This document discusses arthroscopic rotator cuff repair. It begins with the anatomy of the rotator cuff and classifications of tears. It then discusses techniques for arthroscopic repair including single versus double row repairs and different types of sutures and anchors. It summarizes studies comparing biomechanical properties and retear rates of different repair methods. The document concludes with long term follow up of repairs showing rerupture rates increase with larger tear size and age.

1. Arthroscopic Rotator
Cuff Repair
Bijayendra Singh
FRCS (T&O), FRCS, MS, DNB (Ortho)
Consultant Orthopaedic Surgeon
Medway NHS Foundation Trust
Honorary Tutor Royal College of Surgeons Edinburgh
Honorary Treasurer Indian Orthopaedic Society

2. 2
• Anatomy
• Classification
• Methods of repair
• Techniques of Repair
2

3. 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

4. 7
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 impingement
7

5. Incidence
5-40%
Increases with age
Young:
Repetitive use
Throwing sports
Impingement
Older:
Fall
Other trauma
Murrell et al: The Lancet,
Volume 357, Issue 9258, 10 March 2001, Pages 769–
770

6. 7
Indication
• Symptomatic Cuff Tear
– Age no barrier
• When
– Early
• if bony avulsion
• pseudo - paralysis
• No difference in outcome in delayed repair

7. 8
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
8

8. 9
Maximising healing potential
• Restoration of footprint contact area
• Uniform footprint contact pressurization
• Minimization of footprint tendon-bone interface
motion
9

9. 10
Tendon-to-Bone Pressure Distributions
at a Repaired Rotator Cuff Footprint Using
Transosseous Suture And Suture Anchor Fixation
Techniques
Maxwell 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
10

10. 11
Transosseous (TOS)
68mm2
Mattress Suture
anchor (SAM)
26mm2
suture anchorsuture anchor
simple (SAS)simple (SAS)
34.1 mm34.1 mm22

11. 12
Contact Area, Contact Pressure, and Pressure Patterns of
the Tendon-Bone Interface After Rotator Cuff Repair
Yilihamu 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

12. 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

13. 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.

14. 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

15. 1616

16. 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

18. 24
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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20. 26
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).
26

21. 27
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.
27

22. 23
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 failure
23

23. 24
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: 25

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Intraop Scoring
Fair (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

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

27. 19
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.
19

28. 20
Margin Convergence ‘Crescent’
20

29. 21
‘L’ Shape
21

30. 31
Arthroscopic Repair

31. Arthroscopic repair
• Cannula
• Suture Passer
• Suture manipulator
• Appropriate Anchors
• Knotless
• Knot tying
• Suture Cutter
Learning Curve

32. 35
Which Anchor

33. 36
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
36

34. 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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35. 36
Standard Knotless Repair
31

36. Positioning

37. 3838
Text

39. 4141

40. 4242

41. 4332

42. 4433

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44. 29
Single Row vs Double Row

45. 47
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

46. 48
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
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47. 49
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

48. 50
Functional Score
Pre Op
Single
Pre Op
Double
Post Op
Single
Post op
Double
Post Op
Difference
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)

49. 51
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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50. 52
Retear
FT
Single Row
FT
Double
Row
FT & PT
Single Row
FT & PT
Double
Row
22
(19%)
16
(14%)
50
(43%)
21
(27%)

51. 5353

52. 54

53. 56
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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54. 57
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

55. 58
• 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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56. 59
Thank You

57. 60
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