Knotless anatomic double-layer double-row rotator cuff repair: a novel technique re-establishing footprint and shape of full-thickness tears

A Modified Arthroscopic Triple-row Repair Technique for L-shaped Delaminated Rotator Cuff Tears

OBJECTIVE

To compare the clinical outcomes of a modified arthroscopic triple-row (TR) repair technique with the suture bridge (SB) repair technique in treating L-shaped delaminated rotator cuff tears. Various surgical techniques for L-shaped delaminated rotator cuff tears have been reported, many of which aid in increasing the contact area and pressure of the rotator cuff. However, there is still debate over which technique yields superior results.

METHODS

From January 2017 to March 2020, 61 cases of L-shaped delaminated rotator cuff tears were included in this study. Of these, 34 cases underwent the modified arthroscopic triple-row repair technique, while 27 cases were addressed with the suture bridge repair technique. Functional assessment was conducted using the American Shoulder and Elbow Surgeons (ASES) score, the University of California Los Angeles (UCLA) shoulder score, the Constant score (CS), and the visual analogue scale (VAS) score. Magnetic Resonance Imaging (MRI) assessments for rotator cuff healing were performed at the 24-month postoperative mark. Statistical evaluations were conducted using SPSS for Windows (Version 25.0, IBM, Armonk, NY, USA), employing the Wilcoxon signed-rank test to compare preoperative and postoperative data and ROM differences, and the Mann-Whitney U test for statistical differences in clinical outcome scores between the two groups. A p-value of less than 0.05 was considered statistically significant.

RESULTS

Comparative analysis of the preoperative and final follow-up scores revealed a substantial enhancement in shoulder function, as indicated by the ASES, UCLA, CS, and VAS scores, with statistical significance (p < 0.001). At both the preoperative stage and final follow-up, no notable differences were observed in ASES, UCLA, CS, and VAS scores between the two groups. However, the TR repair group exhibited lower VAS scores than the SB group at 1 and 3 months postoperatively. Active range of motion (ROM) showed significant improvement in both groups. No significant differences in ROM were noted between the two groups either before the surgery or at the final follow-up.

CONCLUSION

The study demonstrates that both the modified arthroscopic TR and SB techniques for L-shaped delaminated cuff tears yield satisfactory outcomes, with no significant differences in overall clinical performance. Notably, early postoperative pain management appears more effective with the modified TR technique, suggesting its potential for enhanced early recovery experiences. This technique's design, promoting securer fixation and optimal contact conditions, is implied to facilitate superior long-term healing, warranting further investigation into its long-term benefits.

Comparison of En Masse Repair versus Separate Double-Layer Repair for Delaminated Rotator Cuff Tears: A Systematic Review and Meta-Analysis

BACKGROUND

Delamination of cuff tendons has a negative impact on outcomes following arthroscopic rotator cuff repair (RCR). The purpose of this study is to compare en masse repair (EMR) and separate double-layer repair (SDLR) for delaminated rotator cuff tears.

METHODS

A systematic literature search was conducted on major databases (MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus) until 1 June 2023. Comparative studies with a minimum 24-month follow-up of patients undergoing arthroscopic RCR for delaminated tears were included. The outcomes assessed retear rates and functional outcomes.

RESULTS

Five eligible studies involving 325 cases were analyzed. The meta-analysis showed no significant difference in retear rates between SDLR and EMR for delaminated tears (OR = 0.73, 95% CI: 0.35-1.49). However, the meta-analysis demonstrated a significant intergroup difference in favor of the SDLR for the total Constant score (SMD = 0.68, 95% CI: 0.35 to 1.02), SST score (SMD = 0.37, 95% CI: 0.02 to 0.71), and postoperative range of abduction (SMD = 0.34, 95% CI: 0.03 to 0.64).

CONCLUSION

The evidence suggests that the SDLR in arthroscopic RCR for delaminated rotator cuff tears leads to improved short-term functional outcomes and range of motion compared to EMR. However, there is no significant difference in retear risk between the two approaches.

Outcomes After Double-Layer Repair Versus En Masse Repair for Delaminated Rotator Cuff Injury: A Systematic Review and Meta-analysis

Background

Delamination of rotator cuff tears during arthroscopic shoulder surgery has an incidence of 38% to 92%. Double-layer (DL) repair and en masse (EM) repair are most commonly used in this situation.

Purpose

To compare the clinical results of the DL versus EM repair techniques for delaminated rotator cuff tears using a meta-analysis.

Study Design

Systematic review; level of evidence, 3.

Methods

We identified relevant studies comparing the clinical results of DL and EM repair for delaminated rotator cuff injuries in the PubMed, Embase, and Cochrane databases after the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The primary outcomes were the Constant score and retear rate. Additionally, we compared other postoperative shoulder functional scores, shoulder range of motion, and visual analog scale (VAS) pain scores between the 2 suture methods using a meta-analysis. The mean difference (MD) was compared for continuous outcomes, and the odds ratios (ORs) were compared for categorical outcomes.

Results

Of the 197 studies initially identified, 6 studies were included in this analysis. There were significant differences in the Constant score (MD, 8.64 [95% CI, 4.47 to 12.8]; P < .05) and external rotation (MD, 5.10 [95% CI, 2.63 to 7.56]; P < .05) between the 2 techniques, with DL repair having superior outcomes. No significant differences were observed between the 2 techniques in forward flexion (MD, 0.62 [95% CI, -1.18 to 2.43]; P = .50), VAS pain (MD, -0.03 [95% CI, -0.34 to 0.27]; P = .84), or retear rate (OR, 0.73 [95% CI, 0.37 to 1.41]; P = .35).

Conclusion

Results of this review and meta-analysis suggest that DL repair was more beneficial than EM repair in terms of the Constant score and shoulder external rotation in patients with delaminated rotator cuff injuries.

A Propensity Score-Matched Comparison Between Knotless Layer-by-Layer and En Masse Suture Bridge Techniques for Delaminated Rotator Cuff Tears

BACKGROUND

Because the articular layer is more prone to retraction than the bursal layer of the supraspinatus tendon, it is important to restore each layer anatomically while repairing delaminated rotator cuff tears (RCTs).

PURPOSE

To compare clinical outcomes and tendon integrity between knotless layer-by-layer and conventional en masse repair techniques for delaminated RCTs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively reviewed data from 174 consecutive patients with delaminated RCTs treated by arthroscopic suture bridge repair. Only 115 patients with medium to large supraspinatus tears with delamination were included. The 33 patients treated using the knotless layer-by-layer technique (group 2) were matched 1:1 with patients treated using en masse repair with the suture bridge technique (group 1) based on propensity scores. Tendon thickness was measured on magnetic resonance imaging (MRI). Signal changes in the bursal, articular, and intratendinous layers were assessed using T2-weighted MRI.

RESULTS

Postoperatively, statistically significant improvements were seen in both groups compared with preoperatively functional scores. At the final follow-up, there was a statistically significant difference in the Constant score, which was higher in group 2 than in group 1 (91.4 ± 6.0 and 84.3 ± 16.4, respectively; P = .005). There was 1 case of a retear in each group, representing a 3% retear rate. Group 2 had thicker tendons than group 1 (6.9 ± 1.1 and 6.0 ± 1.2 mm, respectively; P = .017). On T2-weighted MRI, a low signal intensity in the articular layer was more common in group 2 (P = .046).

CONCLUSION

En masse repair using the suture bridge technique and the knotless layer-by-layer technique were both effective. Regarding tendon healing, no significant differences were seen in retear rates. However, superior results in terms of the Constant score, tendon thickness, and signal intensity in the articular layer were observed using the knotless layer-by-layer technique.

The knotless cinch-bridge technique for delaminated rotator cuff tears leads to a high healing rate and a more favorable short-term clinical outcome than suture-bridge repair

PURPOSE

To compare functional outcomes and magnetic resonance image (MRI) tendon integrity following either the suture bridge or the knotless cinch-bridge technique used for arthroscopic double-layer rotator cuff repair.

METHODS

37 prospectively enrolled patients (46-76 years), who were treated with arthroscopic double-layer rotator cuff repair (group 1: suture bridge n = 20, group 2: cinch bridge n = 17) were clinically and radiographically assessed before and at an average of 24.0 ± 4.7 months after the procedure. Shoulder function was evaluated by the constant score (CS), range of motion, and various patient-related scores. Repaired tendon integrity was evaluated by MRI. Peri- and postoperative complications were recorded.

RESULTS

All functional and patient-related scores significantly improved from pre- to postoperative. Significantly better postoperative CS (P = 0.037), flexion (P < 0.001), and abduction (P = 0.009) were detected after arthroscopic cinch compared to suture-bridge repair. The mean CS improvements from baseline to follow-up were not significantly different between the groups (n.s.). Patient-related scores did not show any statistical significant differences. The MRI healing rate following arthroscopic double-layer repair with the suture- and cinch-bridge technique was 95% and 94%, respectively. Fatty infiltration regarding the supraspinatus and infraspinatus increased in 55% and 35% (group 1) and in 53% and 48% (group 2), respectively. Muscle hypotrophy remained stable in all patients. Overall, 92% of the patients were very satisfied or satisfied with the procedure. No complications were detected.

CONCLUSIONS

Arthroscopic knotless double-layer rotator cuff repair with the cinch-bridge technique showed higher CS, forward flexion, and abduction values, as well as similar patient-related short-term outcome and MRI integrity compared to the suture-bridge technique. These results highlight the potential importance of less tendon strangulation for better clinical short-term outcome.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Arthroscopic Knotless Separate Layer Transosseous Equivalent Repair of Delaminated Rotator Cuff Tears

Delamination of rotator cuff tears presents a challenge for surgeons. Recognizing and repairing such a complex tear pattern often require innovative approaches to achieve an anatomic restoration of footprint. In this Technical Note, we described our preferred method that anatomically repairs both layers of delaminated rotator cuff tear separately in a knotless transosseous equivalent technique. Two sutures are placed to the articular layer in a cinch stitch configuration. Then, closed-loop end sutures are passed through both layers while keeping the closed-loop end at the working portal. The free ends of cinch stitches are loaded to anchors with a preloaded fiber tape loop, which is placed to the medial row while approximating the articular layer onto its footprint. Fiber tapes are then shuttled through both layers of tendon with the help of a previously placed closed-loop suture. Finally, the lateral row anchors are placed while fiber tapes are tensioned in a cross-bridge configuration. We believe that this technique may facilitate uneventful healing of delaminated rotator cuffs by providing the biomechanical properties of transosseous equivalent repair.

Clinical and Radiographic Outcomes After Arthroscopic Lamina-Specific Double-Row Repair of Large Delaminated Rotator Cuff Tears in Active Patients

Background:

The presence of delamination and a larger rotator cuff tear (RCT) size have been associated with poorer outcomes in rotator cuff repair. Therefore, we developed a new surgical procedure, arthroscopic lamina-specific double-row fixation (ALSDR), for the repair of large delaminated RCTs.

Purpose:

To investigate the clinical outcomes, magnetic resonance imaging findings, and satisfaction with several variables after ALSDR for large delaminated RCTs.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 30 active patients (mean age, 59.1 years) undergoing ALSDR were assessed by a numeric rating scale (NRS; 0-10) for pain, surgery, work, and exercise as well as American Shoulder and Elbow Surgeons (ASES), Constant, and Simple Shoulder Test (SST) scores at a mean of 65.9 months postoperatively. Rotator cuff integrity was determined by magnetic resonance imaging. The Spearman correlation coefficient (ρ) was used to determine the correlation between clinical and NRS scores.

Results:

Five patients (16.7%) had a retear. Each of the postoperative functional and NRS scores except the NRS work score was significantly better in the healed shoulders than in the shoulders with a retear (P < .001). The NRS pain score showed a significant negative correlation with ASES, Constant, and SST scores (ρ = −0.775, −0.668, and −0.742, respectively; P < .001 for all). The NRS surgery score had a positive correlation with Constant and SST scores (ρ = 0.393 [P = .032] and ρ = 0.456 [P = .011], respectively). The NRS work score had a positive correlation with ASES, Constant, and SST scores (ρ = 0.382 [P = .037], ρ = 0.386 [P = .035], and ρ = 0.414 [P = .023], respectively). The NRS exercise score had a positive correlation with ASES, Constant, and SST scores (ρ = 0.567 [P = .001], ρ = 0.511 [P = .004], and ρ = 0.639 [P < .001], respectively).

Conclusion:

Our results showed that there was a significant correlation between clinical and NRS scores. The results indicate that ALSDR can provide a high degree of functionality and can be a useful alternative treatment for active patients with large delaminated RCTs.

Morphologic Factors Related to Repair Outcomes for Delaminated Rotator Cuff Tears: A Minimum 2-Year Retrospective Comparison Study

PURPOSE

To evaluate clinical outcomes and repair integrity after en masse transosseous-equivalent suture bridge repair for delaminated rotator cuff tears and to analyze the morphologic factors related to clinical outcomes and repair integrity.

METHODS

This study included 99 patients who underwent the technique of en masse transosseous-equivalent suture bridge repair for delaminated rotator cuff tears. Morphologic factors were estimated using magnetic resonance imaging, and clinical outcomes were evaluated using the University of California, Los Angeles score; American Shoulder and Elbow Surgeons score; and Constant shoulder score. The morphologic factors included the shape of delamination, retraction length of the bursal and articular layers, gap distance between the layers, and length of the intrasubstance cleavage. According to follow-up magnetic resonance imaging, cases were categorized into the intact or retear group. The morphologic factors were compared between the 2 groups, including the correlation between the morphologic factors and postoperative outcomes.

RESULTS

Retears occurred in 26 of 99 cases (26%). In both the intact and retear groups, the University of California, Los Angeles, American Shoulder and Elbow Surgeons, and Constant scores improved postoperatively (P < .0001). The most common delamination shape was that of a more retracted articular layer in retears. We found no differences in retears in terms of the retraction length of the bursal layer, gap distance, and length of the intrasubstance cleavage. However, the retraction length of the articular layer differed significantly between the groups (P < .0001). No correlation between the morphologic factors and clinical outcomes was found.

CONCLUSIONS

Arthroscopic en masse transosseous-equivalent suture bridge repair is a useful technique in delaminated tears to achieve optimal repair outcomes. In addition, although there was no correlation between the morphologic factors and postoperative clinical outcomes, the retraction length of the articular layer was identified as a significant factor influencing repair integrity. We recommend emphasizing the reduction of tension within the articular layer during the repair procedure.

LEVEL OF EVIDENCE

Level III, retrospective comparison study.

Comparison of En Masse Versus Dual-Layer Suture Bridge Procedures for Delaminated Rotator Cuff Tears

PURPOSE

To compare clinical outcomes between 2 suturing procedures, conventional en masse suture bridging (EMSB) and dual-layer suture bridging (DLSB), for delaminated rotator cuff tears.

METHODS

From January 2011 through December 2015, 98 consecutive cases with delaminated rotator cuff tears were included in this study (52 with EMSB and 46 with DLSB). The mean age was 65.0 ± 8.9 years (range, 38-85 years). The mean follow-up period was 28.0 ± 6.3 months (range, 24-40 months). The cases included 78 medium tears (1-3 cm) and 20 large tears (3-5 cm). The University of California, Los Angeles (UCLA) rating scale, the Simple Shoulder Test (SST), a visual analog scale for pain, and active range of motion of the shoulder preoperatively and 2 years after surgery were evaluated. Postoperative magnetic resonance imaging was obtained at 12 months after surgery.

RESULTS

Both the EMSB and DLSB groups showed improved clinical outcomes. Postoperative UCLA and SST scores were higher in the DLSB group than in the EMSB group (UCLA score, 33.2 ± 2.3 vs 32.0 ± 3.3 [P = .027]; SST score, 10.0 ± 1.0 vs 9.5 ± 1.2 [P = .014]). Postoperative abduction and external rotation of the shoulder were greater in the DLSB group than in the EMSB group (abduction, 160.1° ± 9.1° vs 154.8° ± 19.8° [P = .030]; external rotation, 53.7° ± 8.5° vs 46.1° ± 9.4° [P = .023]). Postoperative magnetic resonance imaging showed a retear in 7 of 52 cases in the EMSB group and 3 of 46 cases in the DLSB group, with no significant difference between groups.

CONCLUSIONS

The DLSB and EMSB procedures for delaminated rotator cuff tears improved clinical and radiographic outcomes, and the DLSB group achieved better postoperative range of motion of the shoulder than the EMSB group. The DLSB procedure is useful for repairing delaminated rotator cuff tears.

LEVEL OF EVIDENCE

Level III, retrospective, case-control, comparative study.

Arthroscopic Double-Layer Lasso Loop Technique to Repair Delaminated Rotator Cuff Tears

PURPOSE

To evaluate the arthroscopic double-layer lasso loop repair technique for delaminated posterosuperior rotator cuff tears.

METHODS

Forty-one patients underwent arthroscopic rotator cuff repair of a delaminated posterosuperior rotator cuff tear by the double-layer lasso loop technique. Their preoperative and postoperative clinical and functional scores were compared to evaluate surgical outcomes. The prerequisite for inclusion was a minimum follow-up period of 2 years. We excluded patients with a history of shoulder surgery before the double-layer lasso loop repair.

RESULTS

Statistically significant improvements (P < .001) were found in the Constant score (54 vs 83) and University of California, Los Angeles functional score (6.4 vs 9.5). Pain and strength improved according to the Jobe test, bear-hug test, belly-press test, Gerber lift-off test, and external rotation test (P < .001). No significant difference in strength was noted between the operated and nonoperated sides. There was only 1 complete rerupture (3.1%), whereas 5 patients (15.6%) had partial ruptures.

CONCLUSIONS

The arthroscopic double-layer lasso loop repair technique for delaminated posterosuperior rotator cuff tears is an effective procedure. Our series showed a low rerupture rate. At a mean follow-up of 44 months, postoperative recovery with resultant functional, pain, and patient satisfaction scores was good to excellent and was comparable with the nonoperated side.

LEVEL OF EVIDENCE

Level IV, case series.

Double-Layer Rotator Cuff Repair: Anatomic Reconstruction of the Superior Capsule and Rotator Cuff Improves Biomechanical Properties in Repairs of Delaminated Rotator Cuff Tears

BACKGROUND

Delamination in rotator cuff tears has been identified as a prognostic factor for negative outcome after repair, with a reported prevalence between 38% and 88%.

PURPOSE

To compare biomechanical properties of 3 repair techniques for delaminated rotator cuff tears.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eighteen fresh-frozen cadaveric shoulders were used to evaluate rotator cuff footprint reconstruction, contact area and pressure, displacement under cyclical loading, and load to failure of 3 double-row repair configurations: double-row suture repair with medial row knots (medially knotted bridge, mkB); knotless double-row repair using suture tapes (knotless bridge, klB); and knotless double-row, double-layer-specific repair (double-layer, DL). Dynamic pressure sensors were used to assess contact patterns at the footprint region in 0°, 30°, and 60° of glenohumeral abduction and 5 rotational positions (0°, 30° of internal rotation, 30° of external rotation, 60° of internal rotation, 60° of external rotation). Optical markers were used to document whole tendon and individual layer displacement after rotator cuff repair under cyclical loading for 200 cycles (10 N to 100 N at 1 Hz). Specimens were then loaded monotonically to failure at a rate of 33 mm/min.

RESULTS

Mean contact area and footprint restoration were highest in the DL group at 60° of glenohumeral abduction for all rotational positions (mkB mean ± SD, 195.4 ± 54.3 mm², 66.7% ± 19.7%; klB, 250.6 ± 34.9 mm², 76.2% ± 10.3%; DL, 318.4 ± 36.6 mm², 109.1% ± 24.0%; P < .001). The double-layer-specific repair showed the least displacement under cyclical loading (mkB mean ± SD, 0.53 ± 0.18 mm; klB, 0.79 ± 0.37 mm; DL, 0.31 ± 0.24 mm; P = .029), most closely resembling the native tendon. Peak loads at failure were comparable between repair groups (mkB mean ± SD, 366.92 ± 70.59 N; klB, 280.05 ± 77.66 N; DL, 398.35 ± 109.04 N; P = .083).

CONCLUSION

Anatomic restoration of the superior capsular and tendon insertion in delaminated rotator cuff tears with a double-layer-specific repair configuration demonstrated superior footprint restoration with increasing abduction, while providing construct displacement comparable to the native tendon under cyclical loading. Peak load at failure was comparable between repair constructs.

CLINICAL RELEVANCE

The prevalence and clinical importance of delaminated rotator cuff tears have long been underestimated. Anatomically correct individual reconstruction of the superior capsule and rotator cuff could restore near-native biomechanics and potentially reduce the risk of rotator cuff repair failure.

An Arthroscopic Knotless Technique for Anatomical Restoration of the Rotator Cuff and Superior Capsule: The Double-Layer Cinch Bridge

Rotator cuff repairs are the most common procedures in shoulder surgery, but still show long-term retear rates of up to 70%. Nonanatomic reconstruction is one possible cause of repair failure. The rotator cuff histologically consists of 5 separate layers of which 2 are macroscopically identifiable: the superior or tendinous layer and the inferior or capsule-ligamentous layer. In case of rotator cuff tears, these layers are often retracted to different degrees. The intraoperative detectable prevalence of rotator cuff delamination reaches up to 85%. Anatomical rotator cuff repair, which also includes restoration of the layered structure, could re-establish native tendon morphology and thus potentially decreases retear rates. The use of a knotless construct to avoid cuff strangulation and maintaining tendon perfusion could further decrease the risk of repair failure. Double-layer reconstructions are challenging and time consuming because each layer needs to be penetrated separately. Only few studies reported about double-layer reconstruction of the posterosuperior rotator cuff. This Technical Note is the first to present an arthroscopic knotless transosseous-equivalent double-layer repair technique.

[Clinical research of arthroscopic separate double-layer suture bridge technique for delaminated rotator cuff tear]

Objective

To explore the effectiveness of the arthroscopic separate double-layer suture bridge technique in treatment of the delaminated rotator cuff tear.

Methods

Between May 2013 and May 2015, 54 patients with the delaminated rotator cuff tears were recruited in the study. They were randomly allocated into 2 groups to receive repair either using arthroscopic separate double-layer suture bridge technique (trial group, n=28) or using arthroscopic whole-layer suture bridge technique (control group, n=26). There was no significant difference in gender, age, injured side, tear type, and preoperative visual analogue scale (VAS) score, Constants score, American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) score, and the range of motion of shoulder joint between 2 groups ( P>0.05). Postoperative functional scores, range of motion, and recurrence rate of tear in 2 groups were observed and compared.

Results

The operation time was significant longer in trial group than in control group ( t=8.383, P=0.000). All incisions healed at stage Ⅰ without postoperative complication. All the patients were followed up 12 months. At 12 months postoperatively, the UCLA score, ASES score, VAS score, Constant score, and the range of motion were significantly improved when compared with the preoperative values in 2 groups ( P<0.05). However there was no significant difference in above indexes between 2 groups ( P>0.05). Four cases (14.3%) of rotator cuff tear recurred in trial group while 5 cases (19.2%) in control group, showing no significant difference ( χ²=0.237, P=0.626).

Conclusion

Compared with the arthroscopic whole-layer suture bridge technique, arthroscopic separate double-layer suture bridge technique presents no significant difference in the shoulder function score, the range of motion, and recurrence of rotator cuff tear, while having a longer operation time.

Conventional En Masse Repair Versus Separate Double-Layer Double-Row Repair for the Treatment of Delaminated Rotator Cuff Tears

BACKGROUND

The rotator cuff tendon is known to exert a shear force between the superficial and deep layers. Owing to this characteristic, separate repair of delaminated rotator cuff tears has been introduced for the restoration of the physiological biomechanics of the rotator cuff. However, whether conventional en masse repair or separate repair is superior is controversial in terms of outcomes.

PURPOSE

To compare clinical outcomes between conventional en masse repair and separate double-layer double-row repair for the treatment of delaminated rotator cuff tears.

STUDY DESIGN

Randomized controlled study; Level of evidence, 2.

METHODS

Between August 2007 and March 2014, a total of 82 patients who underwent arthroscopic rotator cuff repair of a delaminated tear were enrolled and randomized into 2 groups. In group 1 (n = 48), arthroscopic conventional en masse repair was performed. In group 2 (n = 34), separate double-layer double-row repair was performed. The American Shoulder and Elbow Surgeons score, Constant score, Simple Shoulder Test score, and visual analog scale (VAS) score for pain and range of motion (ROM) were assessed before surgery; at 3, 6, and 12 months after surgery; and at the last follow-up visit. Magnetic resonance imaging (MRI) was performed at 12 months postoperatively to examine the retear rate and pattern.

RESULTS

There was no significant difference between groups in the preoperative demographic data, including patient age, sex, symptom duration, tear size, and functional scores (P > .05). The mean follow-up period was 25.9 ± 1.2 months. Significant improvements in functional and pain scores were observed in both groups at the last follow-up visit. However, no significant differences in functional scores and ROM were found between the 2 groups at each time point, except that group 2 had significantly lower VAS pain scores (P < .05) at 3, 6, and 12 months postoperatively. Eight (17%) of 48 patients in group 1 and 6 (18%) of 34 patients in group 2 showed retears on MRI at 12-month follow-up (P > .05).

CONCLUSION

Both conventional en masse repair and separate double-layer double-row repair were effective in improving clinical outcomes in the treatment of delaminated rotator cuff tears. Lower pain scores were seen in patients who underwent separate double-layer double-row repair.

Comparison of completely knotless and hybrid double-row fixation systems: a biomechanical study

PURPOSE

The purpose of this study was to compare the biomechanical performance of a completely knotless double-row repair system (SutureCross Knotless Anatomic Fixation System; KFx Medical, Carlsbad, CA) with 2 commonly used hybrid double-row repair (medial knot-tying, lateral knotless) systems (Bio-Corkscrew/PushLock [Arthrex, Naples, FL] and Spiralok/Versalok [DePuy Mitek, Raynham, MA]).

METHODS

Fourteen pairs of fresh-frozen cadaveric shoulders were harvested, the supraspinatus tendons were isolated, and full-thickness supraspinatus tears were created. One of each pair was repaired with the completely knotless system, and the contralateral side was repaired with either of the hybrid systems. The repairs were then subjected to cyclic loading followed by load to failure. Conditioning elongation, peak-to-peak elongation, ultimate load, and mechanism of failure were recorded and compared by use of paired t tests. Seven additional shoulders were tested to determine the effect of refrigeration storage on the completely knotless system by use of the same mechanical testing protocol.

RESULTS

For the completely knotless repair group, 11 of 14 paired specimens failed during the cyclic loading period. Only 1 of 14 hybrid repair systems had failures during cyclic loading, and both hybrid repair systems had statistically lower conditioning elongation than the completely knotless repair group. The mean ultimate load of the SutureCross group was 166 ± 87 N, which was significantly lower than that in the Corkscrew/PushLock (310 ± 82 N) and Spiralok/Versalok (337 ± 44 N) groups. There was an effect of refrigeration storage on the peak-to-peak elongation and stiffness of the SutureCross group; however, there was no difference in ultimate tensile load or conditioning elongation.

CONCLUSIONS

The completely knotless repair system has lower time-zero biomechanical properties than the other 2 hybrid systems.

CLINICAL RELEVANCE

The SutureCross system has lower time-zero biomechanical properties when compared with other hybrid repair systems. Clinical outcome studies are needed to determine the significance.

The low-profile Roman bridge technique for knotless double-row repair of the rotator cuff

With advances in arthroscopic surgery, many techniques have been developed to increase the tendon-bone contact area, reconstituting a more anatomic configuration of the rotator cuff footprint and providing a better environment for tendon healing. We present a low-profile arthroscopic rotator cuff repair technique which uses suture bridges to optimize rotator cuff tendon-footprint contact area and mean pressure. A 5.5 mm Bio-Corkscrew suture anchor (Arthrex, Naples, FL, USA), double-loaded with No. 2 FiberWire sutures (Arthrex, Naples, FL, USA), is placed in the anteromedial aspect of the footprint. Two suture limbs from a single suture are both passed through a single anterior point in the rotator cuff. One suture limb is retrieved from the cannula. The second suture limb is passed through a single posterior point in the rotator cuff producing two points of fixation in the tendon, with a tendon bridge between them. The same suture limb is retrieved through the lateral portal, and then inserted into the bone by means of a Pushlock (Arthrex, Naples, FL, USA), placed approximately 1.5-2 cm posterior to the first anchor. This second suture is passed again in the posterior aspect of the cuff. The limbs of the first suture are pulled to compress the tendon in the medial aspect of the footprint. The two free suture limbs are used to produce suture bridges over the tendon by means of a Pushlock (Arthrex, Naples, FL, USA), placed 1 cm distal to the lateral edge of the footprint relative to the medially placed suture anchors anterior to posterior. This technique allows us to perform a low-profile (single pulley-suture bridges) repair for knotless double-row repair of the rotator cuff.