Arthroscopic Rotator Cuff Repair Using the Suture Loop Shuttle Technique

With the arthroscope in the posterior portal, several suture loops are passed through the rotator cuff via the superior lateral portal before the first anchor is inserted. The suture loop is created by passing both free ends of a No. 2 monofilament (48-inch Prolene, Ethilon, or PDS; Ethicon, Somerville, NJ) suture into an arthroscopic suture passing device. The free ends and the loop of each suture loop are temporarily transferred into the anterior cannula. Anchor insertion and passage of the anchored sutures are performed from posterior to anterior. With standard suture anchors, the loop end of the suture loop must be located on the undersurface of the cuff. The suture anchors are inserted one at a time through the superior lateral portal and are placed into the prepared holes. Anchored sutures are temporarily pulled out through the inferior lateral portal. Next, the free ends of the most posterior suture loop are retrieved through the superior lateral portal. The looped end of this suture loop is retrieved through the inferior lateral portal. The suture loop is used to shuttle a single anchored suture through the rotator cuff and out through the superior lateral portal. Then, the other anchored suture is retrieved through the superior lateral portal with a suture grasper and tied.     

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.     

Medial Rotator Cuff Failure After Arthroscopic Double-Row Rotator Cuff Repair

Persistent tendon defects after rotator cuff repair are not uncommon. Recently, the senior author has identified a subset of 5 patients (mean age, 52 years; range, 42 to 59 years) after arthroscopic double-row rotator cuff repair who showed an unusual mechanism of tendon failure. In these patients the tendon footprint appears well fixed to the greater tuberosity with normal thickness. However, medial to the intact footprint, the tendon is torn with full-thickness defects through the rotator cuff. All patients were involved in Workers' Compensation claims. Magnetic resonance arthrography showed an intact cuff footprint but dye leakage in all patients. Revision surgery was performed at a mean of 8.6 months after the index procedure and showed an intact rotator cuff footprint but cuff failure medial to the footprint. Four patients had repair of the defects by tendon-to-tendon side-to-side sutures, whereas one did not undergo repair. Medial-row failure of the rotator cuff is a previously unreported mechanism of failure after double-row rotator cuff repair. Given the small number of patients in this study, it is unclear whether these defects are symptomatic. However, repair of these defects resulted in improvement in pain in 4 of 5 patients.     

Arthroscopic Intratendinous Repair of the Delaminated Partial-Thickness Rotator Cuff Tear in Overhead Athletes

A distinct type of partial-thickness rotator cuff tear has been observed in overhead athletes, characterized by partial failure of the undersurface of the posterior supraspinatus and anterior infraspinatus tendons with intratendinous delamination. We present a technique of percutaneous intratendinous repair using nonabsorbable mattress sutures designed for the management of articular-side delaminated partial-thickness tears. After tear evaluation and preparation, the torn rotator cuff undersurface is held in a reduced position with a grasper through an anterolateral rotator interval portal while viewing intra-articularly. Two spinal needles are then placed percutaneously through the full thickness of the torn and intact rotator cuff. A polydioxanone suture is passed through each needle, retrieved out the anterior portal, and used to shuttle a single nonabsorbable No. 2 suture through the tissue, creating a mattress suture. Multiple mattress sutures can be placed as dictated by tear size and morphology, with suture retrieval and knot securing then proceeding in the subacromial space. We have adopted this approach with the goals of anatomically re-establishing the rotator cuff insertion and sealing the area of intratendinous delamination while preventing significant alteration to the anatomy of the rotator cuff insertion, which could lead to motion deficits, internal impingement, and potential tear recurrence.     

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.     

Biomechanical Fixation in Arthroscopic Rotator Cuff Repair

Rotator cuff repair remains a challenging and rapidly evolving field. Several recent studies have shown that arthroscopic repair yields functional results similar to those of mini-open and open procedures, with all of the benefits of minimally invasive surgery. However, the “best” repair construct remains relatively unknown, with wide variations in surgeon preference and conflicting evidence in the literature. The most recent developments in basic science, suture and suture anchor technology, and innovative prospects for arthroscopic rotator cuff repair are reviewed.     

Clinical and Radiological Evaluation after Arthroscopic Rotator Cuff Repair Using Suture Bridge Technique

Background

We retrospectively assessed the clinical outcomes and investigated risk factors influencing retear after arthroscopic suture bridge repair technique for rotator cuff tear through clinical assessment and magnetic resonance arthrography (MRA).

Methods

Between January 2008 and April 2011, sixty-two cases of full-thickness rotator cuff tear were treated with arthroscopic suture bridge repair technique and follow-up MRA were performed. The mean age was 56.1 years, and mean follow-up period was 27.4 months. Clinical and functional outcomes were assessed using range of motion, Korean shoulder score, Constant score, and UCLA score. Radiological outcome was evaluated with preoperative and follow-up MRA. Potential predictive factors that influenced cuff retear, such as age, gender, geometric patterns of tear, size of cuff tear, acromioplasty, fatty degeneration, atrophy of cuff muscle, retraction of supraspinatus, involved muscles of cuff and osteolysis around the suture anchor were evaluated.

Results

Thirty cases (48.4%) revealed retear on MRA. In univariable analysis, retear was significantly more frequent in over 60 years age group (62.5%) than under 60 years age group (39.5%; p = 0.043), and also in medium to large-sized tear than small-sized tear (p = 0.003). There was significant difference in geometric pattern of tear (p = 0.015). In multivariable analysis, only age (p = 0.036) and size of tear (p = 0.030) revealed a significant difference. The mean active range of motion for forward flexion, abduction, external rotation at the side and internal rotation at the side were significantly improved at follow-up (p < 0.05). The mean Korean shoulder score, Constant score, and UCLA score increased significantly at follow-up (p < 0.01). The range of motion, Korean shoulder score, Constant score, and UCLA score did not differ significantly between the groups with retear and intact repairs (p > 0.05). The locations of retear were insertion site in 10 cases (33.3%) and musculotendinous junction in 20 cases (66.7%; p = 0.006).

Conclusions

Suture bridge repair technique for rotator cuff tear showed improved clinical results. Cuff integrity after repair did not affect clinical results. Age of over 60 years and size of cuff tear larger than 1 cm were factors influencing rotator cuff retear after arthroscopic suture bridge repair technique.     

Arthroscopic Transosseous Reinsertion of the Rotator Cuff

Abstract Objective: Arthroscopic reinsertion of the supraspinatus and infraspinatus tendons by means of imitation of an open trans osseous reinsertion technique. Indications: Tears in the tendon cuffs of the supraspinatus and infraspinatus muscles. Patients < 75 years of age. Contraindications: Retracted tendons that cannot be sufficiently mobilized to provide a tension-free reinsertion. Tears of the tendon cuff of the subscapsularis muscle. Surgical Technique: The free edges of the tendons are sparingly resected. The tendon attachment site on the greater tuberosity is freed of soft tissue and decorticated using an arthroscopic bone burr. A full-radius burr is used to drill insertion sites for the sutures in the tuberosity. A hollow needle is inserted percutaneously to puncture the free edges of the tendon for a single reinsertion suture. The hollow needle is then fed through the greater tuberosity to the lateral portal. The suture is guided through the needle and advanced via a working cannula. If the tear is > 2 cm in width, a mattress suture should be placed via another channel in the bone. This is to provide plane contact of the tendon to the reinsertion site. Postoperative Management: Restriction of movement using a shoulder bandage for 6 weeks after the operation. Results: In the 75 patients treated using a single suture, there was an improvement compared to the related Constant Score from 55.8% before the operation to 80.4% at the follow-up examination, after an average of 26.8 months. The average age in this group was 58.2 years (range 35–75 years). In the 21 patients treated with a mattress suture, there was an improvement compared to the related Constant score from 59% before the operation to 83% at 14.3 months after the operation. The average age in this group was 58 years (range 35–75 years). The following is a reprint from Operat Orthop Traumatol 2006;18:1–18 and continues the new series of articles at providing continuing education on operative techniques to the European trauma community. Reprint from: Oper Orthop Traumatol 2006;18:1–18 DOI 10.1007/s00064-006-1159-1