Transosseous Rotator Cuff Repair Research Articles

Anchorless Transosseous Rotator Cuff Repair: A Technical Note

Background: Transosseous rotator cuff repair provides robust fixation and broad footprint compression without the risk of foreign body reaction that may be seen with suture anchors. We present our technique for anchorless transosseous repair using a modern device to efficiently create bone tunnels and assist in suture passage. Indications: Tears of the supraspinatus tendon, with or without extension to the infraspinatus, in patients with acute or chronic tears, with good bone quality, and who fail appropriate nonoperative management. Technique: The beach-chair position with an articulating arm holder is preferred for this procedure. A glenohumeral diagnostic arthroscopy is performed, and intra-articular pathology is addressed as needed. The arthroscope is brought into the subacromial space, and a lateral viewing portal is established. A thorough bursectomy with or without acromioplasty is performed to attain visualization of the cuff. After the tear is identified, the tendon edges are debrided. It is critical to determine the tear pattern, the reduction maneuvers necessary, and the number of bone tunnels that are warranted. The desired location of the bone tunnel is marked with a pilot hole. The device is positioned over the pilot hole and a power drill is advanced through the lateral cortex. The device assists in creating a bone tunnel through the greater tuberosity and passes a nitinol loop through the tunnel. The loop is retrieved by the device and is brought to the lateral portal. Sutures are loaded into the loop and are brought through the bone tunnel. The sutures are then passed through the tendon using a curved retrograde suture passer in simple fashion and are tied to secure the tendon to the footprint. For larger tears, 2 or 3 tunnels may be used to widen the area for footprint compression. The specific configuration used will depend on the tear size, pattern, and surgeon preference. Results: Arthroscopic transosseous repairs have yielded promising results. Healing rates are comparable to anchor-based techniques, with the benefit of avoiding foreign bodies at the footprint. Discussion: Anchorless transosseous rotator cuff repair may be reproducibly performed with the use of a modern device for bone tunnel creation and suture passage. However, this technique should be used with caution in patients with osteoporosis or poor bone quality due to theoretical concerns of greater tuberosity fracture or suture pullout through the tunnels. 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.

Arthroscopic Transosseous Rotator Cuff Repair

Open transosseous rotator cuff repair (RCR) was the original benchmark surgical technique for RCR. The advent of arthroscopic and suture anchor technology shifted the paradigm from open to arthroscopic surgery. Although technological advances have progressed, they come at a cost. Suture anchor technology is expensive, optimal constructs have yet to be determined, and the technology may lead to challenging complications and revision scenarios. In more recent years, a return to transosseous bone tunnels has been described with new arthroscopic techniques, eliminating the need for suture anchors. The purpose of this article is to review the historical, biomechanical, clinical, and economic literature surrounding arthroscopic transosseous RCR.

Comparison of cost, surgical time, and clinical results between arthroscopic transosseous rotator cuff repair with lateral cortical augmentation and arthroscopic transosseous equivalent suture bridge: A propensity score-matched analysis

BackgroundTo reduce the healthcare burden, the clinical results of arthroscopic rotator cuff repair and the cost of the implants used have recently been focused upon. This study compared implant cost, surgical time, short-term clinical results, and cuff repair integrity 2 years postoperatively between arthroscopic transosseous rotator cuff repair using lateral cortical augmentation (TOA) and arthroscopic transosseous-equivalent suture bridge (TOE). MethodsThis study included 220 patients with rotator cuff repairs performed by a single surgeon between December 2013 and December 2018. Overall, 70 TOA and 68 TOE cases met the inclusion criteria. The same surgeon performed the procedures at two different hospitals, and the techniques differed between the facilities. A total of 42 TOA patients were matched with 42 TOE patients. The patients were matched using a propensity score analysis by gender, age, and cuff tear size. The minimum follow-up period was 2 years. Implant cost and surgical time were compared between the two methods. The range of motion, clinical outcomes, and visual analog scale were evaluated. Magnetic resonance imaging was performed to examine cuff repair integrity 2 years postoperatively. ResultsThe follow-up rate was 81% (112/138 patients). Implant cost was significantly lower with TOA ($1,396 vs. $2,165; p < 0.001) than with TOE. The average surgical time in the TOA method was significantly shorter than that in the TOE method (82 vs. 109 min; p = 0.001). At a minimum 2-year follow-up, the mean active elevation, abduction, and clinical outcomes improved with both methods, although no improvements in external and internal rotations were observed with either method. There were no significant differences in the postoperative variables and retear rate (TOA, 12%; TOE, 19%; p = 0.548) between the two methods. ConclusionsTOA and TOE achieved comparable clinical results; however, TOA was more cost-effective and had a shorter surgical time than TOE. Level of evidenceLevel Ⅲ, retrospective matched control study.

Arthroscopic Anchorless Transosseous Rotator Cuff Repair Produces Equivalent Clinical Outcomes and Imaging Results as a Standard Suture Bridge Technique with Anchors

To compare the clinical and imaging outcome of arthroscopic transosseous (TO)-equivalent rotator cuff repair (RCR) with anchors with arthroscopic anchorless TO RCR at a minimum of 2 years postoperatively. The study population included patients who underwent RCR using either an anchorless TO technique with a TO suture passing device (group A) and those who were matched for tear size and underwent RCR using suture anchors for repair (group B). The inclusion criterion was an easily reducible rotator cuff tear with a sagittal extension of 2 to 4 cm. After a minimum of 2 years, clinical outcome scores and magnetic resonance imaging were obtained. Tendon quality and footprint integration were evaluated using the Sugaya classification. Seventy patients were included. A total of 45 were in group A and 25 were in group B. Group A had 2 bone tunnels and 4 sutures using an X-box configuration, and group B had a suture bridge construct of 4 anchors. Group A and B had identical anteroposterior tear size and were comparable for age. The Constant score improved from 50 ± 17.4 to 88 ± 8.6 in group A versus 48 ± 14.5 to 87 ± 7.2 in B. The SubjectiveShoulder Value rose from 47 ± 19.1 to 95 ± 7.4 in group A vs from 47 ± 19.4 to 95 ± 7.6 in B. Neither the preoperative (P ≥ .502) nor postoperative scores (P ≥ .29) showed a significant difference. Magnetic resonance imaging showed 2 small retears in group A and one in B, resulting in an identical 4% retear rate. The mean Sugaya type was 2.02 versus 2.24 (P= .206) for groups A versus B. Anchorless TO RCR is a valid alternative to suture anchor techniques. Clinical outcome data showed comparable results for both techniques after a follow-up of 2 years. The healing results as observed on magnetic resonance imaging were also equivalent for both groups. Level III, retrospective comparative study.

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.

A Novel Arthroscopic Transosseous Procedure for Rotator Cuff Repair: An Economical Freehand Method

Open transosseous repair was historically considered the gold-standard surgical solution for rotator cuff tears; however, with advancements in arthroscopic surgery, this procedure was largely replaced by anchor-based techniques. Yet, the ability of anchor-based techniques to achieve similar biomechanical fixation remains uncertain.In this article, we describe a reproducible, economical, arthroscopic anchorless transosseous rotator cuff repair technique that uses an Omega configuration. This technique involves two bone tunnels and four high-strength polyethylene sutures and is suitable for medium-to-large rotator cuff tears that would alternatively need multiple anchors. This procedure not only maximizes the tendon-footprint contact area without using any implanted device but also theoretically lowers the bone laceration rate and is cost effective. In the current Technical Note, the procedure is described in detail along with several tips and tricks. ClassificationsLevel I, shoulder; Level II, rotator cuff.

Biomechanical Properties of Double-Row Transosseous Rotator Cuff Repair Combined With the Cinch Stitch in the Lateral Row.

Background:The self-cinching stitch has been verified to have high mechanical strength. The mechanical strength of combining transosseous rotator cuff repair (RCR) and the self-cinching stitch in the lateral row is unknown.Purpose/Hypothesis:The purpose of this study was to evaluate the biomechanical properties of transosseous RCR combined with the cinch stitch in the lateral row. We hypothesized that this construct would have better mechanical strength than would transosseous repair using a vertical cinch stitch or simple stitch.Study Design:Controlled laboratory study.Methods:Rotator cuff tears were simulated in 48 porcine shoulder specimens. The tears were repaired using 1 of 6 repair configurations: 2–simple stitch transosseous repair alone (group 2TO), with a vertical cinch stitch (group 2TO-VC), or with a horizontal cinch stitch (group 2TO-HC) or 4–simple stitch transosseous repair alone (group 4TO), with a vertical cinch stitch (group 4TO-VC), or with a horizontal cinch stitch (group 4TO-HC). All specimens were set at a 45° angle from the footprint and underwent cyclic loading from 10 to 160 N for 200 cycles, followed by a load-to-failure test at 10 mm/min.Results:During cyclic loading, all specimens in group 2TO and half of the specimens in group 2TO-VC failed by suture pullout. In the other groups, none of the specimens failed before 200 cycles. The yield load in group 2TO-HC was significantly greater than that in group 2TO-VC (261.43 vs 219.54 N, respectively; P < .05). There were significant differences between groups 4TO-HC and 4TO with regard to elongation (3.92 vs 5.68 mm, respectively), yield load (304.04 vs 246.94 N, respectively), and linear stiffness (63.44 vs 52.28 N/mm, respectively) (P < .01 for all). Group 4TO-HC also had shorter elongation and a superior yield load and linear stiffness compared with group 2TO-HC (P < .05 for all), and group 4TO-VC had shorter elongation and a stronger maximum load to failure and yield load than did group 2TO-VC (P < .05 for all).Conclusion:Increasing the number of medial simple stitches can prevent suture pullout. Adding the horizontal cinch stitch to the lateral row in transosseous repair can further improve biomechanical properties through a self-cinching mechanism.Clinical Relevance:Transosseous RCR with a horizontal cinch stitch in the lateral row may reduce the retear rate.

Needle-Based Arthroscopic Transosseous Rotator Cuff Repair: A Short-Term Outcomes Analysis.

IntroductionGiven the limitations of anchor-based rotator cuff repair, surgeons have considered and investigated the use of an arthroscopic transosseous repair technique using only sutures to repair tendon tissue. Returning full circle to the gold standard of transosseous repair, but with the modern adaptation of arthroscopy, advocates of arthroscopic transosseous rotator cuff repair believe that many of the risks associated with suture anchors can be avoided. The purpose of this study was to examine the capabilities of a novel needle-based arthroscopic transosseous tunneling device (OmniCuff™ arthroscopic transosseous device, MinInvasive Ltd., Magal, Israel) and evaluate the short-term clinical outcomes and patient satisfaction of patients treated with this technique.Materials and methodsThis study was a prospective, single-arm, multi-center study performed on patients from January 2014 to March 2015. During the study period, thirty-two patients underwent arthroscopic transosseous rotator cuff repair using the OmniCuff™ arthroscopic transosseous device.ResultsThe average age of patients was 58.2 years (range, 44 to 80 years). The sizes of the tears were as follows: seven small, 18 medium, four large, and three massive. The average number of tunnels used per repair was 1.9 with the following breakdown: six one-tunnel repairs, 22 two-tunnel repairs, and four three-tunnel repairs. The mean American Shoulder and Elbow Surgeon (ASES) score improved from 45.1 to 87.7, the mean Simple Shoulder Test (SST) score improved from 42.6 to 92. Overall patient satisfaction was high with an average Likert scale of 4.6.ConclusionOur study demonstrated significantly improved outcomes for patients undergoing arthroscopic transosseous rotator cuff repair using the needle based Omnicuff device. Patients were overall very satisfied with the outcome of their surgery and their ASES and SST scores demonstrated this appropriately.

Clinical and Economic Advantages of Anchorless Arthroscopic Transosseous Suture Repair of the Rotator Cuff

In 2005, an anchorless technique was developed for arthroscopic transosseous rotator cuff repair to reproduce open surgery. Since May 2015, the retear rate has decreased with the use of absorbable sutures in mattress suturing. This study analyzed 389 patients who underwent surgery using absorbable mattress sutures. Three 2-mm Kirschner wires with perforated tips were inserted through the inferior margin of the greater tuberosity into the medial edge of the footprint. After pulling the rotator cuff stump laterally, three Kirschner wires were penetrated through the rotator cuff and skin. Two glycolic acid and three polyester sutures were passed through three bone tunnels using the perforated tips of the Kirschner wires. Surgery was completed by inserting two absorbable mattress sutures and three nonabsorbable bridging sutures. The retear rate after surgery with absorbable mattress sutures was 1.8%. The cost of surgical materials used in our procedure was $12. The application of an absorbable suture in mattress suturing was associated with a low retear rate. Further, this technique only requires sutures. Hence, it is considered economically advantageous.

Arthroscopic transosseous rotator cuff repair: how to avoid damaging the axillary nerve—a cadaveric study

Arthroscopic transosseous rotator cuff repair can be performed with an external guide, although the proximity to the axillary nerve raises safety concerns. The aim of this study is to determine the safety of different drilling angles regarding the axillary nerve. We performed a bone tunnel in the greater tuberosity in 17 fresh frozen shoulders, using an external guide at four different angles: 40°, 50°, 60°, and 70°. At each angle, we measured the distance between the drill and the axillary nerve, the distance from the acromion to the skin incision point, and the perimeter of the arm at the axilla. The distance to the axillary nerve was safe with the guide at an angle of 40°, 50° and 60°, but not at 70° (p = 0.001). We found significant differences between all four angles (p < 0.05). Regression analysis demonstrated the influence of the guide angle in all measurements assessed (p < 0.001). There was no association between the measurements taken and the axillary perimeter (p > 0.5). Arthroscopic transosseous rotator cuff repair with an external guide does not pose a risk for the axillary nerve using angles of 60° or less.

Mid- to Long-Term Outcomes After Deep Infections After Arthroscopic Rotator Cuff Repair

PurposeTo review clinical and subjective outcomes in patients with deep infections after arthroscopic rotator cuff repair.MethodsAll patients in whom deep infections developed after arthroscopic rotator cuff repair at a single center between 2002 and 2016 were retrospectively reviewed. Demographic data, clinical and microbiological findings, and treatment were analyzed. Clinical and subjective outcomes included the Constant score, visual analog scale score for pain, American Shoulder and Elbow Surgeons score, and Simple Shoulder Test score.ResultsThirty patients could be identified and included in the study. The most commonly isolated pathogens were Staphylococcus epidermidis (36.7%) and Cutibacterium acnes (30.0%). In 26 of 30 patients (86.7%), the infection was treated initially with an open surgical approach, whereas 4 patients (13.3%) underwent arthroscopic revision. A transosseous rotator cuff repair could be performed in 20.0% of patients. A single reoperation was sufficient in 80% of patients, whereas 13.3% required 2 revisions and 6.7% required 3. At the final follow-up of 8.3 years (range, 4-14 years), 26 patients (1 woman and 25 men) were available for outcome evaluation. Significant improvement from the initial surgical procedure to final follow-up was detected in the Constant score (25.7 vs 65.7, P < .001), visual analog scale score for pain (7.0 vs 1.7, P < .001), American Shoulder and Elbow Surgeons score (38.0 vs 76.7, P < .001), and Simple Shoulder Test score (4.0 vs 8.3, P < .001).ConclusionsPatients with deep infections after arthroscopic rotator cuff repair showed moderate mid- to long-term outcomes.Level of EvidenceLevel IV, therapeutic case series.

Arthroscopic Transosseous Repair of Rotator Cuff Tear and Greater Tuberosity Cysts

PurposeTo evaluate the short-term outcomes of rotator cuff repair in the presence of a greater tuberosity cyst (GTC) using a transosseous repair technique.MethodsThis study included patients who underwent arthroscopic rotator cuff tear repair with a transosseous technique and were evaluated clinically and by postoperative magnetic resonance imaging (MRI) after 1 year. The inclusion criteria were based on the results of preoperative MRI and were as follows: patients identified as having a repairable full-thickness rotator cuff tear associated with the presence of cystic changes at the tendon insertion site of the greater tuberosity, defined as a GTC involving the footprint area of the torn tendon (supraspinatus and/or infraspinatus tendons).ResultsWe evaluated 25 patients. The mean preoperative and postoperative American Shoulder and Elbow Surgeons scores were 39.48 (P = .530) and 84.64 (P = .035), respectively; Constant shoulder scores, 38.96 (P < .005) and 80.28 (P = .425), respectively; and University of California–Los Angeles shoulder rating scale scores, 10.6 (P = .045) and 29.04 (P = .315), respectively. The GTC mapping system was easily adopted in all the MRI examinations independently from the quality of the images. The GTCs were mostly located in the superficial anterolateral section of the humeral head and in both the posterolateral sections (superficial and deep).ConclusionsArthroscopic transosseous rotator cuff repair led to significant mid-term improvement and satisfactory subjective outcomes with low complication and failure rates in this study. The GTC mapping system could be useful to evaluate GTCs and to aid surgeons in the choice of the best surgical technique.Level of EvidenceLevel IV, therapeutic case series.

Results of Arthroscopic Transosseous Rotator Cuff Repair Using the ArthroCuff System: A Prospective Study

ABSTRACT Introduction Rotator cuff tears are one of the common cause of shoulder pain and disability. Transosseus cuff repair is still considered as the gold standard against which other techniques are compared. We studied the functional outcome of 50 patients with rotator cuff tear treated by our novel reusable arthroscopic transosseous repair system (ArthroCuff). Materials and methods We performed a prospective study involving 50 patients with full thickness rotator cuff tears during the period from January 2017 to December 2107. Repair was done with the ArthroCuff system. The patients were followed up periodically at 6 months and 1 year; 2 years functional outcome was assessed for pain, Oxford Shoulder score and active range of motion. Results At the end of 1 year and 2 years, all our patients had significant improvement in their Oxford Score, range of motion and pain relief. Two patients were trailing behind the mean at 6 months but they improved at 12 months. The results are comparable with other available transosseous systems and arthroscopic double row repair techniques. Conclusion Arthroscopic transosseous repair though a reliable and cost-effective alternate to suture anchors, is not widely available in India. So, in association with the National Hub for Healthcare Device Development, we developed ArthroCuff. For cost-conscious countries a reusable system to provide a robust rotator cuff repair is the need of the hour and we believe surgeons and patients can benefit from the multiple advantages that exist with this system. How to cite this article Rajsirish BS, Rajagopalan S, Nehru R, et al. Results of Arthroscopic Transosseous Rotator Cuff Repair Using the ArthroCuff System: A Prospective Study. J Orth Joint Surg 2020;2(1):4–9.

Arthroscopic, Needle-Based, Transosseous Rotator Cuff Repair

Although open transosseous repair was historically used as a gold-standard surgical solution for rotator cuff tears, this procedure was largely replaced by anchor-based techniques because of the advancement of arthroscopic surgery. However, the ability of anchor-based repair to achieve similar biomechanical fixation remains uncertain. Despite the proposals of numerous methods over the last decade, there remains demand for a standard, reliable technique that integrates the biomechanical advantages of transosseous fixation within the realm of arthroscopy. We describe a technique for transosseous rotator cuff repair using the Omnicuff, a needle-based transosseous suture-passing device that minimizes the risk of failure of suture passage between the bone tunnels. With potential advantages of this design including automated-assisted suture passage, improved bone-tendon healing, and anchorless fixation, surgeons may be inclined to consider these biomechanical and cost-saving benefits. Future studies are warranted to determine clinical outcomes of this technique and its suitability for tears of varying degrees and patterns.

Anchored vs. Anchorless Arthroscopic Transosseous Rotator Cuff Repair: Clinical Outcomes and Structural Integrity of a Matched Cohort

Anchored vs. Anchorless Arthroscopic Transosseous Rotator Cuff Repair: Clinical Outcomes and Structural Integrity of a Matched Cohort

Suture de coiffe sous arthroscopie : meilleurs résultats de l’IRM pour la suture transosseuse comparé avec une technique ancrée standard

Aim To compare the outcome of patients operated using either suture anchors vs a new anchorless transosseous (TO) technique for rotator cuff (RC) repair. We hypothesize that healing at the footprint (FP) as observed on MRI might be better with the anchorless approach. Background The former gold standard of open TO RC repair can now be mimicked arthroscopically. Since 5 years we use the Arthrotunneler (AT) system with 2 bone tunnels and 4-5 high strength sutures in an X-Box configuration for medium to large tears of supra- and infraspinatus, which would otherwise require a four anchor construct. Our impression was that the TO technique provides excellent outcomes and high healing rates. Methods We compared 2 cohorts: Cohort A prospectively includes 50 consecutive patients operated since 12/13 with the AT-device (Tornier, Wright); cohort B entails a retrospective series of 35 patients operated earlier. Included were non-retracted tears with a sagittal extension of 2.5 to 4 cm. Group A was operated without, group B with 4 anchors (Speed-bridge, Arthrex). Groups A and B were comparable in regards to age, sex and tear size. After a minimum of 2 years clinical outcome scores and a native MRI were obtained. Tendon quality and FP integration were evaluated using the Sugaya classification by an independent radiologist. Statistics: ANOVA and Wilcoxon test. Results Excluding 9 patients who declined, FU data are available from 44 patients in group A and 32 in B. Constant Score improved from 49 to 89P in group A vs. 46 to 86P in B (p = 0.66). The SSV rose from 45 to 95 % in group A vs from 44 to 93 % in B (p = 0.84). MRI showed no retears in group A vs 3 retears (= 9 %) in B. Comparing the Sugaya types we observed a significant (p = 0.002) shift to the more favorable Sugaya types I and II (normal & near normal) with 82 % in group A vs 50 % in B. Conclusions The study confirms that anchorless TO RC repair is a good alternative to established suture anchor techniques. The technique can easily be learned by the experienced arthroscopist. Clinical outcome data show equivalent results for both techniques. With EUR 700 vs 1100 material costs are lower for the anchorless technique. The healing results as observed on MRI are superior, maybe due to enhanced blood flow at the FP provided by the bone tunnels.

Intraoperative bone tunnel laceration affects integrity of arthroscopic transosseous rotator cuff repair with a tunneling device

Background: We aimed to evaluate the functional outcomes, incidence of bone tunnel laceration, and bone tunnel morphology of transosseous arthroscopic rotator cuff repair (ARCR) with the Arthro-TunnelerTM. Methods: Between May 2012 and April 2013, patients with full-thickness tears who underwent transosseous ARCR with the Arthro-TunnelerTM and could be followed for a minimum of 2 yr were included in this retrospective study. Functional outcomes, cuff repair integrity, intraoperative bone tunnel laceration, and postoperative bone tunnel morphology were analyzed. Results: We retrospectively evaluated 42 consecutive patients (average age: 67.6 yr) who underwent transosseous ARCR. The mean active forward elevation, mean active abduction, mean Constant-Murley score, mean American Shoulder and Elbow Surgeon Score (ASES), and pain Visual Analogue Scale (VAS) improved from preoperative values of 127 degrees, 118 degrees, 50.3 points, 53.2 points, and 4.5 to 159 degrees, 160 degrees, 83.3 points, 78.5 points, and 1.7, respectively, at the final follow-up (P&lt;0.001, P&lt;0.01, P&lt;0.001, P&lt;0.001, P&lt;0.001, respectively). The re-tear rate was 16.7%. The intraoperative bone tunnel laceration occurrence was 67.8% (61 tunnels). Bone tunnel laceration and re-tear were significantly correlated. We evaluated the morphology of 81 bone tunnels with MRI of 90 bone tunnels. Eight, 37, and 36 tunnels were L-shaped, curve-shaped, and straight-shaped, respectively. Conclusions: The clinical results of transosseous ARCR with the Arthro-TunnelerTM were significantly improved at a minimum of 2 yr of follow-up. However, patients older than 65 yr were at a high risk of developing bone tunnel laceration, which was associated with rotator cuff re-tear.

Is Arthroscopic Transosseous Rotator Cuff Repair Strength Dependent on the Tunnel Angle?

Background:Previous studies have aimed to biomechanically improve the transosseous tunnel technique of rotator cuff repair. However, no previous work has addressed tunnel inclination at the time of surgery as an influence on the strength of the repair construct.Hypothesis:We hypothesized that the tunnel angle and entry point would influence the biomechanical strength of the transosseous tunnel in rotator cuff repair. Additionally, we investigated how tunnel length and bone quality affect the strength of the repair construct.Study Design:Controlled laboratory study.Methods:Mechanical testing was performed on 10 cadaveric humeri. Variations in the bone tunnel angle were imposed in the supraspinatus footprint to create lateral tunnels with inclinations of 30°, 45°, and 90° relative to the longitudinal axis of the humeral shaft. A closed loop of suture was passed through the bone tunnel, and cyclic loading was applied until failure of the construct. Load to failure and distance between entry points were the dependent variables. Analysis of variance, post hoc paired t tests, and the Bonferroni correction were used to analyze the relationship between the tunnel angle and failure load. The Pearson correlation coefficient was then used to evaluate the correlation of the distance between entry points to the ultimate failure load, and t tests were used to compare failure loads between healthy and osteoporotic bone.Results:Tunnels drilled perpendicularly to the longitudinal axis (90°) achieved the highest mean failure load (167.51 ± 48.35 N). However, there were no significant differences in the failure load among the 3 tested inclinations. Tunnels drilled perpendicularly to the longitudinal axis (90°) measured 13.86 ± 1.35 mm between entry points and were significantly longer (P = .03) than the tunnels drilled at 30° and 45°. We found no correlation of the distance between entry points and the ultimate failure load. Within the scope of this study, we could not identify a significant effect of bone quality on failure load.Conclusion:The tunnel angle does not influence the strength of the bone-suture interface in the transosseous rotator cuff repair construct.Clinical Relevance:The transosseous technique has gained popularity in recent years, given its arthroscopic use. These findings suggest that surgeons should not focus on the tunnel angle as they seek to maximize repair strength.

Arthroscopic Transosseous Suture Without Implant for Rotator Cuff Tears: Absorbable Mattress Sutures Versus Non-Absorbable Sutures

AIM: In 2005, we developed an anchorless technique for arthroscopic transosseous rotator cuff repair without implant. We aimed to clarify the differences in clinical outcomes and retear rates between patients receiving absorbable mattress sutures and those receiving non-absorbable sutures. MATERIALS AND METHODS: In this retrospective cohort study, we analyzed 131 cases in which absorbable mattress sutures were used and 384 cases in which only non-absorbable sutures were used. Three 2-mm Kirshner wires with perforated tips were inserted through the inferior margin of the greater tuberosity into the medial edge of the footprint. After pulling the rotator cuff stump laterally, 3 Kirshner wires were threaded through the rotator cuff and skin. Five threads were passed through 3 bone tunnels using the perforated tips of the Kirshner wires. The surgery was completed by inserting 2 mattress sutures and 3 bridging sutures. In addition to retear rates, the surgical cost of other transosseous methods was investigated. RESULTS: The retear rate was 3.1% using absorbable mattress sutures and 6% using non-absorbable suture only. It was 12% using the hollow needle method and 3.7% using the ArthroTunneler method. The surgical cost was $9–12 for our procedure, $121 for the hollow needle method, and $600 for the ArthroTunneler method. CONCLUSIONS: We found that using absorbable thread for mattress sutures reduced the retear rate. A big advantage of our technique is that it is inexpensive because the only surgical materials required are suture threads.

Arthroscopic Transosseous Anchorless Rotator Cuff Repair Using the X-Box Technique

We describe a reproducible, step-by-step arthroscopic technique for anchorless transosseous rotator cuff repair using an X-box configuration with the Arthrotunneler device. The technique uses 2 bone tunnels and 4 high-strength sutures and is suitable for medium to large tears of the supra- and infraspinatus that would alternatively need a double-row repair with 4 anchors. Biomechanically, results appear to be similar as for anchored transosseous equivalent techniques. Enhanced biological healing and lower material costs are the possible benefits of this appealing arthroscopic approach that mimics the previous gold standard.