A Biologic Hybrid Approach Combining Superior Capsular Reconstruction, Long Head of the Biceps Tendon Rerouting, and Rotator Cuff Repair

Abstract

Large to massive posterior superior rotator cuff tears remain challenging to treat because chronic tendon retraction, fatty degeneration, and muscle atrophy often preclude durable repair. Superior capsular reconstruction using fascia lata autograft has been introduced to restore superior glenohumeral stability; however, graft failure, donor site morbidity, and limited biological incorporation remain concerns. Use of the long head of the biceps tendon (LHBT) as an autologous, vascularized tissue source has been proposed to enhance biological healing and avoid allograft‐related complications, although isolated LHBT‐based techniques may provide limited and unpredictable stability. This technical note describes a hybrid arthroscopic technique that combines standard superior capsular reconstruction with LHBT rerouting and augmentation using available rotator cuff tissue. The procedure integrates 3 complementary components: rerouting and fixation of the LHBT as a biologic static stabilizer, dermal allograft‐based superior capsular reconstruction to restore superior capsular integrity, and triple‐row augmentation of remnant rotator cuff tissue over the construct to maximize footprint coverage and biological healing potential. Indications include large to massive posterior superior rotator cuff tears with an intact or minimally torn LHBT and without advanced glenohumeral arthritis. This combined approach aims to improve superior glenohumeral stability, enhance graft support, and create a favorable biological environment while maintaining a reproducible arthroscopic workflow.

Large to massive posterior superior rotator cuff tears   (PSRCTs) continue to pose a significant challenge for shoulder surgeons because chronic tendon retraction, advanced fatty degeneration, and muscle atrophy frequently compromise the success of conventional repair. ¹ , ² , ³ Although several surgical strategies—such as partial repair, marginal convergence, debridement with or without biceps procedures, tendon transfer, and patch augmentation—have been proposed, restoration of optimal shoulder joint kinematics and biomechanics remains challenging, and retear continues to be a substantial clinical concern. Superior capsular reconstruction (SCR) was introduced to address this issue, and clinical studies have shown improvements in shoulder stability and functional outcomes. ⁴ , ⁵ , ⁶ In addition to its role in irreparable rotator cuff tears, SCR has also been applied as a reinforcement technique for arthroscopic rotator cuff repair, with reported improvements in rotator cuff integrity and promising short‐ to midterm clinical outcomes; however, long‐term results remain limited. ⁷ Despite these advantages, graft failure, incomplete biological incorporation, and graft creep remain important limitations of current SCR techniques. ⁸ , ⁹

SCR using the long head of the biceps tendon (LHBT) as an autologous, vascularized tissue source has been proposed to enhance stability and promote biological healing. ¹⁰ , ¹¹ , ¹² , ¹³ Owing to its favorable anatomical relation with the rotator cuff and the simplicity of surgical access, the LHBT can be rerouted or used for SCR to provide additional superior restraint and to supplement deficient capsular tissue. ¹⁴ Furthermore, LHBT‐based augmentation has been used as a reinforcement strategy during arthroscopic rotator cuff repair, showing reduced retear rates and improved functional recovery compared with conventional repair alone. ¹⁵ These techniques offer several advantages, including in situ fixation, preserved vascularity, and avoidance of allograft‐related complications; however, they may provide limited stability, and clinical outcomes can be unpredictable. ¹⁶ , ¹⁷ Building on the respective strengths and limitations of both SCR and LHBT‐based augmentation, the current technical note describes a hybrid technique that combines standard SCR with LHBT rerouting and incorporates available rotator cuff tissue as an additional biological layer. The goal of this combined approach is to achieve a more stable and biologically favorable reconstruction for large to massive PSRCTs while maintaining a straightforward and reproducible arthroscopic workflow.

SURGICAL TECHNIQUE

Indications and Contraindication

The procedure is intended for large to massive PSRCTs, defined arthroscopically as tendons that cannot fully restore coverage of the native footprint. Concomitant partial‐thickness subscapularis tears may be addressed if the tendon remains repairable. Indications include: (1) persistent shoulder pain and weakness despite adequate nonoperative treatment; (2) preoperative imaging confirming a full‐thickness large to massive PSRCTs on magnetic resonance imaging, with tendon retraction to the glenoid level; (3) an intact LHBT or a partial tear involving less than 50% of the tendon diameter; and (4) absence of advanced glenohumeral osteoarthritis (Hamada ¹⁸ grade ≤2). Contraindications include advanced glenohumeral arthritis, fixed shoulder dislocation, biceps tendon tears exceeding 50% of the tendon diameter, shoulder infection, and cervical nerve palsy.

Patient Positioning and Arthroscopic Assessment

The procedure is performed with the patient positioned in the lateral decubitus position under general anesthesia (Video 1). The operative arm is maintained at approximately 30° of abduction and 20° of forward flexion. Diagnostic arthroscopy is performed through standard posterior and anterior portals to assess the glenohumeral joint, evaluate the integrity of the LHBT, and determine the extent and reparability of the rotator cuff tear. When concomitant subscapularis tears were present and deemed repairable, they were repaired arthroscopically prior to the reconstruction using a double‐row suture‐bridge technique in the subacromial space.

VIDEO 1.

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The surgical video shows the hybrid technique combining rerouted long head of the biceps tendon, superior capsular reconstruction, and rotator cuff augmentation performed in the lateral decubitus position in the left shoulder. Video content can be viewed at https://doi.org/10.1002/atn2.70245.

Preparation of the Rotator Cuff and Footprint

Prior to reconstruction, the torn PSCRT is carefully released to maximize tendon excursion. This includes release of the coracohumeral ligament and rotator interval to improve mobility of the supraspinatus and infraspinatus remnants. Nonviable tissue and adhesions are debrided to create healthy tendon margins suitable for subsequent augmentation. These preparatory steps are performed to optimize coverage and biological integration of the reconstructed construct. The supraspinatus and infraspinatus footprints are then debrided and lightly decorticated using a burr to prepare the humeral surface.

Preparation and Rerouting of the LHBT

For LHBT rerouting, a new bony groove is created immediately posterior to the native bicipital groove (Figure 1A). The transverse humeral ligament and surrounding soft tissues are released to allow mobilization of the LHBT into the newly created groove without tension. One triple‐loaded suture anchor (5.5 mm Healicoil Regenesorb; Smith & Nephew, Andover, MA) is placed at the anteromedial aspect of the footprint, adjacent to the articular cartilage (Figure 1B). One suture limb is passed through the LHBT in a looped fashion and tied to secure medial fixation. A double‐loaded suture anchor (1.8 mm Omegaknot; ARC, Gyeonggi‐do, Republic of Korea) is then inserted at the anterolateral aspect of the new bony groove (Figure 1C), and both sutures are looped around the LHBT and tied to complete stable fixation within the new groove (Figure 1D). All remaining suture limbs are preserved for later rotator cuff augmentation.

FIGURE 1.

Rerouting of the LHBT. Arthroscopic images obtained from the lateral portal of the left shoulder in lateral decubitus position show the LHBT rerouting procedure. (A) A new bony groove is created immediately posterior to the LHBT (red asterisk). (B) A triple‐loaded suture anchor (blue arrow) is placed at the anteromedial aspect of the footprint, adjacent to the articular cartilage. (C) One suture limb is passed through the LHBT (red asterisk) in a looped fashion. (D) The looped sutures are tied around the LHBT (red asterisk) to achieve stable fixation within the newly created groove. (LHBT, long head of the biceps tendon.)

Superior Capsular Reconstruction

For SCR, 2 double‐loaded suture anchors (3.0 mm Gryphon; DePuy Mitek, Raynham, MA) are placed at the superior glenoid rim at the 10‐ and 1‐o'clock positions (Figure 2A). A dermal allograft patch, typically measuring approximately 3 × 3 cm with a thickness of 4 mm, is prepared according to the defect size. The dermal allograft patch (Myderm; MSBIO, Gyeonggi‐do, Republic of Korea) is introduced into the subacromial space through the standard lateral portal using a grasper and positioned over the superior glenoid and greater tuberosity. Sutures from the glenoid anchors are passed through the medial edge of the graft, and the graft is secured to the superior glenoid and LHBT to complete medial fixation (Figure 2B). For lateral fixation, an additional double‐loaded suture anchor (4.5 mm Healix; DePuy Mitek, Raynham, MA) is placed at the posteromedial aspect of the prepared footprint. One suture limb is passed through the anterolateral corner of the graft and the other through the posterolateral corner. Sutures from the previously placed anteromedial anchor in the new biceps groove are also passed through the corresponding lateral corners of the graft. These sutures are then tied sequentially to secure the lateral margin of the graft, completing fixation of the SCR construct (Figure 2C,D). All remaining sutures are retained for subsequent cuff augmentation.

FIGURE 2.

SCR. Arthroscopic images obtained from the lateral portal of the left shoulder in lateral decubitus position show the SCR procedure. (A) Two glenoid suture anchors (green arrows) are placed at the superior glenoid rim at the 10‐ and 1‐o'clock positions, and 2 footprint suture anchors (blue arrows) are positioned near the articular margin. (B) The anteromedial corner of the dermal allograft patch (blue asterisk) is secured to the long head of the biceps tendon (red asterisk). (C) The SCR graft (blue asterisk) lies beneath the remnant posterosuperior rotator cuff tissue (yellow asterisk). (D) Complete fixation of the SCR graft (blue asterisk) is shown. (SCR, superior capsular reconstruction.)

Rotator Cuff Augmentation

After the completion of LHBT rerouting and SCR fixation, sutures from the anteromedial anchor are passed through the anterior rotator cuff remnant, whereas sutures from the posteromedial anchor are passed through the posterior rotator cuff remnant (Figure 3A,B). After all sutures are appropriately passed, they are tied to secure the rotator cuff remnants over the SCR patch and LHBT construct (Figure 3C). Final fixation is performed using a triple‐row suture‐bridge configuration with 3 knotless lateral‐row anchors (4.5 mm PopLok; ConMed, FL) (Figure 3D). This hybrid construct integrates the anteriorly rerouted LHBT, the dermal SCR patch, and the augmented rotator cuff tissue, with the goal of restoring superior glenohumeral stability, maximizing footprint coverage, and enhancing the biological healing environment.

FIGURE 3.

Rotator cuff augmentation. Arthroscopic images obtained from the lateral portal of the left shoulder in lateral decubitus position show rotator cuff augmentation. (A) A suture from the anteromedial footprint anchor is passed through the anterior portion of the torn rotator cuff (blue arrow). (B) A suture from the posteromedial footprint anchor is passed through the posterior portion of the torn rotator cuff (yellow arrow). (C) The sutures are tied to secure the rotator cuff remnant (green arrow). (D) The final appearance of rotator cuff augmentation (yellow asterisk) using a double‐row suture‐bridge configuration is shown.

Closure and Postoperative Rehabilitation

All portals are closed in a standard fashion. Postoperatively, the shoulder is immobilized in an abduction brace for 6 weeks. From 3 months postoperatively, passive and self‐assisted range‐of‐motion exercises are initiated. At 3 months postoperatively, active overhead motion and strengthening exercises are commenced and progressed gradually according to individual recovery and clinical assessment.

DISCUSSION

Large to massive PSRCTs remain a significant clinical challenge because of tendon retraction, muscle atrophy, and fatty degeneration, often resulting in persistent pain, loss of function, and limited options for durable repair. ¹ , ² , ¹⁹ Although SCR has emerged as an effective technique to restore superior glenohumeral stability, graft failure and incomplete coverage of the rotator cuff footprint remain concerns. ⁴ , ⁵ , ⁷ , ⁸ , ⁹ , ¹³ The current hybrid technique described here integrates 3 complementary strategies: rerouted LHBT, SCR, and augmentation with the remnant rotator cuff tissue. Rerouting the LHBT into a newly created groove posterior to the bicipital groove allows the tendon to serve as a biologic static stabilizer, helping resist superior translation of the humeral head. ¹⁴ The dermal SCR patch restores superior capsular integrity over the supraspinatus footprint, whereas the residual rotator cuff tissue is augmented onto the patch using a triple‐row suture bridge configuration, maximizing tendon‐to‐bone contact and promoting biologic healing. Compared with conventional SCR or isolated LHBT rerouting, this hybrid construct offers several advantages. First, the LHBT provides additional medial‐to‐lateral support, particularly in the anterior shoulder, and its integration into the SCR patch may enhance graft stability. Second, augmentation with the remnant rotator cuff tissue optimizes coverage of the greater tuberosity footprint and preserves the native tendon footprint, potentially improving load sharing and biological healing potential. ⁷ Third, the use of double‐ and triple‐loaded anchors facilitates secure fixation of multiple tissue layers without over‐tensioning any single structure. ²⁰

Despite these advantages, the technique is technically demanding. The pearls and pitfalls of the procedure are summarized in Table 1, and the advantages and disadvantages are outlined in Table 2. Adequate mobilization of the rotator cuff and proper preparation of the LHBT groove are critical for tension‐free placement and long‐term stability. Careful suture management and stepwise fixation are essential to avoid entanglement and ensure secure integration of the 3 constructs. Long‐term clinical outcomes and biomechanical validation remain areas for further investigation, but this technique may offer a promising strategy for patients with large to massive PSCRCTs who fail conservative management.

TABLE 1.

Pearls and Pitfalls

Pearls	Pitfalls
Create a new bony groove for the LHBT to achieve a stable, tension‐free rerouting without impingement in the native bicipital groove	Inadequate release of the rotator cuff may prevent proper excursion, leading to excessive tension on the repair
Release the coracohumeral ligament and rotator interval to maximize excursion of torn rotator cuff tissue for augmentation	Improper placement of the LHBT groove or anchors may cause tendon slippage or impingement
Maintain suture limbs from LHBT anchors for later use in rotator cuff augmentation	Overtensioning the SCR patch or LHBT can limit shoulder range of motion or compromise vascularity
Use a 4‐mm dermal patch for SCR and size it based on the individual defect (commonly 3 × 3 cm)	Failure to debride nonviable rotator cuff tissue may compromise healing and suture security
Incorporate remnant rotator cuff tissue over the SCR patch to provide biologic augmentation and additional coverage of the footprint	Suture mismanagement can result in entanglement and suboptimal fixation of the hybrid construct
Use a triple‐row suture bridge construct for final fixation to optimize contact pressure and stability of the augmented rotator cuff	Inadequate release of the rotator cuff may prevent proper excursion, leading to excessive tension on the repair

LHBT, long head of biceps tendon; SCR, superior capsular reconstruction.

TABLE 2.

Advantages and Disadvantages

Advantages	Disadvantages
Combines 3 complementary biologic and mechanical stabilizers (LHBT rerouting, SCR graft, and rotator cuff augmentation)	Technically demanding procedure requiring advanced arthroscopic skills
LHBT provides an autologous, vascularized tissue source that may enhance biological healing	Procedure requires an intact or minimally damaged long head of the biceps tendon
SCR restores superior capsular stability and helps prevent superior humeral head migration	Increased operative time because of multiple reconstructive steps
Augmentation with remnant rotator cuff tissue improves footprint coverage and biological integration	Complex suture management may increase the risk of suture entanglement
Triple‐row suture‐bridge fixation maximizes tendon‐to‐bone contact area and construct stability	Multiple anchors may increase surgical cost
Use of LHBT avoids donor‐site morbidity associated with fascia lata autograft harvesting	Potential overtensioning of the construct may restrict postoperative range of motion if not carefully managed

LHBT, long head of biceps tendon; SCR, superior capsular reconstruction.

The hybrid technique combining rerouted LHBT, SCR, and rotator cuff augmentation may provide a promising option for large to massive PSCRCTs. By integrating static stabilization from the LHBT, SCR, and biologic augmentation with the remnant rotator cuff, this approach aims to improve footprint coverage, restore superior glenohumeral stability, and enhance overall repair strength. Although technically demanding, this method offers a promising option for patients with persistent pain and functional deficit after failure of conservative management, potentially improving clinical outcomes and graft longevity.

DISCLOSURES

The authors (B.T.K., H.J.K., H.W.C., S.W.H.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.

Kim Bo Taek, Kim Han Ju, Cho Hyun Woo, Hong Sung Woo. Arthrosc Tech. 2026; 15:e70245. 10.1002/atn2.70245