Knotted suture bridge repair (KSBR) has been widely proven to be an effective method for rotator cuff repairs. However, the occurrence of type 2 failure after suture bridge repair remains a frequent problem because of the stress concentration and disturbance of tendon perfusion in the medial row. The authors have developed the H-loop knotless double–row repair (HLDR) to counteract these problems.
Purpose:
To compare the biomechanical and histological outcomes of HLDR and KSBR for rotator cuff tear in the rabbit model.
Study Design:
Controlled laboratory study.
Methods:
Acute bilateral supraspinatus tears were created on the shoulders of 46 New Zealand White rabbits. HLDR and KSBR were randomly performed on the left side or right side. Thirteen animals each were sacrificed at 2, 4, and 8 weeks after surgery (n = 39), with 6 rabbits used for histological evaluation and the other 7 rabbits for biomechanical testing. The remaining 7 animals from the original 46 were only used for initial biomechanical evaluation at week 0.
Results:
Macroscopically, all repaired tendons were connected to their footprint on the greater tuberosity without postoperative complications at 8 weeks after surgery. The HLDR group had significantly better histological bone–to–tendon integration compared with the KSBR group in terms of fibrocartilage regeneration, collagen composition, and fiber organization. The biomechanical outcomes in the HLDR group were demonstrated to be better than those of the KSBR group at time 0 and 8 weeks after surgery.
Conclusion:
Both repair techniques were effective for rotator cuff tears in a rabbit rotator cuff tear model; however, HLDR demonstrated more advantages in improving biomechanical properties and histological tendon–to–bone healing compared with KSBR.
Clinical Relevance:
This animal study suggested that HLDR might be an alternative choice for rotator cuff tears in humans to increase tendon–to–bone healing and reduce the rate of failure to heal.
BurkhartSDenardPKonicekJHanypsiakB.Biomechanical validation of load–sharing rip-stop fixation for the repair of tissue–deficient rotator cuff tears. Am J Sports Med. 2014;42(2):457-462.
4.
ChanskyHAIannottiJP.The vascularity of the rotator cuff. Clin Sports Med. 1991;10(4):807-822.
5.
CheonSJKimJHGwakHC, et al. Comparison of histologic healing and biomechanical characteristics between repair techniques for a delaminated rotator cuff tear in rabbits. J Shoulder Elbow Surg. 2017;26(5):838-845.
6.
ChoNSLeeBGRheeYG.Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained?Am J Sports Med. 2011;39(10):2108-2116.
7.
ChoNSMoonSCHongSJBaeSHRheeYG.Comparison of clinical and radiological results in the arthroscopic repair of full–thickness rotator cuff tears with and without the anterior attachment of the rotator cable. Am J Sports Med. 2017;45(11):2532-2539.
8.
ChoNSYiJWLeeBGRheeYG.Retear patterns after arthroscopic rotator cuff repair: single–row versus suture bridge technique. Am J Sports Med. 2010;38(4):664-671.
9.
ChoiSKimMKKimGM, et al. Factors associated with clinical and structural outcomes after arthroscopic rotator cuff repair with a suture bridge technique in medium, large, and massive tears. J Shoulder Elbow Surg. 2014;23(11):1675-1681.
10.
ChristoforettiJJKruppRJSingletonSB, et al. Arthroscopic suture bridge transosseus equivalent fixation of rotator cuff tendon preserves intratendinous blood flow at the time of initial fixation. J Shoulder Elbow Surg. 2012;21(4):523-530.
11.
CoonsDABarberFAHerbertMA.Triple-loaded single–anchor stitch configurations: an analysis of cyclically loaded suture–tendon interface security. Arthroscopy. 2006;22(11):1154-1158.
12.
Delaine-SmithRMReillyGC.Mesenchymal stem cell responses to mechanical stimuli. Muscles Ligaments Tendons J. 2012;2(3):169-180.
13.
DenardPJBurkhartSS.Techniques for managing poor quality tissue and bone during arthroscopic rotator cuff repair. Arthroscopy. 2011;27(10):1409-1421.
14.
DuquinTRBuyeaCBissonLJ.Which method of rotator cuff repair leads to the highest rate of structural healing? A systematic review. Am J Sports Med. 2010;38(4):835-841.
15.
El-AzabHBuchmannSBeitzelKWaldtSImhoffAB.Clinical and structural evaluation of arthroscopic double–row suture-bridge rotator cuff repair: early results of a novel technique. Knee Surg Sports Traumatol Arthrosc. 2010;18(12):1730-1737.
16.
ElbulukAMCoxeFRFabricantPD, et al. Does medial–row fixation technique affect the retear rate and functional outcomes after double–row transosseous-equivalent rotator cuff repair?Orthop J Sports Med. 2019;7(5):2325967119842881.
17.
HeinJReillyJMChaeJMaerzTAndersonK.Retear rates after arthroscopic single–row, double-row, and suture bridge rotator cuff repair at a minimum of 1 year of imaging follow-up: a systematic review. Arthroscopy. 2015;31(11):2274-2281.
18.
HottaTYamashitaT.Osteolysis of the inferior surface of the acromion caused by knots of the suture thread after rotator cuff repair surgery: knot impingement after rotator cuff repair. J Shoulder Elbow Surg. 2010;19(8):e17-e23.
19.
HugKGerhardtCHaneveldHScheibelM.Arthroscopic knotless–anchor rotator cuff repair: a clinical and radiological evaluation. Knee Surg Sports Traumatol Arthrosc. 2015;23(9):2628-2634.
20.
IdeJKarasugiTOkamotoN, et al. Functional and structural comparisons of the arthroscopic knotless double–row suture bridge and single–row repair for anterosuperior rotator cuff tears. J Shoulder Elbow Surg. 2015;24(10):1544-1554.
21.
JunqueiraLCCossermelliWBrentaniR.Differential staining of collagens type I, II and III by Sirius Red and polarization microscopy. Arch Histol Jpn. 1978;41(3):267-274.
22.
KimDElAttracheNTiboneJ, et al. Biomechanical comparison of a single–row versus double–row suture anchor technique for rotator cuff repair. Am J Sports Med. 2006;34(3):407-414.
23.
KimSKimJChoiYLeeH.Healing disturbance with suture bridge configuration repair in rabbit rotator cuff tear. J Shoulder Elbow Surg. 2016;25(3):478-486.
24.
KimSHChoWSJoungHYChoiYEJungM.Perfusion of the rotator cuff tendon according to the repair configuration using an indocyanine green fluorescence arthroscope: a preliminary report. Am J Sports Med. 2017;45(3):659-665.
25.
KimSJKimSHMoonHSChunYM.Footprint contact area and interface pressure comparison between the knotless and knot–tying transosseous-equivalent technique for rotator cuff repair. Arthroscopy. 2016;32(1):7-12.
26.
KimYKMoonSHChoSH.Treatment outcomes of single- versus double–row repair for larger than medium–sized rotator cuff tears: the effect of preoperative remnant tendon length. Am J Sports Med. 2013;41(10):2270-2277.
27.
KummerFHerganDThutDPahkBJazrawiL.Suture loosening and its effect on tendon fixation in knotless double–row rotator cuff repairs. Arthroscopy. 2011;27(11):1478-1484.
28.
LädermannAChristopheFKDenardPJWalchG.Supraspinatus rupture at the musclotendinous junction: an uncommonly recognized phenomenon. J Shoulder Elbow Surg. 2012;21(1):72-76.
29.
LeeBChoNRheeY.Modified Mason-Allen suture bridge technique: a new suture bridge technique with improved tissue holding by the modified Mason-Allen stitch. Clin Orthop Surg. 2012;4(3): 242-245.
30.
LiHChenYChenS.Postoperative residual pain is associated with a high magnetic resonance imaging (MRI)-based signal intensity of the repaired supraspinatus tendon. Knee Surg Sports Traumatol Arthrosc. 2019;27(12):4014-4020.
31.
LiXShenPSuWZhaoSZhaoJ.Into-tunnel repair versus onto–surface repair for rotator cuff tears in a rabbit model. Am J Sports Med. 2018;46(7):1711-1719.
32.
LiuVKBouwmeesterTMSmithGCSLamPH.Biomechanical comparison of knotless wide suture double–row SutureBridge rotator cuff repair to double–row standard suture repair. J Shoulder Elbow Surg. 2020;29(8):1621-1626.
33.
MallNALeeASChahalJ, et al. Transosseous-equivalent rotator cuff repair: a systematic review on the biomechanical importance of tying the medial row. Arthroscopy. 2013;29(2):377-386.
34.
NeytonLGodenècheANové-JosserandL, et al. Arthroscopic suture–bridge repair for small to medium size supraspinatus tear: healing rate and retear pattern. Arthroscopy. 2013;29(1):10-17.
35.
NoyesMPLedermanEAdamsCRDenardPJ.Triple-loaded suture anchors versus a knotless rip stop construct in a single–row rotator cuff repair model. Arthroscopy. 2018;34(5):1414-1420.
36.
ParkJYLheeSHOhKSMoonSGHwangJT.Clinical and ultrasonographic outcomes of arthroscopic suture bridge repair for massive rotator cuff tear. Arthroscopy. 2013;29(2):280-289.
37.
ParkMElAttracheNTiboneJ, et al. 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(4):461-468.
38.
ParkMTiboneJElAttracheN, et al. Part II: biomechanical assessment for a footprint–restoring transosseous-equivalent rotator cuff repair technique compared with a double–row repair technique. J Shoulder Elbow Surg. 2007;16(4):469-476.
39.
PulatkanAAnwarWAyıkO, et al. Tear completion versus in situ repair for 50% partial–thickness bursal-side rotator cuff tears: a biomechanical and histological study in an animal model. Am J Sports Med. 2020;48(8):1818-1825.
40.
RheeYGChoNSParkeCS.Arthroscopic rotator cuff repair using modified Mason-Allen medial row stitch: knotless versus knot–tying suture bridge technique. Am J Sports Med. 2012;40(11):2440-2447.
41.
SunYKwakJMKholinneE, et al. Nonabsorbable suture knot on the tendon affects rotator cuff healing: a comparative study of the knots on tendon and bone in a rat model of rotator cuff tear. Am J Sports Med. 2019;47(12):2809-2815.
42.
SunYKwakJMQiC, et al. Remnant tendon preservation enhances rotator cuff healing: remnant preserving versus removal in a rabbit model. Arthroscopy. 2020;36(7):1834-1842.
43.
TakeuchiYSugayaHTakahashiN, et al. Repair integrity and retear pattern after arthroscopic medial knot–tying after suture–bridge lateral row rotator cuff repair. Am J Sports Med. 2020;48(10):2510-2517.
44.
VoletiPBBuckleyMRSoslowskyLJ.Tendon healing: repair and regeneration. Annu Rev Biomed Eng. 2012;14:47-71.
45.
WatkinsJPAuerJAGaySMorganSJ.Healing of surgically created defects in the equine superficial digital flexor tendon: collagen–type transformation and tissue morphologic reorganization. Am J Vet Res. 1985;46(10):2091-2096.
46.
WeilerAPetersGMäurerJUnterhauserFNSüdkampNP.Biomechanical properties and vascularity of an anterior cruciate ligament graft can be predicted by contrast–enhanced magnetic resonance imaging: a two–year study in sheep. Am J Sports Med. 2001;29(6): 751-761.
47.
WuZZhangCZhangP, et al. Biomechanical comparison of modified suture bridge using rip–stop versus traditional suture bridge for rotator cuff repair. Biomed Res Int. 2016;2016:9872643.
48.
XuJSuWChenJ, et al. The effect of antiosteoporosis therapy with risedronate on rotator cuff healing in an osteoporotic rat model. Am J Sports Med. 2021;49(8):2074-2084.
49.
YamakadoKKitaokaKYamadaH, et al. The influence of mechanical stress on graft healing in a bone tunnel. Arthroscopy. 2002; 18(1):82-90.
50.
YildizFBilselKPulatkanA, et al. Comparison of two different superior capsule reconstruction methods in the treatment of chronic irreparable rotator cuff tears: a biomechanical and histologic study in rabbit models. J Shoulder Elbow Surg. 2019;28(3):530-538.
51.
ZhangSLiHTaoH, et al. Delayed early passive motion is harmless to shoulder rotator cuff healing in a rabbit model. Am J Sports Med. 2013;41(8):1885-1892.
52.
ZwolakPMeyerPMolnarLKröberM.The functional outcome of arthroscopic rotator cuff repair with double–row knotless vs knot–tying anchors. Arch Orthop Trauma Surg. 2022;142(1):25-31.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
