Long head of biceps tendon transposition for massive and irreparable rotator cuff tears: A systematic review and meta-analysis

Table 1 Methodological Index for Nonrandomized Studies scores of the clinical studies

Ref.	Study type/LOE	A clearly stated aim	Inclusion of consecutive patients	Prospective collection of data	Endpoints appropriate to the aim of the study	Unbiased assessment of the study endpoint	Follow-up period appropriate to the aim of the study	Loss to follow up less than 5%	Prospective calculation of the study size	An adequate control group	Contemporary groups	Baseline equivalence of groups	Adequate statistical analyses	Score
Barth et al[37], 2020	III, retrospective control study	2	1	2	2	1	2	1	0	2	1	2	0	16
Kocaoglu et al[34], 2020	III, retrospective control study	2	2	2	2	2	2	2	0	2	2	2	0	20
Rhee et al[33], 2021	III, retrospective control study	2	1	1	2	2	2	1	1	2	2	2	1	19
Chiang et al[36], 2021	III, retrospective control study	2	1	2	2	1	2	1	0	1	1	2	0	15
Kawashima et al[35], 2022	III, retrospective control study	2	1	2	2	1	2	1	0	1	2	2	0	16

Table 2 Biomechanical outcomes after long head of biceps transposition

Ref.	Number of shoulders	Age, yr	Surgical technique	Testing conditions/groups	Testing method	Main results	Main conclusion
Park et al[22], 2018	9	58 (33-77)	ACR using autologous proximal biceps tendon for large to massive rotator cuff tears	(1) Intact; (2) Stage II tear (complete tear of the supraspinatus); (3) ACR for stage II tear; (4) Stage III tear (complete tear of the supraspinatus and anterior one-half of the infraspinatus); and (5) ACR for stage III tear	Range of motion, superior translation of the humeral head, and subacromial contact pressure were measured at 0°, 30°, 60°, and 90° of ER with 0°, 20°, and 40° of glenohumeral abduction	ACR for both stage II and stage III showed significantly higher total range of motion compared with intact at all angles. ACR significantly decreased superior translation for stage II tears at 0°, 30°, and 60° ER for both 0° and 20° abduction and for stage III tears at 0° and 30° ER for both 0° and 20° abduction. ACR for stage III tear significantly reduced peak subacromial contact pressure at 30° and 60° ER with 0° and 40° abduction and at 30° ER with 20° abduction	ACR using autologous biceps tendon biomechanically normalized superior migration and subacromial contact pressure, without limiting range of motion
El-shaar et al[21], 2018	10 (5 matched pairs)	63 (59-67)	SCR utilizing a LHB autograft or TFL autograft	(1) After a massive RC tear without SCR; and (2) After SCR with either a TFL autograft or an LHB autograft	Cadaveric demographics, mean force required to superiorly translate the humerus, and change in mean force when normalized to the torn condition were recorded	SCR with an LHB autograft required 393.2% ± 87.9% of the force needed for superior humeral migration in the massive RC tear condition, while SCR with a TFL autograft required 194.0% ± 21.8%. The LHB reconstruction group trended toward a stronger reconstruction when normalized to the torn condition	SCR with an LHB autograft is a feasible procedure that is shown to be biomechanically equivalent and potentially even stronger than SCR with a TFL autograft in the prevention of superior humeral migration
Han et al[30], 2019	7	50-65	SCR using the LHBT or using the LHBT with side-to-side repair	(1) Intact; (2) Simulated complete supraspinatus tendon tear; (3) Modified SCR using LHB; and (4) Modified SCR using LHB and side-to-side repair augmentation	Superior translation of the humerus, subacromial contact pressure and area, and glenohumeral range of motion were tested at 0°, 30°, and 60° of glenohumeral abduction	The complete cuff tear shifted the humeral head superiorly as compared to the intact shoulder. Subacromial peak contact pressure was also increased at 30° and 60° while contact area was increased at 0° and 30°. The modified SCR both with and without side-to-side repair shifted the humeral head inferiorly at 30° and 60°, with contact area further reduced at 60°. Both techniques had comparable results for contact pressure and total rotational range of motion	The LHB with appropriate distal insertion on the greater tuberosity restores shoulder stability in irreparable rotator cuff tears by re-centering the humeral head on the glenoid
Han et al[29], 2020	8	65 (56-69)	PR, BR and BRSS	(1) Intact; (2) IRCT; (3) PR; (4) BR; and (5) BRSS	Total rotational range of motion was measured at 40°, then 20°, and finally 0° of glenohumeral abduction. Superior humeral translation and subacromial contact pressure were measured at 0°, 30°, 6 0°, and 90° of external rotation at each abduction angle	Superior humeral translation was significantly decreased in the BR and BRSS conditions compared with the IRCT and PR conditions at 0° and 20° of GH abduction (P < 0.001). BR and BRSS significantly reduced subacromial contact pressure compared with IRCT and PR at 0° of GH abduction (P < 0.001). There was no significant decrease in total rotational range of motion after BR at any abduction angle	BR biomechanically restored shoulder stability without over constraining range of motion in an IRCT model
Berthold et al[32], 2021	8	53.4 ± 14.2 (20-64)	SCR with V- shaped LHBT reconstruction, box-shaped LHBT reconstruction or single-stranded LHBT reconstruction	(1) Intact; (2) Irreparable psRCT; (3) V-shaped LHBT reconstruction; (4) Box-shaped LHBT reconstruction; and (5) Single-stranded LHBT reconstruction	ghST, MAA, maximum cDF, and sCP were accessed and recorded in each condition	Each of the 3 LHBT techniques for reconstruction of the superior capsule significantly increased MAA while significantly decreasing ghST and cDF compared with the psRCT. Additionally, the V-shaped and box-shaped techniques significantly decreased sCP compared with the psRCT. The V-shaped technique further showed a significantly increased MAA and decreased cDF when compared with the box-shaped and single-stranded techniques, as well as a significantly decreased ghST when compared with the box-shaped technique	Using the LHBT for reconstruction of the superior capsule improved shoulder function by preventing superior humeral migration, decreasing deltoid forces and sCP
Denard et al[31], 2021	8	62 (46-70)	SCR with box-shaped LHBT reconstruction or single-limb LHBT reconstruction	(1) Intact state; (2) A stage III MCT model (complete supraspinatus and anterior one-half of the infraspinatus); (3) Box Biceps SCR; and (4) Single-limb biceps	A custom testing system used to evaluate range of motion, superior translation, and subacromial contact pressure at 0°, 20°, and 40° of abduction	Range of motion was not impaired with either repair construct (P > 0.05). The box SCR decreased superior translation by approximately 2 mm compared with the MCT at 0°, but translation remained greater compared with the intact state in nearly every testing position. The in situ tenodesis had no effect on superior translation. Peak subacromial contact pressure was increased in the MCT at 0° and 20°. Abduction compared with the native state but not different between the native and box SCR at the same positions	A box-shaped SCR using the native biceps tendon partially restores increased superior translation and peak subacromial contact pressure due to MCT. The technique may have a role in augmentation of an IMCT

ACR: Anterior cable reconstruction; IRCT: Irreparable rotator cuff tear; PR: Partial repair; BR: Biceps rerouting; BRSS: Biceps rerouting with side-to-side repair; psRCT: Irreparable posterosuperior rotator cuff tear; ghST: Glenohumeral superior translation; MAA: Maximum abduction angle; cDF: Cumulative deltoid force; sCP: Subacromial peak contact pressure; SCR: Superior capsular reconstruction; LHBT: Long head of biceps tendon; TFL: Tensor fasciae lata; MCT: Massive rotator cuff tear; IMCT: Irreparable and massive rotator cuff tear; ER: External rotation.

Table 3 Overview of included clinical studies

Ref.	Country	Journal	Level of evidence, study type	Groups	No. of shoulder in group	Male:female sex	Age, yr	Follow-up, mo	Outcomes
Barth et al[37], 2020	France	Am J Sports Med	3, retrospective study	DR vs TOE with absorbable patch reinforcement vs SCR with LHBT autograft	28 vs 30 vs 24	15:13 vs 19:11 vs 16:8	63 ± 9 (48-83) vs 59 ± 7.6 (45-71) vs 60 ± 7 (47-81)	25 ± 2 (24-29) vs 27 ± 5 (24-36) vs 25 ± 2 (24-29)	ASES score, VAS score, constant score, range of motion, simple shoulder test, subjective shoulder value, muscle strength, retear rate
Kocaoglu et al[34], 2020	Turkey	Orthop J Sports Med	3, retrospective study	SCR with LHBT autograft vs SCR with a tensor fasciae lata autograft	14 vs 12	N/A	64.6 ± 8.4 vs 62.5 ± 6.5	28 vs 32	ASES score, VAS score, QuickDASH, range of motion, AHD, retear rate
Rhee et al[33], 2021	Korea	Arthroscopy	3, retrospective study	ARCR + BR vs ARCR	59 vs 52	32:27 vs 29:23	63.7 ± 6.5 vs 62.8 ± 6.9	15.1 ± 3.4 vs 25.1 ± 8.7	ASES score, VAS score, constant score, UCLA score, range of motion, muscle strength, AHD, retear rate
Chiang et al[36], 2021	China (Taiwan)	Arthroscopy	3, retrospective study	ARCR and SCR with LHBT autograft vs ARCR and tenotomy of LHBT performed at the insertion site	18 vs 22	7:11 vs 6:16	62.3 ± 7.5 vs 62.2 ± 6.1	26.6 ± 3.9 (24-38) vs 31.9 ± 6.4 (26-45)	ASES score, VAS score, UCLA score, rang of motion, AHD, retear rate
Kawashima et al[35], 2022	Japan	Arthroscopy	3, retrospective study	partial repair vs SCR with LHBT transposition	10 vs 12	6:4 vs 7:5	71.9 ± 7.5 vs 67.8 ± 2.0	37.2 (24-72) vs 24.8 (24-30)	ASES score, UCLA score, rang of motion, AHD, retear rate

AHD: Acromiohumeral distance; ARCR: Arthroscopic rotator cuff repair; ASES: American Shoulder and Elbow Surgeons; DR: Double-row technique; LHBT: Long head of biceps tendon; N/A: Not available; SCR: Superior capsular reconstruction; TOE: Transosseous-equivalent technique; UCLA: University of California at Los Angles; VAS: Visual analogue scale.