Abstract
Background:
Arthroscopic transosseous-equivalent (TOE) techniques may offer additional advantages, including a more efficient surgery with a self-reinforcing construct with equivalent clinical results to medial knotted TOE repair for rotator cuff tears (RCTs).
Indications:
An arthroscopic knotless double-row (DR) rotator cuff repair (RCR) using FiberTak RC anchors for medial row fixation with box configuration may be an appropriate construct for operatively indicated small-to-moderate full-thickness RCTs.
Technique:
Our modified technique uses TOE repair principles to address RCTs too small for traditional 4.75-mm anchors using medial row fixation and too large to apply a single medial to lateral anchor repair. The patient is placed in a beach chair position. In addition to standard anterior and posterior portals, a lower lateral working portal and a higher posterolateral viewing portal are made. Subsequent to supraspinatus footprint visualization/preparation, two 2.6-mm FiberTak RC anchors each loaded with 1 LabralTape and 1 FiberWire are placed medially. The 4 sets of sutures for one anchor are placed through the rotator cuff tendon together in 1 spot and the process is repeated for the second anchor. One FiberWire from each anchor is then tied extracorporeally and then a double pulley technique is used to compress the medial aspect of the repair at the footprint in a box configuration. Finally, 1 limb of LabralTape from each of the medial anchors along with the corresponding FiberWire is secured through 2 lateral-row 4.75-mm anchors anteriorly and posteriorly to restore the lateral footprint and secure the rotator cuff in TOE box configuration. This modified technique can provide anatomical compression of the rotator cuff tendon at the footprint with additional medial compression achieved by the box configuration while taking advantage of knotless fixation.
Results:
Postoperatively, a sling is worn for 4 weeks, passive range of motion (ROM) is initiated at 2 weeks, active ROM is begun at 6 weeks, and strengthening at 3 months. Patients may return to full unrestricted activities around 5 to 6 months.
Discussion/Conclusion:
A modified arthroscopic DR RCR with box configuration is an excellent treatment option for patients with small-to-moderate full-thickness RCT who fail conservative treatment.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
This video demonstrates our technique for an arthroscopic double-row rotator cuff repair with box configuration in a patient with a small-to-moderate full-thickness rotator cuff tear.
Here are our author disclosures.
Here is an outline of the presentation topics we will discuss today.
Rotator cuff tears are common pathologies with a higher disease burden at more advanced ages. Symptoms typically manifest as shoulder pain and diminished range of motion (ROM). Patients with acute traumatic cuff tears require surgical management, but chronic degenerative tears are usually managed conservatively. However, patients who fail conservative management are typically considered surgical candidates.
Many fixation constructs for rotator cuff repair exist, including single-row (SR), double-row (DR), and both knotted and knotless transosseous-equivalent (TOE) techniques.
The DR repair technique was invented to address the lack of footprint restoration with SR techniques, as SR repair typically covers only half of the anatomical footprint on the greater tuberosity. Initially, DR repair consisted of separate nonlinked medial and lateral row anchors, which increased coverage and decreased motion on the footprint.
However, the development of TOE techniques facilitated additional compression between the medial and lateral footprint by creating a link between the medial and lateral rows. The TOE technique has evolved to allow completely knotless constructs, which provide an enhanced self-reinforcing biomechanics design.
Burkhart and colleagues conducted a biomechanics study that documented significantly higher failure loads among TOE constructs compared with traditional double-row repair techniques. 2 These results highlight the additional strength achieved via the self-reinforcing mechanism of the TOE technique. The self-reinforcing behavior of a TOE repair and increased footprint compression result in a biomechanically favorable rotator cuff repair (RCR) relative to either traditional double-row or single-row repair techniques.
There are 2 techniques for TOE repair—medial knots or completely knotless. Park and colleagues 5 illustrated that the completely knotless technique enhanced the self-reinforcing nature of these repairs without diminishing footprint compression. The study also concluded that the presence of medial knots may attenuate the amount of self-reinforcement achieved by TOE constructs.
Furthermore, Boyer et al 1 proposed medial knots may increase re-tear rates compared with knotless TOE techniques. Results from Millett and colleagues 4 in 2017 corroborated these findings with mid-term 5-year follow-up demonstrating sustained clinical improvement and survivorship for both knotted and knotless TOE techniques.
Our case begins with a 58-year-old right-hand dominant male computer programmer with a 9-month history of pain in his nondominant left shoulder. The pain is localized to the lateral shoulder and worsens with overhead activity and at night. He rates his pain a 4/10 and reports a subjective shoulder value of 40%.
On physical examination, he has tenderness over greater tuberosity and biceps tendon. Ipsilateral active ROM is slightly limited, but passive ROM is full and equivalent to the contralateral side. He exhibits weakness of the supraspinatus and post-rotator cuff without evidence of a lag sign. Belly press test is negative, indicating an intact subscapularis.
Results from coronal and sagittal proton density magnetic resonance imaging with fat suppression show a small full-thickness rotator cuff tear without evidence of retraction or atrophy.
The patient expressed a desire to pursue surgical repair considering his persistent symptoms and failure to respond to conservative management. As a result, he underwent a right shoulder arthroscopy with rotator cuff repair with concomitant subacromial decompression and biceps tenodesis as indicated.
We will now transition to the video demonstration of the procedure.
The patient is taken to the operating room and positioned in a beach chair position under a combination of regional anesthesia and sedation.
A standard posterior portal is made and diagnostic arthroscopy is undertaken. A probe and arthroscopic shaver are used to evaluate intra-articular structures, supraspinatus, and biceps tendon as seen here. In this case, the biceps tendon was tenodesed intra-articularly. The scope is then removed from the intra-articular space after completing this portion of the case and then re-introduced into the subacromial space.
A low lateral working portal is established after localization with spinal needle. The subacromial space is then cleared with an arthroscopic shaver and radiofrequency (RF) probe to visualize the rotator cuff tear and expose the undersurface of the acromion. Subacromial decompression was carried out, facilitating better visualization and easy instrumentation.
With the arthroscope now in the lateral cannula, a spinal needle is used to localize a high posterolateral viewing portal that will be used for the majority of the case to allow for thorough visualization of the rotator cuff tear and instrumentation through the lateral portal. This tear is visualized well from the posterolateral portal. The tear is 1.5 cm, which is ideal for our technique of box configuration, which we indicate for tears between 1 and 2 cm. The greater tuberosity is first prepared with an arthroscopic shaver and RF ablator from the articular margin and then laterally over the tuberosity. A medial row drill trajectory is localized off the lateral edge of the acromion with a spinal needle and a drill guide is percutaneously placed.
This technique uses 2.6-mm FiberTak (Arthrex; Naples, FL) RC anchors. The first 2.6-mm FiberTak anchor is then drilled and placed at the juxta-articular margin at the anterior-most aspect of the tear. A FiberLink passing suture is then passed with a scorpion through the anterior aspect of the rotator cuff tear. The LabralTapes and FiberWires from the anterior anchor are then shuttled through the tendon and retrieved out of the anterior cannula. This process is then repeated with a 2.6-mm FiberTak anchor at the articular margin at the posterior aspect of the tear. A Scorpion is again used to pass the FiberLink shuttling suture through the supraspinatus tendon at the posterior aspect of the tear.
This FiberLink is retrieved out of the previous posterior portal and again used to shuttle the LabralTapes and FiberWires through the tendon and out of the posterior portal. Through the lateral cannula, 1 limb of the FiberWire sutures from both the anterior and posterior anchors is retrieved and a nonsliding knot is tied extracorporeally to link the anchors by means of these FiberWires. The opposite ends of both FiberWires are then pulled in double-pulley fashion to reduce the connected medial box limb of the repair to reduce the medial footprint.
One LabralTape from each suture anchor along with the corresponding FiberWire suture is then placed through 2 lateral 4.75-mm Swivelock anchors, which provides a knotless TOE repair with compression provided by LabralTapes in addition to medial compression by linking the 2 anchors through a box using the double-pulley technique.
It is important to note, as illustrated here, that each suture should be tensioned individually to achieve compression of the footprint prior to seating each anchor at the lateral aspect of greater tuberosity.
Viewing posterolaterally as well as through the lateral portal, a solid repair has been achieved with the compression of the rotator cuff tendon to the footprint with the addition of the medial aspect of the FiberWire Box which provides additional security of the medial portion of the footprint at the articular margin. The subacromial space is then irrigated, the portals are closed, the incision is dressed, and sling applied before the patient awakens from anesthesia to the recovery room.
Postoperative rehabilitation includes immediate sling immobilization for 4 weeks. Formal physical therapy starts with passive ROM at 2 weeks postoperatively. Active ROM is started at 6 weeks and strengthening at 3 months postoperatively. The patient may return to full unrestricted activities around 5 to 6 months after surgery.
Because this technique adds an anterior to posterior compressive force at the articular margin, there may be concern for increased risk of medial re-tear. However, on inspection of our results in 120 patients, there seems to be a low re-tear rate of 2.5% at 6 months with only one of those tears occurring medially. This incidence is similar to or lower than rates of re-tear reported in the literature.
We will now conclude by discussing pearls and pitfalls:
The modified “box” DR TOE arthroscopic rotator cuff repair is an excellent option for small or moderate (1-2 cm) full-thickness rotator cuff tears for achieving a more anatomical repair.
The FiberWires from the 2 medial 2.6-mm FiberTak anchors that are also loaded with LabralTape are necessary to allow for medial row compression through the use of a sliding double-pulley technique.
A high posterolateral viewing portal may aid in visualization, which includes understanding the tear pattern for a more anatomical rotator cuff repair.
As the entire construct is completely dependent on lateral row fixation, individual tension on all sutures prior to seating the lateral row anchor is critical to ensuring uniform compression and fixation of the entire footprint.
When preparing the footprint with a burr, special care should be taken to prepare the cortical surface without violating the subchondral bone to prevent medial row suture anchor pull-out.
Below are our references for this presentation.
Thank you for viewing our video presentation of a modified arthroscopic double-row rotator cuff repair with box configuration for small-to-moderate full-thickness RCTs.
Footnotes
Submitted July 5, 2022; accepted October 30, 2022.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
Consent
Informed, written consent has been obtained, and studies have been performed according to the Declaration of Helsinki.
