Mattress suture-bridge technique for bursal-side partial-thickness rotator cuff tears

The standard procedure used to repair partial-thickness tears involves initial progression of the lesion to a full-thickness tear prior to tendon repair. However, the option for a bursal-side partial-thickness rotator cuff tear includes the preservation of as much of the remaining intact fibers as possible. Instead of inserting suture anchors in the medial row, as in the conventional suture-bridge technique, two mattress sutures are inserted into the rotator cuff. Full-thickness access is achieved using a percutaneous spinal needle and medial mattress sutures to preserve the articular bone attachment of the remnant fibers and to compress the repaired tendon on the footprint. Our method can help preserve the remnant rotator cuff tendon without tissue damage and can restore the normal rotator cuff footprint.     

“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.     

Arthroscopic double-pulley suture-bridge technique for rotator cuff repair

After preparation of the bone bed, two doubly loaded suture anchors with suture eyelets are inserted at the articular margin of the greater tuberosity. A retrograde suture-passing instrument penetrates the rotator cuff to retrieve the sutures through the modified Neviaser or subclavian portal. An ipsilateral pair of suture eyelets in the suture anchor is passed through the margins of the rotator cuff tear. The blue suture of the second and third pair is pulled out of the lateral cannula, and the threaded blue suture of the third pair in the needle is passed through the blue suture of the second pair. After retrieving the blue suture of the first pair through the anterior portal, it is pulled out to pass the blue suture of the third pair through the eyelet of the anteromedial anchor. The blue suture is linked between two anchors. The medial row of suture-bridge is repaired with a sliding knot, and the sutures are not cut. Once the rotator cuff repair using the suture-bridge technique has been performed, the two blue strands in the anterior portal are tied. We describe our technique that possesses the advantages of both the double-pulley and suture-bridge techniques, which improves the pressurized contact area and maximizes compression along the medial row.     

Arthroscopic rotator cuff repair using a single-row of triple-loaded suture anchors with a modified suture configuration

Achieving an adequate restoration of the muscle–tendon–bone unit and the anatomical footprint is essential for a successful outcome in open and arthroscopic rotator cuff repair. The described suture grasping technique using triple-loaded suture anchors might combine high initial fixation strength with good footprint coverage. It describes two mattress’ stitches medial at the articular margin of the tendon. Additionally, a third mattress stitch is performed laterally to increase footprint contact and avoid dog-ear deformity. The triple-mattress repair is easy to perform and might be a good alternative in either arthroscopic or open rotator cuff repair.     

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.     

Arthroscopic Fixation for Displaced Greater Tuberosity Fracture Using the Suture-Bridge Technique

With the described technique, two bioabsorbable suture anchors are inserted to create a medial row through the intact cuff for fixation of the fragment of the greater tuberosity. The medial row is repaired with a sliding knot. After confirmation of the fracture site, pilot holes for a PushLock anchor (Arthrex, Naples, FL) are prepared directly in line with the medial anchors and approximately 5 to 10 mm distal to the lateral edge of the fragment of the greater tuberosity. A suture strand from each anchor in the medial row is retrieved. Both suture strands are threaded through the PushLock eyelet on the distal end of the driver. The anchor is advanced completely into the pilot hole. These steps are repeated for a second anchor. If a dog-ear deformity is observed at the margin after complete reduction of the greater tuberosity, a stitch is made by use of a suture hook and one strand of the uncut suture from the lateral row of the joint via the modified suture-bridge technique. Arthroscopic reduction and internal fixation of displaced greater tuberosity fractures with the suture-bridge technique described by us provide adequate fixation with improvement of the pressurized contact area of the fracture and can be used as an additional modality of arthroscopic treatment.     

The low-profile Roman bridge technique for knotless double-row repair of the rotator cuff

With advances in arthroscopic surgery, many techniques have been developed to increase the tendon–bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint and providing a better environment for tendon healing. We present a low-profile arthroscopic rotator cuff repair technique which uses suture bridges to optimize rotator cuff tendon–footprint contact area and mean pressure. A 5.5 mm Bio-Corkscrew suture anchor (Arthrex, Naples, FL, USA), double-loaded with No. 2 FiberWire sutures (Arthrex, Naples, FL, USA), is placed in the anteromedial aspect of the footprint. Two suture limbs from a single suture are both passed through a single anterior point in the rotator cuff. One suture limb is retrieved from the cannula. The second suture limb is passed through a single posterior point in the rotator cuff producing two points of fixation in the tendon, with a tendon bridge between them. The same suture limb is retrieved through the lateral portal, and then inserted into the bone by means of a Pushlock (Arthrex, Naples, FL, USA), placed approximately 1.5–2 cm posterior to the first anchor. This second suture is passed again in the posterior aspect of the cuff. The limbs of the first suture are pulled to compress the tendon in the medial aspect of the footprint. The two free suture limbs are used to produce suture bridges over the tendon by means of a Pushlock (Arthrex, Naples, FL, USA), placed 1 cm distal to the lateral edge of the footprint relative to the medially placed suture anchors anterior to posterior. This technique allows us to perform a low-profile (single pulley–suture bridges) repair for knotless double-row repair of the rotator cuff.     

A New Approach to Improving the Tissue Grip of the Medial-Row Repair in the Suture-Bridge Technique: The “Modified Lasso-Loop Stitch”

The double-row rotator cuff repair has proved to be biomechanically superior to the single-row technique. However, this has not been shown clinically. At the moment, all the methods proposed for medial-row suturing in the suture-bridge technique recommend a mattress suture or a simple stitch. The lasso-loop stitch has been proposed as a technique to improve tissue grip and has been used in open rotator cuff repairs, in biceps tenodesis, and in the Bankart procedure. We propose a method in which a modified version of this stitch can be used to repair the medial row of a double-row repair. In the “modified lasso-loop stitch,” a circumferential stitch is constructed over the posteromedial and anteromedial anchor. This stitch exerts an appropriate amount of radial compression on the encased tendon as the tails of the posteromedial and anteromedial suture are fixed to the anterolateral anchor. Through this technique, the reduction force is augmented and a compression force is created, thus allowing restoration of the rotator cuff footprint. This technique provides a strong cuff-suture interface while appropriate tensioning of the modified lasso-loop stitch allows minimal strangulation of the tendon. This technique has been shown to work with and without a knot.     

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.     

Arthroscopic bone tunnel augmentation for rotator cuff repair

Transosseous repair of the rotator cuff has been shown to recreate the anatomic rotator cuff footprint in a secure and cost-efficient manner. However, the potential for sutures cutting through bone remains a concern with this strategy. Devices have been used successfully during open transosseous rotator cuff repair to augment the bone tunnels, potentially avoiding suture cut-out through the weak bone of the greater tuberosity. Recently, arthroscopic transosseous fixation of rotator cuff tears has become an alternative to arthroscopic suture anchor and open transosseous techniques. This method is expected to have the same potential pitfalls at the bone-suture interface as the open technique. The authors describe a technique for rotator cuff repair using a secure method of arthroscopic bone tunnel augmentation.     

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 Double-Pulley Technique for Double-Row Rotator Cuff Repair

In an effort to maximize the area of footprint coverage, we developed the “double-pulley technique” for double-row rotator cuff repairs. Two suture anchors are inserted at the articular margin of the greater tuberosity (one anterior and one posterior). All 4 suture strands from each anchor are passed through a single medial point on the torn cuff. In this way, the 4 suture strands from the anteromedial anchor pass through 1 point in the cuff and the 4 strands from the posteromedial anchor pass through a different point in the cuff. A suture strand from 1 anchor is tied extracorporeally to a suture strand of the same color from the other anchor. The other ends of those 2 strands are then pulled, thereby delivering this extracorporeal knot into the joint and over the medial footprint. These 2 free suture strands are then tied together as a static knot. The procedure is repeated with the other sutures. This technique creates a double mattress suture medially, which compresses the intervening tendon bridge against its bone bed. We call this procedure the double-pulley technique because it uses the anchor eyelets as pulleys to deliver the extracorporeal knot into the shoulder. After the lateral row repair is performed, the rotator cuff footprint will be completely reconstituted.     

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.     

Current Biomechanical Concepts for Rotator Cuff Repair

For the past few decades, the repair of rotator cuff tears has evolved significantly with advances in arthroscopy techniques, suture anchors and instrumentation. From the biomechanical perspective, the focus in arthroscopic repair has been on increasing fixation strength and restoration of the footprint contact characteristics to provide early rehabilitation and improve healing. To accomplish these objectives, various repair strategies and construct configurations have been developed for rotator cuff repair with the understanding that many factors contribute to the structural integrity of the repaired construct. These include repaired rotator cuff tendon-footprint motion, increased tendon-footprint contact area and pressure, and tissue quality of tendon and bone. In addition, the healing response may be compromised by intrinsic factors such as decreased vascularity, hypoxia, and fibrocartilaginous changes or aforementioned extrinsic compression factors. Furthermore, it is well documented that torn rotator cuff muscles have a tendency to atrophy and become subject to fatty infiltration which may affect the longevity of the repair. Despite all the aforementioned factors, initial fixation strength is an essential consideration in optimizing rotator cuff repair. Therefore, numerous biomechanical studies have focused on elucidating the strongest devices, knots, and repair configurations to improve contact characteristics for rotator cuff repair. In this review, the biomechanical concepts behind current rotator cuff repair techniques will be reviewed and discussed.     

Arthroscopic Fixation of Bursal-Sided Rotator Cuff Tears

Subacromial decompression and debridement of partial-thickness bursal-sided rotator cuff tears are often reported with a high rate of unsatisfactory outcomes. We describe an arthroscopic procedure to repair partial-thickness bursal-sided rotator cuff tears without converting to a full-thickness tear in patients with a normal articular-sided rotator cuff and an A0B2 or A0B3 pattern of tear (minimum thickness of 25% to 75%). The articular side of the rotator cuff experiences greater tension than the bursal side of the cuff. As such, by leaving the articular footprint intact, we accomplish 3 goals: the intact articular fibers act as an internal splint to protect the bursal-sided repair, a wide and anatomic footprint is recreated, and we are able to minimize any length-tension mismatch because the tissue is not excessively lateralized with repair. After bursectomy and acromioplasty, the frayed edges of the bursal flap are gently debrided and the tuberosity is excoriated to bleeding bone. One or two bioabsorbable anchors are placed, and both sutures are placed through the full thickness of the rotator cuff (one anterior and one posterior) by use of a percutaneous suture lasso in this manner: (1) the lasso is passed through the full thickness of the cuff, and the nitinol wire is shuttled out of a single cannula along with the more medial of the suture limbs; (2) the nitinol wire is then pulled back out of the percutaneous portal along with the suture limb, with the suture being passed through the full thickness of the cuff; and (3) the procedure is repeated for the posterior limb of the suture after a lasso is again passed through the full thickness of the rotator cuff in a more posterior position. This subset of patients is treated with an aggressive rehabilitation protocol because the intact articular rotator cuff fibers act as an internal splint to protect the bursal repair.     

Does an Arthroscopic Suture Bridge Technique Maintain Repair Integrity?: A Serial Evaluation by Ultrasonography

Biomechanical studies suggest a suture bridge technique enhances rotator cuff tendon footprint contact area, holding strength, and mean contact pressure. Based on these studies, we asked whether (1) the suture bridge technique would provide a high rate of cuff integrity after surgery, (2) the status of the repaired cuff would change with time, (3) preoperative factors could predict postoperative cuff integrity, and (4) patients with retears had less favorable pain, functional scores, range of motion (ROM), and muscle strength compared with those with intact repairs. We prospectively followed 78 patients with arthroscopic repairs in whom we used the suture bridge technique. The integrity of the rotator cuff repair was determined using ultrasonographic evaluation at 4.5 and 12 months after surgery. Ultrasonography revealed intact cuffs in 91% at 4.5 months postoperatively, all of which were maintained at the 12-month followup. Failure rates were 17.6% (three of 17) for massive tears, 11.1% (two of 18) for large tears, 6.3% (two of 32) for medium tears, and no failures for small tears. Preoperative fatty degeneration of the supraspinatus muscle was a strong predictor of cuff integrity. We found no correlation between the integrity and clinical outcomes except for a temporary decrease of abduction strength at 6 months. Arthroscopic repair using suture bridge technique can achieve a low retear rate in shoulders treated for rotator cuff tears, but the occurrence of retear did not influence the outcome.     

Arthroscopic Grafting of Greater Tuberosity Cyst and Rotator Cuff Repair

Cysts of the greater tuberosity can be a normal finding independent of age and concurrent rotator cuff tear. The presence of a large greater tuberosity cyst can present a challenge at the time of rotator cuff repair. We present a 1-step arthroscopic technique to address these defects at the time of rotator cuff repair using a synthetic graft (OsteoBiologics, San Antonio, TX) originally designed to address osteoarticular defects. With the viewing portal established laterally, a portal allowing perpendicular access to the cyst is established. The cyst is thoroughly debrided, and a drill sleeve is then introduced perpendicular to the surrounding bone, serving as a guide for the matching drill to create a circular socket. A correspondingly sized TruFit BGS cylindrical implant (OsteoBiologics) is then implanted by use of the included instrumentation. The scaffold is placed flush with the surrounding bone. Because our arthroscopic rotator cuff protocol uses a tension-band technique with placement of suture anchors distal and lateral to the rotator cuff footprint, we are subsequently able to proceed with routine rotator cuff repair.     

关节镜下单排带线锚钉修补结合大结节骨髓刺激治疗大到巨大肩袖撕裂

目的研究关节镜下单排带线锚钉修补结合大结节骨髓刺激技术治疗大到巨大肩袖撕裂的临床效果。 方法对24例大到巨大肩袖撕裂患者,在关节镜下采用肩袖止点内移单排带线锚钉修补,并在修补肌腱外侧大结节裸露足印区打孔。术后按照康复计划渐进性康复训练。手术前和术后12个月对患肩采用VAS、UCLA、ASES评分系统进行疼痛和功能评估;并在术后第3天、3个月和12个月进行肩关节磁共振检查,观察肩袖修补和大结节足印区软组织覆盖情况。 结果所有患者随访12个月,术前和术后12个月VAS评分分别为（6.3±1.9）分和（0.4±0.1）分（P<0.05）,UCLA评分分别为（10.1±4.5）分和（30.4±4.2）分（P<0.05）,ASES评分分别为（27.9±17.8）分和（77.6±17.5）分（P<0.05）,所有手术肩关节疼痛和运动能力均较术前明显改善。术后12个月磁共振随访发现2例肩袖再撕裂发生,矢状位显示撕裂宽度均<1 cm;冠状位盂上切迹平面大结节足印区组织覆盖率在术后第3天、3个月、12个月平均分别为34.3%、89.1%和88.7%。 结论关节镜下肩袖单排带线锚钉修补结合大结节骨髓刺激技术治疗大到巨大肩袖撕裂能够提供可靠的修补,显著缓解疼痛,恢复肩关节功能并促进术后大结节足印区软组织覆盖。     

Mode of failure for rotator cuff repair with suture anchors identified at revision surgery

Rotator cuff tears are a common cause of shoulder pain and dysfunction. After surgical repair, there is a significant re-tear rate (25%-90%). The aim of this study was to determine the primary mode of mechanical failure for rotator cuffs repaired with suture anchors at the time of revision rotator cuff repair. We prospectively followed 342 consecutive torn rotator cuffs, repaired by a single surgeon using suture anchors and a mattress-suturing configuration. Of those shoulders, 21 (6%) subsequently underwent a revision rotator cuff repair by the original surgeon, and 1 underwent a second revision repair. Intraoperative findings, including the mode of failure, were systematically recorded at revision surgery and compared with the findings at the primary repair. In addition, 81 primary rotator cuff repairs had a radiographic and fluoroscopic evaluation at a mean of 37 weeks after repair to assess for any loosening or migration of the anchors. At revision rotator cuff repair, the predominant mode of failure was tendon pulling through sutures (19/22 shoulders) (P <.001). Two recurrent tears occurred in a new location adjacent to the previous repair, and one anchor was found loose in the supraspinatus tendon. The mean size of the rotator cuff tear was larger at the revision surgery (P =.043), the tendon quality ranked poorer (P =.013), and the tendon mobility decreased (P =.002), as compared with the index procedure. The radiographs and fluoroscopic examination showed that all 335 anchors in 81 patients were in bone. Rotator cuff repairs with suture anchors that underwent revision surgery failed mechanically by three mechanisms, the most common of which was tendon pulling through sutures. This suggests that the weak link in rotator cuff repairs with suture anchors and horizontal mattress sutures, as determined at revision surgery, is the tendon-suture interface.     

Arthroscopic transhumeral rotator cuff repair: Giant needle technique

An arthroscopic transhumeral rotator cuff repair technique is presented with which the same type of cuff repair can be performed as with an open standard procedure. After adequate arthroscopic subacromial decompression, a bone trough is made on the greater tuberosity and a hole is punctured with a sharp hook. A special bone-cutting needle with a suture (giant needle) is then passed through the skin and deltoid muscle in front of the acromion, through the torn tendon, the hole in the trough, and out through the lateral cortical surface through the deltoid and skin. The suture limbs are pulled out through the instrumentation portal and a sliding knot is made to close the defect. No hardware implants are used and the procedure is not technically complicated. During surgery only two thirds of the steps used for open repair were required. With experience, a large tear was repaired as well as with an open repair. The advantages of this technique are that the strength of cuff fixation does not rely on the quality of the bone in the greater tuberosity, there is no need for complicated suture passing techniques through the rotator cuff, and it offers the same fixation technique as the traditional open repair.Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 18, No 2 (February), 2002: pp 218–223