Double-row Suture-bridge Technique Research Articles

Are We Doing Too Many Margin Convergence? A Prospective MRI Study on Re-Tear Rate after Arthroscopic Rotator Cuff Repair

The use of margin convergence, despite helpful to achieve a successful intra-operative complete repair for arthroscopic assisted rotator cuff repair, did not protect the repair from re-tear. Re-tear after successful arthroscopic rotator cuff repair is common. It is notorious that large and massive cuff tear is associated with a lower successful intra-operative complete repair and a higher postoperative re-tear rate. Margin convergence is commonly used to achieve intra-operative complete repair. Despite a very popular technique, the relationship between margin convergence and re-tear after rotator cuff repair is not known. It was hypothesized that there was no difference in the re-tear rate between the repair performed with margin convergence and those without. A prospective study on primary arthroscopic assisted complete repair of full thickness supraspinatus tendon tear using double-row suture-bridge technique was carried out in the author’s institution from 2010 to 2013. 60 repairs were recruited after applying inclusion and exclusion criteria. The follow-up rate at one-year post-operation was 98% and that of two-year was 95%. 50 patients (83%) received reassessment MRI. The repair status was classified according to Sugaya classification. Full thickness re-tear was defined as Sugaya Type IV or V repair. Association of use of margin convergence technique with retear after rotator cuff repair was examined using univariate analysis with Chi square test. The potential association of retear rate and other known patient-related and cuff-related risk factors (including age, DM, active smoking, heavy manual worker, tear size, tear retraction, tear topography in sagittal plane, tear morphology, number of full thickness tendon tear) were examined. Multivariate analysis was then conducted to determine the most significant factor predicting the rate of re-tear. 50 arthroscopic complete repair of full thickness supraspinatus tendon tear using double-row suture-bridge technique with reassessment MRI was studied. The average age was 59 years. 19 were male and 31 were female. Right shoulder was involved in 36 patients. The average follow-up was 37 +/- 13 months. There was 19 full thickness re-tear found on reassessment MRI (11 Sugaya IV and 8 Sugaya V). The incidence was 38%. 10 patients received margin convergence during the repair. The incidence of re-tear after repair with margin convergence was 80% and that without was 28% (p=0.002). The other risk factors identified by univariate analysis to be significantly associated with incidence of re-tear was (1) large and massive tear (p=0.018); (2) increased number of full thickness tendon tear (p=0.03); (3) medial retraction of tear (p=0.001) and (4) Geometric classification of tear morphology (p=0.004). After running mulivariate analysis, the most significant factor predicting re-tear after arthroscopic rotator cuff repair was medial retraction of tendon (p=0.048). The re-tear rate of Patte I, II and III were 24%, 50% and 100% respectively. The incidence of rate of re-tear was significantly higher when margin convergence was used (80% vs 28%, p=0.002). The most important factor predicting rate of re-tear was degree of tear retraction (p=0.048). Despite helping to achieve a successful intraoperative complete repair, the use of margin convergence did not protect the repair in Patte II and III retraction from going into re-tear.

Predictors of Outcomes after Arthroscopic Double-row Rotator Cuff Repair in 155 Cases

Objectives:The purpose of this study was to analyze predictors of clinical outcomes of knotted versus knotless double-row self-reinforcing rotator cuff repairs of full-thickness rotator cuff tears with propensity score matching.Methods:Patients with arthroscopic repair of full-thickness rotator cuff tears involving the supraspinatus tendon using either a knotted or knotless linked, self-reinforcing double-row technique were included in the study. Preoperative subjective evaluation was performed using the ASES and SF-12 PCS scores. After a minimum two-year follow-up period, ASES and SF-12 PCS scores were collected again along with the SANE score, the QuickDASH score, and patient satisfaction. All data were collected prospectively and retrospectively reviewed. Postoperative ASES and SF-12 PCS scores were then modeled using inverse propensity score weighting in a multiple linear regression model (MLR) with multiple imputations. Age, sex, baseline ASES score, length of follow-up, number of anchors, worker’s compensation, previous cuff repair, and double-row repair technique (knotted or knotless) were the covariates used in this model.Results:155 shoulders in 151 patients (109 men, 42 women; mean age at time of surgery 59±10 years) were eligible for inclusion. Outcomes data were available for 130 of 148 shoulders (87.8%) after exclusion of seven shoulders (4.5%) that underwent revision rotator cuff repair before final follow up (n=33/39 in the knotted group [84.6%]; n=97/109 [88.9%] in the knotless group).The mean follow-up was 2.9 years (range, 2.0-5.4 years). Overall, postoperative outcomes scores were significantly improved when compared to preoperative baselines (p<0.05), with a median postoperative ASES score of 97 for the entire cohort. Our model showed that previous rotator cuff repair had a significant negative effect on postoperative ASES (β = -12.7, p<0.001) and SF-12 PCS scores (β = -5.0, p = 0.036). A workers’ compensation claim (β = -10.6, p = 0.007) also had a significant negative effect on postoperative ASES scores. Higher baseline ASES score (β = +0.14, p = 0.025) positively influenced ASES outcomes. Use of a knotless technique also had a positive effect on postoperative scores (β = +2.5, p = 0.235). Age, gender, the length of follow-up and the numbers of anchors did not influence the outcomes (Table 1).Conclusion:Excellent clinical outcomes can be achieved a minimum of two years following arthroscopic repair of full-thickness rotator cuff tears using either the knotted or knotless linked double-row technique. Negative predictors of outcome include low preoperative ASES score, previous rotator cuff repair, and a workers’ compensation claim. Knotless double-row rotator cuff repair had a non-significantly positive effect on the postoperative ASES score compared to the knotted double-row suture bridge technique.

Tendoscopic Double-Row Suture Bridge Peroneal Retinaculum Repair for Recurrent Dislocation of Peroneal Tendons in the Ankle

Traumatic dislocation of peroneal tendons in the ankle is an uncommon lesion that mainly affects young adults. Unfortunately, most cases lead to recurrent dislocation of the peroneal tendons of the ankle (RPTD). Therefore, most cases need operative treatment. One of the most common operative procedures is superior peroneal retinaculum (SPR) repair. Recently, surgery for RPTD has been achieved with less invasive arthroscopic procedures. In this article, tendoscopic surgery for RPTD using a double-row suture bridge technique is introduced. This technique consists of debridement of the lateral aspect of the fibula under an intrasheath pseudo-cavity, suture anchor insertion into the fibular ridge, and reattachment of the SPR to the fibula using a knotless anchor screwed into the lateral aspect of the fibula. This technique mimics the double-row suture bridge technique for rotator cuff tear repair. The double-row suture bridge technique requires more surgical steps than the single-row technique, but it provides a wider bone-SPR contact surface and tighter fixation than the single-row technique. This procedure is an attractive option because it is less invasive and has achieved results similar to open procedures.

Evaluation of Rotator Cuff Repair Using Korean Shoulder Scoring System

Background: Assessment of the clinical outcomes after rotator cuff repair is essential for their effectiveness on treatment. The Korean Shoulder and Elbow Society devised the Korean Shoulder Scoring System (KSS) for patients with rotator cuff disorder. The purpose of this study was to evaluate the availability of the KSS for assessment of clinical outcomes in patients after arthroscopic rotator cuff repair, and for comparison with other appraisal scoring systems. Methods: A total of 130 patients with partial-thickness or full-thickness rotator cuff tear who underwent arthroscopic repair using a single row or double row suture bridge technique were enrolled. The average follow-up period was 25.9 months. All patients were classified according to various factors. Comparison within corresponding categories was performed, and the correlation between the KSS and other shoulder assessment methods including University of California Los Angeles (UCLA), Constant and American Shoulder and Elbow Surgeons (ASES) score was analyzed. Results: Total score of the KSS response had increased from 59.6 preoperatively to 88.96 at last follow-up. All KSS domains, including function, pain, satisfaction, range of motion, and muscle power had improved up to 24 months postoperatively. Statistical significance was observed mainly in preoperative measurements with number and size of torn tendons, and greater than or equal to grade 3 of fatty infiltration. The KSS was best correlated with the UCLA scoring system in both preoperative (r=0.785) and postoperative (r=0.951) measurements. Conclusions: The KSS was highly reliable and valid as a discriminative instrument, and it showed strong correlation with ASES and UCLA scoring systems.

Clinical Outcomes of Modified Mason-Allen Single-Row Repair for Bursal-Sided Partial-Thickness Rotator Cuff Tears

Background: Various repair techniques have been reported for the operative treatment of bursal-sided partial-thickness rotator cuff tears. Recently, arthroscopic single-row repair using a modified Mason-Allen technique has been introduced. Hypothesis: The arthroscopic, modified Mason-Allen single-row technique with preservation of the articular-sided tendon provides satisfactory clinical outcomes and similar results to the double-row suture-bridge technique after conversion of a partial-thickness tear to a full-thickness tear. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective study was conducted on 84 consecutive patients with symptomatic, bursal-sided partial-thickness rotator cuff tears involving more than 50% thickness of the tendon. A total of 47 patients were treated by the modified Mason-Allen single-row repair technique, preserving the articular-sided tendon, and 37 patients were treated by the double-row suture-bridge repair technique after conversion to a full-thickness tear. The clinical and functional outcomes were evaluated using the American Shoulder and Elbow Surgeons (ASES) and Constant scores and a visual analog scale (VAS) for pain and satisfaction of patients. Magnetic resonance imaging (MRI) was used to analyze the integrity of tendons at 6-month follow-up. Patients were followed up for a mean of 32.5 months. Results: In the 47 patients treated with the modified Mason-Allen suture technique, the VAS score decreased from a preoperative mean of 5.3 ± 0.3 to 0.9 ± 0.5 at the time of final follow-up. There was a statistically significant increase in the mean ASES score (from 45.4 ± 2.9 to 88.6 ± 4.5) and mean Constant score (from 66.9 ± 2.6 to 88.1 ± 2.4) (P < .001). Four of 47 patients (8.5%) demonstrated retears at 6-month postoperative MRI. There was no statistical difference in terms of functional outcomes and the retear rate compared with those of patients with the suture-bridge repair technique (3 patients, 8.1%). However, the mean number of suture anchors used in the patients with modified Mason-Allen suture repair (1.2 ± 0.4) was significantly fewer than that in the patients with suture-bridge repair (3.2 ± 0.4) (P < .01). Conclusion: The modified Mason-Allen single-row repair technique that preserved the articular-sided tendon provided satisfactory clinical outcomes in patients with symptomatic, bursal-sided partial-thickness rotator cuff tears. Despite a fewer number of suture anchors, the shoulder functional outcomes and retear rate in patients after modified Mason-Allen repair were comparable with those of patients who underwent double-row suture-bridge repair. Therefore, the modified Mason-Allen single-row repair technique using a triple-loaded suture anchor can be considered as an effective treatment in patients with bursal-sided partial-thickness rotator cuff tears.

Load to Failure and Stiffness: Anchor Placement and Suture Pattern Effects on Load to Failure in Rotator Cuff Repairs.

Background:Rotator cuff tendinopathy is a frequent cause of shoulder pain that can lead to decreased strength and range of motion. Failures after using the single-row technique of rotator cuff repair have led to the development of the double-row technique, which is said to allow for more anatomical restoration of the footprint.Purpose:To compare 5 different types of suture patterns while maintaining equality in number of anchors. The hypothesis was that the Mason-Allen–crossed cruciform transosseous-equivalent technique is superior to other suture configurations while maintaining equality in suture limbs and anchors.Study Design:Controlled laboratory study.Methods:A total of 25 fresh-frozen cadaveric shoulders were randomized into 5 suture configuration groups: single-row repair with simple stitch technique; single-row repair with modified Mason-Allen technique; double-row Mason-Allen technique; double-row cross-bridge technique; and double-row suture bridge technique. Load and displacement were recorded at 100 Hz until failure. Stiffness and bone mineral density were also measured.Results:There was no significant difference in peak load at failure, stiffness, maximum displacement at failure, or mean bone mineral density among the 5 suture configuration groups (P < .05).Conclusion:According to study results, when choosing a repair technique, other factors such as number of sutures in the repair should be considered to judge the strength of the repair.Clinical Relevance:Previous in vitro studies have shown the double-row rotator cuff repair to be superior to the single-row repair; however, clinical research does not necessarily support this. This study found no difference when comparing 5 different repair methods, supporting research that suggests the number of sutures and not the pattern can affect biomechanical properties.

Ultrasound evaluation of arthroscopic full-thickness supraspinatus rotator cuff repair: single-row versus double-row suture bridge (transosseous equivalent) fixation. Results of a prospective, randomized study

The purpose of this study was to compare the structural outcomes of a single-row rotator cuff repair and double-row suture bridge fixation after arthroscopic repair of a full-thickness supraspinatus rotator cuff tear. We evaluated with diagnostic ultrasound a consecutive series of ninety shoulders in ninety patients with full-thickness supraspinatus tears at an average of 10 months (range, 6-12) after operation. A single surgeon at a single hospital performed the repairs. Inclusion criteria were full-thickness supraspinatus tears less than 25 mm in their anterior to posterior dimension. Exclusion criteria were prior operations on the shoulder, partial thickness tears, subscapularis tears, infraspinatus tears, combined supraspinatus and infraspinatus repairs and irreparable supraspinatus tears. Forty-three shoulders were repaired with single-row technique and 47 shoulders with double-row suture bridge technique. Postoperative rehabilitation was identical for both groups. Ultrasound criteria for healed repair included visualization of a tendon with normal thickness and length, and a negative compression test. Eighty-three patients were available for ultrasound examination (40 single-row and 43 suture-bridge). Thirty of 40 patients (75%) with single-row repair demonstrated a healed rotator cuff repair compared to 40/43 (93%) patients with suture-bridge repair (P = .024). Arthroscopic double-row suture bridge repair (transosseous equivalent) of an isolated supraspinatus rotator cuff tear resulted in a significantly higher tendon healing rate (as determined by ultrasound examination) when compared to arthroscopic single-row repair.

Treatment Outcomes of Single- Versus Double-Row Repair for Larger Than Medium-Sized Rotator Cuff Tears

Background: In rotator cuff repair, no practical guidelines exist for deciding which technique is the most beneficial to outcomes. Purpose: To determine which of 2 repair techniques, the single-row (SR) and double-row suture bridge (DR-SB) methods, leads to better therapeutic outcomes in terms of remnant tendon length in patients with larger than medium-sized cuff tears. Study Design: Cohort study; Level of evidence, 3. Methods: Remnant tendon length, muscle atrophy, and fatty degeneration were measured on preoperative magnetic resonance imaging (MRI) in 78 patients with larger than medium-sized rotator cuff tears who were available for follow-up MRI. There were 30 patients with remnant tendons <10 mm in length (group 1) and 48 with remnant tendons ≥10 mm in length (group 2). In group 1, the SR technique was performed on 17 patients and the DR-SB technique on 13 patients. In group 2, the SR technique was performed on 16 patients and the DR-SB technique on 32 patients. The mean follow-up period for all patients was 26.6 months (range, 24-42 months). Clinical outcomes were evaluated using the University of California, Los Angeles (UCLA), Constant, and American Shoulder and Elbow Surgeons (ASES) scores. Results: In group 1, there was 1 retear (6%) with the SR repair and 6 (46%) with the DR-SB repair. In group 2, there were 3 retears (19%) with the SR repair and 2 (6%) with the DR-SB repair. The retear rate was significantly higher in patients with the DR-SB repair in group 1 (P = .025), while there was no significant difference between the 2 techniques in group 2 (P = .316). The UCLA and Constant scores were significantly higher in patients with the SR repair in group 1 (P = .02 and P = .029, respectively), and the UCLA and ASES scores were significantly higher in patients with the DR-SB repair in group 2 (P < .001 and P = .001, respectively). Conclusion: Remnant tendon length should be considered to improve repair integrity. The SR technique may provide superior rotator cuff integrity when remnant tendons are <10 mm in length.

Rotator Cuff Tendon Blood Flow in a Sheep Model – A Comparison of Single- vs. Double-Row Repairs (SS-19)

Double-row suture anchor repair of rotator cuff tears has been shown to be superior to single-row techniques with regard to footprint reconstruction, load to failure and tendon-to-bone contact pressures. We hypothesized that anchor repair can impair intratendinous blood flow and that the greater contact pressures of double-row techniques would compromise blood flow to a higher degree than single-row repair. The aim of this experimental study was to evaluate the effect of a double-row and a single-row technique on tendon blood flow in a sheep model. 18 sheep underwent detachment and immediate suture anchor repair of the right infraspinatus tendon using either an arthroscopic Mason-Allen suture or a double-row suture-bridge technique. Tendon blood flow was measured using laser Doppler flowmetry before detachment, immediately after repair and 12 weeks thereafter. Six regions of interest were measured, three over the lateral aspect of the footprint and three over the medial aspect. Immediately after repair, tendon blood flow decreased significantly in both repair groups when compared to the native tendons (P= .004). At 12 weeks, a significant increase in flow was observed in both repair groups when compared to the measurements immediately after repair (P= .016). In the single-row group, blood flow decreased by 87.5% after repair, in the double-row group the decrease was 90.6%. The difference between the groups was not statistically significant (P> .05). Subgroup analysis showed that blood flow over the lateral aspect of the footprint decreased by 90% in both groups, whereas over the medial aspect it decreased by 81% in the single-row and by 89% in the double-row group. However, none of these differences were found to be statistically significant. Intratendinous blood flow was significantly compromised immediately after suture anchor repair regardless of the technique used, but appeared to recover within 12 weeks. Since we did not find a significant difference between the two repair groups, our initial hypothesis was rejected.

Single-Row RC-Repair Using A Modified Suture Configuration Versus a Suturebridge Double-Row Repair: Comparable Biomechanical Results and Complete Footprint Coverage Independent of the Initial Tear Size (SS-20)

Introduction Influence of the initial tear size and repair technique of single-row and double-row repairs on the biomechanical properties and footprint coverage. Methods 25 (Bateman grade II) and 35mm (Bateman grade III) artificial defects were created in the rotator cuff of 24 human cadaver shoulders. The reconstructions were performed as either a single-row repair using triple-loaded suture anchors (2-3) and a modified suture configuration or a modified suturebridge double-row repair (4-6). Reconstructions were cyclically loaded from 10-60N. The load was stepwise increased up to 100, 180, and 250N. Cyclic displacement and load-to-failure were determined. Furthermore, footprint widths were quantified before and after the repair. Results In the 25mm rupture, 533±107N were achieved for the SR-repair and 681±250N were measured for the DR-suturebridge technique. In the 35mm artificial tear, ultimate failure load was 792±122N for the SR-reconstruction and 891±174N for the DR-reconstruction. There were no differences in load-to-failure between the tested repairs (p>.05). Cyclic displacement showed no significant differences between the tested configurations at 60, 100, 180 und 250N (p>.05) for the 25mm tear. In the reconstruction of the 35mm RC tear, significant lower gap formation was found for the SR-reconstruction at 180N (p=.037) and 250N (p=.020). No significant differences were found at 60 and 100N (p>.05). A significantly greater footprint width was seen with the double-row technique compared to the single-row repair. However, both reconstructions were able to achieve a complete footprint coverage compared to the initial footprint. Conclusion The single-row repair technique using a modified suture configuration showed similar results in load-to-failure and cyclic displacement compared to the modified double-row suturebridge technique independent of the initial size of the rupture. The double-row repair consistently restored a larger footprint than the single-row method. However, both repair techniques achieved complete footprint coverage.

Clinical and structural evaluation of arthroscopic double-row suture-bridge rotator cuff repair: early results of a novel technique

Assessment of repair integrity and clinical outcome after arthroscopic repair of rotator cuff tears in double-row suture-bridge technique with the use of a new knotless suture-anchor system. The first treated 25 patients with arthroscopic rotator cuff repair in the suture-bridge technique using a novel knotless anchor and chain-link suture system were evaluated. Patients with isolated full-thickness supraspinatus tears were selected. They were followed clinically with functional scores (Constant score, ASES index), visual analog scale (VAS), and instrumentally with Isobex digital strength analyzer preoperatively, at 6 and 14 months postoperatively. The repair integrity was evaluated with MRI at an average of 14 months postoperatively. Significant improvement of pain, strength, range of motion, and functional scores occurred (P < 0.05). There was a re-tear rate of 20%. The subjective parameters (VAS and ASES Index) showed non-significant (n.s.) differences between the re-tear and intact repair groups, whereas the objective parameters (Constant score, muscle power and active ROM) showed significant differences between both groups (P < 0.05). The functional outcome has improved significantly with this new knotless anchor-chain system and was more superior in shoulders with intact repair, whereas the resulted repair integrity was not better than other types of double-row repair techniques mentioned in the recent literature. However, this early report of the novel technique may show limited power for comparison due to the relatively small sample size.

Simultaneous arthroscopic treatment of displaced greater tuberosity and glenoid fracture using a double-row technique

A rare case with concomitant fracture of the greater tuberosity and a bony Bankart lesion is described. Bioabsorbable suture anchors are used to reduce and fix both fractures utilizing a double-row suture-bridge technique. First, the Bankart fracture is reduced, and then the greater tuberosity fracture is reduced through a subacromial approach. This arthroscopic technique provides a firm 3-point fixation for both fractures that is minimally invasive.

Rotator cuff repair fluid extravasation characteristics are influenced by repair technique

This study evaluates rotator cuff repair fluid extravasation characteristics for different rotator cuff repair techniques. Eight fresh-frozen cadaveric shoulders were dissected free of soft tissues, with the glenohumeral joint capsule and rotator cuff muscles being left intact. A custom fluid infusion device was used to deliver fluid at constant pressure into the glenohumeral joint. The shoulders were tested in conditions of (1) intact rotator cuff, (2) supraspinatus tear, (3) repaired supraspinatus tear with a single-row technique, and (4) repaired supraspinatus tear with a double-row suture bridge technique. The volume per minute of saline solution extravasation for single-row repair and double-row suture bridge repair was 48.53 mL/min and 11.73 mL/min, respectively, at 2 psi; 73.3 _ 24.1 mL/min and 24.5 _ 19.7 mL/min, respectively, at 3 psi; and 95.2 _ 22.6 mL/min and 39.2 _ 23.8 mL/min, respectively, at 4 psi. There was a statistically significant greater fluid extravasation for the single-row repair compared with the double-row suture bridge repair at all 3 pressures tested (P < .05). Single-row rotator cuff repair exposes the healing zone to greater extravasation of fluid compared with double-row suture bridge repair. Therefore, double-row repair potentially enhances rotator cuff healing. Controlled laboratory study.

Comparison of Early Results of Rotator Cuff Repair: Single Row MAC Configuration Versus Double Row Suture Bridge Technique (SS-27)

Double- row repair techniques in arthroscopic rotator cuff repair have been increasingly utilized by orthopaedists when treating rotator cuff tears. While this offers theoretical advantage over previous techniques such as single row fixation, the current study is aimed to compare results of the two methods of fixation. To compare single row with double row fixation in rotator cuff repair. Non-randomized assessment of 66 patients who had undergone arthroscopic rotator cuff repair with a single row simple over horizontal configuration (MAC) were compared to 26 patients who had the double row suture bridge configuration which effectively provided double row fixation and re-creation of the rotator cuff footprint. VAS, UCLA, and ASES scores were collected for both groups pre-operatively; then again at 3, 6, and 12 month intervals. In addition, dynometric strength assessment for subscapularis, supraspinatus, and infraspinatus was compared. No significant difference was shown between the two fixation methods preoperatively or at the 3 month follow-up visit. At the 6 month follow-up visit, the suture bridge configuration group showed poorer results for each of the VAS, UCLA, and ASES scores. At 12 months the UCLA and ASES scores were no different and the VAS score was slightly better for the MAC group. Strength in the MAC repair group at 12 months exceeded that for the suture bridge group for subscapularis, supraspinatus, and infraspinatus. Suture bridge configuration for rotator cuff repair is thought to provide a better repair by providing increased contact pressure of the repaired tendinous cuff to the native footprint while also increasing repair strength. Our current results suggest that a single row fixation method with a MAC configuration provides comparable results to double row repair outcomes as per strength assessment as well as VAS scores.