Transosseous Rotator Cuff Repair Research Articles

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.

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.

Long-term results after arthroscopic transosseous rotator cuff repair

The purpose of this study was to evaluate the long-term clinical and radiologic results after arthroscopic transosseous rotator cuff repair (TORCR). A total of 69 patients with full-thickness supraspinatus tendon tears with or without infraspinatus tendon tears treated with arthroscopic TORCR by a single surgeon between 1998 and 2003 were included. Among them, 56 patients (81%) with a mean age of 58 ± 5 years (range, 42-70 years) were available for final follow-up examination after an average of 15 ± 2 years (range, 12-18 years). The Subjective Shoulder Value, Constant score (CS), University of California at Los Angeles score, and American Shoulder and Elbow Surgeons score were recorded. Magnetic resonance imaging (MRI) was performed to visualize tendon integrity in 66% of patients. At final follow-up, the mean CS was 84 ± 8 points; mean University of California at Los Angeles score, 33 ± 2 points; mean American Shoulder and Elbow Surgeons score, 92 ± 10 points; and mean Subjective Shoulder Value, 89% ± 17%. MRI revealed asymptomatic repair failure in 9 patients (27%). Moreover, 4 patients (7%) underwent revision surgery because of a symptomatic rerupture, resulting in an overall retear rate of 33%. Patients with intact repairs at final follow-up showed a significantly higher CS (P = .019) and abduction strength (P = .016) than patients with retears. Arthroscopic TORCR for the treatment of full-thickness rotator cuff tears provided good clinical results 12 to 18 years after surgery. Cuff integrity on follow-up MRI scans had a positive effect on the clinical outcome.

Optimal Angle of the Bone Tunnel for Avoiding Axillary Nerve Injuries During Arthroscopic Transosseous Rotator Cuff Repair: A Magnetic Resonance Imaging-Based Simulation Study.

Background:Axillary nerve injury and suture cutout through the roof of the tunnel are potential complications of arthroscopic transosseous rotator cuff repair (ATORCR).Purpose:To determine a safe angle of drilling for the bone tunnel during ATORCR such that the axillary nerve is not at risk. The thickness of the bone bridge over the tunnel for different angles of drilling was also determined.Study Design:Descriptive laboratory study.Methods:The drilling of a straight tunnel was simulated on 30 magnetic resonance imaging (MRI) scans in the oblique coronal plane by drawing a straight line that passed at a “safe distance” of 5 mm from the axillary nerve and emerging at the medial border of the insertion of the rotator cuff on the greater tuberosity. The angle made by this line with the horizontal axis of the humerus was measured on 3 MRI sections: anterior (passing just posterior to the lateral lip of the bicipital groove), middle (at the most lateral point of the proximal humerus), and posterior (an equal number of cuts away from the middle section as between anterior and middle). The thickness of the overlying bone roof was measured for this line as well as for simulation lines drawn at 50°, 55°, 60°, and 65° with the horizontal axis. A “safe limit,” defined as the mean – 2SD, was also calculated.Results:The axillary nerve was found to be safe, with a safety margin of 5 mm, at drill angles of less than 61.1° and 60.3° in the posterior and middle sections, respectively. The safe limit value for thickness of the overlying bone roof for the tunnel drilled at 60° was 5.0 mm in the posterior section (mean, 8.2 ± 0.3 mm) and 5.5 mm in the middle section (mean, 8.1 ± 0.2 mm). In the anterior section, the minimum safe angle was 57.7°, and the mean thickness of the bone roof for the 55° angle was 6.3 ± 0.2 mm (safe limit, 3.7 mm).Conclusion:Straight bone tunnels in ATORCR surgery should be drilled at an angle of 60° to the horizontal axis of the humerus or 30° to the humeral shaft to ensure the safety of the axillary nerve while at the same time ensuring adequate thickness of the overlying bone roof. The anterior tunnel close to the bicipital groove should be drilled cautiously at 55° to the horizontal axis or 35° to the humeral shaft.Clinical Relevance:The findings of the present study will help the surgeon choose the best angle for drilling tunnels during ATORCR surgery to avoid axillary nerve injuries as well as suture cut-through without the need for any proprietary device.

Rotator cuff failure after surgery: an all-arthroscopic transosseous approach

Tear recurrence is considered the main complication of a rotator cuff repair. The best arthroscopic technique has not yet been established. The aim of the present study was to evaluate, from a clinical and a radiological standpoint, the all-arthroscopic transosseous rotator cuff repair with cortical lateral augmentation, performed in the setting of a revision surgery. Eleven consecutive cases were prospectively followed up for a minimum of 12month after a rotator cuff repair with a novel all-arthroscopic transosseous rotator cuff repair. VAS and UCLA score and patients' satisfaction with the outcomes were analyzed, along with MRI evolution of the repair. All patients underwent a standardized surgery and postoperative rehabilitation program. All patients showed a significant improvement in pain reduction and functional score. Satisfaction was achieved in 10 out of 11 cases, and only 1 case showed a minor discontinuous tendon signal on the 12-month MRI assessment. No complications were noted. Our results favor the use of the all-arthroscopic transosseous rotator cuff revision surgery with the 2MC configuration (double MC means the initials of the authors-MM and CC, who have originally described it). It appears to be safe and effective, providing good clinical, functional, and radiological results, with a very high patient satisfaction.

Rotator Cuff Repair Technique With Transosseous Knotless Anchor System

Various surgical techniques exist for rotator cuff repair that provide a suitable environment for tendon–bone healing. Arthroscopic recreation of transosseous repairs, which had previously been performed by open or miniopen techniques, can now be performed; however, arthroscopic, transosseous passage of suture material can be challenging technically. There are potential biologic and cost-saving advantages of arthroscopic transosseous rotator cuff repair that make an efficient and reproducible technique desirable for arthroscopists. The technique for arthroscopic transosseous rotator cuff repair using a knotless anchor-based system is demonstrated in the current Technical Note. Potential advantages of this construct include excellent biomechanics, enhanced footprint vascularization, and utility in poor bone quality while using minimal anchor numbers. Further studies will be needed to elucidate healing rates and clinical outcomes.

Pullout strength of cement-augmented and wide-suture transosseous fixation in the greater tuberosity

BackgroundObtaining strong fixation in low-density bone is increasingly critical in surgical repair of rotator cuff tears because of the aging population. To evaluate two new methods of improving pullout strength of transosseous rotator cuff repair in low-density bone, we analyzed the effects of 1) using 2-mm suture tape instead of no. 2 suture and 2) augmenting the lateral tunnel with cement. MethodsEleven pairs of osteopenic or osteoporotic cadaveric humeri were identified by dual-energy x-ray absorptiometry. One bone tunnel and one suture were placed in the heads of 22 specimens. Five randomly selected pairs were repaired with no. 2 suture; the other six pairs were repaired with 2-mm suture tape. One side of each pair received lateral tunnel cement augmentation. Specimens were tested to suture pullout. Data were fitted to multivariate models that accounted for bone mineral density and other specimen characteristics. FindingsTwo specimens were excluded because of knot-slipping during testing. Use of suture tape versus no. 2 suture conferred a 75-N increase (95% CI: 37, 113) in pullout strength (P<0.001). Cement augmentation conferred a 42-N improvement (95% CI: 10, 75; P=0.011). Other significant predictors of pullout strength were age, sex, and bone mineral density. InterpretationWe show two methods of improving the fixation strength of transosseous rotator cuff repairs in low-density bone: using 2-mm suture tape instead of no. 2 suture and augmenting the lateral tunnel with cement. These methods may improve the feasibility of transosseous repairs in an aging patient population.

Technique and Outcomes for Knotless Transosseous Rotator Cuff Repair

Rotator cuff tears are a common cause of shoulder disability. Arthroscopic rotator cuff repairs can lead to significant improvement in pain and function, though follow-up imaging studies may still demonstrate a substantial rate of rotator cuff tendon re-tearing. The double-row transosseous-equivalent repair is biomechanically superior to other repair techniques and thereby may improve tendon-to-bone healing. This article describes our preferred technique for knotless rotator cuff repair using a transosseous-equivalent technique.

Arthroscopic trans-osseous rotator cuff repair.

Mechanical factors are at the basis of any tendon healing process, being pressure an aspect able to positively influence it. For this reason transosseous rotator cuff repair represents the gold standard procedure for patients affected by a cuff tear, maximizing the tendon footprint contact area and reducing motion at the tendon to bone interface. The Authors present an all arthroscopic suture bridge-like transosseous repair with the preparation of a single transosseous tunnel perfor med thanks to a precise dedicated instrument (Compasso®) and one implant (Elite-SPK®) with the use of only 3 suture wires. In addition this technique permits to accurately prepare the bony side of the lesion without any risk or complication, such as anchor pull-out and greater tuberosity bone osteolysis. However, even if this technique seems less demanding, the arthroscopic transosseous repair is still an advanced procedure, and should be performed only by well prepared arthroscopic shoulder surgeons. V.

Difference in vascular patterns between transosseous-equivalent and transosseous rotator cuff repair

Vascularity is the important factor of biologic healing of the repaired tissue. The purpose of this study was to clarify sequential vascular patterns of repaired rotator cuff by suture techniques. We randomized 21 shoulders in 20 patients undergoing arthroscopic rotator cuff repair into 2 groups: transosseous-equivalent repair (TOE group, n = 10) and transosseous repair (TO group, n = 11). Blood flow in 4 regions inside the cuff (lateral articular, lateral bursal, medial articular, and medial bursal), in the knotless suture anchor in the TOE group, and in the bone tunnel in the TO group was measured using contrast-enhanced ultrasound at 1 month, 2 months, 3 months, and 6 months postoperatively. The sequential vascular pattern inside the repaired rotator cuff was different between groups. The blood flow in the lateral articular area at 1 month, 2 months, and 3 months (P = .002, .005, and .025) and that in the lateral bursal area at 2 months (P = .031) in the TO group were significantly greater than those in the TOE group postoperatively. Blood flow was significantly greater for the bone tunnels in the TO group than for the knotless suture anchor in the TOE group at 1 month and 2 months postoperatively (P = .041 and .009). This study clarified that the sequential vascular pattern inside the repaired rotator cuff depends on the suture technique used. Bone tunnels through the footprint may contribute to biologic healing by increasing blood flow in the repaired rotator cuff.

Arthroscopic Transosseous Anchorless vs Anchored Rotator Cuff Repair: A Comparison of Clinical and Patient Reported Outcomes, Structural Integrity, and Costs

Recent advancements in instrumentation have accommodated an arthroscopic, anchorless transosseous rotator cuff repair, which reproduces the gold standard of open transosseous repair. This study compares the clinical outcomes and cost effectiveness of anchorless, transosseous (AT) repair to the anchored transosseous, equivalent (TOE) technique. We conducted a retrospective cohort analysis of 92 arthroscopic rotator cuff repairs with minimum 1-year follow up. The experimental group included patients who underwent arthroscopic anchorless, transosseous repair. All patients had full thickness tears of the supraspinatus and/or infraspinatus tendons. We collected numeric rating scale (NRS) pain scores, range of motion, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) scores, and Simple Shoulder Test (SST) scores. Ultrasound studies were performed at 1-year postop. There were 43 patients in the control (TOE) group and 49 patients in the experimental (AT) group who met all inclusion criteria and completed a minimum 1-year follow up. Baseline demographic data for age and sex did not differ between groups. At minimum 1-year follow up, there was no difference between groups with respect to SSV (p = 0.97), VAS (p = 0.46), ASES score (p=0.59), SST score (p=0.90) or range of motion in abduction, forward elevation, and external rotation (p=0.63, 0.65, 0.42 respectively). Ultrasound studies showed no difference in rotator cuff integrity between groups at an average of 15.2 months after surgery. The TOE group had 1/21 partial retears of the rotator cuff. The AT group had 2/26 partial retears and 1 retear of the rotator cuff. Cost analysis suggested 30-80% implant savings per case for the AT group depending on tear size. Arthroscopic transosseous rotator cuff repair achieves similar clinical outcomes, patient-reported outcomes, and healing rates with 30-80% reduction in implant costs, compared to traditional anchored techniques.

Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair.

Purpose:Arthroscopic transosseous (TO) rotator cuff repair has recently emerged as a new option for surgical treatment of symptomatic rotator cuff tears. Limited data is available regarding outcomes using this technique. This study evaluated midterm clinical outcomes following a novel arthroscopic TO (anchorless) rotator cuff repair technique.Materials and Methods:A consecutive series of 107 patients and 109 shoulders underwent arthroscopic TO (anchorless) rotator cuff repair for a symptomatic full-thickness tear. Pre and postoperative range of motion (ROM) was compared at an average of 11.8 months. Postoperative outcome scores were obtained at an average of 38.0 months. Statistical analysis was performed to compare pre and postoperative ROM data. Univariate analysis was performed using Student's t-test to compare the effect of other clinical characteristics on final outcome.Results:Statistically significant improvements were noted in forward flexion, external rotation and internal rotation (P < 0.0001). Average postoperative subjective shoulder value was 93.7, simple shoulder test 11.6, and American Shoulder and Elbow Surgeons (ASES) score 94.6. According to ASES scores, results for the 109 shoulders available for final follow-up were excellent in 95 (87.1%), good in 8 (7.3%), fair in 3 (2.8%), and poor in 3 (2.8%). There was no difference in ROM or outcome scores in patients who underwent a concomitant biceps procedure (tenodesis or tenotomy) compared with those who did not. Furthermore, there was no significant difference in outcome between patients who underwent either biceps tenodesis or tenotomy. Age, history of injury preceding the onset of pain, tear size, number of TO tunnels required to perform the repair, and presence of fatty infiltration did not correlate with postoperative ROM or subjective outcome measures at final follow-up. Two complications and four failures were noted.Conclusions:Arthroscopic TO rotator cuff repair technique leads to statistically significant midterm improvement in ROM and satisfactory midterm subjective outcome scores with low complication/failure rates in patients with average medium-sized rotator cuff tears with minimal fatty infiltration. Further work is required to evaluate radiographic healing rates with this technique and to compare outcomes following suture anchor repair.Level of Evidence:Level IV

The Effect of Platelet-rich Fibrin Matrix on Rotator Cuff Healing in a Rat Model.

The purpose of the current study was to determine if the application of platelet-rich fibrin matrix could improve regeneration of the tendon-bone insertion site in a rat rotator cuff repair model. 25 Lewis syngeneic rats underwent bilateral tenotomy and repair of the supraspinatus tendon. 10 separate rats were used for PRFM harvest. All left (control) shoulders underwent transosseous rotator cuff repair, while all right (treatment) shoulders were repaired similarly with PRFM augmentation. 9 rats were sacrificed at 2-weeks and ten at 4-weeks for biomechanical testing. 3 separate rats were sacrificed at 2-weeks and 4-weeks each for histologic analysis of the insertion site. At 2 weeks, the experimental group repairs were significantly stronger in ultimate load to failure (P=0.01), stress (P=0.03), and stiffness (P=0.03). Differences in biomechanical testing were not found between the groups at 4 weeks. Histological analysis revealed less collagen organization and cartilage formation at the insertion site in the experimental group. Semiquantitative histologic analysis confirmed our qualitative assessment of the specimens. PRFM does not recapitulate the native enthesis, but rather induces an exuberant and disordered healing response that is characterized by fibrovascular scar tissue.

Arthroscopic Transosseous Rotator Cuff Repair: Technical Note, Outcomes, and Complications

The goal of this study was to review the authors' initial experience with arthroscopic transosseous rotator cuff repair. Thirty-one patients with full-thickness rotator cuff tears underwent arthroscopic transosseous rotator cuff repair over a 15-month period. Preoperatively, demographics and subjective scores were recorded. Postoperatively, pain levels, subjective shoulder values, satisfaction scores, American Shoulder and Elbow Surgeons (ASES) scores, complications, and reoperations were noted with a minimum 2-year follow-up. The relationships between pre- and intraoperative variables and outcome scores were determined with univariate analysis. Average patient age was 56 years, and 23 patients (74%) were men. Twenty patients (65%) underwent primary rotator cuff repair, and 11 patients (35%) underwent revision repair. Average time to follow-up was 26 months. Average preoperative pain level and subjective shoulder value were 5.1 of 10 and 35%, respectively. Average postoperative scores included pain level of 0.9 of 10, subjective shoulder value of 84%, satisfaction score of 90.6 of 100, and ASES score of 86.3 of 100. There were 3 (9.7%) major and 2 (6%) minor complications. Patients undergoing revision rotator cuff repair had significantly worse outcomes (pain level, subjective shoulder value, ASES score; P<.05) compared with those undergoing primary repair, and cortical augmentation did not significantly affect outcome. Overall, outcomes after arthroscopic transosseous rotator cuff repair are good, although patients undergoing revision repair do not have the same outcomes as those undergoing primary cuff repair. The procedure is not without complications (9.7% major, 6% minor complications). Cortical augmentation may be used to supplement fixation, although it does not necessarily affect outcomes. Patients without such augmentation may be at increased risk for suture cutout through the bone.

Arthroscopic Double-Row Rotator Cuff Repair Using a Knotless, Interconnected Technique

The surgical techniques used for rotator cuff repair have evolved over the past 3 decades. Technical innovations have contributed to improved clinical outcomes following repair. Recently, double-row repairs have demonstrated substantial biomechanical advantages when compared with single-row repairs, including decreased gap formation, increased ultimate load to failure, and improved footprint coverage. Knotless transosseous equivalent rotator cuff repair has emerged as an alternative to knotted constructs. The lack of medial knots with the knotless repairs is thought to improve vascular inflow, and the wider suture materials may prevent suture cut through of the repaired cuff tendon. Furthermore, knotless techniques may decrease operative time and may eliminate postoperative knot impingement within the subacromial space. This article serves to highlight our preferred surgical technique for the knotless double-row, transosseous equivalent rotator cuff repair and to review the current literature pertaining to the clinical outcomes following knotless and knotted repair constructs.

Gap formation in a transosseous rotator cuff repair as a function of bone quality

BackgroundThe transosseous approach has been well known for a long time as a valid repair approach. Over time, various criticisms have been raised over this technique principally classifiable in two main categories: technical difficulty and related reproducibility in an arthroscopic environment, and repair stability (in the suture–bone contact area). About cyclic performance, several authors have conceived test setups with the aim of simulating a real environment in dynamic load conditions. The aim of this study was to monitor gap formation in a cyclic test setup. MethodsThe performance (measured as gap formation) has been monitored as a function of bone density to verify the effect of the latter. The test blocks have been shaped using sawbones® test bricks (Malmo, Sweden) of different densities, and the following values have been tested: 10, 15, 20, 30 and 40pcf. FindingsThe comparison has been made between the two groups: traditional transosseous and new approach with an interposed device. Regarding the traditional transosseous approach in a 10-pcf environment, not even the first loading cycle was completed, the whole bone bridge was destroyed in the first loading ramp and no further loading capability was present in the repair. By increasing the block density, the surface damage in the suture-block contact decreased. InterpretationWith this work, it has been demonstrated how the traditional transosseous approach is strongly influenced by the bone quality up to the point where, in certain conditions, a safe and reliable repair is not guaranteed.

Arthroscopic Rotator Cuff Repair—Transosseous Equivalents

As attempts have been made to improve rotator cuff healing, transosseous equivalent repairs have garnered interest because they combine strong initial fixation with broad foot print coverage. A number of different suture configurations can be used to secure the rotator cuff repair. Results, particularly in large or massive tears, have been encouraging for the double-row technique. Areas for concern include disruption of the vascular supply to the healing tendon, increased cost and operating room time, and potentially higher risk for tuberosity fracture. Rotator cuff tendon healing is a complex interaction between biomechanical, biological, and patient factors. Although the technique and overall outcomes are still evolving, transosseous rotator cuff repair may offer improvements in the biomechanical stability and clinical outcomes of rotator cuff repairs.

Arthroscopic Bone Tunnel Augmentation for Rotator Cuff Repair

Transosseous repair of the rotator cuff has been shown to recreate the anatomic rotator cuff footprint in a secure and cost-efficient manner. However, the potential for sutures cutting through bone remains a concern with this strategy. Devices have been used successfully during open transosseous rotator cuff repair to augment the bone tunnels, potentially avoiding suture cut-out through the weak bone of the greater tuberosity. Recently, arthroscopic transosseous fixation of rotator cuff tears has become an alternative to arthroscopic suture anchor and open transosseous techniques. This method is expected to have the same potential pitfalls at the bone-suture interface as the open technique. The authors describe a technique for rotator cuff repair using a secure method of arthroscopic bone tunnel augmentation.

Is Arthroscopic Transosseous Tunnel Rotator Cuff Repair as Strong as Suture Anchor Rotator Cuff Repair with Suture Bridges?

Is Arthroscopic Transosseous Tunnel Rotator Cuff Repair as Strong as Suture Anchor Rotator Cuff Repair with Suture Bridges?