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Arthroscopic rotator cuff repair: Double-row and transosseous equivalent techniques


OVERVIEW

Chapter synopsis

  • Double-row and transosseous equivalent repair techniques provide improved footprint coverage, pressurized contact area, reduced motion at the footprint tendon-bone interface, and greater load to failure. It is believed that improved contact characteristics will help maximize the healing potential between repaired tendons and the greater tuberosity.

Important points

  • While double-row rotator cuff repair may improve healing biology and biomechanics, TOE techniques optimize healing biology at the repaired rotator cuff insertion and have shown to improve mean footprint pressure when compared with the double row technique.

Clinical and surgical pearls

  • Properly prepare the subacromial space to ensure a clear view of the entire rotator cuff from the musculotendinous junction to the lateral margin of greater tuberosity and enable adequate access to the area where the lateral row will be located.

  • U-shaped tears can have poor lateral mobility and may require margin convergence in order to reduce stress on the repair.

  • The lateral-row suture anchors must be placed as lateral as possible to avoid overcrowding of the tuberosity with implants and to maximize repair site contact.

  • Suture bridge repair constructs create optimal footprint restoration and rotator cuff–to-tuberosity contact mechanics.

Clinical and surgical pitfalls

  • The rotator cuff tear pattern must be correctly identified for adequate tear mobilization and repair.

  • The medial-row anchors should be positioned as medial as possible at the sulcus or articular margin of the humeral head in order to maximize and reproduce contact at the repair site and to avoid overcrowding of the greater tuberosity with implants.

Video available

  • : Tear pattern.

  • : Edited punch.

  • : Anchor placement.

  • : Passing sutures through cuff.

  • : Tying sutures for medial row.

  • : ID lateral anchor placements.

  • : Lateral-row anchor and complete cuff repair.

Introduction

Reports of rotator cuff tear prevalence in the general population have varied from 5% to 39%. Several risk factors have been identified for symptomatic rotator cuff tears, including age, body mass index (BMI), smoking history, family history, hypercholesterolemia, and the male sex. Symptomatic rotator cuff tears can cause pain, weakness, and inability to perform activities of daily living. Given current demographic trends, the incidence of symptomatic tears has continued to increase and will continue to place a burden on the aging population.

Surgical techniques have been developed, which have improved patient-reported outcomes. Despite widespread adoption, early arthroscopic techniques yielded a structural failure rate anywhere from 30% to 94%. Causes for these failures included implant pullout, gap formation, breakdown at the suture-tendon interface, and biologic factors. Galatz et al. demonstrated reduced risk of failure with proper initial fixation, limitation of gap formation, and increase in the load sharing of the construct across the tendon unit.

Arthroscopic single-row repair restores only 65% of the normal surface area, failing to restore the full footprint of the supraspinatus tendon on the greater tuberosity. As a result, technique innovation has led to the development of double-row and transosseous equivalent (TOE) techniques. Biomechanical studies have demonstrated that double-row and suture bridge repair techniques provide improved footprint coverage, produce a pressurized contact area and increased contact pressure at the footprint, reduced motion at the footprint tendon-bone interface, improved resistance to rotational forces, and provide greater load to failure. TOE techniques were developed to optimize healing biology at the repaired rotator cuff insertion and have shown to improve pressurized contact area and mean footprint pressure when compared with the double row technique. It is believed that improved contact characteristics will help maximize healing potential between repaired tendons and the greater tuberosity. ,

Preoperative considerations

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