Evolution of rotator cuff repair techniques: are our patients really benefiting?

Abstract

The repair integrity of rotator cuff tears, which are a common disorder, is influenced by many biologic, environmental, and surgical factors. Surgery for rotator cuff repairs has evolved significantly over the past decade. The technical goals of rotator cuff repair include achieving high initial fixation strength, minimizing gap formation, and maintaining mechanical stability until biologic healing occurs. A variety of surgical techniques have been established to capitalize on certain aspects of these tenets and have been shown to provide biomechanical and biologic benefits; however, overall clinical outcomes may be dependent on certain tear characteristics. It is important for orthopaedic surgeons to be familiar with the natural history of rotator cuff disease to understand the various repair strategies and techniques and the outcomes associated with these procedures.

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Evolution of Rotator Cuff Repair Techniques:
Are Our Patients Really Benefiting?
CDR Matthew T. Provencher, MD, MC, USN
James S. Kercher, MD
Leesa M. Galatz, MD
Neal S. EIAttrache, MD
Rachel M. Frank, BS
Brian J. Cole, MD, MBA
stract
rt:pair integrity of rotator cuff tears, which are a common disorder, is in flu-
; by many biologic, environmental, and surgical factors. Surgery for rotator
· ~ a i r
cuff repair include achieving high initial .fixation strength, minimizing gap
. .1tion, and maintaining mechanical stability until biologic healing occurs. A
· ry of surgical techniques have been established to capitalize on certain aspects
~ s e tenets and have been shown to provide biomechanical and biologic bene-
however, overall clinical outcomes may be dependent on certain tear character-
It is important for orthopaedic surgeons to be familiar with the natural his-
of rotator cuff disease to understand the various repair strategies and
11iques and the outcomes associated with these procedures.
lnstr Course Lect 2011 ;60:123-136.
s has evolved significantly over the past decade. The technical goals of ro-
tor cuff repair is one of the most
mon orthopaedic shoulder proce-
. The primary goal of rotator cuff
repair is to successfully reconstitute
glenohumeral joint function by restor-
ing normal rotator cuff kinematics. It
is well known that rotator cuff repairs
are at risk for failure, with 20% to
40% of primary repairs resulting in
failure. Even higher rates of failure
have been reported in revision cases.1-6
Outcome studies following rotator
cuff repair have shown that patients re-
port high satisfaction ratings,5•7•8 often
despite the failure of complete ana-
tomic healing. Recent data have shown
that healing and the anatomic integrity
of the rotator cuff repair site correlates
with improved outcomes, particularly
with regard to strength and functional
1-4 s 9 R
recovery. · · epa1r met o s
significantly evolved over the past
decade to allow improvement in
. h d h
ave
·•·mcher or an immediate fomily member serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the
.:m Orthopaedic Society for Sports Medicine, the Arthroscopy Association of North America, and the Society of Military Orthopaedic Surgeons. Dr. Galatz or an im-
fomily member serves ns a board member, owner, officel; or committee member of the American Shoulder and Elbow Surgeons. Dr. ElAmache or an immediate
member serves as a board member, owner, offiw; or committee member of the American Orthopaedic Society for Sports Medicine; has received royalties from Ar-
a member o f a speakers' bureau or has made paid presentations on behalf of Arthrex; serves as a paid consultant to or is an employee of Arthrex; has received re-
liT imtitutional support from Arthrex; owns stock or stock options in Arthrex; and has received nonincome support (such as equipment or services), commercially de-
noraria, or other non-research-related fonding (such as paid travel) from Arthrex. Dr. Cole or an immediate fomily member has received royalties from Arthrex,
"Thopaedics, Lippincott, and Elsevier; is a member of a speakers' bureau or has made paid presentations on behalfofGenzyme; serves as a paid consultant to or is an
·e of Zimmer, Arthrex, Carticept, Biomimmetic, and Allosource; and hns received research or institutional support ji-om Regentis, Arthrex, Smith & Nephew, and
:hopaedics. Neither of the following authors nor any immediate fomily member has received anything of value ji-om or owns stock in a commercial company or in-
" related directly or indirectly to the subject of this chapter: D1: Kercher and Dr. Frank.
~
~ m ~ s expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or
Government.
2011 AAOS Instructional Course Lectures, Volume 60 123

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Shoulder
postoperative cuff integrity, strength,
and overall outcomes.
Recent biomechanical and clinical
research has focused on the numerous
variables that are known to influence
repair integrity and clinical outcomes.
The natural history of rotator cuff dis-
ease, with a focus on the important ex-
amination and presentation findings
that have a known association with re-
pair success, are discussed in this chap-
ter. Various rotator cuff repair strate-
gies are also reviewed, including the
evolving repair constructs, guidelines
for using repair techniques, and an
overview of the outcomes associated
with the evolving repair techniques.
Tendon Healing and the
Natural History of the
Disease
The incidence of rotator cuff disease
.
all
mcreases natur y Wit age.
guchi et al10 examined bilateral shoul-
ders using ultrasound in a large group
of patients with unilateral shoulder
pain. Contralateral asymptomatic tears
were present in a large percentage of
patients and occurred in an age-
dependent fashion. The mean age of
the patients with no tear on the con-
tralateral side was 49 years, with uni-
lateral tears, 59 years, and with bilat-
eral tears, 68 years. These results
strongly suggest that rotator cuff dis-
ease is a progressive, age-related, de-
generative process.
Full-thickness tears of the rotator
cuff initiate a cascade of alterations
that compromise the muscle-tendon
unit. These include atrophy, degenera-
tion, retraction, fibrosis, and decreased
11
.
co agen expressiOn,
significant roles in the success of re-
pairs. Outcomes following rotator cuff
repair are primarily dependent on fac-
tors such as patient age, tear size, mus-
cle atrophy, fatty change, and chronic-
ity.1 '2'4'7'8' 11'12' 15 In one of the first
studies to identify age as a significant
'h
IO v
uma-
1'1-14
h' h 1
· w IC
p ay
124
factor affecting healing, Boileau et al1
evaluated cuff integrity after ar-
throscopic repair of the supraspinatus
tendon. The authors reported a 70%
healing rate, although healing oc-
curred in only 45% of patients older
than 65 years. Similar results were re-
ported by Lichtenberg et al16 in a
study of 53 patients in whom the over-
all healing rate was 75%. The average
age of the patients with healed repairs
was 59 years compared with an average
age of 65 years for patients in whom
healing did not occur. Age as an inde-
pendent variable related to retearing
following rotator cuff repair has re-
cently been challenged by Oh et al.17
Based on a multivariate analysis, the
authors determined that advanced age
did not act independently of tendon
retraction and the degree of fatty de-
generation as a factor in retearing after
repair.
The classification system defining
fatty degeneration of the rotator cuff
was first described by Goutallier
et al; 18 it was subsequently determined
that degenerative changes are indica-
tive of the size and chronicity of the
tear.19-22 The amount of fatty degen-
eration is an important factor relating
to outcomes after repair.23-25 Using
MRI to correlate muscle atrophy and
fatty degeneration to patient out-
comes, Gladstone et al26 evaluated
38 patients 1 year after rotator cuff re-
pair. It was found that muscle atrophy
and fatty degeneration of the rotator
cuff were independent predictors of
American Shoulder and Elbow Sur-
geons and Constant scores?6
In addition to biologic factors, en-
vironmental factors such as smoking or
other chemical exposure may have sig-
nificant affects on healing. In an evalu-
ation of a population of patients with
shoulder pain, a highly statistically sig-
nificant association, which demon-
strated a time- and dose-dependent re-
sponse, was reported between moking
and the presence of a rotator cuff
tear.27 More recent smoking and
heavier smoking were also associated
with the presence of a tear.27 Smoking
also has been shown to be detrimental
to rotator cuff healing.10 In an animal
model, the administration of nicotine
resulted in decreased cell proliferation
and extracellular matrix production in
the healing tendon?8 Biomechanical
testing showed inferior material prop-
erties of the repair tissue exposed to
nicotine when compared with a con-
trol group.10
Basic science research on tendon bi-
ology and healing has proliferated in the
past several years. In general, a tendon
heals by scar formation rather than by
tendon regeneration. The healing pro-
cess is largely (but not independently)
modulated by transforming growth fac-
tor beta-1 rather than by transforming
growth factor beta-3, which leads to
scar-free healing in skin and tendon in
fetal models of soft-tissue injury. In an-
imal models of rotator cuff healing,
most repairs attain only 50% of the
structural properties and 10% of the
material properties compared with nor-
mal tendon.29·30 The challenge going
forward is to integrate the use of growth
factor and tissue engineering strategies
to enhance healing in a cost-effective
and reliable manner.
Biomechanical Rationale
The technical goals of rotator cuff re-
pair include achieving high initial fixa-
tion strength, minimizing gap forma-
tion, and maintaining mechanical
stability until biologic healing. The
important characteristics of rotator
cuff repair at time zero are shown in
Table 1. It is well documented that
healing of the rotator cuff repair site
correlates with superior outcomes, par-
ticularly regarding the recovery of
function and strength. 1-4•8·9
Bone-to-tendon
with the formation of a fibrovascular
healing begins
© 2011 AAOS Instructional Course Lectures, Volume 60

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ution of Rotator Cuff Repair Techniques: Are Our Patients Really Benefiting?
Chapter 12
interface between the tendon
bone.29•30 Early on, bone will
into the interface tissue,31 which
owed by a gradual increase in col-
fiber continuity created between
ndon and bone.29 The fibrovas-
tissue interface is an important
deration regarding the improved
;e area for healing afforded
restoration of the
. 3?-34 "r d. . al . I
nnt. - Ha mon
result in persistent tear rates
ng from 29% to 90%.1•7·8•35
tears may be caused in part by
rolonged and complex biologic
of rotator cuff tendon healing,
.ck of footprint restoration, and
chanica! considerations. Typi-
after a rotator cuff tear, the tissue
latively avascular for several
hs. To incite a vascular response,
ic factors necessary for healing
originate from bone; however,
filctors are impeded by the syno-
nvironment because the synovial
and other factors are believed to
n impediment to healing at the
n-bone interface. The repaired
n must remain relatively still for
periods of time over as large an
of the healing zone as possible to
rain the healing response; this is
.ult to achieve because of tendon-
interface motion and is the rea-
hy increasing tissue compression
ne potentially enhances the heal-
process.36 An ideal rotator cuff re-
hould be strong and gap-resistant
compression forces that protect
endosteal healing factors. In an at-
pt to address these considerations,
mr cuff repair configurations have
ved considerably over the past de-
anatomic
smg e-row
Technical failures related to tech-
ue, implants, and suture selection
becoming less commonplace be-
of recent technologic advance-
ms in implant materials. More con-
ning is the concept of anatomic
Table 1
Ideal Rotator Cuff Repair
Construct Characteristics at
Time Zero
Restoration of anatomic footprint
Resistance to gap formation
Ultimate tensile strength
Resistance to cyclic elongation
Number of cycles to failure
failure, which takes into consideration
the rotator cuff tendon footprint, bio-
mechanics, and resting tension on the
repair. The footprint of the supraspi-
natus rotator cuff tendon is two-
dimensional and measures approxi-
mately 12 to 14 mm medial to lateral
d 25
an mm antenor to postenor. ·
Pressure on the rotator cuff tendon
should be considered as a third dimen-
sion, taking into account compression
on the tendon and contact area. Many
biomechanical studies have established
that double-row configurations signifi-
cantly increase the amount of native
footprint covered with the repaired
tendon?3•39•40 In a cadaver study, Meier
and Meier34 reported that a double-
row repair restores the supraspinatus
tendon footprint more closely than a
single-row technique. Brady et al33 re-
ported on a clinical intraoperative
study of patients treated with repair of
full-thickness rotator cuff tears using
double-row fixation. The authors com-
pared the footprint coverage of repairs
after an initial lateral-row repair and
after the double-row repair and deter-
mined that single-row repairs left an
average of 52.7% of the rotator cuff
footprint uncovered. After a double-
row repair in which the medial-row su-
tures were secured, there was complete
(1 00%) footprint coverage in all pa-
tients, representing a mean increase in
footprint coverage of 119%.
Double-row repairs
shown improved strength, less gap for-
.
0
37 38
also have
2011 AAOS Instructional Course Lectures, Volume 60
Figure 1
transosseous equivalent (TOE) rota-
tor cuff repair.
Arthroscopic image of a
marion, and significantly increased re-
. I' d' I
sJstance to eye 1c 1sp acement.
meta-analysis47 compared the biome-
chanical properties of single-row and
double-row constructs in 15 studies
using animal and human models. Nine
studies demonstrated a statistically sig-
nificant advantage to a double-row re-
pair with regard to biomechanical
strength, repair failure, and gap forma-
tion. Additionally, five of the studies
demonstrated the double-row repair
was superior to single-row repairs with
respect to anatomic restoration.
41-46 A
0
°
47
Transosseous Equivalent
Repairs
When discussing double-row rotator
cuff repairs, a differentiation must be
made between first-generation con-
structs and newer constructs contain-
ing bridging sutures between the me-
dial and lateral rows, known as the
modified double-row or transosseous
equivalent (TOE) repair48-50 (Fig-
ure 1). First-generation, double-row
repair constructs consist of a medial
row of mattress-type sutures with sim-
ple sutures placed at the lateral edge of
the cuff without linkage between the
two rows.51 This configuration has
been shown to mechanically outper-
form single-row suture anchor tech-
niques in the laboratory in terms of
125

Page 4

Shoulder
footprint restoration and construct
strength. 34•44 However, anchor crowd-
ing can occur on the tuberosity, and
biomechanical testing also has shown
that first-generation, double-row con-
figurations fail to prevent repair site
gapping during humeral rotation, es-
'all h
peCI y at t e an tenor anc or pomt.
TOE repairs perform better than
single-row repairs under cyclic load-
ing and ultimate failure testing while
providing biologic
and tissue-to-bone
sion?3•34'44'49·50·52 Anatomic anchor
crowding is diminished because the
lateral fixation is placed more distally
on the lateral wall of the greater tuber-
osity rather than proximally on the lat-
eral crest of the tuberosity. Biomechan-
ical testing that emphasized internal
and external rotation during high
loading conditions showed the TOE
construct was superior because of self-
reinforcing properties, allowing for
solid tendon fixation during rotational
testing. 53
Bisson and Manohar54 compared
open transosseous repair (considered
the gold standard) with the bridging
TOE construct for supraspinatus tears
in paired cadaver shoulders. The au-
thors reported no significant difference
between the two techniques with re-
spect to elongation, load to failure, or
stiffness. In addition, these repair
methods demonstrated failure loads of
approximately 400 to 450 N, which is
approximately 50% of the strength of
an intact supraspinatus tendon.55
However, failure loads were higher
than those previously reported for ear-
l.
Ier-generauon tee mques. · · ·
Gerber et al57 reported that the single-
row configuration produces an ulti-
mate tensile strength of 208 N, which
is barely sufficient to resist the physio-
logic rotator cuff load of the supraspi-
natus. The repair strength at time zero
was reported to be 336 N for double-
row59 and 443 N for TOE repairs. 5°
. h .
41
containment
compres-
. h .
39 44 45 56-58
126
Mini-Open and Arthroscopic
Repairs: Making the
Transition
Advancements in arthroscopy have
dramatically changed rotator cuff sur-
gery and have facilitated the evolution
from open to mini-open to complete
arthroscopic repairs. Arthroscopically
assisted rotator cuff repair is a hybrid
technique, which combines the bene-
fits of mini-open and arthroscopic
techniques and is useful for certain re-
pairs and by surgeons transitioning to
complete arthroscopic procedures. The
mini-open technique, first described
by Levy et al60 in 1990, uses arthros-
copy to treat intra-articular pathology
and subacromial decompression and is
followed by rotator cuff repair through
a limited deltoid-splitting approach.
The approach, which is an extension
of the anterior portal, allows the del-
toid fibers to be split in line for access
to the repair and avoids deltoid take-
down from its origin. The addition of
arthroscopic inspection permits a de-
tailed examination of the glenohu-
meral joint for possible concomitant
disorders such as degenerative biceps
lesions, labral pathology, cartilage de-
fects, and glenohumeral arthritis. Sev-
eral studies have documented the high
incidence of intra-articular pathology
found during arthroscopy; knowledge
of this pathology provides important
. d
'l 61-64
prognostic etaJ s.
The main advantages of the ar-
throscopically assisted mini-open tech-
nique over traditional open surgery are
lower perioperative morbidity, im-
proved cosmesis, accelerated rehabili-
tation, improved identification of
intra-articular pathology, and preserva-
tion of the deltoid. The open repair al-
lows the use of transosseous repair su-
tures, which are considered the gold
standard;8 however, the results of this
technique have not been fully eluci-
dated. A disadvantage of the mini-
open technique is increased subdeltoid
scarring, which leads to higher rates of
stiffness. There are also a variety of
tears that are difficult to treat using
this technique, including massive tears
with a posterior-to-anterior
U-shape orientation, as well as re-
tracted tears.
The indications for mini-open and
arthroscopic rotator cuff repairs are the
same as those for open repairs and in-
clude persistent pain or weakness and a
documented tear of the rotator cuff.
Specific indications for the mini-open
repair include tears with minimal re-
traction and those that are primarily
limited to the supraspinatus tendon.
Relative contraindications
throscopic repair include active or re-
cent infection, medical comorbidities
making anesthesia unsafe, massive
tears with fixed tendon retraction, and
those with superior escape.
and
to ar-
Arthroscopic Rotator
Cuff Repair
Arthroscopic rotator cuff repair repre-
sents a notable improvement with re-
gard to morbidity associated with del-
toid takedown and postoperative
rehabilitation. In comparison to the
open or mini-open methods, the com-
plete arthroscopic procedure is more
technically demanding and requires a
steep learning curve before it can be
done proficiently. The arthroscopic ro-
tator cuff repair technique has unique
complications, including fluid extrava-
sation, device failure, thermal injury,
longer surgical times, and concerns
about higher cost.65 The advantages of
the arthroscopic technique include a
marked improvement in cuff tear visu-
alization, an expedited postoperative
phase, the ability to identifY and treat
all concomitant pathologies, and the
ability to repair the rotator cuff with
minimal surgical insult to the deltoid.
Most notably, the arthroscopic tech-
nique offers greater versatility in recog-
nizing and anatomically reducing a va-
© 2011 AAOS Instructional Course Lectures, Volume 60

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ion of Rotator Cuff Repair Techniques: Are Our Patients Really Benefiting?
Chapter 12
Crescent
U-Shaped
L-Shaped
B
c
re 2
· .s the m o ~ t basic pattern and may be approached with a variety of tech-
..;es. B, The U-shaped tear is usually more chronic and degenerative in na-
: and can require margin before footprint. C, The L-shaped tear consists
~ , anterior-to-posterior component at the footprint in conjunction with a
al-to-lateral component, which can be either anterior or posterior at the
aspinatus-infraspinatus junction.
Illustration of the basic rotator cuff tear patterns. A, The crescent
of partial- and full-thickness tear
ms. Patients should be advised
a more minimally invasive ap-
ro repair does not equate with
•ved tendon healing and faster re-
ry from a functional standpoint,
differences at 1 year postopera-
' except the incision size, are in-
nguishable.
oscopic Strategy
ful arthroscopic rotator cuff re-
- begins by determining the tear
rn. Although several classification
ms exist, the most valuable is a
hrforward description of the tear
ern as crescent, U-shaped, or
aped (Figure 2).66•67 The crescent
is typically an avulsion injury and
e most basic pattern. The crescent
cr is unique because it is typically
re and has excellent biologic heal-
potential. This pactern may be
red with a variety of techniques;
.vever, an acceptable result may be
·eved using a single-row configura-
" with multiple anchors as needed67
tgure 3). To assist with reducing the
.u, it may be helpful ro repair the
posterior margin first, followed by the
anterior portion and then the central
portion of the tear. The U-shaped tear
is usually more chronic and degenera-
tive in nature. In general, this type of
. .
repair may require margm convergence
or side-to-side repair (Figure 4) before
the footprint repair and begins at the
apex of the tear progressing medially to
laterally. Using this technique will help
reduce tension and repair length at the
repair site. The repair is completed us-
ing a single- or double-row technique,
depending on the surgeon's preference.
One of the most common configu-
rations is the L-shaped tear, which
consists of an anterior-to-posterior
component at the footprint in con-
junction with a medial-to-lateral com-
ponent. The medial-to-lateral compo-
nent is almost always one of the limbs
of the L and extends upward into the
weaker tissue of the rotator interval;
however, the L (or reverse L) may ex-
tend into the junction between the su-
praspinatus and infraspinatus. The lat-
eral limb of the L-shaped tear is usually
located along the rotator cuff cable or
where the infraspinatus comes around
.
2011 AAOS Instructional Course Lectures, Volume 60
Figure 3
showing an intact single-row rotator
cuff repair .
Arthroscopic image
Figure 4
showing margin convergence of a
large U-shaped rotator cuff tear be-
fore footprint repair. These tears are
typically chronic and/or degenerative
in nature.
Arthroscopic image
laterally to envelop the supraspinatus
(Figure 5). The apex of the L-shaped
rear should be anatomically reduced to
the exact area in which it was torn to
reduce the risk of postoperative failure
(Figure 5, C). Arthroscopic visualiza-
tion of these rear pacterns greatly facil-
itates anatomic reduction and a
tension-minimized repair construct.
Surgical Technique:
Critical Steps
Complete arthroscopic repair begins in
the same manner as that previously de-
127

Page 6

Shoulder
Figure 5
posterior component at the footprint in conjunction with a medial-to-lateral component. A, L-shaped tear. B, Anatomic
reduction of the tear. C, Final intact repair.
Arthroscopic images showing the pathology and repair of an L-shaped tear consisting of an anterior-to-
Figure 6
tor cuff with pericapsular release. In
chronic rotator cuff tears, the tendon
may be adherent to the glenoid
neck, and releasing the capsule
above the superior labrum and
around the glenoid is helpful. The
dotted line represents the plane of
the release.
Mobilization of the rota-
scribed for mini-open repairs; how-
ever, there are a few key steps that are
critical to success. Tendon releases are
crucial and can be performed with ar-
throscopic hand instruments, an elec-
trothermal device, or an arthroscopic
elevator to obtain mobilization of the
128
Figure 7
showing visualization of rotator cuff
pathology through the lateral portal.
Arthroscopic image
rotator cuff tissue and prevent undue
tension on the repair. Initially, releases
should be performed between the rota-
tor cuff tendon and the undersurface
of the acromion. Anteriorly, releases
are performed to separate adhesions in
the rotator interval (interval slide) re-
gion between the supraspinatus and
subscapularis, with releases performed
to the base of the coracoid. A posterior
release or slide will separate the su-
praspinatus and the infraspinatus, al-
though this is rarely required. In
chronic rotator cuff tears, the tendon
may adhere to the glenoid neck; releas-
ing the capsule above the superior
labrum and around the glenoid is
helpful (Figure 6).
Tendon footprint reconstruction
can be performed using a variety of
configurations; however, the surgeon
must be aware of appropriate portals
and the benefits of each in facilitating
suture passing. Although viewing from
the posterior portal and working
through the lateral portal is possible,
viewing through the lateral portal and
working through the posterior, ante-
rior, and accessory anterolateral portals
improves suture passing capabilities
and direct visualization (Figure 7). To
establish the accessory anterolateral
portal, an 18-gauge spinal needle is
used to determine the proper trajec-
tory for anchor placement and suture
passing (Figure 8). Footprint prepara-
tion also is performed through this
portal. When preparing the footprint,
it is important to create a bleeding sur-
face by removing only minimal corti-
cal bone to improve suture anchor
pull-out strength. However, with TOE
fixation constructs, more cortical bone
may be removed with the burr during
preparation to obtain a viable bleeding
bony surface of the greater tuberosity.
The anchor position is dependent
on the suture repair configuration.
When performing a single-row repair,
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ution of Rotator Cuff Repair Techniques: Are Our Patients Really Benefiting?
Chapter 12
Anterolateral
rking
portal
Lateral
viewing portal
Posterior portal
Illustration showing standard portal placement for an arthroscopic
:ator cuff repair.
anchor is placed at or near the !at-
edge of the greater tuberosity. In a
ble-row repair, the medial row of
ors (Figure 9) is placed just off
articular margin of the footprint.
~ e r a l row anchors are placed after
.dial knots are tied and are posi-
"led lateral to the footprint just off
greater tuberosity. Following an-
r placement, sutures are passed
•ough the rotator cuff tendon using
ariety of suture passing devices, tis-
penetrators, or suture shuttle de-
. Arthroscopic knot tying is cru-
to a successful repair. Although
y sliding and nonsliding knots
·e been described (including the
der, the midshipman, the Revo,
the western), using simple half-
rch knots passed on alternating posts
from posterior to anterior is a reli-
le and simple technique. There are
w numerous devices, anchors, and
rure configurations to replicate the
OE, both with and without knots.
everal authors have reported the
nical outcomes of complete ar-
roscopic repairs that are comparable
to the results achieved with open
and arthroscopically assisted tech-
niques.68-75 A brief summary of there-
sults comparing mini-open to all-
arthroscopic rotator cuff repairs is
found in Table 2.
Evolution of Techniques:
Clinical Outcomes
The clinical outcomes of the newer su-
ture repair constructs have yet to be
fully defined. It is important to note
that not all of the reported data can be
generalized to a particular repair con-
struct. When evaluating the literature
on repair techniques and outcomes,
there are numerous contributing fac-
tors to consider, such as the number of
anchors used, the chronicity of the
tear, and patient age. Although reports
will typically describe the basic repair
configuration (single-row, double-row,
or TOE), it is important to note the
total number of anchors involved in
the repair, the number of anchors that
are used for the medial and lateral rows
in double-row repairs, and the config-
uration of the sutures as they bridge
2011 AAOS Instructional Course Lectures, Volume 60
Figure 9
showing the placement of medial
row anchors just off the articular
margin of the footprint in a double-
row rotator cuff repair.
Arthroscopic image
the tissue from medial to lateral (such
as straight medial to lateral, sutures
crossed over one another to create in-
terconnectivity, or knotless or knotted
medial row). The number of anchors
represents the number of fixation
points; therefore, it may be possible
that, regardless of how the repair is
configured, more fixation points may
I .
u nmate y resu t 111 a stronger repair.
This may also be true in studies involv-
ing larger rotator cuff repairs because
more anchors are used in large repairs,
and outcomes may be dependent on
this factor. Chronicity and the number
of tendons involved should also be
considered.
In certain situations,
chronic tears can be less amenable to
double-row constructs because the tis-
sue may not allow full reapproxima-
tion to re-create the anatomic foot-
print. Patient age should be noted
because younger patients may place
higher loads on the repair site despite
the fact that their tissue quality is often
supenor.
Currently, prospective results have
suggested that rotator cuff repair ten-
don healing occurs more frequently in
patients treated with double-row re-
pairs compared
. 6 76-78 s
repairs. ' ugaya et
I I . . 44
with single-row
compare
al79 d
129

Page 8

Shoulder
Table 2
Summary of Results Comparing All-Arthroscopic to Mini-Open Rotator Cuff Repairs
Authors (Year)
Kose et al68 (2008)
Pearsall et al69 (2007)
Verma et al70 (2006)
Sauerbrey et al71
(2005)
Warner et af2 (2005)
Youm et al73 (2005)
Severud et al74 (2003)
Kim et al75 (2003)
Number of Patients
25 all-arthroscopic,
25 mini-open
27 all-arthroscopic,
25 mini-open
38 all-arthroscopic,
33 mini-open
28 all-arthroscopic,
26 mini-open
9 all-arthroscopic,
12 mini-open
42 all-arthroscopic,
42 mini-open
35 all-arthroscopic,
29 mini-open
42 all-arthroscopic,
34 mini-open
39 patients treated with a single-row
repair to 41 patients treated with stan-
dard double-row suture anchor repair
at an average follow-up of 35 months.
Using MRI, the authors found a
25.6% retear rate in the single-row
constructs compared with a 9.8% re-
tear rate in the double-row repairs.
Similarly, Charousset et af6 used CT
to assess healing at 6 months in both
single- and standard double-row re-
pairs. Double-row fixation resulted in
a significantly greater healing rate (19
of 31 repairs; 61%) compared with
single-row fixation (14 of 35 repairs;
40%). Duquin et af7 performed a sys-
tematic review of more than 1, 100 ro-
tator cuff repairs described in studies
that compared single-row to double-
row constructs. A statistically signifi-
cant decrease in anatomic retear rates
was found for true double-row repairs
when compared with single-row re-
pairs for all tears larger than 1 em.
Although double-row repairs ap-
pear to be superior in the laboratory
and on imaging exhibit improved heal-
ing rates over single-row repairs, simi-
130
Mean Follow-up Reported Outcomes
26 months Preoperative and postoperative Constant-Murley
and University of California at Los Angeles
scores and satisfaction not significantly differ-
ent between groups
50.6 months No statistical difference in outcome between the
two groups
minimum 2 years No difference in clinical outcomes between the
two techniques
33 months All improved; the difference in scores between
the two techniques not statistically significant
minimum 27 months No differences in outcomes
minimum 2 years Arthroscopic and mini-open rotator cuff repairs
produced similar results for small, medium,
and large rotator cuff tears with equivalent pa-
tient satisfaction rates
44.6 months
Shoulders in the all-arthroscopic group showed
better motion at 6 and 12 weeks
39 months No difference in shoulder scores, pain, and re-
turn to activity between the groups
lar clinical outcomes between the two
techniques have been reported in most
studies. Franceschi et al80 performed a
randomized controlled trial comparing
30 patients with single-row repairs and
30 patients with standard double-row
fixation. Although the authors be-
lieved that the double-row technique
produced a mechanically superior con-
struct as evidenced by better cuff in-
tegrity on postoperative MRI, they
found no significant difference in post-
operative clinical scores or range of
motion between the two groups at
2-year follow-up.80 Similarly, in a ran-
domized clinical
40 patients (20 single-row and 20
double-row constructs), Burks et al81
reported no significant differences in
clinical outcomes or physical examina-
tion results. There were no significant
differences in MRI measurements of
footprint coverage, tendon thickness,
and tendon signal
groups.81 Many of these studies may
be underpowered, which presents a
significant challenge in interpreting
the data and applying the information
trial comparing
between the
clinically. Researchers at Rush Univer-
sity in Chicago recently determined
that to detect a 1 Oo/o difference in heal-
ing rates based on an estimated 30%
failure rate for single-row repairs and a
20% failure rate for double-row re-
pairs, 219 patients in each group
would be needed for the study to be
considered appropriately powered. A
summary of the studies comparing
single- to double-row repairs and the
results of double-row outcome studies
are found in Tables 3 and 4,
respectively. 6•76•79-86
The TOE bridging construct was
developed to provide increased contact
and compression on the footprint to
enhance healing potential. The medial
row of anchors theoretically may pro-
vide a barrier between the synovial en-
vironment and the healing zone to
contam healing factors. Although
there are limited clinical data on TOE
constructs, early results have been
promising. To evaluate the healing rate
ofTOE repairs, Frank et al78 examined
a cohort of 25 patients with a mini-
mum 1-year follow-up. Postoperative
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lution of Rotator Cuff Repair Techniques: Are Our Patients Really Benefiting?
Chapter 12
Table 3
ummary of Results Comparing Single-Row to Double-Row Rotator Cuff Repairs
uthors (Year)
rks et al81 (2009)
:>ark et al84 (2008)
=ranceschi et al80
2007)
~ .arousset et al76
2007)
.;gaya et al79 (2005)
Number of
Patients
20 SR,
20 DR
40 SR,
38 DR
30 SR,
30 DR
35 SR,
31 DR
39 SR,
41 DR
=single row, DR= double row
Table 4
ummary of Results Following Arthroscopic Double-Row Rotator Cuff Repairs
Mean Age
(years)
56.5
56
61
59
57.9
Mean Anchors
SR: 2.2
DR: 3.2
Not given
SR: 1.9
DR: 2.3
Not given
SR: 2.4
DR: 3.2
Reported Outcomes
No clinical or MRI differences between SR
or DR repairs
No difference between SR and DR for all,
but DR had better outcome scores
and Shoulder Strength Index for tears
> 3 em
Both had comparable clinical outcome at
2 years; DR repairs produced mechani-
cally superior construct compared with
SR repairs
No significant difference in clinical results,
but tendon healing rates were better
with DR repairs
No statistical difference between the
groups in the postoperative scores; DR
repairs had improved structural out-
comes
Number of
Patients thors (Year) Mean Follow-up Reported Outcomes
, ~ h
:J10}
. 'osse et al83 (2008)
n a v and MilletB5
17 with knotless self-
reinforcing DR system
1.5 years
Average pain scores decreased; average SANE scores
increased; satisfaction 9.8 of 10
1 05 with DR of SS or
SS +IS
Prospective (minimum
2 years)
12 failed repairs (11 %); intact RCR associated with sig-
nificantly increased strength and ROM; postoperative
Constant score 80.1 ± 11.1
.gaya et al6 (2007)
86 with full-thickness
RCT using suture
anchors
_ ~ ma n s et al82
242 with DR suture
anchor technique
7)
erson et al86
:'.06)
52 with DR suture
anchor technique
Prospective, average
31 months (14 months
for MRI)
22 months (minimum
12 months)
30 months (minimum
24 months)
All clinical outcomes scores significantly improved
(P < 0.05); retear rate higher for larger/massive tears
VAS improved from 7.4 to 0.7; good to excellent out-
come in 220 (91 %); intact RCR in 174 (83%) via US;
improved strength and ROM in intact repairs
L'lnsalata shoulder ratings improved from 42 to 93
(P < 0.001 ); active ROM improved in all planes
(P < 0.001); strength increased in ER and FE
(P< 0.001) and IR {P= 0.033); failure rate of 17%
= double row, SANE = single assessment numeric evaluation, SS = supraspinatus, IS = infraspinatus, RCR = rotaror cuff repair, ROM = range of motion,
= uluasound, ER =external rotation, FE= forward elevation, IR = internal rotation, VAS =visual analog scale
showed intact rotator cuff repairs
__ of 25 patients (88%). In tears that
-e limited to the supraspinatus ten-
16 of 18 patients (89%) had intact
...irs. Healing was noted in three tears
were considered massive.78
ith the development of these
nd-generation double-row repair
constructs, a new failure mode has
been reported. Historically, recognized
failure modes for arthroscopic rotator
cuff repairs included failure at the
bone-anchor interface, the anchor-
suture interface, and the suture-tendon
.
c
mtenace. owever, repa1r 1a1 ure
at the musculotendinous junction fol-
87-89 H . c -1
2011 AAOS Instructional Course Lectures, Volume 60
lowing double-row and TOE repairs
are now being reported. Trantalis
et al90 identified a subset of five pa-
tients who showed an atypical mech-
anism of tendon failure after a double-
row repair. The tendon footprint
appeared well fixed in these patients;
however, medial to the intact foot-
131

Page 10

Shoulder
print, the tendon was torn through the
rotator cuff. Other investigators have
d
reporte Simi ar ra1 ure mo es. ' -
Cho et al91 reported on 46 retears fol-
lowing either single-row or TOE re-
pairs. Most of the TOE repairs
(74.1 o/o) had a retear pattern that had
remnant cuff tissue at the rotator cuff
footprint, with the tear occurring more
medially. The authors concluded that
the TOE technique tended to better
preserve the footprint, but retear oc-
curred mainly in the musculotendi-
nous junction. This information may
have significant implications in revi-
sion surgery following failed bridging
repairs. There are several consider-
ations related to this failure mode. If
healing rates are superior in double-
row or TOE repairs, advocating the
implementation of these techniques
should be weighed against the poten-
tial mechanism of failure. This finding
has not been appreciated by most stud-
ies that used MRI or ultrasound to
evaluate retear rates following double-
row or TOE repairs.1•6·78·80-83 Cer-
tainly, there are technical precautions
that will minimize this failure mode,
and it should be assumed that this fail-
ure mode could occur with either stan-
dard double-row or TOE repairs. Pre-
ventive measures, such as avoiding
overtensioning of the medial row by
performing an anatomic cuff tear re-
duction, will reduce stress at the mus-
culotendinous junction. Placing the
medial suture lateral to the musculo-
tendinous junction and closer to the
rotator cuff cable entirely within the
tendon may also minimize this type of
failure.
. .1
c .1
d 91 9?
Clinical Decision Making:
Single-Row Versus
Double-Row Techniques
With such a large amount of data
available in the literature and the simi-
larities of the various results, it is pru-
dent to consider patients individually
132
before generalizing the use of a certain
construct to all patients. Factors such
as patient characteristics, length of the
procedure, surgical cost, and technical
demands are important when weigh-
ing the benefits of the different tech-
niques. Churchill and Ghorai65 exam-
ined the total cost and operating room
time of mini-open compared with all-
arthroscopic rotator cuff repair tech-
niques at low-, intermediate-, and
high-volume centers using the 2006
New York State Ambulatory Surgery
Database. The authors reported that
the surgical rime was significantly
shorter in the mini-open group (103
minutes) compared with the all-
arthroscopic group (113 minutes).
Surgical costs were also significantly
less in the mini-open group ($7,841)
compared with the all-arthroscopic
group ($8,985), resulting in an addi-
tional cost of $1,144 more per patient
when an arthroscopic repair was per-
formed.65 Although a breakdown in
cost was not reported between the dif-
ferent arthroscopic techniques, it can
be assumed that the cost would be
higher when a double-row construct is
used rather than a single-row repair.
Similar surgical rime differences were
found by Franceschi et al80 in a study
comparing single-row to double-row
outcomes. It was reported that the av-
erage surgical time for single-row pro-
cedures was 42 ± 18.9 minutes and
that double-row repair averaged 65 ±
23.4 minutes. These studies did not
consider the financial burden associ-
ated with anatomic failure following
rotator cuff repair (such as time off
work or the cost of revision surgery).
Decision making must also take
into account certain clinical factors.
Probably the most important of these
is the size of the rotator cuff rear. Most
studies to dare examining outcomes
from single- and double-row repairs
typically have enrolled most patients
with tears that are less than
3 cm.6·41•76·8 1•93 Parker al84 compared
40 patients with single-row fixation to
38 patients treated with double-row
fixation. The mean age of the patients
was 56 years, and outcomes were mea-
sured at 2 years postoperatively using
the American Shoulder and Elbow
Surgeons and Constant scoring sys-
tems and the Shoulder Strength Index.
The authors reported improvement in
functional outcome in both groups,
but there was no significant difference
between the groups. When patient re-
sults were stratified by tear size, no dif-
ference was found between the repair
techniques in patients with small to
medium ( < 3 em) tears; however, in
patients with large to massive tears
(> 3 em), all outcome measures were
significantly improved in the group
that had been treated with a double-
. 84Th.
row repa1r. IS may e ev1 ence to
support the use of single-row fixation
in small to medium rotator cuff tears
while reserving double-row techniques
for large and massive tears.
b 'd
Summary
Many factors play a vital role in ob-
taining a successful result after a rota-
tor cuff repair. Patient factors such as
age, biology, and environmental influ-
ences are beyond the control of the
treating surgeon; however, the surgeon
does influence the technique of cuff re-
duction and the repair construct. Re-
cently, many advances have been made
in rotator cuff repair. Despite these im-
provements, it is important to keep in
mind the basic tenets of achieving a
strong repair, including minimizing
motion, achieving an anatomic repair,
and preventing
second-generation techniques appear
to be biomechanically superior to
single-row repairs, additional research
is needed to define the patient charac-
teristics and type of rotator cuff tear
that would benefit from a double-row
or TOE repair construct.
gaps. Although
© 2011 AAOS Instructional Course Lectures, Volume 60

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~ v o l u t i o n of Rotator Cuff Repair Techniques: Are Our Patients Really Benefiting?
Chapter 12
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134
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.olution of Rotator Cuff Repair Techniques: Are Our Patients Really Benefiting? Chapter 12
Park MC, Tibone JE, El-
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