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Arthroscopic Transosseous-Equivalent Rotator Cuff Repair
Arthroscopic Transosseous-Equivalent Rotator Cuff Repair Kyle P. Lavery, M.D., Jeffrey F. Rasmussen, M.D., and Aman Dhawan, M.D.
Abstract: Rotator cuff repair techniques continue to evolve in an effort to improve repair biomechanics, maximize the biologic environment for tendon healing, and ultimately improve patient outcomes. The arthroscopic transosseousequivalent technique was developed to replicate the favorable tendon-bone contact area for healing seen in open transosseous tunnel repair. In this technical note and accompanying video, we present our all-arthroscopic transosseousequivalent rotator cuff repair technique with a focus on technical pearls.
T
he last 2 decades have seen dramatic advancements in rotator cuff repair technique and instrumentation. Despite innovations, there is still no consensus on the ideal rotator cuff repair construct. Surgeons continue to use open, mini-open, and arthroscopic approaches with single- and double-row suture configurations. Double-row suture anchor techniques were developed in an attempt to increase the tendon-footprint contact area, improve unacceptably high retear rates, and ultimately improve functional outcomes. Transosseousequivalent repair, as described by Park et al.,1 sought to further maximize the tendon-footprint contact area and biomechanics by simulating a traditional open repair through transosseous tunnels. This technique preserves the suture limbs of the medial row, bridging them over the tendon’s native insertion with fixation in the lateral humeral cortex. In this technical note with accompanying video (Video 1), we present an example of an arthroscopic transosseous-equivalent double-row rotator cuff repair.
Surgical Technique We prefer an interscalene block with sedation to maximize the duration of patient analgesia and intraoperative blood pressure control while diminishing the From the Department of Orthopaedic Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received January 4, 2013; accepted February 7, 2013. Address correspondence to Aman Dhawan, M.D., University Orthopaedic Associates, 4810 Belmar Blvd, Ste 102, Wall, NJ 07753, U.S.A. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/1312/$36.00 http://dx.doi.org/10.1016/j.eats.2013.02.001
potential for cerebral hypoxic events. The patient is situated in the beach-chair position, and the shoulder and upper extremity are prepared and draped in standard aseptic fashion. Prophylactic antibiotics are infused within 1 hour of surgical incision. A modified posterior arthroscopic portal is established 1 cm inferior and 1 cm medial to the posterolateral corner of the acromion to ensure optimal visualization of both the subacromial space and glenohumeral joint. A standard anterosuperior portal is made under direct visualization, and a systematic diagnostic glenohumeral arthroscopy is performed. Careful attention is paid to the long head of the biceps and subscapularis tendinous insertion to evaluate for concomitant pathology. The arthroscope is then introduced into the subacromial space, and a midlateral portal 1 cm posterior and 3 to 4 cm distal to the midpoint of the lateral acromion is established. This portal can be tailored to the specific anatomy of the tear and desired anchor placement. A thorough bursectomy is performed with an arthroscopic shaver and radiofrequency device. A limited acromioplasty to co-plane the anterolateral acromion and elute marrow elements can be performed subsequent to the repair to limit osseous bleeding. After completion of the bursectomy, the configuration of the tear is characterized. The tendon is mobilized with a combination of subacromial and paraglenoid releases. Paraglenoid releases can be performed with a radiofrequency wand while one is viewing within the glenohumeral joint, releasing the interval between the superior labrum and undersurface of the rotator cuff (Fig 1). The potential for tension-free repair is confirmed by tendon mobilization with a grasper to the native footprint. The free tendon edge is debrided of attenuated tissues, and the greater tuberosity footprint is abraded with a 4.5-mm shaver in preparation for repair. Because anchor pullout may be facilitated by removal of the thin
Arthroscopy Techniques, Vol 2, No 2 (May), 2013: pp e183-e185
e183
e184
K. P. LAVERY ET AL.
Fig 1. We recommend spending time understanding the tear pattern and performing adequate releases and mobilization of the rotator cuff to create a tension-free repair. In the case shown, we performed paraglenoid releases between the superior labrum and undersurface of the rotator cuff tear with a radiofrequency device. Grasping the leading edge and applying longitudinal tension as the release was being performed facilitated tissue mobilization.
lamellar bone on the greater tuberosity, we do not recommend decortication of the footprint with a burr. A robust healing environment is promoted by removal of all soft tissue and abrasion with an arthroscopic shaver, use of vented anchors, and microfracture of the rotator cuff footprint by use of awls. In the case presented, 2 (anterior and posterior) medial-row 4.5-mm Healicoil PK suture anchors (Smith
Fig 2. Localization of the percutaneous anchor placement portal is shown. Placement of anchors in this fashion allows an improved angle of insertion. This portal can be placed anteriorly or posteriorly, depending on the tear configuration and location. The humerus can be rotated internally or externally to facilitate access to various locations of the greater tuberosity. Suture management can also be facilitated by use of this percutaneous skin incision.
Fig 3. We recommend tying of the medial-row sutures to prevent synovial fluid contact with the repair site and to enhance repair construct biomechanics.
& Nephew, London, England) are placed at the articular margin of a left shoulder after we first prepared a pilot hole with the accompanying tap. Bioabsorbable anchors are avoided because of the potential for cystic resorption, osteolysis, and alteration of the biologic healing environment. Instead, vented anchors made of polyetheretherketonedan inert, nonabsorbable, radiolucent materialdare used. These allow mesenchymal stem cell elution to the repair site and potentially decrease biomechanical deterioration of a bioresorbable construct as bony ingrowth into the anchor occurs over time. Pilot hole and anchor placement is performed through a small percutaneous stab incision adjacent to the anterolateral acromial edge (Fig 2). This is made as close to the acromion as possible and verified with a spinal needle to ensure proper trajectory into the greater tuberosity. The patient’s shoulder can be rotated to facilitate access to the desired portion of the tuberosity as needed. Suture limbs are sequentially passed through the tendon in a horizontal mattress fashion with an Expressew suture passer device (DePuy Synthes, Warsaw, IN) distal to the musculotendinous junction. The medial row is tied with Revo static knots (Fig 3), and the suture limbs are preserved for the creation of suture bridges over the lateral aspect of the tendon. Tying of the medial-row mattress stitches has been shown to improve both the biology of the repair site and biomechanics of the repair construct. Next, attention is directed toward lateral-row fixation. A gold punch is used to create a pilot hole 1 cm distal to the lateral edge of the native footprint in line with the anterior medial-row anchor. One suture limb from each of the medial-row mattress knots is retrieved through the lateral portal and loaded into a 4.5-mm Footprint PK knotless anchor (Smith & Nephew). The anchor is inserted, and the individual limbs are tensioned until
TRANSOSSEOUS-EQUIVALENT ROTATOR CUFF REPAIR
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Table 1. Technical Pearls The midlateral portal should be placed at the midpoint of the tear and tailored to the patient’s specific pathology. Decortication of the footprint is performed with a shaver only. All soft tissue is removed, and a bleeding bed for tissue repair is created. The use of a burr is avoided, because removal of the thin lamellar bone of the greater tuberosity has been reported to decrease anchor pullout strength. Suture anchors are placed through a small percutaneous incision placed just adjacent to the acromion at either the anterior or posterior corner (depending on tear configuration and location). This allows a better angle of insertion of the anchor into the greater tuberosity. This percutaneous stab incision can also be used for suture management if needed. Microfracture of the greater tuberosity repair site may be performed after placement of medial-row anchors to enhance repair-site biology. This should be performed after tying of the medial-row mattress stitches to ensure that the site of microfracture will not be needed for anchor placement should the initial anchors placed on the medial row fail. Polyetheretherketone or titanium anchors are used for approximating the rotator cuff back to bone. Bioabsorbable anchors are avoided because of the potential for cystic resorption, osteolysis, and alteration of the biologic healing environment. Suture management can be facilitated by removal of the cannula through which the suture limbs are traversing and replacement of this cannula through the same skin portal with the recently shuttled sutures outside the cannula.
tissue indentation is seen through the medial-row knots and bridging suture, indicating optimal footprint tissue compression. A posterolateral anchor is inserted and tensioned in similar fashion, creating a repair with parallel and crossed suture bridges. The surgeon visualizes the repair arthroscopically as the shoulder is taken through internal and external rotation, verifying a secure, watertight, anatomic repair construct.
and initial fixation strength comparable to the favorable traditional transosseous repair.6,7 Short-term follow-up studies have shown promising functional results, although postoperative retear rates remain unacceptably high.8,9 This technical note with video presents an example of an all-arthroscopic transosseous-equivalent rotator cuff repair (Table 1).
Discussion
1. Park MC, ElAttrache NS, Ahmad CS, Tibone JE. “Transosseous-equivalent” rotator cuff repair technique. Arthroscopy 2006;22:1360.e1-1360.e5. 2. Fealy S, Kingham TP, Altchek DW. Mini-open rotator cuff repair using a two-row fixation technique: Outcomes analysis in patients with small, moderate, and large rotator cuff tears. Arthroscopy 2002;18:665-670. 3. Cole BJ, McCarty LP III, Kang RW, Alford W, Lewis PB, Hayden JK. Arthroscopic rotator cuff repair: Prospective functional outcome and repair integrity at minimum 2-year follow-up. J Shoulder Elbow Surg 2007;16:579-585. 4. Lapner PL, Sabri E, Rakhra K, et al. A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am 2012;94:1249-1257. 5. Apreleva M, Ozbaydar M, Fitzgibbons PG, Warner JJP. Rotator cuff tears: The effect of the reconstruction method on three-dimensional repair site area. Arthroscopy 2002;18: 519-526. 6. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ. Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg 2007;16:461-468. 7. Behrens SB, Bruce B, Zonno AJ, Paller D, Green A. Initial fixation strength of transosseous-equivalent suture bridge rotator cuff repair is comparable with transosseous repair. Am J Sports Med 2012;40:133-140. 8. Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: Is the repair integrity actually maintained? Am J Sports Med 2011;39:2108-2116. 9. Kim KC, Shin HD, Lee WY. Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair. J Bone Joint Surg Am 2012;94:e48.
References Surgical goals of rotator cuff repair include anatomic repair with high initial fixation strength and minimal gap formation with loading, maintenance of mechanical stability through the healing process, and a biologic environment to promote healing. We believe that our technique for arthroscopic transosseous-equivalent rotator cuff repair best facilitates achieving these goals. Double-row suture anchor repair, which adds a second point of fixation at the lateral footprint, was developed in an effort to improve construct biomechanics and ultimately tendon-to-bone healing, because repair integrity has been shown to correlate with range of motion and strength testing.2,3 Double-row rotator cuff repair has shown improved healing rates over singlerow repairs as assessed by postoperative imaging.4 Apreleva et al.5 reported that a traditional transosseous mattress suture configuration resulted in larger repair site contact area than more modern suture anchor techniques. In an attempt to replicate the favorable tendon-bone contact seen in open transosseous repair through arthroscopic means, a variant of the doublerow repair, the transosseous-equivalent technique, was developed. This makes use of sutures from the medial row bridged over the tendon and secured lateral to the native footprint. Sutures are not passed through the lateral tendon tissue, which is often of poor quality. There are several proposed advantages to transosseousequivalent rotator cuff repair. Cadaveric studies have found increased contact area pressures compared with standard suture anchoreonly double-row techniques
Abstract: Rotator cuff repair techniques continue to evolve in an effort to improve repair biomechanics, maximize the biologic environment for tendon healing, and ultimately improve patient outcomes. The arthroscopic transosseousequivalent technique was developed to replicate the favorable tendon-bone contact area for healing seen in open transosseous tunnel repair. In this technical note and accompanying video, we present our all-arthroscopic transosseousequivalent rotator cuff repair technique with a focus on technical pearls.
T
he last 2 decades have seen dramatic advancements in rotator cuff repair technique and instrumentation. Despite innovations, there is still no consensus on the ideal rotator cuff repair construct. Surgeons continue to use open, mini-open, and arthroscopic approaches with single- and double-row suture configurations. Double-row suture anchor techniques were developed in an attempt to increase the tendon-footprint contact area, improve unacceptably high retear rates, and ultimately improve functional outcomes. Transosseousequivalent repair, as described by Park et al.,1 sought to further maximize the tendon-footprint contact area and biomechanics by simulating a traditional open repair through transosseous tunnels. This technique preserves the suture limbs of the medial row, bridging them over the tendon’s native insertion with fixation in the lateral humeral cortex. In this technical note with accompanying video (Video 1), we present an example of an arthroscopic transosseous-equivalent double-row rotator cuff repair.
Surgical Technique We prefer an interscalene block with sedation to maximize the duration of patient analgesia and intraoperative blood pressure control while diminishing the From the Department of Orthopaedic Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick, New Jersey, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received January 4, 2013; accepted February 7, 2013. Address correspondence to Aman Dhawan, M.D., University Orthopaedic Associates, 4810 Belmar Blvd, Ste 102, Wall, NJ 07753, U.S.A. E-mail: [email protected] Ó 2013 by the Arthroscopy Association of North America 2212-6287/1312/$36.00 http://dx.doi.org/10.1016/j.eats.2013.02.001
potential for cerebral hypoxic events. The patient is situated in the beach-chair position, and the shoulder and upper extremity are prepared and draped in standard aseptic fashion. Prophylactic antibiotics are infused within 1 hour of surgical incision. A modified posterior arthroscopic portal is established 1 cm inferior and 1 cm medial to the posterolateral corner of the acromion to ensure optimal visualization of both the subacromial space and glenohumeral joint. A standard anterosuperior portal is made under direct visualization, and a systematic diagnostic glenohumeral arthroscopy is performed. Careful attention is paid to the long head of the biceps and subscapularis tendinous insertion to evaluate for concomitant pathology. The arthroscope is then introduced into the subacromial space, and a midlateral portal 1 cm posterior and 3 to 4 cm distal to the midpoint of the lateral acromion is established. This portal can be tailored to the specific anatomy of the tear and desired anchor placement. A thorough bursectomy is performed with an arthroscopic shaver and radiofrequency device. A limited acromioplasty to co-plane the anterolateral acromion and elute marrow elements can be performed subsequent to the repair to limit osseous bleeding. After completion of the bursectomy, the configuration of the tear is characterized. The tendon is mobilized with a combination of subacromial and paraglenoid releases. Paraglenoid releases can be performed with a radiofrequency wand while one is viewing within the glenohumeral joint, releasing the interval between the superior labrum and undersurface of the rotator cuff (Fig 1). The potential for tension-free repair is confirmed by tendon mobilization with a grasper to the native footprint. The free tendon edge is debrided of attenuated tissues, and the greater tuberosity footprint is abraded with a 4.5-mm shaver in preparation for repair. Because anchor pullout may be facilitated by removal of the thin
Arthroscopy Techniques, Vol 2, No 2 (May), 2013: pp e183-e185
e183
e184
K. P. LAVERY ET AL.
Fig 1. We recommend spending time understanding the tear pattern and performing adequate releases and mobilization of the rotator cuff to create a tension-free repair. In the case shown, we performed paraglenoid releases between the superior labrum and undersurface of the rotator cuff tear with a radiofrequency device. Grasping the leading edge and applying longitudinal tension as the release was being performed facilitated tissue mobilization.
lamellar bone on the greater tuberosity, we do not recommend decortication of the footprint with a burr. A robust healing environment is promoted by removal of all soft tissue and abrasion with an arthroscopic shaver, use of vented anchors, and microfracture of the rotator cuff footprint by use of awls. In the case presented, 2 (anterior and posterior) medial-row 4.5-mm Healicoil PK suture anchors (Smith
Fig 2. Localization of the percutaneous anchor placement portal is shown. Placement of anchors in this fashion allows an improved angle of insertion. This portal can be placed anteriorly or posteriorly, depending on the tear configuration and location. The humerus can be rotated internally or externally to facilitate access to various locations of the greater tuberosity. Suture management can also be facilitated by use of this percutaneous skin incision.
Fig 3. We recommend tying of the medial-row sutures to prevent synovial fluid contact with the repair site and to enhance repair construct biomechanics.
& Nephew, London, England) are placed at the articular margin of a left shoulder after we first prepared a pilot hole with the accompanying tap. Bioabsorbable anchors are avoided because of the potential for cystic resorption, osteolysis, and alteration of the biologic healing environment. Instead, vented anchors made of polyetheretherketonedan inert, nonabsorbable, radiolucent materialdare used. These allow mesenchymal stem cell elution to the repair site and potentially decrease biomechanical deterioration of a bioresorbable construct as bony ingrowth into the anchor occurs over time. Pilot hole and anchor placement is performed through a small percutaneous stab incision adjacent to the anterolateral acromial edge (Fig 2). This is made as close to the acromion as possible and verified with a spinal needle to ensure proper trajectory into the greater tuberosity. The patient’s shoulder can be rotated to facilitate access to the desired portion of the tuberosity as needed. Suture limbs are sequentially passed through the tendon in a horizontal mattress fashion with an Expressew suture passer device (DePuy Synthes, Warsaw, IN) distal to the musculotendinous junction. The medial row is tied with Revo static knots (Fig 3), and the suture limbs are preserved for the creation of suture bridges over the lateral aspect of the tendon. Tying of the medial-row mattress stitches has been shown to improve both the biology of the repair site and biomechanics of the repair construct. Next, attention is directed toward lateral-row fixation. A gold punch is used to create a pilot hole 1 cm distal to the lateral edge of the native footprint in line with the anterior medial-row anchor. One suture limb from each of the medial-row mattress knots is retrieved through the lateral portal and loaded into a 4.5-mm Footprint PK knotless anchor (Smith & Nephew). The anchor is inserted, and the individual limbs are tensioned until
TRANSOSSEOUS-EQUIVALENT ROTATOR CUFF REPAIR
e185
Table 1. Technical Pearls The midlateral portal should be placed at the midpoint of the tear and tailored to the patient’s specific pathology. Decortication of the footprint is performed with a shaver only. All soft tissue is removed, and a bleeding bed for tissue repair is created. The use of a burr is avoided, because removal of the thin lamellar bone of the greater tuberosity has been reported to decrease anchor pullout strength. Suture anchors are placed through a small percutaneous incision placed just adjacent to the acromion at either the anterior or posterior corner (depending on tear configuration and location). This allows a better angle of insertion of the anchor into the greater tuberosity. This percutaneous stab incision can also be used for suture management if needed. Microfracture of the greater tuberosity repair site may be performed after placement of medial-row anchors to enhance repair-site biology. This should be performed after tying of the medial-row mattress stitches to ensure that the site of microfracture will not be needed for anchor placement should the initial anchors placed on the medial row fail. Polyetheretherketone or titanium anchors are used for approximating the rotator cuff back to bone. Bioabsorbable anchors are avoided because of the potential for cystic resorption, osteolysis, and alteration of the biologic healing environment. Suture management can be facilitated by removal of the cannula through which the suture limbs are traversing and replacement of this cannula through the same skin portal with the recently shuttled sutures outside the cannula.
tissue indentation is seen through the medial-row knots and bridging suture, indicating optimal footprint tissue compression. A posterolateral anchor is inserted and tensioned in similar fashion, creating a repair with parallel and crossed suture bridges. The surgeon visualizes the repair arthroscopically as the shoulder is taken through internal and external rotation, verifying a secure, watertight, anatomic repair construct.
and initial fixation strength comparable to the favorable traditional transosseous repair.6,7 Short-term follow-up studies have shown promising functional results, although postoperative retear rates remain unacceptably high.8,9 This technical note with video presents an example of an all-arthroscopic transosseous-equivalent rotator cuff repair (Table 1).
Discussion
1. Park MC, ElAttrache NS, Ahmad CS, Tibone JE. “Transosseous-equivalent” rotator cuff repair technique. Arthroscopy 2006;22:1360.e1-1360.e5. 2. Fealy S, Kingham TP, Altchek DW. Mini-open rotator cuff repair using a two-row fixation technique: Outcomes analysis in patients with small, moderate, and large rotator cuff tears. Arthroscopy 2002;18:665-670. 3. Cole BJ, McCarty LP III, Kang RW, Alford W, Lewis PB, Hayden JK. Arthroscopic rotator cuff repair: Prospective functional outcome and repair integrity at minimum 2-year follow-up. J Shoulder Elbow Surg 2007;16:579-585. 4. Lapner PL, Sabri E, Rakhra K, et al. A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am 2012;94:1249-1257. 5. Apreleva M, Ozbaydar M, Fitzgibbons PG, Warner JJP. Rotator cuff tears: The effect of the reconstruction method on three-dimensional repair site area. Arthroscopy 2002;18: 519-526. 6. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ. Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg 2007;16:461-468. 7. Behrens SB, Bruce B, Zonno AJ, Paller D, Green A. Initial fixation strength of transosseous-equivalent suture bridge rotator cuff repair is comparable with transosseous repair. Am J Sports Med 2012;40:133-140. 8. Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: Is the repair integrity actually maintained? Am J Sports Med 2011;39:2108-2116. 9. Kim KC, Shin HD, Lee WY. Repair integrity and functional outcomes after arthroscopic suture-bridge rotator cuff repair. J Bone Joint Surg Am 2012;94:e48.
References Surgical goals of rotator cuff repair include anatomic repair with high initial fixation strength and minimal gap formation with loading, maintenance of mechanical stability through the healing process, and a biologic environment to promote healing. We believe that our technique for arthroscopic transosseous-equivalent rotator cuff repair best facilitates achieving these goals. Double-row suture anchor repair, which adds a second point of fixation at the lateral footprint, was developed in an effort to improve construct biomechanics and ultimately tendon-to-bone healing, because repair integrity has been shown to correlate with range of motion and strength testing.2,3 Double-row rotator cuff repair has shown improved healing rates over singlerow repairs as assessed by postoperative imaging.4 Apreleva et al.5 reported that a traditional transosseous mattress suture configuration resulted in larger repair site contact area than more modern suture anchor techniques. In an attempt to replicate the favorable tendon-bone contact seen in open transosseous repair through arthroscopic means, a variant of the doublerow repair, the transosseous-equivalent technique, was developed. This makes use of sutures from the medial row bridged over the tendon and secured lateral to the native footprint. Sutures are not passed through the lateral tendon tissue, which is often of poor quality. There are several proposed advantages to transosseousequivalent rotator cuff repair. Cadaveric studies have found increased contact area pressures compared with standard suture anchoreonly double-row techniques