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Treatment of full-thickness rotator cuff repairs vary in surgical technique depending on many factors including tear geometry, delamination of soft tissue, tissue quality, and rotator cuff retraction. The described technique presents a reproducible method of addressing tear patterns where the tear may be larger laterally, but the medial footprint exposure is small. This can be addressed with a single medial anchor combined with a knotless lateral-row technique to provide compression for small tears or two medial row anchors for moderate to large tears. In this modification of the standard knotless double row (SpeedBridge) technique, 2 medial row anchors are used, with 1 augmented with additional fiber tape and an additional lateral row anchor to create a triangular repair construct, increasing the size and stability of the footprint of the lateral row.
Technique Video
See video under supplementary data.
Knotless self-reinforcing transosseous equivalent double-row rotator cuff repair, commonly known as the SpeedBridge technique, has become a reliable treatment option for full-thickness rotator cuff tears with good clinical outcomes.
Arthroscopic rotator cuff repair: Scientific rationale, surgical technique, and early clinical and functional results of a knotless self-reinforcing double-row rotator cuff repair system.
Predictors of outcomes after arthroscopic transosseous equivalent rotator cuff repair in 155 cases: A propensity score weighted analysis of knotted and knotless self-reinforcing repair techniques at a minimum of 2 years.
The growing acceptance of this technique may be in large part due to its repair strength and reproducibility. For certain rotator cuff tear patterns, this method can have its limitations, which include rotator cable (dog-ear) restoration and providing large enough repair surface area in the setting of limited medial row footprint. Surgical cases with increasing complexity can have varied outcomes despite considerable advances in both biological augmentation and repair techniques.
Here we present a technique to address high-grade bursal-sided or full-thickness rotator cuff tears with limited medial footprint using a knotless double-row technique. We also present technique pearls and modifications for managing tear delamination, rotator cable (dog-ear) repair, and matching construct to tear geometry. As part of this “triple package” repair technique, we use an additional broad suture tape and an additional lateral row anchor to create a triangular repair construct, which may increase the size and stability of the repair footprint.
Surgical Technique
Positioning, Diagnostic Arthroscopy, and Cuff Tear Evaluation
The surgical technique is demonstrated in Video 1. The procedure is routinely performed with the patient under general anesthesia with or without an interscalene block. The patient is placed in the beach chair position, because this allows easy conversion to open subpectoral biceps tenodesis if indicated. Diagnostic arthroscopy of the shoulder is first performed using a 30° arthroscope. The rotator cuff is evaluated for tissue quality, retraction, and delamination. The amount of excursion of the rotator cuff is determined after full mobilization of the rotator cuff, and, once the decision is made to proceed with rotator cuff repair, standard arthroscopic portals are created, and cannulas are placed.
Portals and Cannulas
Posterior, posterolateral, lateral, anterolateral, and anterior portals are used throughout the procedure. Cannulas include a self-retracting cannula (Gemini; Arthrex Inc., Naples FL) in the lateral portal, 8 mm × 3 mm soft cannula (Passport; Arthrex Inc.) in the anterolateral portal and an 8 mm × 4 mm soft cannula in the posterolateral portal. Standard posterior and anterior portals provide adequate trajectory for use of the 90° suture passing device (SutureLasso; Arthrex Inc.) without the need for cannulas because they are primarily used for suture docking and passing. Demonstration of the portal and cannula placement and orientation is indicated in Figure 1.
Fig 1Open view, right shoulder, viewing from above the shoulder with the patient in the beach chair position. The 5 standard portal locations are identified with corresponding cannulas in the posterolateral, lateral, and anterior lateral portals.
Placement of Medial Row Anchors and Passing of Compression Tapes
The tendon is lightly debrided with an arthroscopic shaver to remove scar and low-quality tissue, as well as to stimulate a healing response (Fig 2). The greater tuberosity is prepared by removing residual rotator cuff debris or fibrous tissue using bipolar electrocautery (Fig 3). Microfracture of the footprint is performed with a 30° powered awl (PowerPick; Arthrex Inc.). In predominantly bursal-sided tears, there may be limited exposure of the medial footprint.
Fig 2Arthroscopic view of a right shoulder with the 30° arthroscope in the posterolateral viewing portal. The supraspinatus tendon is demonstrated with a crescent tear with significant associated delamination. Note that the space at the medial footprint for medial row anchor placement is small.
Fig 3Arthroscopic view of a left shoulder with the 30° arthroscope in the lateral portal. Some delaminated tissue has been debrided, demonstrating the narrow crescent pattern with minimal exposed medial footprint but significant retraction in the central portion of the tear.
The articular margin is identified, and placement of 1 or 2 medial anchors is determined based on available area within the torn tendon footprint at the articular margin. The first anchor is placed approximately 2 mm lateral to the articular margin, near the anterior margin of the rotator cuff tear. This is typically just posterior to the long head of the bicep tendon. It is important to leave a minimum of 5 to 6 mm of intact bone between adjacent anchors in the medial row.
The anterior anchor, 4.75 mm Bio-composite, knotless vented anchor (SwiveLock; Arthrex Inc.) is loaded with a single compression tape suture (FiberTape; Arthrex Inc.). Typically, the anterolateral portal provides the ideal trajectory for insertion of the anterior anchor. In the setting of dense bone, a tap is occasionally used. Additionally, coloring the insertion punch with a surgical marker can aid in locating anchor sites between punch insertion and anchor insertion.
For the more posterior medial row anchor, a similar 4.75 mm Bio-composite, Knotless, Vented Anchor (SwiveLock) is loaded with two broad suture tapes (FiberTape). We typically color 1 of these 2 tapes with a surgical marker to aid in identification during the shuttling process. This anchor may be placed via the posterolateral portal, through the anterolateral portal by rotating the arm internally, or through a separate percutaneous incision that is identified with the assistance of a spinal needle (Fig 4).
Fig 4Arthroscopic view of a left shoulder with the 30° arthroscope in the posterior lateral portal. A suture anchor with a single blue tape has already been placed anteriorly and is not visualized. The posterior suture anchor is being placed with 2 broad sutures tapes in the posterior position on the medial footprint. One suture tape is colored purple with a surgical pen to assist with suture management.
After placement of each anchor, a 90° suture passing device (SutureLasso; Arthrex Inc.) is inserted through the anterior portal. The passing wire is retrieved via the lateral portal, and the corresponding suture tape limb is retrieved from its corresponding anchor. The tendon is pierced just lateral to the myotendinous junction in the medial to lateral direction, and with the intention of dividing the tear into thirds in the anterior to posterior direction (Fig 5). Delamination may be addressed by using an arthroscopic suture grasper to grasp both the deep capsular and more superficial cuff tissue while using the suture passing device to pierce the tissue perpendicularly. This will bring the 2 tissue planes together during reduction.
Fig 5Arthroscopic view of a left shoulder with the 30° arthroscope in the lateral portal. A suture-passing device is seen entering from the anterior portal. A suture grasper is used first to reduce the delaminated layers of the rotator cuff (left image) and then to retrieve the suture passing wire from the suture passage device (right image) from the posterior lateral portal.
The process is then repeated with the passing of each compression suture tape. It may be helpful to place colored (purple) suture tape centrally, leaving both the anterior and posterior tapes uncolored (blue) for ease of suture management. Once completed there will be a total of 6 suture tape limbs evenly divided among 3 locations in the rotator cuff tendon.
Anterior and Posterior Cable Reconstruction the Using Knotless Technique
When necessary to reduce dog-ears anteriorly and posteriorly to restore the rotator cable, knotless mechanisms from the medial anchor may be deployed. In this case, the knotless suture from the previously placed anchors is first shuttled through the anteromedial margin of the rotator cuff tear, and passed through the anterior anchor, to reduce the anteriormost portion of the rotator cuff tear to the anteromedial anchor (Fig 6). It is important to pass this suture anterior to the anterior-most FiberTape in order to reduce any dog-ear which may present for an anterior cable reconstruction. Before tensioning this suture, the rotator cuff is reduced to its footprint using a rotator cuff grasper. This same technique is performed for posterior cable reconstruction by passing the posterior knotless suture from the posterior anchor just behind the posterior-most FiberTape. The manner of suture passage is similar to the previously described for the compression suture tapes. In cases where the rotator cable does not require stabilization or dog-ears are not anticipated this step may be omitted.
Fig 6Arthroscopic view of a left shoulder with the 30° arthroscope in the posterior lateral portal. The suture from the knotless mechanism in the anteriormost medial anchor has been passed anterior to the broad suture tapes and is being secured to restore the anteriormost aspect of the rotator cable, as well as to prevent dog-ear formation. This step is repeated for the posterior knotless anchor (not shown).
Fixation of the Lateral Row Compression FiberTape Sutures
The primary modification from the standard technique is the addition of a third lateral row anchor. The corresponding medial sutures for each anchor will be described from anterior to posterior.
Starting with the most anterior of the 3 lateral anchors, 1 compression tape from the most anterior pass through the rotator cuff, and 1 from the middle pass (blue and purple) are tensioned and anchored using a 4.75 mm Bio-composite, vented anchor (SwiveLock) in a location laterally at the greater tuberosity just anterior to the location of the anteromedial row anchor. All compression tapes are retrieved using a suture tape grasper through the lateral working portal and the lateral anchors are subsequently inserted through the lateral portal as well (Fig 7).
Fig 7Arthroscopic view of a left shoulder with the 30° arthroscope in the posterior lateral portal. One suture tape from the central portion of the rotator cuff (purple) and one from the anterior portion that have been previously passed through the rotator cuff tissue medially are loaded into a lateral suture anchor and are seen being inserted in the anteriormost position of the lateral row. The process is then repeated with the other anterior tape and a posterior tape for the central lateral row anchor and the central and posterior rotator cuff to the most posterior lateral row anchor (not shown).
The process is repeated. The middle anchor includes two uncolored (blue) suture tapes, one from the anterior and one from the posterior passes, placed into a 4.75 mm knotless anchor (SwiveLock). This anchor is placed centrally on the lateral footprint.
Lastly, the remaining two tapes from the middle and posterior passes (blue and purple) are retrieved into the lateral portal, loaded into the eyelet of the 4.75 mm anchor (SwiveLock) and then inserted in a posterior location. It is often helpful to change the rotation of the humerus to ensure a direct line of approach when inserting these anchors.
In the event of any laxity of the compression tapes, the knotless suture in the central lateral anchor can be used to increase tension of the repair by passing the knotless suture around the loose tape and then cinching the locking mechanism to increase tension to the central anchor.
The final construct is inspected, and the shoulder is rotated to confirm even compression and reduction of the rotator cuff repair (Fig 8). Pearls and pitfalls of the procedure are listed in Table 1.
Fig 8Arthroscopic view of a left shoulder with the 30° arthroscope in the lateral portal demonstrates the final construct, including medial suture row passage sites through the rotator cuff tissue and lateral row anchors.
Goal of repair: One fewer medial row anchor than lateral row.
Same number of tapes as the lateral row.
One medial row anchor contains two FiberTapes
Knotless anchors at periphery of medial row anchors to repair dog-ears and reconstruct anterior and posterior rotator cable tissue.
Knotless anchor at center of lateral row anchor may be used to retention repair in event of laxity.
Tear delamination: Use a 90° lasso to reliably shuttle FiberTapes through delaminated tear.
Pitfalls
Improper or untimely tightening of the medial row knotless sutures can lead to improper reduction of rotator cuff to footprint. Be sure to reduce rotator cuff to footprint before tensioning.
Uneven tensioning of FiberTapes into lateral row can lead to laxity in repair. In the event of laxity, the central knotless anchor can be used to tension loose FiberTapes.
Overtensioning the lateral row may cause FiberTape cutout in poor-quality tissue.
Improper suture management, resulting in crossing of FiberTapes into the lateral row may result in weakened, poorly tensioned repair.
Closure of portals is performed according to standard technique. Routine dressings are applied. Postoperatively, the patient is placed into a shoulder immobilizer. Patients are instructed to initiate physical therapy within 1 week after surgery for education on passive range of motion exercises. Patients are advanced to active-assist, then active range of motion by 4 to 6 weeks. Strengthening exercises begin at 3 months after surgery, followed by gradual return to unrestricted activity by 4 to 6 months.
Discussion
Arthroscopic rotator cuff repair is a frequently performed outpatient orthopaedic procedure that has been shown to improve patient outcomes.
The repair strength should be such that it creates anatomic stability to withstand loading forces applied to the shoulder. The biomechanical factors of contact pressure, force, and area over time of transosseous-equivalent repairs have been shown to be superior to other arthroscopic techniques.
Part II: Biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique.
When considering medium to large rotator cuff tears, arthroscopic knotless double-row technique demonstrates lower retear rates, while also being faster and more cost-effective than knotted single row repairs as well.
As tear size and complexity increases, however, maximizing repair contact pressure, force, and area over time often warrants the usage of additional anchors and implants to create an appropriate repair. This leads to increased implant cost and operative time, which are 2 of the primary drivers of arthroscopic rotator cuff repair surgery.
The primary advantage in this technique is the ability to increase repair contact surface area, while potentially saving time and space for anchors placed along the articular margin. This repair technique also preserves medial row bone stock, which may be helpful in the setting of revision repairs or cystic changes of the medial footprint. The use of the knotless SwiveLock anchors also allows for the appropriate restoration of the rotator cable (medial row) and retensioning any laxity in the repair (lateral row).
Risks of this procedure are potential failure of the medial row anchors, specifically the double-loaded medial row anchor. The bone quality of the medial footprint is typically stronger than lateral row and thus more accommodating to double-loaded anchors.
Use of 3 lateral row anchors may limit further bone stock if a revision repair is warranted in the future.
In conclusion, we describe a modification of a well-established, common technique allowing for increased repair strength and footprint coverage, while still being cost effective.
The knotless double row technique for rotator cuff repair and associated pearls and modifications is demonstrated.
References
Vaishnav S.
Millett P.J.
Arthroscopic rotator cuff repair: Scientific rationale, surgical technique, and early clinical and functional results of a knotless self-reinforcing double-row rotator cuff repair system.
Predictors of outcomes after arthroscopic transosseous equivalent rotator cuff repair in 155 cases: A propensity score weighted analysis of knotted and knotless self-reinforcing repair techniques at a minimum of 2 years.
Part II: Biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique.
The authors report the following potential conflict of interest or source of funding: D.G. reports grants from Arthrex, Medacta, Stryker, Smith and Nephew, Donjoy, and Breg; personal fees from Arthrex. B.B.G. reports personal fees from Arthrex and Doximity; non-financial support from Arthrex, Stryker, Smith and Nephew, Don Joy, Ossur, Mammoth Hospital, Catalyst Ortho Science, ROM 3, and Doximity; and committee or board membership with Smart Medical Devices, AANA, and Arthroscopy Journal. ICMJE author disclosure forms are available for this article online, as supplementary material.
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