Fig. 1
Patient position and portal locations for transosseous equivalent suture bridge repair technique. Beach chair position, standard posterior and anterior portals, mid-lateral viewing portal 2 cm from the acromial edge, anterolateral working portal immediately off the lateral acromion for large cannula. Anchor placements will be through percutaneous incisions just lateral to the acromial edge
Tear Assessment and Decision Making
While viewing through the lateral portal, a grasper is then placed through the anterolateral portal to plan rotator cuff repair strategy by assessing the rotator cuff tendon integrity, by identifying the tear pattern (crescent, L shape, reverse L shape), and by attempting to reduce the tear to the greater tuberosity footprint. If needed, a careful mobilization of the tear will be performed (Fig. 2).
Fig. 2
Lateral view. A grasper is placed through the anterolateral portal to assess tendon mobility, identify tear pattern, and attempt to reduce the tear to the footprint
If the tear pattern is amenable to a suture bridge repair technique then the surgeon can perform a transosseous equivalent technique utilizing medial and lateral suture anchors, or a transosseous anchorless fixation technique.
Transosseous Equivalent Repair Technique
It is our senior author’s preference to perform a knotless “speed bridge” transosseous equivalent rotator cuff repair whenever possible in order to limit irritation of the subacromial space from prominent knots in either the medial or lateral row (Fig. 3). The knotless speed bridge technique is described here.
Fig. 3
The scope is into the lateral portal and a posterior medial anchor is placed through the posterolateral portal. Medial anchors should be placed close to the articular margin at a 45° dead’s man angle
Footprint Preparation
The greater tuberosity footprint is prepared with a high-speed burr introduced through the anterolateral cannula. A cortical bone abrasion is carried out with the high-speed burr until bleeding cancellous bone is present in order to stimulate a biologic response and augment repair. Alternatively, a microfracture of the footprint can be performed either with an awl or commercially available marrow stimulation device.
Medial Anchor Placement
The medial row anchors are placed at the osteoarticular junction at a 45° “dead man’s angle.” The medial row anchors are typically placed percutaneously after localizing with a spinal needle. The number of medial row anchors is dictated by the tear size and configuration (Fig. 4). Depending on the patient age, bone quality, or surgeon preference, suture anchors made of either metal, PEEK, or PLLA biocomposite material may be used (Swivel Lock CTM, Arthrex). When performing a knotless speed bridge technique, each medial row anchor is loaded with a 2 mm wide suture constructed of a multi-strand, long-chain ultra-high molecular weight polyethylene (UHMWPE) core with a braided jacket of polyester and UHMWPE (FiberTapeTM, Arthrex). For a small or medium-sized tear, commonly two medial and two lateral anchors are required. Care must be taken to place each medial anchor at least 7 mm apart from the other in order to avoid contiguous tapping and/or loss of anchor fixation. Once the medial row anchors have been placed, the surgeon may proceed with suture passage. Many commercially available suture passage devices allow the surgeon to pass suture through a retrograde or antegrade fashion. Regardless of suture passage device used, each suture is carefully passed medial through the tendon but not too medial through the musculotendinous junction. The FiberTapeTM suture limbs of each anchor can be passed together or individually in a horizontal mattress fashion through the rotator cuff tendon. Sutures passed through the cuff are then retrieved through the anterior or posterior portals. Alternatively, the medial row can then be tied at this moment and then the tied limbs are retrieved through the anterior or posterior portals (Fig. 5).
Fig. 4
Transosseous equivalent “speed bridge” knotless suture bridge
Fig. 5
Transosseous equivalent suture bridge with medial row knots
Lateral Anchor Placement
The proper location for the lateral row anchors is typically found 5–10 mm distal to the lateral edge of the footprint of the greater tuberosity. Careful debridement of the lateral row anchor site is necessary to visualize the anchor insertion site. Overaggressive debridement may injure the intact infraspinatus tendon, and therefore, it must be avoided. When incorporating the sutures from the medial row into the lateral row, there are many different possible suture configurations. When using two medial anchors and two lateral anchors, a single limb from each medial anchors is incorporated into each lateral anchor. Prior to incorporation of the medial row sutures into the lateral anchors, the surgeon may evaluate for potential “dog ears” that may form after lateral row fixation. If dog ears are likely to form, the surgeon has the option to pass cinch stitches through each dog ear and incorporate these sutures into the lateral row anchors to compress the dog ears. Prior to insertion of the lateral anchors into the bone, the slack on each of the sutures must be removed individually to compress the tendon onto the footprint equally and avoid “spot welds.” Once the lateral anchors are placed, the free sutures ends may be cut at the anchor insertion site (Fig. 6).
Fig. 6
Speed bridge with chinch stiches to compress the dog ears
Transosseous (Anchorless) Repair Technique
When performing a transosseous anchorless repair technique, the creation of six portals is often necessary. In addition to standard posterior and anterior portals, superior and inferior anterolateral portals are created in line with the anterior edge of the supraspinatus tendon. In addition, superior and inferior posterolateral portals are created. The transosseous repair will be performed through these four lateral portals. Once the subacromial space is prepared and the reparability of the rotator cuff is assessed, the transosseous repair is begun. Typically the footprint is not decorticated with the burr to avoid suture cut out of the cancellous bone. While viewing through the posterior portal, a specific drill guide is inserted through the anterior superior portal to create a 2.9-mm medial tunnel immediately adjacent to the articular surface. Next, through the inferior anterolateral portal, the device that allows the creation of an intersecting tunnel (ArthroTunneler, Tornier, Edina, MN, USA) is introduced. Through this inferior anterolateral portal, the lateral intersecting 2.5-mm tunnel is drilled. The position of the inferior anteriorlateral tunnel is approximately 1.5 cm below the superior tip of the greater tuberosity and can be localized under direct arthroscopic visualization. Next, a loaded suture inserter is introduced through the hole of the device. The loop is moved into the retrieval position, and the suture inserter is removed leaving the suture passed in a transosseous fashion through the greater tuberosity. Next, the device will retrieve the suture through the superior anterolateral portal thereby completing the transosseous suture passage. This suture can be used to complete the tendon repair or as a suture shuttle to pass 2 or 3 definitive sutures through the tunnel. All transosseous sutures are first placed in the bone and then passed through the cuff with different suture passing devices according to surgeon preference. The sutures are managed through the anterior portal. The same steps are taken to pass suture transosseously through the posterior aspect of the tear utilizing the posterolateral portals. Various suture configurations repair patterns are possible (Fig. 7a, b).
Fig. 7
(a) Represents transosseous equivalent suture bridge technique with “M” suture configuration. (b) Transosseous anchorless repair technique also with “M” suture configuration
Postoperative Rehabilitation
Immobilization in a sling with an abduction pillow is recommended for 6 weeks. Only home pendulum exercises and elbow and wrist mobilization are allowed in the first week after surgery. From week 2 to 6, a physical therapist will help the patient to recover the passive range of motion in order to avoid scar formation and postoperative stiffness due to the immobilization. Subsequently, active assisted range of motion and active motion as tolerated will be allowed. Strengthening exercises will start after a full recovery of the active range of motion, usually 12 weeks after surgery. After that, the patient will be directed to a home exercise program or alternatively to a specific training sport-related exercise program. Return to competitive sport activities are usually allowed 6 months after surgery.
Literature Review
Many factors can contribute to an optimal repair. Biological factors, such as tendon quality, muscle atrophy, and fatty infiltration, as well as patient’s related factors such as age, smoking, and osteoporosis have been reported to influence the tendon healing response [46–48]. Nevertheless, biomechanical factors play an important role, especially in the early stage of the healing process. Initial fixation strength and footprint coverage are essential in optimizing rotator cuff repair; therefore, numerous biomechanical studies have focused on clarifying the strongest devices, knots, and repair configurations [49]. Suture bridge fixation techniques have been shown to provide numerous biomechanical advantages when compared with previous arthroscopic repair techniques, including increased failure loads, improved footprint restoration and pressurized area as well as decreased gap formation [18, 19, 50, 51]. In an attempt to maximize the biomechanical properties of suture bridge techniques, different configurations have been described [38–44]. They can be generally divided between two main categories: those in which the medial row is tied and all-knotless repairs. Tying the medial knots can result in knot impingement and strangulation, which has been advocated as a possible explanation for the high number of medial row failure with double-row techniques [36, 51, 52]. Nevertheless, a recent systematic review [53] reported that biomechanical factors, such as ultimate load, stiffness, gap formation, and contact area, are significantly improved when medial knots are tied.
Tissue strangulation is one of the main concerns associated with a suture bridge configuration. It might be due not only to knots type but also to high contact pressure, multiple tendon perforations, and strong synthetic sutures [34]. Currently, only one study [54] showed a reduced but preserved blood flow in the tendon repair site after placing the second row. Therefore, excessive tensioning of the lateral row is not recommended, but further studies are needed to elucidate possible biological consequences in the healing process.
Transosseous equivalent configurations have been rapidly evolved. They were first based on two medial mattress sutures with four tied suture bridges fixed laterally by knotless anchors. Subsequently, an anterior augmentation through an additional lateral single stitch has been proposed to prevent gap formation at ultimate load in dynamic external rotation [28, 55]. Recently, the speed bridge technique has been developed. It combines quick arthroscopic application and eliminates medial and lateral knot impingement. As already described, speed bridge consists of a four strands, knotless construct with suture tapes of 2-mm width. Suture tapes should provide better high footprint coverage and compression between the tendon and bone to help promote healing. In addition, the theoretical risk of cut-through resistance on medial rows may have been reduced because this new construct is supposed to better distribute the pressure to the underlying tendon tissue [30, 41, 56]. Pauly et al. [52] compared four different Speed Bridge configurations with or without medial or lateral row reinforcement. The authors showed that double tendon perforation per anchor and additional medial mattress stitches significantly enhance biomechanical construct stability at time zero. Moreover, lateral addition of simple stitches reduces lateral “dog ear” deformities, but did not improve repair stability.
Besides biomechanical studies, several clinical studies evaluated repair integrity with regard to healing and functional outcomes after suture bridge techniques. Comparable or even better results than single and traditional double-row techniques have been reported. According to the recent literature, re-tear rates after suture bridge repairs vary between 9 and 29 % [38–42, 57].
Perhaps in an attempt to control implant costs, arthroscopic transosseous techniques have recently been revisited [45, 58, 59]. Open transosseous rotator cuff repair was first described by McLaughlin in 1944 [60] and it has been considered the gold standard for a long time. Transosseous sutures showed numerous biological and biomechanical advantages: allow reduction of the tendon bone gap formation; increase blood flow through the tunnel, maximizing the healing potential; improve footprint restoration, providing a more direct tendon to bone compression vector; and avoid the presence of implant devices in the footprint insertion, reducing the risk of anchor pullout and simplifying future revision surgeries [61, 62]. Currently, a few biomechanical studies have compared anchorless transosseous techniques with different transosseous equivalent suture anchor techniques. Nevertheless, a recent biomechanical study [Beherens 2012] showed comparable initial fixation strength between transosseous equivalent suture anchor fixation and traditional open transosseous anchorless technique. Two other studies [63, 64] showed equivalent biomechanical properties in regard to gap formation, ultimate load, and linear stiffness. One study [65] showed that suture anchor repair offers higher failure load than transosseous repair regardless of tunnel or suture configuration. Further biomechanical and clinical studies are needed to clarify potential clinically relevant differences.
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