Abstract
Background:
Rotator cuff pathology is the leading cause of shoulder-related disability, with approximately 250,000 rotator cuff procedures performed annually in the United States. Large rotator cuff tears can disrupt the force-couple of the shoulder, leading to loss of active motion, increased pain, and decreased function.
Indications:
Arthroscopic rotator cuff repair has become the predominant surgical approach. Double-row constructs, such as the suture bridge technique (transosseous equivalent), have been developed to improve repair anatomy and fixation strength. However, despite these technical advances, retear rates remain high, especially for larger tears.
Technique Description:
The following technique demonstrates the triple-row modification of the knotless speed bridge repair for rotator cuff tears. The triple-row modification of the suture bridge technique uses a third row of fixation placed between the typical medial and lateral rows.
Results:
The goal of the middle-row anchor is to reduce the cuff back into its anatomic position before tying the medial row anchors and can be easily incorporated into the standard speed bridge construct.
Discussion/Conclusion:
The triple-row modification of the knotless speed bridge repair offers a more anatomic repair with improved rotator cuff footprint contact area and an extra point of fixation.
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
Background
Rotator cuff pathology is the leading cause of shoulder-related disability in the United States, with approximately 250,000 rotator cuff procedures performed annually. 10 Arthroscopic rotator cuff repair has become the predominant surgical approach. Double-row constructs, such as the suture bridge technique, have been developed to improve repair anatomy and fixation strength. 5 However, retear rates from 11% to 40% remain, especially when treating larger tears.2,3,6-8 The triple-row modification of the suture bridge technique, described by Ostrander et al, 4 has been shown to improve repair anatomy, provide an additional point of fixation, increase rotator cuff footprint contact area and pressure, and reduce the retear rate. The triple-row modification of the speed bridge technique, a knotless configuration, provides similar benefit.
Indications
The patient is a 55-year-old male landscaper with 6 months of shoulder pain. He reports increased pain and loss of ability to perform his job. Pertinent examinatoion findings include full passive range of motion, 4 of 5 weakness with supraspinatus testing, and a positive Neers and Hawkins test. Magnetic resonance imaging (MRI) demonstrated a large-full thickness tear of the supraspinatus tendon.
Surgical indications include full-thickness rotator cuff tears or high-grade partial-thickness tears treated with completion of the tear and failure of nonoperative treatment. Contraindications include irreparable rotator cuff tears, significant glenohumeral arthropathy, and medical comorbidities that make the risk of anesthesia too high.
Technique Description
The preoperative evaluation includes a complete and thorough physical examination, including shoulder range of motion and rotator cuff strength. Imaging routinely includes radiographs. Anteroposterior, Grashey, supraspinatus outlet, and axillary views are obtained. Ultrasound is a quick and easy to evaluate the rotator cuff. It has similar accuracy in evaluating for full-thickness rotator cuff tears and muscle atrophy. An MRI is really the gold standard for evaluating the rotator cuff. It has high sensitivity and specificity for detecting tears.
In terms of surgical technique, it starts with patient positioning. The patient is placed in the lateral decubitus position and stabilized with a bean bag. The upper extremity is placed in balanced suspension at approximately 60° of abduction and slight forward flexion with approximately 10 to 15 pounds of weighted traction.
Here we have the patient in the lateral decubitus position with the typical portals: a posterior portal, an anterior portal, an accessory lateral portal off the lateral border of the acromion, and a lateral portal. Here we have a large tear involved in the supraspinatus and a portion of the infraspinatus. We are debriding some of the degenerative portions of the tear, and we will prepare the tuberosity to bleeding bone to stimulate a healing response. I always like to look at the cuff from 2 different angles. It allows me to do a little bit more preparation, and it also gives me a better idea of the anatomy of the tear. Once we have the tear and tuberosity prepared, we are going to place cannulas. The scope is back posteriorly. We are going to place an anterior cannula. We will place an accessory lateral cannula right off the lateral border of the acromion. We place our medial row anchors through this cannula and then a lateral cannula. So, we've got 3 cannulas, and we are viewing from posteriorly. When placing anchors, I like to view from the lateral portal. It allows me to get a better idea of the spacing anterior to posterior when I am placing multiple anchors and also make sure I get right on the articular margin. So, we are placing our anterior anchor here. We have the arm adducted to give us the appropriate trajectory. Before final seating of the anchor, I always like to screw back the sheath, so that I can make sure that the anchor is buried just under the bone. I want rotator cuff to bone contact and not rotator cuff to tendon neck contact. We are going to shuttle these sutures out of our anterior cannula and place our second anchor more posteriorly. Again, we have the arm adducted to get the appropriate trajectory. Once we have our 2 anchors placed, I am going to place the scope back posteriorly and pass the tapes through the rotator cuff. We do this through the lateral portal. I am going to reach in and grab this tissue and pull it toward my anchor to make sure that I am passing this suture anatomically. Once it has passed, we are going to shuttle it out of the anterior cannula to get it out of the way. Then, we will pass our more posterior tape through the cuff in similar fascia. Once I have the tape posterior, we are going to again pull it out through our anterior cannula. Once I have both tapes passed, we are going to place a suture into the leading edge of the cuff. This is going to be for the middle-row anchor. We are going to grab a bite of cuff here at the leading edge. I like to mark this suture with a marking pen at its midpoint, so that when I pull it through the cuff here once I get to the marked area, I know I am going to end up with 2 equal limbs. I am going to take a second bite, about 5 mm posterior to my first bite. If you space out these bites too much, you bunch up the cuff. So now I am going to pull out this suture and reduce the cuff anatomically. Sometimes, you need to pull it anteriorly, sometimes posteriorly, depending on which way the cuff retracted. But typically, you know you are right when you eliminate the dog ear. Once I know where I want to put the cuff, I am going to mark the spot on the tuberosity with a radiofrequency wand and then mark our lateral-row spots as well. This one is just posterior to your bicipital groove. This one is just anterior to these vessels, which are commonly present. So now we are going to punch for the middle-row anchor and load our tapes; there is a little bit of a learning curve to this. These tapes are thick, and they do not glide through the islet of the anchor very well. So, you have to put the appropriate amount of slack in the construct before you put it down, so that you do not overreduce or underreduce it. So, there is a little learning curve on how much slack to put in here, so that when you deploy the anchor, the cuff is reduced anatomically. So, now I have the cuff tacked down anatomically. We are doing this before final fixation and compression, and there is no dog ear. I am going to grab one limb of tape from each of the anchors, pull out any slack in the system, and load them into our anchors. I am going to pull out the slack again, and then I am going to add a little bit again. Again, these tapes do not slide through this islet very well, so if it is too tight, it will cut out through the bone, and you compromise your fixation. Now we are going to grab the 2 remaining tapes for our posterior lateral-row anchor. Pull out the slack, and make sure there is no slack in the system. But then add a little bit, so that as we deploy the anchor, it does not cut out at the bone. So, this is the triple-row modification of the speed bridge technique. Again, the middle-row suture and anchor reduce the cuff anatomically before final fixation and compression. This eliminates dog ears, spreads the cuff over the tuberosity anatomically, and provides an extra point of fixation.
Medial anchors are placed through the accessory lateral portal while viewing from the lateral portal. Sutures are passed through the rotator cuff while viewing from the posterior portal, working from anterior to posterior. Appropriate slack should be placed in the tape for the middle-row anchor to ensure anatomic reduction of the rotator cuff to the footprint. The anterior lateral-row anchor is placed just posterior to the bicipital groove. The posterior lateral-row anchor is placed just anterior to the vessel branches running longitudinally up the posterior proximal humerus and posterior rotator cuff.
Results
Intraoperative
Use of the lateral decubitus position lessens the risk of hypotension and cerebrovascular events when compared to the beach-chair position. Neuropraxias can be avoided with proper patient positioning. Proper portal placement is critical to avoid injury to neurovascular structures around the shoulder.
Postoperative Complications
Infection is rare after arthroscopic rotator cuff repair but leads to worse outcomes. Thromboembolic events are also rare.
In terms of postoperative management, patients are placed into a shoulder sling with an abduction pillow for 6 weeks. Postoperative pain is controlled with an interscalene block and an indwelling catheter that remains for 2 to 3 days. Physical therapy is generally started within a week, allowing for an early, gentle passive range of motion. Patients are generally seen at 2 weeks to evaluate wound healing and remove sutures. Follow-up is performed at 6 weeks, 3 months, and 6 months.
Our postoperative physical therapy protocol starts with the maximum protection phase, days 1 to 14. Treatments include gentle, pain-free passive range of motion, submaximal nonpainful isometrics, and rhythmic stabilization drills. The moderate protection phase is from weeks 3 to 6. Treatment includes initiating manually resisted external and internal rotation, as well as resistance tubing in a neutral arm position. The intermediate strengthening phase is from weeks 6 to 12. Treatment includes increasing resistance on strengthening exercises as well as initiating progressive closed kinetic-chain exercises. The advanced strengthening phase is from weeks 13 to 24. Treatment includes continuing to progress advanced strength exercises and upper extremity advanced plyometric exercise programs for overhead and contact athletes. The final phase is discharge testing and planning from months 6 to 9. Biomechanical assessments of performance are made to approve initiation of interval return-to-sports programs.
Return Guidelines
At 6 months, we start them on an advanced upper extremity plyometric strengthening program. Throwers can begin their interval throwing program, and golfers can begin an interval return-to-play program. At months 9 to 12, decisions are made whether to endorse full return to sport or previous activity level.
Despite advances in rotator cuff repair techniques, standard double-row retear rates remain as high as 40%, especially in larger tears.6-8 The triple-row modification has demonstrated significantly lower retear rates. Buckup et al 1 and the Journal of Shoulder and Elbow Surgery looked at a series of 101 shoulders with retracted, full-thickness rotator cuff tears treated with triple-row repairs. The retear rate of 4.9% was based on ultrasound evaluation. Tanaka et al 9 and Arthroscopy compared 212 double-row repairs using the suture bridge technique to 206 triple-row repairs. Retear rates were significantly lower in the triple-row group (3.4%) compared to the double-row group (9.4%).
Discussion/Conclusion
In conclusion, although most outcomes following rotator cuff repair are good or excellent, a retear rate of upward of 40% in larger tears repaired with the standard double-row technique leaves room for improvement. The triple-row modification offers improved biomechanics with increased footprint contact area and pressure compared to the double-row repair. These improved biomechanics accompanied with a more anatomic repair should lead to improved healing rates.
Footnotes
Submitted July 12, 2023; accepted November 11, 2024.
One or more of the authors has declared the following potential conflict of interest or source of funding: R.V.O. received food, beverage, travel, and lodging fees from CGG Medical and Arthrex. S.T.H. received food, beverage, travel, and lodging fees from Smith & Nephew, Arthrex, CGG Medical, Plyant Medical, and Stryker Corporation. E.A.B. received food, beverage, travel, and lodging fees from Smith & Nephew, Stryker, and Breg. 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.
