- Email: [email protected]
Arthroscopic Double-Row Repair of Full-Thickness Rotator Cuff Tears Using a Suture Bridge Technique
Arthroscopic Double-Row Repair of Full-Thickness Rotator Cuff Tears Using a Suture Bridge Technique Chris Bales, MD, and Kyle Anderson, MD There has been a recent trend towards arthroscopic treatment of full-thickness rotator cuff tears. The results of this technique have compared favorably with those of open and arthroscopically assisted mini-open rotator cuff repairs. Obtaining tendon to bone healing however still remains an issue. High failure rates have been reported in the literature with each of these techniques, particularly with large and massive tears. Recent interest has focused on reestablishing the anatomical foot print of the rotator cuff using an arthroscopic double-row repair to provide an increased surface area for tendon to bone healing. However, traditional double-row repairs using knots for the medial and lateral rows fail to produce compression between the rows. In this article we describe our technique for a double-row repair using a suture bridge technique that functions to broaden the area of compression between the two rows. Oper Tech Sports Med 15:144-149 © 2007 Elsevier Inc. All rights reserved. KEYWORDS double-row repair, suture bridge technique, rotator cuff repair, arthroscopic
T
he rotator cuff plays a vital role in the function of the shoulder, and tears of the rotator cuff are a common cause of pain and disability in the upper extremity.1,2 Surgical management of these tears has evolved during the past 2 decades with a trend toward arthroscopic repairs.3-5 Results of arthroscopic repairs have compared favorably with those of open and arthroscopically assisted mini-open rotator cuff repairs in terms of postoperative pain, range of motion and patient satisfaction.3,6-8 However, achieving tendon to bone healing remains an issue. Structural failure rates of 30% to 50% have been reported in open and mini-open repairs at 3 to 5 years postoperatively.9-11 Similar or higher failure rates have been found with arthroscopic repairs. In fact, one study showed an almost 100% structural failure rate of large and massive tears fixed using an arthroscopic single-row repair.12,13 These findings are concerning as functional results of rotator cuff repairs appear to fair better with healed cuffs and initially good clinical results from arthroscopic repairs tend to deteriorate with time.10,12-14 Boileau and coworkers demonstrated a completely healed tendon in only 71% of the patients treated with a single row arthroscopic repair.12 These results worsened in patients older than the age of 65 years, with only 43% demonstrating completely healed tendons. Even more alarming results were reported by Galatz and Department of Orthopedics, William Beaumont Hospital, Royal Oak, MI. Address reprint requests to Chris Bales, MD, 3003 Ferris Avenue, Royal Oak, MI 48073. E-mail: [email protected]
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coworkers, 14 who found recurrent tears in 17 of 18 patients treated for large and massive rotator cuff tears using a singlerow arthroscopic repair technique. A 2-row repair technique involves placing 1 row of suture anchors medially at the articular margin of the humeral head and a second row on the lateral aspect of the greater tuberosity. Cadaveric studies have shown that traditional repair techniques do not reproduce the anatomical footprint of the supraspinatus insertion.15,16 Meier and Meier15 demonstrated that double-row fixation consistently reproduced 100% of the supraspinatus footprint, whereas single-row and transosseous fixation only reproduced 46% and 71%, respectively. Brady and coworkers17 compared the restoration of the footprint in vivo after an initial lateral-row repair and again after the double-row repair was complete. They found that after the initial lateral-row repair approximately 50% to 60% of the footprint remained uncovered. The double-row repair covered on average twice the footprint area compared with the single-row repair. Biomechanical studies have also demonstrated that double-row suture anchor fixation is significantly stronger and more resistant to gap formation than a single-row repair.18-21 By reestablishing the rotator cuff footprint the surgeon provides an increased surface area for tendon to bone healing.15-17 The potential to improve healing is critical as re-repairs have significantly poorer outcomes.22 Recent clinical interest has focused on reestablishing the rotator cuff footprint using a double-row repair to provide a greater surface area for tendon to bone healing. Even more
Arthroscopic double-row repair of full-thickness rotator cuff tears
145
recently, a suture bridge technique has been proposed that would potentially broaden the area of compression between the two rows. This would be advantageous as traditional two-row repairs using arthroscopic knots on the medial and lateral rows do not necessarily compress the tissue between the rows. One cadaveric study using pressure sensitive film showed that while the double-row repair had a 60% greater contact area, the actual contact pressure was slightly higher with the single-row repair.23 We have transitioned from a 2-row technique to the suture bridge technique with the goal of distributing this compression over a broader area. We also thought that the bridge technique may be more amenable to delivering growth factors to the tendon-bone interface as the techniques evolve to more biologic solutions. This article will describe our approach for an arthroscopic double-row rotator cuff repair using this suture bridge technique.
lary view can be used to evaluate for an os acromiale which some feel predisposes to impingement and rotator cuff tears.33 It is also helpful in evaluating glenohumeral arthritis, humeral head position, as well as the presence of glenoid erosion. The outlet view is used to determine the acromial morphology and the presence of acromial spurring.34 For those who have failed nonsurgical treatment and in patients with a suspected traumatic tear, a preoperative MRI is obtained. The MRI is currently considered the gold standard imaging study and it serves several purposes. First, it can be used to evaluate other pathology, such as labral tears, biceps lesions, paralabral cysts, and articular cartilage damage. MRI also has been shown to be very specific and sensitive in diagnosing full-thickness rotator cuff tears.35 Muscle atrophy, tendon thickness, retraction, and quality of the rotator cuff tissue also can be assessed on the MRI. It is very important to assess the amount of fatty infiltration as this has been shown to be an important prognostic factor in rotator cuff surgery.36,37 Ultrasound is less expensive and better tolerated but is more technician dependent. In experienced hands, ultrasonography has been shown to be as accurate as MRI.38 Arthrograms are able to distinguish full-thickness tears from partial tears or tendinosis but are more invasive and rarely necessary to determine the significance of a tear.
Preoperative Evaluation When to repair a full-thickness rotator cuff tear depends on a number of factors. Patient age, general health, lifestyle, occupation, duration of symptoms under treatment, and degree of disability are just a few of the factors the surgeon must take into consideration. The duration of nonoperative treatment is debatable because this treatment has not resulted in a high rate of healing.24-27 However, not all rotator cuff tears are symptomatic. The incidence of asymptomatic full-thickness rotator cuff tears increases with age. Ultrasonographic and magnetic resonance imaging (MRI) studies have shown rotator cuff tears in approximately 30% of individuals older than 60 years of age, increasing to greater than 50% in those older than 80 years of age.28,29 The natural history of asymptomatic rotator cuff tears has been assessed using ultrasound with tear progression noted in approximately 40% of shoulders and development of symptoms in 50% of these patients.24 A trial of conservative management is generally warranted in many cases, with most authors recommending approximately a 3- to 6-month course of nonoperative treatment. A combination of anti-inflammatory medications and physical therapy have been shown to result in significant improvement even in patients with full-thickness rotator cuff tears.25-27 Although early nonoperative management is appropriate in most patients, younger patients, patients with high functional demands and those with traumatic tears should be considered for more aggressive treatment. The surgeon must also take into consideration that smaller tears tend to have improved results with early surgical repair and that the rate of tendon healing is superior with single tendon tears.12,30,31 Also, the patient must be made aware that there is considerable likelihood of tear progression with nonsurgical treatment.24 The initial evaluation of patients suspected of having rotator cuff pathology should include a complete history and physical examination along with plain radiographs, which include an anterior–posterior (AP), axillary and supraspinatus outlet view of the involved shoulder. Narrowing of the acromiohumeral space on the AP view can be suggestive of a large rotator cuff tear,32 and in patients with chronic, massive tears, articulation with the acromion may be seen. The axil-
Surgical Technique Most patients are given an interscalene injection or catheter in the preoperative area. Patients are then taken to the operating room, where a general anesthetic or sedation is administered, and they are positioned in the beach chair position. An examination under anesthesia is performed documenting range of motion and joint stability. We use a pneumatic arm holder to appropriately position the arm during the procedure. The superficial anatomical landmarks are then carefully marked as well as our anticipated viewing and working portals. For the majority of our rotator cuff repairs, we use a standard posterior portal along with a lateral and an auxiliary superolateral portal (Fig. 1). The portal sites, posterior joint capsule and subacromial space are injected with approximately 5 to 10 mL of 0.5% naropin. Hypotensive anesthesia is used to facilitate visualization during the acromioplasty. A standard posterior portal is established, and a diagnostic arthroscopy is performed. In patients with full-thickness rotator cuff tears, we then establish our lateral portal at the junction of the anterior (1/4) and posterior (3/4) of the acromion using an 18-gauge spinal needle (Fig. 2). If necessary, debridement of superior labral fraying or other intraarticular pathology can be performed through this portal. If more extensive intraarticular work is required or if the full-thickness tear is not immediately evident, an anterior portal through the rotator interval is established with an outside-in technique. In tears with retraction and scarring on the undersurface of the cuff, the tissue on the articular side is mobilized using an arthroscopic retractable blade or ablation wand, always keeping in mind the proximity of the suprascapular nerve. We have a low threshold for performing capsular releases in patients with large rotator
146
Figure 1 Superficial anatomical landmarks and arthroscopic portals for a left shoulder in the beach chair position. (Color version of figure is available online.)
Figure 2 Intra-articular view from posterior portal with shaver debriding the greater tuberosity from lateral portal. (Color version of figure is available online.)
Figure 3 View from posterior portal in subacromial space after preparation of the greater tuberosity. (Color version of figure is available online.)
C. Bales and K. Anderson
Figure 4 Viewing from the lateral portal an 18-gauge spinal needle is used to identify the correct angle for anchor insertion. (Color version of figure is available online.)
Figure 5 Placement of medial anchor at the articular margin of the humeral head. (Color version of figure is available online.)
cuff tears that may assist with tissue mobilization. The degenerated tendon margins are then debrided and the bony bed on the greater tuberosity is prepared using a bone-cutting shaver (Fig. 3). Next, the arthroscope is transferred into the subacromial space. The subacromial space is then cleared of bursal tissue and adhesions to enhance visualization of the rotator cuff tear. In most cases a subacromial decompression is performed. An ablation wand is used to expose the undersurface of the acromion and recess the coracoacromial ligament and then a bur is used to create a flat, upsloping Type I acromion. The mobility of the rotator cuff is assessed and further releases performed if necessary to ensure a low tension placement of the tendon into its anatomic position. If the rotator cuff is easily reducible to the lateral aspect of the greater tuberosity then an optimal double row repair can be performed. At this point, we prefer to visualize from the lateral portal,
Arthroscopic double-row repair of full-thickness rotator cuff tears
Figure 6 The medial row of sutures are passed in a retrograde fashion using tissue penetrators.
and any remaining posterior bursal tissue is resected with the shaver through the posterior portal. An auxiliary superolateral portal is created for placement of the anchors using an 18-gauge spinal needle to identify the correct angle of insertion (Fig. 4).39 The medial suture anchors are placed immediately lateral to the articular margin of the humeral head. A bone punch is used and depending on the tear size one or two 5.5-mm Bio-Corkscrew fully threaded suture anchors, double loaded with number 2 Fiberwire (Arthrex Inc, Naples, FL), are placed (Fig. 5). It is important to leave an adequate bone bridge between anchors (approximately 1 cm). The medial sutures are passed through the rotator cuff working from posterior to anterior placing them approximately 4 to 5 mm apart. The number of medial anchors is determined by tear size. Because there are 4 suture strands per anchor, and we place the sutures 4 to 5 mm apart, one anchor can generally cover 16 to 20 mm of tear size. Sutures can be passed in a number of different ways. We use tissue penetrators for the medial row because they allow ideal placement of the suture
Figure 7 The medial row of sutures are tied in a horizontal mattress configuration, leaving the “tails” for use in the lateral row fixation.
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Figure 8 Lateral row fixation using the “tails” from the medial row sutures.
and are not limited by the length of the jaws of some antegrade suture passing devices. The average rotator cuff footprint is 16 to 18 mm from medial to lateral and either method must allow for adequate tissue depth when passing the medial sutures.40,41 We will often use an additional, small anterior portal to allow passage of sutures through the anterior cuff and for suture management (Fig. 6). This portal is established with a small 3-mm incision, using a spinal needle to determine the proper angle of approach to the anterior cuff tissue. Once all of the sutures have been passed, the medial row is tied in a horizontal mattress configuration (Fig. 7). The type of knot is according to surgeon preference. We use a sliding knot such as a Duncan loop or a sliding/locking knot such as the Weston knot. It is of note that with the bridge technique knot prominence is not a significant issue since the knot will be pulled over with the tails used for the lateral fixation. The
Figure 9 Final repair demonstrating the suture bridge configuration. In this case of a larger tear, 3 sutures were included in each lateral row anchor.
C. Bales and K. Anderson
148 lateral row anchors are placed just lateral to the drop off of the greater tuberosity. We use the 4.5-mm Pushlock anchors (Arthrex, Naples, FL) to create a suture bridge using two or three of the tails from the previous knots of the medial row (Fig. 8). The tails used can be crossed for even greater compression over the entire repair construct. Care must be taken to avoid excessive suture tension in these lateral anchors because it may potentially compromise tendon vascularity. The excess suture is then cut and the integrity of the repair is assessed by palpation and by rotation of the arm (Fig. 9). The patient is placed in an abduction type sling and taken to the post-anesthesia core unit.
7. 8. 9.
10.
11.
12.
Postoperative Rehabilitation The patient is kept in a sling with a small abduction pillow for the first 4 to 6 weeks. During the first postoperative week passive range of motion (PROM) in the scapular plane and pendulum exercises are done with avoidance of extension and adduction. Submaximal isometrics (push/pull, internal rotation, and adduction) with the elbow at 90° are started. Elbow and hand range of motion as well as gripping exercises are continued throughout the rehabilitation process. During weeks 2 to 4, PROM is advanced to the patient’s level of tolerance. Submaximal isometrics are continued with the addition of external rotation at 2 to 3 weeks. The goal is full PROM by 6 weeks postoperatively. At 6 weeks, the patient progresses to active assist range of motion with active range of motion to 90° started during weeks 8 to 10. Full active range of motion is desired by 12 weeks. Progressive strengthening exercises are started in weeks 10 to 14 with a more aggressive rotator cuff program beginning during weeks 14 to 20. Return to most sports training is initiated at 4 to 6 months
13.
14. 15.
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21.
Conclusions
22.
Although current data on the suture bridge technique is limited, we reported on the structural integrity of a double-row rotator cuff repair at a minimum 2-year follow-up with 83% of patients showing no evidence of retear or persistent defect on postoperative ultrasound.32 The suture bridge technique is currently being investigated and the preliminary clinical results and healing rates by ultrasonography are encouraging.
23.
References
27.
1. Cofield RH: Rotator cuff disease of the shoulder. J Bone Joint Surg Am 67:974-979, 1985 2. Lo IK, Burkhart SS: Current concepts in arthroscopic rotator cuff repair. Am J Sports Med 31:308-324, 2003 3. Jones CK, Savoie FH: Arthroscopic repair of large and massive rotator cuff tears. Arthroscopy 19:564-571, 2003 4. Burkhart SS: Current concepts: A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles. Arthroscopy 16: 82-90, 2000 5. Burkhart SS: Arthroscopic treatment of massive rotator cuff tears. Clin Orthop 390:107-118, 2001 6. Warner JP, Tetreault P, Lehtinen J, et al: Arthroscopic versus mini-open
24.
25. 26.
28.
29. 30.
31.
rotator cuff repair: A cohort comparison study. Arthroscopy 21:328-332, 2005 Buess E, Steuber K, Waibl B: Open versus arthroscopic rotator cuff repair: A comparative view of 96 cases. Arthroscopy 21:597-604, 2005 Wolf EM, Pennington WT, Agrawal V: Arthroscopic rotator cuff repair: 4- to 10- year results. Arthroscopy 20:5-12, 2004 Liu SH, Baker CL: Arthroscopically assisted rotator cuff repair: Correlation of functional results with integrity of the cuff. Arthroscopy 10: 54-60, 1994 Harryman DT 2nd, Mack LA, Wang KY, et al: Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 73:982-989, 1991 Knudsen HB, Gelineck J, Sojbjerg JO, et al: Functional and magnetic resonance imaging evaluation after single-tendon rotator cuff reconstruction. J Shoulder Elbow Surg 8:242-246, 1999 Boileau P, Brassart N, Watkinson DJ, et al: Arthroscopic repair of fullthickness tears of the supraspinatus: Does the tendon really heal? J Bone Joint Surg Am 87:1229-1240, 2005 Galatz LM, Craig MB, Teefey SA, et al: The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am 86:219-224, 2004 Jost B, Pfirrmann CW, Gerber C, et al: Clinical outcome after structural failure of rotator cuff repairs. J Bone Joint Surg Am 82:304-314, 2000 Meier SW, Meier JD: Rotator cuff repair: The effect of double-row fixation on three-dimensional repair site. J Shoulder Elbow Surg 15: 691-696, 2006 Mazzocca AD, Millet PJ, Guanche, et al: Arthroscopic single-row verus double-row suture anchor rotator cuff repair. Am J Sports Med 2005; 33:1861-1868 Brady PC, Arrigoni P, Burkhart SS: Evaluation of residual rotator cuff defects after in vivo single versus double row rotator cuff repairs. Arthroscopy 22:1070-1075, 2006 Meier SW, Meier JD: The effect of double-row fixation on initial repair strength in rotator cuff repair: A biomechanical study. Arthroscopy 22:1168-1173, 2006 Smith CD, Alexander S, Hill AM, et al: A biomechanical comparison of single and double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am 88:2425-2431, 2006 Ma CB, Comerford L, Wilson J, et al: Biomechanical evaluation of arthroscopic rotator cuff repairs: Double-row compared with singlerow fixation. J Bone Joint Surg Am 88:403-410, 2006 Waltrip RL, Zheng N, Dugas JR, et al: Rotator cuff repair: A biomechanical comparison of three techniques. Am J Sports Med 31:493-497, 2003 DeOrio JK, Cofield RH: Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg 66:563-567, 1984 Tuoheti Y, Itoi E, Yamamoto N, et al: Contact area, contact pressure, and pressure patterns of the tendon-bone interface after rotator cuff repair. Am J Sports Med 33:1869-1874, 2005 Yamaguchi K, Tetro AM, Blam O, et al: Natural history of asymptomatic rotator cuff tears: A longitudinal analysis of asymptomatic tears detected sonographically. J Shoulder Elbow Surg 10:199-203, 2001 Bartolozzi A, Andreychik D, Ahmad S: Determinants of outcome in the treatment of rotator cuff disease. Clin Orthop 308:90-97, 1994 Bokor DJ, Hawkins RJ, Huckell GH, et al: Results of nonoperative management of full thickness rotator cuff tears. Clin Orthop 294:103110, 1993. Wirth MA, Basamania C, Rockwood CA: Nonoperative management of full-thickness tears of the rotator cuff. Orthop Clin North Am 28:5967, 1997. Sher JS, Uribe JW, Posada A, et al: Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 77:10-15, 1995 Tempelhof S, Rupp S, Seil R: Age-related prevalence of rotator cuff tears in asymptomatic shoulders. J Shoulder Elbow Surg 8:296-299, 1999 Bigliani LU, Cordasco FA, McIlveen SJ, et al: Operative treatment of massive rotator cuff tears: Long term results. J Shoulder Elbow Surg 1:120-130, 1992 Hawkins RJ, Misamare GW, Hobeika PE: Surgery for full-thickness rotator cuff tears. J Bone Joint Surg Am 67:1349-1355, 1985
Arthroscopic double-row repair of full-thickness rotator cuff tears 32. Saupe N, Pfirrmann CW, Schmid MR, et al: Association between rotator cuff abnormalities and reduced acromiohumeral distance. AJR Am J Roentgenol 187:376-382, 2006 33. Mudge MK, Wood VE, Frykman GK: Rotator cuff tears associated with Os acromiale. J Bone Joint Surg 66:427-429, 1984 34. Park TS, Park DW, Kim SI, et al: Roentgenographic assessment of acromial morphology using supraspinatus outlet radiographs. Arthroscopy 17:496-501, 2001 35. Iannotti JP, Zlatkin MB, Esterhai JL, et al: Magnetic resonance imaging of the shoulder: Sensitivity, specificity and predictive value. J Bone Joint Surg Am 73:17-29, 1991 36. Goutallier D, Postel JM, Gleyze P, et al: Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full thickness tears. J Shoulder Elbow Surg 12:550-554, 2003
149 37. Goutallier D, Postel JM, Bernageau J, et al: Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop 304:78-83, 1994 38. Teefey SA, Rubin DA, Middleton WD, et al: Detection and quanficiation of rotator cuff tears. Comparison of ultrasonographic, magnetic resonance imaging, and arthroscopic findings in seventy-one cases. J Bone Joint Surg Am 86:708-716, 2004 39. Burkhart SS: The deadman theory of suture anchors: Observations along a South Texas fence line. Arthroscopy 11:119-123, 1995 40. Dugas JR, Campbell DA, Warren RF, et al: Anatomy and dimensions of rotator cuff insertions. J Shoulder Elbow Surg 11:498-503, 2002 41. Tierney JJ, Curtis AS, Kowalk DL, et al: The footprint of the rotator cuff. Arthroscopy 15:556-557, 1999
T
he rotator cuff plays a vital role in the function of the shoulder, and tears of the rotator cuff are a common cause of pain and disability in the upper extremity.1,2 Surgical management of these tears has evolved during the past 2 decades with a trend toward arthroscopic repairs.3-5 Results of arthroscopic repairs have compared favorably with those of open and arthroscopically assisted mini-open rotator cuff repairs in terms of postoperative pain, range of motion and patient satisfaction.3,6-8 However, achieving tendon to bone healing remains an issue. Structural failure rates of 30% to 50% have been reported in open and mini-open repairs at 3 to 5 years postoperatively.9-11 Similar or higher failure rates have been found with arthroscopic repairs. In fact, one study showed an almost 100% structural failure rate of large and massive tears fixed using an arthroscopic single-row repair.12,13 These findings are concerning as functional results of rotator cuff repairs appear to fair better with healed cuffs and initially good clinical results from arthroscopic repairs tend to deteriorate with time.10,12-14 Boileau and coworkers demonstrated a completely healed tendon in only 71% of the patients treated with a single row arthroscopic repair.12 These results worsened in patients older than the age of 65 years, with only 43% demonstrating completely healed tendons. Even more alarming results were reported by Galatz and Department of Orthopedics, William Beaumont Hospital, Royal Oak, MI. Address reprint requests to Chris Bales, MD, 3003 Ferris Avenue, Royal Oak, MI 48073. E-mail: [email protected]
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1060-1872/07/$-see front matter © 2007 Elsevier Inc. All rights reserved. doi:10.1053/j.otsm.2007.05.005
coworkers, 14 who found recurrent tears in 17 of 18 patients treated for large and massive rotator cuff tears using a singlerow arthroscopic repair technique. A 2-row repair technique involves placing 1 row of suture anchors medially at the articular margin of the humeral head and a second row on the lateral aspect of the greater tuberosity. Cadaveric studies have shown that traditional repair techniques do not reproduce the anatomical footprint of the supraspinatus insertion.15,16 Meier and Meier15 demonstrated that double-row fixation consistently reproduced 100% of the supraspinatus footprint, whereas single-row and transosseous fixation only reproduced 46% and 71%, respectively. Brady and coworkers17 compared the restoration of the footprint in vivo after an initial lateral-row repair and again after the double-row repair was complete. They found that after the initial lateral-row repair approximately 50% to 60% of the footprint remained uncovered. The double-row repair covered on average twice the footprint area compared with the single-row repair. Biomechanical studies have also demonstrated that double-row suture anchor fixation is significantly stronger and more resistant to gap formation than a single-row repair.18-21 By reestablishing the rotator cuff footprint the surgeon provides an increased surface area for tendon to bone healing.15-17 The potential to improve healing is critical as re-repairs have significantly poorer outcomes.22 Recent clinical interest has focused on reestablishing the rotator cuff footprint using a double-row repair to provide a greater surface area for tendon to bone healing. Even more
Arthroscopic double-row repair of full-thickness rotator cuff tears
145
recently, a suture bridge technique has been proposed that would potentially broaden the area of compression between the two rows. This would be advantageous as traditional two-row repairs using arthroscopic knots on the medial and lateral rows do not necessarily compress the tissue between the rows. One cadaveric study using pressure sensitive film showed that while the double-row repair had a 60% greater contact area, the actual contact pressure was slightly higher with the single-row repair.23 We have transitioned from a 2-row technique to the suture bridge technique with the goal of distributing this compression over a broader area. We also thought that the bridge technique may be more amenable to delivering growth factors to the tendon-bone interface as the techniques evolve to more biologic solutions. This article will describe our approach for an arthroscopic double-row rotator cuff repair using this suture bridge technique.
lary view can be used to evaluate for an os acromiale which some feel predisposes to impingement and rotator cuff tears.33 It is also helpful in evaluating glenohumeral arthritis, humeral head position, as well as the presence of glenoid erosion. The outlet view is used to determine the acromial morphology and the presence of acromial spurring.34 For those who have failed nonsurgical treatment and in patients with a suspected traumatic tear, a preoperative MRI is obtained. The MRI is currently considered the gold standard imaging study and it serves several purposes. First, it can be used to evaluate other pathology, such as labral tears, biceps lesions, paralabral cysts, and articular cartilage damage. MRI also has been shown to be very specific and sensitive in diagnosing full-thickness rotator cuff tears.35 Muscle atrophy, tendon thickness, retraction, and quality of the rotator cuff tissue also can be assessed on the MRI. It is very important to assess the amount of fatty infiltration as this has been shown to be an important prognostic factor in rotator cuff surgery.36,37 Ultrasound is less expensive and better tolerated but is more technician dependent. In experienced hands, ultrasonography has been shown to be as accurate as MRI.38 Arthrograms are able to distinguish full-thickness tears from partial tears or tendinosis but are more invasive and rarely necessary to determine the significance of a tear.
Preoperative Evaluation When to repair a full-thickness rotator cuff tear depends on a number of factors. Patient age, general health, lifestyle, occupation, duration of symptoms under treatment, and degree of disability are just a few of the factors the surgeon must take into consideration. The duration of nonoperative treatment is debatable because this treatment has not resulted in a high rate of healing.24-27 However, not all rotator cuff tears are symptomatic. The incidence of asymptomatic full-thickness rotator cuff tears increases with age. Ultrasonographic and magnetic resonance imaging (MRI) studies have shown rotator cuff tears in approximately 30% of individuals older than 60 years of age, increasing to greater than 50% in those older than 80 years of age.28,29 The natural history of asymptomatic rotator cuff tears has been assessed using ultrasound with tear progression noted in approximately 40% of shoulders and development of symptoms in 50% of these patients.24 A trial of conservative management is generally warranted in many cases, with most authors recommending approximately a 3- to 6-month course of nonoperative treatment. A combination of anti-inflammatory medications and physical therapy have been shown to result in significant improvement even in patients with full-thickness rotator cuff tears.25-27 Although early nonoperative management is appropriate in most patients, younger patients, patients with high functional demands and those with traumatic tears should be considered for more aggressive treatment. The surgeon must also take into consideration that smaller tears tend to have improved results with early surgical repair and that the rate of tendon healing is superior with single tendon tears.12,30,31 Also, the patient must be made aware that there is considerable likelihood of tear progression with nonsurgical treatment.24 The initial evaluation of patients suspected of having rotator cuff pathology should include a complete history and physical examination along with plain radiographs, which include an anterior–posterior (AP), axillary and supraspinatus outlet view of the involved shoulder. Narrowing of the acromiohumeral space on the AP view can be suggestive of a large rotator cuff tear,32 and in patients with chronic, massive tears, articulation with the acromion may be seen. The axil-
Surgical Technique Most patients are given an interscalene injection or catheter in the preoperative area. Patients are then taken to the operating room, where a general anesthetic or sedation is administered, and they are positioned in the beach chair position. An examination under anesthesia is performed documenting range of motion and joint stability. We use a pneumatic arm holder to appropriately position the arm during the procedure. The superficial anatomical landmarks are then carefully marked as well as our anticipated viewing and working portals. For the majority of our rotator cuff repairs, we use a standard posterior portal along with a lateral and an auxiliary superolateral portal (Fig. 1). The portal sites, posterior joint capsule and subacromial space are injected with approximately 5 to 10 mL of 0.5% naropin. Hypotensive anesthesia is used to facilitate visualization during the acromioplasty. A standard posterior portal is established, and a diagnostic arthroscopy is performed. In patients with full-thickness rotator cuff tears, we then establish our lateral portal at the junction of the anterior (1/4) and posterior (3/4) of the acromion using an 18-gauge spinal needle (Fig. 2). If necessary, debridement of superior labral fraying or other intraarticular pathology can be performed through this portal. If more extensive intraarticular work is required or if the full-thickness tear is not immediately evident, an anterior portal through the rotator interval is established with an outside-in technique. In tears with retraction and scarring on the undersurface of the cuff, the tissue on the articular side is mobilized using an arthroscopic retractable blade or ablation wand, always keeping in mind the proximity of the suprascapular nerve. We have a low threshold for performing capsular releases in patients with large rotator
146
Figure 1 Superficial anatomical landmarks and arthroscopic portals for a left shoulder in the beach chair position. (Color version of figure is available online.)
Figure 2 Intra-articular view from posterior portal with shaver debriding the greater tuberosity from lateral portal. (Color version of figure is available online.)
Figure 3 View from posterior portal in subacromial space after preparation of the greater tuberosity. (Color version of figure is available online.)
C. Bales and K. Anderson
Figure 4 Viewing from the lateral portal an 18-gauge spinal needle is used to identify the correct angle for anchor insertion. (Color version of figure is available online.)
Figure 5 Placement of medial anchor at the articular margin of the humeral head. (Color version of figure is available online.)
cuff tears that may assist with tissue mobilization. The degenerated tendon margins are then debrided and the bony bed on the greater tuberosity is prepared using a bone-cutting shaver (Fig. 3). Next, the arthroscope is transferred into the subacromial space. The subacromial space is then cleared of bursal tissue and adhesions to enhance visualization of the rotator cuff tear. In most cases a subacromial decompression is performed. An ablation wand is used to expose the undersurface of the acromion and recess the coracoacromial ligament and then a bur is used to create a flat, upsloping Type I acromion. The mobility of the rotator cuff is assessed and further releases performed if necessary to ensure a low tension placement of the tendon into its anatomic position. If the rotator cuff is easily reducible to the lateral aspect of the greater tuberosity then an optimal double row repair can be performed. At this point, we prefer to visualize from the lateral portal,
Arthroscopic double-row repair of full-thickness rotator cuff tears
Figure 6 The medial row of sutures are passed in a retrograde fashion using tissue penetrators.
and any remaining posterior bursal tissue is resected with the shaver through the posterior portal. An auxiliary superolateral portal is created for placement of the anchors using an 18-gauge spinal needle to identify the correct angle of insertion (Fig. 4).39 The medial suture anchors are placed immediately lateral to the articular margin of the humeral head. A bone punch is used and depending on the tear size one or two 5.5-mm Bio-Corkscrew fully threaded suture anchors, double loaded with number 2 Fiberwire (Arthrex Inc, Naples, FL), are placed (Fig. 5). It is important to leave an adequate bone bridge between anchors (approximately 1 cm). The medial sutures are passed through the rotator cuff working from posterior to anterior placing them approximately 4 to 5 mm apart. The number of medial anchors is determined by tear size. Because there are 4 suture strands per anchor, and we place the sutures 4 to 5 mm apart, one anchor can generally cover 16 to 20 mm of tear size. Sutures can be passed in a number of different ways. We use tissue penetrators for the medial row because they allow ideal placement of the suture
Figure 7 The medial row of sutures are tied in a horizontal mattress configuration, leaving the “tails” for use in the lateral row fixation.
147
Figure 8 Lateral row fixation using the “tails” from the medial row sutures.
and are not limited by the length of the jaws of some antegrade suture passing devices. The average rotator cuff footprint is 16 to 18 mm from medial to lateral and either method must allow for adequate tissue depth when passing the medial sutures.40,41 We will often use an additional, small anterior portal to allow passage of sutures through the anterior cuff and for suture management (Fig. 6). This portal is established with a small 3-mm incision, using a spinal needle to determine the proper angle of approach to the anterior cuff tissue. Once all of the sutures have been passed, the medial row is tied in a horizontal mattress configuration (Fig. 7). The type of knot is according to surgeon preference. We use a sliding knot such as a Duncan loop or a sliding/locking knot such as the Weston knot. It is of note that with the bridge technique knot prominence is not a significant issue since the knot will be pulled over with the tails used for the lateral fixation. The
Figure 9 Final repair demonstrating the suture bridge configuration. In this case of a larger tear, 3 sutures were included in each lateral row anchor.
C. Bales and K. Anderson
148 lateral row anchors are placed just lateral to the drop off of the greater tuberosity. We use the 4.5-mm Pushlock anchors (Arthrex, Naples, FL) to create a suture bridge using two or three of the tails from the previous knots of the medial row (Fig. 8). The tails used can be crossed for even greater compression over the entire repair construct. Care must be taken to avoid excessive suture tension in these lateral anchors because it may potentially compromise tendon vascularity. The excess suture is then cut and the integrity of the repair is assessed by palpation and by rotation of the arm (Fig. 9). The patient is placed in an abduction type sling and taken to the post-anesthesia core unit.
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Postoperative Rehabilitation The patient is kept in a sling with a small abduction pillow for the first 4 to 6 weeks. During the first postoperative week passive range of motion (PROM) in the scapular plane and pendulum exercises are done with avoidance of extension and adduction. Submaximal isometrics (push/pull, internal rotation, and adduction) with the elbow at 90° are started. Elbow and hand range of motion as well as gripping exercises are continued throughout the rehabilitation process. During weeks 2 to 4, PROM is advanced to the patient’s level of tolerance. Submaximal isometrics are continued with the addition of external rotation at 2 to 3 weeks. The goal is full PROM by 6 weeks postoperatively. At 6 weeks, the patient progresses to active assist range of motion with active range of motion to 90° started during weeks 8 to 10. Full active range of motion is desired by 12 weeks. Progressive strengthening exercises are started in weeks 10 to 14 with a more aggressive rotator cuff program beginning during weeks 14 to 20. Return to most sports training is initiated at 4 to 6 months
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Conclusions
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Although current data on the suture bridge technique is limited, we reported on the structural integrity of a double-row rotator cuff repair at a minimum 2-year follow-up with 83% of patients showing no evidence of retear or persistent defect on postoperative ultrasound.32 The suture bridge technique is currently being investigated and the preliminary clinical results and healing rates by ultrasonography are encouraging.
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References
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