My approach to rotator cuff repair in 2007: Arthroscopic tools still have a place

Arthroscopic double-row suture bridge method offers restoration of the anatomic footprint.

Issue: July 2007

ByWilliam N. Levine, MD

Arthroscopic rotator cuff repair has evolved tremendously over the last decade.

Initially, “single-row” repairs were performed mainly due to limitations in technology and surgeons becoming comfortable with the technique. Ultimately, this contributed in part to higher failure rates than traditionally obtained with mini-open and open rotator cuff repairs. With improved instruments, understanding of the anatomical and biomechanical factors, and surgeon comfort and skill, evolution towards “double-row” rotator cuff repairs has occurred.

Double-row repair refers to an anatomic restoration of the “footprint” of the rotator cuff. The supraspinatus footprint, for example, is approximately 12 mm to 16 mm (medial-lateral plane) and 22 mm to 26 mm (anteroposterior plane). An improved understanding of the anatomic footprint has allowed surgeons to better reestablish the rotator cuff during surgery.

Figure 1: A 62-year-old man with a rotator cuff tear is placed in the beach chair position. Note how the affected shoulder girdle is brought over the edge of the table to maximize exposure and access for the procedure. Appropriate anatomic landmarks are drawn: A= acromion; Cl= clavicle; ACJ = AC joint. In addition, routine portals including a posterior portal (PP), midlateral portal (MLP), anterior portal (AP) and an accessory superior portal (ASP) are drawn out.

Images: Levine WN

The issues with single-row repair are that they do not re-establish the normal footprint anatomy. In addition, single-row repairs have decreased footprint pressure and contact area and increased interface motion compared to transosseous repairs and double-row repairs. Although there has been some controversy, most recent studies have shown a biomechanical superiority of double-row compared to single-row repairs. In addition, two recent studies have investigated a “transosseous equivalent” arthroscopic technique and showed that is superior to a traditional double-row technique.

This paper will highlight the technical aspects, pearls and pitfalls of the arthroscopic double-row suture bridge technique (ie, the “transosseous” equivalent).

Technique

The patient is given a regional interscalene block in the anesthetic block room outside the operating room. We place the patient in the beach chair position and draw anatomic landmarks, including the acromion, clavicle and AC joint (Figure 1). We then perform diagnostic arthroscopy from a routine posterior portal and identify coexistent pathology such as labral tears, biceps pathology and glenohumeral chondromalacia.

The glenohumeral joint and features such as tear size, the number of tendons involved, and the degree of retraction (Figure 2) are identified. I then focus on the subacromial space, where the tear is better characterized by viewing from the posterior portal (Figure 3a) and the mid-lateral portal (Figure 3b).

After abrasion of the footprint to encourage healing, a medial row of suture anchors is placed at the junction of the articular cartilage and the anatomic rotator cuff footprint (Figures 4 and 5).

Passing the sutures

One suture pair are then removed from each medial row anchor (anchors typically are double-loaded), leaving one pair of sutures in the anteromedial anchor (AM) and one suture pair in the posteromedial anchor (PM). These sutures will then be passed in horizontal mattress fashion 14 mm to 16 mm from the tendon edge, remembering that the medial-lateral footprint is 14 mm to 16 mm. The sutures can either be passed medially via a shuttling system from Neviaser’s portal or can be passed laterally with any of a number of commercially available suture passers.

The first suture pair (blue in this example) are passed through the anteromedial tendon at the desired location and spread it out approximately 5 mm to 10 mm in the AP plane. These sutures are then “parked” outside the anterior cannula (Figure 6).

The second suture pair (white sutures) is passed through the posteromedial rotator cuff at the desired location and is also spread out approximately 5 mm to 10 mm in the AP plane. The sutures are tied from the midlateral portal (but not cut) and then likewise parked outside the anterior cannula (Figure 7).

The blue suture pair is shown after being retrieved outside the midlateral portal in anticipation of tying. I don’t cut it.

Figure 2: The posterior view of the glenohumeral joint demonstrates a 2.5-cm tear involving the supraspinatus with retraction to the midhumeral level.	Figure 3a: This posterior view of the rotator cuff tear (RCT) demonstrates a U-shaped tear with retraction to the midhumeral level. The humeral head (HH) and footprint (FP) are visible.	Figure 3b: A midlateral view of the U-shaped rotator cuff tear showing the labrum (L) and the glenoid (GL).	Figure 4: A bioabsorbable suture anchor is placed from the accessory anterosuperior portal at the junction of the articular cartilage (AC) and the footprint in the anteromedial (AM) position.
Figure 5: The posteromedial (PM) suture anchor is placed into the previously fashioned tunnel. This can be done from either the accessory anterosuperior portal or from an accessory posterosuperior portal.	Figure 6: The first suture pair is passed through the anteromedial rotator cuff (RC) at the desired location (ie, 14 mm to 16 mm medial to the tendon edge). The sutures are then “parked” outside the anterior portal (AP).	Figure 7: The posteromedial suture pair is passed and tied and the sutures have been parked outside the anterior cannula. The anteromedial suture pair has been retrieved outside the midlateral portal and will be tied.	Figure 8: William N. Levine, MD, retrieves one blue suture from the anteromedial pair and one white suture from the posteromedial pair outside the midlateral portal. He makes a pilot hole with a tap, and places the suture ends through a specially designed eyelet implant. The sutures are then appropriately tensioned and the rotator cuff is anataomically red and then the 4.5-mm push-lock anchor (Arthex; Naples, Fla.) is tapped into position securing the repair.

Pilot hole

I tap a pilot hole into the lateral greater tuberosity; and mark the hole with purple ink to make finding it easier. Next, one blue (anteromedial) and one white (posteromedial) suture are retrieved out the midlateral portal and placed through an eyelet in a specially designed anchor, which should be placed on the lateral greater tuberosity in the anterolateral (AL) position (Figures 8, 9).

Subsequent to this, I retrieve the remaining 2 sutures (1 white and 1 blue) and pass them through a second 4.5-mm anchor, placing them on the lateral greater tuberosity in the posterolateral (PL) position.

Final repair from the posterior (Figure 10a) and midlateral (Figure 10b) portals demonstrates the double-row suture bridge technique with anatomic restoration of the rotator cuff to the footprint.

Always place the arthroscope back into the glenohumeral joint at the conclusion of the case to confirm anatomic restoration of the rotator cuff to the footprint.

There will usually be synovitis, which was not previously identified since it was medially displaced with the tendon tear. This is a good sign that you have anatomically restored the rotator cuff (Figure 11a). You can ablate the synovitis with cautery, and then visualize the final repair (Figure 11b).

Finally, the patient is placed in a sling in the neutral rotation and discharged home following a short recovery room stay.

We determine postoperative rehabilitation based on the size of the tear. Recent evidence has demonstrated, however, that slower rehabilitation is appropriate for larger tears to decrease the likelihood of recurrence.

We typically do not start any physical therapy for large and massive tears for the first 4 to 6 weeks.

Rather, we start physical therapy for small- and medium-sized tears around 2 to 4 weeks postoperatively.

Figure 9: The 4.5-mm push-lock anchor can be seen through the cannula just before it is to be tapped into final position on the lateral greater tuberosity.	Figure 10a: A posterior viewing portal (PL) demonstrates anatomic restoration of the rotator cuff with the double-row suture bridge technique.	Figure 10b: A midlateral viewing portal demonstrates the final repair.
Figure 11a: This posterior glenohumeral view demonstrates synovitis (SYN) that surgeons previously missed because it was on the medially displaced rotator cuff. This indicates an anatomic repair in most situations.	Figure 11b: This posterior glenohumeral view shows ablation of the synovitis with electrocautery. The rotator cuff insertion is clearly seen at its anatomic footprint.

For more information:

William N. Levine, MD, can be reached at the Center for Shoulder, Elbow and Sports Medicine, Columbia University Medical Center, 622 W. 168th St., PH-1117, New York, NY 10032; 212-305-0762; fax: 212-305-4040; e-mail: wn11@columbia.edu.

References:

Ahmad CS, Stewart AM, Izquierdo R, Bigliani LU. Tendon-bone interface motion in transosseous suture and suture anchor rotator cuff repair techniques. Am J Sports Med 2005;33:1667-1671.

Bishop J, Klepps S, Lo IK, Bird J, et al. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg. 2006;15:290-299.

Brady PC, Arrigoni P, Burkhart SS. Evaluation of residual rotator cuff defects after in vivo single- versus double-row rotator cuff repairs. Arthroscopy. 2006;22:1070-1075.

Curtis AS, Burbank KM, Tierney JJ, Scheller AD, et al. The insertional footprint of the rotator cuff: an anatomic study. Arthroscopy. 2006;22:609.

Galatz LM, Ball CM, Teefey SA, Middleton WD, et al. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86-A:219-224.

Kim KC, Rhee KJ, Shin HD, Kim YM. Arthroscopic hybrid double-row rotator cuff repair. Knee Surg Sports Traumatol Arthro. 2007;15(6):794-799.

Lee E, Bishop JY, Braman JP, Langford J, et al. Outcomes after arthroscopic rotator cuff repairs. J Shoulder Elbow Surg. 2007;16:1-5.

Lo IK, Burkhart SS. Double-row arthroscopic rotator cuff repair: Re-establishing the footprint of the rotator cuff. Arthroscopy. 2003;19:1035-1042.

Ma CB, Comerford L, Wilson J, Puttlitz CM. Biomechanical evaluation of arthroscopic rotator cuff repairs: double-row compared with single-row fixation. J Bone Joint Surg Am. 2006:88:403-410.

Mazzocca AD, Millett PJ, Guanche CA, Santangelo SA, et al. Arthroscopic single-row versus double-row suture anchor rotator cuff repair. Am J Sports Med. 2005;33:1861-1868.

Park MC, Cadet ER, Levine WN, Bigliani LU, et al. Tendon-to-bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques. Am J Sports Med. 2005;33:1154-1159.

Park MC, Elattrache NS, Tibone JE, Ahmad CS, et al. Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row technique. J Shoulder Elbow Surg. 2007;Feb. 21:epub.

Park MC, Tibone JE, Elattrache NS, Ahmad CS, et al. Part II: Biomechanical assessment for a footprint-restoring transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg. 2007;Feb.21:epub.

Smith CD, Alexander S, Hill AM, et al. A biomechanical comparison of single and double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am. 2006:88:2425-2431.