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Arthroscopic Rotator Cuff Repair: Double-Row (Knotted Anchors Medial and Lateral)


Introduction

With advances in arthroscopic surgery, several techniques have been developed to increase the tendon–bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint and providing a better environment for tendon healing. On the basis of magnetic resonance imaging (MRI) findings, the double-row repair is a more anatomic construct, which better restores the native structures of the rotator cuff footprint. However, this does not seem to translate into superior clinical outcomes, except for large-to-massive tears (>3 cm), in which the double-row technique provides better clinical outcomes compared with the single row. For mobile crescent-shaped cuff tears, we propose the double-row fixation with anchors and knotted sutures as the standard for arthroscopic rotator cuff repair.

Procedure

The double-row repair is similar to that described by Lo and Burkhart. Two double-loaded 5.0-mm screws are inserted just lateral to the articular surface of the humeral head, with a center-to-center distance of approximately 1.5 cm in the anterior-to-posterior direction. The first medial anchor is inserted 5 mm from the bicipital groove. The suture strands from each medial anchor are passed approximately 7 mm apart in a mattress fashion. The lateral row consists of two double-loaded 5.0-mm screw suture anchors just lateral to the “drop-off” of the greater tuberosity, with a center-to-center distance of approximately 1.5 cm in the anterior-to-posterior direction. The suture from each lateral anchor is passed through the tendon as a simple stitch. All knots are completed with a static six-throw surgeon’s knot.

Patient History

  • Shoulder pain patterns and characteristics

  • General information (age, dominant handedness, sports, occupational activity)

  • Medical information (chronic or acute medical problems, review of systems, preexisting or recurrent shoulder problems, other musculoskeletal problems (acute or distant)

  • Shoulder complaints (symptoms, pain, weakness, fatigue instability, stiffness)

  • Injury pattern (sudden or acute onset, gradual or chronic onset, traumatic fall or blow, recurrent)

  • Symptom characteristics (location, character and severity, provocation, duration, paresthesias, related activities, disability)

  • Related symptoms (cervical, peripheral nerve, brachial plexus, entrapment)

Patient Examination

  • 1.

    Observation

    • Look at both shoulders

    • Feel and compare both shoulders

    • Move both shoulders

    • Deformities, swelling, color, etc.

    • Position of humeral head (forward posture), atrophy/wasting, popeye deformity

  • 2.

    Palpation (sternoclavicular, clavicle, acromioclavicular joint, acromion, coracoid, bicipital groove, greater tuberosity, scapula, musculature)

  • 3.

    Active and passive range of movement (aROM and pROM)

    • Compare to normal shoulder

    • Careful measurements with goniometer

  • 4.

    Strength testing

    • Grade strength 0–5

  • 5.

    Examination of movement patterns

  • 6.

    Functional testing (stability tests, rotator cuff tests, impingement tests, biceps tendon tests)

    • Rotator cuff tests

    • Supraspinatus tendon test: empty can test (also known as Jobe test) ( Fig. 21.1 ), full can test, resisted isometric abduction, resistance test, painful arc test, palpation of the supraspinatus, drop-arm test for supraspinatus

      FIG. 21.1, Empty can test (also known as Jobe test) for supraspinatus tendon.

    • Infraspinatus and teres minor tendon tests: external rotation strength test (also known as Patte test), external rotation lag sign (ERLS), dropping sign, weakness with external rotation

    • Subscapularis tendon tests: lift-off test, internal rotation lag sign (IRLS), belly press test, Napoleon test, bear-hug test

    • Impingement tests: Neer impingement sign and test, Hawkins-Kennedy impingement test, internal rotation resistance stress test

  • 7.

    Vascular examination

    • Adson test for thoracic outlet

    • Distal pulses

  • 8.

    Neurological examination

    • Motor and sensation of the radial, median, ulnar, musculocutaneous, and axillary nerves

Imaging

Several imaging techniques are available to study the rotator cuff:

  • 1.

    Radiographs

  • 2.

    MRI

  • 3.

    Echotomography

  • 4.

    Computed tomography (CT)

1

Radiographs

  • Plain radiographs of the shoulder should include anteroposterior, scapular-Y, and axillary views.

  • The scapular-Y lateral view allows assessment of acromion morphology, a rotator cuff impingement should be suspected in those with a type III acromion.

  • Sclerosis of the greater tuberosity and the undersurface of the acromion is a nonspecific finding that can often be noted in patients with rotator cuff impingement.

  • Massive tears appear radiographically as superior migration of the humeral head, with the loss of continuity of the gothic arch formed by the medial neck of the proximal humerus and the inferior aspect of the glenoid neck, as well as a decrease in the acromiohumeral distance (normal >6 mm).

2

MRI

  • MRI is a noninvasive technique that represents the gold standard for assessment of rotator cuff pathology. In particular, MRI can assess the size and shape of the tear, degree of tendon retraction, degree of muscle atrophy, and quality of residual tendon. Moreover, MRI is able to distinguish other causes of shoulder pain that can mimic rotator cuff tears. In addition, MRI has high specificity and selectivity, which allows us to diagnose and differentiate small or very deep tears, or articular and bursal partial tears.

  • The use of intra-articular contrast (MRI arthrogram) increases sensitivity in the diagnosis of partial-thickness rotator cuff tears and associated labral pathology.

  • The entire scapula should be included on the MRI to assess both rotator cuff muscles for atrophy and fatty infiltration.

  • Supraspinatus atrophy is considered as a negative prognostic indicator for rotator cuff healing, and the degree of supraspinatus atrophy can be quantified with the tangent sign.

3

Echotomography

  • Ultrasound is a viable alternative to MRI for the assessment of rotator cuff disorders, especially in patients with metal implants. Its sensitivity and specificity approach that of MRI.

  • Ultrasound retains the advantages of being quick, inexpensive, noninvasive, with the benefit of enabling dynamic examination.

  • However, the accuracy of this practice is extremely operator-dependent and requires extensive experience in performing and reading musculoskeletal ultrasound images.

4

CT

  • CT is not the first choice to assess rotator cuff disorders. Although it can be useful for studying bone composition, CT is not suitable for the assessment of soft tissues and it does not add information about the state of the tendons compared with ultrasound.

Treatment Options: Nonoperative and Operative

  • The choice of treatment is influenced by many factors, some of which are not always objectified in rigid schemes. The goal of treatment is to reduce pain and improve joint function and quality of life.

  • In order to choose the appropriate treatment, it is necessary to define the type of rotator cuff tear. First it is useful to distinguish between chronic nontraumatic cuff tears, traumatic tears (rarer), and acute or chronic tears. Furthermore, the thickness and size of the tears should be considered.

  • For mobile full-thickness rotator cuff tears, there are nonoperative versus operative treatment options.

Nonoperative

  • Initial management should be nonoperative in all patients, but in young active patient with a full thickness tear

  • Antiinflammatory drugs (NSAIDs)

  • Corticosteroid injections

  • Concern regarding the effect of multiple injections on tendon quality

  • Consider few injections in patients with associated adhesive capsulitis, partial-thickness tears, or elderly patients with large/massive tears.

  • Physical therapy

  • Activity modification, avoiding heavy overhead activities, exercises focused on strengthening the rotator cuff and stabilizing the scapula

  • Ultrasound, phonophoresis, or iontophoresis

  • Efficacy has not yet been established.

  • Age, tear size, activity level influence the duration of nonoperative management. Consider surgery after 3 months of unsuccessful nonoperative treatments.

  • Follow up patients with successful nonoperative treatment.

  • Check clinically if they become symptomatic or develop weakness.

  • Check on MRI possible progression of the tear.

Operative

  • Debridement

  • Subacromial decompression

  • Biceps tenotomy / Biceps tenodesis

  • Rotator cuff repair

  • Over the years, different types of fixation have been proposed to treat rotator cuff tears. In particular, the principal techniques described are transosseous, single-row, double-row, and transosseous equivalent repair.

  • Transosseous repairs refer to the repairs that are performed by using open and mini-open techniques in which sutures are placed directly through transosseous tunnels for soft-tissue fixation.

  • Single-row repairs are performed by placing the anchors in a linear fashion (usually one to two anchors placed laterally).

  • Double-row repairs include techniques that use some configuration of a medial row of suture anchors placed at the articular cartilage margin of the anatomic neck and a second more laterally placed row along the lateral edge of the rotator cuff footprint along the tuberosity.

  • Transosseous equivalent repairs use suture anchors to achieve what is considered to resemble biomechanically traditional open transosseous repairs.

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