Transosseous-equivalent Repair Research Articles

An isolated bioinductive repair vs sutured repair for full-thickness rotator cuff tears: 2-year results of a double blinded, randomized controlled trial

BackgroundPartial-thickness rotator cuff tears treated with an isolated bioinductive repair (IBR) in lieu of a completion-and-repair have shown complete healing. This treatment option is afforded by the remaining tendon’s structural integrity, which is similar to that present in small/medium full-thickness tears (FTTs) when the rotator cable remains intact. This randomized controlled trial (RCT) investigated whether an IBR for small/medium FTTs resulted in superior healing and patient-reported outcomes (PROs) compared with a sutured repair. MethodsThis prospective, double blinded (patients and outcome assessors), single-center RCT enrolled patients ≥18 years with a small/medium (≤2.5cm) full thickness supraspinatus tear and intact rotator cable. Patients were randomized and blinded to arthroscopic transosseous-equivalent repair (control, n = 30) or IBR (n = 30). The primary outcome was tendon quality on biopsy at 6 months. Secondary outcomes were PROs (American Shoulder and Elbow Surgeons [ASES], Constant-Murley Shoulder [CMS], and pain visual analogue scale scores) and tendon thickness and healing measured via MRI at 6, 12, and 24 months; satisfaction at 12 and 24 months; and time to return to work. ResultsBaseline demographic, tear, and surgical characteristics were comparable between the groups (IBR: mean age, 54.2 years, 14 male; control: mean age, 56.4 years, 16 male). Measured via 6 month biopsy, highly organized, parallel bundles of collagen, without inflammation, were present in all IBR patients, whereas poorly organized, non-parallel collagen fibers were present in 24/30 (80%) of control patients (P < .0001), with 28/30 having minimal to mild inflammation. The increase in tendon thickness measured via MRI at 6 months from baseline was greater in the IBR group (2.0 mm) than in the control group (0.8 mm) (P < .0001). All IBR patients had 100% healing on MRI at 12 and 24 months. Compared with the control group, the IBR group had higher ASES and CMS scores at each evaluation, less pain at 6 and 12 months, and greater satisfaction at 12 and 24 months (P < .0003). The IBR group returned to work significantly faster (median 90 days [IQR, 25] vs. median 163.5 days [IQR, 24]; P < .0001) than the control group. ConclusionCompared with a sutured repair, the IBR treatment resulted in superior tendon quality, patient outcomes, satisfaction, and return to work. The IBR enabled a robust healing response evident through MRI and biopsy evaluation, demonstrating superior tendon quality and healing.

Anchorless Arthroscopic Transosseous Rotator Cuff Repair.

Rotator cuff repair techniques have evolved over time. The original techniques were open procedures, then surgeons adopted arthroscopic repair procedures with anchors and implants. Today, rotator cuff repair has evolved to be performed as an arthroscopic transosseous technique that is again performed without the use of anchors. In this video, the 5 essential steps of arthroscopic transosseous repair will be demonstrated. (1) Position the patient in either the beach chair or lateral decubitus position. (2) Utilize 4-portal arthroscopy, which allows a consistent vantage point while having 3 other portals for instrumentation. (3) Perform just enough bursectomy to expose the rotator cuff. (4) Anatomically reduce the rotator cuff anatomy where possible. (5) Triple-load the transosseous tunnels with high-strength sutures in order to maximize the biomechanical strength of the repair. Alternative surgical techniques include open rotator cuff repair and single and double-row rotator cuff repair using anchors. The goal of any rotator cuff repair is to anatomically restore the rotator cuff. The fundamental principles include a strong initial biomechanical fixation, cuff footprint anatomy restoration, and maximization of biological factors to promote healing of the rotator cuff. Rotator cuff repair was originally performed as an open procedure, which allows for direct visualization of the tear and repair; however, open repair requires some level of deltoid splitting, which can potentially affect postoperative early mobilization. Single-row and double-row cuff repairs can both be performed arthroscopically. Proponents of the double-row procedure prefer that technique for its footprint restoration and stronger biomechanical fixation; however, the double-row procedure can result in overtensioning of the repair and can lead to medial-based rotator cuff failures. Proponents of the single-row procedure prefer that technique for its ease of operation, fewer implants, lower cost, and low repair tension; however, the single-row procedure fixes the tendon at a single point, limiting the repaired footprint, and can be associated with lower fixation strength. The arthroscopic transosseous rotator cuff repair achieves all of the above goals as it provides strong initial fixation and anatomic footprint restoration, which allows maximal patient biology for healing. There are numerous studies that can attest to the success of arthroscopic transosseous repair. Some of the benefits include decreased health-care costs and postoperative pain levels. In a 2016 study of 109 patients undergoing arthroscopic transosseous rotator cuff repair, Flanagin et al. reported a mean American Shoulder and Elbow Surgeons (ASES) score of 95 and a failure rate of 3.7% at mid-term follow-up1. Similarly, in a study comparing transosseous repair to transosseous equivalent repair, Srikumaran et al. reported that patients undergoing transosseous repair had a mean ASES score of 92 and a failure rate of 14%, with no significant differences between treatment groups2. Finally, in a study assessing the results of arthroscopic transosseous rotator cuff repair at >10 years postoperatively, Plachel et al. reported a mean ASES score of 92 and a failure rate of 27%3. Compared with conventional rotator cuff with anchors, the transosseous cuff repair can lead to cut-out of the repair sutures from the bone.Use a 4-portal arthroscopy technique, which will help the surgeon visualize all tear configurations while instrumenting them.Perform just enough bursectomy, in order to preserve the growth factors for cuff healing.Take care to minimize tuberosity trauma as a result of burring.Prepare the transosseous tunnels with a wide bone bridge.Load each tunnel with 3 high-strength sutures in order to maximize repair strength.Restore the rotator cuff footprint to facilitate tissue healing. ASES = American Shoulder and Elbow SurgeonsRCR = rotator cuff repairATRCR = arthroscopic transosseous rotator cuff repairARCR = arthroscopic rotator cuff repairPDS = polydioxanone sutureROM = range of motionSSV = Subjective Shoulder ValueFF = forward flexionOR = operating roomFU = follow-up.

Augmentation of a Transosseous-Equivalent Repair in Posterosuperior Nonacute Rotator Cuff Tears With a Bioinductive Collagen Implant Decreases the Retear Rate at 1 Year: A Randomized Controlled Trial

To determine whether the addition of a bioinductive collagen implant (BCI) over a transosseous equivalent (TOE) repair of medium-to-large posterosuperior rotator cuff tears improves the healing rate determined by magnetic resonance imaging (MRI) at 12-month follow-up. A Level I randomized controlled trial was performed in 124 subjects with isolated, symptomatic, reparable, full-thickness, medium-to-large posterosuperior nonacute rotator cuff tears, with fatty infiltration ≤2. These were randomized to 2 groups in which an arthroscopic posterosuperior rotator cuff tear TOE repair was performed alone (Control group) or with BCI applied over the TOE repair (BCI group). The primary outcome was the retear rate (defined as Sugaya 4-5) determined by MRI at 12 months of follow-up. Secondary outcomes were characteristics of the tendon (Sugaya grade and thickness of the healed tendon) and clinical outcomes (pain levels, EQ-5D-5L, American Shoulder and Elbow Surgeons, and Constant-Murley scores) at 12 months of follow-up. Of the 124 randomized patients, 122 (60 in the BCI group and 62 in the Control group) were available for MRI evaluation 12.2 ± 1.02 months after the intervention. There were no relevant differences in preoperative characteristics. Adding the BCI reduced the retear rate (8.3% [5/60] in the BCI group vs 25.8% [16/62] in the Control group, P= .010; relative risk of retear of 0.32 [95% confidence interval 0.13-0.83]). Sugaya grade was also better in the BCI group (P=.030). There were no differences between groups in the percentage of subjects who reached the MCID for CMS (76.7% vs 81.7%, P= .654) or American Shoulder and Elbow Surgeons (75% vs 80%, P= .829), in other clinical outcomes or in complication rates at 12.4 ± 0.73 (range 11.5-17) months of follow-up. Augmentation with a BCI of a TOE repair in a medium-to-large posterosuperior rotator cuff tear reduces the retear rate at 12-month follow-up by two-thirds, yielding similar improvements in clinical outcomes and without increased complication rates. Level I, randomized controlled trial.

Arthroscopic Double-Row Rotator Cuff Repair With Box Configuration

Background: Arthroscopic transosseous-equivalent (TOE) techniques may offer additional advantages, including a more efficient surgery with a self-reinforcing construct with equivalent clinical results to medial knotted TOE repair for rotator cuff tears (RCTs). Indications: An arthroscopic knotless double-row (DR) rotator cuff repair (RCR) using FiberTak RC anchors for medial row fixation with box configuration may be an appropriate construct for operatively indicated small-to-moderate full-thickness RCTs. Technique: Our modified technique uses TOE repair principles to address RCTs too small for traditional 4.75-mm anchors using medial row fixation and too large to apply a single medial to lateral anchor repair. The patient is placed in a beach chair position. In addition to standard anterior and posterior portals, a lower lateral working portal and a higher posterolateral viewing portal are made. Subsequent to supraspinatus footprint visualization/preparation, two 2.6-mm FiberTak RC anchors each loaded with 1 LabralTape and 1 FiberWire are placed medially. The 4 sets of sutures for one anchor are placed through the rotator cuff tendon together in 1 spot and the process is repeated for the second anchor. One FiberWire from each anchor is then tied extracorporeally and then a double pulley technique is used to compress the medial aspect of the repair at the footprint in a box configuration. Finally, 1 limb of LabralTape from each of the medial anchors along with the corresponding FiberWire is secured through 2 lateral-row 4.75-mm anchors anteriorly and posteriorly to restore the lateral footprint and secure the rotator cuff in TOE box configuration. This modified technique can provide anatomical compression of the rotator cuff tendon at the footprint with additional medial compression achieved by the box configuration while taking advantage of knotless fixation. Results: Postoperatively, a sling is worn for 4 weeks, passive range of motion (ROM) is initiated at 2 weeks, active ROM is begun at 6 weeks, and strengthening at 3 months. Patients may return to full unrestricted activities around 5 to 6 months. Discussion/Conclusion: A modified arthroscopic DR RCR with box configuration is an excellent treatment option for patients with small-to-moderate full-thickness RCT who fail conservative treatment. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Rates of medial and lateral row failure and risk factors for Re-tear in arthroscopic double row rotator cuff repair

A common postoperative complication after rotator cuff repair is re-tear requiring a secondary procedure. Double row and trans-osseous equivalent repair techniques have become increasingly popular in recent years, however repair failure remains a relatively common complication after primary rotator cuff repair. A retrospective observational study of 389 consecutive patients undergoing arthroscopic double-row rotator cuff repair from February 1, 2014 to March 31, 2020 was conducted. Univariate and multivariate statistics were used to assess differences in demographics, comorbidities, and tear characteristics between patients who experienced re-tear and those who did not. Repair failures were confirmed by plain MRI or intraoperatively during repeat surgical treatment. A subgroup analysis of patients who experienced re-tear due to medial row failure was conducted. The overall re-tear rate was 8.2% (32 patients). Six patients (1.5%) experienced medial row failure, while 26 patients (6.7%) experienced lateral row failure. The average time to re-tear was 279.3 ± 291.2 days. On multivariate analysis, patients with Goutallier Classification ≥3 (OR: 4.274, p = 0.046) and 3 anchor repair (OR: 5.387, p = 0.027) were at significantly increased risk for any re-tear after controlling for other tear characteristics. No statistically significant independent risk factors for medial row failure were identified after controlling for confounding variables. Goutallier classification greater than 3 and a primary repair with 3 anchors are significant risk factors for re-tear after double row rotator cuff repair, however they are not associated with increased occurrence of medial row failure. Further evaluation of risk factors for medial row failure is required to avoid this rare but serious re-tear pattern.

A PROSPECTIVE STUDY OF FUNCTIONAL OUTCOME AFTER ROTATOR CUFF REPAIR FOR LARGE ROTATOR CUFF TEARS FOLLOWING ARTHROSCOPIC DOUBLE ROW -TRANSOSSEOUS EQUIVALENT REPAIR V/S SINGLE ROW ROTATOR CUFF REPAIR

Tears of the rotator cuff tendons remain a common source of pain and disability among the adult population. Age appears to be the most common aetiology, with 25% of individuals in their 60's and in 50% of individuals in their 80's being found to have rotator cuff tears. Prevalence of partial thickness rotator cuff tears ranges from 15 to 32% in the general population, and is higher (40%) in the dominant arm. Arthroscopic Adequate Initial xation plays a key role in achieving successful healing with rotator cuff tears. A number of surgical techniques have been described for the repair of rotator cuff injuries. These include xation both single- and double-row suture anchor techniques, transosseous Equivalent Repair. Much debate exists over the gold standard surgical technique, in particular with regards to Single Vs Double row methods.

Knotted and knotless double row transosseous equivalent repair techniques for arthroscopic rotator cuff repair demonstrate comparable post-operative outcomes.

To compare failure rates and outcomes after transosseous equivalent (TOE) double row (DR) knotted suture bridge versus knotless suture tape bridge repair techniques for rotator cuff tears. A consecutive series of 272 shoulders in 256 patients who underwent arthroscopic, double row, TOE repair for full-thickness tears of the supraspinatus tendon were reviewed. Eighty-four shoulders were repaired using knotted suture bridge (KSB) technique, and 188 shoulders were repaired using all knotless suture tape bridge (KTB) technique. Revision procedures and concomitant subscapularis tendon repairs were excluded from analysis. The minimum follow-up was 12months. Primary outcome was failure of surgical repair, defined as either confirmed retear on MRI and/or need for revision surgery. Secondary clinical outcome measures were assessed including range of motion, strength, visual analog scale (VAS), operative time, subjective shoulder value (SSV), Patient-Reported Outcomes Measurement Information System (PROMIS) mental and physical health, American Shoulder and Elbow Surgeons Shoulder Score (ASES), Brophy shoulder activity scores, and need for manipulation under anesthesia (MUA). A total of 127 shoulders (38 KSB and 89 KTB) met inclusion criteria for the study. No significant difference in demographic variables were present between the groups at baseline. Supraspinatus tear size and average follow-up time did not differ significantly between groups. Failure rates were similar between the KSB and KTB repairs (13.1 vs 7.9%, n.s.). There was no significant difference in functional outcomes including strength, range of motion in forward flexion and external rotation, as well as patient reported outcomes including VAS, SSV, PROMIS, ASES, and Brophy scores between the groups. There was also no difference in post-operative stiffness requiring MUA. Both KSB and KTB repair techniques demonstrate low retear rates with excellent functional outcomes when compared to pre-operative examination. Both KSB and KTB techniques are viable options for achieving a successful rotator cuff repair. Level III.

Surgical Technique of Arthroscopic Transosseous Implant-Less Rotator Cuff Repair Using “Arthrocuff” System

Rotator cuff tears remain one of the most common causes of shoulder pain and disability. Although many repair techniques like single-row, double-row, and transosseous equivalent repair have become popular, transosseous repair still remains the gold standard.Arthroscopic transosseous repair is a safe and affordable alternative to suture anchors. Considering this fact, a reusable instrumentation “ArthroCuff”, was developed by SpowerN Medical Equipment (Chennai, India) in collaboration with the National Hub for Healthcare Device Development, India. Arthrocuff system not only aids a robust transosseous rotator cuff repair, but it is also cost-effective. We present the video technique of Arthrocuff for rotator cuff repair.

Long-term outcomes after arthroscopic transosseous-equivalent repair: clinical and magnetic resonance imaging results of rotator cuff tears at a minimum follow-up of 10 years.

The objective of this study was to evaluate the long-term functional outcomes and structural integrity of medium to massive rotator cuff tears at 10-12 years of follow-up after arthroscopic transosseous-equivalent (TOE) repair. This was a retrospective study of a consecutive series of patients who underwent primary arthroscopic TOE repair of medium- to massive-sized degenerative rotator cuff tears performed by a single surgeon between January 2007 and August 2009. Patients were examined at a minimum follow-up of 10 years, and magnetic resonance imaging (MRI) was performed to assess tendon integrity. The Constant score (CS), American Shoulder and Elbow Surgeons score, and pain level documented using a visual analog scale were compared between intact repairs and recurrent defects. Univariate analysis was performed to identify factors related to recurrent defects. A total of 102 patients met the inclusion criteria, and 79 shoulders in 76 patients (74.5% of eligible patients) with a mean age at surgery of 55 ± 8 years (range, 40-72 years) were available for clinical evaluation at a mean follow-up time of 10.9 years (range, 10-12 years). The mean anteroposterior tear size was 3.1 ± 1.1 cm, and there were 41 medium (52%), 26 large (33%), and 12 massive (15%) tears. MRI was performed in 72 shoulders in 69 patients (91% of available shoulders) and revealed that 13 shoulders had recurrent defects (Sugaya stages 4 and 5). During the follow-up period, 3 patients underwent revision surgery, and the overall recurrent defect rate was 21.3%. A clinically meaningful improvement was observed in all outcome measures at the final follow-up regardless of tendon integrity. Patients with intact repairs showed superior outcomes compared with those with recurrent defects; however, only the overall CS met the threshold for clinical relevance. A significant linear correlation was observed between the Sugaya classification and all outcome scores except the CS pain subscale; however, the strength of correlation was weak. The presence of diabetes (odds ratio [OR], 8.6; 95% confidence interval [CI], 2.25-33.2; P = .002), tear size (OR, 2.08; 95% CI, 1.16-3.46; P = .012), and tear retraction (OR, 4.07; 95% CI, 1.11-14.83; P = .033) were associated with recurrent defects in the univariate analysis. Arthroscopic TOE repair of rotator cuff tears provided improved clinical outcomes with a recurrent defect rate of 21.3% at 10-12 years after surgery. Future research focusing on tendon healing is needed as repair integrity on MRI correlates with clinical outcomes.

Long Term Outcomes After Arthroscopic Transosseous Equivalent Repair: Clinical and MRI Results of Medium to Large Rotator Cuff Tears At a Minimum Follow-Up of 10 Years

The objective of this study was to evaluate the long-term functional outcomes and structural integrity after arthroscopic double row TOE repair of rotator cuff tears at a minimum follow-up of 10 years.

Arthroscopic Knotless Separate Layer Transosseous Equivalent Repair of Delaminated Rotator Cuff Tears

Delamination of rotator cuff tears presents a challenge for surgeons. Recognizing and repairing such a complex tear pattern often require innovative approaches to achieve an anatomic restoration of footprint. In this Technical Note, we described our preferred method that anatomically repairs both layers of delaminated rotator cuff tear separately in a knotless transosseous equivalent technique. Two sutures are placed to the articular layer in a cinch stitch configuration. Then, closed-loop end sutures are passed through both layers while keeping the closed-loop end at the working portal. The free ends of cinch stitches are loaded to anchors with a preloaded fiber tape loop, which is placed to the medial row while approximating the articular layer onto its footprint. Fiber tapes are then shuttled through both layers of tendon with the help of a previously placed closed-loop suture. Finally, the lateral row anchors are placed while fiber tapes are tensioned in a cross-bridge configuration. We believe that this technique may facilitate uneventful healing of delaminated rotator cuffs by providing the biomechanical properties of transosseous equivalent repair.

Open Capsulorrhaphy for Recurrent Multidirectional Instability of the Shoulder

Background: The management of multidirectional instability (MDI) of the shoulder remains challenging, especially in athletes who participate in sports and may require multiple surgical procedures to achieve shoulder stabilization. Open or arthroscopic procedures can be performed to address shoulder MDI. Indications: Open capsulorrhaphy is preferred in patients with underlying tissue hyperlaxity and who had 1 or more, previously failed, arthroscopic shoulder stabilization procedures. Technique Description: With the patient in the beach-chair position (45°), tissue dissection is performed to the level of subscapularis tendon via the deltopectoral approach. The subscapularis tenotomy is performed in an L-shaped fashion, and the subscapularis tendon is tagged with multiple sutures and mobilized. Careful separation of the subscapularis tendon from the underlying capsular tissue is critical. Capsulotomy is performed, consisting of a vertical limb and an inferior limb that extends to the 5 o’clock position on the humeral neck (right shoulder). After evaluating the integrity of the labrum, the capsule is shifted superiorly and laterally, and repaired using 4 to 5 suture anchors. The redundant capsule is excised, and the subscapularis tendon is repaired in a side-to-side fashion, augmented by transosseous equivalent repair using the capsular sutures. Results: Adequate shoulder stabilization was achieved following open capsulorrhaphy in a young female athlete with tissue hyperlaxity and history of a previously failed arthroscopic soft tissue stabilization surgery of the shoulder. The athlete returned to sport at 6 months postoperatively and did not experience recurrent shoulder instability episodes at midterm follow-up. Discussion/Conclusion: Based on the existing literature, 82% to 97% of patients who underwent open capsulorrhaphy for MDI had no recurrent shoulder instability episodes at midterm follow-up. One study reported 64% return-to-sport rate following open capsulorrhaphy in 15 adolescent athletes with Ehlers-Danlos syndrome, but more research is necessary to better define the indications and outcomes of this procedure in physically active patients.

Intratendinous Strain Variations of the Supraspinatus Tendon Depending on Repair Technique: A Biomechanical Analysis Regarding the Cause of Medial Cuff Failure

Background: Double-row (DR) and transosseous-equivalent (TOE) techniques for rotator cuff repair offer more stability and promote better tendon healing compared with single-row (SR) repairs and are preferred by many surgeons. However, they can lead to more disastrous retear patterns with failure at the medial anchor row or the musculotendinous junction. The biomechanics of medial cuff failure have not been thoroughly investigated thus far. Purpose: To investigate the intratendinous strain distribution within the supraspinatus tendon depending on repair technique. Study Design: Controlled laboratory study. Methods: Twelve fresh-frozen cadaveric shoulders were used. The intratendinous strain within the supraspinatus tendon was analyzed in 2 regions—(1) at the footprint at the greater tuberosity and (2) medial to the footprint up to the musculotendinous junction—using a high-resolution 3-dimensional camera system. Testing was performed at submaximal loads of 40 N, 60 N, and 80 N for intact tendons, after SR repair, after DR repair, and after TOE repair. Results: The tendon strain of the SR group differed significantly in both regions from that of the intact tendons and the TOE group at 40 N (P≤ .043) and from the intact tendons, the DR group, and the TOE group at 60 N and 80 N (P≤ .048). SR repairs showed more tendon elongation at the footprint and less elongation medial to the footprint. DR and TOE repairs did not provide significant differences in tendon strain when compared with the intact tendons. However, the increase in tendon strain medial to the footprint from 40 N to 80 N was significantly more pronounced in the DR and TOE group (P≤ .029). Conclusion: While DR and TOE repair techniques more closely reproduced the strains of the supraspinatus tendon than did SR repair in a cadaveric model, they showed a significantly increased tendon strain at the musculotendinous junction with higher loads in comparison with the intact tendon. Clinical Relevance: DR and TOE rotator cuff reconstructions lead to a more anatomic tendon repair. However, their use has to be carefully evaluated whenever tendon quality is diminished, as they lead to a more drastic increase in tendon strain medial to the footprint, putting these repairs at risk of medial cuff failure.

Maximum Bridging Suture Tension Provides Better Clinical Outcomes in Transosseous-Equivalent Rotator Cuff Repair: A Clinical, Prospective Randomized Comparative Study

Background: Some studies reporting clinical outcomes after transosseous-equivalent (TOE) repair have attributed type II rotator cuff failure to excessive bridging suture tension, as it can cause overloading on the medial row. In a previous biomechanical cadaveric study, increasing bridging suture tension over 90 N did not improve the contact area and ultimate failure load of the TOE construct, despite increasing the contact force and contact pressure. Purpose: To compare the clinical outcomes of different bridging suture tensions after TOE rotator cuff repair based on the results of a previous biomechanical study. Study Design: Randomized controlled trial; Level of evidence, 2. Methods: A total of 78 patients who underwent arthroscopic rotator cuff repair for medium- to large-sized tears were prospectively enrolled and randomly divided into 2 groups according to the applied bridging suture tension: optimum tension group (96.3 ± 4.9 N) and maximum tension group (199.0 ± 20.3 N). Bridging suture tension was measured with a customized tensiometer, as used in the previous biomechanical study. The functional outcome was measured at the final follow-up (27.4 ± 5.9 months [range, 24-45 months]) using the visual analog scale for pain, American Shoulder and Elbow Surgeons score, Simple Shoulder Test, and Constant score, and the anatomic outcome was evaluated using magnetic resonance imaging or ultrasonography at least 12 months after surgery. Results: Overall, 64 patients (32 in each group) were analyzed. The functional outcomes improved significantly compared with preoperative values (all P < .05) but did not show significant differences between the 2 groups (all P > .05). Regarding the anatomic outcomes, the maximum tension group (n = 1; 3.1%) had a significantly lower healing failure rate than the optimum tension group (n = 9; 28.1%) (P = .013). One patient in the maximum tension group had a type II failure. Conclusion: Maximum bridging suture tension in TOE repair for medium- to large-sized rotator cuff tears provided better anatomic healing with less risk of medial rotator cuff failure, which differs from the results of a previous time-zero biomechanical study.

Does the Dog-Ear or Bird-Beak Deformity Remodel After Rotator Cuff Repair?

Background: Dog-ear and bird-beak deformities are common after transosseous-equivalent repair (suture bridge technique). The natural course of deformities after rotator cuff (RC) repair using the suture bridge technique is unclear. The remodeling potential of these deformities has not been investigated. Purpose: To evaluate remodeling and retear rates associated with deformities after RC repair. Study Design: Cohort study; Level of evidence, 3. Methods: Between November 2011 and February 2012, we studied 99 consecutive shoulders. All patients underwent arthroscopic RC repair via the suture bridge technique with or without additional sutures. Two groups were formed: no deformity (n= 46) and deformity (n = 53). Deformity was defined as marginal detachment and protrusion of the RC after repair, involving inappropriate compression of the suture limbs from the anchors. Tendon height was measured from the highest point of the most protruding portion of the cuff to the cortex on semi-coronal magnetic resonance imaging (MRI) scan. Change in tendon height was evaluated on MRI scan at 1 week and 6 months postoperatively. Clinical assessment at every patient visit included the American Shoulder and Elbow Surgeons (ASES) score, Constant shoulder score, and visual analog scale for pain (pVAS) score. Results: No significant differences were found in age, sex, symptom duration, tear size, and preoperative ASES, Constant, and pVAS scores (P > .05) between the 2 groups. The initial tendon height was 7.4 ± 1.5 mm in the no-deformity group and 9.3 ± 2.0 mm in the deformity group. Follow-up height was 6.3 ± 2.1 mm in the no-deformity group and 6.4 ± 1.6 mm in the deformity group. Mean postoperative tendon heights were 90.1% ± 23.8% of the initial height in the no-deformity group and 73.2% ± 15.1% in the deformity group. Clinical scores (ASES, Constant, and pVAS) were not significantly different between the groups at 6 months. There were 4 shoulders in each group that experienced retearing (types 4 and 5 according to the Sugaya classification) at 6 months postoperatively. There was no difference in retear rate (P > .999). Conclusion: Most deformities after RC repair were remodeled with no effect on retears. Clinical outcomes were not affected by deformities.

Minimum Five-year Outcomes and Clinical Survivorship for Arthroscopic Transosseous-equivalent Double-row Rotator Cuff Repair.

Despite the widespread use of arthroscopic double-row transosseous-equivalent (TOE) rotator cuff repair (RCR) techniques, midterm outcome data are limited. The purpose of this article was to assess midterm clinical outcomes of patients following arthroscopic TOE RCR using either a knotless tape bridge (TB) repair or knotted suture bridge (SB) repair technique. We hypothesized that there would be significant improvements in patient-reported outcomes with TOE RCR that would be durable over time. We also hypothesized that the knotless TB technique would yield equivalent clinical results to the knotted SB technique, but that there would be differences in retear types between the two TOE techniques. Patients included were a minimum of 5 years from an index arthroscopic double-row TOE repair using either a knotless TB or knotted SB technique for one, two, or three tendon full-thickness rotator cuff tears involving the supraspinatus tendon. Preoperative and postoperative American Shoulder and Elbow Surgeons, Short-Form 12 Physical Component Summary, Quick Disabilities of the Arm, Shoulder, and Hand, Single Assessment Numeric Evaluation, and satisfaction scores were collected. Scores were also stratified and compared based on primary and revision repair, tear location, and tear chronicity. Outcomes between techniques were contrasted, and survivorship analysis was conducted, with failure defined as progression to revision surgery. One-hundred ninety-two shoulders were included with a mean follow-up of 6.6 years (range, 5.0 to 11.0 years). Fifteen shoulders (7.8%) underwent revision cuff repair. All scores improved significantly for TB repair (P < 0.001). For SB repair, all scores improved, but only American Shoulder and Elbow Surgeons and Short-Form 12 Physical Component Summary scores (P < 0.05) demonstrated statistical significance. No statistically significant differences were found between the repair techniques when stratified by primary and revision repairs, tear location, or chronicity. Postoperative clinical survivorship was 96.6% and 93.6% for knotted SB repairs and 96.7% and 93.9% for knotless TB repairs at 2 and 5 years, respectively. TOE RCR results in significant clinical improvement and excellent survivorship at a minimum of 5 years of follow-up, using either knotted SB or knotless TB repair techniques in primary and revision cases and in small and large tears. Equivalent results were obtained with both TOE techniques. Patients undergoing repair with a TOE showed significant improvements in patient-reported outcomes that were durable at a minimum of 5 years postoperatively.

Improved Rotator Cuff Footprint Contact Characteristics With an Augmented Repair Construct Using Lateral Edge Fixation

Background: The transosseous-equivalent (TOE) rotator cuff repair construct has become the gold standard for the repair of medium and large rotator cuff tears. Repair failure, however, continues to be a problem. One contributing factor may be the inability of the TOE repair to replicate the native footprint contact characteristics during shoulder movement, especially in rotation. This results in higher strain across the repair, which leads to gapping and predisposes the construct to failure. In an effort to better reproduce the native compression forces throughout the footprint, an augmented TOE construct supplemented with lateral edge fixation is proposed, and the contact characteristics were compared with those of the gold standard TOE construct. Hypothesis: The augmented TOE repair will demonstrate improved footprint contact characteristics when compared with the classic TOE repair. Study Design: Controlled laboratory study. Methods: Ten fresh-frozen cadaveric shoulders underwent supraspinatus repair using both the classic TOE double-row construct and the augmented TOE repair. For the augmented repair, 2 luggage tag sutures were used to secure the lateral edge and incorporated into the lateral row anchors. A Tekscan pressure sensor (Tekscan Inc) placed under the repaired tendon was used to collect footprint contact area, force, peak pressure, and contact pressure data for each construct. Results: The augmented construct demonstrated significantly greater contact forces (average difference, 4.9 N) and significantly greater contact pressures (average difference, 23.1 kPa) at all degrees of abduction and all degrees of rotation. At 30° of internal and 30° of external rotation at both 0° and 30° of shoulder abduction, the augmented construct demonstrated significantly greater peak contact pressures. Conclusion: The augmented construct showed superior contact characteristics when compared with the classic TOE technique. The addition of lateral edge fixation to the classic TOE repair significantly improves bone-tendon contact characteristics with minimal additional surgical effort. Clinical Relevance: The results of this study indicate that lateral augmentation of the classic TOE repair produces a biomechanically superior construct that may optimize tendon healing.

Arthroscopic Knotless Separate Layer Transosseous Equivalent Repair of Delaminated Rotator Cuff Tears

Delamination of rotator cuff tears presents a challenge for surgeons. Recognizing and repairing such a complex tear pattern often require innovative approaches to achieve an anatomic restoration of footprint. In this Technical Note, we described our preferred method that anatomically repairs both layers of delaminated rotator cuff tear separately in a knotless transosseous equivalent technique. Two sutures are placed to the articular layer in a cinch stitch configuration. Then, closed-loop end sutures are passed through both layers while keeping the closed-loop end at the working portal. The free ends of cinch stitches are loaded to anchors with a preloaded fiber tape loop, which is placed to the medial row while approximating the articular layer onto its footprint. Fiber tapes are then shuttled through both layers of tendon with the help of a previously placed closed-loop suture. Finally, the lateral row anchors are placed while fiber tapes are tensioned in a cross-bridge configuration. We believe that this technique may facilitate uneventful healing of delaminated rotator cuffs by providing the biomechanical properties of transosseous equivalent repair.

Superior Capsular Reconstruction for Massive Rotator Cuff Tears

» A massive rotator cuff tear is defined as a tear involving &gt;2 tendons or &gt;5 cm of retraction.» Superior capsular reconstruction is done with either a folded fascia lata autograft (6 to 8 mm in thickness) or acellular dermal allograft (3 to 4 mm in thickness). The graft is secured arthroscopically with anchors on the superior glenoid rim and multiple anchors on the humeral head with use of a transosseous-equivalent repair technique.» Superior capsular reconstruction is indicated for younger patients with massive and irreparable rotator cuff tears involving the supraspinatus and infraspinatus with minimal arthritis, intact subscapularis, and a functional deltoid. Contraindications include bone defects, stiffness, and moderate to severe arthropathy.» Arthroscopic superior capsular reconstruction with fascia lata autograft or humeral dermal allograft is a surgical option, with multiple studies showing statistically significant improvement in short-term outcomes for both pain and function among younger patients with massive irreparable rotator cuff tears. The long-term clinical effectiveness and value have yet to be determined.» Biomechanical data suggest improved restoration of superior glenohumeral stability with decreased subacromial contact pressures in association with the use of the 8-mm fascia lata graft as compared with the 4-mm acellular humeral dermal allograft. In addition, fascia lata graft has shown less elongation and thinning than humeral dermal graft.» Either fascia lata autograft or humeral dermal allograft may be used clinically for arthroscopic superior capsular reconstruction; however, a graft thickness of at least 3 mm is recommended to decrease the risk of radiographic and clinical failure.» No comprehensive quality-of-life or cost-comparison analyses are available to compare superior capsular reconstruction, reverse total shoulder arthroplasty (rTSA), tendon transfer, and partial rotator cuff repair for the treatment of massive irreparable rotator cuff tears. However, the potential higher cost of superior capsular reconstruction and the lack of long-term clinical outcomes or revision data suggest that either an attempt at repair or primary arthroplasty may be more cost-effective than superior capsular reconstruction.» Long-term outcome data are essential to determine the role of superior capsular reconstruction for young patients with massive irreparable rotator cuff tears.» Superior capsular reconstruction using fascia lata autograft may provide a different biomechanical and biological healing environment compared to acellular dermal allograft. Thus, the clinical outcome data between the 2 graft methods should not be generalized.

Does Medial-Row Fixation Technique Affect the Retear Rate and Functional Outcomes After Double-Row Transosseous-Equivalent Rotator Cuff Repair?

Background:Double-row transosseous-equivalent (TOE) rotator cuff repair techniques have been widely accepted because of their superior biomechanical properties when compared with arthroscopic single-row repair. Concerns regarding repair overtensioning with medial-row knot tying have led to increased interest in knotless repair techniques; however, there is a paucity of clinical data to guide the choice of technique.Hypothesis:Arthroscopic TOE repair techniques using knotless medial-row fixation will demonstrate lower retear rates and greater improvements in the Constant score relative to conventional knot-tying TOE techniques.Study Design:Systematic review; Level of evidence, 4.Methods:A systematic review of 3 databases (PubMed, Cochrane, and Embase) was performed using PRISMA (Preferred Reporting Items for Systematic Meta-Analyses) guidelines. Inclusion criteria were English-language studies that examined repair integrity or Constant scores after arthroscopic rotator cuff repair with TOE techniques. Two investigators independently screened results for relevant articles. Data regarding the study design, surgical technique, retear rate, and Constant shoulder score were extracted from eligible studies. A quality assessment of all articles was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria.Results:The systematic review identified a total of 32 studies (level of evidence, 1-4) that met inclusion and exclusion criteria. Of the 32 studies, 5 reported on knotless TOE techniques, 25 reported on knot-tying TOE techniques, and 2 reported on both. In the knotless group, retear rates ranged from 6% to 36%, and Constant scores ranged from 38-65 (preoperative) to 73-83 (postoperative). In the knot-tying group, retear rates ranged from 0% to 48%, and Constant scores ranged from 42-64 (preoperative) to 55-96 (postoperative).Conclusion:Despite several theoretical advantages of knotless TOE repair, both knotless and knot-tying techniques reported considerable improvement in functional outcomes after rotator cuff repair. Although tendon failure rates showed a downward trend in knotless studies, additional prospective studies are warranted to better understand the role of medial-row fixation on tendon repair integrity and postoperative clinical outcomes.