Rotator Cuff Repair Techniques Research Articles

Cell biological and biomechanical evaluation of two different fixation techniques for rotator cuff repair

Our objective was to evaluate the cell biology and biomechanical aspects of the healing process after two different techniques in open rotator cuff surgery - double-loaded bio-absorbable suture anchors combined with so-called arthroscopic Mason-Allen stitches (AAMA) and a trans-osseous suture technique combined with traditional modified Mason-Allen stitches (SMMA). Thirty-six mature sheep were randomized into two repair groups. After 6, 12, or 26 weeks, evaluation of the reinsertion site of the infraspinatus tendon was performed. The mechanical load-to-failure and stiffness results did not indicate a significant difference between the two groups. After 26 weeks, fibrocartilage was sparse in the AAMA group, whereas the SMMA group showed the most pronounced amount of fibrocartilage. We found no ultrastructural differences in collagen fiber organization between the two groups. The relative expression of collagen type II mRNA in the normal group was 1.11. For the AAMA group, 6 weeks after surgery, the relative expression was 55.47, whereas for the SMMA group it was 1.90. This in vivo study showed that the AAMA group exhibited a tendon-to-bone healing process more favorable in its cell biology than that of the traditional SMMA technique. Therefore, the AAMA technique might also be more appropriate for arthroscopic repair.

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).

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.

Whatʼs New in Shoulder and Elbow Surgery

Ramsey, Matthew L. MD1; Getz, Charles L. MD1; Parsons, Bradford O. MD2 Author Information

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.

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.

Impingement syndrome of the shoulder following double row suture anchor technique for arthroscopic rotator cuff repair: a case report

IntroductionArthroscopic repair of the rotator cuff is a demanding surgery. Accurate placement of anchors is key to success.Case presentationA 38-year-old woman received arthroscopic repair of her rotator cuff using a double row suture anchor technique. Postoperatively, she developed impingement syndrome which resulted from vertical displacement of a suture anchor once the shoulder was mobilised. The anchor was removed eight weeks following initial surgery and the patient had an uneventful recovery.ConclusionImpingement syndrome following arthroscopic repair of the rotator cuffs using double row suture anchor has not been widely reported. This is the first such case where anchoring has resulted in impingement syndrome.

회전근 개 대파열 및 거대 파열에서 상완 이두 근 장두를 포합한 회전근 개 봉합술의 중기 추시 결과

Purpose: The aim of this study is to analyze the clinical results of using the technique of rotator cuff repair without parting the biceps long head from the glenoid for large or massive tear of the rotator cuff. Material and Methods: Form January 2005 to January 2007, we performed the arthroscopic biceps repair with incorporating suture to the rotator cuff for 21 patients with large or massive rotator cuff tear. The mean follow up period was 23 months (range: 6-48months). The number of males and females was 9 and 13, respectively. The age distribution ranged from 47 to 73 years with a mean age of 60.3 years. We compared the preoperative score with the postoperative scores using the University of California Los Angeles (UCLA) score, the shoulder index of the American Shoulder and Elbow Surgeons (ASES) and a simple shoulder test (SST). Results: The improvement in the VAS, ASES and the UCLA and SST scores was statistically significant at the final follow up (average follow-up 23 months) (p>0.05). Two of nine cases were found to have partial tear with continuity but seven cases were found to have complete tear according to the ultrasonography and MRI. Conclusion: The technique of rotator cuff repair without parting the biceps long head from the glenoid for large or massive tear of the rotator cuff is considered to be recommendable.

Single-Row Versus Double-Row Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Study

The purpose of this study was to compare the clinical outcome of arthroscopic rotator cuff repair with single-row and double-row techniques. Eighty patients with a full-thickness rotator cuff tear underwent arthroscopic repair with suture anchors. They were divided into 2 groups of 40 patients according to repair technique: single row (group 1) or double row (group 2). Results were evaluated by use of the Disabilities of the Arm, Shoulder and Hand (DASH) and Work-DASH self-administered questionnaires, normalized Constant score, and muscle strength measurement. On analyzing the results at a 2-year follow-up, we considered the following independent variables: baseline scores; age; gender; dominance; location, shape, and area of cuff tear; tendon retraction; fatty degeneration; treatment of biceps tendon; and rotator cuff repair technique (anchors or anchors and side to side). Univariate and multivariate statistical analyses were performed to determine which variables were independently associated with the outcome. Significance was set at P < .05. Of the patients, 8 (10%) were lost to follow-up. Comparison between groups did not show significant differences for each variable considered. Overall, according to the results, the mean DASH scores were 15.4 +/- 15.6 points in group 1 and 12.7 +/- 10.1 points in group 2; the mean Work-DASH scores were 16.0 +/- 22.0 points and 9.6 +/- 13.3 points, respectively; and the mean Constant scores were 100.5 +/- 17.8 points and 104.9 +/- 21.8 points, respectively. Muscle strength was 12.7 +/- 5.7 lb in group 1 and 12.9 +/- 7.0 lb in group 2. Univariate and multivariate analysis showed that only age, gender, and baseline strength significantly and independently influenced the outcome. Differences between groups 1 and 2 were not significant. At short-term follow-up, arthroscopic rotator cuff repair with the double-row technique showed no significant difference in clinical outcome compared with single-row repair. Level I, high-quality randomized controlled trial with no statistically significant differences but narrow confidence intervals.

In vitro and finite element analysis of a novel rotator cuff fixation technique

The purpose of this investigation was to assess the biomechanic strength and stress dispersion at the repair site of surface-holding repair techniques for rotator cuff repair compared to the double-row technique. Eighteen bovine infraspinatus tendons were repaired using 3 different repair techniques: double-row repair, surface-holding repair with transosseous sutures, and surface-holding repair with knotless anchors. Biomechanical testing and two-dimensional finite element analysis were performed. The surface-holding repair with transosseous sutures provided 87.9% more stiffness than the double-row repair. The number of tendon-suture site failures of the surface-holding repair with transosseous sutures was smaller than the other 2 techniques. The finite element analysis showed that the surface-holding repair model had a more dispersing stress pattern compared to a double-row repair model. It suggests that these repair techniques can prevent high stress concentration compared to the double-row repair.

Biomechanical comparison of single-row arthroscopic rotator cuff repair technique versus transosseous repair technique

This study determined the effect of tear size on gap formation of single-row simple-suture arthroscopic rotator cuff repair (ARCR) vs transosseous Mason-Allen suture open RCR (ORCR) in 13 pairs of human cadaveric shoulders. A massive tear was created in 6 pairs and a large tear in 7. Repairs were cyclically tested in low-load and high-load conditions, with no significant difference in gap formation. Under low-load, gapping was greater in massive tears. Under high-load, there was a trend toward increased gap with ARCR for large tears. All repairs of massive tears failed in high-load. Gapping was greater posteriorly in massive tears for both techniques. Gap formation of a modeled RCR depends upon the tear size. ARCR of larger tears may have higher failure rates than ORCR, and the posterior aspect appears to be the site of maximum gapping. Specific attention should be directed toward maximizing initial fixation of larger rotator cuff tears, especially at the posterior aspect.

Single-Row Versus Double-Row Arthroscopic Rotator Cuff Repair: A Prospective Randomized Clinical Study (SS-26)

The aim of this study was to compare the outcome of arthroscopic rotator cuff repair with single-row and double-row technique in a prospective randomized study. Eighty patients with a full-thickness rotator cuff tear underwent an arthroscopic repair with suture anchors. They were divided in two groups of 40 patients each, according to repair technique. Results were evaluated using the Constant score, and the DASH and Work-DASH questionnaires. At two-year follow-up, double-row repair showed slightly better clinical outcome than single-row repair, although the difference was not significant. To compare the clinical outcome of arthroscopic repair of full-thickness rotator cuff tears with single-row and double-row technique in a prospective randomized study. Eighty patients with a full-thickness tear of the posterior-superior rotator cuff underwent an arthroscopic repair with metal suture anchors. They were divided in two groups of 40 patients each, according to repair technique: single-row technique in group 1, and double-row technique in group 2. Exclusion criteria were: partial-thickness and irreparable cuff tears, subscapularis tears, labral pathology, os acromiale, degenerative arthritis of glenohumeral joint, symptomatic arthritis of acromioclavicular joint, rotator cuff arthropathy, previous surgery to the same shoulder, and workers' compensation claims. Results were evaluated using the Constant score normalized for age and gender, and the DASH and Work-DASH self-administered questionnaires. On analyzing the results at a two-year follow-up, we considered the following independent variables: age, gender, dominance, location, shape, and area of cuff tear, tendon retraction, fatty degeneration of cuff muscles, treatment of the biceps tendon, and rotator cuff repair technique. Univariate and multivariate statistical analysis were performed in order to find out variables that were independently associated to the outcome. Significance was set at p < .05. The null hypothesis was that differences between the two groups at the clinical outcome were not significant. Eight patients (10%) were lost at follow-up: 3 in group 1 and 5 in group 2. Comparison between groups did not show significant differences for each variable considered. Overall results for Constant score were 100.5 points in group 1 and 104.9 points in group 2; for DASH score were 15.4 points in group 1 and 12.7 points in group 2; for Work-DASH score were 16.0 points in group 1 and 9.6 points in group 2. Univariate and multivariate analysis showed that only age and gender significantly and independently influenced the outcome. Differences between groups 1 and 2 were not significant for each scoring system considered. Therefore, the null hypothesis was not rejected. At a short-term follow-up, arthroscopic repair of rotator cuff tears with double-row technique showed slightly better clinical outcome than single-row repair, although the difference was not significant.

Biomechanical Performance of Rotator Cuff Repairs with Humeral Rotation

Background Traditional biomechanical evaluations of rotator cuff repair techniques employ cyclic loading of the supraspinatus tendon in an isolated medial direction. Purpose This study was conducted to evaluate 2 different rotator cuff repair techniques that are currently the subject of debate with cyclic loading and with internal and external humeral rotation to better simulate postoperative rehabilitation. Study Design Controlled laboratory study. Methods Nine fresh-frozen paired human cadaver shoulders (18 shoulders) were studied. A single-row repair with 2 suture anchors was compared with a double-row repair with 4 suture anchors. The shoulders were tested in a custom device to position the shoulder in neutral, 45° of internal rotation, and 45° of external rotation. Cyclic loading of the supraspinatus tendon was performed with an MTS material testing machine. Gap formation was measured and analyzed for each rotational position using the MTS device. Results For the single-row repair, average gap formation per 100 cycles in the positions of neutral, internal, and external humeral rotation was 1.47 ± 0.63, 3.11 ± 1.55, and 2.24 ± 0.94 mm, respectively. For the double-row repair, average gap formation per 100 cycles in the positions of neutral, internal, and external humeral rotation was 1.25 ± 0.54, 2.29 ± 1.10, and 1.57 ± 0.48 mm, respectively. For gapping averaged over all positions, the double-row repair had significantly less gapping than the single-row repair (P = .0109); gapping was greatest for internal rotation, followed by external rotation, and least for neutral (P < .0001). Conclusion The testing method of including a rotational component in biomechanical rotator cuff repair testing is a more realistic model of the loading conditions experienced by a repaired rotator cuff as the patient participates in postoperative rehabilitation. Double-row repair has better fixation strength than single-row repairs when exposed to cyclic loading and changes in humeral rotation position. Clinical Relevance Humeral rotation affects rotator cuff fixation and should be considered in postoperative rehabilitation.

Biomechanical testing of a new knotless suture anchor compared with established anchors for rotator cuff repair

Various suture anchors are available for rotator cuff repair. For arthroscopic application, a knotless anchor was developed to simplify the intra-operative handling. We compared the new knotless anchor (BIOKNOTLESStrade mark RC; DePuy Mitek, Raynham, MA) with established absorbable and titanium suture anchors (UltraSorbtrade mark and Super Revo 5mmtrade mark; ConMed Linvatec, Utica, NY). Each anchor was tested on 6 human cadaveric shoulders. The anchors were inserted into the greater tuberosity. An incremental cyclic loading was performed. Ultimate failure loads, anchor displacement, and mode of failure were recorded. The anchor displacement of the BIOKNOTLESStrade mark RC (15.3 +/- 5.3 mm) after the first cycle with 75 N was significantly higher than with the two other anchors (Super Revo 2.1 +/- 1.6 mm, UltraSorb: 2.7 +/- 1.1 mm). There was no significant difference in the ultimate failure loads of the 3 anchors. Although the Bioknotlesstrade mark RC indicated comparable maximal pullout strength, it bares the risk of losing contact between the tendon-bone-interface due to a significantly higher system displacement. Therefore, gap formation between the bone and the soft tissue fixation jeopardizes the repair. Bioknotlesstrade mark RC should be used in the lateral row only when a double row technique for rotator cuff repair is performed, and is not appropriate for rotator cuff repair if used on its own.

Double-Row Rotator Cuff Repairs

Advances in surgical technique and implants for arthroscopic rotator cuff repair have generated an interest in the indications and application of double- and single-row repairs. Recently, a variation of the double-row technique, known as the transosseous equivalent repair, has also been described. Previous reports of unacceptably high failure rates after arthroscopic repair of large and massive rotator cuff tears have led to the scrutiny of both this technique and the implants used. Biomechanically, double-row techniques are superior to single-row with respect to restoring the anatomic footprint, minimizing gap formation, and providing a greater load to failure at time equals zero. Furthermore, the recently described transosseous equivalent fixation technique provides improved footprint restoration, greater contact pressure across the bone-tendon interface, and an increased load to failure when compared to double-row repair. Although the biomechanical data are encouraging, clinical studies are still in progress to assess the efficacy of double-row versus single-row techniques, particularly with regard to tendon healing. The potential advantages may be offset by the added surgical time, required technical expertise, and potential increase in cost. The purpose of this study is to review the biomechanical, histological, and in vivo results of double-row and transosseous equivalent arthroscopic rotator cuff repairs while also discussing our indications and technique for double-row repairs.

Clinical Trial with New Double Row Fixation using Suture Reel Technique for Arthroscopic Rotator Cuff Repair

Clinical Trial with New Double Row Fixation using Suture Reel Technique for Arthroscopic Rotator Cuff Repair

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.

Biomechanical evaluation of rotator cuff repairs in a sheep model: Suture anchors using arthroscopic Mason-Allen stitches compared with transosseous sutures using traditional modified Mason-Allen stitches

Background The optimal method for rotator cuff repair of the shoulder is not yet known. The aim of this study was to compare the time-dependent biomechanical properties of the traditional open transosseous suture technique and modified Mason-Allen stitches (group 1) versus the double-loaded suture anchors technique and so-called arthroscopic Mason-Allen stitches (group 2) in rotator cuff repair. Methods Eighteen adult female sheep were randomized into two groups: in an open approach in which the released infraspinatus tendon was repaired with group 1, and with group 2. Animals were sacrificed at 6, 12, or 26 weeks; shoulders were harvested and magnetic resonance imaging was performed. Eight untreated contralateral shoulders served as controls. Tendons of 16 additional unpaired cadaver shoulder joints of adult female sheep were identically treated for analysis at time zero. In a biomechanical evaluation all specimens were loaded to failure at a constant displacement rate using a standard universal testing machine. The load-to-failure and stiffness of the healed bone-tendon interface were calculated. Results Magnetic resonance imaging analysis showed cuff integrity in all cases, and no evidence of foreign body reaction to the anchors. Load-to-failure and stiffness data did not indicate any significant difference between the two treatment groups, neither at 6 weeks nor at 12 or 26 weeks. However, at time zero the group 2 had a higher load-to-failure in comparison to the group 1 ( P < 0.010), but there was no difference for the stiffness ( P < 0.121). Conclusions This in vivo study showed that, postoperatively, the group 2 technique provides superior stability and after healing would gain strength comparable to the group 1 technique.

The Roman Bridge: a "double pulley – suture bridges" technique for rotator cuff repair

BackgroundWith 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.MethodsWe present an arthroscopic rotator cuff repair technique which uses suture bridges to optimize rotator cuff tendon-footprint contact area and mean pressure.ResultsTwo medial row 5.5-mm Bio-Corkscrew suture anchors (Arthrex, Naples, FL), which are double-loaded with No. 2 FiberWire sutures (Arthrex, Naples, FL), are placed in the medial aspect of the footprint. Two suture limbs from a single suture are both passed through a single point in the rotator cuff. This is performed for both anchors. The medial row sutures are tied using the double pulley technique. A suture limb is retrieved from each of the medial anchors through the lateral portal, and manually tied as a six-throw surgeon's knot over a metal rod. The two free suture limbs are pulled to transport the knot over the top of the tendon bridge. Then the two free suture limbs that were used to pull the knot down are tied. The end of the sutures are cut. The same double pulley technique is repeated for the other two suture limbs from the two medial anchors, but the two free suture limbs are used to produce suture bridges over the tendon, by means of a Pushlock (Arthrex, Naples, FL), placed 1 cm distal to the lateral edge of the footprint.ConclusionThis technique maximizes the advantages of two techniques. On the one hand, the double pulley technique provides an extremely secure fixation in the medial aspect of the footprint. On the other hand, the suture bridges allow to improve pressurized contact area and mean footprint pressure. In this way, the bony footprint in not compromised by the distal-lateral fixation, and it is thus possible to share the load between fixation points. This maximizes the strength of the repair and provides a barrier preventing penetration of synovial fluid into the healing area of tendon and bone.

The Multi-suture Technique for Rotator Cuff Repair: A Biomechanical Evaluation

Multi-suture fixation of supraspinatus rotator cuff tears provides excellent fixation and biomechanical failure characteristics.