Open rotator cuff repairs were commonly performed in a transosseous fashion. With the advent of arthroscopic rotator cuff repair, this method was abandoned for simpler configurations such as single-row repair. With improved surgical instrumentation and surgeon skill, the focus has returned to repair methods that attempt to recreate the biomechanics of original transosseous repairs. These repair constructs include double-row, transosseous equivalent, and transosseous techniques. The development of improved rotator cuff repair techniques has been motivated by the relatively high failure and retear rates, reaching 30% to 94%, with particularly high recurrence rates for massive tears or older patients.1,2 Failure modes can include implant failure, gap formation, or breakdown at the suture-tendon interface. Likely multiple factors contribute to failure of repair, which can be reduced by proper initial fixation, limitation of gap formation, and increase in the load sharing of the construct across the tendon unit. With an average footprint of 350 mm², a single-row repair does not reproduce the native supraspinatus footprint.^3,4 Biomechanical studies have demonstrated that double-row and suture bridge repair techniques provide improved footprint coverage,⁵ a pressurized contact area and contact pressure at the footprint,^6,7 reduced motion at the footprint tendon-bone interface,⁸ improved resistance to rotational forces,⁹ and greater load to failure.^5,10,11,29 It is believed that improved contact characteristics will help maximize healing potential between repaired tendons and the greater tuberosity. Despite the numerous theoretical and biomechanical advantages, clinical data to corroborate biomechanical superiority had been lacking. Recent clinical trials comparing single-row and double-row arthroscopic repair in the treatment of rotator cuff tears have demonstrated improved postoperative cuff strength and decreased rate of retear with double-row repairs, particularly in tears larger than 30 mm.^12,13

Preoperative Considerations

History

• Anterolateral shoulder pain frequently radiating toward the deltoid insertion.

• Usually insidious in onset, although patients may recall specific trauma.

• The pain is usually dull at rest.

• The pain is frequently exacerbated by overhead and reaching activities (combing hair, reaching into an overhead cabinet, and, in large multitendon tears, reaching into a back pocket).

• Night pain when sleeping on the affected side.

• Weakness with overhead activity.

Physical Examination

• Atrophy of the supraspinatus and infraspinatus.¹⁴

• Subacromial crepitation.

• Decreased active range of motion (ROM).

• Tenderness over greater tuberosity.

• Presence of impingement signs such as those revealed by the Neer test (sensitivity, 0.79; specificity, 0.53) and Hawkins-Kennedy test (sensitivity, 79%; specificity, 59%).¹⁵

• Supraspinatus tears may be evidenced by weakness to forward elevation, Jobe empty can test (sensitivity, 53%; specificity, 82%), and drop arm test (sensitivity, 35%; specificity, 88%).¹⁶

• Infraspinatus tears may be evidenced by weakness to external rotation or the external rotation lag sign (ERLS).

• Hornblower’s sign may be indicative of severe degeneration or absence of the teres minor muscle (sensitivity, 95%; specificity, 92%).¹⁷ To assess for the hornblower’s sign, the examiner places the patient’s shoulder in 90 degrees of abduction, the elbow in 90 degrees of flexion, and the shoulder in maximal external rotation. Inability to maintain external rotation is suggestive of significant teres minor degeneration.

• Subscapularis tears may be evidenced by limited internal rotation, lift-off test, belly press test (Napoleon test), and bear hug test. The high specificity associated with the bear hug (92%) and belly press tests (98%) makes them valuable tests for ruling in subscapularis muscle tears.¹⁸

– Lift-off test: The patient is instructed to place the hand of the same side as the affected shoulder against his or her lumbar spine and then to lift the hand off the back. Inability to lift off indicates a subscapularis tear.

– Belly press test: The hand is used to press into the patient’s abdomen, and the elbow is brought forward past the body midline. Inability to bring the elbow anteriorly past midline indicates a subscapularis tear.

– Bear hug test: The patient is instructed to place the hand of the same side as the affected shoulder on the superior aspect of the contralateral shoulder. The patient tries to hold the starting position by means of resisted internal rotation while the examiner tries to pull the patient’s hand superiorly off the shoulder with an external rotation force. Inability to maintain the starting position indicates a subscapularis tear.

Imaging

• Plain radiographs including a true anteroposterior (Grashey) view and an axillary view may demonstrate degenerative changes, calcific tendinitis, contributing acromial morphology and, most important, proximal humerus migration.

• Ultrasonography is a noninvasive, inexpensive test with good sensitivity (85%) and specificity (92%).¹⁴ Drawbacks of ultrasonography are that it is operator dependent and less sensitive for partial-thickness tears (sensitivity, 66%; specificity, 94%).¹⁴

• Magnetic resonance imaging (MRI) is the standard imaging study (sensitivity, 86%; specificity, 90.4%).¹⁴ It delineates which tendons are involved, degree of retraction, muscle atrophy, and fatty infiltration of the muscle bellies (degree of fatty degeneration can be graded according to the Goutallier classification).¹⁹