Arthroscopic Side-to-Side Suture Repair for Full-Thickness Transtendinous Supraspinatus Rotator Cuff Tear

Abstract

Background:

Full-thickness, transtendinous supraspinatus tears involve a significant portion of the remnant tendon that remains attached to the greater tuberosity footprint. This tear type often leaves insufficient medial tissue for tension-free footprint restoration with traditional repair techniques. In these clinical scenarios, side-to-side suture repair is an effective repair technique.

Indications:

Indications for this procedure include an acute mechanism of injury, sufficient remnant tendon left on the greater tuberosity, and a medial tear location such that primary repair of the medial tendon would not result in overtensioning of the repair.

Technique Description:

Following diagnostic arthroscopy, 2 suture tapes are passed through the medial and lateral portion of the tendon surface in a simple side-to-side fashion. Two FiberLink sutures (Arthrex) are then placed in luggage tag fashion, in between the side-to-side sutures within the myotendinous portion of the tear. The suture tapes are then tied in an arthroscopic fashion, completing the side-to-side repair. The looped sutures are then secured through a 4.75-mm BioComposite SwiveLock lateral row anchor (Arthrex) as an added reinforcement to prevent medial retraction of the myotendinous portion of the tear, creating a tension-free environment for optimal tear healing.

Results:

Available literature suggests that the side-to-side repair technique in patients with transtendinous supraspinatus rotator cuff tears yields excellent outcomes equivalent to that of tendon-to-bone double-row suture anchor repair for conventional tendon to bone type tears. This surgical technique reduces risk of overtensioning the repair and optimizes the healing environment in this rare clinical scenario.

Discussion/Conclusion:

Side-to-side suture repair for full-thickness transtendinous supraspinatus tears is an effective treatment for patients with this uncommon presentation. When healthy tendon is present, a robust repair can be achieved with excellent outcomes and low rates of surgical complications.

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.

Graphical Abstract

This is a visual representation of the abstract.

Video Transcript

Arthroscopic side-to-side suture repair for full-thickness transtendinous supraspinatus rotator cuff tear as presented by Fritz Steuer and Dr Albert Lin. All relevant disclosures are listed below.

Background and Indications

Full-thickness, transtendinous supraspinatus tears involve a significant portion of remnant tendon that remains attached to the greater tuberosity footprint, typically with at least 1 cm of remnant tendon. This presentation is rare in rotator cuff tears with an incidence of 1.79%. ¹ This pathology creates a unique clinical challenge, often leaving insufficient medial tissue for a tension-free repair if the decision is made to debride the remnant tendon and perform a traditional tendon-to-bone suture anchor repair. Even if the footprint is medialized, there is an elevated risk of failure and stiffness with traditional repair techniques. In this surgical technique video, we present a side-to-side suture repair technique involving direct repair of the transtendinous tear with augmented lateral row support, resulting in a tension-free repair and optimizing the healing environment.

Indications and contraindications are listed below. In our practice, indications include typically an acute mechanism of injury involving the myotendinous junction (with adequate tissue quality that is amenable to repair). Additionally, there must be significant remnant tendon intact on the greater tuberosity such that robust purchase can be achieved with side-to-side suture tape repair. A mirrored set of contraindications includes poor tendon quality or significant fatty infiltration, insufficient remnant tendon for suture purchase, or more medial muscle junction tears such that tendon tissue is not available on both sides of the tear for optimal repair.

For this case, we will discuss a 59-year-old, right hand–dominant man with a history of right-sided rotator cuff repair presenting with 8 weeks of left shoulder pain that started after performing heavy lifting.

On examination, the patient is tender to palpation near the greater tuberosity. He has preserved range of motion with a painful flexion arc and 4/5 strength in forward elevation and abduction. Provocative testing reveals positive impingement signs, as well as positive O’Brien and Speed tests, with a negative belly press sign.

Preoperative shoulder radiographs were obtained and were largely unremarkable except for incidentally noted advanced acromioclavicular (AC) joint osteoarthritis.

Magnetic resonance imaging (MRI) was obtained, with coronal cuts showing a full-thickness tear involving the mid-to-posterior portion of the supraspinatus with 1.5 cm of retraction. While less evident in this patient, these tears may present in an acute setting with a “wavy” appearance of the supraspinatus due to an acute loss of tension.

Preoperative planning starts with evaluation of the MRI for thickness, length, and location of the tear, along with the degree of retraction of the medial tendon. Further, an initial assessment of quantity and quality of the remnant tendon can be performed, but intraoperative evaluation of the remnant tissue will best guide surgical decision-making. Level of muscle atrophy and glenohumeral joint arthritis should also be assessed.

We will now shift our focus to the surgical technique.

Technique Description

The patient is placed in the beach-chair position, and bony prominences are well padded. Next, the operative extremity is prepped and draped in a standard sterile fashion and then placed in an articulated arthroscopic arm holder.

In addition to standard anterior and posterior portals, we prefer using a low anterior lateral portal and high posterior lateral viewing portal. A standard posterior viewing portal is established, and a 30° scope is introduced into the glenohumeral joint. A standard diagnostic arthroscopy is then performed, followed by a bicep tenodesis. Viewing from the lateral portal, the full-thickness intratendinous supraspinatus tear is identified, showing significant remnant tendon still attached to the insertion site on the humeral head. Then, a posterolateral viewing portal is established and used as the medial and lateral tendon edges are gently debrided to clean edges for planned side-to-side suture repair. The lateral limb of the suture tape is then passed with a lasso suture passer through the remnant tendon. A scorpion suture passer is used to pass a suture tape through the medial portion of the tendon surface for the repair. Suture management is achieved through accessory portals. A second suture tape is passed in a similar fashion posterior to the previous suture tape and retrieved through the posterior portal. Next, from the lateral portal, 2 FiberLink sutures (Arthrex) in a luggage tag fashion are placed through the medial tendon tissue, in between the prior placed sutures tapes. The side-to-side suture tapes are then tied with 6 alternating arthroscopic half-hitches, thus anatomically repairing and reapproximating the tendon. These tied suture tapes are then cut. The FiberLink sutures (Arthrex) are then secured through a 4.75-mm BioComposite Swivelock lateral row anchor (Arthrex) as an added reinforcement to prevent medial retraction of the myotendinous portion of the tear, creating a tension-free environment for optimal healing.

We have included the following sketch to better visualize this technique. As you can see, the addition of this knotless lateral row construct helps to take tension off the side-to-side repair. This construct creates an anatomic, tension-free repair of this intratendinous tear. The patient was immobilized in a sling at the end of the procedure.

Pearls and pitfalls of side-to-side suture repair include achieving adequate exposure to visualize the anterior and posterior border of the tear to allow you to distribute the tension appropriately, as well as portal placement that allows for good visualization and suture management. We prefer a high posterolateral viewing portal. Pitfalls of this procedure include overtensioning of the FiberLinks (Arthrex) through the lateral row anchor and overreducing the tendon. No additional tension should be placed on the FiberLink sutures when placing the lateral row anchor; rather, these sutures serve as an additional checkrein to prevent medial retraction of the myotendinous portion of the tear.

Potential complications of this procedure are similar to those of traditional double-row rotator cuff repairs and include failure of the repair construct, incomplete healing of the tear, and postoperative stiffness.

Our postoperative protocol includes complete immobilization in a sling for 6 weeks with no formal physical therapy or pendulums, although elbow range of motion is initiated at the first postoperative visit to prevent stiffness. Starting at 6 weeks, pendulum exercises are initiated and passive range of motion exercises begin. Active assist and active range of motion are initiated at 8 to 10 weeks, followed by strengthening exercises at 12 weeks.

Patients are generally allowed to return to sport or full activity 5 to 6 months postoperatively, but final determination is based upon individual performance in return-to-sport testing protocols that are administered by our physical therapists and athletic trainers.

Results

Regarding clinical outcomes, initial small cohort studies with 2-year follow-up showed improved strength and function with improvement in visual analog scale (VAS) score of 6.2, subjective shoulder value (SSV) score of 48.6, and mean postoperative American Shoulder and Elbow Surgeons (ASES) score of 97.9. ¹ Our experience in our institution with follow-up on 18 patients at 2 years has shown excellent outcomes with an SSV score of 92.2 and an ASES score of 90.8.

These are our references.

Thank you for your attention, and we hope that you have found this technique video to be useful.