Transosseous tunneling offers cost-effective fixation method for arthroscopic cuff repair

Issue: December 2016

ByBrett S. Sanders, MD

Transosseous repair of shoulder tendons offers a cost-effective, biologically advantageous, biomechanically sound and clinically effective fixation method for facilitating the healing of tendons to bone. As a result, it has been considered the gold standard of cuff repair for decades. During the last few decades, anchor-based repairs have become popular due to the ease-of-use, high-initial fixation strength and ability to apply fixation points arthroscopically.

Initial healing rates of early arthroscopic single-row anchor constructs were documented to be poor. More recently, double-row and transosseous equivalent repairs have been adopted with satisfactory outcomes, although the need for multiple anchors to recreate the footprint, such as transosseous equivalent methods, adds cost and is difficult to justify since clinical outcomes in single- vs. double-row repairs are similar. Despite of the adoption of anchors, the literature has not fundamentally demonstrated any differences in outcomes or retear rates between anchor-based or transosseous techniques. By many accounts, transosseous tunnels have equivalent biomechanical properties, superior footprint reconstruction, fewer hardware problems, superior biological properties and similar time in the OR.

Brett S. Sanders

Regardless of repair technique, re-tear rates of the rotator cuff remain high and functional outcomes fail to correlate with repair integrity. Arthroscopic methods to achieve transosseous cuff repair have been described, which have similar clinical results and decreased technology cost relative to benefit, especially as downward cost pressure has increased in the value-based era of care. Anchor-based and transosseous techniques have various clinical distinctions, but are not mutually exclusive and thus can be effectively used synergistically to treat all cases of rotator cuff repair, while maximizing outcome and minimizing cost.

Advantages, disadvantages

Transosseous techniques have several relevant differences compared to anchor-based repairs. Small-diameter suture tunnels are easier to manage in revision settings and do not preclude the placement of anchors or repeat tunnels in the same position. Transosseous tunnels offer the benefits of double-row fixation with a single tunnel, as there may be a trend toward less retear in double-row repair patterns.

Single-tunnel cuff repair from the posterior view is shown.

The failure mode of transosseous repairs generally spare tendon substance in a type 1 failure, while anchor-based repairs seem to have a unique failure mechanism, which transects the tendon and leads to truncation of the tendon and difficult revision scenarios. Moreover, multiple repeat fixation points within a case may be utilized, and various numbers and configurations of sutures per fixation point can be selected by the surgeon. Additional high-strength sutures are generally more cost-effective than additional anchors, as more cuff repairs move into the outpatient setting in the value-based era of care. These facts create a myriad of possible repair constructs that may be utilized in complex cases.

Shown are various transosseous repairs: stitch in a box; x-box; and double-box with and without tapes.

In transosseous repair, there is no inert substance blocking egress of bone marrow into the repair site and thus biological considerations are excellent. Since the strength of the repair is proportional to the number of sutures crossing the repair site, high-strength biomechanical constructs can be achieved. Concerns regarding transosseous tunnels generally center around plastic deformation of the bone or suture cut through the bone, especially in chronic tears where trabecular resorption has occurred.

Cortical buttons, screw augmentation, suture tapes or anchor hybrid techniques may alleviate the concern over fixation failure with historical transosseous techniques. The ramifications of suture cut through bone include fixation loss and minimal, if any, secondary damage or pain due to third body wear. Thus repair failure does not necessarily imply a revision surgery, whereas anchor pull-out from soft bone often creates a large defect and may require costly and difficult revision due to painful or damaging loose hardware.

Single anchor hybrid — A single-anchor hybrid is shown. Lateral anchors add little in terms of strength to the repair since forces are transmitted to the medial anchor. A single-anchor hybrid technique uses tunnels rather than anchors to reconstruct the footprint, but maintains a medial anchor if the surgeon desires. The appearance is similar to a transosseous equivalent repair, with five fixation points and one anchor (a). Shown is the anchor placed laterally (b).

A clinical proband group for transosseous techniques has been followed for nearly 2 years. For all transosseous techniques, patients with follow-up greater than 6 months (mean 15.2 months) have a mean increase of 44 points in American Shoulder and Elbow Surgeons score, mean decrease of 4.66 in VAS and a clinical 3.2% retear rate, which was either documented by imaging or reoperation based on symptoms. Results and complications have generally been equivalent to fully anchor-based techniques.

The emerging cost pressure of value-based medicine has not been fully implemented in practice yet, but the shoulder offers a prime joint to lead value-based techniques. There is ample evidence to show anchor burden increases cost, but relatively minimal data showing one implant is superior to another. At the moment, there are implant carve-outs in many states, but there is a rapid move toward bundling of care, which may favor the use of implant-free or reduced implant techniques.

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Sutures are generally less costly than anchors, and in the future, there may be a cogent argument to treat the high-strength suture as an implant, as is currently done with all suture, “soft” anchors employed in the rotator cuff. The Transos tunneler (Tensor Surgical), a limited reusable device, has accordingly been introduced to facilitate adoption of all suture, implant-free techniques of the shoulder.

Various two-anchor hybrid transosseous techniques with regular suture, with tapes and in a cadaver are shown.

Here are described techniques and decision algorithms we have adopted to facilitate adoption in various clinical circumstances.

Transosseous repairs

For a small tear, a single-tunnel or a single anchor are equivalent, as these are both are likely to have high healing rates. However, a single tunnel offers two small diameter fixation points rather than one, which allows for anatomic footprint reconstruction. When combined with arthroscopic mason and allen sutures, a highly anatomic repair is achieved (Figure 1).

In younger patients with more acute, smaller tears, the bone is often hard enough that there is little concern regarding cut through. We use awls that compact the bone, rather than removing or weakening the bone to make tunnels. Clinically, if the awl can be pushed into the bone by hand, we consider that a cortical augmentation of some kind. If a mallet is required to make the medial tunnel, we consider the bone of reasonable quality and proceed with all transosseous repair based on cuff size, retraction and bone quality.

Shown is biceps tendosesis — the biceps may be cerclage arthroscopically, then fixed through bone tunnels in the strongest bone of the humerus (a), and final tenodesis in the supra pectoral location through bone tunnels in the biceps groove is shown (b).

Various patterns have been described, including simple box, x-box and three tunnel-double box. Sutures can be shuttled into inverted mattress or crossing configurations as desired. Six or eight fixation point repairs are easily achievable, which reduce dog-ear and bird-beak deformities. A promising pattern is a simple stitch in a box, which micro fractures the footprint to provide excellent healing potential and multiple fixation point repair in a small surface area (Figure 2a). For single-tendon tears, we use the x box (Figure 2b), and for two tendon tears, we use the double box (Figure 2c).

Hybrid repairs

Tunnels and anchors are like two sides of the same coin; they can be used simultaneously and synergistically since bone and tendon quality can vary even in the same shoulder. If the surgeon believes it is warranted to employ the benefits of both, hybrid repairs can maximize outcome and minimize cost.

Sanders and his colleagues have developed a cost-effective technique to repair all tears with one anchor and multiple tunnels. A single anchor is placed medially, and the sutures are passed through the tendon and shuttled through the lateral tunnels (Figure 3a). These are tied to themselves medially; this creates a five-fixation point repair with only one anchor. Alternatively, promising techniques exist to place a single anchor laterally (Figure 3b).

Tunnels for extra fixation points — Tunnels may be used for extra fixation points in complex cases, such as superior capsule reconstruction or with additional cortical fixation.

In a two-anchor hybrid (Figure 4), one anchor is placed medially and bounded by two tunnels. The sutures from the medial anchor are shuttled through the bone and tied medially, while the second anchor is placed laterally.

Anchor tunnel hybrids have shown to have high-initial fixation strength. A surgeon who prefers to use anchors may adopt a four-anchor repair with transosseous tunnels in between anchors to take advantage of the cerclage effect of transosseous tunnels, while securing the rotator cables with anchor fixation. These techniques may be beneficial in bundled scenarios, where any size cuff repair could be repaired with two anchors and a tunneler for cost reproducibility, which should be valued by facilities and payers in the near future.

Advanced techniques

The bone in the biceps groove is the hardest reliable bone in the shoulder. It is available for fixation techniques for the biceps, which eliminates another anchor, has equivalent pain relief because of release of the biceps sheath and avoids an axillary incision prone to dehiscence or infection (Figure 5a). We typically use two tunnels: the first supra pectoral tunnel is placed using the anterior portal (Figure 5b) and an accessory anteroinferior portal passes a grasping, locking loop-style suture configuration, and the second, more superior, tunnel is created with a circumferential loop placed around the tendon with an interlocking sutures configuration.

The repeatable unlimited fixation points within a case and small-diameter holes that do not preclude placement of other hardware can be an advantage in advanced techniques. There is an almost unlimited amount of techniques that may be utilized synergistically, including tapes, anchors, screws or other fixation devices. These may be applied arthroscopically or open as desired (Figure 6).

Transosseous tunnels are quickly and easily deployed arthroscopically in reusable fashion. In the coming era of value-based care, this should add a robust technique to the surgeon’s armamentarium that can synergize with or replace existing techniques. Payment and business methodologies are heterogeneous around the world, but this technique may offer a platform that could be adopted in many payment restricted areas to accomplish gold standard arthroscopic cuff repair.

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For more information:
Brett S. Sanders, MD, can be reached at the Center for Sports Medicine, 2415 McCallie Ave., Chattanooga, TN 37404; email: sandbrett@gmail.com.

Disclosure: Sanders reports he is the co-founder of Tensor Surgical.