Biceps augmentation to improve the footprint coverage and functional outcomes in the treatment of large to massive rotator cuff tears

Biceps augmentation to improve the footprint coverage and functional outcomes in the treatment of large to massive rotator cuff tears | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Biceps augmentation to improve the footprint coverage and functional outcomes in the treatment of large to massive rotator cuff tears Sung Weon Jung, Sang Heun Kim, Hwan Kyu Jeong This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8930567/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background The biceps tendon can be used as an option for augmentation in large to massive rotator cuff (RC) tears, although no definitive recommendations can be given. The purpose of the study was to compare the functional outcomes of arthroscopic RC repair with biceps augmentation with RC partial repair alone in treatment of large to massive tears. Methods A retrospective review of 175 patients with large to massive RC tears was conducted, and 45 patients who underwent RC repair with biceps augmentation were included. One or two margin convergences with the biceps tendon was performed to reduce the tear gap, and the repair of the torn RC to the original footprint using a combination of RC tendons and biceps tendon. Patients treated with the RC repair with biceps augmentation were placed in the biceps cohort and were age- and sex-matched 1:1 with a second cohort treated with RC partial repair alone, referred to as the partial cohort. Acceptable footprint coverage was defined when the humeral head was completely covered and small defect of footprint coverage was left during surgery. All patients were evaluated preoperatively and were followed up with a visual analog scale for pain, Constant score, radiographs, and ultrasonography. Results A total of 45 patients were included in the B cohort and 45 in the P cohort. Statistical analysis demonstrated significant differences in acceptable footprint coverage (34 vs. 15 cases), average acromiohumeral interval at final follow-up (8.6 vs. 7.5 mm), average Constant scores at final follow-up (79.8 vs. 75.2 points), and ultrasonographic findings of partial-to-intact healing (38 vs. 17 cases) between the two cohorts. Overall satisfactory outcomes were achieved in most patients regardless of biceps augmentation, the Constant scores of B cohort were significantly higher at final follow-up. Conclusions Arthroscopic RC repair with biceps augmentation was associated with increased acromiohumeral interval and better functional outcomes compared with RC partial repair alone, and improved footprint coverage might affect the outcomes. Study Design Prognostic, cohort study, therapeutic Level III rotator cuff tear large size massive margin convergence biceps augmentation partial repair shoulder Introduction While small to medium one-tendon rotator cuff (RC) tears present with a simple tear pattern, large to massive two-tendon RC tears present with a complex tear pattern and are more likely to undergo structural deterioration. 1,2) As large to massive tears show diverse tear morphologies, the accurate identification of the tear pattern is an initial step for the footprint restoration. 3,4,5) The delamination is present in most large sized tears, and careful assessment is needed for determining the repair technique. 4,5) Anatomic restoration and stable repair of RC fibers could increase the potential for complete healing and good function, but full coverage of the footprint is often challenging. 5,6) Several procedures have been proposed for managing large to massive RC tears, including partial repair, biceps or patch augmentation based on primary repair, autogenous or allogenous tendon transfer, subacromial balloon spacer placement, and reverse total shoulder arthroplasty. 7–11) There has been growing interest in the use of patches or scaffolds to enhance tendon-to-bone healing during RC repair. Some studies have reported the use of the long head of biceps tendon for treating large to massive tears including biceps augmentation, biceps rerouting, anterior cable reconstruction, and bio-SCR. 5,10,12–15) Biceps augmentation primarily aims to fill defects and enhance healing after RC repair. 5) The biceps rerouting technique relocates the tendon to a new groove to facilitate footprint coverage while maintaining its anatomic continuity. 13) Anterior cable reconstruction focuses on restoring the anterior cable, a key structural element of RC function. 12) The bio-SCR technique utilizes the biceps tendon, which is posteriorly transposed and secured to augment partial or complete RC repairs. 14) Dermal allograft patch augmentation has also been used to restore superior RC structures and prevent superior migration of the humeral head. 6,16) These kinds of augmentation techniques offer potential benefits, high re-tear rates remain a concern. 2,17–19) The long head of biceps tendon can be used as an option for augmentation in massive RC tears, although no definitive recommendations can be given. The purpose of this study was to compare the functional outcomes of arthroscopic RC repair with biceps augmentation with those of RC partial repair alone in the treatment of large to massive tears that are not suitable for primary repair. We hypothesized that RC repair with biceps augmentation would yield significant improvements in functional outcomes. Materials and Methods Among 550 patients who underwent arthroscopic RC repair between January 2018 and December 2023, those with small- to medium-sized tears, advanced massive tears with degeneration, glenohumeral arthritis, revision surgery, or loss to follow-up were excluded. A retrospective review was conducted for 175 patients with large to massive tears, and 45 patients who underwent the RC repair with biceps augmentation were finally included. According to the classification of DeOrio and Cofield, 33 patients had large tears and 12 had massive tears, with large tears defined as 3–5 cm in length and massive tears defined as greater than 5 cm. 2,6) When large to massive tears with exposed biceps tendon were identified, the tear was suitable for biceps autograft augmentation. One or two margin convergences with the biceps tendon was first performed to reduce the tear gap, and the repair of the torn RC to the original footprint using a combination of RC tendons, the biceps tendon, and sometimes bursal tissue. This method represents a form of simple biceps augmentation in which the biceps tendon is incorporated into the primary RC repair construct to improve the footprint coverage of the greater tuberosity. 5,7) The concept of this biceps augmentation technique derives from the mechanical principle of composite repair, in which the objective is to restore the damaged structure in a manner that approximates the original material properties. 9) All surgeries were performed by a single surgeon. 45 patients treated with the RC repair with biceps augmentation were placed in the biceps cohort (B cohort) and were age- and sex-matched 1:1 with a second cohort treated with partial repair alone, referred to as the partial cohort (P cohort). Clinical examinations were performed one day before surgery and at 6, 12, and 24 months postoperatively by two orthopedic resident surgeons. Subjective pain levels before and after surgery were assessed using the visual analog scale (VAS), a widely used pain measurement tool ranging from 0 (no pain) to 10 (extremely severe pain). 10) The Constant score was used for clinical assessment and this shoulder-specific scoring system comprises four components: shoulder pain (0–15 points), activities of daily living (0–20 points), range of motion (0–40 points), and strength (0–25 points). 12) With regards to pain, 15 points indicate no pain, 10 points indicate mild pain, 5 points indicate moderate pain, and 0 points indicate severe pain that interferes with activities. Scores for activities of daily living were assigned based on performance, with a maximum of 20 points. Range of motion was measured using a wall goniometer, assessing forward flexion, abduction, internal rotation, and external rotation for a total of 40 points. Strength was evaluated using a digital dynamometer in the scapular plane of abduction, with values (kg) multiplied by two to generate the final strength score. A score of 0 indicated inability to hold 1 kg, and 25 points indicated the ability to hold 12 kg at 90° abduction. Standard radiographs were performed preoperatively, including anteroposterior (AP) view, supraspinatus outlet view, 30° caudally angled AP view (Rockwood view), and axillary lateral view. Preoperative magnetic resonance imaging (MRI) of the affected shoulder was obtained, and fatty degeneration and atrophy of the rotator cuff muscles were evaluated. Fatty degeneration was evaluated using the 5-stage grading system suggested by Goutallier et al. 14,17) Acceptable footprint coverage was defined when the humeral head was completely covered and small defect of footprint coverage was left during surgery. 9,20) The acromiohumeral interval was assessed as the shortest perpendicular distance from the underside of the acromion to the top of the humeral head on preoperative and follow-up radiographs. 18) The integrity of the RC repair was determined by ultrasonographic evaluation, which all patients underwent at the final follow-up. Two orthopedic surgeons evaluated supraspinatus and infraspinatus integrity, classifying repairs into intact cuff, partial-thickness tear, or full-thickness tear. 21) Re-tears were defined when an absence of continuous tendon fibers visualized over the humeral head and attaching to the greater tuberosity. Repeated measurements were performed with an interval of 1 month to minimize potential examiner bias. In case of disagreement between the two examiners, the final interpretation was provided by a musculoskeletal radiologist with over 10 years of experience, who had no knowledge of the intraoperative findings. This study was approved by the Institutional Review Board of our institution. Operative technique After the patient was positioned in the lateral decubitus position, physical examination and manipulation were performed under general anesthesia. The arthroscope was inserted into the shoulder joint and all inflamed tissues were debrided with careful evaluation of the subscapularis tendon, the biceps tendon, and other findings within the joint. The arthroscope was placed into the subacromial space through the posterior portal, and a bursectomy and acromioplasty was performed. The decision to perform an acromioplasty was based on acromial morphology and a flat acromion was created when indicated. After debridement of the degenerated tendon edge, footprint, tear size, tear pattern, delamination, and biceps tendon were assessed via the posterolateral and direct lateral portal. Tear size was intraoperatively measured using an arthroscopic probe. Mobility of the anterior and posterior leaf of the torn cuffs was attempted using an arthroscopic tendon grasper. Mobilization procedures included coracohumeral ligament release at the coracoid base, capsular release at the superior aspect of the labrum, and posterior release of scar tissue at scapular spine. When the tear size was beyond 3 cm in any direction with the subscapularis tear and biceps tendon was located between the torn RC leaves, surgical decision was made to incorporate the biceps tendon into the RC repair construct (Fig. 1 A). The biceps tendon was debrided and mobilized with an arthroscopic shaver, and one or two margin convergences with the biceps (side-to-side suture) were first performed to reduce the tear gap with 2 − 0 ethibond. The anchor portal was placed and a 2.3 mm soft suture anchor (Iconx, Stryker, USA) was inserted, and the suture limb was passed 8 to 12 mm from the cuff margin. After making a transverse line, suture limbs were passed again over this line together with the biceps tendon to tighten the torn cuff (Fig. 1 B). This procedure was repeated posteriorly until adequate suture passes were achieved, and six suture passes were made with two medial anchors (Fig. 1 C). Between the RC and the biceps tendon, 3–5 sutures were placed, and this secure incorporation was potentially valuable in reinforcing the repair construct. Lateral holes for the push-in type device were created using a punch, 1–2 cm distal to the lateral edge of the footprint. Instead of tying medial knots, three anterior suture limbs were inserted into the anterior lateral hole under constant tension using the push-in type device (Reelex, Stryker, USA) and three posterior limbs were inserted into the posterior hole in the same manner. It is important to note that the anatomical repair was performed as much as possible and sutures were also used to approximate the anterior and posterior RC tendons with biceps tendon. Finally, RC repair with biceps augmentation was completed in an end-to-end fashion to make footprint coverage (Fig. 1 D). The sutured biceps tendon served as augmentation post to the RC repair construct. After completing the repair, the biceps tendon was cut, and the remaining distal stump was sutured to adjacent soft tissue at the proximal bicipital groove using a single suture. All patients were placed in a sling with an abduction pillow after surgery. All patients were treated with a standardized protocol of sling immobilization for the first 6–8 weeks after the surgery, and immediate active motion was allowed at the elbow, wrist, and digits. They were instructed to wear their sling full-time even while sleeping, with the exception of changing clothes and bathing. At 6–8 weeks, the sling was discontinued, and passive and active-assisted exercises using a stick were begun. Active motion and muscle-strengthening exercises were started at 3 months after surgery, as most re-tears occur within this period. Strengthening was introduced under low-load conditions with minimal biceps activation, and return to full labor and unrestricted activities was permitted at 6 months after surgery. Statistical analysis Measurements are expressed as the mean ± SD unless otherwise stated. Propensity score-matched analysis was performed using two covariates (age, sex). The caliper was set at 0.2 and groups were matched by 1:1 ratio without replacement. Comparisons of categorical variables between two cohorts were performed using the Pearson's chi-square test or Fisher's exact test. Comparisons of continuous variables between two cohorts were performed using the independent t-test. Null hypothesis was not different between two cohorts. All calculations were performed using STATA 15.1 (Stata Corporation, College Station, TX, USA). P-values < .05 were considered statistically significant. Results This study included 90 patients with large to massive RC tears, consisting of 64 men and 26 women, with a mean age of 69.5 years (range, 48 to 80 years). The mean postoperative follow-up period was 32.4 months (range, 24–96 months). Fifty-two patients had a history of trauma, and 55 were classified as heavy laborers. The average preoperative acromiohumeral interval was 7.1 mm (range, 5 to 12 mm). 54.4% of patients (49 of 90) had acceptable footprint coverage during surgery. Patient demographic characteristics are listed in Table 1 . Table 1 Patients baseline characteristics (n = 90). Sex Male, n 64 (71.11%) Female 26 (28.89%) Age (years) 69.50 ± 5.87 Tears size Large, n 65 (72.22%) Massive 25 (25.78%) Trauma hx Yes 52 (57.78%) No 38 (42.22%) Heavywork Yes 55 (61.11%) No 35 (38.89%) Acrominohumeral interval (mm) 7.06 ± 1.01 Bony spur Yes 32 (35.56%) No 58 (64.44%) Pseudoparalysis Yes 30 (33.33%) No 60 (66.66%) VAS score 7.18 ± 0.80 Constant pain (15) 5.00 ± 0.00 Activities of daily living (20) 10.00 ± 1.30 Range of motion (40) 14.50 ± 4.37 Strength (25) 5.06 ± 3.55 Total 34.56 ± 6.03 Muscle supraspinatus atrophy 2.79 ± 0.59 Infraspinatus atrophy 2.14 ± 0.57 Subscapularis atrophy 1.38 ± 0.51 Tangent sign Yes 54 (60.00%) No 36 (40.00%) Footprint coverage Yes 49 (54.44%) No 41 (45.55%) Follow up (months) 32.39 ± 11.19 Patients treated with the RC repair with biceps augmentation were placed in B cohort. A total of 45 patients were included in B cohort, they were present in about 25.7% of 175 patients, the mean age was 69.8 years, and 71.1% of the patients were male. The average VAS pain score improved from 7.12 preoperatively to 2.3 at 6 months, 2.0 at 1 year, and 1.8 at the final follow-up. The average Constant score improved from 34.6 preoperatively to 74.1 at 6 months, 78.5 at 1 year, and 79.8 at the final follow-up. Acceptable footprint coverage was achieved in 75.5% of patients (34 of 45) (Fig. 2 A, B, C, D). The average acromiohumeral interval improved from 7.1 mm to 8.6 mm (Fig. 2 E, F). Functional outcomes by Constant scores included 11 excellent, 22 good, 9 fair, and 3 poor results. Ultrasound evaluation showed 17 intact cuffs, 21 partial-thickness tears, and 7 full-thickness tears according to the Naqvi classification. Patients were age- and sex-matched 1:1 with a second cohort treated with partial repair, referred to as the P cohort. 45 patients were included in P cohort, the mean age was 69.2 years, and 71.1% of such patients were male. The average VAS pain scores improved from 7.2 preoperatively to 2.3 at 6 months, 2.3 at 1 year, and 2.1 at the final follow-up. The average Constant score improved from 34.6 preoperatively to 75.7 at 6 months, 77.0 at 1 year, and 75.2 at the final follow-up. Acceptable footprint coverage was achieved in 33.3% of patients (15 of 45). The average acromiohumeral interval improved from 7.0 mm to 7.5 mm. Functional outcomes included 9 excellent, 18 good, 15 fair, and 3 poor results. Ultrasound evaluation identified 8 intact cuffs, 9 partial-thickness tears, and 28 full-thickness tears (Table 2 ). Table 2 Comparison of composite cohort (n = 45) and partial cohort (n = 45). C cohort P cohort p-value Sex Male, n 32 (71.11) 32 (71.11) > 0.999 Female 13 (28.89) 13 (28.89) Age (years) 69.84 ± 5.42 69.16 ± 6.32 0.580 Tears size Large, n 33 (73.33) 32 (71.11) 0.814 Massive 12 (26.67) 13 (28.89) Trauma hx Yes 28 (62.22) 24 (53.33) 0.393 No 17 (37.78) 21 (46.67) Heavywork Yes 29 (64.44) 26 (57.78) 0.517 No 16 (35.56) 19 (42.22) Acrominohumeral interval (mm) 7.11 ± 1.01 7.00 ± 1.02 0.605 Bony spur Yes 17 (37.78) 15 (33.33) 0.660 No 28 (62.22) 30 (66.67) Pseudoparalysis Yes 14 (31.11) 16 (35.56) 0.671 No 31 (68.88) 29 (64.44) VAS score 7.16 ± 0.80 7.20 ± 0.81 0.794 Constant pain (15) 5.00 ± 0.00 5.00 ± 0.00 - Activities of daily living (20) 9.89 ± 1.30 10.11 ± 1.30 0.420 Range of motion (40) 14.22 ± 4.26 14.78 ± 4.52 0.550 Strength (25) 5.44 ± 3.67 4.67 ± 3.44 0.302 Total 34.56 ± 5.92 34.56 ± 6.20 0.785 Muscle supraspinatus atrophy 2.82 ± 0.58 2.76 ± 0.61 0.595 Infraspinatus atrophy 2.18 ± 0.57 2.11 ± 0.57 0.583 Subscapularis atrophy 1.42 ± 0.54 1.33 ± 0.48 0.412 Tangent sign Yes 29 (64.44) 25 (55.56) 0.389 No 16 (35.56) 20 (44.44) Footprint coverage Yes 34 (75.55) 15 (33.33) 0.011 No 11 (24.44) 30 (66.66) Statistical analysis demonstrated significant differences in acceptable footprint coverage (34 vs. 15 cases, p = .01), average acromiohumeral interval at the final follow-up (8.6 vs. 7.5 mm, p = .02), average Constant scores at the final follow-up (79.8 vs. 75.2 points, p = .03), and ultrasonographic findings of partial-to-intact healing (38 vs. 17 cases, p = .01) between the two cohorts. Overall satisfactory outcomes were achieved in most patients regardless of biceps augmentation, the Constant scores of B cohort were significantly higher at final follow-up (p = .03). No significant differences were observed in VAS scores, complication rates, or revision surgeries. Complications occurred in 7 of the 90 patients (7.7%), the reoperation rate due to complications was 4.4% (4 of 90). Two patients, who had persistent pseudoparalysis, underwent open RC repair surgery. The other two patients who experienced sudden arm drop and massive re-tears during follow-up, underwent reverse shoulder arthroplasty. After revision surgery, the patients fully recovered. Three cases of painful and stiff shoulders were noted but were managed conservatively. No incidences of nerve palsy or infection were recorded (Table 3 ). Table 3 Comparison of outcomes of composite cohort (n = 45) and partial cohort (n = 45). C cohort P cohort p-value VAS 6months 2.31 ± 1.11 2.33 ± 1.24 VAS 1year 2.01 ± 1.81 2.25 ± 1.84 VAS last 1.82 ± 0.81 2.13 ± 0.84 0.077 Constant total 6months 74.11 ± 11.35 75.67 ± 11.85 0.526 Constant total 1year 78.49 ± 7.75 76.98 ± 10.79 0.448 Constant total last 79.78 ± 7.07 75.22 ± 11.38 0.025 Acrominohumeral interval (mm) 8.56 ± 2.42 7.51 ± 1.60 0.018 Functional result 0.235 excellent 11 9 good 22 18 fair 9 15 poot 3 3 Ultra sonography 0.013 Intact 17 (37.78) 8 (17.78) Partial 21 (46.67) 9 (20.0) Retear 7 (15.55) 28 (62.22) Complication 3 (6.66) 4 (8.88) 0.526 Revision surgery 1 (2.22) 3 (6.66) 0.174 Discussion The goal of RC repair should be a tendon-to-bone healing. While a conventional single row or double row repair technique could be applied for small to medium RC tears, a different surgical technique should be considered for large to massive tears. 2,7) Chronic large to massive RC tears are often not fully repairable because of substantial tear size and muscle atrophy. Primary RC repair with proper augmentation is a basic requirement for successful outcome, which can be achieved using one of several types of graft material, including autograft, allograft, xenograft and synthetic materials. l2,16,22,23) Partial repair is a relatively simple technique that restores the force couple by converting a nonfunctional tear into a functional tear. Koh et al. reported that although clinical outcomes improved after partial repair, footprint coverage of less than 50% was associated with a relatively high re-tear rate. 23) Jung et al. further demonstrated that partial repair with humeral head coverage resulted in better clinical outcomes compared with partial repair alone, and that preserved shoulder motion, maintenance of the acromiohumeral space, and less muscle atrophy were associated with successful coverage. 20) Other studies have shown that partial repair may yield favorable short-term results but may deteriorate over time, including reductions in the acromiohumeral space. 3,19) Therefore, repair strategies should be individualized according to tear pattern and tissue quality, with emphasis on maximizing footprint coverage. Both biceps and patch augmentation can improve outcomes in large to massive tears, although the optimal choice depends on the tear characteristics and the surgeon’s experience. 24,25) Biceps augmentation is particularly advantageous in cases of anterior retracted tears when a healthy biceps tendon is available. The concept of biceps tendon augmentation for massive tears was first introduced by Rhee et al., who utilized the biceps tendon as an autograft between the torn RC and the greater tuberosity. In their series of sixteen patients, the average Constant score was 83.5, and MRI follow-up demonstrated tendon healing in 64.3% of cases. 5) More recently, Green et al. conducted a systematic review of comparative studies and reported a lower re-tear rate in the biceps tendon autograft group compared with controls. The biceps tendon acts as a local autograft that provides structural scaffolds, enhances healing potential, and helps prevent superior migration of the humeral head (bridging augmentation). Patch augmentation may also offer mechanical support, modulate cellular activity at the tendon–bone interface, and promote healing in large to massive tears (onlay or covering augmentation). When comparing bridging versus onlay augmentation biceps tendon autograft techniques, the onlay augmentation method demonstrated a lower re-tear rate (31.4% vs. 49.5%). 7) We believe that secure suturing techniques and reinforcing grafts can reduce the mechanical load on the initial repair and improve the structural stability of the reconstructed tendon. Although biological grafts, such as autografts or allografts, have contributed to improved outcomes, fibrotic healing and relatively high re-tear rates persist. 16,25) Original tendon fibers are the ideal graft material, but allodermal patch materials should be considered when a composite construct is indicated. 16,24) The most important findings of this study were that pain relief and functional improvement were consistently achieved following RC surgery, and that patients who underwent RC repair with biceps augmentation demonstrated increased acromiohumeral interval and better functional outcomes compared with those who received partial repair alone. This technique uses the biceps tendon to augment the primary RC repair construct, improving footprint coverage and securing the biceps tendon to the torn RC tendons and the greater tuberosity (as referred to RC–biceps composite repair). This composite repair technique aligns with the fundamental mechanical principles of composite repair: removing compromised tissue, preparing a bond-ready surface, applying a structurally supportive layer, and establishing a mechanically stable interface. 9) This technique aims to optimize both mechanical and biological incorporation between the RC and the biceps tendon, thereby enhancing durability and restoring the original footprint as effective as possible. This approach offers a viable treatment option for large to massive RC tears that aren’t suitable for primary repair. Open RC repair with biceps augmentation was sometimes performed in selected patients who were unable to undergo arthroscopy, even in these limited cases, a secure repair and acceptable footprint coverage were confirmed intraoperatively. A major strength of this study is that it compared outcomes characteristics in age- and sex-matched cohorts, providing valuable insights into why the acromiohumeral space is preserved and how much footprint coverage is necessary to restore the shoulder biomechanics. Considerable care was taken to maximize humeral head coverage and secure repair constructs in large to massive RC tears. However, this study has several limitations. First, the small sample size increases the likelihood of type II errors. Enrollment was restricted due to the relatively low number of patients who underwent the RC repair with biceps augmentation technique, even under the care of a high-volume surgeon. Second, the retrospective study design introduces the potential for selection and information bias. Finally, small, non-normally distributed samples may reduce the statistical precision of the findings. In conclusion, arthroscopic RC repair with biceps augmentation was associated with increased acromiohumeral interval and better functional outcomes compared with RC partial repair alone, and improved footprint coverage might affect the outcomes. RC repair with biceps augmentation represents a simple and effective alternative for patients with large to massive RC tears that are not suitable for primary repair. Declarations Ethics approval and consent to participate This study was approved by the Sungkyunkwan university School of medicine, Samsung Changwon hospital, Institutional Review (SCMC 2025 07 011) and all participants provided informed, written consent. All research was conducted in accordance with the Declaration of Helsinki. Consent for publication Not applicable. Availability of data and materials The datasets used during the current study are available from the corresponding author on reasonable request. The data are not publicly available due to privacy Competing interests The authors declare they have no competing interests. Clinical trial number Not applicable Funding None Authors’ contributions Sung Weon Jung was responsible for writing of the manuscript and qualified as corresponding author, and responsible for data collection. Sang Heun Kim and Hwan Kyu Jeong were responsible for data analysis and supervised data acquisition, and analysis. All authors have given final approval of the version to be published. Acknowledgements None References Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears. Am J Sports Med. 2012;40:2248–55. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired rotator cuff tears. J Bone Joint Surg Am. 2004;86:219–24. Frank RM, Cvetanovich GL, Cole BJ. 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Five- to ten-year follow-up after superior capsule reconstruction. Am J Sports Med. 2019;47:389–98. Koh KH, Lim TK, Park YE, Lee SW, Park WH, Yoo JC. Preoperative factors affecting footprint coverage in rotator cuff repair. Am J Sports Med. 2014;42(4):869–76. 10.1177/0363546513518581 . Collin P, Treseder T, Denard PJ, et al. Classification of massive rotator cuff tears and surgical outcomes. Orthop Traumatol Surg Res. 2010;96:133–8. Steinhaus ME, Makhni EC, Cole BJ, et al. Biologic augmentation for rotator cuff repair: an updated meta-analysis. Arthroscopy. 2016;32:284–98. Figure Figures are available in the Supplementary Files section. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8930567","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":597859626,"identity":"8103f36f-d0c7-4f23-bbf2-dcae0d90b9c8","order_by":0,"name":"Sung Weon Jung","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYJCCAx8M2OQMwEwDC6J0MB6cUcFnDNUiASSYCWphPsxzRi5xA4RDhBb+9rMHDvC2maVvZz97dMOPAgkGc/b+A3i1SJzJSzgg2ZaWu7MnL+1mD9Bhlj2H8dtiwJBjcMCw7VjuhgM5Zjd4gFoMbiQT0ML/xuBAYtv/dIPzb8xu/gFpuf+YgBYJoC0HzrAlGNzIMbsNsYWA9yVuvDE42FDBZrjhxhuz2zIGEjwGZ5IN8Grh788x/vzHgE3e4HyO2c03f2zkDI4ffIDfGnTAQ5ryUTAKRsEoGAVYAQAJ30n3cHaLKAAAAABJRU5ErkJggg==","orcid":"","institution":"Sungkyunkwan University School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Sung","middleName":"Weon","lastName":"Jung","suffix":""},{"id":597859628,"identity":"81c9db58-1d6e-4f12-b8fb-20c70e54b196","order_by":1,"name":"Sang Heun Kim","email":"","orcid":"","institution":"Sungkyunkwan University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Sang","middleName":"Heun","lastName":"Kim","suffix":""},{"id":597859630,"identity":"277daccb-9436-4253-9920-4518d426a9c0","order_by":2,"name":"Hwan Kyu Jeong","email":"","orcid":"","institution":"Sungkyunkwan University School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hwan","middleName":"Kyu","lastName":"Jeong","suffix":""}],"badges":[],"createdAt":"2026-02-21 04:53:45","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8930567/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8930567/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103728593,"identity":"1be735b2-a83f-4f70-a614-d1af83f61845","added_by":"auto","created_at":"2026-03-02 08:43:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":622391,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8930567/v1/45d19efb-8d56-48ac-a682-4c24033673fa.pdf"},{"id":103728505,"identity":"14bbf3a0-683e-43bf-b30b-858e2b333342","added_by":"auto","created_at":"2026-03-02 08:43:17","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":15159,"visible":true,"origin":"","legend":"","description":"","filename":"FigureLegends.docx","url":"https://assets-eu.researchsquare.com/files/rs-8930567/v1/f1d52aa3d11a489f767456a6.docx"},{"id":103728419,"identity":"658d7d0e-cce4-40cc-aff6-1a4f0f7ce90b","added_by":"auto","created_at":"2026-03-02 08:43:04","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":1061441,"visible":true,"origin":"","legend":"","description":"","filename":"Figures.docx","url":"https://assets-eu.researchsquare.com/files/rs-8930567/v1/a395b9b063c20ed8ba242794.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Biceps augmentation to improve the footprint coverage and functional outcomes in the treatment of large to massive rotator cuff tears","fulltext":[{"header":"Introduction","content":"\u003cp\u003eWhile small to medium one-tendon rotator cuff (RC) tears present with a simple tear pattern, large to massive two-tendon RC tears present with a complex tear pattern and are more likely to undergo structural deterioration.\u003csup\u003e1,2)\u003c/sup\u003e As large to massive tears show diverse tear morphologies, the accurate identification of the tear pattern is an initial step for the footprint restoration.\u003csup\u003e3,4,5)\u003c/sup\u003e The delamination is present in most large sized tears, and careful assessment is needed for determining the repair technique.\u003csup\u003e4,5)\u003c/sup\u003e Anatomic restoration and stable repair of RC fibers could increase the potential for complete healing and good function, but full coverage of the footprint is often challenging.\u003csup\u003e5,6)\u003c/sup\u003e Several procedures have been proposed for managing large to massive RC tears, including partial repair, biceps or patch augmentation based on primary repair, autogenous or allogenous tendon transfer, subacromial balloon spacer placement, and reverse total shoulder arthroplasty.\u003csup\u003e7\u0026ndash;11)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThere has been growing interest in the use of patches or scaffolds to enhance tendon-to-bone healing during RC repair. Some studies have reported the use of the long head of biceps tendon for treating large to massive tears including biceps augmentation, biceps rerouting, anterior cable reconstruction, and bio-SCR.\u003csup\u003e5,10,12\u0026ndash;15)\u003c/sup\u003e Biceps augmentation primarily aims to fill defects and enhance healing after RC repair.\u003csup\u003e5)\u003c/sup\u003e The biceps rerouting technique relocates the tendon to a new groove to facilitate footprint coverage while maintaining its anatomic continuity.\u003csup\u003e13)\u003c/sup\u003e Anterior cable reconstruction focuses on restoring the anterior cable, a key structural element of RC function.\u003csup\u003e12)\u003c/sup\u003e The bio-SCR technique utilizes the biceps tendon, which is posteriorly transposed and secured to augment partial or complete RC repairs.\u003csup\u003e14)\u003c/sup\u003e Dermal allograft patch augmentation has also been used to restore superior RC structures and prevent superior migration of the humeral head.\u003csup\u003e6,16)\u003c/sup\u003e These kinds of augmentation techniques offer potential benefits, high re-tear rates remain a concern.\u003csup\u003e2,17\u0026ndash;19)\u003c/sup\u003e The long head of biceps tendon can be used as an option for augmentation in massive RC tears, although no definitive recommendations can be given. The purpose of this study was to compare the functional outcomes of arthroscopic RC repair with biceps augmentation with those of RC partial repair alone in the treatment of large to massive tears that are not suitable for primary repair. We hypothesized that RC repair with biceps augmentation would yield significant improvements in functional outcomes.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003eAmong 550 patients who underwent arthroscopic RC repair between January 2018 and December 2023, those with small- to medium-sized tears, advanced massive tears with degeneration, glenohumeral arthritis, revision surgery, or loss to follow-up were excluded. A retrospective review was conducted for 175 patients with large to massive tears, and 45 patients who underwent the RC repair with biceps augmentation were finally included. According to the classification of DeOrio and Cofield, 33 patients had large tears and 12 had massive tears, with large tears defined as 3\u0026ndash;5 cm in length and massive tears defined as greater than 5 cm.\u003csup\u003e2,6)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eWhen large to massive tears with exposed biceps tendon were identified, the tear was suitable for biceps autograft augmentation. One or two margin convergences with the biceps tendon was first performed to reduce the tear gap, and the repair of the torn RC to the original footprint using a combination of RC tendons, the biceps tendon, and sometimes bursal tissue. This method represents a form of simple biceps augmentation in which the biceps tendon is incorporated into the primary RC repair construct to improve the footprint coverage of the greater tuberosity.\u003csup\u003e5,7)\u003c/sup\u003e The concept of this biceps augmentation technique derives from the mechanical principle of composite repair, in which the objective is to restore the damaged structure in a manner that approximates the original material properties.\u003csup\u003e9)\u003c/sup\u003e All surgeries were performed by a single surgeon. 45 patients treated with the RC repair with biceps augmentation were placed in the biceps cohort (B cohort) and were age- and sex-matched 1:1 with a second cohort treated with partial repair alone, referred to as the partial cohort (P cohort).\u003c/p\u003e \u003cp\u003eClinical examinations were performed one day before surgery and at 6, 12, and 24 months postoperatively by two orthopedic resident surgeons. Subjective pain levels before and after surgery were assessed using the visual analog scale (VAS), a widely used pain measurement tool ranging from 0 (no pain) to 10 (extremely severe pain).\u003csup\u003e10)\u003c/sup\u003e The Constant score was used for clinical assessment and this shoulder-specific scoring system comprises four components: shoulder pain (0\u0026ndash;15 points), activities of daily living (0\u0026ndash;20 points), range of motion (0\u0026ndash;40 points), and strength (0\u0026ndash;25 points).\u003csup\u003e12)\u003c/sup\u003e With regards to pain, 15 points indicate no pain, 10 points indicate mild pain, 5 points indicate moderate pain, and 0 points indicate severe pain that interferes with activities. Scores for activities of daily living were assigned based on performance, with a maximum of 20 points. Range of motion was measured using a wall goniometer, assessing forward flexion, abduction, internal rotation, and external rotation for a total of 40 points. Strength was evaluated using a digital dynamometer in the scapular plane of abduction, with values (kg) multiplied by two to generate the final strength score. A score of 0 indicated inability to hold 1 kg, and 25 points indicated the ability to hold 12 kg at 90\u0026deg; abduction.\u003c/p\u003e \u003cp\u003eStandard radiographs were performed preoperatively, including anteroposterior (AP) view, supraspinatus outlet view, 30\u0026deg; caudally angled AP view (Rockwood view), and axillary lateral view. Preoperative magnetic resonance imaging (MRI) of the affected shoulder was obtained, and fatty degeneration and atrophy of the rotator cuff muscles were evaluated. Fatty degeneration was evaluated using the 5-stage grading system suggested by Goutallier et al.\u003csup\u003e14,17)\u003c/sup\u003e Acceptable footprint coverage was defined when the humeral head was completely covered and small defect of footprint coverage was left during surgery.\u003csup\u003e9,20)\u003c/sup\u003e The acromiohumeral interval was assessed as the shortest perpendicular distance from the underside of the acromion to the top of the humeral head on preoperative and follow-up radiographs.\u003csup\u003e18)\u003c/sup\u003e The integrity of the RC repair was determined by ultrasonographic evaluation, which all patients underwent at the final follow-up. Two orthopedic surgeons evaluated supraspinatus and infraspinatus integrity, classifying repairs into intact cuff, partial-thickness tear, or full-thickness tear.\u003csup\u003e21)\u003c/sup\u003e Re-tears were defined when an absence of continuous tendon fibers visualized over the humeral head and attaching to the greater tuberosity. Repeated measurements were performed with an interval of 1 month to minimize potential examiner bias. In case of disagreement between the two examiners, the final interpretation was provided by a musculoskeletal radiologist with over 10 years of experience, who had no knowledge of the intraoperative findings. This study was approved by the Institutional Review Board of our institution.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eOperative technique\u003c/h2\u003e \u003cp\u003eAfter the patient was positioned in the lateral decubitus position, physical examination and manipulation were performed under general anesthesia. The arthroscope was inserted into the shoulder joint and all inflamed tissues were debrided with careful evaluation of the subscapularis tendon, the biceps tendon, and other findings within the joint.\u003c/p\u003e \u003cp\u003eThe arthroscope was placed into the subacromial space through the posterior portal, and a bursectomy and acromioplasty was performed. The decision to perform an acromioplasty was based on acromial morphology and a flat acromion was created when indicated. After debridement of the degenerated tendon edge, footprint, tear size, tear pattern, delamination, and biceps tendon were assessed via the posterolateral and direct lateral portal. Tear size was intraoperatively measured using an arthroscopic probe. Mobility of the anterior and posterior leaf of the torn cuffs was attempted using an arthroscopic tendon grasper. Mobilization procedures included coracohumeral ligament release at the coracoid base, capsular release at the superior aspect of the labrum, and posterior release of scar tissue at scapular spine. When the tear size was beyond 3 cm in any direction with the subscapularis tear and biceps tendon was located between the torn RC leaves, surgical decision was made to incorporate the biceps tendon into the RC repair construct (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e1\u003c/span\u003eA). The biceps tendon was debrided and mobilized with an arthroscopic shaver, and one or two margin convergences with the biceps (side-to-side suture) were first performed to reduce the tear gap with 2\u0026thinsp;\u0026minus;\u0026thinsp;0 ethibond. The anchor portal was placed and a 2.3 mm soft suture anchor (Iconx, Stryker, USA) was inserted, and the suture limb was passed 8 to 12 mm from the cuff margin. After making a transverse line, suture limbs were passed again over this line together with the biceps tendon to tighten the torn cuff (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e1\u003c/span\u003eB). This procedure was repeated posteriorly until adequate suture passes were achieved, and six suture passes were made with two medial anchors (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e1\u003c/span\u003eC). Between the RC and the biceps tendon, 3\u0026ndash;5 sutures were placed, and this secure incorporation was potentially valuable in reinforcing the repair construct. Lateral holes for the push-in type device were created using a punch, 1\u0026ndash;2 cm distal to the lateral edge of the footprint. Instead of tying medial knots, three anterior suture limbs were inserted into the anterior lateral hole under constant tension using the push-in type device (Reelex, Stryker, USA) and three posterior limbs were inserted into the posterior hole in the same manner. It is important to note that the anatomical repair was performed as much as possible and sutures were also used to approximate the anterior and posterior RC tendons with biceps tendon. Finally, RC repair with biceps augmentation was completed in an end-to-end fashion to make footprint coverage (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e1\u003c/span\u003eD). The sutured biceps tendon served as augmentation post to the RC repair construct. After completing the repair, the biceps tendon was cut, and the remaining distal stump was sutured to adjacent soft tissue at the proximal bicipital groove using a single suture. All patients were placed in a sling with an abduction pillow after surgery.\u003c/p\u003e \u003cp\u003eAll patients were treated with a standardized protocol of sling immobilization for the first 6\u0026ndash;8 weeks after the surgery, and immediate active motion was allowed at the elbow, wrist, and digits. They were instructed to wear their sling full-time even while sleeping, with the exception of changing clothes and bathing. At 6\u0026ndash;8 weeks, the sling was discontinued, and passive and active-assisted exercises using a stick were begun. Active motion and muscle-strengthening exercises were started at 3 months after surgery, as most re-tears occur within this period. Strengthening was introduced under low-load conditions with minimal biceps activation, and return to full labor and unrestricted activities was permitted at 6 months after surgery.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eMeasurements are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD unless otherwise stated. Propensity score-matched analysis was performed using two covariates (age, sex). The caliper was set at 0.2 and groups were matched by 1:1 ratio without replacement. Comparisons of categorical variables between two cohorts were performed using the Pearson's chi-square test or Fisher's exact test. Comparisons of continuous variables between two cohorts were performed using the independent t-test. Null hypothesis was not different between two cohorts. All calculations were performed using STATA 15.1 (Stata Corporation, College Station, TX, USA). P-values \u0026lt;\u0026thinsp;.05 were considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThis study included 90 patients with large to massive RC tears, consisting of 64 men and 26 women, with a mean age of 69.5 years (range, 48 to 80 years). The mean postoperative follow-up period was 32.4 months (range, 24\u0026ndash;96 months). Fifty-two patients had a history of trauma, and 55 were classified as heavy laborers. The average preoperative acromiohumeral interval was 7.1 mm (range, 5 to 12 mm). 54.4% of patients (49 of 90) had acceptable footprint coverage during surgery. Patient demographic characteristics are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients baseline characteristics (n\u0026thinsp;=\u0026thinsp;90).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex Male, n\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (71.11%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26 (28.89%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69.50\u0026thinsp;\u0026plusmn;\u0026thinsp;5.87\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTears size Large, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65 (72.22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25 (25.78%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma hx Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e52 (57.78%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38 (42.22%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeavywork Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e55 (61.11%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35 (38.89%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcrominohumeral interval (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.06\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBony spur Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (35.56%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58 (64.44%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudoparalysis Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30 (33.33%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e60 (66.66%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant pain (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivities of daily living (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange of motion (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.50\u0026thinsp;\u0026plusmn;\u0026thinsp;4.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrength (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.06\u0026thinsp;\u0026plusmn;\u0026thinsp;3.55\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34.56\u0026thinsp;\u0026plusmn;\u0026thinsp;6.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscle supraspinatus atrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.59\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfraspinatus atrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscapularis atrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.38\u0026thinsp;\u0026plusmn;\u0026thinsp;0.51\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTangent sign Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54 (60.00%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36 (40.00%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFootprint coverage Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49 (54.44%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41 (45.55%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow up (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32.39\u0026thinsp;\u0026plusmn;\u0026thinsp;11.19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePatients treated with the RC repair with biceps augmentation were placed in B cohort. A total of 45 patients were included in B cohort, they were present in about 25.7% of 175 patients, the mean age was 69.8 years, and 71.1% of the patients were male. The average VAS pain score improved from 7.12 preoperatively to 2.3 at 6 months, 2.0 at 1 year, and 1.8 at the final follow-up. The average Constant score improved from 34.6 preoperatively to 74.1 at 6 months, 78.5 at 1 year, and 79.8 at the final follow-up. Acceptable footprint coverage was achieved in 75.5% of patients (34 of 45) (Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, B, C, D). The average acromiohumeral interval improved from 7.1 mm to 8.6 mm (Fig.\u0026nbsp;\u003cspan refid=\"Fig12\" class=\"InternalRef\"\u003e2\u003c/span\u003eE, F). Functional outcomes by Constant scores included 11 excellent, 22 good, 9 fair, and 3 poor results. Ultrasound evaluation showed 17 intact cuffs, 21 partial-thickness tears, and 7 full-thickness tears according to the Naqvi classification. Patients were age- and sex-matched 1:1 with a second cohort treated with partial repair, referred to as the P cohort. 45 patients were included in P cohort, the mean age was 69.2 years, and 71.1% of such patients were male. The average VAS pain scores improved from 7.2 preoperatively to 2.3 at 6 months, 2.3 at 1 year, and 2.1 at the final follow-up. The average Constant score improved from 34.6 preoperatively to 75.7 at 6 months, 77.0 at 1 year, and 75.2 at the final follow-up. Acceptable footprint coverage was achieved in 33.3% of patients (15 of 45). The average acromiohumeral interval improved from 7.0 mm to 7.5 mm. Functional outcomes included 9 excellent, 18 good, 15 fair, and 3 poor results. Ultrasound evaluation identified 8 intact cuffs, 9 partial-thickness tears, and 28 full-thickness tears (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of composite cohort (n\u0026thinsp;=\u0026thinsp;45) and partial cohort (n\u0026thinsp;=\u0026thinsp;45).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC cohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP cohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex Male, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32 (71.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (71.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;0.999\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13 (28.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (28.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e69.84\u0026thinsp;\u0026plusmn;\u0026thinsp;5.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e69.16\u0026thinsp;\u0026plusmn;\u0026thinsp;6.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.580\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTears size Large, n\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e33 (73.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32 (71.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.814\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMassive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12 (26.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13 (28.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrauma hx Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (62.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24 (53.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.393\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (37.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21 (46.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeavywork Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (64.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26 (57.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.517\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (35.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19 (42.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcrominohumeral interval (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.00\u0026thinsp;\u0026plusmn;\u0026thinsp;1.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBony spur Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17 (37.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.660\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28 (62.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePseudoparalysis Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14 (31.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (35.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31 (68.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29 (64.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e7.20\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.794\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant pain (15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5.00\u0026thinsp;\u0026plusmn;\u0026thinsp;0.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActivities of daily living (20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.420\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRange of motion (40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e14.78\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.550\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrength (25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5.44\u0026thinsp;\u0026plusmn;\u0026thinsp;3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.67\u0026thinsp;\u0026plusmn;\u0026thinsp;3.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.302\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34.56\u0026thinsp;\u0026plusmn;\u0026thinsp;5.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34.56\u0026thinsp;\u0026plusmn;\u0026thinsp;6.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.785\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMuscle supraspinatus atrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.595\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInfraspinatus atrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.18\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.583\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubscapularis atrophy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.42\u0026thinsp;\u0026plusmn;\u0026thinsp;0.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.33\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.412\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTangent sign Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e29 (64.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25 (55.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.389\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e16 (35.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (44.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFootprint coverage Yes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e34 (75.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15 (33.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.011\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e11 (24.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30 (66.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eStatistical analysis demonstrated significant differences in acceptable footprint coverage (34 vs. 15 cases, p = .01), average acromiohumeral interval at the final follow-up (8.6 vs. 7.5 mm, p = .02), average Constant scores at the final follow-up (79.8 vs. 75.2 points, p = .03), and ultrasonographic findings of partial-to-intact healing (38 vs. 17 cases, p = .01) between the two cohorts. Overall satisfactory outcomes were achieved in most patients regardless of biceps augmentation, the Constant scores of B cohort were significantly higher at final follow-up (p = .03). No significant differences were observed in VAS scores, complication rates, or revision surgeries.\u003c/p\u003e \u003cp\u003eComplications occurred in 7 of the 90 patients (7.7%), the reoperation rate due to complications was 4.4% (4 of 90). Two patients, who had persistent pseudoparalysis, underwent open RC repair surgery. The other two patients who experienced sudden arm drop and massive re-tears during follow-up, underwent reverse shoulder arthroplasty. After revision surgery, the patients fully recovered. Three cases of painful and stiff shoulders were noted but were managed conservatively. No incidences of nerve palsy or infection were recorded (Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of outcomes of composite cohort (n\u0026thinsp;=\u0026thinsp;45) and partial cohort (n\u0026thinsp;=\u0026thinsp;45).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eC cohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP cohort\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS 6months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS 1year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.01\u0026thinsp;\u0026plusmn;\u0026thinsp;1.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVAS last\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant total 6months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74.11\u0026thinsp;\u0026plusmn;\u0026thinsp;11.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.67\u0026thinsp;\u0026plusmn;\u0026thinsp;11.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.526\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant total 1year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78.49\u0026thinsp;\u0026plusmn;\u0026thinsp;7.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.98\u0026thinsp;\u0026plusmn;\u0026thinsp;10.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.448\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant total last\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.78\u0026thinsp;\u0026plusmn;\u0026thinsp;7.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.22\u0026thinsp;\u0026plusmn;\u0026thinsp;11.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcrominohumeral interval (mm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.56\u0026thinsp;\u0026plusmn;\u0026thinsp;2.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.51\u0026thinsp;\u0026plusmn;\u0026thinsp;1.60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFunctional result\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.235\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eexcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003efair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltra sonography\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.013\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntact\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (37.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (17.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (46.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRetear\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (15.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (62.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (6.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (8.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.526\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRevision surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (6.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.174\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe goal of RC repair should be a tendon-to-bone healing. While a conventional single row or double row repair technique could be applied for small to medium RC tears, a different surgical technique should be considered for large to massive tears.\u003csup\u003e2,7)\u003c/sup\u003e Chronic large to massive RC tears are often not fully repairable because of substantial tear size and muscle atrophy. Primary RC repair with proper augmentation is a basic requirement for successful outcome, which can be achieved using one of several types of graft material, including autograft, allograft, xenograft and synthetic materials. \u003csup\u003el2,16,22,23)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePartial repair is a relatively simple technique that restores the force couple by converting a nonfunctional tear into a functional tear. Koh et al. reported that although clinical outcomes improved after partial repair, footprint coverage of less than 50% was associated with a relatively high re-tear rate.\u003csup\u003e23)\u003c/sup\u003e Jung et al. further demonstrated that partial repair with humeral head coverage resulted in better clinical outcomes compared with partial repair alone, and that preserved shoulder motion, maintenance of the acromiohumeral space, and less muscle atrophy were associated with successful coverage.\u003csup\u003e20)\u003c/sup\u003e Other studies have shown that partial repair may yield favorable short-term results but may deteriorate over time, including reductions in the acromiohumeral space.\u003csup\u003e3,19)\u003c/sup\u003e Therefore, repair strategies should be individualized according to tear pattern and tissue quality, with emphasis on maximizing footprint coverage.\u003c/p\u003e \u003cp\u003eBoth biceps and patch augmentation can improve outcomes in large to massive tears, although the optimal choice depends on the tear characteristics and the surgeon\u0026rsquo;s experience.\u003csup\u003e24,25)\u003c/sup\u003e Biceps augmentation is particularly advantageous in cases of anterior retracted tears when a healthy biceps tendon is available. The concept of biceps tendon augmentation for massive tears was first introduced by Rhee et al., who utilized the biceps tendon as an autograft between the torn RC and the greater tuberosity. In their series of sixteen patients, the average Constant score was 83.5, and MRI follow-up demonstrated tendon healing in 64.3% of cases.\u003csup\u003e5)\u003c/sup\u003e More recently, Green et al. conducted a systematic review of comparative studies and reported a lower re-tear rate in the biceps tendon autograft group compared with controls. The biceps tendon acts as a local autograft that provides structural scaffolds, enhances healing potential, and helps prevent superior migration of the humeral head (bridging augmentation). Patch augmentation may also offer mechanical support, modulate cellular activity at the tendon\u0026ndash;bone interface, and promote healing in large to massive tears (onlay or covering augmentation). When comparing bridging versus onlay augmentation biceps tendon autograft techniques, the onlay augmentation method demonstrated a lower re-tear rate (31.4% vs. 49.5%).\u003csup\u003e7)\u003c/sup\u003e We believe that secure suturing techniques and reinforcing grafts can reduce the mechanical load on the initial repair and improve the structural stability of the reconstructed tendon. Although biological grafts, such as autografts or allografts, have contributed to improved outcomes, fibrotic healing and relatively high re-tear rates persist.\u003csup\u003e16,25)\u003c/sup\u003e Original tendon fibers are the ideal graft material, but allodermal patch materials should be considered when a composite construct is indicated.\u003csup\u003e16,24)\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe most important findings of this study were that pain relief and functional improvement were consistently achieved following RC surgery, and that patients who underwent RC repair with biceps augmentation demonstrated increased acromiohumeral interval and better functional outcomes compared with those who received partial repair alone. This technique uses the biceps tendon to augment the primary RC repair construct, improving footprint coverage and securing the biceps tendon to the torn RC tendons and the greater tuberosity (as referred to RC\u0026ndash;biceps composite repair). This composite repair technique aligns with the fundamental mechanical principles of composite repair: removing compromised tissue, preparing a bond-ready surface, applying a structurally supportive layer, and establishing a mechanically stable interface.\u003csup\u003e9)\u003c/sup\u003e This technique aims to optimize both mechanical and biological incorporation between the RC and the biceps tendon, thereby enhancing durability and restoring the original footprint as effective as possible. This approach offers a viable treatment option for large to massive RC tears that aren\u0026rsquo;t suitable for primary repair. Open RC repair with biceps augmentation was sometimes performed in selected patients who were unable to undergo arthroscopy, even in these limited cases, a secure repair and acceptable footprint coverage were confirmed intraoperatively.\u003c/p\u003e \u003cp\u003eA major strength of this study is that it compared outcomes characteristics in age- and sex-matched cohorts, providing valuable insights into why the acromiohumeral space is preserved and how much footprint coverage is necessary to restore the shoulder biomechanics. Considerable care was taken to maximize humeral head coverage and secure repair constructs in large to massive RC tears. However, this study has several limitations. First, the small sample size increases the likelihood of type II errors. Enrollment was restricted due to the relatively low number of patients who underwent the RC repair with biceps augmentation technique, even under the care of a high-volume surgeon. Second, the retrospective study design introduces the potential for selection and information bias. Finally, small, non-normally distributed samples may reduce the statistical precision of the findings.\u003c/p\u003e \u003cp\u003eIn conclusion, arthroscopic RC repair with biceps augmentation was associated with increased acromiohumeral interval and better functional outcomes compared with RC partial repair alone, and improved footprint coverage might affect the outcomes. RC repair with biceps augmentation represents a simple and effective alternative for patients with large to massive RC tears that are not suitable for primary repair.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Sungkyunkwan university School of medicine, Samsung Changwon hospital, Institutional Review (SCMC 2025 07 011) and all participants provided informed, written consent. All research was conducted in accordance with the Declaration of Helsinki.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used during the current study are available from the corresponding author on reasonable request.\u0026nbsp;The data are not publicly available due to privacy\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003eNone\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSung Weon Jung was responsible for writing of the manuscript and qualified as corresponding author, and responsible for data collection. Sang Heun Kim and Hwan Kyu Jeong were responsible for data analysis and supervised data acquisition, and analysis. All authors have given final approval of the version to be published.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003eNone\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears. Am J Sports Med. 2012;40:2248\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGalatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired rotator cuff tears. J Bone Joint Surg Am. 2004;86:219\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFrank RM, Cvetanovich GL, Cole BJ. Biologic augmentation for massive rotator cuff tears. Am J Sports Med. 2018;46:2349\u0026ndash;57.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLe BT, Wu XL, Lam PH, Murrell GA. Factors predicting rotator cuff healing. J Bone Joint Surg Am. 2014;96:778\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCho NS, Lee BG, Rhee YG. Arthroscopic biceps augmentation for irreparable massive rotator cuff tears. Am J Sports Med. 2013;41:2314\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetri M, Warth RJ, Horan MP, Greenspoon JA, Millett PJ. Outcomes after arthroscopic rotator cuff repair with patch augmentation: biomechanical and clinical evaluation. Am J Sports Med. 2015;43:1247\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGreen A, Adler RS, et al. Systematic review of LHBT autograft augmentation for massive rotator cuff tears. Arthroscopy. 2024;40:112\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDenard PJ, Brady PC, Adams CR, Burkhart SS. Preliminary results of arthroscopic superior capsule reconstruction. Arthroscopy. 2018;34:93\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWalch G, Edwards TB, Boulahia A. Tenotomy versus tenodesis of the long head of the biceps in massive cuff tears. J Shoulder Elb Surg. 2005;14:59\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee BG, Cho NS, Rhee YG. Anterior cable reconstruction using the long head of the biceps tendon. Clin Orthop Surg. 2018;10:72\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElhassan BT, Wagner ER, Werthel JD. Tendon transfers for irreparable massive cuff tears. J Bone Joint Surg Am. 2016;98:183\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoum T, ElAttrache NS, Tibone JE, McGarry MH, Lee TQ. Biomechanical effects of biceps rerouting for massive cuff tear. Arthroscopy. 2013;29:111\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim DH, ElAttrache NS, Tibone JE, et al. Footprint contact characteristics: single-row vs double-row repair. Am J Sports Med. 2006;34:1174\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcClatchy SG, Parsell DE, Hobgood ER, Field LD. Augmentation of Massive Rotator Cuff Repairs Using Biceps Transposition Without Tenotomy Improves Clinical and Patient-Reported Outcomes: The Biological Superior Capsular Reconstruction Technique. Arthroscopy. 2024;40(1):47\u0026ndash;54. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.arthro.2023.06.014\u003c/span\u003e\u003cspan address=\"10.1016/j.arthro.2023.06.014\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBurkhart SS, Hartzler RU. Superior capsular reconstruction. Arthroscopy. 2014;30:372\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHan F, Kong CH, Hasan MY, Ramruttun AK, Kumar VP. Systematic review and meta-analysis of patch augmentation in rotator cuff repair. Am J Sports Med. 2019;47:1741\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoosmayer S, Lund G, Seljom US, et al. Randomized controlled trial of rotator cuff repair vs physiotherapy. J Bone Joint Surg Am. 2014;96:1504\u0026ndash;14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBaumgarten KM, Gerlach D, Galatz LM, et al. Factors predicting retear after rotator cuff repair. Am J Sports Med. 2010;38:455\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePark MC, McGarry MH, Campbell ST, et al. Biomechanics of margin convergence. Am J Sports Med. 2007;35:2004\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJung SW, Kim DH, Park TH, Park JY, Jeon JM. Humeral head coverage in arthroscopic partial repair of massive rotator cuff tears improves functional outcomes: an analysis of influential factors. J Shoulder Elb Surg. 2022;31(11):2233\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.jse.2022.03.030\u003c/span\u003e\u003cspan address=\"10.1016/j.jse.2022.03.030\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMall NA, Kim HM, Millett PJ, et al. Healing integrity after rotator cuff repair and clinical outcomes. J Bone Joint Surg Am. 2010;92:590\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMihata T, Lee TQ, Watanabe C, et al. Five- to ten-year follow-up after superior capsule reconstruction. Am J Sports Med. 2019;47:389\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKoh KH, Lim TK, Park YE, Lee SW, Park WH, Yoo JC. Preoperative factors affecting footprint coverage in rotator cuff repair. Am J Sports Med. 2014;42(4):869\u0026ndash;76. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/0363546513518581\u003c/span\u003e\u003cspan address=\"10.1177/0363546513518581\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCollin P, Treseder T, Denard PJ, et al. Classification of massive rotator cuff tears and surgical outcomes. Orthop Traumatol Surg Res. 2010;96:133\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSteinhaus ME, Makhni EC, Cole BJ, et al. Biologic augmentation for rotator cuff repair: an updated meta-analysis. Arthroscopy. 2016;32:284\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Figure","content":"\u003cp\u003eFigures are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"rotator cuff tear, large size, massive, margin convergence, biceps augmentation, partial repair, shoulder","lastPublishedDoi":"10.21203/rs.3.rs-8930567/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8930567/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe biceps tendon can be used as an option for augmentation in large to massive rotator cuff (RC) tears, although no definitive recommendations can be given. The purpose of the study was to compare the functional outcomes of arthroscopic RC repair with biceps augmentation with RC partial repair alone in treatment of large to massive tears.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective review of 175 patients with large to massive RC tears was conducted, and 45 patients who underwent RC repair with biceps augmentation were included. One or two margin convergences with the biceps tendon was performed to reduce the tear gap, and the repair of the torn RC to the original footprint using a combination of RC tendons and biceps tendon. Patients treated with the RC repair with biceps augmentation were placed in the biceps cohort and were age- and sex-matched 1:1 with a second cohort treated with RC partial repair alone, referred to as the partial cohort. Acceptable footprint coverage was defined when the humeral head was completely covered and small defect of footprint coverage was left during surgery. All patients were evaluated preoperatively and were followed up with a visual analog scale for pain, Constant score, radiographs, and ultrasonography.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 45 patients were included in the B cohort and 45 in the P cohort. Statistical analysis demonstrated significant differences in acceptable footprint coverage (34 vs. 15 cases), average acromiohumeral interval at final follow-up (8.6 vs. 7.5 mm), average Constant scores at final follow-up (79.8 vs. 75.2 points), and ultrasonographic findings of partial-to-intact healing (38 vs. 17 cases) between the two cohorts. Overall satisfactory outcomes were achieved in most patients regardless of biceps augmentation, the Constant scores of B cohort were significantly higher at final follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eArthroscopic RC repair with biceps augmentation was associated with increased acromiohumeral interval and better functional outcomes compared with RC partial repair alone, and improved footprint coverage might affect the outcomes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePrognostic, cohort study, therapeutic Level III\u003c/p\u003e","manuscriptTitle":"Biceps augmentation to improve the footprint coverage and functional outcomes in the treatment of large to massive rotator cuff tears","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-02 08:41:46","doi":"10.21203/rs.3.rs-8930567/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-03T09:01:04+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-02T13:35:46+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"189334183779608502571680106032308411974","date":"2026-03-23T22:15:03+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T19:32:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"214883260941555284228023630303066239453","date":"2026-03-15T20:52:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44595230497464893475467224838830520065","date":"2026-03-15T18:51:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"301124253577569205712560111297591738270","date":"2026-03-09T17:28:04+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-25T21:39:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-25T21:38:02+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-24T07:03:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-24T04:37:15+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2026-02-24T03:13:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d5301e8-6d46-40af-82a4-855f58a9c147","owner":[],"postedDate":"March 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T21:23:33+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-02 08:41:46","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8930567","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8930567","identity":"rs-8930567","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}