Technical Note

Arthroscopic In Situ Superior Capsular Reconstruction

Using the Long Head of the Biceps Tendon
Yang-Soo Kim, M.D., Ph.D., Hyo-Jin Lee, M.D., Ph.D., In Park, M.D., Ph.D.,
Gwang Young Sung, M.D., Dong-Jin Kim, M.D., and Jong-Ho Kim, M.D.

Abstract: Large to massive rotator cuff tears are challenging to repair, although there are several options for dealing with
them. Among them, superior capsular reconstruction was recently introduced as an effective procedure for retaining the
static stability of the shoulder joint and preventing the progression to cuff tear arthropathy. The purpose of this technique-
based article is to describe a surgical option, called arthroscopic in situ superior capsular reconstruction, for large to massive
rotator cuff tears using the long head of the biceps tendon.

L arge to massive tears of rotator cuff tendons usually

cause atrophy and fatty degeneration of the rotator
cuff muscles and painful loss of shoulder function.
shown to increase glenohumeral translation, particu-
larly with superior translation at 5 and 30 of
abduction.14 Mihata et al.15 enrolled 24 RCTs
Several treatment options for large to massive rotator (11 large, 13 massive) and studied the clinical out-
cuff tears (RCTs) exist; they include arthroscopic partial comes from superior capsular reconstruction (SCR)
repair,1-3 tuberoplasty,4,5 debridement3,6 with possible using the tensor fascia lata. The minimum follow-up
biceps tenotomy, tenodesis or augmentation,7,8 tendon was 2 years postsurgery. Range of motion (ROM)
transfer,9-11 superior capsular reconstruction,12-16 and acromiohumeral distance of the shoulder joint
patch augmentation,17-20 bridging rotator cuff significantly increased, and functional scores also
reconstruction with a graft,21 and reverse total shoul- improved significantly. The results of this study indi-
der arthroplasty.22-24 Despite all of these options, large cated that arthroscopic superior capsular reconstruc-
to massive RCTs are still difficult to manage and treat tion could be an efficient tool to manage large to
effectively. massive rotator cuff tears.
The superior capsule of the shoulder joint plays an Also, because of the proximity of the long head of the
important role as a static stabilizer of the gleno- biceps tendon (LHBT) to the rotator cuff, many trials
humeral joint. In patients with large to massive RCTs, have used the LHBT to support RTC repair.7,8,25 This
the superior shoulder capsule is concomitantly torn. Technical Note describes an arthroscopic in situ SCR
Biomechanically superior capsular defects have been with the LHBT by using a rerouting technique for
large to massive RCTs (Video 1, Table 1).

From the Department of Orthopedic Surgery, Seoul St. Mary’s Hospital,

The Catholic University of Korea (Y-S.K., H-J.L., G.Y.S., D-J.K., J-H.K.), and Surgical Technique
the Department of Orthopaedic Surgery, Ewha Womans University Mokdong
Hospital, Ewha Womans University (I.P.), Seoul, Republic of Korea. Positioning and Examination of Glenohumeral Joint
The authors report that they have no conflicts of interest in the authorship and Subacromial Space
and publication of this article. Full ICMJE author disclosure forms are Our patient was prepared in the usual mannerdin
available for this article online, as supplementary material.
the left lateral decubitus position with general endo-
Received May 12, 2017; accepted August 10, 2017.
Address correspondence to Jong-Ho Kim, M.D., Banpo-Daero 222, Secho- tracheal anesthesia. The operative arm was placed at
gu, Seoul, Korea, 06591, Department of Orthopedic Surgery, Seoul St. 30 abduction and 20 forward flexion.
Mary’s Hospital, The Catholic University of Korea, Seoul, Republic of Korea. Diagnostic arthroscopy was performed with 30
E-mail: [email protected] arthroscope viewing through a standard arthroscopic
Ó 2017 by the Arthroscopy Association of North America. Published by
portal to examine the glenohumeral joint of the right
Elsevier. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/). shoulder. The posterior portal is used as the viewing
2212-6287/17674 portal and anterior portal is used as the working
https://doi.org/10.1016/j.eats.2017.08.058 portal. The joint was routinely examined to detect

Arthroscopy Techniques, Vol 7, No 2 (February), 2018: pp e97-e103 e97

e98 Y-S. KIM ET AL.

Table 1. Order of Steps With Pitfalls and Pearls

Surgical Steps Pitfalls Pearls
Debridement of the soft tissue around the Removal of the transverse humeral ligament Removes synovitis, which can be a pain
LHBT catches the LHBT in the biceps groove source, and makes the LHBT more mobile
and easy to handle
Decortication of bone bed of footprint for With insufficient debridement, remnant bone Has a tuberoplasty effect and can make
rerouting the LHBT can damage rerouted LHBT postoperatively posterior LHBT movement easier,
and make poor biological healing Makes enough of a bone bed for LHBT and RC
to be fixated biologically
Lateral insertion of anchor to fix the LHBT Malpositioning of the anchor, anchor pullout, Posteriorly re-routed LHBT can be an efficient
and greater tuberosity fracturing static stabilizer for the GH joint and sutures
finishing the LHBT fixation can be used
again for RCR
One lasso-loop and two wrap-around ties Insufficent suture technique, resulting in loss Makes one lasso-loop first to grip the LHBT
were made at the lateral anchor of LHBT fixation more powerfully
so that the LHBT has enough fixation power,
resulting in a downward press of the
humeral head
Medial insertion of another anchor and Malpositioning of the anchor, anchor pullout, Additional power for fixation of the LHBT and
fixation of the medial LHBT and humeral head fracture in the GH joint downward pressure on the humeral head
Insertion of an additional anchor just posterior Malpositioning of the anchor, anchor pullout, Enough sutures can be provided for rotator
to the lateral LHBT anchor and greater tuberosity fracture cuff repair
Rotator cuff repair is performed with sutures Too tight repair of the less reducible rotator Can perform a separate repair for the
from 3 anchors cuff can lead to poor outcome, including delaminated tear, and the LHBT can be
retear used for articular side remnant cuff repair;
LHBT can be used for RCR and provides a
space-occupying effect
GH, glenohumeral; LHBT, long head of biceps tendon; RC, rotator cuff; RCR, rotator cuff repair; SCR, superior capsular reconstruction.

any articular lesions on the supraspinatus tendon. posteriorly reposition the LHBT to the GT of the hu-
The integrity of the LHBT was also checked. If the meral head (Fig 2B).
LHBT was completely torn, we could not perform this
technique. The arthroscope was moved into the sub- Fixation of LHBT
acromial space through the posterior portal, After anchor insertion (5.5-mm Healicoil; Smith &
which was similarly used for the examination of the Nephew, Andover, MA; Fig 3A) at the midlateral aspect of
glenohumeral joint and a bursectomy was performed footprint, we preloaded a suture hook (Linvatec, Largo,
by a shaver (Advantage Turbo; ConMed, Largo, FL) FL) with a No. 1 PDS (Ethicon, Somerville, NJ) and
through the anterolateral portal. An acromioplasty introduced the hook through the anterior portal to make a
was performed only for large sharp spurs. We used lasso-loop tie.26 The tip of the hook should pass through
a laser-marked probe to assess the tear extent the body of the LHBT to make a lasso-loop around the
(Fig 1A). LHBT to capture the tendon at the anchor site. The shuttle
of the suture that is used to make the lasso-loop should not
Preparation of LHBT for Rerouting and Bone Bed of pass the tendon completely to make a loop at the body of
the Greater Tuberosity of the Humeral Head the LHBT (Fig 3B). After making of the loop at the body of
To ensure muscle mobility and re-route the LHBT the LHBT, the end of the suture that formed the loop
posterolaterally, we removed the soft tissue around the should pass through the loop to complete the lasso-loop
LHBT, including the transverse humeral ligament, us- (Fig 3C). And with the opposite part of the suture, ties
ing an electrocautery device (Vapr Suction Electrodes; are made 4 to 5 times to fix the LHBT. After making a
DePuy Synthes Mitek, Raynham, MA; Fig 1B). The lasso-loop tie, we made two more wrap-around ties to
decortication of bone bed of the footprint was per- ensure successful fixation of the LHBT (Fig 3D). Similarly,
formed through the anterolateral portal with careful the medial side of the LHBT was fixated by another anchor
use of a bone-cutter blade (4.2-mm Tiger Sterling suture. At the junction of joint cartilage and the footprint,
Arthroscopy blade; ConMed, Largo, FL; Fig 1C), until the medial suture anchor was inserted (Fig 4A). Then, the
the cancellous bone of the general tuberosity (GT) of LHBT is securely fixed again at the medial site of the
the humeral head is exposed enough. This bone bed of footprint in the same manner using one lasso-loop tie, and
the GT of the humeral head is used for the biologic two wrap-around ties were also made (Fig 4B). All the
fixation of LHBT and rotator cuff to the bone. The strands should remain uncut for further suture of the torn
mobility and integrity of the LHBT should be checked rotator cuff tendon. This is the final procedure of arthro-
with a tendon grasper (Fig 2A). We used a retriever to scopic in situ SCR using an LHBT procedure via a
 IN SITU SUPERIOR CAPSULAR RECONSTRUCTION e99

Fig 1. Subacromial space of

right shoulder viewing from
the posterior portal (A). The
extent of the tear was
measured by a laser-marked
probe. (B) To make the
LHBT mobile and reroute
the tendon posterolaterally,
removal of the soft tissue
around the LHBT, including
the transverse humeral lig-
ament, was performed with
an electrocautery device
(Vapr Suction Electrodes;
Depuy Synthes Mitek). (C)
The bone bed of the greater
tuberosity of the humeral
head was prepared through
the anterolateral portal with
careful use of a bone cutter
blade (4.2-mm Tiger Ster-
ling Arthroscopy blade;
ConMed). (LHBT, long head
of biceps tendon; SSP,
supraspinatus tendon.)

re-routing technique. A tenotomy of the LHBT can be Rotator Cuff Repair

performed at the distal aspect of the lateral anchor if After finishing the arthroscopic in situ SCR with the
tendon integrity is not sufficient to maintain itself. LHBT, rotator cuff repair should be performed.

Fig 2. (A) The mobility and

integrity of the LHBT
should be checked by a
tendon grasper. (B) Trial to
reposition the LHBT poste-
riorly to the greater tuber-
osity of the humeral head
was performed by a
retriever. (LHBT, long head
of biceps tendon.)
e100 Y-S. KIM ET AL.

Fig 3. (A) Lateral anchor

insertion (5.5-mm Heali-
coil; Smith & Nephew) at
the midlateral portion of
the footprint for LHBT fix-
ation was performed. (B) A
suture hook (Linvatec)
which was preloaded with
No. 1 PDS (Ethicon) was
introduced through the
anterior portal to make a
lasso-loop tie26 and then
was passed through the
body of the LHBT. (C) One
lasso-loop tie was made at
the lateral anchor. (D) Two
more wrap-around ties
were made to ensure LHBT
fixation after making the
lasso-loop tie. (LHBT, long
head of biceps tendon.)

Rotator cuff repair can be performed using the sutures Postoperative Care
from the two previously inserted anchors used to fix Postoperative pain is usually controlled by an inter-
the LHBT and an additional anchor that can be scalene block or interscalene nerve catheter. Post-
inserted into the posterolateral aspect of the GT of the operative rehabilitation initially focuses on limited and
humeral head just behind the LHBT for posterior RCT protected passive range of motion, with an abduction
(Fig 5). In the case of delaminated rotator cuff tear, brace. Because of the re-routing and anchoring of the
the articular side rotator cuff can be repaired with LHBT, even passive motion of the elbow is prohibited
sutures from the previously medially inserted anchor during the entire brace application period. Passive
for LHBT fixation. For delaminated tears, separate motion starts 4 to 6 weeks postoperatively after
double-row repair or separate bridge repair can be removal of the brace. Pendulum and pulley exercises
performed.27 And for massive rotator cuff tears, start just after brace removal. Active range of motion
which cannot be covered by remnant cuff tissue, typically starts after 8 weeks, and external rotation
partial repair is acceptable through arthroscopic in strengthening exercises start after 12 weeks. The main
situ SCR with the LHBT. rehabilitation goals are to improve active shoulder
Compared with preoperative radiographs (Fig 6A), motion and to facilitate and maintain the biomechanics
our patient’s immediate postoperative radiograph of glenohumeral joints.
(Fig 6B) showed significantly increased acromio-
humeral distance. This suggests that arthroscopic in situ
SCR using the LHBT may improve static stability for the Discussion
glenohumeral joint of the shoulder with large to SCR was recently introduced and has become popular
massive RCTs. in many centers.12,13,15,16 The superior capsule is
 IN SITU SUPERIOR CAPSULAR RECONSTRUCTION e101

Fig 4. (A) At the junction

of joint cartilage and the
footprint, the insertion of
medial side anchor was
performed. (B) One lasso-
loop tie and two wrap-
around ties were then
made for the medial fixa-
tion of the LHBT. (LHBT,
long head of biceps
tendon.)

important for stability of the glenohumeral joint. The We demonstrated an arthroscopic SCR technique
rotator cuff is a dynamic stabilizer; it helps to using the LHBT instead of the autologous tensor fascia
reinforce the capsule and gives strength to overhead lata15 in this report. We prefer the LHBT to the fascia
movements. On the other hand, the superior capsule lata autograft, which Mihata et al.15 originally reported.
is considered to be a key static stabilizer. This concept There are many advantages of using LHBT instead of
explains why the SCR can relieve severe pain and the autologous tensor fascia lata15 or dermal allo-
improve disability from irreparable massive rotator graft.12,13,16 It can be used very easily during
cuff tears. In a cadaver study, Ishihara et al.14 sug- arthroscopic shoulder surgery because of the
gested that a defect in the superior capsule, as seen in proximity of this tendon and because donor-site
massive cuff tears, can increase glenohumeral trans- morbidity can be avoided. Furthermore, our tech-
lations in all directions. This means that alterations in nique of re-routing the LHBT creates a downward force
the static stability of the shoulder joint due to the to the humeral head; thus, postoperative radiographs
absence of a superior capsule can cause progression to show down-migration of the humeral head after our
cuff tear arthropathy. In their original description, procedure (Fig 6). Also, because this procedure is per-
Mihata et al.15 reported good short-term results from formed just in the shoulder joint, the risk of infection
this reconstructive procedure. They found this to be a can be reduced and the operation time is reduced by
safe and reproducible procedure. skipping the harvesting of a graft tendon or trimming

Fig 5. (A) An additional

anchor can be inserted
posterolaterally into the
greater tuberosity of the
humeral head just behind
the LHBT for repair of the
posterior rotator cuff. (B)
The sutures from the two
previously inserted anchors
that serve to fix the LHBT
can be used to repair the
rotator cuff. (LHBT, long
head of biceps tendon.)
e102 Y-S. KIM ET AL.

Fig 6. Compared with pre-

operative radiograph (A),
immediate postoperative
radiograph (B) showed that
humeral head migrated
inferiorly about 7 mm.

the interposition tissues. Most importantly, we expect To summarize, SCR is considered a reasonable treat-
that our technique is quite effective for preventing ment option for younger patients with posterosuperior
progression into cuff tear arthropathy for large to large to massive RCTs who want to avoid tendon
massive RCTs, not only because our technique includes transfer or reverse total shoulder arthroplasty. Finally,
coincident repair of the rotator cuff but also because of our technique, arthroscopic in situ SCR using LHBT,
the downward force induced by the rerouted LHBT and can be an effective procedure for patients to avoid
the space-occupying effect of the SCR. The LHBT is progression to cuff tear arthropathy. Further clinical
fixated with a medial and lateral anchor and has an trials are needed to investigate the long-term benefits of
LHB tenodesis effect as a result. Therefore, this tech- this technique, as well as to determine the best in-
nique yields additional therapeutic effects for patients dications for this procedure.
who have biceps pathologies, such as biceps tendinitis
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