Double-row Rotator Cuff Repair Research Articles

Arthroscopic Knotless Double-Row Rotator Cuff Repair Without Side-to-Side Suture Placement

Arthroscopic Knotless Double-Row Rotator Cuff Repair Without Side-to-Side Suture Placement

Comparison of Mechanical Stability in Double-Row Rotator Cuff Repairs Between a Knotless Transtendon Construct Versus the Addition of Medial Knots

Our purpose was to investigate the importance of medial-row knot tying to mechanical stability in a double-row rotator cuff repair by comparing a knotless construct with transtendon anchor passage versus a similar construct implementing medial knots. A standard defect was created in the infraspinatus tendons of 14 bovine humeri. All defects were repaired with 2 medial and 2 lateral anchors (SutureCross System; KFx Medical, Carlsbad, CA). The medial anchors were either placed by transtendon passage in a knotless construct or placed directly into bone with needle passage of suture to create bursal-sided knots medially. Constructs were subjected to a cyclic loading protocol and then loaded to failure. The medially knotted constructs had a statistically higher stiffness at both the initial and final cycles (P < .001 and P < .001, respectively) and a lower displacement during cyclic loading (P < .02). There were strong trends toward decreased gauge displacement (P = .12) and decreased cycles to 3 mm of displacement (P = .07) in the medially knotted group. Maximal yield strength was greater in the medially knotted group (350 +/- 270 N v 650 +/- 530 N), although this was not found to be statistically significant (P = .5). Our data suggest that creation of medial knots increases construct stiffness and stability in arthroscopic double-row cuff repair. This is likely because of increased load transfer to the lateral anchor and suture-tendon interface in the knotless construct. Medial knots create increased mechanical stability that theoretically may improve rotator cuff healing. This mechanical advantage must be weighed against surgical efficiency, with consideration given to factors such as tissue quality.

Early Structural and Functional Outcomes for Arthroscopic Double Row Transosseous Equivalent Rotator Cuff Repair (SS-02)

Several investigators have studied the clinical outcomes after arthroscopic repair and have reported that the short-term clinical outcomes are comparable. However, the influence of the repair technique on the failure rates and functional outcomes after open or arthroscopic rotator cuff repair remains controversial. Several studies have evaluated biomechanical strength, contact area, and failure modes of single-row suture anchor, double-row suture anchor, as well as transosseous repairs and their ability to restore native the native rotator cuff. We present here out data from 155 consecutive patients who underwent double-row transosseous equivalent (suture bridge technique) rotator cuff repairs. Between June 2006 and October 2007, 225 patients underwent the arthroscopic double-row transosseous equivalent repair of a torn rotator cuff at two surgical centers. One hundred and fifty-five of these patients were available for follow up at an average of 15 months postoperatively. At this evaluation, patients had either an MRI or CT arthrogram of the operative shoulder. The Constant scores, pain ranking (0-15 scale), forward flexion and strength were also collected at the follow up examination. Failure rates were determined based on analysis of the radiographic outcomes. During this period 155 patients were clinically and radiologically evaluated at a mean of 15 months (5.5-26.1). 54% male 46% female at an average age of 57.73 years (18-80). 47, 89, 19 patients had Patte type I, II, III lesions (respectively). Mean preoperative Constant Score improved from 44.21 (23-66) to 80.41 (40-96) p<0.001 at follow up. Mean preoperative pain score improved from 3.83 (0-10) to 12.83 (5-15) p<0.001 at follow up. Mean preoperative forward flexion improved form 122.22 (60-170) to 162.44 (15-170) p<0.001. 35% (54 patients) had an arthrogram, 65% (100 patients) had an MRI and 0.7% (1 patient) during or after their follow up evaluation. Imaging demonstrated that 92%, 80%, 58% of the Type I, II, III lesions respectively were intact at follow up. The results of this study indicate that the transosseous equivalent double-row rotator cuff repair (the suture bridge technique) has excellent results at greater than 1 year follow up.

Bridging Self-Reinforcing Double-Row Rotator Cuff Repair: We Really Are Doing Better

Single-row versus double-row repair of rotator cuff tears is currently a controversial topic. In this Level V article, we articulate why we believe that second-generation double-row repair techniques, which use bridging sutures to link the 2 rows of suture anchors together in a self-reinforcing manner, are producing superior clinical and biomechanical results.

Single-row versus double-row arthroscopic rotator cuff repair in small- to medium-sized tears

Double-row rotator cuff repair leads to superior cuff integrity and clinical results compared with single-row repair. The study enrolled 68 patients with a full-thickness rotator cuff tear who were divided into 2 groups of 34 patients according to repair technique. The patients were followed-up for at least 2 years. The results were evaluated by Constant score. Despite the biomechanical studies and cadaver studies that proved the superiority of double-row fixation over single-row fixation, our clinical results show no difference in functional outcome between the two methods. It is evident that double-row repair is more technically demanding, expensive, and time-consuming than single-row repair, without providing a significant improvement in clinical results. Comparison between groups did not show significant differences. At the final follow-up, the Constant score was 82.2 in the single-row group and 78.8 in the double-row group. Functional outcome was improved in both groups after surgery, but the difference between the 2 groups was not significant. At long-term follow-up, arthroscopic rotator cuff repair with the double-row technique showed no significant difference in clinical outcome compared with single-row repair in small to medium tears.

Arthroscopic rotator cuff repair: Scientific rationale, surgical technique, and early clinical and functional results of a knotless self-reinforcing double-row rotator cuff repair system

Rotator cuff repair has shown to improve shoulder function and reduce pain experienced by patients. Successful repairs should have high fixation strength, allow minimal gap formation, maintain stability, and restore normal anatomy and function of the supraspinatus footprint. The purpose of this study is to describe our preferred method for rotator cuff repair using a knotless self-reinforcing double-row system, and to cite biomechanical data rationalizing its use. Seventeen of 22 patients were identified as undergoing primary rotator cuff repair with minimum follow-up of 1 year (mean, 535 days; range, 370-939). The average age was 63 (range, 43-79). Data collected included average pain today, average worst pain, Single Assessment Numeric Evaluation (SANE), and patient satisfaction. For all patients, average pain today and average worst pain decreased and functional scores (SANE) increased. Patient satisfaction was 9.8 out of 10 (range, 7-9). The patients also began rehabilitation earlier and returned to full activities at 4 months. These results indicate that the knotless self-reinforcing double-row repair system is a viable option in treating rotator cuff tears. This system provides improved contact area and restores the native footprint of the tendon leading to better outcomes.

Single-row Versus Double-row Rotator Cuff Repair: Techniques and Outcomes

Double-row rotator cuff repair techniques incorporate a medial and lateral row of suture anchors in the repair configuration. Biomechanical studies of double-row repair have shown increased load to failure, improved contact areas and pressures, and decreased gap formation at the healing enthesis, findings that have provided impetus for clinical studies comparing single-row with double-row repair. Clinical studies, however, have not yet demonstrated a substantial improvement over single-row repair with regard to either the degree of structural healing or functional outcomes. Although double-row repair may provide an improved mechanical environment for the healing enthesis, several confounding variables have complicated attempts to establish a definitive relationship with improved rates of healing. Appropriately powered rigorous level I studies that directly compare single-row with double-row techniques in matched tear patterns are necessary to further address these questions. These studies are needed to justify the potentially increased implant costs and surgical times associated with double-row rotator cuff repair.

Tension band versus single and double row rotator cuff repair a biomechanical analysis

Tension band versus single and double row rotator cuff repair a biomechanical analysis

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

We report 4 cases of medial-row failure after double-row arthroscopic rotator cuff repair (ARCR) without arthroscopic subacromial decompression (ASAD), in which there was pullout of mattress sutures of the medial row and knots were caught between the cuff and the greater tuberosity. Between October 2006 and January 2008, 49 patients underwent double-row ARCR. During this period, ASAD was not performed with ARCR. Revision arthroscopy was performed in 8 patients because of ongoing symptoms after the index operation. In 4 of 8 patients the medial rotator cuff failed; the tendon appeared to be avulsed at the medial row, and there were exposed knots on the bony surface of the rotator cuff footprint. It appeared that the knots were caught between the cuff and the greater tuberosity. Three retear cuffs were revised with the arthroscopic transtendon technique, and one was revised with a single-row technique after completing the tear. ASAD was performed in all patients. Three of the four patients showed improvement of symptoms and returned to their preinjury occupation. Impingement of pullout knots may be a source of pain after double-row rotator cuff repair.

Biomechanical Advantages of Triple-Loaded Suture Anchors Compared With Double-Row Rotator Cuff Repairs

Biomechanical Advantages of Triple-Loaded Suture Anchors Compared With Double-Row Rotator Cuff Repairs

Clinical Outcomes of Double-Row Versus Single-Row Rotator Cuff Repairs

Clinical Outcomes of Double-Row Versus Single-Row Rotator Cuff Repairs

Clinical Outcomes of Double-Row Versus Single-Row Rotator Cuff Repairs

Clinical Outcomes of Double-Row Versus Single-Row Rotator Cuff Repairs

Biomechanical Advantages of Triple-Loaded Suture Anchors Compared With Double-Row Rotator Cuff Repairs

To evaluate the strength and suture-tendon interface security of various suture anchors triply and doubly loaded with ultrahigh-molecular weight polyethylene-containing sutures and to evaluate the relative effectiveness of placing these anchors in a single-row or double-row arrangement by cyclic loading and then destructive testing. The infraspinatus muscle was reattached to the original humeral footprint by use of 1 of 5 different repair patterns in 40 bovine shoulders. Two single-row repairs and three double-row repairs were tested. High-strength sutures were used for all repairs. Five groups were studied: group 1, 2 triple-loaded screw suture anchors in a single row with simple stitches; group 2, 2 triple-loaded screw anchors in a single row with simple stitches over a fourth suture passed perpendicularly ("rip-stop" stitch); group 3, 2 medial and 2 lateral screw anchors with a single vertical mattress stitch passed from the medial anchors and 2 simple stitches passed from the lateral anchors; group 4, 2 medial double-loaded screw anchors tied in 2 mattress stitches and 2 push-in lateral anchors capturing the medial sutures in a "crisscross" spanning stitch; and group 5, 2 medial double-loaded screw anchors tied in 2 mattress stitches and 2 push-in lateral anchors creating a "suture-bridge" stitch. The specimens were cycled between 10 and 180 N at 1.0 Hz for 3,500 cycles or until failure. Endpoints were cyclic loading displacement (5 and 10 mm), total displacement, and ultimate failure load. A single row of triply loaded anchors was more resistant to stretching to a 5- and 10-mm gap than the double-row repairs with or without the addition of a rip-stop suture (P < .05). The addition of a rip-stop stitch made the repair more resistant to gap formation than a double row repair (P < .05). The crisscross double row created by 2 medial double-loaded suture anchors and 2 lateral push-in anchors stretched more than any other group (P < .05). Double-row repairs with either crossing sutures or 4 separate anchor points were more likely to fail (5- or 10-mm gap) than a single-row repair loaded with 3 simple sutures. The triple-loaded anchors with ultrahigh-molecular weight polyethylene-containing sutures placed in a single row were more resistant to stretching than the double-row groups.

Double-row vs single-row rotator cuff repair: A review of the biomechanical evidence

A review of the current literature will show a difference between the biomechanical properties of double-row and single-row rotator cuff repairs. Rotator cuff tears commonly necessitate surgical repair; however, the optimal technique for repair continues to be investigated. Recently, double-row repairs have been considered an alternative to single-row repair, allowing a greater coverage area for healing and a possibly stronger repair. We reviewed the literature of all biomechanical studies comparing double-row vs single-row repair techniques. Inclusion criteria included studies using cadaveric, animal, or human models that directly compared double-row vs single-row repair techniques, written in the English language, and published in peer reviewed journals. Identified articles were reviewed to provide a comprehensive conclusion of the biomechanical strength and integrity of the repair techniques. Fifteen studies were identified and reviewed. Nine studies showed a statistically significant advantage to a double-row repair with regards to biomechanical strength, failure, and gap formation. Three studies produced results that did not show any statistical advantage. Five studies that directly compared footprint reconstruction all demonstrated that the double-row repair was superior to a single-row repair in restoring anatomy. The current literature reveals that the biomechanical properties of a double-row rotator cuff repair are superior to a single-row repair. Basic Science Study, SRH = Single vs. Double Row RCR.

Subacromial Internal Spacer for Rotator Cuff Tendon Repair: “The Balloon Technique”

Lateral reattachment of the rotator cuff and the more recent introduction of the double-row rotator cuff repair technique require adequate visualization to define the rotator cuff footprint and the greater tuberosity. In many cases extensive debridement in this area is required to remove the overlying subdeltoid bursa, which can impair visualization laterally on the proximal humerus. Inadequate visualization laterally may lead to improper placement of the lateral row of fixation, compromising the reduction and fixation of the repaired rotator cuff tendon. We describe a surgical technique used to improve lateral visualization of the proximal humerus for placement of lateral anchors during arthroscopic rotator cuff repair using a Foley catheter. The end of a 14F-diameter Foley catheter is cut just proximal to the balloon end. One to three catheters are introduced in the subacromial space through small anterolateral or posterolateral portals and inflated with 15 mL of air. Adequate distension of the subacromial space allows better visualization, triangulation of the arthroscopic instruments, and anatomic repair of the rotator cuff tendon.

Suture anchor loading after rotator cuff repair: Effects of an additional lateral row

Our initial hypothesis was that the medial row of double-row rotator cuff repair techniques would bear most of the load on the repaired cuff. Six cadaver shoulders underwent simulated rotator cuff repairs using sequential single row, double-row, and suture-bridge repair techniques. Suture tensions at each anchor were measured for several static, simulated shoulder positions by specially designed, instrumented anchors. Significantly greater suture tensions were measured in the anchors in a single row repair construct than either the double row repair or suture bridge repair construct (P < .001). In the double-row and suture bridge techniques, there was no apparent difference in the loads born by the medial and lateral row anchors. Shoulder abduction from 45 degrees to 60 degrees had little effect on anchor tensions; 45 degrees internal and external rotation significantly (P = .032) increased loads on the anterior and posterior anchors by at least 125%. Forces are transmitted through the entire portion of the tendon at its humeral fixation, loading the lateral anchors as well as the medial row for the techniques studied. This "load sharing" can explain the higher fixation strengths of double row techniques seen experimentally. The magnitude and distribution of anchor suture tensions could have important implications for lateral row fixation devices and post-operative positioning and activity. Basic Science.

Functional Outcomes and Radiographic Appearance of Single versus Double Row Rotator Cuff Repair (SS-04)

Double row transosseous arthroscopic rotator cuff repair (ARCR) techniques are thought to theoretically provide an improved repair by providing increased contact area and pressure of the repaired tendinous cuff to the native footprint while also increasing repair strength. This study aims to compare the double row fixation to single row fixation of simple over horizontal configuration (the arthroscopic Mason-Allen equivalent).

Comparison of Medial Knot versus Trans-Tendon Suture Pass on the Mechanical Stability of Double Row Rotator Cuff Repair (SS-02)

Several arthroscopic double row methods involve trans-tendon passage of suture which is 'bridged' to a lateral anchor. Although this is relatively simple and quick, we were concerned about the potential for decreased construct stability at the medial margin of the repair. The purpose of this study was to compare the effects of medial knot tying versus simple trans-tendon suture passage upon construct stability with double row repair.

The Effect of Abduction and Rotation on Footprint Contact for Single-Row, Double-Row, and Modified Double-Row Rotator Cuff Repair Techniques

Background An abduction pillow and abduction and rotation exercises are commonly used after rotator cuff repair. The effect of glenohumeral abduction and rotation on footprint contact has not been elucidated. Hypothesis Abduction will decrease tendon-to-bone contact for all repairs. A modified double-row repair will maintain footprint contact more effectively at each position of humeral abduction and rotation than double- or single-row repairs. Study Design Controlled laboratory study. Methods In 6 fresh-frozen human shoulders, a modified double-row supraspinatus tendon repair was performed; a suture limb from each of 2 medial anchors was bridged over the tendon and fixed laterally. Double- and single-row repairs were performed sequentially; a total of 3 repairs were tested. For all repairs, a Tekscan pressure sensor was fixed at the tendon-footprint interface. The tendon was loaded with 30 N. The shoulders were tested at 0°, 30°, and 60° of abduction with 0° of rotation. For both dual-row repairs, 5 rotation positions were tested. Results The greatest contact areas at neutral rotation were achieved at 0° of abduction for the modified double-row, double-row, and single-row repairs (151.3 ± 10.7 mm2, 80.7 ± 30.0 mm2, and 61.3 ± 26.1 mm2, respectively), with values decreasing as abduction increased. Each repair was significantly different from one another at each abduction angle (P <. 05), except between single-and double-row repairs at 0° of abduction. Mean interface pressure exerted over the footprint was greater for the modified double-row technique than for the other techniques at each abduction angle (P <. 05). With respect to rotation, the modified double-row repair had significantly more footprint contact than did the double-row repair at each position tested (P <. 05). Conclusion For a given repair, increasing abduction at neutral rotation reduced footprint contact. Internal rotation to 60° provided among the highest contact measurements. The modified double-row technique provided the most contact. Clinical Relevance Results are consistent with the practice of immobilizing the shoulder with 30° or less of abduction and up to 60° of internal rotation to optimize footprint contact. A dual-row repair may maximize contact when initiating rehabilitation that involves abduction and rotation.

Simple Double-Row Rotator Cuff Repair Technique for Large and Massive Cuff Tears

Double-row rotator cuff repair techniques were developed with the aim of reducing retear rates of single-row techniques by improving the cuff-to-footprint contact area. Double-row repair displays more improved biomechanical properties than single-row repair in the laboratory and has gained popularity because of its good reported results and theoretical advantages. However, the techniques can be complex and time-consuming, particularly for large and massive tears. In addition, all involve arthroscopic knot tying. We present a simplified and quick double-row technique, specifically for large and massive tears, that does not require any arthroscopic knot tying and reproduces a broad footprint area. We have performed this technique on 24 large and massive cuff tears with significant improvements in the Constant and Oxford scores and a low retear rate.