Arthroscopic rotator cuff repair

Arthroscopic rotator cuff repair is being performed by an increasing number of orthopaedic surgeons. The principles, techniques, and instrumentation have evolved to the extent that all patterns and sizes of rotator cuff tear, including massive tears, can now be repaired arthroscopically. Achieving a biomechanically stable construct is critical to biologic healing. The ideal repair construct must optimize suture-to-bone fixation, suture-to-tendon fixation, abrasion resistance of suture, suture strength, knot security, loop security, and restoration of the anatomic rotator cuff footprint (the surface area of bone to which the cuff tendons attach). By achieving optimized repair constructs, experienced arthroscopic surgeons are reporting results equal to those of open rotator cuff repair. As surgeons' arthroscopic skill levels increase through attendance at surgical skills courses and greater experience gained in the operating room, there will be an increasing trend toward arthroscopic repair of most rotator cuff pathology.     

Biologic and pharmacologic augmentation of rotator cuff repairs

As rotator cuff repair techniques have improved, failure of the tendon to heal to the proximal humerus is less likely to occur from weak tendon-to-bone fixation. More likely causes of failure include biologic factors such as intrinsic tendon degeneration, fatty atrophy, fatty infiltration of muscle, and lack of vascularity of the tendons. High failure rates have led to the investigation of biologic augmentation to potentially enhance the healing response. Histologic studies have shown that restoration of the rotator cuff footprint during repair can help reestablish the enthesis. In animal models, growth factors and their delivery scaffolds as well as tissue engineering have shown promise in decreasing scar tissue while maintaining biomechanical strength. Platelet-rich plasma may be a safe adjuvant to rotator cuff repair, but it has not been shown to improve healing or function. Many of these strategies need to be further defined to permit understanding of, and to optimize, the biologic environment; in addition, techniques need to be refined for clinical use.     

“Transosseous-Equivalent” Rotator Cuff Repair Technique

In order to optimize healing biology at a repaired rotator cuff footprint, we have developed a “transosseous-equivalent” rotator cuff repair that can be performed arthroscopically. What the arthroscopically repaired tendon experiences is “equivalent” to what is experienced with a traditional open suture-bridge technique. This repair maximizes the utility of a single-row repair technique by preserving the suture limbs of the medial single-row and bridging these sutures over the footprint insertion with distal-lateral interference screw suture fixation; the medial row uses a mattress suture configuration. The geometry of the construct compresses the tendon, optimizing tendon-to-tuberosity contact dimensions, while providing strength sufficient to withstand immediate postoperative rehabilitation.     

Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique

Rotator cuff repair via transosseous tunnels can improve footprint contact area and pressure when compared with suture anchor techniques. A double-row technique has been used clinically to improve footprint coverage by a repaired tendon. We hypothesized that a transosseous-equivalent rotator cuff repair via tendon suture bridges would demonstrate improved pressurized contact between the tendon and tuberosity when compared with a double-row technique. In 6 fresh-frozen human shoulders, a transosseous-equivalent rotator cuff repair was performed: a suture limb from each of 2 medial anchors was bridged over the tendon and fixed laterally with an interference screw (4 suture bridges). In 6 of the contralateral specimens, two types of repair were performed randomly in each specimen: (1) a double-row repair and (2) a transosseous-equivalent repair with a single screw (2 suture bridges). For all repairs, pressure-sensitive film was placed at the tendon-footprint interface, and software was used to obtain measurements. The mean pressurized contact area between the tendon and insertion was significantly greater for the 4-suture bridge technique (124.2 +/- 16.3 mm2, 77.6% footprint) compared with both the double-row (63.3 +/- 28.5 mm2, 39.6% footprint) and 2-suture bridge (99.7 +/- 22.0 mm2, 62.3% footprint) techniques (P < .05). The mean interface pressure exerted over the footprint by the tendon was greater for the 4-suture bridge technique (0.27 +/- 0.04 MPa) than for the double-row technique (0.19 +/- 0.01 MPa) (P = .002). The transosseous-equivalent rotator cuff repair technique can improve pressurized contact area and mean pressure between the tendon and footprint when compared with a double-row technique. A transosseous-equivalent technique, using suture bridges, may help optimize the healing biology at a repaired rotator cuff insertion.     

Editorial Commentary: Take What You're Given and Play the Best Shot You Can: The Load-Sharing Rip-Stop for Arthroscopic Repair of Retracted and Poor-Quality Rotator Cuff Tendon Tissue

The surgical management of chronic, large to massive rotator cuff tears is frequently complicated by the presence of retracted, poor-quality tendon tissue, and a number of adjunct techniques have been described to assist the surgeon in mobilizing tissues while minimizing the amount of tension placed on the final repair. The load-sharing rip-stop suture configuration is one such adjunct, and biomechanical data suggest that this construct may be superior to other suture configurations and may be associated with improved rotator cuff repair healing rates in situations that preclude a linked double-row repair.     

骨质疏松对肩袖损伤修复的影响研究进展

老年人群因合并有不同程度的骨质疏松,肩袖损伤修复再撕裂率高。为解决这一难题,手术医师尝试通过增加锚钉初始固定强度、改变局部骨质情况等方法来降低这类患者肩袖损伤的再撕裂率。组织工程学的快速发展也使生长因子的辅助应用成为可能。但在目前的临床工作中,合并有骨质疏松的肩袖损伤修复仍然是临床工作者面临的一个巨大挑战。如何更好地增加锚钉固定强度,改善腱骨愈合微环境,降低肩袖再撕裂率成为了近年来的研究热点。本文从骨质疏松与肩袖损伤的关系、骨质疏松对肩袖腱骨愈合的影响及目前采用的减少骨质疏松对腱骨愈合的不同方法3个方面进行综述,以便更好地指导临床治疗,提高患者的手术效果及术后满意率。     

Rotator cuff repair with a novel mesh suture: An ex vivo assessment of mechanical properties

Surgical repair is a common treatment for rotator cuff tear; however, the retear rate is high. A high degree of suture repair strength is important to ensure rotator cuff integrity for healing. The purpose of this study was to compare the mechanical performance of rotator cuffs repaired with a mesh suture versus traditional polydioxanone suture II and FiberWire sutures in a canine in vitro model. Seventy‐two canine shoulders were harvested. An infraspinatus tendon tear was created in each shoulder. Two suture techniques—simple interrupted sutures and two‐row suture bridge—were used to reconnect the infraspinatus tendon to the greater tuberosity, using three different suture types: Mesh suture, polydioxanone suture II, or FiberWire. Shoulders were loaded to failure under displacement control at a rate of 20 mm/min. Failure load was compared between suture types and techniques. Ultimate failure load was significantly higher in the specimens repaired with mesh suture than with polydioxanone suture II or FiberWire, regardless of suture technique. There was no significant difference in stiffness among the six groups, with the exception that FiberWire repairs were stiffer than polydioxanone suture II repairs with the simple interrupted technique. All specimens failed by suture pull‐out from the tendon. Based on our biomechanical findings, rotator cuff repair with the mesh suture might provide superior initial strength against failure compared with the traditional polydioxanone suture II or FiberWire sutures. Use of the mesh suture may provide increased initial fixation strength and decrease gap formation, which could result in improved healing and lower re‐tear rates following rotator cuff repair. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:987–992, 2018.

     

Arthroscopic Rotator Cuff Repairs: An Anatomic and Biomechanical Rationale for Different Suture-Anchor Repair Configurations

The goal of rotator cuff repairs is to achieve high initial fixation strength, minimize gap formation, maintain mechanical stability under cyclic loading, and optimize the biology of the tendon-bone interface until the cuff heals biologically to the bone. We have seen an evolution in our approaches to fixing rotator cuff tears from open to mini-open to all arthroscopic. In our arthroscopic techniques, we have also seen a change in the types of anchors and sutures we use and our repair techniques including an evolution in techniques that include single row, double row, and, most recently, transosseous equivalent fixation. Single-row repairs are least successful in restoring the footprint of the rotator cuff and are most susceptible to gap formation. Double-row repairs have an improved load to failure and minimal gap formation. Transosseous equivalent repairs have the highest ultimate load and resistance to shear and rotational forces and the lowest gap formation. This review will discuss the anatomy and biomechanics of a normal rotator cuff, the biomechanical factors that play a role in rotator cuff repairs, the initial fixation repair mechanics, and finally propose an algorithm for rotator cuff fixation based on tissue quality and tear configuration.     

Anatomic Reduction and Next-Generation Fixation Constructs for Arthroscopic Repair of Crescent,L-Shaped,and U-Shaped Rotator Cuff Tears

Emerging techniques and instrumentation have allowed orthopaedic surgeons to achieve rotator cuff repair through an all-arthroscopic technique. The most critical steps in rotator cuff repair consist of proper identification of the cuff tear pattern and anatomic restoration of the torn tendon footprint. With anatomic reduction of the rotator cuff tendons, a sound fixation construct can help restore rotator cuff contact pressure and kinematics, allowing for decreased repair tension and optimal healing potential. We provide surgical methods to recognize tear patterns and present a repair construct that will restore the anatomic footprint of the torn rotator cuff tendon. The key, initial maneuver to restore the anatomic footprint of the cuff includes placement of a suture anchor at the anterolateral corner for L-shaped tears and at the posterolateral corner for reverse L–shaped and U-shaped tears. After insertion of the medial-row anchors, the tendon stitches should be planned by use of a grasper to hold the tendon in a reduced position and guide location of the stitch. The lateral row with suture bridge can be visualized, and the final repair construct should produce an anatomic restoration of the rotator cuff footprint.     

促进肩袖止点腱骨愈合的研究进展

肩袖修补术是肩袖撕裂常用的治疗方式,能有效缓解肩关节疼痛,改善肩关节的活动,但肩袖修补术后肩袖再撕裂的发生率依然很高,主要原因在于肩袖修补术后肩袖止点处腱—骨愈合差,不能恢复原有的组织学结构和生物力学性能。因此,如何有效提高肩袖止点处腱骨愈合是解决此类问题的关键。目前随着人们对于肩袖止点研究的不断深入,各类治疗方法在改善肩袖止点腱骨愈合方面取得了较大的进展。本文将从影响肩袖止点处腱骨愈合的因素、肩袖止点处腱骨界面的恢复以利于肩袖腱骨愈合以及组织工程学在腱骨愈合中的应用3个方面阐述近几年关于肩袖腱骨愈合的研究进展,以期为肩袖撕裂的临床治疗提供一定的指导。     

Double-row arthroscopic rotator cuff repair: re-establishing the footprint of the rotator cuff

Recently, there has been an increased interest in the normal anatomy of the rotator cuff footprint and the re-establishment of the footprint during rotator cuff repair. Single-row suture anchor techniques have been criticized because of their inability to restore the normal medial-to-lateral width of the rotator cuff footprint. In this report, the authors describe a double-row technique for rotator cuff repair that re-establishes the normal rotator cuff footprint, increases the contact area for healing, and may potentially improve clinical results.     

The Evolution of Suture Anchors in Arthroscopic Rotator Cuff Repair

The advancement of suture anchor design and technology has fostered the transition from open to arthroscopic rotator cuff repair. Current suture-bridging constructs have greatly surpassed the biomechanical strength parameters of transosseous repairs and have shown impressive healing rates after arthroscopic rotator cuff repair. This review describes this evolution and discusses the important characteristics of suture anchors.     

Clinical Evidence Shows No Difference Between Single- and Double-Row Repair for Rotator Cuff Tears

Tears of the rotator cuff may be repaired by single- or double-row techniques. Single-row methods do not restore the rotator cuff footprint but do provide a good functional outcome. We surveyed the literature to ascertain the origin of the current trend of using double-row methods of repair. The footprint repair is a benefit of double-row fixation with strong evidence of its biomechanical success. However, the functional outcome of double-row fixation is equivalent to single-row fixation. Given the lack of scientific evidence and despite the enthusiasm of surgeons for this new technique, single-row fixation remains an acceptable method for managing these injuries, and it is our opinion that it is the preferable method.     

Double-Row Fixation of Upper Subscapularis Tears With a Single Suture Anchor

The recognition of and discussion of operative techniques for subscapularis tendon tears have lagged behind those for the posterosuperior rotator cuff. The advancement of shoulder arthroscopy has provided the opportunity to see the articular side of the rotator cuff and has led to increased recognition of subscapularis tears. Double-row fixation of the posterosuperior rotator cuff has become popular because of improved biomechanical strength, footprint restoration, and tendon healing compared with single-row fixation. Double-row fixation of the subscapularis, however, has been challenging because of the small anterior space overlying the subscapularis. Whereas the subacromial space allows freedom of movement, the limited subcoracoid space makes visualization, instrument manipulation, and knot tying more difficult. We describe a new technique for double-row fixation of the upper subscapularis footprint using a knotless technique without an additional anchor, which eases some of the aforementioned difficulties. The technique is indicated for partial- or full-thickness tears of the upper 50% of the subscapularis tendon and therefore applies to the majority of tears involving the subscapularis tendon.     

关节镜下肩袖损伤缝合技术研究进展

关节镜下肩袖修补术已非常普遍.许多单排锚钉、双排锚钉和经骨隧道修复技术应用于临床,但肩袖修复的最佳方法仍不清楚.生物力学研究证明相比于单排,双排锚钉修复的力度更强,而单排锚钉中的巨大肩袖缝合技术和改良Mason-Allen缝合技术力学性能最佳.临床研究显示双排锚钉修复能改善肩袖愈合率,但各种缝合技术的预后功能评分无明显...     

Arthroscopic Rotator Cuff Repair in 2019: Linked,Double Row Repair for Achieving Higher Healing Rates and Optimal Clinical Outcomes

The primary aim of rotator cuff repair surgery is to restore the musculotendinous units by creating a complete, tension-free repair construct that optimizes conditions for tendon-to-bone healing. There are many factors outside the control of the surgeon that are capable of affecting the healing process; however, there are also a number of important technical considerations that the surgeon can control, including familiarity with methods to deal with immobile tissues and techniques to perform novel repair constructs. It is clear that linked double row repairs are more likely to heal, and healed rotator cuff repairs best restore shoulder strength, improve patients' satisfaction, and maximize functional outcomes.     

Bone grafting of humeral head cystic defects during rotator cuff repair

Cystic bony defects of the humeral head greater tuberosity are often encountered during rotator cuff repair. These defects may be idiopathic, related to a patient's rotator cuff disease, or secondary to suture anchor placement from previous repairs. Some cysts are visible on preoperative magnetic resonance imaging, but most are discovered on footprint exploration or implant removal during revision surgery. These osseous defects reduce biological healing capacity and may decrease repair fixation strength. Bone grafting techniques are needed to address these defects. In this article, we present an arthroscopic allograft compaction technique with concomitant suture anchor rotator cuff repair.     

Rotator Cuff Repair: Patch the Shoulder

Rotator cuff tears are a common problem in our growing and aging population. Because of this, rotator cuff repair is consistently one of the most frequently performed operations by orthopaedic surgeons every year. Successful outcomes have been directly correlated to a successful repair to the tuberosity; however, healing rates have varied greatly depending on tear size, tear type, and tear chronicity. Despite advances in techniques and repair technology, healing rates have remained relatively stable.Improving the biology at the site of a rotator cuff repair has been proposed as a way of increasing healing rates. A recent bio-inductive patch has been introduced to improve the vascularity and collagen formation at the site of tendon repair. The implant is made from type I bovine collagen that is highly porous. It is nonstructural and does not provide any tensile strength. The patch improves collagen formation at the site of a repair, thus decreasing strain on the repaired tendon.Limited clinical trials involving the collagen patch have shown healing rates from 89% to 96% in small sample sizes. The patch has been successfully and safely applied in tear sizes ranging from partial thickness tears to massive tears, as well as primary and revision repair settings. To date, no adverse clinical reactions to the patch have been observed; however, no randomized clinical trials have been performed, and the patch is a significantly increased cost to the procedure.     

Editorial Commentary: “Knot” Less Strength at Half the Cost—Is It Time to Abandon Medial Row Anchors in Shoulder Double-Row Rotator Cuff Repair?

Transosseous equivalent rotator cuff repair is an expensive construct that has demonstrated biomechanical superiority when compared with other rotator cuff repair techniques. A novel transosseous knotless repair that substitutes medial row anchors for a transosseous tunnel rivals the biomechanical advantages of transosseous equivalent rotator cuff repair at half the cost and with reduced dependence on bone quality. Surgeons should carefully consider if “knotless transosseous is more.”