Suture Bridge and Transosseous Techniques

Abstract

Over the past 40 years, rotator cuff tear repair techniques have undergone a notable evolution. The surgical approach has progressed from open to mini-open to arthroscopic techniques. Currently, the clinical results reported with arthroscopic procedures are equivalent to those reported for both open and mini-open techniques [1–3]. However, despite good clinical outcomes, structural healing of the tendon to bone interface remains problematic. Failure rates after rotator cuff repairs remain high with retear rates ranging from 10 % in small tears up to 90 % in large to massive tears [3–10]. Though controversial, several studies have documented that healed rotator cuff tears have improved functional outcomes compared with tears that have not healed after rotator cuff repair [11, 12]. As postulated by Gerber et al. [13], from a biomechanical perspective, the goal of the rotator cuff repair should reasonably be the achievement of tendon healing through high initial fixation strength, minimal gap formation, and mechanical stability. Therefore, several arthroscopic techniques have been developed in the last decades. Arthroscopic procedures evolved from single-row [14, 15] to double row [16, 17], and recently to transosseous equivalent techniques [18–20] in an attempt to more closely reproduce the normal rotator cuff footprint anatomy. Double row repair was created to increase the footprint contact area and distribute the stress over multiple fixation points [16]. Numerous studies reported superior biomechanical properties of traditional double-row when compared to single-row fixation techniques, in terms of loading conditions and gap formation at time zero, contact area, and restoration of the anatomic footprint [21–26]. Much controversy remains about clinical correlation with biomechanical findings. Nho et al. [27] showed no difference between healing in single-row and double-row techniques. In contrast, Duquin et al. [12] demonstrated superior healing in rotator cuff tears repaired with double-row compared with single-row techniques. The transosseous equivalent, or suture bridge technique, has been developed to increase the compressive forces between the tendon and the bone interface, mimicking an open transosseous tunnel technique [18–20]. Technically, the major differences between the transosseous equivalent and the traditional double row fixation techniques are the suture bridge over the tendon and the more distal fixation points for the lateral row. The suture bridge connects the medial and lateral rows, as well as the anterior and posterior rows, allowing compression throughout the entire footprint. Compared with the traditional double-row technique, biomechanical studies showed that the suture bridge technique provide improved contact area and pressure between rotator cuff tendon and insertion footprint [28, 29]. Currently, transosseous equivalent techniques have largely replaced traditional double row techniques and various suture bridge configurations have been developed [30–36].