The Hosentraeger Technique: An Arthroscopic Tendon-in-Tendon Interposition Approach Using the Long Head of the Biceps for Irreparable Rotator Cuff Tears

Abstract

Massive and irreparable rotator cuff tears (MIRCTs) represent a challenging clinical problem, particularly in younger patients in whom joint-preserving strategies are preferred. Although a range of surgical techniques exist—including partial repair, superior capsular reconstruction, and tendon transfer—none have shown clear superiority, and failure rates remain high. Autologous grafts such as long head of the biceps tendon (LHBT) grafts have gained attention because of their biological compatibility and accessibility. In this technical note, we present an arthroscopic tendon-in-tendon interposition technique—the “Hosentraeger technique”—that uses the LHBT to reconstruct the rotator cable in MIRCTs. After subpectoral tenodesis and glenoid tenotomy, the LHBT is passed through the remaining resistant portion of the rotator cuff and anchored laterally using knotless fixation. This technique aims to achieve stable biological integration by creating a direct tendon-to-tendon interface while restoring dynamic force transmission across the superior cuff. By avoiding the need for allografts or excessive tension on degenerated tendon remnants, this approach offers a reproducible, biologically favorable, and mechanically robust solution for MIRCTs in selected patients.

Rotator cuff tears represent a substantial burden of musculoskeletal pathology, particularly within the aging population. Epidemiological studies indicate that 54% of asymptomatic individuals over 60 years and 62% of those over 80 years, as well as 20% of the general population at any age, exhibit evidence of rotator cuff tears.1, 2, 3 Massive and irreparable rotator cuff tears (MIRCTs) constitute a particularly complex subset of rotator cuff pathology.

Definitions of massive rotator cuff tears vary, with criteria including a coronal tear diameter of 5 cm or more (Cofield⁴), 2 or more tendon tears (Gerber et al.⁵), contracted tears of at least 2 × 2 cm in the coronal and sagittal planes (Davidson and Burkhart⁶), stage III retraction to the glenoid (Patte⁷), and geometric involvement (Collin et al.⁸). Schumaier et al.⁹ defined MIRCTs as tears with retraction to the glenoid rim or at least 67% exposure of the greater tuberosity.

Intraoperatively, many massive rotator cuff tears are classified as irreparable based on predictive factors such as a positive magnetic resonance imaging tangent sign, Goutallier grade 3 or 4 fatty infiltration, an acromiohumeral distance less than 6 mm, and chronic pseudoparalysis.10, 11, 12 Management of MIRCTs without significant glenohumeral arthritis remains challenging, with options including partial repair, superior capsular reconstruction (SCR), tendon transfer, patch use, and artificial spacer placement.13, 14, 15

Current treatment strategies can be categorized into passive stabilizing techniques (SCR, subacromial spacer placement) and active stabilizing techniques (interposition grafting, tendon transfer). For graft interposition, options include acellular allografts, fascia lata or hamstring autografts, and long head of the biceps tendon (LHBT) autografts. Fascia lata and hamstring autografts present risks of donor site morbidity, whereas allografts are not readily available in all settings and are cost-intensive.16, 17, 18, 19, 20 Previous techniques using the LHBT as a graft include an open approach with tenotomy at the glenoid origin and fixation at the greater tuberosity with a screw, described by Selim and Badawy,²¹ as well as an arthroscopic approach preserving the proximal LHBT attachment, described by Golovachev et al.²²

We present an arthroscopic interposition technique for irreparable rotator cuff tears using the LHBT in a tendon-in-tendon approach, aiming to overcome limitations of previous methods by achieving more complete integration within the rotator cuff. Given the longitudinal orientation and dual-limb configuration of the graft construct, which functionally and visually resembles a suspensory system, the technique is informally referred to as the “Hosentraeger technique.”

Surgical Technique

Patient Assessment

A thorough patient history, functional assessment, clinical examination, and radiologic evaluation are essential (Fig 1). Magnetic resonance imaging is used to assess muscular atrophy, tendon retraction, and fatty infiltration. Inclusion criteria include Patte stage II to III retraction and an irreparable rotator cuff tear with failed conservative treatment. Exclusion criteria include glenohumeral osteoarthritis, rheumatoid arthritis, end-stage fatty infiltration per the Goutallier classification,¹² feasible primary cuff repair, and a highly degenerated biceps tendon. Inclusion and exclusion criteria are summarized in Table 1.

Fig 1.

Preoperative magnetic resonance imaging (MRI) of the right shoulder of a 65-year-old male patient. (A) In the coronal view, a large posterosuperior rotator cuff tear is observed, with stage III retraction of the supraspinatus tendon (white arrow) according to the Patte classification. (B) In the axial view, tendinopathy of the long head of the biceps is noticeable (black arrow); however, the tendon remains intact. (C) The parasagittal view reveals muscle atrophy and grade 2 fatty infiltration according to Goutallier et al.¹² The asterisk indicates the supraspinatus muscle.

Table 1.

Inclusion and Exclusion Criteria

Inclusion criteria

Retraction (Patte stage II-III)

Irreparable rotator cuff tear

Failed conservative treatment

Exclusion criteria

Glenohumeral osteoarthritis

Rheumatoid arthritis

Fatty infiltration (Goutallier grade 3 or higher)

Primary cuff repair feasible at surgery

Highly degenerated biceps tendon

Patient Positioning and Preparation

Patients are placed in the beach-chair position with the affected arm secured in a hydraulically adjustable arm holder. An interscalene block combined with general anesthesia is administered. The procedure begins with mini-open subpectoral in situ tenodesis.

Subpectoral Tenodesis

A 2- to 3-cm vertical incision is made at the inferior border of the pectoralis major muscle. After exposure, the LHBT is identified and armed with nonabsorbable sutures in a Krackow stitch technique. A BicepsButton (Arthrex, Naples, FL) is used for fixation in a unicortical drill hole, and the tendon is transected above the tenodesis site (Fig 2).

Fig 2.

Biceps tenodesis and graft preparation. After the long head of the biceps tendon is exposed (A) and secured with nonabsorbable sutures using Krackow stitches (B), the tendon is fixed in a unicortical manner using a BicepsButton (C). (D) Subsequently, the tendon is cut just above the tenodesis site. (E, F) After arthroscopic tenotomy, the approximately 70-mm biceps autograft is sutured at both ends with FiberWire by the Krackow stitch technique for further use. The asterisks indicate the long head of the biceps tendon. (C, caudal; Cr, cranial.)

Diagnostic Arthroscopy and Tear Assessment

A 30° arthroscope is introduced through the standard dorsal portal for diagnostic arthroscopy. Additional portals are established as needed (Fig 3). After debridement of the rotator cuff margins, tendon mobility is evaluated. If appropriate, other repairable rotator cuff tears are addressed, and acromial spurs or lateral clavicle can be resected.

Fig 3.

With the patient placed in the beach-chair position, anatomic landmarks and portal sites are marked on the right shoulder, viewed from the lateral aspect. (A, acromion; C, clavicle; 1, anterior portal; 2, lateral portal; 3, posterolateral portal; 4, posterior portal; 5, Neviaser portal.)

Rotator Cuff Preparation and Mobilization

The degree of retraction and the size of the cuff remnant are assessed. A supporting suture may be passed through the retracted tendon to evaluate mobilization potential. Extensive release of the cuff is performed both subacromially and between the cuff and superior labrum (Fig 4).

Fig 4.

Arthroscopic visualization of a right shoulder with the patient in the beach-chair position. (A) The interval region is visualized using a scope in the posterior portal, showing an intact long head of the biceps tendon (LHB) on the superior rim of the glenoid (G). (B) After debridement and partial resection of the bursa, a complete supraspinatus (SSP) lesion extending to the glenoid rim is observed. After transection of the LHB at the level of the labrum (C), the supraspinatus tendon is released as much as possible, and a suture is placed through the tendon to facilitate its mobilization toward the footprint (D).

Graft Preparation

Tenotomy of the LHBT is performed at the superior glenoid rim, and the tendon is released. After retrieval, the biceps tendon is reinforced at both ends with nonabsorbable sutures using the Krackow stitch technique (Fig 2).

Final Cuff Repair and Interposition Grafting

Through a Neviaser portal, sutures from one end of the armed LHBT are shuttled from the articular to the bursal side through the remaining resistant portion of the tendon—primarily the thick preserved cable structure in posterosuperior tears—using a sharp suture passer. If the tendon is too thick to pass, the opening can be gradually enlarged using an arthroscopic BirdBeak (Arthrex) followed by gentle dilation with a blunt trocar (approximately 5 mm), introduced through the Neviaser portal. Once shuttled through the supraspinatus cable, both limbs of the biceps tendon are mobilized to the footprint (Fig 5).

Fig 5.

Arthroscopic visualization in a right shoulder with the patient in the beach-chair position. After penetration of the rotator cuff cable from the Neviaser portal (A), a grasper is used to shuttle the reinforced long head of the biceps graft (LHBG) through the lateral portal and then through the retracted tendon (B-E). After fixation of the 2 limbs of the graft at the footprint (FP) with 2 ReelX knotless anchors (Stryker, Kalamazoo, MI) (F-H), the cable is restored and repositioned (I). (J) From the intra-articular view, the defect is closed. (G, glenoid; HH, humeral head; SSP, supraspinatus tendon.)

For longer grafts or when the infraspinatus is also involved, additional posterior passage can be performed, creating a U-shaped configuration (Fig 6). The footprint is debrided, and one graft limb is fixed using a knotless anchor. The other limb is fixed laterally or in the upper bicipital groove with an additional anchor.

Fig 6.

Positioning of the long head of the biceps tendon graft. For isolated retracted supraspinatus ruptures, a C-configuration may be suitable (type I). If the harvested graft is long enough, a U-configuration can be formed through the rotator cuff cable (type II). For more extensively retracted ruptures, if 2 C-configurations are planned, allografts can be used to shape 2 separate C-configurations (type III). If an additional tendon is ruptured and retracted, a U-configuration with a long head of the biceps autograft can be formed through both the supraspinatus (SSP) and infraspinatus (ISP) tendons (type IV).

Adjacent parts of the torn rotator cuff should be reconstructed using additional anchors. After documentation, the arthroscopic portals are closed in layers (Video 1).

Rehabilitation

Postoperatively, the shoulder is immobilized in an orthosis in 30° of abduction and 15° of external rotation (for posterosuperior cuff tears) or 30° of abduction and 20° of internal rotation (for anterosuperior cuff tears) for 6 weeks, while passive range-of-motion exercises are performed under physiotherapist supervision. Active rehabilitation begins after this initial phase, with follow-up evaluations at 6 weeks and 3, 6, 12, and 24 months after surgery.

Discussion

The tendon-in-tendon technique, or Hosentraeger technique, offers advantages over alternative approaches for MIRCT repair. SCR, although biomechanically beneficial,²³ remains susceptible to graft elongation and failure, particularly with acellular dermal allografts,²⁴ and represents a passive construct against superior humeral head migration. The advantages and disadvantages of our approach are summarized in Table 2, and pearls and pitfalls are presented in Table 3.

Table 2.

Advantages and Disadvantages of Technique

Advantages

Possibility of anatomic reconstruction of rotator cable

Biceps tendon is rich in collagen

Easy to harvest

Use of autograft

Low risk of graft reactions

Fixation of cuff to reconstructed rotator cable and not to footprint

May prevent cuff arthropathy

Arthroscopic technique

No donor site morbidity

Disadvantages

Possible degenerative biceps tendon

High tension on cuff and tendon graft

Not feasible in cases of end-stage fatty infiltration

Not feasible in cases of extensive retraction of rotator cuff tendons

Fragile thin remnant tendon in cases of rerupture

Table 3.

Pearls and Pitfalls

The biceps tendon should be harvested as distally as possible.

Extensive release of the rotator cuff should be performed.

The surgeon should determine the fixation point on the greater tubercle of the LHBT graft with adequate tension of the rotator cuff before fixating the graft.

Spindle-shaped reinforcement of one graft end can facilitate smoother passage through the cuff remnant.

Gradual enlargement of the tendon channel within the cuff remnant may be required to facilitate smooth graft passage.

Failure to enlarge the passage may result in graft damage or poor positioning.

Incorrect tensioning may lead to over-tensioning or slack in the construct.

LHBT, long head of biceps tendon.

A systematic review of 291 SCR cases reported an 11.7% graft failure rate, with acellular dermal allografts showing a higher failure rate (15.2%) than fascia lata autografts (5.0%).^24,25 Interposition techniques aim to provide active stabilization by integrating the graft within the remaining rotator cuff. Human dermal allografts have shown high retear rates (12%-24%), often owing to poor medial attachment.^26,27 Fascia lata autografts show greater mechanical integrity but are associated with donor site morbidity and an increased risk of stiffness.²⁴

Rhee et al.²⁸ reported outcomes after LHBT grafting in 31 patients, with a 21% retear rate but significant improvement in the Constant score (from 48 points preoperatively to 82 points postoperatively). A comparative study between fascia lata autograft interposition and partial rotator cuff repair showed the clinical superiority of the interposition technique, with a lower failure rate (20% vs 42%).²⁹

The Hosentraeger technique offers several important advantages in the treatment of irreparable rotator cuff tears. It enables the restoration of the natural anatomy of the rotator cable by using an autologous graft, thereby preserving the shoulder’s native biomechanics. The technique makes use of the long head of the biceps tendon, which is rich in collagen and has been shown to support biological healing processes.³⁰ Through tension applied during the procedure, the graft is integrated into the rotator cuff in a way that may enhance stable tendon-to-tendon healing. This configuration contributes to joint stability and may prevent superior migration of the humeral head, a common complication in massive cuff tears. In addition, fixation is achieved without the use of supplementary suture material, reducing the risk of mechanical failure or suture pullout over time and potentially improving the durability of the repair. However, the technique faces challenges including potential rerupture, potential persisting muscle weakness—due to fatty infiltration—and tendon retraction, and the need for careful graft tensioning. If the biceps tendon is unavailable because of rupture or severe tendinosis, alternative grafts such as hamstring grafts or allografts may be used.

The tendon-in-tendon technique, or Hosentraeger technique, for reconstructing the rotator cable using a biceps tendon interposition autograft represents a promising option for treating irreparable rotator cuff tears. The method leverages the natural biomechanical properties of the biceps tendon, providing a readily available autograft without additional harvest site morbidity. By securing the graft in a tendon-in-tendon procedure behind the rotator cable without additional suture material, this approach potentially enables improved function and integrity of the rotator cuff while minimizing complications such as suture pullout, inadequate healing, or rerupture.

Declaration of Generative AI and AI-Assisted Technologies in the Writing Process

During the preparation of this work, the authors used ChatGPT in order to shorten the manuscript. After using this tool/service, the author reviewed and edited the content as needed and take full responsibility for the content of the publication.

Disclosures

The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D.E. reports a consulting or advisory relationship with Stryker; receives speaking and lecture fees from Stryker; and receives travel reimbursement from Stryker. P.M. reports a consulting or advisory relationship with Arthrex, Medacta International, and Alyve Medical and owns equity or stocks in Zurimed and Kairos Medical. M.S. reports a consulting or advisory relationship with Stryker. F.F. reports a consulting or advisory relationship with Stryker. All other authors (C.J.L., D.B.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Supplementary Data

Video 1

Hosentraeger technique: arthroscopic tendon-in-tendon interposition technique using the long head of the biceps (LHB) tendon for irreparable rotator cuff tears. Key steps include intra-articular identification and release of the LHB tendon, subacromial mobilization of the ruptured rotator cuff tendon, preparation of the cuff stump, tendon-in-tendon integration, and lateral fixation with 2 anchors. The technique is reproducible and joint preserving, and it provides dynamic stabilization of the humeral head.