The Hybridge Technique: A Combined Technique of Suture Bridge and Tension Band for an Arthroscopic Eco-Responsible Rotator Cuff Repair

Arthroscopic rotator cuff repair is mainly based on 2 proven biomechanical concepts: suture bridge and tension band. This Technical Note describes the use of a combination of these 2 techniques to repair extensive lesions with only 3 anchors. Besides being less expensive, the use of a limited number of anchors is part of a global medicoeconomic and eco-responsible approach to our surgical activities.

N umerous techniques have been described for rotator cuff repair. Various biomechanical studies have confirmed the reliability of both double-row suture-bridge fixation 1 and single-row tension band (TB). 2 Although the latter requires fewer anchors, it may result in decreased contact at the footprint during tendon repair. 3 In contrast, the suture-bridge technique, associated with biceps tenodesis, may require 5 or more anchors with no clear clinical benefit or improved healing.
Several recent studies have discussed the impact of health care on greenhouse gas emissions (8.5% of total emissions in the United States, 6% in France), with one-half of these associated with operating room activities. 4,5 To participate in the reduction of the carbon footprint, it would be reasonable to develop techniques that reduce the number of anchors used in each patient with a similar clinical and anatomical result. This Technical Note describes a hybrid fixation technique that combines double-row suture-bridge and TB for repair of a large superior cuff tear (Type C or D of Colin's classification) 6 with 2 first-row anchors and a single knotless second-row anchor. It may also be combined with a biceps tenodesis.

Surgical Technique (With Video Illustration) Preoperative Evaluation
The hybridge technique is indicated in patients with a symptomatic posterosuperior rotator cuff lesion, without risk factors for poor healing: nonsmokers, no hypercholesterolemia. Magnetic resonance imaging or computed tomography arthroscan is necessary to evaluate the size of the lesion in the anteroposterior plane, which should ideally be between 1.5 and 3.5 cm for this technique. For smaller lesions, a single first-row anchor or a TB with a single lateral anchor should be chosen. For larger lesions, an additional number of anchors is recommended. In the frontal plane, the tendon retraction and the critical shoulder angle measurement also are assessed on imaging to determine whether it will be possible to use a spinal needle as a suture pass intraoperatively. Finally, the muscular fatty infiltration index should be measured, ideally less than 2.

Surgery
Demonstration of arthroscopic rotator cuff repair of a left shoulder using the Hybridge technique is presented in Video 1.
The advantages and disadvantages of the technique are listed in Table 1 and pearls and pitfalls in Table 2.
Surgery is performed under interscalene block and general anesthesia. The patient is placed in the lateral decubitus position, but the scope will be turned 90 to obtain a vertical view like in the beach-chair position. The upper limb is stabilized with a hydraulic arm (AssistArm; ConMed, Largo, FL). A transparent operating field is created after the skin has been prepared. Two portals are used: a posterior portal (PP), mainly for the arthroscope, and a mainly instrumental anterolateral portal (ALP).
First, the subacromial space is explored with a scope in the PP, with a bursectomy to obtain a view of the entire superficial aspect of the cuff. Once the lesion is identified, the lateral part of the footprint and tendon tear are debrided.
The scope is positioned in the glenohumeral joint through the PP to visualize the deep surface of the cuff. The bone is shaved at the footprint and a first 4.5-mm FIXIT anchor (SBM; Lourdes, France) is placed anteromedially in line with the biceps tendon gutter (Fig 1). Biceps tenodesis is performed with the first suture and a simple knot (Fig 2). A loop is created with a 22-gauge spinal needle and double monofilament to be used as a suture passer to successively pass the 2 strands of the second suture from the anchor to the anterior supraspinatus (Figs 3, 4, and 5A). The intra-articular view provides good visualization of the rotator cable to optimize penetration of the sutures on the articular surface of the tendon, to restore the anatomical footprint, and for optimal contact and adequate tension on the cuff during reduction. Precise spacing of 5 to 8 mm between the 2 strands is also possible. The landmark on the skin for optimal needle placement is just in contact with the lateral edge of the acromion (transcutaneous) (Fig 5B).
A second 4.5-mm FIXIT anchor (SBM) is placed at the most posterior part of the tear at the medial footprint and 1 of the 2 sutures is removed and put aside for the TB (Fig 6). The 2 threads of the second sutures are again passed through the posterior part of the lesion and spaced 5 to 8 mm apart (Fig 7).
The spinal needle is again used to place the suture for the central TB with an intra-articular view, thanks to 2 successive passes in the space between the 2 anchor wires and medial to the rotator cable. A U-shaped passage is obtained (Figs 8 and 9A). The ALP is suturefree because the 6 strands are passed transcutaneously at the lateral edge of the acromion (Fig 9B).
The scope is then positioned in the subacromial space through the PP (Fig 10). The 2 strands of the anteromedial anchor are passed through ALP with a suture retriever and a surgeon's knot is made on the most anterior strand. The knot pusher is left on the strand to cut the second strand (Fig 11). Then, the 2 strands of the posterior anchor are also retrieved through the ALP, Draw the acromion on the skin to facilitate positioning of the spinal needle.
To work without a cannula, retrieve the 2 strands in one pass just before tying them.
Leave the punch tap in place in the bone when mounting the second-row anchor and the strands to keep the axis. Turn the scope so that the punch-tap is vertical to the screen before removing, and screw in the anchor on exactly the same axis (12 o'clock technique). Always use a second-row anchor with a diameter that is larger than the pinch-tap used (1 or even 2 mm depending on the bone quality).
Use of the spinal needle impossible with a retracted cuff or with high CSA. The use of an automatic plier is recommended.
Cutting the knotted strand of the first-row anchors instead of the traction strand and risk of knot failure.
CSA, critical shoulder angle. and another knot is made on the posterior strand, which is retained, while the other strand is cut. Finally, the U-shaped suture is also passed through the ALP (Fig 12). The 4 remaining strands are recovered in a single pass with the suture retriever through the ALP: one main strand from each of the 2 anchors and the 2 strands of the U-shaped suture (Fig 13). The patient's arm is repositioned with more abduction to expose and clean the lateral greater tuberosity. The 4.5-mm punch/tap is used perpendicular to the cortex. The 4 strands are passed through a 5.5-mm FIXIT Knotless anchor (SBM) with the reusable screwdriver (Fig 14). The knotless anchor is inserted and the 4 strands are tightened before fully tightening the screws (Fig 15). An anchor that is bigger than the tap should be used to optimize the forces of friction on the sutures. In case of poor bone quality when inserting the 4.5 punch/tap, the use of a 6.5-mm FIXIT Knotless anchor (SBM) is recommended in order to maintain a good interference with bone and sutures.
Correct assembly and reduction of the cuff are confirmed anterolaterally, posteriorly (Fig 16), and intra-articularly. If the cuff is too retracted or the critical shoulder angle is high, the use of a spinal needle is not possible. The Hybridge technique can still be carried out, using an automatic suture pass plier and working with subacromial view for the whole procedure.

Postoperative Care
The patient is immobilized in a sling in internal rotation for 4 weeks during the day and 6 weeks at night, while performing self-rehabilitation exercises including active scapulothoracic mobilization and passive glenohumeral mobilization beginning the day after surgery, as well as rehabilitation with a physiotherapist 3 times a week.

Discussion
Numerous repair techniques have been described for rotator cuff tears. [1][2][3] The main clinical criteria for optimal healing include a low muscular fatty infiltration index (2) 7,8 and moderate-to-intermediate tendon retraction. 8 Other recent studies mention the harmful effects of tobacco, 9 alcohol, and dyslipidemia. 10 These should be The Hybridge technique is mainly proposed to repair Colin type D lesions, which involve the entire supraspinatus tendon and part or all of the infraspinatus tendon. 6 It also may be proposed for type C lesions by preserving the threads of the biceps tenodesis and repairing the superior tear of the subcapsular tendon. It is not indicated for isolated supraspinatus tendon lesions, as a TB with 1 or 2 anchors is usually sufficient in these cases, further limiting the cost and carbon impact. In contrast, in the case of severe posterior Colin's type E lesions, more anchors are recommended.
Several scientific studies have reported the carbon impact and greenhouse gases generated by health care, 4,5,11 in particular due to operating rooms. 12,13 The main areas of improvement are the reduction of waste volumes and in the equipment supply chain. [14][15][16] Surgeons play a primary role in reducing the surgical carbon footprint. 12,17 Reducing the number of anchors used during surgery is simple and innovative as well as eco-responsible. The surgical technique we have described meets these criteria thanks to the following: (1) The use of only one second-row anchor, allowing easy passage of at least 4 strands rather than 2, like certain other anchor designs. (2) The use of a reusable screwdriver and wire feeder for this second row, limiting waste since no disposable screwdrivers are thrown away. 15 Packaging is greatly reduced, limiting greenhouse gas emissions  This reduces both the direct costs and the carbon impact of surgery, as well as indirect costs by shortening the operating time, resulting in less electricity consumption in operating rooms and anesthesia, which has a very high greenhouse effect. 5,14 Economically, this also contributes directly and indirectly to reducing the overall cost of procedures, which is a very sensitive issue in many countries. 13,18 Conclusions The Hybridge repair technique is indicated for the treatment of extensive superior cuff tears. It combines the advantages of the suture-bridge and TB techniques. The use of a limited number of anchors and a reusable screwdriver, if possible, decreases the volume of greenhouse gases as part of a global approach to reducing the carbon footprint of health care worldwide.