Modified Superior Capsule Reconstruction Using the

Long Head of the Biceps Tendon as Reinforcement to

Rotator Cuff Repair Lowers Retear Rate in Large to
Massive Reparable Rotator Cuff Tears
Chen-Hao Chiang, M.D., Leo Shaw, M.D., Wei-Hsing Chih, M.D., Ming-Long Yeh, Ph.D.,
Hsiao-Hsien Ting, M.D., Chang-Hao Lin, M.S., Chao-Ping Chen, M.D., and
Wei-Ren Su, M.S.

Purpose: To retrospectively assess the clinical outcomes of the patients with large to massive reparable RCTs treated by
arthroscopic rotator cuff repair (ARCR) combined with modified superior capsule reconstruction (mSCR) using the long
head of biceps tendon (LHBT) as reinforcement with a minimum of 2 years of follow-up. Methods: We retrospectively
evaluated 40 patients with large to massive reparable RCTs who underwent ARCR and mSCR (group I) between February
2017 and June 2018 (18 patients) or underwent ARCR and tenotomy of LHBT performed at the insertion site (group II)
between January 2015 and January 2017 (22 patients). The pain visual analog score (VAS) was assessed preoperatively
and 1, 3, 6, 12, 24 months postoperatively. American Shoulder and Elbow Surgeons (ASES) scores, the University of
California, Los Angeles (UCLA) shoulder rating scale, and active range of motion (AROM) were assessed before surgery
and 6, 12, and 24 months after surgery. The integrity of the rotator cuff and mSCR was evaluated using magnetic
resonance images at 12 months postoperatively. Results: After surgery, both groups had significantly improved in VAS,
ASES, UCLA and AROM scores in the final follow-up. There were no significant between-group differences in the
characteristics of the patients before surgery. Group I had improved pain relief at 1 month (P < .001) and at 3 months (P <
.01) after surgery. For the AROM, group I (flexion, external rotation, internal rotation) demonstrated better improvement
than group II 6 months after surgery (all P < .05) and better internal rotation 12 and 24 months after surgery (all P < .05).
The mSCR survival rate was 94.4% (17/18). The retear rate of repaired rotator cuffs for groups I and II was 16.7% (3/18)
and 40.9% (9/22), respectively, and the differences were significant (P < .046). Conclusions: ARCR combined with
mSCR using LHBT as reinforcement may lead to a lower retear rate and earlier functional recovery than conventional
ARCR with tenotomy of LHBT for large to massive reparable RCTs. Level of Evidence: Level III, retrospective thera-
peutic comparative trial.

I t is difficult to achieve successful repair of large and

massive RCTs because of a high retear rate after
repair, even with use of techniques such as tendon
transfer, patch augmentation, or bridging augmentation
with grafts, which have yielded controversial outcomes.
The retear rates of repaired rotator cuffs range from 9%
to 94%.1-5 Superior capsule reconstruction (SCR) using
a tensor fascia lata (TFL) autograft was developed as an
alternative option for irreparable RCTs, where rotator
cuff repair was not possible. The technique proposed by

From the Department of Biomedical Engineering, National Cheng Kung
University (C-H.C., M-L.Y.) Tainan, Taiwan; Department of Orthopaedics,
Ditmanson Medical Foundation Chia-Yi Christian Hospital (C-H.C., W-H.C.,
C-H.L.), Chiayi, Taiwan; Department of Orthopaedics, Taichung Veterans’
General Hospital (L.S., C-P.C.), Taichung, Taiwan; Department of Anesthe-
siology, Ditmanson Medical Foundation Chia-Yi Christian Hospital (H-H.T.),
Chiayi, Taiwan; Department of Health Services Administration, China
Medical University (C-P.C.), Taichung, Taiwan; Department of Acupressure
Technology, Jen-Teh Junior College of Medicine, Nursing and Management
(C-P.C.), Miaoli, Taiwan; and the Department of Orthopaedics, National
Cheng Kung University Hospital (W-R.S.), Tainan, Taiwan, R.O.C
The authors report no conflicts of interest in the authorship and publication
of this article. Full ICMJE author disclosure forms are available for this article
online, as supplementary material.
Received September 28, 2020; accepted April 2, 2021.
Address correspondence to Leo Shaw, M.D., Department of Orthopaedics,
Taichung Veteran’s General Hospital, 1650 Taiwan Boulevard Sect. 4, Tai-
chung, Taiwan 40705. E-mail: lancetchop@gmail.com
Ó 2021 by the Arthroscopy Association of North America
0749-8063/201610/$36.00
https://doi.org/10.1016/j.arthro.2021.04.003

2420 Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 37, No 8 (August), 2021: pp 2420-2431
 ARTHROSCOPIC ROTATOR CUFF REPAIR WITH LHBT MSCR LOWERS RETEAR RATE 2421

Mihata et al.6 achieved excellent American Shoulder subscapularis tendon),15 or insufficient follow-up
and Elbow Surgeons (ASES) scores with a minimum of duration (n ¼ 10) (<2 years) were excluded from this
a 2-year follow-up. The superior capsule has a crucial study. All patients received ARCR using either single-
role in maintaining the kinematics of the shoulder joint row (SR), double-row (DR), or double-row suture
and preventing the upward migration of the proximal bridge (SB) techniques. The patient screening process is
humerus. The importance of SCR to the stability of the presented as a flowchart in Figure 1.
shoulder and its functions has been well established in
many cadaveric biomechanical studies.7-10 Surgical technique for ARCR combined with mSCR
Currently, irreparable RCTs under arthroscopic rota- The full details of the surgical techniques were pub-
tor cuff partial repair with SCR is a popular combination lished previously by Chiang et al.13 After administration
because of improved functional scores and significantly of general anesthesia, the patients were placed in a
lowered retear rates, as demonstrated in studies pub- beach chair position. An arthroscopic examination was
lished by Mihata et al.,6 Barth et al.,11 and Denard performed to evaluate the pattern of subscapularis
et al.12 However, the role of SCR for large to massive tears, the intraarticular quality of the LHBT, and the
reparable RCTs has not been established.6,11 Since shoulder joint from the standard posterior and anterior
2017, we have used long head of biceps tendon (LHBT) portals as the view and working portals, respectively. In
autografts as SCR to reinforce arthroscopic rotator cuff subacromial space, acromioplasty, bursectomy,
repair (ARCR) for large to massive reparable RCTs in an
effort to improve clinical outcomes and prevent retear
of repaired rotator cuffs.13 This combination of tech-
niques was called ARCR with modified superior capsule
reconstruction (mSCR) with LHBT used as reinforce-
ment. This method has a rapid learning curve, elimi-
nates possible donor site morbidities, and has few extra
costs.
The purpose of this study is to retrospectively assess
the clinical outcomes of the patients with large to
massive reparable RCTs treated by ARCR combined
with mSCR using LHBT as reinforcement with a mini-
mum of 2 years of follow-up. We hypothesized that this
combination would achieve better clinical outcomes
and lower retear rates for patients with large to massive
reparable RCTs.

Materials and Methods

After institutional review board approval (Chia-Yi
Christian Hospital IRB No: 105001), we retrospectively
reviewed our medical database for patients who
received ARCR by a single surgeon (C-H.C.) between
January 2015 and June 2018 in the author’s hospital. A
total of 236 patients matched our initial search. All data
were collected prospectively. The inclusion criteria
were patients diagnosed with large to massive reparable
RCTs (
3 cm) according to the Cofield classification.14
All patients were treated either using ARCR combined
with mSCR (group I) or using ARCR with tenotomy of Fig 1. Patient screening flowchart. Review process of all pa-
the LHBT performed at the insertion site (group II). tients enrolled in this study. The tear size of the rotator cuff
Patients with small RCTs (n ¼ 83), medium RCTs (n ¼ was identified using the Cofield classification (Cofield, 1982)
63), irreparable RCTs (n ¼ 9), fracture, or infection- (small, <1 cm; medium, 1-3 cm; large, 3-5 cm; massive, >5
cm). Subscapularis tear greater than LaFosse type III, superior
related pathologies (n ¼ 2), severe glenohumeral joint
two-thirds to complete subscapularis tendon tear. ARCR,
osteoarthritis (n ¼ 1), deformity of the humeral head arthroscopic rotator cuff repair; AROM, active range of mo-
(n ¼ 1), normal LHBT without tenotomy (n ¼ 3), tion; ASES, American Shoulder and Elbow Surgeons; LHBT,
intraarticularly absent LHBT (n ¼ 15), tenodesis of the long head of the biceps tendon; MRI, magnetic resonance
LHBT (n ¼ 3), revised cases (n ¼ 2), subscapularis tears imaging; mSCR, modified superior capsule reconstruction
greater than LaFosse type III (n ¼ 4) (more than using the LHBT; UCLA, University of California Los Angeles;
complete rupture of the upper two thirds of the VAS, visual analog scale.
2422 C-H. CHIANG ET AL.

Fig 2. Illustrations of the surgical techniques involving ARCR combined with mSCR as reinforcement applied on a right
shoulder. Arthroscopic figures were viewed from posterolateral portal. The patient was placed in the beach chair position with
the shoulder in 30 abduction, 10 flexion, and the elbow in 90 flexion. (A, B) Large to massive reparable RCT with acceptable
quality of LHBT. (C, D) A double-loaded suture anchor was inserted at the medial (mediolateral aspect) and middle (ante-
roposterior aspect) footprint. The sutures were passed through the anterior and posterior two-thirds of the LHBT and tied with
SMC knots. Tenotomy of the LHBT was performed approximately 1 to 1.5 cm distal to the fixation, and finally, the mSCR was
completed. (E, F) The RCT was repaired using a suture bridge technique, and the mSCR was sandwiched between the footprint
and the repaired rotator cuff. #, mSCR; ARCR, arthroscopic rotator cuff repair; F, footprint of rotator cuff; HH, humeral head;
LHBT, long head of the biceps; mSCR, modified superior capsule reconstruction using LHBT; RC, rotator cuff; RCT, rotator cuff
tear; SMC, Samsung Medical Center knot.

footprint preparation, debridement, and release of the
torn rotator cuff were performed through the lateral
portal (Fig 2, A and B). After that, we transferred the
arthroscope to the posterolateral portal (about 1.0 to
1.5 cm anterior to the posterior corner of the acromial
region, just lateral to the acromion) to improve anterior
vision. The lesion size was measured in the ante-
roposterior and mediolateral aspect with a laser marked
probe. A double-loaded suture anchor (5.0-mm Twin-
Fix Ti Suture Anchor; Smith & Nephew, London, UK)
was placed into the middle (anteroposterior aspect) and
medial (mediolateral aspect) of the prepared footprint,
and the sutures were passed through the anterior and
posterior two-thirds of the LHBT and then were fixed in
place with a Samsung Medical Center (SMC) knot in
the shoulder placed at a 30 abduction and 10 forward
flexion, with the elbow placed in a 90 flexion position.
The tenotomy of the LHBT was performed about 1 to
1.5 cm distal to the fixation, and mSCR was completed
(Fig 2, C and D). Last, the torn rotator cuff was repaired
superiorly to mSCR using either SR, DR, or SB tech-
niques (Fig 2, E and F).
Clinical Functional Assessment
All patients went through detailed physical exami-
nations at the outpatient department if surgical inter-
vention was indicated. Surgical complications were
recorded. The intensity of pain was measured with the
visual analogue scale (VAS, 10-point grading system)
before surgery and 1, 3, 6, 12, and 24 months after
surgery.16 The active range of motion (AROM) and
functional score were documented before surgery and
6, 12, and 24 months after surgery. Clinical functional
assessments were recorded with 2 main scoring sys-
tems: the ASES (100-point scoring system) and the
University of California, Los Angeles shoulder rating
scale (UCLA, 35-point scaling system).17,18 We
measured the forward flexion (FF), external rotation at
90 abduction (ERab), and internal rotation at the side
(IRs) as the AROM. FF and ERab were measured at the
 ARTHROSCOPIC ROTATOR CUFF REPAIR WITH LHBT MSCR LOWERS RETEAR RATE
outpatient department on a painted wall. IRs was
measured by recording the highest vertebral body the
patient could reach with the thumb. The minimal
clinically important difference (MCID) threshold for
VAS, UCLA, and ASES scores were 1.37, 2.9, and 6.4
points.19-21
Radiography and Magnetic Resonance Imaging
Assessment
The preoperative condition of the glenohumeral joint
plays a crucial role in the outcome of this technique.
Therefore, the bony structure of the shoulder, the
severity of the tear, and the condition of the torn ro-
tator cuff and LHBT were carefully surveyed. Standard
anteroposterior and outlet radiographs were performed
to assess the acromiohumeral distance (AHI), the
acromial spur classification, osteonecrosis, and the
Hamada Fukuda classification of the glenohumeral
joint (Fig 3).22 After surgery, a radiographic survey of
the glenohumeral joint, AHI, and the screw position
was performed immediately and 6 and 12 months after
surgery. A magnetic resonance imaging (MRI, 1.5-Tesla
scanner Magneton Essenza 1.5 T, Siemens, Germany)
evaluation of the rotator cuff integrity was performed
before surgery and 1 year after surgery. Preoperative
MRI assessments were focused on the fatty change
based on Goutallier’s grade of the entire rotator cuff,
the retraction Patte classification of the supraspinatus,
the LaFosse classification of the subscapularis, the
integrity of the LHBT, and other lesions, such as SLAP
or labral tears.15,23,24 The focus of the postoperative
MRI assessments was on the integrity of the repaired
rotator cuff, the mSCR, and the location of the teno-
tomized LHBT. The integrity of the repaired rotator cuff
tendon was classified as no retear (Sugaya classification
1, 2), partial retear (Sugaya classification 3), and
Fig 3. Comparison of preopera-
tive and postoperative radio-
graphs from a right shoulder. (A)
AHI was 2.7 mm, and an inter-
rupted Moloney’s line could be
observed. (B) AHI was improved
to 10.6 mm, and a continuous
Moloney’s line was observed 1
year after ARCR combined with
mSCR. AHI, acromiohumeral in-
terval; ARCR, arthroscopic rotator
cuff repair; mSCR, modified su-
perior capsule reconstruction us-
ing the long head of the biceps
tendon.
2423
complete retear (Sugaya classification 4, 5) as used by
Heuberer et al (Figs 4 and 5).25,26 In healed rotator cuffs
and good mSCR, laminated phenomena will be found
(Fig 4, C and D). The preoperative and postoperative
MRI were reviewed blindly 3 times by 3 senior shoulder
surgeons with more than 10 years’ experience (C-H.C.,
W-H.C., W-R.S.) (Tables 1 and 2). After the blind re-
view, the intraobserver coefficient was 0.84, and the
interobserver coefficient was 0.78.
Postoperative rehabilitation
After surgery, the 2 groups experienced the same
postoperative protocols. The shoulder was immobilized
with an abductor brace for 4 weeks. During this time,
active motion of the elbow, wrist, and head were
allowed. After 4 weeks, passive motion of the shoulder
was started. Active motion of the shoulder was added 3
months after surgery, and the patients were permitted
to participate in sports requiring overhead motion 6
months after surgery.
Statistical analysis
The statistical analysis was performed with SPSS 21.0
software (SPSS Inc., Chicago, IL). The generalized
estimating equation was used for the repeated mea-
sures. For comparison of the 2 groups, a t-test, the
Mann-Whitney U test, Fisher’s exact test, and c2 tests
were used. A P value <0.05 was considered statistically
significant.
Results
After the screening process, a total of 40 patients
were enrolled in this study. Group I had 18 patients
treated from February 2017 to June 2018, and group
II had 22 patients treated from January 2015 to
January 2017. There were no significant between-
2424 C-H. CHIANG ET AL.
group differences in the characteristics of the patients,
radiograms, or MRI scans obtained before surgery.
There were no significant differences in operation
time (group I and group II, 83.9  18.9 and 81.5 
15.7 minutes, respectively; P ¼ .665). There were also
no significant between-group differences in the tear
size of the rotator cuff, the intraarticular quality of the
LHBT, or the rotator cuff repair techniques (SR, DR, or
SB) (Table 1).
Clinical outcomes
Both groups exhibited significant improvement in the
pain scales, functional outcomes, and AROM during 2
years of follow-up. For group I, the VAS, percentage of
night pain, ASES, and UCLA scores were significantly
improved from 6.6  1.8, 88.9% (16/18), 47.4  14.6,
14.7  2.4, respectively, to 0.3  0.7, 11.1% (2/18),
90.0  5.6, 31.0  2.0, respectively, at the final post-
operative follow-up (P < 0.001). The FF, ERab, and IRs
Fig 4. MRI of showed no retear
after a right shoulder was treated
by ARCR with mSCR. (A) Coro-
nal view and (B) sagittal view
before surgery, the torn rotator
cuff was retracted to the glenoid
(Patte classification stage 3). (C)
Coronal view and (D) sagittal
view of ARCR combined with
mSCR at 1 year after operation.
The rotator cuff was healed, and
the arrow shows laminated mSCR
from healed rotator cuff. ARCR,
arthroscopic rotator cuff repair;
MRI, Magnetic resonance image;
mSCR, modified superior capsule
reconstruction using the long
head of the biceps tendon.
AROM were also significantly improved from 135.8 
41.8, 56.1  20.3, and L3, respectively, to 175.4  7.6,
81.6  4.0, T11, respectively, at the final postoperative
follow-up (P < .001) (Fig 6). The percentage of patients
reaching the MCID for VAS during the follow-up period
(1 month, 3 months, 6 months, 1 year, and 2 years) for
group I were 88.9% (16/18), 100% (18/18), 100% (18/
18),100% (18/18), and 100% (18/18), respectively; for
group II were 82% (18/22), 86.3% (19/22), 95.4% (21/
22), 100% (22/22) and 100% (22/22), respectively. All
patients reached the MCID for ASES and UCLA after
operation.
Although there were no significant between-group
differences in VAS or functional outcomes at the final
follow-up, group I demonstrated early improvements in
pain as compared to group II at 1 month (P < .001) and
3 months (P < .01). Also, group I demonstrated more
rapid AROM improvements than group II 6 months
after surgery (P < .05) and better IRs 1 year and 2 years
 ARTHROSCOPIC ROTATOR CUFF REPAIR WITH LHBT MSCR LOWERS RETEAR RATE 2425

Fig 5. MRI of partial and com-

plete retear after ARCR of a right
shoulder. (A) Coronal view and
(B) sagittal view. The arrow
revealed partial retear of the ro-
tator cuff with preserved conti-
nuity of the tendon at 1 year after
operation. (C) Coronal view and
(D) sagittal view. Complete retear
with discontinuity of the rotator
cuff at 1 year after operation.
ARCR, arthroscopic rotator cuff
repair; MRI, magnetic resonance
image.

after surgery (P < .05). The term “early” for the result of
follow-up duration was defined as data collected within
6 months after surgery.
The tenotomized LHBT of Group I was significantly
more distal than that of group II because of the different
site of the LHBT tenotomy (Table 2). There were no
significant between-group differences in the occurrence
of the Popeye deformity. This deformity was highly
correlated with the body mass index (BMI). The pa-
tients with Popeye’s deformity had significantly lower
BMI (P < .001) (Table 3).
complete retear. Group I had better cuff integrity than
group II (P ¼ .046) (Table 2).
Complications
There were no major surgical complications in either
groups, such as deep infection, nerve injury, or suture
anchor loosening. One patient in group II had a su-
perficial infection in the lateral portal wound. The
second surgery for wound debridement was performed
4 weeks later, and the wound was healed completely
without sequelae.

Image Outcomes Discussion

The radiographic survey at the 1-year follow-up
showed the AHI was significantly increased in both
groups compared to the preoperative AHI. However,
group I (10.2  1.8 mm) had better AHI than Group II
(8.2  2.8 mm) (P ¼ .015). The survival rate of the
mSCR was 94.4% (17/18). The integrity of the repaired
rotator cuff was defined as no retear, partial retear, and
ARCR combined with mSCR reinforcement using the
LHBT counters the upward tension of the humerus and
provides tensionless repairs of the RCTs. In this study,
the retear rate of ARCR combined with mSCR for large
to massive reparable RCTs was significantly lower than
ARCR with tenotomy of LHBT. Furthermore, patients
treated by ARCR with mSCR demonstrated better
2426 C-H. CHIANG ET AL.

Table 1. Characteristic of Patients

Group I Group II P Value

No. of patients 18 22
Age (y) 62.3  7.5 62.2  6.1 .581
Male/female 7/11 6/16 .435
Body mass index 25.7  5.3 25.2  3.3 .840
Follow-up duration 26.6  3.9 (24-38) 31.9  6.4 (26-45) .003
Side of surgery, right/left 13/5 18/4 .705
Operative time (minutes) 83.9  18.9 81.5  15.7 .665
Rotator cuff repair methods, n
Single-row 3 6 .457
Double-row 1 0
Suture bridge 14 16
Preoperative X-ray
Acromial spurs classification
I/II/III, n 9/6/3 4/9/9 .075
Acromiohumeral interval (mm) 6.6  2.4 6.2  2.5 .672
Hamada Fukuda classification
I/II/III, n 10/3/5 10/9/3 .256
Preoperative MRI, n
Supraspinatus retraction Patte classification
I/II/III 0/13/5 1/14/7 .858
Fatty change grade* (0/1/2/3)
Subscapularis 12/3/3/0 13/7/2/0 .531
Supraspinatus 0/4/13/1 0/9/12/1 .502
Infraspinatus 7/5/5/1 5/10/7/0 .365
Teres minor 16/2/0/0 20/2/0/0 1.000
Arthroscopic measures
Tear size in AP aspect (cm) 4.1  1.3 3.9  1.1 .605
Tear size in ML aspect (cm) 3.5  0.8 3.7  0.9 .251
SLAP lesion (0/1/2), n 3/7/8 4/7/11 .914
Quality of the intraarticular part of the LHBT, n(%)
Normal 10(55.6%) 9(41.0%) .197
Tendinitis 2(11.1%) 3(13.6%)
Partial tear, < 30% 6(33.3%) 5(22.7%)
Partial tear,
30% 0(0.0%) 5(22.7%)
Data are expressed as mean  standard deviation.
AP, anteroposterior; Group I, arthroscopic rotator cuff repair with modified superior capsule reconstruction using the long head of the biceps
tendon; Group II, arthroscopic rotator cuff repair with tenotomy of the long head of the biceps tendon at insertion area; LHBT, long head of the
biceps tendon; ML, mediolateral.
*Comparison of fatty change grade between groups in subscapularis, supraspinatus, infraspinatus, and teres minor.

functional recovery in VAS score, IR, ER, and FF within
6 months after operation. This technique does not
prolong operation time, and it effectively uses the LHBT
as an autograft without donor site morbidity.
The concept of SCR used in repair of irreparable RCTs
was originated from Mihata et al.,6 his method
currently has the highest healing rates with significant
improvement of clinical outcomes even after almost 3
years (34 months) of follow-up. A wide variety of patch
augmentation materials have been developed to pre-
vent donor site morbidity, shorten graft harvesting time
and reduce the learning curve compared to the TFL
autograft harvesting procedure. The choices of grafts for
SCR have always been debatable because of different
biomechanical strengths, graft thickness, possible graft
rejections, or extra costs. Xenograft augmentation, such
as porcine small intestinal submucosa grafts, are not
suitable for treatment of large to massive rotator cuff
tears due to possible severe inflammatory reactions, low
tendon healing rates, and high retear rates, as reported
in multiple studies.27-30 The current SCR results with
human dermal allografts for treatment of irreparable
massive rotator cuff tears published by Denard et al.12
in 2018 showed encouraging results with a 74.6%
success rate. However, the therapeutic effects of human
dermal allografts for irreparable RCT remains unestab-
lished because of debates over graft thickness, a higher
conversion rate of reverse total shoulder arthroplasty, a
lack of improvement in AHI over time, and a wide
range of retear rates ranging from 20% to 75% as
compared to conventional TFL autografts.31-38 ARCR
and LHBT tenotomy is a common practice to improve
the clinical outcomes of rotator cuff repair sur-
gery.31,39,40 Our methods make effective use of the
LHBT before tenotomy, because the mSCR preserves
the blood supply from the LHBT; therefore the repaired
 ARTHROSCOPIC ROTATOR CUFF REPAIR WITH LHBT MSCR LOWERS RETEAR RATE 2427

Table 2. Results of the 1-Year Postoperative Findings of the Radiology and Magnetic Resonance Imaging

Group I Group II P Value

Acromiohumeral interval (mm) 10.2  1.8 8.2  2.8 .015
mSCR survival, n (%) 17 (94.4%) 0 (0.0%) <.001
Rotator cuff integrity, n* (%)
Sugaya classification (1/2/3/4/5) 8/7/2/0/1 6/7/1/4/4
No retear 15 (83.3%) 13 (59.1%) .046
Partial retear 2 (11.1%) 1 (4.5%)
Complete retear 1 (5.6%) 8 (36.4%)
Relation between tenotomized LHBT and bicipital groove, n(%)
Proximal to the groove 0 1(4.5%) .004
Upper half of the groove 4(22.2%) 15(68.2%)
Lower half of the groove 12(66.7%) 6(27.3%)
Distal to the groove 2(11.1%) 0
Data are expressed as mean  standard deviation.
Group I, arthroscopic rotator cuff repair with modified superior capsule reconstruction using the long head of the biceps tendon; group II,
arthroscopic rotator cuff repair with tenotomy of the long head of the biceps tendon at insertion area; LHBT, long head of the biceps tendon;
mSCR, modified superior capsule reconstruction using the long head of the biceps tendon.
*The integrity of the repaired rotator cuff tendon was classified as no retear (Sugaya classification 1, 2), partial retear (Sugaya classification 3),
and complete retear (Sugaya classification 4, 5).

rotator cuff has additional blood supply from the
transposed LHBT other than the prepared footprint to
provide abundant nutrients for tenocyte growth.11,41-43
Only 1 complete retear was found in a patient during
MRI follow-up at the 1-year follow-up, and all patients
had significantly improved clinical outcomes without
any conversion to reverse total shoulder arthroplasty,
and the AHI was maintained at around 10.2  1.8 mm
during 2 years of follow-up after ARCR combined with
mSCR.
The failure rate of the mSCR in this study was
approximately 5.6% (1/18) at the 1-year follow-up,
and the failed cases still achieved satisfactory clin-
ical outcomes without any critical complaints. There
have been different study results with regard to the
relationship between clinical outcome and graft tears.
In a study with 12.8 months of follow-up performed
by Lim et al.,44 they found no statistically significant
differences in terms of clinical outcome between the
group with graft tears and the group with intact
grafts. The findings of their study matched those of
the present study. However, because of the lack of
sample size data and thorough follow-up in recent
studies, the relationship between clinical outcomes
and graft retears still needs to be determined. Some
studies have been concerned about the biomechan-
ical strength of the transposed LHBT in SCR.45,46 The
average thickness of the LHBT was 6 mm, which was
similar to the 6 to 8 mm autologous TFL used by
Mihata et al.47 Furthermore, in their cadaveric
biomechanical study, El-Shaar et al.45 concluded that
SCR with an LHBT autograft has been proven to be
equivalent and potentially even stronger than SCR
with a TFL autograft for the prevention of superior
humeral migration. More cases and longer follow-up
durations are needed to determine whether graft
failure will have negative impacts on clinical out-
comes over time.
Recently, Barth et al.11 compared the retear rate of
massive posterosuperior RCTs with DR, SB with
absorbable patch reinforcement, and SCR using the
LHBT autograft. His study showed that SCR using LHBT
was superior in terms of structural integrity over the
other techniques. An ultrasound survey 1 year after
surgery showed that 91.7% (22 of 24) of the SCR group
remained healed, whereas the DR and SB groups
exhibited inferior healing rates of 60.7% (17 of 28) and
56.7% (17 of 30), respectively.11 Unlike graft failure,
which doesn’t seem to have negative impact on the
clinical outcomes discussed in the current literature, a
retear of the rotator cuff almost always results in poor
outcomes, where the injury deteriorates over
time.26,48,49 Depending on the type of technique and
study protocol, the retear rate of the repaired rotator
cuff ranged from 9% to 94%.1-5 In our study, the retear
rate in group II was 40.9% (8/22 complete tear, 1/22
partial tear); however, the retear rate in group I was
reduced to 16.7% (1/18 complete tear, 2/18 partial
tear). Regardless of the treatment type, the VAS, UCLA,
and ERab exhibited significantly inferior performance
in patients, with complete retear (9/40) (0.9  0.8,
24.9  4.3, 62.8  19.7, respectively) as compared to
patients with a rotator cuff without retear (28/40) (0.2
 0.6, 30.4  3.6, 79.2  7.0, respectively) (P ¼ .008,
P ¼ .001, and P ¼ .037, respectively). Even though in a
study done by Galatz et al.,1 patients with retear still
achieved better clinical outcomes than their presur-
gery status, the results were similar as those in our
study.
The current literature is controversial about the
complications from isolated tenotomy and tenotomy
followed by tenodesis.50 Recently, in a prospective
2428 C-H. CHIANG ET AL.

Fig 6. Comparison of clinical outcomes between group I (ARCR combined with mSCR) and Group II (ARCR with tenotomy of
the LHBT). In terms of postoperative VAS score, group I had better early pain control during the first month and third month of
follow-up. Furthermore, Group I also had significant difference in internal rotation, external rotation, and flexion during six
months follow-up as compared to group II. ARCR, arthroscopic rotator cuff repair; ASES, American Shoulder and Elbow Sur-
geons score (100-point scoring system); External rotation, external rotation at 90 abduction; Internal rotation, internal rotation
at the side; mSCR, modified superior capsule reconstruction using the long head of the biceps tendon; UCLA, University of
California, Los Angeles Shoulder rating scale (35-point scaling system); VAS, visual analog scale (10-point grading system). * P <
.05; ** P < .01; *** P < .001.

double-blinded randomized controlled trial conducted 10%). The rate of Popeye’s deformity in our study was
by MacDonald et al.,51 it was concluded that there was higher (62.5%, 25/40) than in MacDonald’s study, but
higher rate of Popeye’s deformity when patients were only 1 patient complained about cramping pain in the
treated with tenotomy relative to tenodesis (33% vs biceps 6 months after surgery. In addition, from our
collected data, we found that the occurrence of
Table 3. Postoperative Finding of the Popeye Deformity Popeye’s deformity was related to the BMI rather than
the type of surgical approach to LHBT. In our study,
Positive Negative P Value patients with BMIs below 27 kg/m2 (22/28) had more
No. of patients 25 15 instances of Popeye’s deformity than those with BMIs
Body mass index 23.9  3.6 28.0  4.2 .001
Distribution, n .622
above 27 kg/m2 (3/12) (P ¼ .001). Our results matched
Group I 12 6 the theory tested by Almeida et al.52 in previous pub-
Group II 13 9 lished studies. They found that males with BMIs below
Relation between tenotomized .677 30 kg/m2 had more complaints about Popeye’s defor-
LHBT and bicipital groove, n(%) mity.52 Therefore we would suggest the use of LHBT
Proximal to the groove 0 (0.0%) 1 (6.7%)
Upper half of the groove 12 (48.0%) 7 (46.7%)
tenodesis in patients with BMIs <27 or in patients
Lower half of the groove 12 (48.0%) 6 (40.0%) where there is significant concern about possible
Distal to the groove 1 (4.0%) 1 (6.7%) Popeye’s deformity. Furthermore, tenotomy may
Data are expressed as mean  standard deviation. relieve shoulder pain caused by biceps tendon pathol-
Group I, arthroscopic rotator cuff repair with modified superior ogy that coexist with the RCTs.51,53
capsule reconstruction using the long head of the biceps tendon;
group II, arthroscopic rotator cuff repair with tenotomy of the long Limitations
head of the biceps tendon at insertion area; LHBT, long head of the
This study had several limitations. First, it was a
biceps tendon.
retrospective study with a historical control group of
 ARTHROSCOPIC ROTATOR CUFF REPAIR WITH LHBT MSCR LOWERS RETEAR RATE
patients from two different timelines, there could be
selection bias for these comparisons. Second, the im-
aging classification (Sugaya and Goutallier classifica-
tion) used in this study have low reliability despite their
wide use in other studies.54 However, we tried to
overcome this flaw by making the subjective evaluation
by 3 experienced shoulder surgeons. Third, a complete
postoperative evaluation was lacking. Postoperative
MRI was only done 1 year after operation. Another
MRI survey 2 years after operation could reveal the
durability of the mSCR and whether retears had
occurred. Besides, measurement of muscle power re-
covery was not performed, this data could reflect
another aspect of the patient’s improvement after sur-
gery. Fourth, the intraarticular quality of LHBT is
important; therefore this technique was not available
for all patients with large to massive RCTs. Last, the
scale of this study was limited. The cases presented in
our study were operated by the same operator in a
single center, and the sample sizes were small. There-
fore we believe a larger sample size with different op-
erators and longer follow-up duration will reveal the
true therapeutic effect of this technique.
Conclusion
ARCR combined with mSCR using LHBT as rein-
forcement may lead to a lower retear rate and earlier
functional recovery than conventional ARCR with
tenotomy of LHBT for large to massive reparable RCTs.
Acknowledgments
The authors thank C.K. Hong, M.D., and Mrs. H.Y.
Chang (Department of Orthopaedics, National Cheng
Kung University Hospital, Tainan, Taiwan) for the
assistance in this study
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