medicine and shoulder service. outcomes after arthroscopic repair of type-II SLAP lesions. The Journal of Bone and Joint Surgery. American Volume. 2009;**91**(7):1595-1603

[12] Cohen DB, Coleman S, Drakos MC, Allen AA, O'Brien SJ, Altchek DW, et al. Outcomes of isolated type II SLAP lesions treated with arthroscopic fixation using a bioabsorbable tack. Arthroscopy. 2006;**22**(2):136-142

[13] Jang SH, Seo JG, Jang HS, Jung JE, Kim JG. Predictive factors associated with failure of nonoperative treatment of superior labrum anterior-posterior tears. Journal of Shoulder and Elbow Surgery. 2016;**25**(3):428-434

[14] Knesek M, Skendzel JG, Dines JS, Altchek DW, Allen AA, Bedi A.

*Failure of SLAP Tear Repair and the Management of Long Head of Biceps Pathology DOI: http://dx.doi.org/10.5772/intechopen.114163*

Diagnosis and management of superior labral anterior posterior tears in throwing athletes. The American Journal of Sports Medicine. 2013;**41**(2):444-460

[15] Pogorzelski J, Horan MP, Hussain ZB, Vap A, Fritz EM, Millett PJ. Subpectoral biceps tenodesis for treatment of isolated type II SLAP lesions in a young and active population. Arthroscopy. 2018;**34**(2):371-376

[16] Ek ET, Shi LL, Tompson JD, Freehill MT, Warner JJ. Surgical treatment of isolated type II superior labrum anterior-posterior (SLAP) lesions: Repair versus biceps tenodesis. Journal of Shoulder and Elbow Surgery. 2014;**23**(7):1059-1065

[17] Stetson WB, Polinsky S, Morgan SA, Strawbridge J, Carcione J. Arthroscopic repair of type II SLAP lesions in overhead athletes. Arthroscopy Techniques. 2019;**8**(7):e781-e792

[18] Gobezie R, Zurakowski D, Lavery K, Millett PJ, Cole BJ, Warner JJ. Analysis of interobserver and intraobserver variability in the diagnosis and treatment of SLAP tears using the Snyder classification. The American Journal of Sports Medicine. 2008;**36**:1373-1379

[19] Provencher MT, McCormick F, Dewing C, McIntire S, Solomon D. A prospective analysis of 179 type 2 superior labrum anterior and posterior repairs: Outcomes and factors associated with success and failure. The American Journal of Sports Medicine. 2013;**41**(4):880-886

[20] Werner BC, Evans CL, Holzgrefe RE, Tuman JM, Hart JM, Carson EW, et al. Arthroscopic suprapectoral and open subpectoral biceps tenodesis: A comparison of minimum 2-year clinical outcomes. The American Journal of Sports Medicine. 2014;**42**(11):2583-2590

[21] Denard PJ, Lädermann A, Parsley BK, Burkhart SS. Arthroscopic biceps tenodesis compared with repair of isolated type II SLAP lesions in patients older than 35 years. Orthopedics. 2014;**37**(3):e292-e297

[22] Nadeem IM, Vancolen S, Horner NS, Leroux T, Alolabi B, Khan M. Management of failed SLAP repair: A systematic review. HSS Journal. 2020;**16**(3):261-271

[23] Weber SC, Martin DF, Seiler JG 3rd, Harrast JJ. Superior labrum anterior and posterior lesions of the shoulder: Incidence rates, complications, and outcomes as reported by American Board of Orthopedic Surgery. Part II candidates. The American Journal of Sports Medicine. 2012;**40**(7):1538-1543

[24] Lehtinen JT, Tingart MJ, Apreleva M, Ticker JB, Warner JJ. Anatomy of the superior glenoid rim. Repair of superior labral anterior to posterior tears. The American Journal of Sports Medicine. 2003;**31**(2):257-260

[25] Morgan RJ, Kuremsky MA, Peindl RD, Fleischli JE. A biomechanical comparison of two suture anchor configurations for the repair of type II SLAP lesions subjected to a peel-back mechanism of failure. Arthroscopy. 2008;**24**(4):383-388

[26] Yoneda M, Hirooka A, Saito S, Yamamoto T, Ochi T, Shino K. Arthroscopic stapling for detached superior glenoid labrum. Journal of Bone and Joint Surgery. British Volume (London). 1991;**73**(5):746-750

[27] Chalmers PN, Erickson BJ, Verma NN, D'Angelo J, Romeo AA. Incidence and return to play after biceps tenodesis in professional baseball players. Arthroscopy. 2018;**34**(3):747-751

[28] Gorantla K, Gill C, Wright RW. The outcome of type II SLAP repair: A systematic review. Arthroscopy. 2010;**26**(4):537-545

[29] Laughlin WA, Fleisig GS, Scillia AJ, Aune KT, Cain EL Jr, Dugas JR. Deficiencies in pitching biomechanics in baseball players with a history of superior labrum anterior-posterior repair. The American Journal of Sports Medicine. 2014;**42**(12):2837-2841

[30] O'Brien SJ, Allen AA, Coleman SH, et al. The trans- rotator cuff approach to SLAP lesions: Technical aspects for repair and a clinical follow-up of 31 patients at a minimum of 2 years. Arthroscopy. 2002;**18**:372-377

[31] Kartus J, Ejerhed L, Funck E, Köhler K, Sernert N, Karlsson J. Arthroscopic and open shoulder stabilization using absorbable implants. A clinical and radiographic comparison of two methods. Knee Surgery, Sports Traumatology, Arthroscopy. 1998;**6**(3):181-188

[32] McCulloch PC, Andrews WJ, Alexander J, Brekke A, Duwani S, Noble P. The effect on external rotation of an anchor placed anterior to the biceps in type 2 SLAP repairsina cadaveric throwing model. Arthroscopy. 2013;**29**:18-24

[33] Domb BG, Ehteshami JR, Shindle MK, Gulotta L, Zoghi-Moghadam M, MacGillivray JD, et al. Biomechanical comparison of 3 suture anchor configurations for repair of type II SLAP lesions. Arthroscopy. 2007;**23**(2):135-140

[34] Dines JS, Elattrache NS. Horizontal mattress with a knotless anchor to better recreate the normal superior labrum anatomy. Arthroscopy. 2008;**24**(12):1422-1425

[35] Hammarstedt JE, Rinaldi J, Guth JJ, Akhavan S. The loop 'N' tack biceps Tenodesis: An all-arthroscopic, intraarticular technique. Arthroscopy Techniques. 2020;**9**(12):e1899-e1902

[36] Lacheta L, Imhoff AB, Siebenlist S, Scheiderer B. Subpectoral biceps tenodesis: All-suture anchor Onlay technique. Arthroscopy Techniques. 2020;**9**(5):e651-e655

[37] Kennedy NI, Godin JA, Ferrari MB, Sanchez G, Cinque ME, Hussain ZB, et al. Subpectoral biceps tenodesis: Interference screw and cortical button fixation. Arthroscopy Techniques. 2017;**6**(4):e1415-e1420

[38] Chiang FL, Hong CK, Chang CH, Lin CL, Jou IM, Su WR. Biomechanical comparison of allsuture anchor fixation and interference screw technique for subpectoral biceps tenodesis. Arthroscopy. 2016;**32**(7):1247-1252

[39] Meeks BD, Meeks NM, Froehle AW, Wareing E, Bonner KF. Patient satisfaction after biceps tenotomy. Orthopaedic Journal of Sports Medicine. 2017;**5**(5):2325967117707737

[40] Liu H, Song X, Liu P, Yu H, Zhang Q, Guo W. Clinical outcomes of arthroscopic tenodesis versus tenotomy for long head of the biceps tendon lesions: A systematic review and meta-analysis of randomized clinical trials and cohort studies. Orthopaedic Journal of Sports Medicine. 2021;**9**(4):2325967121993805

[41] Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR. Biceps tenotomy versus tenodesis: A review of clinical outcomes and biomechanical results. Journal of Shoulder and Elbow Surgery. 2011;**20**(2):326-332

*Failure of SLAP Tear Repair and the Management of Long Head of Biceps Pathology DOI: http://dx.doi.org/10.5772/intechopen.114163*

[42] Gurnani N, van Deurzen DF, Janmaat VT, van den Bekerom MP. Tenotomy or tenodesis for pathology of the long head of the biceps brachii: A systematic review and meta-analysis. Knee Surgery, Sports Traumatology, Arthroscopy. 2016;**24**(12):3765-3771

[43] Abdul-Rassoul H, Defazio M, Curry EJ, Galvin JW, Li X. Return to sport after the surgical treatment of superior labrum anterior to posterior tears: A systematic review. Orthopaedic Journal of Sports Medicine. 2019;**7**(5):2325967119841892

[44] Chalmers PN, Monson B, Frank RM, Mascarenhas R, Nicholson GP, Bach BR Jr, et al. Combined SLAP repair and biceps tenodesis for superior labral anterior-posterior tears. Knee Surgery, Sports Traumatology, Arthroscopy. 2016;**24**(12):3870-3876

#### **Chapter 2**

## Treatment of Rotator Cuff Tears: New Modalities and Innovations

*James Young Jin Lee, Mazen Zamzam, Maxwell Li, Alex Martusiewicz, Brett P. Wiater and Jerome Michael Wiater*

#### **Abstract**

Although frequently performed, rotator cuff repair carries a not insignificant failure rate. A number of studies including biomechanical and clinical studies have attempted to identify factors affecting rotator cuff repair and healing. Poor prognostic factors likely include age, fatty atrophy of rotator cuff muscles, large tear size, chronicity, and smoking. Recent rotator cuff tear research has been devoted to addressing both biologic and structural concerns of repair. Adjuvant repair techniques aimed at improving biology have emerged, and many are now clinically available and include biologic patch augmentation, bone marrow aspirate, platelet-rich plasma, and utilizing local bone marrow egress. Novel structural techniques have been developed to augment, alter, or replicate the structural properties of rotator cuff, particularly in the setting of irreparable rotator cuff tears. These include subacromial balloon spacers, tendon transfers, superior capsular reconstruction, anterior cable reconstruction, bursal acromial reconstruction, and biologic tuberoplasty. This chapter will examine these novel biological and structural techniques and review available clinical outcomes.

**Keywords:** rotator cuff repair, patch augmentation, biologics, novel rotator cuff reconstruction techniques, shoulder arthroscopy

#### **1. Introduction**

The prevalence of rotator cuff tears within the general population is estimated to be approximately 22.1% [1]. It is the most common source of shoulder pain and disability [2, 3]. As a result, arthroscopic rotator cuff repair is one of the most frequently performed orthopedic procedures [4, 5].

The most common complaint of a patient with a torn rotator cuff is pain [5]. In a study by Itoi et al. 87.9% of patients reported shoulder pain as the reason for the visit, and 10.8% reported pain and muscle weakness [6]. First-line treatments commonly include nonsteroidal anti-inflammatory (NSAIDs), corticosteroid injections, and physical therapy.

Although frequently performed, rotator cuff repair carries a not insignificant failure rate. Retear rates may range from 20% to 70% [7–11]. A number of studies including biomechanical and clinical studies have attempted to identify factors affecting rotator cuff repair and healing. Poor prognostic factors likely include age, fatty atrophy of rotator cuff muscles, large tear size, chronicity, and smoking.

Recent rotator cuff tear research has been devoted to addressing both biological and structural concerns of repair. Adjuvant repair techniques aimed at improving biology have emerged, and many are now clinically available and include biologic patch augmentation, bone marrow aspirate, platelet-rich plasma, and utilizing local bone marrow egress. Novel structural techniques have been developed to augment, alter, or replicate the structural properties of rotator cuff, particularly in the setting of irreparable rotator cuff tears. These include subacromial balloon spacers, tendon transfers, and superior capsular reconstruction (SCR), anterior cable reconstruction (ACR), bursal acromial reconstruction (BAR), and biologic tuberoplasty. This chapter will examine these novel biological and structural techniques and will review the available clinical outcomes.

#### **2. Biologic augmentation of rotator cuff repair: An evolving field**

Primary rotator cuff repair itself continues to evolve. Recent advancements in repair techniques and materials have allowed for continued improvement in time-zero fixation. These include various anchor types, suture materials, stitch configurations, and tissue penetrating devices [12]. However, retear rates after rotator cuff repair remain high, ranging from 20% to 40% at 2 years [11, 13–16]. As such, tendon repair augmentation methods have been proposed to provide a biological scaffold for mechanical stability and long-term incorporation by providing a porous structure onto which collagen can migrate. The utilization of a mechanical augmentation patch dates back to 1986. Ozaki et al. utilized Teflon felt to augment rotator cuff repair [17].

Cuff augmentation can be utilized in several different ways. It can be utilized as a mechanical interposition graft to bridge the gap between the tendon and bone when the tendon does not reach the footprint in the setting of a retracted, irreparable tear [9–11]. Second, an augmentation patch can be applied on the bursal side of the repair in an "on-lay" fashion [18]. Third, biologic grafts can be interposed between the tendon and the bone with the goal of promoting soft tissue integration and subsequent robust healing.

Many types of grafts are available for use in the market currently. These include synthetic, xenograft, allograft, or autograft patches. Several early studies utilized xenograft small intestine submucosal graft, which revealed high rates of repair failure as well as a profound inflammatory response and led to poor clinical outcomes [19, 20]. As such, utilization of small intestine submucosal graft has largely been abandoned. The simple on-lay of reconstituted bovine collagen implant (REGENETEN, Smith, and Nephews) impregnated with growth factors has been shown to significantly increase tendon thickness in the setting of partial thickness rotator cuff tears as seen on MRI at 2 years. These patients also reported improved clinical outcomes. Despite these promising early results on the REGENETEN patch, high-level comparative studies are needed to draw conclusions on its superiority over standard repair or other augmentation methods (**Figure 1**) [21].

A randomized controlled trial of 92 patients utilizing an acellular porcine dermal matrix scaffold in small to medium rotator cuff tears showed improved constant and strength scores compared to the nonbiologically augmented group. This evidence suggests an accelerated return to function without any graft-specific complications [22]. Similar results were seen in a randomized controlled trial of 112 patients with large

#### **Figure 1.**

*Schematic of reconstituted bovine collagen implant (REGENETEN, Smith, and Nephews) used in an on-lay fashion to augment rotator cuff repair.*

to massive rotator cuff using a synthetic 3D collagen scaffold augmentation. This study showed significantly higher 6-month UCLA and constant scores, suggesting an earlier return to function, although no difference was found at the final follow-up of 28 months [23].

The most utilized form of allograft rotator cuff augmentation is an acellular dermal allograft. This graft is composed of type I collagen processed to remove donor cells while preserving the extracellular matrix. Several acellular dermal allografts are available and have been utilized in orthopedic surgery and plastic surgery for decades. In biomechanical studies, allograft augmentation utilized in an on-lay fashion on top of a repair likely increases the load to failure in rotator cuff tendon repairs [24]. In vivo studies have demonstrated that the removal of cellular components allows infiltration of fibroblasts, tenocytes, and vascular tissues while causing minimal host inflammation [25, 26]. High porosity seen in new generations of "open matrix" dermal allografts may allow for deeper penetration of mesenchymal cells, leading to fibroplasia. Clinically, a prospective randomized study of 42 patients showed higher rates of the intact cuff in the on-lay acellular dermal patch augmentation group compared with the control group (85% vs. 40%) with higher American shoulder and elbow surgeons (ASES) and Constant scores at 2 years [27]. Autograft such as tensor fascia lata has also been utilized for rotator cuff augmentation with superior constant scores compared to partial repairs in a cohort study of 48 patients at minimum 7-year follow-up [28].

The use of biological and structural augmentation is an emerging solution to enhance healing in rotator cuff surgery. Various options are clinically available, and the popularity of these techniques continues to grow. Although promising data is emerging, further high-level comparative studies are necessary to define the indications, efficacy, and value.

#### **3. Superior capsular reconstruction: Indications, techniques, and outcomes**

SCR is a surgical procedure performed in the setting of irreparable cuff tears. The goal of SCR is to restore the stability of the shoulder joints, thereby re-establishing the mechanical fulcrum of the joint to the level of the glenohumeral articulation and potentially improving the force couple of the remaining rotator cuff tendons. Originally, SCR was described using a fascia lata autograft patch [29]. SCR is indicated for patients with a nonarthritic glenohumeral joint and a functional deltoid in the setting of an irreparable rotator cuff tendon (RCT) tear [29]. Patients with an intact subscapularis tendon also show improved outcomes compared to subscapularis deficient shoulders [30]. Ideally, patients should have a repairable or intact subscapularis when undergoing an SCR [30, 31].

The most commonly utilized and studied grafts are fascia lata autograft and extracellular dermal matrix allograft. The procedure can also be performed either arthroscopically or in the open, with sutures and anchors being placed either before or after the placement of the graft [32]. The original SCR technique involves an arthroscopic procedure to be done using a fascia lata autograft that is attached medially to the glenoid using two titanium suture anchors and laterally to the greater tuberosity using double-row techniques and suture bridge. The graft is stabilized with a side-to-side suture posteriorly to the residual infraspinatus and anteriorly to the subscapularis or residual anterior-superior tendon [29].

SCR outcomes are variable. The original authors of the technique involved 24 shoulders who underwent SCR with a fascia lata [29]. Thirty-four months after surgery, patients demonstrated improved active abduction and external rotation as well as improved ASES scores [29]. Denard et al. studied 59 patients who had an SCR and showed improvements in forward flexion, external rotation, VAS, and ASES scores [33]. Unfortunately, 11 (18.6%) of patients in the study underwent a revision procedure, including seven of them undergoing reverse shoulder arthroplasties [9]. More recently, Pennington published outcomes with 86 patients who underwent SCR with a dermal allograft and demonstrated significant improvements in ASES and VAS scores after 16–28 months [34].

The rehabilitation protocol for patients who undergo a SCR is similar to those who also undergo massive rotator cuff repairs. For the first 4 to 6 weeks, postoperatively, patients are placed in a sling with an abduction pillow. Generally, progressive range of motion (ROM) exercises when the wedge is removed at 4–6 weeks postoperatively. Most surgeons then have patients begin strengthening exercises at 12 weeks postoperatively, but a subset starts as early as the 8-week mark (**Figure 2**) [35].

#### **Figure 2.**

*Schematic of a SCR done using dermal cellular allograft fixed using suture anchors (note: long head of biceps tenodesed).*

#### **4. The subacromial balloon spacer for irreparable rotator cuff tears**

Approximately half of all patients diagnosed with a torn rotator cuff undergo a surgical repair [36]. A subset of these patients are found either preoperatively or intraoperatively to have tears that are too large and retracted to perform a primary repair. As stated earlier, graft augmentation or SCR may be considered by both to be technically difficult to perform and may not be the ideal choice for lower-demand individuals. Also, there is some evidence that procedures that utilize grafts may negatively affect the outcomes of subsequent reverse shoulder arthroplasty (RSA) [37]. In lieu of this, the InSpace subacromial balloon (Stryker, USA) spacer was developed in 2010 [37] and was food and drug administration (FDA)-approved in 2021. The device consists of a saline-filled biodegradable balloon which is inserted between the humeral head and the acromion [38]. After arthroscopic insertion in the subacromial space, the InSpace balloon is insufflated with a recommended volume of saline proportional to the implant size selected. The outer material of the balloon is made of a copolymer designed to degrade in 12 months 7. It is theorized that a pseudocapsule remains after it degrades to help maintain the balloon effect. Currently, it is indicated in patients with massive (>5 cm) irreparable tears involving two or more tendons with a functional deltoid, little to no glenohumeral joint osteoarthritis, and preserved passive range of motion on examination. Similar SCR, the goal of the subacromial balloon is to restore the acromio-humeral interval and thereby re-establishing the normal mechanic of the shoulder during elevation. A theoretical advantage is that it may also reduce friction between tissue planes and potentially result in less early postoperative pain [38, 39].

While the InSpace subacromial balloon spacer is a novel device, it has already been implanted in approximately 29,000 patients internationally. However, current research is limited, and further studies are needed to evaluate its efficacy and safety. Nevertheless, the InSpace subacromial balloon spacer holds great promise in the management of irreparable rotator cuff tears, particularly in patients who are not suitable for more complex procedures (**Figure 3**).

Given earlier availability of the implant in Europe, international studies provide more data on postoperative outcomes of the surgical procedure. Gervasi et al. [40] showed that pain score improvement was found as early as 1 week postoperatively,

**Figure 3.** *Schematic diagram of InSPACE balloon inserted in the subacromial space.*

and strength improvement 18 months postoperatively. Constant scores increased from 31.9 to 69.8 at 1 year follow-ups, demonstrating improvements in function, and mobility. More recently, a level 1 randomized controlled study emerged from the United States to evaluate the balloon over the course of 2 years. Participants underwent a partial tendon repair or an InSpace balloon insertion. ASES scores improved for both groups; however, a larger increase was noted for the InSpace group (46.22 vs. 42.53) [41]. InSpace implants also demonstrated functional and patient-reported outcomes comparable to partial repair of irreparable massive rotator cuff tears with intact subscapularis [41]. The InSpace device group demonstrated an earlier recovery based on improvements in ASES, WORC, and constant scores [41]. The range of motion measurements was also superior [41]. After the degradation of the implant, a 2-year follow-up demonstrated maintained clinical improvement.

Although the results of Hazra et al. are promising, other studies challenge this. A multicenter double-blinded randomized controlled trial (START:REACTS) in the United Kingdom showed less desirable outcomes [42]. This study randomized patients to debridement alone vs. debridement and subacromial balloon spacer insertion. This study was prematurely halted due to statistically greater improvement in the debridement alone group. While considered one of the emerging techniques for massive irreparable rotator cuff tears, the technique is considered controversial due to the conflicting data from the two high-level randomized controlled trials. Although approved for use by the FDA, further high-quality research is necessary to establish the role of the subacromial balloon spacer in treating irreparable rotator cuff tears.

Relative indications for use:

	- a.Measuring 5 cm or greater in diameter
	- b.Involving two or more tendons

#### **5. Tendon transfers for massive irreparable rotator cuff tears: A review of latissimus dorsi transfer (LDT) and lower trapezius transfer (LTT)**

Tendon transfers are another option for massive, irreparable rotator cuff tears. Patients with low-grade rotator cuff arthropathy (Hamada I or II) and a maintained glenohumeral joint with pseudoparalysis are potential candidates. Tendon transfers have been utilized to restore motion, strength, and function via force coupling. From a biomechanical point of view, the transferred tendons are thought to act as humeral head depression and concavity compression (compression of the

#### *Treatment of Rotator Cuff Tears: New Modalities and Innovations DOI: http://dx.doi.org/10.5772/intechopen.112729*

articulation). They can improve external rotation via a transfer force vector [43]. Latissimus dorsi transfer (LDT) and LTT are both options and can be performed open or with arthroscopic assistance. Indications for LDT and LTT include a relatively young, active patient with a massive irreparable rotator cuff tear, intact deltoid function, without subscapularis deficiency and/or anterior-superior escape of the humerus. The ability to comply with a long rehabilitation protocol is a favorable patient characteristic as well.

LDT was first described by L'Episcopo [44] in the setting of obstetric brachial plexopathy and later adopted by Gerber et al. [45] (**Figures 4** and **5**) for the management of irreparable posterosuperior rotator cuff tears. A level IV study by Gerber et al. studied long-term results of LDT at 10 years follow-up in 46 shoulders. Improvements in flexion, abduction, and external rotation as well as abduction strength were demonstrated. Inferior outcomes were demonstrated in those with subscapularis insufficiency and teres minor atrophy [46]. A recent randomized prospective evaluation of

#### **Figure 4.**

*Through a posterior-based incision, the latisimuss dorsi is harvested from its attachment on the humerus. Nonabsorbable sutures secure the tendon using a locking Krackow technique. The graft is then tunneled through a separate incision deep to deltoid and superficial to infraspinatous.*

#### **Figure 5.**

*The lateral edge of the graft is secured on to the greater tuberosity via preferred technique. Remnant supraspinatous can be attached to the medial border of the graft and the distal edge of the graft is secured to upper border of subscapularis (note: long head of biceps tenodesed).*

LDT vs. SCR demonstrated that LDT provides statistically significant improvements in range of motion and patient-reported outcomes, although more favorable outcomes in ASES and constant scores were seen in the SCR group [47]. LDT has also been described as option for treatment of subscapularis deficiency with improved function, pain scores, as well as internal rotation in retrospective case series studies [48, 49].

Compared to LDT, LTT offers a better in-line pull similar to the infraspinatus, and biomechanical studies have shown improved external rotation force compared with LDT [50]. Due to the short length of the tendon of the lower trapezius, a bridging graft is necessary. Achilles tendon allograft and semi-tendinosis autograft have both been described in the literature [51, 52]. In either case, the lower trapezius is isolated and harvested from its insertion on the inferomedial scapular spine. Care should be taken not to violate the neurovascular pedicle, including the spinal accessory nerve and transverse cervical artery, which lie medial to the scapula on the undersurface of the muscle. The graft is tunneled through the infraspinatus fascia and under the deltoid and affixed to the greater tuberosity via bone tunnels or suture anchors. The transfer is tensioned with the arm abducted to 90 and in maximal external rotation [52]. Significant improvements in functional scores and active range of motion have been reported across multiple studies [53, 54]. Elhassan et al. reported on 41 patients with irreparable posterior superior rotator cuff tears treated with arthroscopically assisted LTT. They reported significant improvements in visual analog scale, SSV, and disabilities of the arm, shoulder and hand (DASH) scores in 37 of their patients at a mean follow-up of 14 months. Unlike LDT, subscapularis insufficiency was not correlated to inferior outcomes in LTT [53]. A level III retrospective cross-over study comparing LDT with LTT demonstrated greater active external rotation as well as post-operative ASES score. A maintained acromiohumeral distance and a lower progression of arthritis in LTT also revealed that it might be the preferred tendon transfer option for irreparable posterosuperior rotator cuff tears [55]. Rehabilitation after the tendon transfer procedures typically involves 6 weeks of full immobilization in an externally rotated and abducted position, followed by an additional 6 weeks of limited internal or external rotation to protect the transfer.

Although outcomes are suboptimal compared to primary RTC repair, LDT and LTT can serve as attractive options for younger patients with massive, irreparable rotator cuff tears (**Figure 6**).

**Figure 6.** *LTT with utilization of bridging achilles tendon autograft to allow insertion onto greater tuberosity.*

#### **6. Anterior cable reconstruction with long head of biceps tendon: A novel technique for rotator cuff repair**

The rotator cable is a semi-circular thickening that interweaves with the supraspinatus and infraspinatus tendons. It runs perpendicular to the tendon fibers and blends anteriorly with subscapularis. The analogy of the rotator cable acting as a load-bearing suspension bridge is described by Burkhart et al. [56]. Anatomically, the rotator cable is about 2.59 times thicker than the rotator crescent and provides a stress shielding effect to the thinner tissue of the rotator crescent, where the rotator cuff is inherently prone to tearing [56]. Being a critical structure in biomechanical functioning of the rotator cuff, there have been efforts to address this surgically during the repair of a torn rotator cuff tendon.

ACR with a long head of biceps tendon (LHBT) was described by Park et al. in 2018 [57]. The LHBT is a good graft option for several reasons. It has a proximal attachment on the glenoid, close to the native capsule, and does not require fixation of graft on to the glenoid. The LHBT is often tenotomized, and the proximal stump of tissue is discarded. Thus, it represents a local, expendable, and autologous source of tissue, obviating donor site morbidity as well as foreign body reaction and inflammation associated with nonautologous sources of tissue.

After arthroscopic evaluation of the LHBT, the subacromial space is entered using a standard posterior viewing portal and lateral working portal, and a tuberosity footprint is prepared. A posterolateral viewing portal is made at the posterior edge of a torn tendon in the subacromial space. A triple-loaded medial anchor is then placed at the anterior border of infraspinatus on the cartilage junction. A biceps tenodesis is performed at the site of this anchor. The arm is externally rotated to reduce the strain that may restrict the range of motion. One suture knot is made anterior and one posterior to the tendon and suture remnants after tenodesis as well. A pair of strands that have not been used are then passed through the rotator cuff tendon which are utilized for side-to-side repair over the tenodesis biceps tendon (**Figure 7**). A lateral anchor is then inserted where the anteriorly moved infraspinatus and distal portion of LHBT tendon can lie together. Each of the paired strands is passed through the LHBT and rotator cuff and tied. A biceps tenotomy is then performed (**Figure 7**) [58].

Biomechanically, this has been shown to decrease superior translation of the humeral head and normalize subacromial contact pressures without limiting the range of motion. Clinically, a level III retrospective study of 41 arthroscopic rotator cuff repairs with ACR and 84 without ACR in patients was performed in rotator cable deficient full-thickness supraspinatous tendon tear >2 cm. This demonstrated equivalent VAS, ASES, and ROM but statistically significantly improved acromiohumeral distance and retear rates (4.9% vs. 7.1%) at minimum follow-up of 12 months [58].

Multiple variations of ACR have been described such as a LHBT rerouting procedure [58, 59]. In this procedure, LHBT is mobilized from surrounding soft tissue. A groove is created more laterally on the tuberosity and biceps tenodesis performed in the rerouted position. The rotator cuff repair is completed with the LHBT interposed between the rotator cuff and humeral head (**Figure 7**) [60]. A case series of 80 patients with a large rotator cuff tear and a follow-up of 21 months demonstrated statistically significant improvement in ASES, Korean Shoulder Score, active ROM, and acromiohumeral distance compared with preoperative scores [60].

ACR is an emerging novel technique utilized with good success in a limited number of preliminary studies. There is an increasing level of interest in such techniques,

**Figure 7.** *Schematic depiction of ACR using long head of biceps autograft.*

but higher-level comparative studies are lacking and are needed to define the role of ACR in irreparable rotator cuff tears (**Figure 7**).

#### **7. Bursal acromial reconstruction**

The evolution of arthroscopic techniques led to the creation of methods such as superior capsule reconstruction, which utilize allografts [61]. However, the SCR is time-consuming, potentially complex, and expensive. This led to the evolution of the BAR, a technique that provides an interposition allograft graft preventing contact between the humerus and acromion [62]. Potential advantage of BAR is lower cost, lower post-operative rehab demands, and anesthesia time compared with techniques such as SCR, tendon transfers, and reverse total shoulder arthroplasty.

Patients are prepared for the surgery by being placed in the beach chair position or the lateral decubitus, ensuring that the acromioclavicular joint (ACJ) is within the surgical field [62]. A bursectomy, minimal acromioplasty, and a lateral clavicle excision is performed with the intention of providing a flat surface for graft insertion and tying around the acromion [62]. The acromial surface area is then measured, and the allograft is trimmed to that measurement. A crossed suture tape configuration with a lasso-loop knot is then created at each corner by passing a high tensile nonabsorbable suture from corner to corner [62]. A suture tape retriever is then placed through the Neviaser portal, and a suture manipulator is placed through the mid-ACJ port [62]. The tape from the posteromedial graft corner is then introduced into a cannula and passed off to the retriever within the Neviaser portal. After insertion of the tape into the anteromedial corner of the graft in the subacromial space, the graft is passed into the waiting tape retriever within the ACJ portal. After all three sutures are inserted, the graft can now be inserted within the subacromial space. After insertion of the graft under the acromion, the three lateral sutures are to be passed via a needle in outside-in-technique [62]. After the passage of all six sutures in the bursa, the corresponding tails are then retrieved for tying [62].

BAR is best indicated for patients with complex rotator cuff tears who are older than 75 years of age and do not show any osteoarthritis [62]. While older *Treatment of Rotator Cuff Tears: New Modalities and Innovations DOI: http://dx.doi.org/10.5772/intechopen.112729*

**Figure 8.** *Arthroscopic view of a dermal allograft affixed to the greater tuberosity.*

osteoarthritic patients, or older patients with a torn rotator cuff typically undergo a RSA some can qualify to possibly undergo a BAR [63]. RSA has shown excellent clinical outcomes in patients who undergo the procedures, but not all patients who undergo an RSA may be good candidates [63, 64]. This can include comorbidities or desire to not undergo an arthroplasty [64]. In the case of irreparable rotator cuffs in the elderly, BAR can also be an alternative within those cases. With BAR being a very new procedure, little information on long-term patient outcomes is available. One study, however, released mid-term outcomes for patients undergoing BAR. Patients demonstrated significantly improved Western Ontario Rotator cuff score, and the disabilities of the arm, shoulder, and hand improved, with 92% and 74% of patients meeting clinical differences for the scores respectively (**Figure 8**) [65].

#### **8. Biologic tuberoplasty: A novel option for massive irreparable rotator cuff tears in low-demand patients**

For patients with significant comorbidities who are unable to undergo an extensive procedure to treat massive irreparable rotator cuff tears, surgical treatment options are limited. Biologic tuberoplasty is a novel procedure that provides a quicker, bonesparing option for massive, irreparable rotator cuff tears in low-demand patients. Ideally, patients have little to no glenohumeral joint arthritis [66, 67]. Coverage of tuberosity with an acellular dermal allograft is thought to act as interpositional tissue and prevent bone-on-bone contact between the undersurface of the acromion and the tuberosity, leading to pain relief. The phenomenon of "biologic tuberoplasty" was first described by Mirzayan et al. They noted that patients who had undergone SCR, and had a graft failure, still had equivalent visual analog scale scores and functional outcome scores as patients with intact graft. It was postulated that the residual graft left on the greater tuberosity was preventing bone-on-bone contact with the acromion. In a case series study of 10 patients, there was a significant improvement in ASES, SANE, and VAS scores at a mean follow-up of 21 months with magnetic resonance imaging evidence of healed graft onto the tuberosity in all cases [68]. This novel technique does not, however, restore normal glenohumeral joint kinematics and is intended solely for pain relief. The clinical benefits of this novel technique have yet

to be proven with high-level comparative studies. Further comparative data is needed to understand short and long-term outcomes.

Advantages:

Disadvantages/risks and/or limitations:

### **9. Platelet-rich plasma: An emerging supplementation in rotator cuff repair**

The use of platelet-rich product (PRP) supplementation is a particular area of interest in orthopedic surgery. PRP is a biologically active concentrate produced by centrifuging of whole blood. PRP has been utilized in an attempt to improve biologic healing environment as a standalone treatment and adjunct supplementation at the time of rotator cuff repair surgery. Four types of PRP exist depending on preparation: pure platelet-rich plasma (P-PRP), leukocyte- and platelet-rich plasma (L-PRP), pure

**Figure 9.** *Schematic of a BAR.*

#### *Treatment of Rotator Cuff Tears: New Modalities and Innovations DOI: http://dx.doi.org/10.5772/intechopen.112729*

platelet-rich fibrin (P-PRF), and leukocyte- and platelet-rich fibrin (L-PRF) [69]. It contains numerous growth factors important for tissue repair and wound healing such as transforming growth factor B1, platelet-derived growth factor, vascular endothelial growth factor, epithelial growth factor, and insulin-like growth factors [70–72]. There have been extensive research on clinical utility of PRP at time of rotator cuff repair, with mixed results [73, 74]. Recent meta-analysis of randomized controlled trials by Ryan et al. in 2021. This study included 17 level I or II randomized controlled trials comparing 553 patients treated with PRP to 551 control patients with varying size and severity of rotator cuff tears [75]. This study demonstrated favorable results for using PRP in conjunction with rotator cuff repair with lower retear rates. It improved constant scores SST scores, and VAS scores compared to the control group, with P-PRP appearing to be the most effective formulation. Other biologics such as bone marrow aspirate concentrate and stem cells are under investigation; however, clinical data in the setting of rotator cuff repair surgery is lacking.

#### **10. Conclusion**

Despite arthroscopic rotator cuff repair being one of the most frequently performed orthopedic procedures, it carries a significant failure rate.

Recent research has focused on addressing both biological and structural concerns of repair, with the emergence of adjuvant repair techniques aimed at improving biology and novel structural techniques developed to augment or replicate the structural properties of rotator cuff. These techniques include biologic patch augmentation, subacromial balloon spacers, tendon transfers, SCR, ACR, BAR, and biologic tuberoplasty.

Further studies are needed to evaluate the efficacy and safety of these emerging techniques. However, the currently available clinical outcomes are encouraging, and these techniques hold great promise in improving the management of rotator cuff tears, especially in the setting of irreparable rotator cuff tears.

#### **Author details**

James Young Jin Lee, Mazen Zamzam, Maxwell Li, Alex Martusiewicz, Brett P. Wiater and Jerome Michael Wiater\*

Department of Orthopaedic Surgery, Corewell Health William Beaumont University Hospital, Royal Oak, MI, USA

\*Address all correspondence to<EMAIL_ADDRESS>
© 2023 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Chakravarty K, Webley M. Shoulder joint movement and its relationship to disability in the elderly. Journal of Rheumatology. 1993;**20**:1359-1361

[2] Largacha M, Parsons IM, Campbell B, Titelman RM, Smith KL, Matsen F. Deficits in shoulder function and general health associated with sixteen common shoulder diagnoses: A study of 2674 patients. Journal of Shoulder and Elbow Surgery. 2006;**15**:30-39

[3] Flatow EL, Soslowsky LJ, Ticker JB, Pawluk RJ, Hepler M, Ark J, et al. Excursion of the rotator cuff under the acromion. Patterns of Subacromial Contact. The American Journal of Sports Medicine. 1994;**22**:779-788

[4] Tempelhof S, Rupp S, Seil R. Agerelated prevalence of rotator cuff tears in asymptomatic shoulders. Journal of Shoulder and Elbow Surgery. 1999;**8**:296-299

[5] Chang KV, Hung CY, Han DS, Chen WS, Wang TG, Chien KL. Early versus delayed passive range of motion exercise for arthroscopic rotator cuff repair: A meta-analysis of randomized controlled trials. The American Journal of Sports Medicine. 2015;**43**:1265-1273

[6] Minagawa H, Yamamoto N, Abe H, Fukuda M, Seki N, Kikuchi K, et al. Prevalence of symptomatic and asymptomatic rotator cuff tears in the general population: From mass-screening in one village. Journal of Orthopaedics. 26 Feb 2013;**10**(1):8-12. DOI: 10.1016/j. jor.2013.01.008. PMID: 24403741; PMCID: PMC3768248

[7] Kim YS, Chung SW, Kim JY, Ok JH, Park I, Oh JH. Is early passive motion exercise necessary after

arthroscopic rotator cuff repair? The American Journal of Sports Medicine. 2012;**40**:815-821

[8] Keener JD, Galatz LM, Stobbs-Cucchi G, Patton R, Yamaguchi K. Rehabilitation following arthroscopic rotator cuff repair: A prospective randomized trial of immobilization compared with early motion. Journal of Bone and Joint Surgery. American Volume. 2014;**96**:11-19

[9] Tashjian RZ, Hollins AM, Kim HM, Teefey SA, Middleton WD, Steger-May K, et al. Factors affecting healing rates after arthroscopic double-row rotator cuff repair. The American Journal of Sports Medicine. 2010;**38**:2435-2442

[10] Slabaugh MA, Nho SJ, Grumet RC, Wilson JB, Seroyer ST, Frank RM, et al. Does the literature confirm superior clinical results in radiographically healed rotator cuffs after rotator cuff repair? Arthroscopy. 2010;**26**:393-403

[11] Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. Journal of Bone and Joint Surgery. American Volume. 2004;**86**:219-224

[12] Ponce BA, Hosemann CD, Raghava P, Tate JP, Sheppard ED, Eberhardt AW. A biomechanical analysis of controllable intraoperative variables affecting the strength of rotator cuff repairs at the suturetendon interface. The American Journal of Sports Medicine. 2013;**41**:2256-2261

[13] Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and

*Treatment of Rotator Cuff Tears: New Modalities and Innovations DOI: http://dx.doi.org/10.5772/intechopen.112729*

functional outcome after arthroscopic double-row rotator cuff repair: A prospective outcome study. Journal of Bone and Joint Surgery. American Volume. 2007;**89**(5):953-960

[14] Kim SJ, Kim SH, Lee SK, Seo JW, Chun YM. Arthroscopic repair of massive contracted rotator cuff tears: Aggressive release with anterior and posterior interval slides do not improve cuff healing and integrity. Journal of Bone and Joint Surgery. American Volume. 2013;**95**:1482-1488

[15] Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan S. Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal? Journal of Bone and Joint Surgery. American Volume. 2005;**87**(6):1229-1240

[16] Cole BJ, McCarty LP III, Kang RW, Alford W, Lewis PB, Hayden JK. Arthroscopic rotator cuff repair: Prospective functional outcome and repair integrity at minimum 2-year follow-up. Journal of Shoulder and Elbow Surgery. 2007;**16**(5):579-585

[17] Ozaki J, Fujimoto S, Masuhara K, Tamai S, Yoshimoto S. Reconstruction of chronic massive rotator cuff tears with synthetic materials. Clinical Orthopaedics and Related Research. Jan 1986;**202**:173-183. PMID: 3955946

[18] Burkhead WZ, Schiffern SC, Krishnan SG. Use of Graft-Jacket as an augmentation for massive rotator cuff tears. Seminars in Arthroplasty. 2007;**18**:11-18

[19] Sclamberg SG, Tibone JE, Itamura JM, Kasraeian S. Six-month magnetic resonance imaging follow-up of large and massive rotator cuff repairs reinforced with porcine small intestinal

submucosa. Journal of Shoulder and Elbow Surgery. 2004;**13**:538-541

[20] Iannotti JP, Codsi MJ, Kwon YW, Derwin K, Ciccone J, Brems J. Porcine small intestine submucosa augmentation of surgical repair of chronic two-tendon rotator cuff tears. Journal of Bone & Joint Surgery. 2006;**88-A**(6):1238-1244

[21] Bushnell BD, Connor PM, Harris HW, Ho CP, Trenhaile SW, Abrams JS. Two-year outcomes with a bioinductive collagen implant used in augmentation of arthroscopic repair of full-thickness rotator cuff tears: Final results of a prospective multicenter study. Journal of Shoulder and Elbow Surgery. Dec 2022;**31**(12):2532-2541. DOI: 10.1016/j.jse.2022.05.025. Epub 2022 Jul 1. PMID: 35788057

[22] Avanzi P, Giudici LD, Capone A, et al. Prospective randomized controlled trial for patch augmentation in rotator cuff repair: 24-Month outcomes. Journal of Shoulder and Elbow Surgery. 2019;**28**:1918-1927

[23] Cai YZ, Zhang C, Jin RL, et al. Arthroscopic rotator cuff repair with graft augmentation of 3-dimensional biological collagen for moderate to large tears: A randomized controlled study. The American Journal of Sports Medicine. 2018;**46**:1424-1431

[24] Barber FA, Herbert MA, Boothby MH.  Arthroscopy. 2008;**24**(1):20-24

[25] Beniker D, McQuillan D, Livesey S, et al. The use of acellular dermal matrix as a scaffold for periosteum replacement. Orthopedics. 2003;**26**(5 Suppl):s591-s596

[26] Adams JE, Zobitz ME, Reach JS Jr, An KN, Steinmann SP. Rotator cuff repair using an acellular dermal matrix graft: An in vivo study in a canine model. Arthroscopy. 2006;**22**(7):700-709

[27] Barber AF, Burns JP, Deutsch A, Labbé MR, Litchfield RB. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Journal of Arthroscopic & Related Surgery. 2012;**28**(1):8-15. DOI: 10.1016/j. arthro.2011.06.038

[28] Mori D, Kizaki K, Funakoshi N, Yamashita F, Mizuno Y, Shirai T, et al. Irreparable large to massive rotator cuff tears with low-grade fatty degeneration of the infraspinatus tendon: Minimum 7-year follow-up of fascia autograft patch procedure and partial repair. The American Journal of Sports Medicine. 2021;**49**(13):3656-3668. DOI: 10.1177/03635465211043501

[29] Mihata T, Lee TQ, Watanabe C, Fukunishi K, Ohue M, Tsujimura T, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy. 2013;**29**(3):459-470

[30] Hirahara AM, Adams CR. Arthroscopic superior capsular reconstruction for treatment of massive irreparable rotator cuff tears. Arthroscopy Techniques. 2015;**4**(6):e637-e641

[31] Noyes MP, Denard PJ. Arthroscopic superior capsular reconstruction: Indications and outcomes. Operative Techniques in Sports Medicine. 2018;**26**(1):29-34

[32] Hartzler RU, Burkhart SS. Superior capsular reconstruction. Orthopaedics. 2017;**40**(5):271-280

[33] Denard PJ, Brady PC, Adams CR, Tokish JM, Burkhart SS. Preliminary

results of arthroscopic superior capsule reconstruction with dermal allograft. Arthroscopy. 2018;**34**(1):93-99

[34] Pennington WT, Bartz BA, Pauli JM, Walker CE, Schmidt W. Arthroscopic superior capsular reconstruction with acellular dermal allograft for the treatment of massive irreparable rotator cuff tears: Short-term clinical outcomes and the radiographic parameter of superior capsular distance. Arthroscopy. 2018;**34**(6):1764-1773

[35] Dimock RAC, Malik S, Consigliere P, Imam MA, Narvani AA. Superior capsule reconstruction: What do we know? Archives of Bone and Joint Surgery. 2019;**7**(1):3-11 PMID: 30805409; PMCID: PMC6372269

[36] Parikh N, Martinez DJ, Winer I, Costa L, Dua D, Trueman P. Direct and indirect economic burden associated with rotator cuff tears and repairs in the US. Current Medical Research and Opinion. 2021;**37**(7):1199-1211

[37] Cvetanovich GL, Waterman BR, Verma NN, Romeo AA. Management of the irreparable rotator cuff tear. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2019;**27**(24):909-917

[38] Savarese E, Romeo R. New solution for massive, irreparable rotator cuff tears: The subacromial "biodegradable spacer". Arthroscopy Techniques. 2012;**1**(1):e69-e74

[39] Johns WL, Ailaney N, Lacy K, Golladay GJ, Vanderbeck J, Kalore NV. Implantable subacromial balloon spacers in patients with massive irreparable rotator cuff tears: A systematic review of clinical, biomechanical, and financial implications. Arthroscopy, Sports Medicine, and Rehabilitation. 2020;**2**(6):e855-e872

*Treatment of Rotator Cuff Tears: New Modalities and Innovations DOI: http://dx.doi.org/10.5772/intechopen.112729*

[40] Gervasi E, Maman E, Dekel A, Cautero E. Fluoroscopy-guided biodegradable spacer implantation using local anesthesia: Safety and efficacy study in patients with massive rotator cuff tears. Musculoskeletal Surgery. 2016;**100**(Suppl. 1):19-24. DOI: 10.1007/ s12306-016-0433-0

[41] Hazra ROD, Hazra MED, Hanson JA, Millett PJ. The InSpace balloon: Useful augmentation or first-line therapy? Commentary on an article by Nikhil Verma, MD, et al. "InSpace Implant Compared with Partial Repair for the Treatment of Full-Thickness Massive Rotator Cuff Tears. A Multicenter, Single-Blinded, Randomized Controlled Trial". Journal of Bone & Joint Surgery. 2022;**104**(14):e65

[42] Metcalfe A, Parsons H, Parsons N, et al. Subacromial balloon spacer for irreparable rotator cuff tears of the shoulder (START:REACTS): A groupsequential, double-blind, multicentre randomised controlled trial. Lancet. 2022;**399**(10339):1954-1963

[43] Henseler JF, Nagels J, Nelissen RG, de Groot JH. Does the latissimus dorsi tendon transfer for massive rotator cuff tears remain active postoperatively and restore active external rotation? Journal of Shoulder and Elbow Surgery. 2014;**23**:553-560. DOI: 10.1016/j. jse.2013.07.055

[44] L'Episcopo JB. Tendon transplantation in obstetrical paralysis. American Journal of Surgery. 1934;**25**(1):122-125

[45] Gerber C, Vinh TS, Hertel R, et al. Latissimus dorsi transfer for the treatment of massive tears of the rotator cuff. Clinical Orthopaedics and Related Research. 1988;**232**:51-61

[46] Gerber C, Rahm SA, Catanzaro S, et al. Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years. Journal of Bone & Joint Surgery. 2013;**95**(21):1920-1926

[47] Ozturk BY, Ak S, Gultekin O, Baykus A, Kulduk A. Prospective, randomized evaluation of latissimus dorsi transfer and superior capsular reconstruction in massive, irreparable rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2021;**30**(7):1561- 1571. DOI: 10.1016/j.jse.2021.01.036 Epub 2021 Mar 4. PMID: 33675971

[48] Kany J, Guinand R, Croutzet P, et al. Arthroscopic-assisted latissimus dorsi transfer for subscapularis deficiency. European Journal of Orthopaedic Surgery and Traumatology. 2016;**26**(3):329-334

[49] Elhassan BT, Wagner ER, Kany J. Latissimus dorsi transfer for irreparable subscapularis tear. Journal of Shoulder and Elbow Surgery. 2020;**29**(10):2128-2134

[50] Reddy A, Gulotta LV, Chen X, et al. Biomechanics of lower trapezius and latissimus dorsi transfers in rotator cuff– deficient shoulders. Journal of Shoulder and Elbow Surgery. 2019;**28**(7):1257-1264

[51] Aibinder WR, Elhassan BT. Arthroscopic lower trapezial transfer for irreparable rotator cuff tears. Operative Techniques in Orthopaedics. 2018;**28**(4):217-225

[52] Elhassan BT, Alentorn-Geli E, Assenmacher AT, et al. Arthroscopicassisted lower trapezius tendon transfer for massive irreparable posteriorsuperior rotator cuff tears: Surgical technique. Arthroscopy Techniques. 2016;**5**(5):e981-e988

[53] Elhassan BT, Sanchez-Sotelo J, Wagner ER. Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posteriorsuperior rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2020;**29**(10):2135-2142

[54] Stone MA, Kane LT, Ho JC, et al. Short-term outcomes of lower trapezius tendon transfer with Achilles allograft for irreparable posterosuperior rotator cuff tears. Arthroscopy, Sports Medicine, and Rehabilitation. 2021;**3**(1):e23-e29

[55] Baek C, Lee D, Kim J. Lattisimus dorsi transfer vs. lower trapezius transfer for posterosuperior irreparable rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2022;**31**:1810-1822

[56] Burkhart SS, Esch JC, Jolson RS. The rotator crescent and rotator cable: An anatomic description of the shoulder's "suspension bridge". Arthroscopy. 1993;**9**(6):611-616. DOI: 10.1016/ s0749-8063(05)80496-7 Erratum in: Arthroscopy 1994 Apr;10(2):239. PMID: 8305096

[57] Park SR, Sun DH, Kim J, et al. 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**:1969-1977

[58] Shin S, Kim I, Park I, Lee S, Kim M. Anterior cable reconstruction using the biceps tendon in retracted anterior L-shaped rotator cuff tears. Arthroscopy Techniques. 2021;**10**(1):e55-e60

[59] Seo J, Kwak K, Park B, Yoo J. Anterior cable reconstruction using the proximal biceps tendon for reinforcement of arthroscopic rotator cuff repair prevent retear and increase acromiohumeral distance. Journal of Orthopaedics. 2021;**23**:246-249

[60] Kim J, Lee H, Park T, Lee J, Kim Y. Preliminary outcomes of arthroscopic biceps rerouting for the treatment of large to massive rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2021;**30**:1384-1392

[61] Tokish JM, Beicker C. Superior capsule reconstruction technique using an acellular dermal allograft. Arthroscopy Techniques. 2015;**4**:e833-e839

[62] Ravenscroft M, Barnes MW, Muench LN, Mazzocca AD, Berthold DP. Bursal acromial reconstruction (BAR) using an acellular dermal allograft as a surgical solution for the treatment of massive irreparable rotator cuff tears. Arthroscopy Techniques. 2021;**10**(3):e877-e885. DOI: 10.1016/j. eats.2020.11.002. PMID: 33738228; PMCID: PMC7953327

[63] Mulieri P, Dunning P, Klein S, Pupello D, Frankle M. Reverse shoulder arthroplasty for the treatment of irreparable rotator cuff tear without glenohumeral arthritis. Journal of Bone and Joint Surgery. American Volume. 2010;**92**:2544-2556

[64] Petrillo S, Longo UG, Papalia R, Denaro V. Reverse shoulder arthroplasty for massive irreparable rotator cuff tears and cuff tear arthropathy: A systematic review. Musculoskeletal Surgery. 2017;**101**:105-112

[65] Awad MA, Sparavalo S, Ma J, King JP, Wong I. Interposition graft bridging reconstruction of irreparable rotator cuff tears using acellular dermal matrix: Medium-term results. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2022;**38**(3):692-698

[66] Mirzayan R, Bouz G. Biologic tuberoplasty with an acellular dermal allograft for massive rotator cuff

*Treatment of Rotator Cuff Tears: New Modalities and Innovations DOI: http://dx.doi.org/10.5772/intechopen.112729*

tears. Arthroscopy Techniques. 2021;**10**:e1743-e1749. DOI: 10.1016/j. eats.2021.03.016

[67] Griffin JW, Runzo D, Bonner KF. Arthroscopic biologic interpositional tuberosity graft for the treatment of irreparable rotator cuff tears. Arthroscopy Techniques. 2021;**10**:e1729-e1735. DOI: 10.1016/j. eats.2021.03.024

[68] Mirzayan R. Preliminary outcomes of arthroscopic biologic tuberoplasty in the treatment of massive irreparable rotator cuff tears. Cureus. 2023;**15**(1):e34402. DOI: 10.7759/cureus.34402

[69] Ehrenfest, David M. Dohan, et al. Classification of platelet concentrates (Platelet-Rich Plasma-PRP, Platelet-Rich Fibrin-PRF) for topical and infiltrative use in orthopedic and sports medicine: Current consensus, clinical implications and perspectives. Muscles, Ligaments and Tendons Journal 2014;**4**(1):3

[70] Arnoczky SP, Delos D, Rodeo SA. What is platelet-rich plasma? Operative Techniques in Sports Medicine. 2011;**19**(142-148):23

[71] Sanchez M, Azofra J, Aizpurua B, Andıa I, Anitua E. Use of autologous plasma rich in growth factors in arthroscopic surgery. Cuadernos de Artroscopia. 2003;**10**(12-19):24

[72] Anitua E, Sanchez M, Nurden AT, et al. Autologous fibrin matrices: A potential source of biological mediators that modulate tendon cell activities. Journal of Biomedical Materials Research. 2006;**77**:285-293

[73] Hurley ET, Lim Fat D, Moran CJ, Mullett H. The efficacy of plateletrich plasma and platelet-rich fibrin in arthroscopic rotator cuff repair: A meta-analysis of randomized controlled trials. The American Journal of Sports Medicine. 2019;**47**:753-761

[74] Warth RJ, Dornan GJ, James EW, Horan MP, Millett PJ. Clinical and structural outcomes after arthroscopic repair of full-thickness rotator cuff tears with and without platelet-rich product supplementation: A meta-analysis and meta-regression. Arthroscopy. 2015;**31**:306-320

[75] Ryan J, Imbergamo C, Sudah S, Kirchner G, Greenberg P, Monica J, et al. Platelet-rich product supplementation in rotator cuff repair reduces retear rates and improves clinical outcomes: A metaanalysis of randomized controlled trials. Arthroscopy. 2021;**37**(8):2608-2624. DOI: 10.1016/j.arthro.2021.03.010

#### **Chapter 3**

## Arthroscopic Treatment for Massive Cuff Tears

*Petru Razvan Melinte*

#### **Abstract**

In the current literature, several definitions are provided for massive cuff tears. At the same time, a massive cuff tear can be reparable or irreparable. As a consequence, certain criteria need to be defined to address this issue of reparability—quality of tendon, status of muscle atrophy, bone of greater tuberosity, status of glenohumeral joint, and last but not least the clinical criterion, that is the functionality of shoulder. Several arthroscopic treatment options are described — from simple biceps tenotomy, partial reconstruction techniques with or without biologic augmentation, and superior capsule reconstruction to other rather new tools such as balloon spacer implantation.

**Keywords:** massive tear, cuff, arthroscopic, shoulder, treatment

#### **1. Introduction**

What is a massive rotator cuff tear? The definition is somehow inconsistent. Cofield [1] defined a massive cuff tear as a tear with a width larger than 5 cm; Gerber [2] defined an MCT intraoperatively as a tear that after extensive debridement appears to affect two or more tendons; other authors [3] take into consideration an exposure of the humeral head wider than 3 cm, which usually has a surface of more than 9 cm. On the other hand, Hamada and Fukuda looked at X-rays in patients with MCT and described the elevation of the humeral head in the absence of glenohumeral arthritis, and they proposed their well-known classification. However, if we analyze these definitions for MCT, they take into consideration the size but make no indication regarding reparability; therefore, an MCT is not necessarily an irreparable tear. Hamada and Fukuda radiologic classification indicates that when the tear is chronic and its chronicity leads to humeral head elevation, then it is generally accepted that the tear should be considered irreparable. Surgeons should understand this important distinction, as an MCT can be reparable when it is acute or most likely irreparable in a chronic situation.

So, the next thing that needs to done is to define what is irreparable; irreparable can be considered as being both unfixable and unhealable. Unfixable is the inability to physically repair the tendon back to bone after expensive releases. Irreparable may be also unhealable, as described by Gerber [2], as any repair that is achieved but that will most likely be followed by failure, such as the need for reoperation due to retear,

poor postoperative motion or strength, or poor outcome [4]. The Gold standard of irreparability is intraoperative inability to repair after extensive releases.

Nevertheless, most of the times, it is difficult preoperatively to decide if an RC tear is irreparable; surgeons must also take into consideration intraoperative findings. In general, arguments of irreparability include advanced fatty infiltration according to Goutallier classification (Goutallier grade 3 or more), decreased acromiohumeral distance (less than 6 mm), dramatic decrease of tendon length, and poor-quality tendon tissue.

Pascal Boileau [5] looked at the problem from a different perspective and gave us 7 good reasons not to repair an RCT: no tendon, due to resorbtion; no rotator cuff muscle, due to atrophy, fatty infiltration; no good bone – greater tuberosity osteoporosis seen especially in women; no good joint – glenohumeral osteoarthritis; static superior and anterior humeral head subluxation; dynamic humeral head subluxation, due to pseudoparalysis; and previous surgery – destroyed anterior deltoid, low grade infection.

Patients with a massive cuff tear usually complain about shoulder pain and decrease of function, which is often declared as decrease of active anterior elevation and/or active external rotation; the symptoms may be singular or in combination. Generally, three questions need to be asked: is this shoulder functional or not? is the muscle balance preserved; second—is the long head of biceps present, as a painful shoulder can be caused by a long head of biceps subluxation; and third — in which plane is the shoulder unbalanced—vertical plane, horizontal plane, or both. Answering these questions may help us choose the right treatment tailored to the patients' symptoms and the type of shoulder muscle imbalance. The management of irreparable rotator cuff tears can be achieved by both surgical and nonsurgical methods that can address both functional and non-functional shoulders. Certainly, we must consider non-operative treatment for the right patient—usually nonsurgical treatment consists of: medication such as anti-inflammatory drugs, injection of corticosteroids substances inside subacromial space, and physical therapy.

While non-functional shoulder may benefit from tendon transfers and/or reverse shoulder arthroplasty, for functional shoulders, there are several surgical options for repairing massive rotator cuff tears. Despite the rapidly increasing numbers of reverse shoulder arthroplasties, alternative options are available [6–18]; among those, we mention biceps tenotomy or tenodesis, arthroscopic debridement, partial repair, complete repair, augmentation of repair with different types of patches, superior capsular reconstruction, and muscle tendon transfer [19]. Recently, superior capsular deficiency can be treated by the use of various autografts/allograft; respected shoulder surgeons present several surgical techniques such as: rerouting the long head of biceps tendon, use of long head of biceps tendon as an autograft, use of semitendinosus as an allograft, or simpler methods — subacromial spacers [20]. In the literature [19, 21], there is a lack of consensus and lack of guidelines on the appropriate indications for specific surgical treatment options, although, recent work from [20, 22] present an agreement on treatment of massive irreparable rotator cuff tears by the Neer Circle of the American Shoulder and Elbow Surgeons [20, 22].

To improve the success rates of operative results, there are several factors to be considered according to [19, 23] who proposed that some specific aspects should be met in order to achieve the best clinical results: subacromial decompression should be performed thoroughly; integrity of the deltoid muscle fibers origin should be preserved; torn tendons should be adequately mobilized, and interval slide should be

#### *Arthroscopic Treatment for Massive Cuff Tears DOI: http://dx.doi.org/10.5772/intechopen.114107*

done whenever necessary; tendons should be repaired down to bone; postoperative rehabilitation is a must. In addition, Yoon [24] proposed two essential requirements: the repaired rotator cuff should be able to sustain early tension during the initial healing stage, and one must obtain a certain biological environment that favors the healing ability of the repair site—that is, the bone-tendon junction [19]. Thus, surgical treatment performed must ensure decompression and debridement of the subacromial space and considerable strength in the repaired area; in this way, the repaired rotator cuff will be able to stabilize the glenohumeral joint; at the same time, we emphasize once more that providing a good biological environment will sustain a maximum healing capacity, allowing for safe mobilization [19, 23].

#### **2. Debridement and biceps Tenotomy**

Arthroscopic debridement was traditionally applied to massive rotator cuff tears in old patients with comorbidities and low functional expectations [19, 21, 25]. Early results presented clinical benefits such as decreased symptoms and improved range of motion. Berth et al. [19, 26] published several studies proving that debridement alone is associated with temporary benefits; debridement alone did not improve shoulder strength [19, 27]. Consequently, as new arthroscopic repair techniques emerged, debridement has become less popular.

Biceps tendon lesions are an important source of shoulder pain and often accompany massive rotator cuff tears. Greenspoon et al. [19, 21] confirmed that shoulder pain and dysfunction are reduced after biceps tenotomy or tenodesis, inducing good satisfaction in patients [19]; however, the natural history of rotator cuff tears is not influenced by biceps procedures alone [19]. In addition, some studies [19] showed no significant clinical improvements after arthroscopic debridement and biceps tenotomy when compared to arthroscopic debridement alone [19, 21].

Another systematic review study [4] demonstrates that arthroscopic debridement procedures are followed by good midterm to long-term patient outcomes; all 16 included studies presented significant clinical improvement in pain and range of motion. Thus, arthroscopic debridement is presented as a safe and reproducible surgical option with a low risk of complication (4.1%) [4]. The included studies presented in [4] seem to underline that pain relief has a greater importance than improvements of shoulder function in patients older than 65 years that underwent debridement.

Walch et al. [28] reported that patients with MCT treated nonoperatively declared pain relief after spontaneous long head of the biceps ruptures [19, 28]. They compared these findings to the results after arthroscopic biceps tenotomy in the same category of patients; similar improvements in pain and range of motion were observed. But these studies involving biceps showed decreases in the acromiohumeral distance, which seems logical if one takes into consideration the depressor effect of the long head of the biceps onto the humeral head [19, 29, 30]. Interestingly, patients still declared reduced pain and slightly better outcomes despite associated superior humeral head elevation [19, 29, 30]. Walch [28] also mentioned that fatty infiltration had negative prognostic effect on function and X-ray progression of arthritis.

Boileau [31] presented 72 irreparable cuff tears treated with tenotomy and debridement showing 78% satisfied patients; according to his observations, teres minor atrophy worsens prognosis, and he considered pseudoparalysis and severe cuff arthropathy as contraindication.

#### **3. Rotator cuff repair**

When compared to other surgical techniques, arthroscopic repair seems to lead to the best results, at least from a clinical point of view [32, 33]. Nevertheless, even when the tear is repaired anatomically, it may have a low chance of healing. There are some factors that are related to tendon, such as the chronicity of the tear, the quality of the muscle, and the pattern and size of the tear that were proved to be associated to a low healing rate [34–36]. The healing of rotator cuff is additionally negatively influenced by other factors related to the age of patients and their comorbidities like smoking, hyperlipidemia, and diabetes [32, 37]. In conclusion, if we take into account the patient and its tendon-related factors, the ideal tear for repair is in a patient that still has a good joint space, with an X-ray that can be classified as Hamada 1 or 2, while clinical examination reveals preserved range of motion [32, 38, 39]. Massive tears in patients that present with pseudoparalysis that occurred in the last 6 months should be arthroscopically repaired as studies have proved that pseudoparalysis can be reversed [32, 39]. But, neglected pseudoparalysis or pseudoparalysis that appeared as a complication of a repair is less likely to recover into a good functional shoulder [32].

As emphasized above, it is generally agreed among surgeons that a complete repair of a massive cuff tear should tempt to completely restore the anatomic insertion of tendon to footprint, but in some patients, this goal cannot be achieved due to shortening of torn tendons, as muscles contract and retract quickly [40]. In such cases, a partial repair, although incomplete and not anatomic, can be tried [40]. Arthroscopic partial repair is advised in patients that are young and have a preserved structure of muscle with quite a low fatty infiltration that can be quantified using the MRI-based Fuchs classification [41]. In order to improve the functional results, these types of procedures can be performed together with a tendon transfer; depending on the location of the irreparable tear, the tendon used for transfer may be: latissimus dorsi or lower trapezius muscle fibers in case of posterosuperior tears; pectoralis major or sometimes latissimus dorsi in anterosuperior tears [40]. Arthroscopic partial repair and/or tendon transfer for MCT was proved to lead to satisfactory outcomes as claimed by quite a number of clinical studies [26, 40, 42–51].

Recently, a systematic review of the literature [40] was published; it inquired internet databases about studies dealing with arthroscopic repair of MCT; 55 studies have been identified, and 11 clinical studies were considered eligible, comprising 643 patients. Muscle strength was found to be significantly improved in all studies, while the functional range of motion was noted in the majority of cases [40]. Apparently, even a partial repair allows the shoulder to get balance and become less painful and more mobile [40, 52]. All these accomplishments are possible apparently with a low reoperation and complication rate [40]. Revision surgery had rarely to be performed because in case of repair failure, it was rather uncommon for the patient to complain about persistent pain [40]. So, as an intermediate conclusion, arthroscopic partial repair is a safe salvage solution [40]. Postoperative MRI or ultrasound found the retear rate to be about 50% [40]. The actual value of partial repair is challenged by this quite elevated risk of failure; much controversy is raised by the continuous improvement in symptoms and functionality even when the structural integrity of the repaired cuff is altered [40]. Lubiatowski [53] claims that clinical outcomes are not influenced by the preserved integrity of the repaired cuff [40, 53]. This finding might be explained by the increase of muscle strength after lavage, debridement, and synovectomy; consequently, there is less pain induced by muscle activity, so the status

#### *Arthroscopic Treatment for Massive Cuff Tears DOI: http://dx.doi.org/10.5772/intechopen.114107*

of repair would not matter anymore [26, 40, 54]. If the surgeon adds a decompression of suprascapular nerve, then the clinical outcome will significantly improve and will not be affected by the structural integrity of the repaired cuff [40, 55].

Nevertheless, there are some drawbacks to the previously mentioned studies [26, 40, 42–51] as the number of patients surveyed was quite small, the follow-up was widely variable, and long-term follow-up was not reported in any of the studies cited [40, 42–51]. With that being said, the value of arthroscopic partial repair technique needs to be proved by new studies dealing with the long-term patient outcomes [40]. Other negative aspects are that some papers dealt with heterogeneous populations characterized by different muscle structural anomalies such as fatty infiltration and by different sizes and numbers of tendon lesions [40, 42–51]. Finally, when we review the literature, even the type of the surgical procedure was not exactly the same as surgeons performed arthroscopic partial repair differently; some used a medialization of footprint in order to reduce tension of the repaired cuff [40, 56]; others were more conservative and applied margin convergence technique described by Burkhart [40, 57].

As an intermediate conclusion, we may say that arthroscopic partial repair might be an effective solution for contracted massive cuff tear, where an anatomic and complete repair cannot be achieved. The benefits are that it may improve strength and may improve the outcome of operation while restoring the muscle force couples, but it dramatically increases recovery if you treat it like a standard cuff repair; in old age populations where there is a low chance of healing, the question that is raised is: are you creating more morbidity? And last but not least, as mentioned before [40, 42–51], the quality of the available literature is low or at most moderate.

#### **4. Mechanical and biological augmentation of rotator cuff repair**

In order to promote and improve healing after partial/complete repair of massive cuff tears, various patch augmentation devices have been developed; according to the structure and origin of the graft, they may be synthetic extracellular matrix scaffolds, xenograft, and allograft [19, 58]. There are no clear recommendations for implanting scaffolds in rotator cuff surgery, but augmentation through the use of extracellular matrix patches is being investigated [19].

Scaffold augmentation is promoted because it can support mechanically the repair especially during the sensitive early phase of healing; other researchers state that they can also supply a network to accommodate the migrated cells that are mandatory for the healing process at the tendon-to-bone interface [19]. To this extent, synthetic scaffolds ensure structural and mechanical support and maintain the stability of the repair, gaining time until the tissue heals; they do not influence directly the biological environment at the repair [19, 59–62].

The use of scaffolds derived from human dermis led to the improvement of shoulder scores and a better structural integrity of the repair, when implanted as an augment (85% in augmentation group vs. 40% in control group) [19, 61–65]; histologic samples from the repair site with augmentation showed no inflammation, infection, or calcifications at 3 months after surgery. But these scaffolds used for augmentation have a lower elasticity when compared to tendons, and therefore, theoretically, the repaired construct may have a higher tear rate [19, 60–62].

Extracellular matrix xenografts still pose the problem of immunogenicity despite adequate cell removal during the rigorous graft preparation process [60]; there are

recommendations against these augmentation scaffolds, because in a high percentage of patients, important inflammatory responses have been signaled [19, 66, 67]. Other studies, like those conducted by Throckmorton and Gerlinger [19, 58], present favorable outcomes with dermal-origin scaffolds. Throckmorton and Gerlinger [19, 58] studies have also presented statistical information showing a decrease of clinical symptoms and an increase in function, strength, and shoulder scores.

Another graft option could be synthetic polymer implants that have no immunologic risk [19]. Synthetic extracellular matrix scaffolds proved to significantly increase the functionality of the repaired RCT [19, 58, 68]. A comparative study investigating patients with cuff surgery augmented by xenograft or synthetic graft noted retearing rates at 1-year follow-up of 51% and 17%, respectively, when related to 41% in patients with no augmentation [19, 60, 69].

Advanced research on the biology of healing of the rotator cuff tears, deep to the cellular level, even in augmented repaired cuff tears opened the path to new direct therapies [19]. Cellular growth factors applied at the repair site in animal studies induced neovascularization and cell proliferation [19]. However, the mechanical quality of the repair and tendon resistance to load did not improve according to these studies [19]. In another article, Cheung et al. [70, 71] stated that growth factors may enhance tendon-to-bone healing, *in vivo*.

The application of orthobiologics during arthroscopic rotator cuff repair has gained increasing clinical interest in the past decade, despite clear evidence studies; they are supposed to enhance tendon healing and improve clinical outcomes [72].

Platelet-rich plasma (PRP) is an autologous blood-derived fluid that contains growth factors; some of them are considered to be crucial in bone-to-tendon healing [19, 71]. The growth factors in PRP include an insulin-like growth factor-1, plateletderived growth factor, vascular endothelial growth factor, and transforming growth factor-b [19, 73]. Theoretically, PRP at the repair site should promote healing, but there is controversy over its role because of contradictory results reported in the literature [60]. Many shoulder surgeons advocate that there is not enough evidence for the benefit of PRP biologic augmentation in any rotator cuff repair [19, 74–77].

Ryan et al. [78] conducted a comprehensive systematic review and meta-analysis to determine the influence of different types of platelet-rich plasma as an augmentation procedure to rotator cuff repair; 17 studies were investigated, and the influence of leukocyte and platelet-rich plasma, leukocyte and platelet-rich fibrin, pure platelet-rich plasma (P-PRP), and pure platelet-rich fibrin was observed; the conclusion was that all types of PRP significantly reduce retear rate, especially when P-PRP is used [78].

In another study, Feltri et al. [79] looked at 36 randomized controlled trials and concluded that the augmentation with PRP reduces the retear rate but has no benefits on clinical outcomes; the same study [79] pointed out that PRP in patients treated conservatively failed to present any clear advantage.

Besides PRP, bone marrow aspirate concentrate (BMAC) has rapidly spread as an alternative biological therapy to augment tendon-to-bone healing.

Schoch et al. [72] investigated the effect of bone marrow aspirate concentrate (BMAC) and platelet-rich plasma augmentation on the rate of revision rotator cuff repair; the study included a total of 760 patients who underwent biological augmentation during rotator cuff repair — 646 patients with PRP and 114 patients with BMAC. They concluded that the application of BMAC led to a significant decrease in the rate of revision surgery, but there was no apparent effect of PRP.

#### *Arthroscopic Treatment for Massive Cuff Tears DOI: http://dx.doi.org/10.5772/intechopen.114107*

But, Cole et al. [80] in a prospective randomized trial found out that BMACaugmented arthroscopic repair of isolated supraspinatus tendon tears largely fails to improve failure rates and clinical outcomes when compared with simple arthroscopic repair.

Muench et al. [81] developed and published an arthroscopic technique biologically augmented with PRP, autologous subacromial bursa tissue, platelet-poor plasma (PPP), concentrated bone marrow aspirate, and bovine thrombin as stabilizer; a recent case series of patients treated with a very similar technique showed improvement in functional outcomes and quite a substantial clinical benefit [82].

Stem cells have multiple differentiation potentials, which stimulate tendon remodeling and increase biomechanical strength [83]. Additionally, stem cell-derived extracellular vesicles (EVs) can increase collagen synthesis while inhibiting inflammation and adhesion formation by carrying regulatory proteins and microRNAs [83]. Taking all that into account and reading all the literature available, stem cell-based therapy in rotator cuff repair seems to be the future, although basic clinical research is definitely required [83].

#### **5. Superior capsular reconstruction**

The superior capsule of glenohumeral joint spans from the superior labrum to the greater tuberosity of humerus; it covers the footprint of the supraspinatus tendon, and from a biomechanical point of view, it acts like a static stabilizer for the glenohumeral joint [19, 20, 84–87].

Biomechanically, superior capsule reconstruction (SCR) can restore and thus regain balance of the force couples necessary for shoulder function [19, 20, 84]. Superior capsule is a static stabilizer that reduces the glenohumeral, allowing muscles like the deltoid and pectoralis major to function in proper conditions [19, 20, 84, 85, 87]. Superior capsular reconstruction is indicated in patients with irreparable tear of posterior superior cuff but with minimal or no glenohumeral arthritis (Hamada stage 1 and 2) and functional deltoid and trapezius; force couples should be balanced in the transverse plane, that is, intact teres minor and intact or reparable subscapularis, in other words—Type C and D according to Collin classification [34].

Mihata [85] observed the superior translation of humeral head, secondary increased acromiohumeral pressure, and associated low joint compression force while studying the biomechanical properties of glenohumeral joints with irreparable supraspinatus tears [85, 88, 89]. As an operative solution, he described the reconstruction of superior capsule (SCR) using a fascia lata as an autograft [85, 88, 89]. He fixed the fascia lata autograft to the scapular neck and the opposite side to the greater tuberosity; the interposed autograft would prevent the superior migration of the humeral head [19, 85, 88–91].

Mihata [85] published excellent clinical results even in mid-term follow-up studies. The American Shoulder and Elbow Surgeons score increased from 29 preoperatively to 83 and 92 postoperatively after one year and five years, respectively; forward elevation increased from 85° preoperatively to 138° and 151° postoperatively after one year and five years, respectively; acromiohumeral distance also improved (preoperative—3.4 mm; one year postoperatively—9.1 mm; five years after surgery—8.1 mm) [19, 20, 91].

Harvesting fascia lata was linked to donor site morbidity and longer surgery times, so as a consequence, allogenic dermal allografts have been introduced. These allografts have been proven to act biomechanically like fascia lata to restore the humeral head position after a massive rotator cuff tear [19, 20, 92]. Burkhart et al. [19, 20, 93] used allograft reconstruction of superior capsule, and the published results are promising; in their series; they reported improvements of clinical outcome, quantified by American Shoulder and Elbow Surgeons and visual analog scale scores that increased from 45.6 to 85.8 and 5.26 to 0.96, respectively, at one year postoperatively [19, 20, 93].

Despite the relatively high costs of SCR with allograft (cost of dermal allograft and a large number of anchors used for appropriate fixation), SCR does not restore the active function of the supraspinatus muscle; therefore, some would consider these observations as drawbacks of the procedure. However, the technique still represents a viable treatment option in young and active patients who would not favor shoulder replacement [19, 20].

#### **6. Other arthroscopic techniques for superior stabilization of humeral head**

Recently, the long head of biceps tendon has been utilized in numerous surgical techniques to reconstruct the superior capsule [12, 13, 16, 22, 86, 94, 95]. These techniques are classified into techniques that reroute the tendon and techniques that use the tendon as a graft [19, 20]. All of these procedures require an intact long head of biceps tendon and seize the opportunity to harvest a locally available and viable autograft. In shoulders with intact long head of biceps tendon and intact glenohumeral cartilage, the use of biceps tendon for superior stabilization of the humeral head led to good clinical outcomes [19, 20].

Kim [17] published a technique that uses the long head of biceps tendon to perform *in situ* reconstruction of the superior capsule. In this technique, intraarticular biceps tenotomy is performed keeping the labral attachment intact; then, the freed end of tendon is fixed at the level of greater tuberosity; thus, biceps tendon pushes down the humeral head, reducing superior humeral head migration [19, 20].

Han [14] used seven fresh frozen shoulders to analyze from a biomechanical point of view this rerouting procedure; the results were promising, showing a stable shoulder as this rerouting technique successfully centers the humeral head into the glenoid cavity, thus reducing subacromial contact pressure and allowing for a functional range of motion [14, 19, 20]. To further support this technique, Sang-Yup Han [87] conducted biomechanical experimental studies on eight cadaveric shoulders and investigated the effects of biceps tendon rerouting with and without associated rotator cuff repair; the results reported a lower translation of humeral head, a more centered head with secondary reduced subacromial pressure, and no negative influence on the rotational range of motion [19, 20, 94]. When used in combination to arthroscopic cuff repair, this rerouting technique resulted in low retear rates and good clinical outcomes [15, 20, 96, 97]. However, data for an isolated biceps rerouting for massive irreparable rotator cuff tears are not available yet [15, 20, 96, 97].

Tang and Zhao [16, 19, 20] introduced a similar technique called arthroscopic *dynamic* rerouting; they created a new bicipital groove lateral to the native bicipital grove; the tendon is not attached at the level of greater tuberosity. Until now, clinical or biomechanical data have not been published [19, 20].

In a systematic review comparing superior capsular reconstruction techniques using long head of biceps tendon, Kitridis [93] arrived to the conclusion that these new biceps rerouting techniques were easy, time-efficient, and cost-effective [19, 20].

#### *Arthroscopic Treatment for Massive Cuff Tears DOI: http://dx.doi.org/10.5772/intechopen.114107*

Denard [13] introduced another surgical technique that uses the biceps tendon in a box configuration; he supported his proposal with a biomechanical study on eight cadaveric shoulders. Apparently, in patients with massive rotator cuff tears, the technique did not restore the translation to previous range, although it decreased superior migration of the humeral head [13, 19, 20]. Clinical results for this technique have not been published yet [20]. Kim [17] proposed a variant of this technique that takes long head of biceps tendon with both its intraarticular and extraarticular parts and reconstructs the superior capsule; he referred to it as the Snake/Triple Bundle technique [17, 20]; the biceps tendon was sutured with tape, and an open subpectoral tenodesis was performed as an additional procedure. No clinical data have been reported yet [20].

Milano [98] used a semitendinosus tendon autograft and presented a surgical technique for superior capsular reconstruction. The semitendinosus tendon is harvested and debrided; then, it is armed with non-absorbable sutures; the graft is attached with anchors at the superior part of glenoid neck; the surgeon can create a box shape, V-shape, or reverse V-shape, depending on the graft length, and then attach it to the previously decorticated greater tuberosity [19, 20, 98, 99].

Bader and Garcia in 2020 [100] proposed the pivot superior capsular reconstruction fixation technique; it also uses a semitendinosus autograft that is shuttled through a hole in the scapular neck and then fixed in the greater tuberosity, preferably with an interference screw [19, 20, 100]. In 2021, Berthold [101] published a biomechanical cadaver study, investigating the best biceps and other graft rerouting surgical techniques; the results suggested that the V- shape and box-shape configurations significantly decreased superior humeral head migration and decreased deltoid cumulative forces [20, 101].

#### **7. Biodegradable balloon**

The subacromial spacer was approved by the US-FDA (Food and Drug Administration), for the treatment of MIRCTs, in 2021.

In 2012, in their studies, Romeo and Savarese [102] proposed the use of InSpace balloon, due to its simple and easy applicability technique [20, 102]. Consisting of poly-l-lactide-co-є-caprolactone, the pre-shaped InSpace spacer has an adsorption time of 1 year (12 months) [20, 102–105]. As a surgical technique, the first step is the usual method of debridement and bursectomy, followed by positioning the biodegradable-type spacer through the lateral portal. Afterwards, a 0.9% saline solution is inserted, with the help of a Luer-Lock syringe, using the application system [20, 102]. The balloon size is proportional to the inserted volume of saline solution. Balloon sizing depends either on the tear and shoulder morphology or on the arthroscopic probe measurements, so their size varies, from small—40 × 50 mm, to medium—50 × 60 mm and large—60 × 70 mm [20, 102].

The long-term as well as mid-term outcomes and efficiency have been debated, due to the fact that the balloon is biodegradable within 1 year (12 months) [20, 98]. In a prospective study conducted by Familiari [103], 51 patients (mean age 63 – range 50–78 years old) were observed during a mean period of 36 months (24–56 months) [20, 103]. The results of Familiari's prospective research showed improvement of Constant Score (CS) from 27 ± 7.4 up to 77 ± 15 (P ≤ 0.01). Furthermore, good to excellent scores were described in 46 patients, while five patients experienced unsatisfactory outcomes [20, 103]. Currently, in the existing literature, for the treatment options in massive irreparable rotator cuff tears, there are no comparative studies between other methods and InSpace Balloon technique [20].

#### **8. Bursal acromial resurfacing**

Based on the concept of subacromial spacer, in his study, Ravenscroft [106] proposed a special surgical technique, known as bursal acromial resurfacing (BAR). This procedure consists of an allograft—dermal-type, acellular—regarded as an option for irreparable rotator cuff tears [20].

Elderly patients (70 years old or over) presenting minimal or even no osteoarthritic evidences should benefit from this type of surgery. With the purpose of, on one hand, reducing the pain and, on the other hand, decreasing down to the minimum humeral head-acromion contact, as authors stated [20, 106], this surgical procedure should mix both grafts' longevity, together with balloon simplicity. So far, no further evidence, such as clinical results, have been presented [20, 106].

#### **9. Arthroscopic biologic inter-positional tuberosity graft**

The greater tuberosity is a rare place for the dermal allografts to fail [107, 108]; instead, they usually fail within the graft's mid-substance or at the glenoid level [20, 107, 108]. The clinical and imagistic study described by Mirazayan [109] showed that even failed dermal-type allograft superior capsular reconstruction relieves pain and improves functional outcomes [20, 109]; this observation could be explained by the so called "Biologic Tuberoplasty Effect" [20, 110].

As it is placed between the greater tuberosity and acromion, the graft is regarded as an interposition, biologic spacer, having a role in restricting the painful contact between these structures. Clinical outcomes for this type of procedures still require more studies and are not conclusive yet.

#### **Author details**

Petru Razvan Melinte University of Medicine and Pharmacy from Craiova, Romania

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© 2024 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

[1] Cofield RH. Rotator cuff disease of the shoulder. The Journal of Bone and Joint Surgery. American Volume. 1985;**67**:974-979

[2] Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. The Journal of Bone and Joint Surgery. American Volume. 2000;**82**:505-515

[3] Nobuhara K, Hata Y, Komai M. Surgical procedure and results of repair of massive tears of the rotator cuff. Clinical Orthopaedics and Related Research. Jul 1994;(304):54-59. PMID: 8020234

[4] Soderlund M, Boren M, O'Reilly A, San JA, Mahlys JM. Arthroscopic debridment for management of massive, irreparable rotator cuff tears: A systematic review of outcomes. JSES Reviews, Reports and Techniques. 2022;**2**:1-7

[5] Boileau P, Andreani O, Schramm M, Baba M, Barret H, Chelli M. The effect of tendon delamination on rotator cuff healing. The American Journal of Sports Medicine. 2019;**47**(5):1074-1081. DOI: 10.1177/0363546519835491

[6] Marigi EM, Johnson QJ, Dholakia R, Borah BJ, Sanchez-Sotelo J, Sperling JW. Cost comparison and complication profiles of superior capsular reconstruction, lower trapezius transfer, and reverse shoulder arthroplasty for irreparable rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2022;**31**:847-854. DOI: 10.1016/j. jse.2021.08.027

[7] Gerber C. Latissimus dorsi transfer for the treatment of irreparable tears of the rotator cuff. Clinical Orthopaedics

and Related Research. 1992;**275**:152-160. Available from: https://pubmed.ncbi. nlm.nih.gov/1735206/

[8] Waltenspül M, Jochum B, Filli L, Ernstbrunner L, Wieser K, Meyer D, et al. Mid-term results of arthroscopically assisted latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2021;**30**:e676-e688. DOI: 10.1016/j.jse.2021.03.149

[9] Elhassan BT, Sanchez-Sotelo J, Wagner ER. Outcome of arthroscopically assisted lower trapezius transfer to reconstruct massive irreparable posterior-superior rotator cuff tears. Journal of Shoulder and Elbow Surgery. 2020;**29**:2135-2142. DOI: 10.1016/j. jse.2020.02.018

[10] Gerber C, Rahm SA, Catanzaro S, Farshad M, Moor BK. Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: Long-term results at a minimum follow-up of ten years. Journal of Bone and Joint SurgeryAmerican Volume. 2013;**95**:1920-1926. DOI: 10.2106/ JBJS.M.00122

[11] Samuelsen BT, Wagner ER, Houdek MT, Elhassan BT, Sánchez-Sotelo J, Cofield R, et al. Primary reverse shoulder arthroplasty in patients aged 65 years or younger. Journal of Shoulder and Elbow Surgery. 2017;**26**:e13-e17. DOI: 10.1016/j.jse.2016.05.026

[12] Tang D, Jang Y, Park J, On M. Arthroscopic superior capsular reconstruction with biceps autograft: Snake technique. Arthroscopy Techniques. 2019;**8**:e1085-e1092

[13] Denard PJ, Chae S, Chalmers C, Choi JH, McGarry MH, Adamson G, et al. Biceps box configuration for superior capsule reconstruction of the glenohumeral joint decreases superior translation but not to native levels in a biomechanical study. Arthroscopy, Sports Medicine, and Rehabilitation. 2021;**3**:e343-e350

[14] Han F, Kong CH, Hasan MY, Ramruttun AK, Kumar VP. Superior capsular reconstruction for irreparable supraspinatus tendon tears using the long head of biceps: A biomechanical study on cadavers. Orthopaedics & Traumatology, Surgery & Research. 2019;**105**:257-263. DOI: 10.1016/j. otsr.2018.10.023

[15] Rhee SM, Youn SM, Park JH, Rhee YG. Biceps rerouting for semirigid large-to-massive rotator cuff tears. Arthroscopy. 2021;**37**:2769-2779. DOI: 10.1016/j.arthro.2021.04.008

[16] Tang J, Zhao J. Dynamic biceps rerouting for irreparable posteriorsuperior rotator cuff tear. Arthroscopy Techniques. 2020;**9**:e1709-e1714.  Arthroscopic in situ superior capsular reconstruction using the long head of the biceps tendon. Arthroscopy Techniques. 2018;**7**:e97 e103. DOI: 10.1016/j.eats.2017.08.058

[18] Colbath G, Murray A, Siatkowski S, Pate T, Krussig M, Pill S, et al. Autograft long head biceps tendon can be used as a scaffold for biologically augmenting rotator cuff repairs. Arthroscopy. 2022;**38**:38-48. DOI: 10.1016/j. arthro.2021.05.064

[19] Joseph Y. Rho, Yong suk Kwon, Sungwook Choi. Current concepts and recent trends in arthroscopic treatment of large to massive rotator cuff tears: A review, Clinics in Shoulder and

Elbow. 2019;**22**(1):50-57. DOI: 10.5397/ cise.2<IP_ADDRESS>