Arthroscopic Rotator Cuff Repair

Bijayendra SinghFRCS (T&O), FRCS, MS, DNB (Ortho)

Consultant Orthopaedic SurgeonMedway NHS Foundation Trust

Honorary Tutor Royal College of Surgeons Edinburgh

Honorary Treasurer Indian Orthopaedic Society

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• Anatomy• Classification• Methods of repair• Techniques of Repair

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Anatomy• Footprint of Supraspinatus =

25 x 11-22 mm (Nottage 2003)

• Supraspinatus and Infraspinatus is 8 cmƒU (Bassett 1990) 

• Infraspinatus is partly covering the supraspinatus.

• Supraspinatus: hardly bare bone between the cartilage of the head and insertion of the tendon (Nottage 2003)

• Infraspinatus: bare area

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Etiology

• Age related degeneration• Compromised microvascular supply

– Codman (1934) described critical zone– Rathburn (1970) position related to

blood supply– Lohr (1990) bursal side better blood

supply • Increased incidence of articular surface

tears?

• Outlet impingement7

Incidence5-40%Increases with age

Young:

Repetitive useThrowing sportsImpingementOlder:

Fall Other trauma

Murrell et al: The Lancet, Volume 357, Issue 9258, 10 March 2001, Pages 769–770

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Indication

• Symptomatic Cuff Tear– Age no barrier

• When– Early

• if bony avulsion • pseudo - paralysis

• No difference in outcome in delayed repair

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Biomechanical Factors

• Suture tendon interface– Suture material– Suture method

• Tendon-bone interface– Suture anchor/ bone tunnel fixation

strength– Tendon-bone contact area– Tendon-bone interface motion– Tendon-bone footprint pressurization

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Maximising healing potential

• Restoration of footprint contact area• Uniform footprint contact pressurization• Minimization of footprint tendon-bone

interface motion

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Tendon-to-Bone Pressure Distributions at a Repaired Rotator Cuff Footprint Using Transosseous Suture And Suture Anchor

Fixation TechniquesMaxwell C Park,  Edwin R Cadet,  William N Levine,  Louis U Bigliani, 

Christopher S Ahmad.The American Journal of Sports Medicine.  Aug 2005.Vol.33, Iss. 8;  pg. 1154

• Hypothesis: Suture anchor fixation for rotator cuff repair has greater interface motion between tendon and bone than does transosseous suture fixation

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Transosseous (TOS)68mm2

Mattress Suture anchor (SAM)

26mm2

suture anchor suture anchor simple (SAS)simple (SAS)

34.1 mm34.1 mm22

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Contact Area, Contact Pressure, and Pressure Patterns of the Tendon-Bone Interface After Rotator

Cuff RepairYilihamu Tuoheti,  Eiji Itoi,  Nobuyuki Yamamoto,  Nobutoshi

Seki,  et al. The American Journal of Sports Medicine. 

Dec 2005.Vol.33, Iss. 12;  pg. 1869

Contact Area Contact Pressure

Codman (1934)

• Full thickness tears (FTRCT)• Partial thickness tears (PTRCT)

– bursal side– articular side (rim rent)– Intratendinous– vertical, with connection from joint to

bursa, not involving the whole breadth (width?) of the tendon

Full Thickness

• DeOrio and Cofield (1984) • Small: < 2 cm in diameter (from stump to

cartilage)

• Medium: 1-3 cm diameter• Large: 3-5 cm diameter• Massive: more than 5 cm diameter

(nearly always with involvement of Infraspinatus)

This classification only refers to frontal measurement, can be used for arthroscopy and is most frequently used.

MRI / CT Arthro

• Stage 1: stump at level at footprint

• Stage 2: stump at level of humeral head

• Stage 3: stump at level of glenoid

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Fatty Infiltration (Goutallier 1994)

• Stage 0: absence of fat

• Stage 1: several fine fat lines

• Stage 2: fat less than muscle

• Stage 3: fat equivalent to muscle

• Stage 4: fat greater than muscle

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Literature

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Arthroscopic vs Transosseous

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Bisson LJ & Manohar LM - Biomechanical comparison of transosseous suture anchor & suture bridge rotator cuff, Am J Sports Med, 2009, Oct: 37, 1991 - 5

• Eight paired cadaveric shoulder specimens (16 specimens)

• Cycled from 10 to 180 N for 200 cycles,

• Testing to failure at 33 mm/s

• No significant difference between transosseous-suture anchor repairs and suture bridge repairs for elongation or stiffness

• The most common mode of failure with each method was suture cutting through tendon.

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Chhabra et al: In vitro analysis of rotator cuff repairs - comparison of tacks, anchors & open transosseous repairs: Arthroscopy 2005, 21 (3), 323 - 7

• Full-thickness 3 cm rotator cuff defects, 25 fresh-frozen cadaveric shoulders

• Randomized to 1 of 4 repair groups:

– (1) open repair with transosseous sutures

– (2) arthroscopic repair with 2 singly loaded suture anchors,

– (3) arthroscopic repair with 2 doubly loaded suture anchors,

– (4) arthroscopic repair with cuff tacks.

• Testing:

– Cyclically & Gap Formation

• Results (cycles to 100% failure)

– Significantly higher for the arthroscopic doubly loaded suture anchor repairs when compared with the (1) open transosseous suture repair (P = .009), (2) arthroscopic cuff tack repair (P = .003), and (3) arthroscopic singly loaded suture anchor repair (P = .02).

– Number of cycles to 50% failure was significantly higher for all anchors versus open or tack repair (P = .03 for both).

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Duquin et al: Which method of rotator cuff repair leads to highest rate of structural healing? A

systematic review, Am J Sports Med, 2010, Apr, 38 835 - 41

• Hypothesis

– rotator cuff repair method will not affect retear rate

– surgical approach will not affect the retear rate for a given repair method.

• transosseous (TO), single-row(SA), double-row (DA), and suture bridge (SB)

• Open (O), miniopen (MO), and arthroscopic (A) approaches.

• Results:

– Retear rates were significantly lower for double-row repairs when compared with TO or SA for all tears greater than 1 cm

– Double Row Repair - 7% for tears less than 1 cm to 41% for tears greater than 5 cm

– single-row techniques (TO and SA) of 17% to 69% for tears less than 1 cm and greater than 5 cm, respectively.

– There was no significant difference in retear rates between TO and SA repair methods or between arthroscopic and nonarthroscopic approaches for any tear size

– double-row repair methods lead to significantly lower re-tear rates when compared with single-row methods for tears greater than 1 cm.

– Surgical approach has no significant effect on retear rate.

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Salata et al: Biomechanical Evaluation of Transosseous RCR -

Do anchors Really Matter?Am J Sports Med - 41, 2, 2013, p 283

• Purpose:– Compare biomechanical performance

between TOE with anchors, TO, Simple Anchor & X box

• Methods:– 28 human cadavers– Dissected to create isolated supra-

spinatus tear– Initial preload, Cyclic testing & Pull to

failure23

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Results & Conclusion

• Mechanical testing– TOE - 558+/-122.9 – TO - 325.3 +/- 79.9– AT - 291.7 +/- 57.9– ATX - 388.5 +/- 92.6

TOE TO AT ATX

Tendon Failure 4 0 2 7

Suture Failure 0 6 1 0

Bone Failure 3 1 3 0

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Wu et al - Intraoperative determinants of Rotator Cuff Repair Integrity: Analysis of 500 cases

AJSM, 2012, 40, 2771

• 500 consecutive cases at St George Hospital, Sydney

• Single Surgeon• Retear rate - 19% at 6 months• Predictors:

– Tear size - Correlatio coeff: 0.33 • < 2cm - 10%, 2-4 cm 16%, 4-6 cm 31%, 6-8 cm

50%

– Repair quality, Tendon Mobility & Quality

• Formula:• 0.38 + (0.02 x tear size in cm2) - (0.08 x repair

quality)25

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Intraop ScoringFair (1 pt) Good

(2 pts)Very Good (3 pts)

Excellent (4 pts)

Quality of Tendon

Thin, Friable, Does not hold suture

Patchy thickness, holds suture

Normal thickness, holds suture well

Thick & Robust, holds suture well

Tendon Mobility

Immobile & Retracted

Poor mobility, barely pulled to footprint

Mobile, easily pulled to foot print

Mobile, easily pulled to foot print

Repair Quality

Very Weak Repair

Repair not optimal

Relatively Strong Repair

Very Strong Repair

Cuff Repairs

• Tear patterns and how to treat them • Margin convergence • Single row repairs • Double row repairs • Instrumentation review • Anchor type options

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Tear Patterns(Davidson & Burkhart)

• Type 1

– Crescent-shaped tears

– Repaired end to bone - good to excellent prognosis

• Type 2

– longitudinal (L- or U-shaped) tears

– Margin convergence - good to excellent

• Type 3

– Massive contracted tears

– interval slides or partial repair; fair to good prognosis

• Type 4

– Rotator cuff arthropathy

– Irreparable; and require arthroplasty if surgery is considered.

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Margin Convergence ‘Crescent’

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‘L’ Shape

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Arthroscopic Repair

Arthroscopic repair• Cannula• Suture Passer• Suture manipulator• Appropriate

Anchors • Knotless• Knot tying

• Suture Cutter

Learning Curve

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Which Anchor

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Schneeberger et al: Mechanical Strength of Arthroscopic Rotator Cuff Repair Techniques. JBJS,

84A, 2152 - 2160

• Five Bone Anchors– Revo Screw

– Mitek Rotator CUff

– 5 mm Statak

– Panalok

– 5mm Bio-Statak

• Two types of sutures– Arthroscopic Mattress

– Mason-Allen

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Pull out Strength

Tendon Stitch Failure Load (N)Revo – Mattress 228 ± 26 (200-250)

Revo – Modified Mason-Allen 210 ± 22 (200-250)

BioStatak – Mattress 230 ± 57 (150-300)

BioStatak – Modified Mason-Allen

168 ± 46 (140-250)

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Standard Knotless Repair

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Positioning

3838

Text

4141

4242

4332

4433

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Single Row vs Double Row

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Nho et al: Does the support double-row suture anchor fixation for arthroscopic rotator cuff repair? A systematic review comparign DR vs SR, Arthroscopy

2009, Nov, 25(11), 1319 - 28

• Clinical outcome of single-row (SR) and double-row (DR) suture anchor fixation in arthroscopic rotator cuff repair

* January 1966 to December 2008

* Inclusion criteria

+ Cohort studies (Levels I to III) that compared SR and DR suture anchor

+ Arthroscopic treatment of full-thickness rotator cuff tears

* 5 studies that met the criteria

No clinical differences between the SR and DR suture anchor repair techniques for arthroscopic

rotator cuff repairs. 47

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Saridakis et al: Outcomes of Single Row & Double Row - Systematic Review, JBJS 92(A),

732 - 42

* Systematic Review of English Language Literature

* Difference between SR & DR fixation - clinical outcomes & radiographic healing

* Six studies included– no significant difference between the single-row and double-row groups

• One study

– Two groups with < 3 cm & those with > or = 3 cm

– patients with large to massive tears who had DR, better ASES & Constant Score

• Two studies demonstrated a significant difference with structural healing with DR

• Conclusion:• Better structural healing with DR compared with SR

• Little evidence to support functional difference between the two techniques 48

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De Haan et al: Does Double Row Repair Improve Functional Outcome compared to

Single Row.AJSM, 40(5), 1176

• Systematic Review - Level I & II studies• Seven Studies

Single Row Double Row

Patients 226 220

Mean Age 59 57.7

Dominant 76 75

Male 43 52

Mean Tear Size 3.1 3.2

Small Tear 50.8 43.4

Large Tear 49.2 56.6

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Functional ScorePre Op Single

Pre Op Double

Post Op Single

Post op Double

Post Op Differenc

e

ASES 40.4 38.9 91.3 92.5 1.2 (-0.2 to

2.8)

Constant 50.2 50.6 80.4 80.9 0.5 (-1.4

to2.6)

UCLA 14 13.7 31.4 31.9 0.5 (-0.7 to

1.8)

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Complications

• No intraop complications• 6 in single row & 4 in double row

– 5 adhesive capsulitis (3 vs 2)– 2 anchor failure ( 1 each)– 2 infection (1 each)

• 56 / 186 complications in single row• 35/180 complications in double row

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Retear

FT Single Row

FT Double

Row

FT & PT Single Row

FT & PT Double

Row

22 (19%)

16 (14%)

50 (43%)

21 (27%)

5353

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Kluger et al - Long term Survivorship using ultrasound

& MRI• 107 consecutive patients• 95 patients followed up• 7 - 11 years, Median - 96 months• Age: 37 - 77 yrs (60 +/- 9)

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Results

• 33% failure rate (35)– 74% within 3 months– 11% 3 - 6 months– 15% 2-5 years: usually additional trauma

/ sports– 3 had further repair, 6 had debridement

• Others:– 4 stiffness (1 arthrolysis)– 4 impingement (3 decompression)– Second arthroscopy in 13 57

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• At 84 months:– Size

• 86% with cuff tear < 500 mm2 - intact• 48% with cuff tear >500 mm2 - intact

– Age• < 65 = 31% rerupture• >65 = 38% rerupture

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Thank You

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