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Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, TainanSkeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, TainanDepartment of Biomedical Engineering, National Cheng Kung University, and the Division of Traumatology, National Cheng Kung University Medical Center, TainanDivision of Orthopaedics, Department of Surgery, National Cheng Kung University Hospital Dou Liou Branch, National Cheng Kung University, Yunlin, Taiwan
Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, TainanSkeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, TainanDivision of Orthopaedics, Department of Surgery, National Cheng Kung University Hospital Dou Liou Branch, National Cheng Kung University, Yunlin, Taiwan
Address correspondence to Kai-Lan Hsu, M.D., Department of Orthopedics, National Cheng Kung University Hospital, 138 Sheng-Li Rd., Tainan, Taiwan, R.O.C.
Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, TainanSkeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, TainanDepartment of Biomedical Engineering, National Cheng Kung University, and the Division of Traumatology, National Cheng Kung University Medical Center, Tainan
Numerous techniques have been formulated for increasing the tendon–bone contact area and for providing a better healing environment for the tendon in cases of rotator cuff tear. An ideal rotator cuff repair maximizes the tendon–bone interface and provides the rotator cuff with sufficient biomechanical strength for it to withstand a high load. In this article, we propose a technique with the advantages of both the double-pulley and the rip-stop suture-bridge techniques, which increases the pressurized contact area along the medial row, achieves higher failure loads than non-rip-stop techniques, and reduces tendon cut-through.
Technique Video
See video under supplementary data.
Rotator cuff repair techniques have been evolving over the past 30 years with improvements in biomechanics and in the creation of environments that are most suitable for tendon–bone healing.
The suture bridge technique has been widely applied in rotator cuff repair because it has favorable biomechanical properties and yields satisfactory clinical outcomes.
Functional and structural comparisons of the arthroscopic knotless double-row suture bridge and single-row repair for anterosuperior rotator cuff tears.
Transosseous-equivalent/suture bridge arthroscopic rotator cuff repair in combination with late postoperative mobilization yield optimal outcomes and retear rate: A network meta-analysis of randomized controlled trials.
demonstrated that tying the medial knots of horizontal mattress stitches decreases gap formation and increases ultimate and yield loads. Arrigoni et al.
described an alternative double-row rotator cuff repair technique using medial-row anchors with an extracorporeal and static knot, termed the “double-pulley technique,” which was designed to maximize medial footprint compression. Kim et al.
described how their modified double-pulley technique possesses the advantages of both the double-pulley and suture bridge techniques, which increases the pressurized contact area and maximizes compression along the medial row. We describe our technique and demonstrate how it possesses advantages of both the double-pulley and the rip-stop suture bridge techniques (Video 1). Our technique increases the pressurized contact area along the medial row, achieves higher failure loads than non-rip-stop techniques do, and reduces tendon cut-through.
Surgical Technique
Patient Positioning, Portal Placement, and Diagnostic Arthroscopy
Surgery is performed with the patient under general anesthesia with an additional interscalene block. The patient is placed in the lateral decubitus position with index arm traction by a 3-point traction system (Arthrex, Naples, FL). After aseptic preparation and draping, a standard posterior portal is created. Thereafter, a standard anterior portal is created using spinal needle localization immediately lateral to the tip of the coracoid, and the glenohumeral joint space is examined and debrided.
Suture Anchor Placement
The scope is then shifted to the subacromial space and anterolateral and lateral portals were established using a spinal needle. After the scope is shifted to the lateral portal, bursectomy and limited acromioplasty are performed. The footprint of the rotator cuff is prepared. Two doubly loaded, 5.5-mm suture anchors (CrossFT; ConMed, Utica, NY) with suture eyelets are inserted at the articular margin of the greater tuberosity. The first anchor is placed in the anteromedial aspect of the footprint beside the biceps groove. The second anchor is placed 1.5 to 2 cm posterior to the first anchor, which is in the posterior aspect of the footprint.
Suture Management
Initially, we place an 8.25 mm, fully threaded clear cannula (Arthrex) through the lateral portal. With the use of a second-generation antegrade suture passer (Arthrex), a Hi-Fi suture (ConMed) is passed through the appropriate position on the anteromedial part of the supraspinatus. An ipsilateral pair of suture eyelets (a blue and a white suture) in the suture anchor is shuttled by Hi-Fi suture through the cuff. These steps are repeated 3 times to equally divide the rotator cuff tear (Fig 1).
Fig 1Illustration (A) and arthroscopic image (B) of the first step. The patient was placed in the lateral decubitus position with right arm traction by a three-point traction system. Full thickness supraspinatus tear was noted via lateral portal. After applying two doubly loaded suture anchors. Four ipsilateral pairs of suture eyelets (black arrow, a blue and a white suture) in the suture anchors are shuttled by Hi-Fi suture through the cuff.
The white suture of the first pair and the blue suture of the fourth pair are pulled out of the lateral cannula beneath the other sutures (Fig 2). These 2 strands are then tied outside. Subsequently, the white suture of the second pair and the blue suture of the third pair are pulled above the other sutures. Consequently, the knot is passed through the cannula, down to the cuff and beneath the medial row, creating a “rip-stop” (Fig 3) of tissue that is compressed against the bone. A static knot is tied with the finger knot pusher, and the sutures are not cut. The medial row of the suture bridge (a pair of blue sutures in the anterior anchor and a pair of white sutures in the posterior anchor) is left knotless (Fig 4).
Fig 2Illustration (A) and arthroscopic image (B) of the second step. The patient was placed in the lateral decubitus position with left arm traction. The camera is in the posterolateral viewing portal. The white suture of the first pair and the blue suture of the fourth pair are pulled out of the lateral cannula beneath the other sutures and then tied outside (black arrow).
Fig 3Illustration (A) and arthroscopic image (B) of the third step. The patient was placed in the lateral decubitus position with left arm traction. The camera is in the posterolateral viewing portal. The white suture of the second pair and the blue suture of the third pair are pulled above the other sutures. This delivers the knot through the cannula and down to the cuff and beneath the medial row, creating a “rip-stop” (black arrow).
Fig 4Illustration (A) and arthroscopic image (B) of the fourth step. The patient was placed in the lateral decubitus position with left arm traction. The camera is in the posterolateral viewing portal. A static knot is tied with the finger knot pusher, and the sutures are not cut (black arrow). The medial row of the suture bridge is left knotless.
Pilot holes for knotless anchors (Poplock 4.5 mm; ConMed Linvatec, Largo, FL) are prepared directly in line with the medial anchors and approximately 10 mm distal to the lateral edge of the greater tuberosity. A suture strand from each anchor in the medial row and 1 suture from the static knot are retrieved. All suture strands are threaded through the eyelet of the knotless anchors on the distal end of the driver, and the knotless anchor is advanced entirely into the pilot hole. These steps are repeated to place a second knotless anchor (Fig 5).
Fig 5Illustration (A) and arthroscopic image (B) of the fifth step. The patient was placed in the lateral decubitus position with left arm traction. The camera is in the posterolateral viewing portal. A suture strand from each anchor in the medial row and one suture from the static knot are fixed in lateral row (black arrow) by the knotless suture anchor. These steps are repeated for a second knotless anchor.
Maximum footprint compression should be achieved in rotator cuff repairs to provide (1) a favorable healing environment for tendon healing and (2) sufficient biomechanical strength to withstand loading forces applied to the shoulder. In the conventional double-row rotator cuff repair technique, the sutures of each medial anchor are tied, and this inevitably leads to the separation of the mattress sutures.
To prevent such separation, the double-pulley technique reconstitutes the native rotator cuff footprint while evenly distributing the compressive forces between 2 double loops of sutures.
The prevention of tendon cut-through has recently become a key problem. A rip-stop suture theoretically reduces the probability of suture cut-out and maintains loop security.
Previous biomechanical studies have compared the load-sharing rip-stop construct with a standard single-row construct and shown that the ultimate failure load of the load-sharing rip-stop construct is 1.7 times that of the single-row construct in a cadaveric model.
Although studies involving different types of rip-stop configurations have provided promising results, many variables and considerations remain to be addressed.
The modified double-pulley technique we present combines the previously described knotted double-pulley and rip-stop techniques. The advantages of our technique include (Table 1) compression across the medial and lateral aspects of the footprint. The knotted double-pulley suture bridge maximizes footprint area and compression and increases overall biomechanical strength.
Knotted transosseous-equivalent technique for rotator cuff repair shows superior biomechanical properties compared with a knotless technique: A systematic review and meta-analysis.
The remaining suture covers the double-pulley construct to the lateral raw and grasp the double-pulley construct as rip stop. This technique improves the healing process by increasing the pressurized contact area and reducing tendon cut-through.
Table 1Advantages and disadvantages of the modified double-pulley and rip-stop suture bridge technique
Advantages
Double-pulley repair construct which can maximize the contact pressure and area across the footprint
The combination of the rip stop configuration can minimize the risk of tendon cut through
Limited knot over the cuff can avoid the type II failure
Disadvantages
Technically challenging in the beginning, pulling suture limb need to be well planned and tangle of sutures should be avoided
Our technique has some limitations (Table 1). First, the technique is challenging to implement. When the double-pulley suture bridge is secured, a pair of sutures must be pulled beneath the remaining suture; furthermore, the order in which sutures are pulled must be well planned to prevent the sutures from becoming entangled. Second, the technique has yet to be compared with existing double-row suture anchor techniques with respect to their biomechanical properties.
In conclusion, our modified double-pulley and rip-stop suture bridge technique is effective in increasing the pressurized contact area along the medial row, achieving higher failure loads than non-rip-stop techniques, and reducing type II failure of the rotator cuff. The technique is reproducible, versatile, and efficient, easing the learning curve for surgeons and reducing surgery time.
Acknowledgment
We thank Medical Device R & D Core Laboratory, National Cheng Kung University Hospital, Tainan, Taiwan, and Ms. Shing-Yun Chang BS, MSc (Department of Orthopedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan) for assistance with this project. We also thank the Skeleton Materials and Bio-compatibility Core Lab, Research Center of Clinical Medicine, National Cheng Kung University Hospital (NCKUH-11102001) and Ministry of Science and Technology (MOST 111-2314-B-006-058) for the assistance of this project. Special thanks are given to Prof. Shoji Fukuta (Chief executive director of National Hospital Organization Kochi National hospital, Japan), who shared his clinical experience of double pully technique in rotator cuff repair.
In this video, we demonstrate the modified double-pulley and rip-stop suture bridge technique in arthroscopic rotator cuff repair. The technique increases the pressurized contact area along the medial row, achieves higher failure loads than non-rip-stop techniques do, and reduces tendon cut-through. This case involved the right shoulder of a patient who had supraspinatus tear. The patient was placed in the lateral decubitus position with index arm traction by a three-point traction system. Standard posterior and anterior portals were created. The scope was then shifted to the subacromial space, and anterolateral and lateral portals were established. Two doubly loaded suture anchors were inserted at the articular margin of the greater tuberosity. An ipsilateral pair of suture eyelets (a blue and a white suture) in the suture anchor was shuttled by Hi-Fi suture through the cuff. These steps were repeated three times to equally divide the rotator cuff tear. The white suture of the first pair and the blue suture of the fourth pair were pulled out of the lateral cannula beneath the other sutures. These two strands were then tied outside. Subsequently, the white suture of the second pair and the blue suture of the third pair were pulled above the other sutures. Consequently, the knot was sent through the cannula and down to the cuff and beneath the medial row, creating a “rip-stop.” A static knot was tied with the finger knot pusher, and the sutures were not cut. A suture strand from each anchor in the medial row and one suture from the static knot was fixed in lateral row by the knotless suture anchor. These steps were repeated for a second knotless anchor.
References
Lo I.K.
Burkhart S.S.
Double-row arthroscopic rotator cuff repair: Re-establishing the footprint of the rotator cuff.
Functional and structural comparisons of the arthroscopic knotless double-row suture bridge and single-row repair for anterosuperior rotator cuff tears.
Transosseous-equivalent/suture bridge arthroscopic rotator cuff repair in combination with late postoperative mobilization yield optimal outcomes and retear rate: A network meta-analysis of randomized controlled trials.
Knotted transosseous-equivalent technique for rotator cuff repair shows superior biomechanical properties compared with a knotless technique: A systematic review and meta-analysis.
The authors report that they have no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
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