This document discusses arthroscopic transosseous rotator cuff repair. It begins with a brief history of rotator cuff repair techniques. It then describes the ideal properties of rotator cuff repair and how arthroscopic transosseous repair achieves high fixation strength, stability, and biology. The document outlines the surgical technique and presents clinical and biomechanical data supporting the procedure. It concludes that arthroscopic transosseous repair provides equivalent outcomes to current anchor-based techniques with benefits including no implants, multiple sutures, and potential for easier revision surgery.

1. IAS 2014
ARTHROSCOPIC TRANSOSSEOUS
(No implant) ROTATOR CUFF REPAIR
Dr. Raghuveer Reddy. K
Sai Institute of Sports Injury & Arthroscopy
Shoulder & Knee Specialty Centre, Hyderabad

2. I am Thankful to Dr. Sumant G. Krishnan
for providing with Biomechanical work
& Clinical outcome statistics of his
study done in U.S.

3. History

4. Cycle of Rotator Cuff Repair
Open
Transosseous
Mini-Open
Transosseous
Mini-Open
with Anchors
Arthroscopic
Transosseous
Arthroscopic
with Anchors
SR vs DR vs
TOE

5. The Perfect RCR
 Large Contact Area
 High Initial Fixation Strength
 Stable Construct
 Biology
 High Contact Pressure
 Low Tension Repair

6. Cuff Healing - Stimulation
Mechanical fixation Biological healing
Suture strength
Multiple sutures
Suture configuration
Suture anchors
Transosseous Equivalent
Transosseous Repair
Prepare bone foot print
? Acromioplasty??
• Collagen coated suture
Growth Factors ( PRP)
Stem Cells
ECM Grafts
Biologic Scaffolds
Graft Jacket

7. Cyclic Testing
Tunnel: Bone Failure
Anchors: Tendon Failure
Burkhart et al Arthroscopy 1997

8. Design Arthrotunneller

9. Arthroscopic Transosseous RCR
HISTORICAL PERSPECTIVE
 Fleega 2002
 “Giant Needle”
 Krishnan 2002
 All-Arthroscopic
Transosseous
 Lu 2005
 ACL Guide
 Beauchamp 2007
 Curved passers
 Resch 2009
 Curved hollow needle
 Castagna 2012
 Taylor Stitch
 Kuroda 2013
 Customized drill guide

10. ATRCR
The Surgical Technique

11. ARTHROSCOPIC TRANSOSSEOUS
(ANCHORLESS) ROTATOR CUFF REPAIR

13. ARTHROSCOPIC TRANSOSSEOUS
(ANCHORLESS) ROTATOR CUFF REPAIR
Surgical Technique –
Any suture configuration possible
 Simple (medial)
 Mattress (ant/post)
 Bridges

14. ARTHROSCOPIC TRANSOSSEOUS
(ANCHORLESS) ROTATOR CUFF REPAIR
Single Tunnel

15. ARTHROSCOPIC TRANSOSSEOUS
(ANCHORLESS) ROTATOR CUFF REPAIR
Two Tunnel

16. ATRCR
The Science
BIOMECHANICAL EVALUATION

17. Ideal Rotator Cuff Repair
● High initial fixation strength
● Minimal gap formation
● Mechanical stability till tendon bone healing
Gerber JBJS (Br) 1994
Sugaya JBJS 2007

18. Arthroscopic Transosseous RCR
REVISITING HISTORY
● Burkhart et al. - Arthroscopy, 2000
● Barber et al. - Arthroscopy, 2010
● Jost et al. - JBJS, 2012
“Increasing the number of sutures crossing the repair
site increases the load to failure and decreases gap
formation under cyclic loading”

21. ATRCR
The Outcomes of
Our Prospective Clinical Study &
Sumant’s Randomized Study

22. My Experience
PROSPECTIVE CLINICAL STUDY
Material 2013 - 14 20 cases

23. Our Prospective Clinical Study
 Primary 18, Revision 2
 Posterior superior tears 14, Superior 6 tears
 Single tunnel 11Pts. Simple Suture
Two tunnel 9Pts. Mattress Suture
 10 Cases evaluated. 6 - 12 months follow up
 Functional evaluation (VAS, ASES)
One pt. Had ASES < 70
 MRI Evaluation – Sugaya criteria for cuff healing
5 pts. Type I Three pts , Type II Two pts

24. MRI evaluation using Sugaya
Criteria for Cuff Healing Arthroscopy 2005
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity

25. Case 1 Post op MRI
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity

26. Case 2 Post op MRI
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity

27. Case 3 Post op MRI
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity

28. Prospective Randomized Study - Sumant
INCLUSION CRITERIA
Posterosuperior rotator cuff tear amenable
to GT footprint repair without tension (L ,
Crescent, reverse L)
• No subscapularis tendon involvement
• Grade I, II, III (Goutallier) FI
• One single surgeon
• Prospective Randomized allocation
• MRI evaluation at 1 year postop from 3
independent radiologists using Sugaya
Criteria for cuff healing

29. TECHNIQUE AT SUTURE ANCHORS
N cases 28 24
Retear (NH) 4 (14%) 4 (16%)
Grade I 10 (38%) 6 (26%)
Grade II 13 (48%) 8 (34%)
Grade III (PT) 1 (3%) 6 (26%)
OVERALL 86% 84%

30. Type I healing Type III healing
Type I: Sufficient thickness with homogeneously low intensity
Type II: Sufficient thickness with partial high intensity
Type III: Insufficient thickness without discontinuity
Type IV: Presence of a minor discontinuity
Type V: Presence of a major discontinuity

31. Arthroscopic Transosseous Repair Integrity
Various Centers
LOCATION STRUCTURAL INTEGRITY
# OF CASES
TO DATE
Krishnan ASES 2010 82% (49/60) MRI 1350
Mozes ISRAEL 2011 96% (48/50) U/S 98
Brassart FRANCE 2011 86% (33/38) U/S 241
Mikek SECEC 2011 95% (56/59) U/S 175
OVERALL 86% (214/239) >2000

32. Double Row & TOE Repair Integrity
Study Overall Integrity Type
Sugaya JBJS 2007 83% ( 71 / 86 ) DR SA
DeBeer JBJS 2007 83% ( 174 / 210 ) DR SA
LaFosse JBJS 2007 89% (93 / 105 ) DR SA
ElAttrache AJSM 2008 88% (22 /25) TOE/Suture bridge
Gartsman ASES 2010 94% (44 / 47) TOE/Suture bridge
Volgt AJSM 2010 71% ( 32 / 45) TOE/Suture bridge
Boileau Nice 2010 72% (28 / 39) TOE/Suture bridge
Sethi JSES 2010 83% (33 / 40) TOE/Suture bridge
Toussaint AJSM 2011 86% (132 / 154) TOE/Suture bridge
Rhee AJSM 2011 67% (58 / 87) TOE/Suture bridge
Kim JBJS 2012 85% (62 / 73) TOE/Suture bridge
OVERALL 82% (749 / 911)

33. Ideal Rotator Cuff Repair
Transosseous repairs10,000+ cases worldwide
Requirement Transosseous
RCR
Suture Anchor
RCR
Contact Area X X
Initial Strength X X
Contact Stability X X
Gap Formation X X
Mechanical Stability X X
Biology X
No Implants in Bone X

34. Arthroscopic Transosseous RCR
WHAT ARE THE CONCERNS AND RISK?
Bone Tunnel
Placement
Bone Quality
Overtensioning
Of repair
Number of
Tunnels

35. Arthroscopic Transosseous RCR
REVISITING HISTORY
 Tunnel Augmentation
 Warner JP, Piza P
 Warren Alpert Medical School 2012
 Bone “Tunnel Protection”
Courtesy: Warner JP

36. Arthroscopic Transosseous RCR
ASSESS THE TEAR AND AVOID OVERTENSIONING
Myotendinous Junction Retears
Some cuffs cannot be pulled all the
way out to cover the old footprint
Shorter tendon = increased tension if pulled to normal length

37. Arthroscopic Transosseous RCR
Tight Cuff Tears
• Covers the footprint as much as possible and
remaining with suture
• Auto adjusts the tension – Spiral Binding
• Less over tensioning when compared to DR/ TOE

38. Comparison
ARTHROTUNNELER Vs ANCHORS
Implant ARTHROTUNNELER
No Implant
ANCHORS
Implant Present
Small Tears
Single tunnel
Expensive Cheap
Large Tears
Two or three tunnel
Cheap Expensive
Technique Simple suture - Easy SR - Easy
Mattress suture - Demanding DR - Demanding
TOE - Easy
Biology Bone marrow from tunnel - More Less in vented anchors
Re tear Easy Re -operation Difficult

39. Arthroscopic Transosseous RCR
CONCLUSIONS
● Equivalent to Current Methods
● Repair Integrity
● Biomechanical Strength
● Reliable/Reproducible Technique
● Multiple Sutures
● Bone Tunnel Augmentation
● Assess the lesion
● Anatomic repair and avoid over tensioning
● More easy reoperation in case of Re-tear
● Biology
● Marrow elements from bone tunnels

41. IAS 2014
ARTHROSCOPIC TRANSOSSEOUS
(ANCHORLESS) ROTATOR CUFF REPAIR
Dr. Raghuveer Reddy. K
Sai Institute of Sports Injury & Arthroscopy
Shoulder & Knee Specialty Centre, Hyderabad

42. 06 Hrs

43. Recent Advances
Rotator Cuff Repair
OASIS 2014
ARTHROSCOPIC TRANSOSSEOUS
(ANCHORLESS) ROTATOR CUFF REPAIR
Dr. Raghuveer Reddy. K
Sai Institute of Sports Injury & Arthroscopy
Shoulder & Knee Specialty Centre, Hyderabad

44. TOE Concerns
Myotendinous Junction Retears
Lill, et al. Arthroscopic Supraspinatus Tendon Repair with
Suture Bridging Technique: Functional Outcome
and MRI. - AJSM 2010
Retear rate by MRI at 12 mos: 28.9%
Cho, et al. Retear Patterns After Arthroscopic Cuff Repair:
Single Row vs. Suture Bridge Technique. - AJSM
2010
27 cases of failed suture bridge technique
74% failure at myotendinous junction
Gerhardt et
al.
Arthroscopic Single-Row Modified Mason-Allen
Repair vs. Double-Row SutureBridge
Reconstruction for Supraspinatus Tendon Tears -
AJSM Dec. 2012
20 patients/5 retears
80% retears at myotendinous junction

45. TOE Concerns
Myotendinous Junction Retears
Hayashida et al. Characteristic re-tear pattern after arthroscopic double-row
repair. Arthroscopy, 2012
15% retear rate at myotendinous junction
Conclusion:
“A new repair method, which achieves a wide
footprint, a good initial fixation strength, and
avoids re-tearing around the proximal suture
anchors should be developed to obtain better
cuff integrity and clinical results.”