Castagna 2007- arthroscopic rotator cuff repair using a triple-loaded suture anchor and a modified mason-allen technique (alex stitch)

1. Technical Note
Arthroscopic Rotator Cuff Repair Using a Triple-Loaded Suture
Anchor and a Modified Mason-Allen Technique (Alex Stitch)
Alessandro Castagna, M.D., Raffaele Garofalo, M.D., Marco Conti, M.D.,
Mario Borroni, M.D., and Stephen J. Snyder, M.D.
Abstract: Surgical repair of the rotator cuff must have good resistance and should restore the tendon
footprint. To attain this goal, a stitch with a strong biomechanical profile that avoids tissue
strangulation should be used. We describe an arthroscopic suture technique undertaken to repair
rotator cuff tears with a single triple-loaded suture anchor. The technique consists of a combination
of a horizontal mattress and 2 vertical simple sutures that are positioned medial to the mattress suture.
The suture anchor used is the 5-mm self-tapping ThRevo (Linvatec). This anchor is loaded with 3
sutures: 2 No. 2 nonabsorbable braided polyester sutures of different colors and a central high-
strength No. 2 polyethylene suture. The shape of the anchor eyelet permits all 3 sutures to glide
freely. A modified Mason-Allen technique (Alex stitch) that combines a horizontal side-to-side suture
and 2 simples sutures as vertical loops is used. With use of the Spectrum suture passing device and
shuttle relay system (Linvatec), both limbs of the centrally located polyethylene suture are passed
through the cuff from bottom to top, approximately 1 cm from the tendon edge. This suture is not
immediately tied. Next, with use of the same system, the other 2 sutures are placed medially and over
the previous horizontal suture. Simple sutures are placed at an approximately 30° angle from the
center of the anchor; 1 is placed anterior and the other posterior. The sutures are tied through the
lateral portal. The mattress horizontal central stitch is always tied first, followed by the 2 vertical
sutures. The horizontal mattress suture serves as a “rip stop stitch” and theoretically reduces the
possibility of cutting out of the simple sutures. Key Words: Rotator cuff repair—Shoulder—
Footprint—Modified Mason-Allen technique—Triple-loaded suture anchor—Alex stitch.
In recent years, arthroscopic repair has become a well-
established surgical technique for the treatment of
patients with rotator cuff tears. Despite continual im-
provement in surgical techniques and instrumentation,
re-tear of the tendons does occur in some patients.1
The repaired rotator cuff has several potential points of
weakness: the tendon–suture interface, the suture itself,
the suture–eyelet interface, and the bone–anchor inter-
face. The weakest link has been shown to be the suture–
tendon interface.2,3 Previous studies have shown that the
modified Mason-Allen stitch leads to the least gap for-
mation and slippage and has the highest ultimate tensile
load when compared with other suturing techniques.4
Because of technical difficulties involved in placing the
modified Mason-Allen stitch in an arthroscopic manner,
arthroscopic suture configurations have been limited to
the simple or horizontal mattress type. The simple suture
technique has shown inferior mechanical strength with
failure by tissue pullout at a low ultimate load.3-5 Gerber
et al.3 showed that the tendon grasping technique that
From the Shoulder Surgery Service, Humanitas Institute (A.C.,
R.G., M.C., M.B.), Milan, Italy; and Southern California Orthope-
dic Institute (S.J.S.), Van Nuys, California, U.S.A.
The authors report no conflict of interest.
Address correspondence and reprint requests to Raffaele Garo-
falo, M.D., Via Padova 13-70029, Santeramo in Colle-Ba, Italy.
E-mail: raffaelegarofalo@hotmail.com
© 2007 by the Arthroscopy Association of North America
Cite this article as: Castagna A, Garofalo R, Conti M, Bor-
roni M, Snyder SJ. Arthroscopic rotator cuff repair using a
triple-loaded suture anchor and a modified Mason-Allen tech-
nique (Alex Stitch). Arthroscopy 2007;23:440.e1-440.e4 [doi:
10.1016/j.arthro.2006.07.046].
0749-8063/07/2304-6177$32.00/0
doi:10.1016/j.arthro.2006.07.046
440.e1Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 23, No 4 (April), 2007: pp 440.e1-440.e4

2. combines single and mattress stitches allowed a strong
tissue holding stitch and caused less strangulation of the
rotator cuff tendon than were seen with other major
suture techniques. In addition, Apreleva et al.6 found that
rotator cuff repairs done with simple suture configura-
tions fail to reestablish the normal footprint of the rotator
cuff. For these reasons, we believe it is important to
investigate alternative suture configurations for rotator
cuff repair to optimize initial fixation strength and resto-
ration of the cuff footprint, both of which may theoreti-
cally increase the likelihood of successful outcomes after
rotator cuff repair.
The purpose of this paper is to present a new arthro-
scopic suture configuration performed with the use of a
single row anchor loaded with 3 sutures. The goals of
this technique are to increase the medial-to-lateral foot-
print width of the repaired rotator cuff and to enhance the
strength of the repair.
SURGICAL TECHNIQUE
The authors performed all shoulder arthroscopies
with patients in the lateral decubitus position. With the
arm in 70° of abduction and 20° of forward flexion, 4 to
5 kg of balanced suspension was used, along with a
shoulder traction system. Routine portals were devel-
oped, and the glenohumeral joint was inspected and
evaluated for disease. Upon completion of glenohumeral
arthroscopy, traction was changed from 70° to 15° of
abduction, shifting the arm into the bursoscopy position.
The arthroscope was placed into the subacromial space,
and subacromial smoothing was performed as needed.
The rotator cuff footprint on the greater tuberosity was
lightly debrided down to bleeding bone. Cuff tear
configuration was assessed, and the degree of tendon
mobility medial to lateral and posterior to anterior
was evaluated with a grasping tool. In patients with
U-shaped, L-shaped, or V-shaped tears, margin con-
vergence was performed, starting medially. This was
done to reduce strain on the sutures within the anchor
and to avoid propagation of a vertically oriented tear.
A crescent-shaped suture hook with a suture shuttle
relay (Linvatec, Largo, FL) was passed across the cuff
tear from posterior to anterior, and sutures were car-
ried back across the side-to-side tear. Tying the side-
to-side sutures advances the leading edge of cuff
tendon laterally, closer to the anchor sight on the
tuberosity.
The suture anchor used was the 5-mm self-tapping
ThRevo (Linvatec). This anchor has a horizontally ori-
ented eyelet and is loaded with 3 sutures: 2 No. 2
nonabsorbable braided polyester sutures of different col-
ors and a central high-strength No. 2 polyethylene suture.
The shape of the anchor eyelet permits all 3 sutures to
glide freely, which facilitates suture tying with sliding
locking knots. The suture anchor was inserted at a 45°
angle (dead man’s angle) to maximize anchor resistance
to pullout.7 A modified Mason-Allen technique that
combined a horizontal side-to-side suture and 2 simple
sutures as vertical loops was used (Alex stitch). The
arthroscope was introduced through the standard lateral
portal. With the Spectrum suture passing device and
shuttle relay system (Linvatec), both limbs of the cen-
trally located polyethylene suture were passed through
the cuff from bottom to top, approximately 1 cm from
the tendon edge. This suture was not immediately tied.
Next, with the curved spectrum suture hook and shuttle
relay system, the other 2 sutures from the suture anchor
were placed medially and over the previous horizontal
mattress suture. The simple sutures were placed at an
approximately 30° angle from the center of the anchor; 1
was placed anterior and the other posterior (Fig 1).
At this point, the arthroscope was introduced through
the posterior portal, and all sutures were tied through the
lateral portal. The horizontal suture was tied first, fol-
lowed by the 2 vertical sutures (Fig 2). The resultant
suture configuration is a modified Mason-Allen stitch,
with 1 horizontal mattress suture and 2 vertical (sim-
ple) sutures placed medial to the mattress suture (Alex
stitch). The horizontal mattress central stitch was al-
ways tied first to enhance the holding power of the 2
simple vertical sutures. The horizontal mattress suture
serves as a “rip stop stitch” and theoretically reduces
the possibility of cutting out of the simple sutures,
especially in a degenerative tendon (Fig 3).
DISCUSSION
Structural failure after rotator cuff repair has been
frequently reported, regardless of the surgical tech-
nique.1 These failures are multifactorial in origin but
represent a potential area of weakness in the tendon–
suture interface,5 in that some failures may occur
because of suture cutting out of the tendon.3 Various
grasping techniques and suture configurations for ro-
tator cuff repair have been described in the literature.4
In particular, the modified Mason-Allen stitch leads to
the least gap formation and slippage and has the
highest ultimate tensile load when placed in an open
manner.3,4 However, this stitch is biomechanically
less favorable when it is performed arthroscopically.
Another concept that recently has come under close
investigation is anatomic restoration of the rotator cuff
footprint during repair.8,9 Apreleva et al.6 found that
440.e2 A. CASTAGNA ET AL.

3. suture anchor repair constructs with a single row of
anchors restored only 67% of the original footprint of
the rotator cuff. On the other hand, the transosseous
simple suture repair was able to restore approximately
85% of the surface area. Burkhart10 advocated the
placement of multiple simple sutures to distribute the
load over multiple fixation points. The margin con-
vergence technique was advocated to reduce strain in
the repaired tendon, thus protecting it from tear prop-
agation and suture failure. Several studies have
showed that a more anatomic footprint can be restored
with a double-row anchor repair as compared with a
single-row technique.9,11 However, this entails use of
more anchors, which increases the cost and the time of
surgery.
Ultimately, the success of repair is dependent on the
strength of fixation of the repair.12 We know that the
modified Mason-Allen stitch is strong and has less
potential for tissue strangulation in comparison with
other common suture techniques.4 Although its use is
common in open rotator cuff repair, it is very difficult
to perform this procedure arthroscopically. As a result,
numerous attempts have been made to create a mod-
ified Mason-Allen stitch that is amenable to use of the
arthroscope.
The modified suture grasping technique described
in this paper follows the principles of the Mason-Allen
technique. The idea of a combination of a horizontal
and a vertical loop during arthroscopic cuff repair is
not new in the literature.8,12 The Alex stitch presents
FIGURE 1. (A) V-shaped rotator cuff tear repaired with the ThRevo technique. Number 1 identifies the central high-strength No. 2
polyethylene suture, and the numbers 2 and 3 identify the 2 No. 2 nonabsorbable braided polyester sutures. The number 1 suture passed
laterally with respect to the other 2 sutures will be used to perform the horizontal side-to-side suture. The numbers 2 and 3 will be used to
perform the 2 simple vertical loops. (B) Arthroscopic view of a right shoulder shows the same sutures passed through the rotator cuff tear.
(HH, humeral head; RC, rotator cuff.)
FIGURE 2. (A) The horizontal suture is tied first, followed by the 2 vertical sutures, which were (B) passed previously through the anterior
and posterior limbs of the tear.
440.e3MODIFIED MASON-ALLEN TECHNIQUE FOR ROTATOR CUFF REPAIR

4. some challenges related to the use of a triple-loaded
suture anchor. As in the technique described by Schei-
bel and Habermeyer,8 1 of the sutures of the suture
anchor is used to perform the horizontal mattress
stitch. However, the advantage of the triple-loaded
anchor is that 2 vertical sutures can be placed over the
horizontal mattress stitch. A recent biomechanical
study5 has shown that a suture technique that com-
bines a horizontal loop and a vertical loop at the site of
rotator cuff repair can provide strength and stiffness
comparable with that provided by the modified Ma-
son-Allen stitch. We hypothesize that the presence of
an additional vertical loop, similar to the Mac
stitch,5,12 will enhance the biomechanical profile of
the repair, thus reducing the risk of suture cutout and
failure of the repair itself. In an experimental study
performed on sheep tendon, the Alex stitch showed
resistance to loading similar to the modified Mason-
Allen and greater than that of simple and mattress
sutures.13 We believe that this suture configuration
may also allow for a more anatomic reproduction of
the rotator cuff footprint; this will be evaluated in
future studies.
In conclusion, the Alex stitch with a triple-loaded
suture anchor and combination of a central horizontal
mattress and 2 bridging simple suture loops may rep-
resent a promising alternative in arthroscopic rotator
cuff repair. Further study is warranted.
Acknowledgment: The authors thank Jose Silberberg,
M.D., and Victor Naula, M.D., for providing illustrations
and scientific contribution.
REFERENCES
1. Mansat P, Cofield RH, Kersten TE, Rowland CM. Complica-
tions of rotator cuff repair. Orthop Clin North Am 1997;28:
205-213.
2. Rossouw DJ, McElroy BJ, Amis A, Emery R. Biomechanical
evaluation of suture anchors in repair of the rotator cuff.
J Bone Joint Surg Br 1997;79:458-461.
3. Gerber G, Schneeberger AG, Perren SM, Nyffeler RW. Ex-
perimental rotator cuff repair: A preliminary study. J Bone
Joint Surg Am 1999;81:1281-1290.
4. Gerber G, Schneeberger AG, Beck M, Schlegel U. Mechanical
strength of repairs of the rotator cuff. J Bone Joint Surg Br
1994;76:371-380.
5. Ma CB, MacGillivray JD, Clabeaux J, Lee S, Otis JC. Bio-
mechanical evaluation of arthroscopic rotator cuff stitch.
J Bone Joint Surg Am 2004;86:1211-1216.
6. Apreleva M, Ozbazdar M, Fitygibbons BA, Warner JJP. Ro-
tator cuff tears: The effect of the reconstruction method on
three-dimensional repair site area. Arthroscopy 2002;18:519-
526.
7. Burkhart SS. The deadman theory of suture anchors:
Observations along a south Texas fence line: Technical
note. Arthroscopy 1995;11:119-123.
8. Scheibel MT, Habermeyer P. A modified Mason-Allen tech-
nique for rotator cuff repair using suture anchors. Arthroscopy
2003;19:330-333.
9. Lo IK, Burkhart SS. Double-row arthroscopic rotator cuff
repair: Re-establishing the footprint of the rotator cuff. Arthro-
scopy 2003;19:1035-1042.
10. Burkhart SS. Arthroscopic treatment of massive cuff tears.
Clin Orthop 2001;390:107-118.
11. Mazzocca AD, Millett PJ, Guanche CA, Santangelo SA, Ar-
ciero RA. Arthroscopic single-row versus double-row suture
anchor rotator cuff repair. Am J Sports Med 2005;33:1861-
1868.
12. Mac Gillivray JD, Ma CB. An arthroscopic stitch for massive
rotator cuff tears: The Mac stitch. Arthroscopy 2004;20:669-
671.
13. Bungaro P, Rotini R, Traina F, et al. Comparative and exper-
imental study on different tendinous grasping techniques in
rotator cuff repair: A new reinforced stitch. Chir Organi Mov
2005;90:113-119.
FIGURE 3. (A) Arthroscopic view from a posterior portal of the right shoulder shows the final view of a repaired rotator cuff tear performed
with a ThRevo technique. (B) The same shoulder viewed through the lateral subacromial portal shows optimal repair of a rotator cuff tear
with the modified Mason-Allen stitch.
440.e4 A. CASTAGNA ET AL.