Arthroscopic Transosseous Anchorless Rotator Cuff Repair Using the X-Box Technique

Arthroscopic transosseous anchorless rotator cuff repair reduces bone defects related to peri-implant cyst formation: a comparison with conventional suture anchors using propensity score matching

BACKGROUND

The transosseous anchorless repair (ToR) technique was recently introduced to avoid suture anchor-related problems. While favorable outcomes of the ToR technique have been reported, no previous studies on peri-implant cyst formation with the ToR technique exist. Therefore, this study compared the clinical outcomes and prevalence of peri-implant cyst formation between the ToR technique and the conventional transosseous equivalent technique using suture anchors (SA).

METHODS

Cases with arthroscopic rotator cuff repair (ARCR) between 2016 and 2018 treated with the double-row suture bridge technique were retrospectively reviewed. Patients were divided into ToR and SA groups. To compare clinical outcomes, 19 ToR and 57 SA cases without intraoperative implant failure were selected using propensity score matching (PSM). While intraoperative implant failure rate was analyzed before PSM, retear rate, peri-implant cyst formation rate, and functional outcomes were compared after PSM.

RESULTS

The intraoperative implant failure rate (ToR, 8% vs. SA, 15.3%) and retear rate (ToR, 5.3% vs. SA, 19.3%) did not differ between the two groups (all P>0.05). However, peri-implant cysts were not observed in the ToR group, while they were observed in 16.7% of the SA group (P=0.008). Postoperative functional outcomes were not significantly different between the two groups (all P>0.05).

CONCLUSIONS

The ToR technique produced comparable clinical outcomes to conventional techniques. Considering the prospect of potential additional surgeries, the absence of peri-implant cyst formation might be an advantage of ToR. Furthermore, ToR might reduce the medical costs related to suture anchors and, thereby, could be a useful option for ARCR. Level of evidence: III.

Arthroscopic Transosseous Superior Capsular Reconstruction

Superior capsular reconstruction is a common treatment option for irreparable rotator cuffs. Arthroscopic surgery procedures mostly use anchor-based methods. However, difficulty in preoperative graft measurement and intra-articular knot-tying present an obstacle for most sport surgeons. Complementing the known advantages of the transosseous technique in rotator cuff repair, a feasible, economical arthroscopic transosseous superior capsular reconstruction technique is described in this Technical Note. This procedure results not only in similar fixation strength and stability and greater bone stock but also in greater cost effectiveness due to using fewer anchors. This Technical Note describes the procedure in detail and compares it with conventional procedures.

Arthroscopic Anchorless Transosseous Rotator Cuff Repair Produces Equivalent Clinical Outcomes and Imaging Results as a Standard Suture Bridge Technique with Anchors

Purpose

To compare the clinical and imaging outcome of arthroscopic transosseous (TO)-equivalent rotator cuff repair (RCR) with anchors with arthroscopic anchorless TO RCR at a minimum of 2 years postoperatively.

Methods

The study population included patients who underwent RCR using either an anchorless TO technique with a TO suture passing device (group A) and those who were matched for tear size and underwent RCR using suture anchors for repair (group B). The inclusion criterion was an easily reducible rotator cuff tear with a sagittal extension of 2 to 4 cm. After a minimum of 2 years, clinical outcome scores and magnetic resonance imaging were obtained. Tendon quality and footprint integration were evaluated using the Sugaya classification.

Results

Seventy patients were included. A total of 45 were in group A and 25 were in group B. Group A had 2 bone tunnels and 4 sutures using an X-box configuration, and group B had a suture bridge construct of 4 anchors. Group A and B had identical anteroposterior tear size and were comparable for age. The Constant score improved from 50 ± 17.4 to 88 ± 8.6 in group A versus 48 ± 14.5 to 87 ± 7.2 in B. The Subjective Shoulder Value rose from 47 ± 19.1 to 95 ± 7.4 in group A vs from 47 ± 19.4 to 95 ± 7.6 in B. Neither the preoperative (P ≥ .502) nor postoperative scores (P ≥ .29) showed a significant difference. Magnetic resonance imaging showed 2 small retears in group A and one in B, resulting in an identical 4% retear rate. The mean Sugaya type was 2.02 versus 2.24 (P = .206) for groups A versus B.

Conclusions

Anchorless TO RCR is a valid alternative to suture anchor techniques. Clinical outcome data showed comparable results for both techniques after a follow-up of 2 years. The healing results as observed on magnetic resonance imaging were also equivalent for both groups.

Level of Evidence

Level III, retrospective comparative study.

A Novel Arthroscopic Transosseous Procedure for Rotator Cuff Repair: An Economical Freehand Method

Open transosseous repair was historically considered the gold-standard surgical solution for rotator cuff tears; however, with advancements in arthroscopic surgery, this procedure was largely replaced by anchor-based techniques. Yet, the ability of anchor-based techniques to achieve similar biomechanical fixation remains uncertain.In this article, we describe a reproducible, economical, arthroscopic anchorless transosseous rotator cuff repair technique that uses an Omega configuration. This technique involves two bone tunnels and four high-strength polyethylene sutures and is suitable for medium-to-large rotator cuff tears that would alternatively need multiple anchors. This procedure not only maximizes the tendon-footprint contact area without using any implanted device but also theoretically lowers the bone laceration rate and is cost effective. In the current Technical Note, the procedure is described in detail along with several tips and tricks.

CLASSIFICATIONS

Level I, shoulder; Level II, rotator cuff.

Comparison of Occurrence of Bone Tunnel Laceration, Clinical Results, and Cuff Repair Integrity of Transosseous Arthroscopic Rotator Cuff Repair With and Without Lateral Cortical Augmentation

Purpose

To compare the occurrence of bone tunnel laceration, the short-term clinical results, and cuff repair integrity of transosseous arthroscopic rotator cuff repair (ARCR) using a tunneling device, with and without lateral cortical augmentation.

Methods

A retrospective review of patients who underwent transosseous ARCR from May 2012 to December 2017 was conducted. The inclusion criterion was repairable medium- to massive-sized full-thickness rotator cuff tear. This study included 2 consecutive series of patients undergoing transosseous ARCR with and without lateral cortical augmentation, called the ITO method and AT method, respectively. The incidence of bone tunnel laceration was evaluated intraoperatively. Patients were assessed through a range of motion and Constant scores preoperatively and at final follow-up. Further, magnetic resonance imaging was performed at 24 months postoperatively to examine the repaired rotator cuff integrity.

Results

A total of 121 subjects were included: 33 in the AT group and 88 in the ITO group. The intraoperative bone tunnel laceration occurrence rate was 67% and 4% for the AT and ITO methods, respectively; the difference was significant (P = .001). Anatomic failure rate (Sugaya Ⅲ, Ⅳ, and Ⅴ) rate for medium- to large-sized tears was significantly lower for the ITO than for the AT method (29% vs 65%, P = .004), but not for massive tears (61% vs 69%, P = .515). The mean forward elevation, abduction, external rotation, internal rotation, and Constant score were significantly improved at final follow-up from preoperative values. There were no significant differences between the 2 methods.

Conclusions

Transosseous ARCR using a tunneling device with and without lateral cortical augmentation is a reliable method of improving clinical results at a minimum follow-up of 2 years. The intraoperative occurrence rate of bone tunnel laceration occurrence rate and the anatomic failure rate of medium- to large-sized cuff tear were lower with lateral cortical augmentation than without it.

Level of Evidence

Level Ⅳ, therapeutic cases series.

Arthroscopic, Needle-Based, Transosseous Rotator Cuff Repair

Although open transosseous repair was historically used as a gold-standard surgical solution for rotator cuff tears, this procedure was largely replaced by anchor-based techniques because of the advancement of arthroscopic surgery. However, the ability of anchor-based repair to achieve similar biomechanical fixation remains uncertain. Despite the proposals of numerous methods over the last decade, there remains demand for a standard, reliable technique that integrates the biomechanical advantages of transosseous fixation within the realm of arthroscopy. We describe a technique for transosseous rotator cuff repair using the Omnicuff, a needle-based transosseous suture-passing device that minimizes the risk of failure of suture passage between the bone tunnels. With potential advantages of this design including automated-assisted suture passage, improved bone-tendon healing, and anchorless fixation, surgeons may be inclined to consider these biomechanical and cost-saving benefits. Future studies are warranted to determine clinical outcomes of this technique and its suitability for tears of varying degrees and patterns.

True Transosseous Hybrid Rotator Cuff Repair

Transosseous repair has been used safely and effectively for primary and revision rotator cuff repair for decades; as a result, it is considered by many the historical gold standard of open repair techniques. Transosseous repair offers the advantage of excellent biology, double-row anatomic footprint reconstruction, and the ability to create multiple low-cost fixation points per surface area of tendon with high-strength suture, while avoiding anchor pullout, cyst formation, and imaging artifact. More recently, in arthroscopic applications, transosseous-equivalent anchor-based repairs have been introduced that have shown satisfactory clinical and biomechanical results; however, these attributes have been coupled with increased cost, nonbiologic burden to the healing interface of the tendon, and new catastrophic failure modes including tendon transection, anchor pullout, and bone voids. This article delineates a technique for arthroscopic true transosseous hybrid cuff repair that combines the use of anchors and transosseous techniques to maximize the benefits and minimize the detriments of both techniques. Level 1 (shoulder); level 2 (rotator cuff).