Arthroscopic Rotator Cable Reconstruction With Dermal Allograft Tuberoplasty Augmentation for an Irreparable Massive Rotator Cuff Tear

Abstract

Background:

Massive irreparable rotator cuff tears present significant management challenges, particularly with nonarthroplasty options. The combination of rotator cable reconstruction with dermal allograft tuberoplasty represents a technique designed to partially restore biomechanical function while addressing persistent pain through biologic augmentation.

Indications:

This technique is indicated for patients with massive rotator cuff tears involving multiple tendons with significant retraction where complete repair is not possible, particularly when patients experience persistent pain and functional limitations despite conservative management.

Technique Description:

The procedure involves 2 primary components performed arthroscopically. First, rotator cable reconstruction is performed using nonabsorbable ultrahigh molecular weight polyethylene suture placed in a running nonlocking fashion along the free edge of the rotator cuff from anterior to posterior, with locking stitches at endpoints. The cable is secured at the anterior and posterior margins of the greater tuberosity with a knotless 4.75-mm biocomposite suture anchor. Second, tuberoplasty is performed using power instrumentation to create a smooth acromiohumeral articulation, followed by dermal allograft augmentation. The dermal allograft patch is secured medially using the knotless suture in the previously placed medial anchors and laterally with 5.5-mm biocomposite anchors. Key technical considerations include using accessory percutaneous portals, rolling the graft for insertion through a cannula, and selecting appropriate anchors based on bone quality.

Results:

The literature supports favorable outcomes, with cable reconstruction demonstrating reduced retear rates and improved acromiohumeral distance, with tuberoplasty separately demonstrating improved pain relief in the setting of rotator cuff tears. The combined approach seeks to address both biomechanical restoration and pain relief through biologic interpositional grafting.

Conclusion:

Rotator cable reconstruction with dermal allograft tuberoplasty offers a promising nonarthroplasty treatment option for massive irreparable rotator cuff tears. This technique partially restores suspension bridge function while providing biologic augmentation for pain relief and improved acromiohumeral mechanics. The procedure represents an important addition to the surgical armamentarium for managing complex rotator cuff pathology, although further clinical research is needed to establish clinical outcomes and optimal patient selection criteria.

Patient Consent Disclosure Statement:

The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Graphical Abstract.

This is a visual representation of the abstract.

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DOI: 10.1177/26350254261419140.M1

Video Transcript

Hello, my name is Alexander Markes, and along with James P. Bradley, we will discuss our technique on arthroscopic rotator cuff cable reconstruction with dermal allograft tuberoplasty augmentation for an irreparable massive rotator cuff tear.

Background and Indications

Massive irreparable rotator cuff tears present a challenging clinical scenario with significant controversy over optimal nonarthroplasty management. When complete repair is not possible, a partial repair with cable reconstruction can be performed, restoring the transverse force couples of the suspension bridge by repairing the anterior and posterior rotator cable attachments.^1,2,6 Partial repair can still leave a bare greater tuberosity, leading to pain; thus, tuberoplasty with dermal allograft augmentation can be added to create a smooth acromiohumeral articulation with a biologic interpositional graft to aid in humeral head depression and pain relief.^8,9

In this case, we will present a 65-year-old male with worsening right shoulder pain who landed on his arms 3 months prior and has had difficulty lifting his arm above his head and severe pain at night, which has not improved despite a home exercise program and anti-inflammatory medication. On examination, his range of motion is listed here, with strength 3 out of 5 to the supraspinatus and infraspinatus and 4 out of 5 to the subscapularis tendon. He has a positive Neer, Hawkin, and Jobe test. Otherwise, sensation is intact distally.

His magnetic resonance imaging shows a massive rotator cuff tear involving all 3 tendons with retraction to the glenoid rim.

Technique Description

With the patient in the lateral position, we perform diagnostic arthroscopy through the posterior portal, demonstrating the rotator cuff tear. We determined that the patient's subscapularis tendon was retracted and could not be sufficiently mobilized for repair before proceeding with our cable reconstruction technique.

Our technique begins with using SutureTape (Arthrex) to create a running, nonlocking stitch along the rotator cable, starting anteriorly and working posteriorly (Figure 1). After establishing a lateral working portal, we use either a self-grabbing suture passing device or a suture passer, followed by a loop grasper to establish the running stitch. The SutureTape is passed from anterior to posterior along the free edge of the rotator cuff tendon. The first 2 passes and the final 2 passes through the tendon are passed in a locking fashion to ensure adequate fixation at the anterior and posterior cable.

Figure 1.

Rotator cable reconstruction is performed using nonabsorbable ultrahigh-molecular-weight polyethylene suture placed in a running, nonlocking fashion along the free edge of the rotator cuff from anterior to posterior, with locking stitches at the endpoints. (Created in BioRender. Markes, A. 2025. https://BioRender.com/qsonm0u; adapted from: Adams CR, Pasqualini I, Heidenthal JM, Brady PC, Denard PJ. A Technique for a Suture-Based Cable Reconstruction of an Irreparable Posterosuperior Rotator Cuff Tear. Arthroscopy Techniques. 2022;11(11):e2055-e2060).

The anterior and posterior ends of the SutureTape are then anchored into 4.75-mm knotless SwiveLock anchors (Arthrex) at the anterior and posterior margins of the medial edge of the greater tuberosity (Figure 2). The blue repair stitch, as well as the passing suture of the knotless anchor, is seen here coming out of the anchors. The 3 strands of the knotless No. 2 FiberWire Mechanism are kept coming out of the anterior and posterior accessory portals for later use with our allograft augmentation. After anchoring our anterior SutureTape, we demonstrate good excursion of the rotator cable posteriorly, which is then anchored into the posterior Swivelock anchor.

Figure 2.

The cable is secured at the anterior and posterior margins of the greater tuberosity with a knotless 4.75-mm biocomposite suture anchor. The blue repair stitch, as well as the passing suture of the knotless anchor, keeps coming out of the anterior and posterior accessory portals for later use with our allograft augmentation. (Created in BioRender. Markes, A. 2025. https://BioRender.com/qsonm0u; Adapted from: Adams CR, Pasqualini I, Heidenthal JM, Brady PC, Denard PJ. A Technique for a Suture-Based Cable Reconstruction of an Irreparable Posterosuperior Rotator Cuff Tear. Arthroscopy Techniques. 2022;11(11):e2055-e2060).

Here, we see the completed repair of the rotator cuff at its anterior and posterior insertion points, partially restoring the suspension-bridge function of the rotator cable.

Our technique for allograft augmentation tuberoplasty utilizes the knotless mechanism of the medial anchors to advance the graft (ArthroFlex; Arthrex). To do so, the repair sutures from the anterior and posterior anchors are, respectively, passed through the anterior and posterior medial margins of the patch outside the skin. A SutureTape is passed through the anterior and posterior lateral margins of the graft in a simple cinch fashion to be later anchored. The free ends of the shuttling sutures exiting the anterior and posterior percutaneous portals are used to shuttle the repair stitch through the graft back through the knotless anchor, advancing the graft onto the greater tuberosity (Figure 3A). The lateral SutureTapes are then anchored into 5.5-mm Swivelock anchors at the anterior and posterior lateral edge of the greater tuberosity, completing the augmentation (Figure 3B).

Figure 3.

(A) The dermal allograft patch is advanced onto the greater tuberosity and secured medially using the knotless suture anchor. (B) The graft is then secured laterally by anchoring 2 sutures placed in a cinch configuration into biocomposite anchors. (Created in BioRender. Markes, A. 2025. https://BioRender.com/qsonm0u; Adapted from: Adams CR, Pasqualini I, Heidenthal JM, Brady PC, Denard PJ. A Technique for a Suture-Based Cable Reconstruction of an Irreparable Posterosuperior Rotator Cuff Tear. Arthroscopy Techniques. 2022;11(11):e2055-e2060).

Returning to our arthroscopic images, we see the use of a suture from our anterior anchor to estimate the patch dimensions. In this example, the anterior-to-posterior length of the patch was 45 mm, and the medial-to-lateral length was 12 mm. The patch is cut to length on the back table.

We next perform tuberoplasty using a power rasp and bur to create a smooth and congruent acromiohumeral articulation.

After inserting a passport cannula through the lateral working portal and passing our suture through the graft, as previously described outside the skin, the graft is inserted through the cannula and tensioned to the medial row of anchors utilizing the knotless anchor mechanism.

Once appropriate tension is achieved, the sutures are cut, and our attention is turned to the lateral fixation, where the lateral SutureTapes previously passed through the graft are anchored to the tuberosity via 5.5 mm Swivelock anchors placed at the anterior and posterior lateral margins of the greater tuberosity.

Here, we see our final repair construct with the rotator cable secured at the anterior and posterior margins, and the dermal allograft patch overlying our greater tuberosity tuberoplasty.

Results and Discussion

Technical pearls the authors would like to highlight include utilizing accessory anterior and posterior percutaneous portals to assist with suture management. A locking stitch is performed at the beginning and end of the running stitch of the free edge of the rotator cuff. The graft is rolled in the A-to-P dimension and inserted via a passport cannula to facilitate easier insertion, and a 5.5-mm anchor is used in the lateral row, particularly in the setting of poor bone quality.

The postoperative protocol consists of the use of a sling for 6 weeks. A self-directed passive range of motion protocol begins at 24 hours. The patient then starts physical therapy, in which isometrics and active range of motion are started. At 6 to 8 weeks, the sling is removed, the patient's range of motion increases, and light strengthening begins. At 2 to 3 months, eccentric exercises and gentle plyometrics are begun. At 4 months, progressive plyometrics and a total body conditioning program are started. At 5 months, the patient may begin work and sport-specific activities. At 6 months, clearance for work and/or sport will depend on patient-specific strength progression and demands of activity.

To the authors’ knowledge, no high-level evidence exists yet evaluating the specific technique described here, although multiple studies have evaluated cable reconstruction with either allograft or biceps augmentation. A cadaveric model showed that a V-shaped semitendinosus allograft anterior cable reconstruction restored peak subacromial contact pressures to the intact pre-tear levels. ³ Additionally, they found that glenohumeral kinematics were not affected by the cable reconstruction compared with the intact state. From a clinical perspective, a study comparing anterior cable reconstruction in 41 patients with massive rotator cuff tears to a conventional repair group found a 4.9% retear rate in the cable reconstruction group compared with a 7.1% retear rate in their conventional repair group. ⁷ They also noted a larger postoperative acromiohumeral distance in the cable reconstruction group. However, there were no significant differences in postoperative visual analog pain scale scores, American Shoulder Elbow Surgeons scores, or range of motion values between the 2 groups.

Conclusion

Tuberoplasty has also been shown to improve pain and patient-reported outcome scores. A study by Lee at al ⁴ on 32 patients found that arthroscopic tuberoplasty improved the Constant score, the University of California, Los Angeles shoulder score, and range of motion at final follow-up. Additionally, failed glenoid-sided superior capsular reconstruction with dermal allograft was not found to be predictive of worse outcomes, leading to interest in the addition of biologic tuboplasty augmentation to the standard tuboplasty for pain relief. ⁵ Future research is needed to expand upon the clinical outcomes of this combined with rotator cable reconstruction.