Infraspinatus/Teres Minor Transfer Biceps In Situ Tenodesis Procedure: Initial Results of a Technique for Massive Cuff Tears

Massive rotator cuff tears may not be primarily repairable with salvage options not necessarily providing acceptable results. Extrinsic tendon transfer is a significant undertaking with prolonged rehabilitation and variable outcome. A novel technique for the reconstruction of massive tears, not amenable to primary repair, by performing a transfer of the intrinsic posterior rotator cuff onto an intact, tenodesed long head of biceps tendon acting as a scaffold for the intrinsic transfer is described. The clinical results at short to medium term in 17 initial patients are presented. Encouraging results from this study suggest that this is a viable option for the management of massive rotator cuff tears with an intact posterior cuff with results equal or superior to other reconstructive techniques. 1. Introduction Rotator cuff pathology is a common problem, with tears causing a significant amount of time off work, pain, and loss of function. Tears can be graded according to a number of different systems, massive tears generally being considered the most difficult for surgical management. In the case of a massive tear with a retracted, deficient, or grossly degenerate tendon margin, direct primary repair is not possible. Present reconstructive options include medialisation of the supraspinatus footprint, margin convergence, subscapularis transfer, and extrinsic latissimus dorsi/teres major transfer. A novel technique for the primary reconstruction of a massive, retracted, and irreparable tear is described. This utilizes the infraspinatus and teres minor muscles, as well as an intact long head of biceps to create a new, postero-superior force couple with a more anatomic force transmission alignment of the transferred tendon compared to an extrinsic transfer. The transferred tendon acts as a humeral head depressor as well as force couple to facilitate return to normal shoulder kinematics. The procedure has the advantage of being performed as a primary operation and is easily accomplished in the deck-chair position. Recovery appears similar to simple rotator cuff repair, and postoperative pain is minimal. 2. Methods In deck-chair position, initial glenohumeral and subacromial arthroscopy is performed. Arthroscopic subacromial decompression is completed, and the cuff is inspected for a posterior cuff margin, and the presence of the long head of biceps. If amenable to reconstruction, an open approach to the shoulder is made. The presence of an irreparable rotator cuff tear is confirmed. The infraspinatus tendon is elevated by sharp dissection from the posterior