Biomechanical Strength of Rotator Cuff Repairs: A Systematic Review and Meta-regression Analysis of Cadaveric Studies

Arthroscopic Double-Pulley Suture-Bridge Repair of Supraspinatus Tendon Tear

At present, the suture bridge is a widely used surgical pattern in the treatment of supraspinatus tendon tear, but the shortcomings of a suture bridge, including expensive lateral-row anchor and increased type 2 retear rate, is obvious. The double-pulley suture-bridge described in this Technical Note uses a double-loaded suture anchor (medial-row anchor) as lateral-row anchor instead of traditional lateral-row anchor, combined with double-pulley technology forming suture-bridge in treatment of supraspinatus tendon tears. The surgical technique is described in pearls, pitfalls, advantages, and disadvantages.

Combined Biologic Augmentation Strategies with Collagen Patch Graft, Microfractures, and Platelet Concentrate Injections Improve Functional and Structural Outcomes of Arthroscopic Revision Rotator Cuff Repair

BACKGROUND

Arthroscopic revision rotator cuff repair (ARRCR) is challenging. Biologic strategies seem to be promising. The aim was to evaluate the effectiveness of the combination of microfractures of the greater tuberosity, augmentation with collagen patch graft, and platelet concentrate injections in ARRCR.

METHODS

A retrospective comparative study was conducted on patients that underwent ARRCR with a minimum follow-up of two years. Patients in the augmentation group underwent ARRCR combined with microfractures, collagen patch graft, and postoperative subacromial injections of platelet concentrate. A standard rotator cuff repair was performed in the control group.

PRIMARY OUTCOME

Constant-Murley score (CMS).

SECONDARY OUTCOMES

disease-specific, health-related quality of life using the Disabilities of the Arm, Shoulder, and Hand (DASH) score; assessment of tendon integrity with magnetic resonance at least six months after surgery. Significance was set at p < 0.05.

RESULTS

Forty patients were included. Mean follow-up was 36.2 ± 8.7 months. The mean CMS was greater in the augmentation group (p = 0.022). No differences could be found for DASH score. Healing failure rate was higher in the control group (p = 0.002).

CONCLUSION

Biologic augmentation of ARRCR using a combination of microfractures, collagen patch graft, and subacromial injections of platelet concentrate is an effective strategy in improving tendon healing rate.

LEVEL OF EVIDENCE

retrospective cohort study, level III.

Effect of CCR2 Knockout on Tendon Biomechanical Properties in a Mouse Model of Delayed Rotator Cuff Repair

BACKGROUND

The high incidence of incomplete or failed healing after rotator cuff repair (RCR) has led to an increased focus on the biologic factors that affect tendon-to-bone healing. Inflammation plays a critical role in the initial tendon-healing response. C-C chemokine receptor type 2 (CCR2) is a chemokine receptor linked to the recruitment of monocytes in early inflammatory stages and is associated with an increase in pro-inflammatory macrophages. The purpose of this study was to evaluate the role of CCR2 in tendon healing following RCR in C57BL/6J wildtype (WT) and CCR2-/- knockout (CCR2KO) mice in a delayed RCR model.

METHODS

Fifty-two 12-week-old, male mice were allocated to 2 groups (WT and CCR2KO). All mice underwent unilateral supraspinatus tendon (SST) detachment at the initial surgical procedure, followed by a delayed repair 2 weeks later. The primary outcome measure was biomechanical testing. Secondary measures included histology, gene expression analysis, flow cytometry, and gait analysis.

RESULTS

The mean load-to-failure was 1.64 ± 0.41 N in the WT group and 2.50 ± 0.42 N in the CCR2KO group (p = 0.030). The mean stiffness was 1.43 ± 0.66 N/mm in the WT group and 3.00 ± 0.95 N/mm in the CCR2KO group (p = 0.008). Transcriptional profiling demonstrated 7 differentially expressed genes (DEGs) when comparing the CCR2KO and WT groups (p < 0.05) and significant differences in Type-I and Type-II interferon pathway scores (p < 0.01). Flow cytometry demonstrated significant differences between groups for the percentage of macrophages present (8.1% for the WT group compared with 5.8% for the CCR2KO group; p = 0.035). Gait analysis demonstrated no significant differences between groups.

CONCLUSIONS

CCR2KO may potentially improve tendon biomechanical properties by decreasing macrophage infiltration and/or by suppressing inflammatory mediator pathways in the setting of delayed RCR.

CLINICAL RELEVANCE

CCR2 may be a promising target for novel therapeutics that aim to decrease failure rates following RCR.

Risk Factors and Corresponding Management for Suture Anchor Pullout during Arthroscopic Rotator Cuff Repair

INTRODUCTION

Due to the aging of the population, the incidence of rotator cuff tears is growing. For rotator cuff repair, arthroscopic suture-anchor repair has gradually replaced open transosseous repair, so suture anchors are now considered increasingly important in rotator cuff tear reconstruction. There are some but limited studies of suture anchor pullout after arthroscopic rotator cuff repair. However, there is no body of knowledge in this area, which makes it difficult for clinicians to predict the risk of anchor pullout comprehensively and manage it accordingly.

METHODS

The literature search included rotator cuff repair as well as anchor pullout strength. A review of the literature was performed including all articles published in PubMed until September 2021. Articles of all in vitro biomechanical and clinical trial levels in English were included. After assessing all abstracts (n = 275), the full text and the bibliographies of the relevant articles were analyzed for the questions posed (n = 80). Articles including outcomes without the area of interest were excluded (n = 22). The final literature research revealed 58 relevant articles. Narrative synthesis was undertaken to bring together the findings from studies included in this review.

RESULT

Based on the presented studies, the overall incidence of anchor pullout is not low, and the incidence of intraoperative anchor pullout is slightly higher than in the early postoperative period. The risk factors for anchor pullout are mainly related to bone quality, insertion depth, insertion angle, size of rotator cuff tear, preoperative corticosteroid injections, anchor design, the materials used to produce anchors, etc. In response to the above issues, we have introduced and evaluated management techniques. They include changing the implant site of anchors, cement augmentation for suture anchors, increasing the number of suture limbs, using all-suture anchors, using an arthroscopic transosseous knotless anchor, the Buddy anchor technique, Steinmann pin anchoring, and transosseous suture repair technology.

DISCUSSION

However, not many of the management techniques have been widely used in clinical practice. Most of them come from in vitro biomechanical studies, so in vivo randomized controlled trials with larger sample sizes are needed to see if they can help patients in the long run.

Arthroscopic Double-Row Repair of Posterosuperior Rotator Cuff Tears: Suture Bridge Technique Reinforced With Modified Mason-Allen and Simple Sutures

Rotator cuff (RC) tears represent one of the most common causes of pain and dysfunction of the shoulder. Numerous RC repair techniques have been reported. In this Technical Note, we introduce an arthroscopic double-row repair technique that combines a suture bridge construct with modified Mason-Allen and simple suture fixation to optimize load-sharing and compression of the RC to the footprint. The described technique is ideal for crescent-shaped and large reparable U-shaped posterosuperior RC tears.

Mechanical consequences at the tendon-bone interface of different medial row knotless configurations and lateral row tension in a simulated rotator cuff repair

Purpose

Little is known about the direct influence of different technical options at the rotator cuff tendon-bone interface (TBI) and, more specifically, at the medial bearing row (MBR), regarding local contact force, area and pressure. We evaluated the mechanical repercussions of different medial row anchor configurations for that setting using different values of tension in the lateral row anchors.

Methods

Knotless transosseous equivalent (TOE) rotator cuff repairs with locked versus nonlocked medial anchors and single versus double-hole suture passage were tested in a synthetic rotator cuff mechanical model, using 2 different values of lateral row tension. Contact force, area, pressure, peak force and MBR force were compared at the simulated TBI using a pressure mapping sensor.

Results

When compared to locked anchors, medial row sliding configurations generate lower values for all the above-mentioned parameters.

The use of double-hole suture passage in the medial cuff generated slightly higher values contact area regardless of lateral row tension. At higher lateral row tension values, lower values of the remaining parameters, including MBR force, were found when compared to single-hole suture passage.

Lateral row anchor tension increase induced an increase of all parameters regardless of the medial row configuration and TBI contact force and MBR force were the most susceptible parameters, regardless of the medial row pattern.

Conclusion

Medial row mechanism, suture configuration and lateral row tension interfere with the mechanical force, area and pressure at by TBI. Lateral row tension increase is a major influencer in those parameters.

These results can help surgeons choose the right technique considering its mechanical effect at the TBI.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40634-022-00536-1.

Single Medial-Row Anchor With Biceps Tenodesis in a Transosseous Double-Row Construct for Massive Rotator Cuff Tear

Massive rotator cuff tears are a common issue for patients and can be challenging to manage surgically. While the literature has shown that repair construct can affect the outcome of a rotator cuff repair, and the double-row repair is typically favored over the single-row repair for larger rotator cuff tears, the double-row repair also has some shortcomings. These shortcomings are related to the increased technical difficulty of the procedure, as well as increased costs due to the increased number of anchors used. Both of these factors also lead to an increase in the amount of time spent in the operating room as well. This study describes a surgical technique to help mitigate this shortcoming of the double-row repair by using a single medial-row anchor in our double-row construct for repair of a massive rotator cuff tear.

Limited Biomechanical Evidence Behind Single Row Versus Double Row Repair of Subscapularis Tears: A Systematic Review

Purpose

To systematically review the literature for studies investigating the biomechanical properties of constructs used to repair isolated subscapularis tears in time zero human cadaveric studies.

Methods

A systematic review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three electronic databases were searched for studies that reported on the construct technique and biomechanical outcomes for the repair of isolated subscapularis tears in human cadaveric specimens. Ultimate load, gap formation, stiffness, and failure mode were documented. Methodological quality was assessed using the Quality Appraisal for Cadaveric Studies (QUACS) scale.

Results

Six articles qualified (104 shoulders [72 single-row, 26 double-row, 6 transosseous]; mean QUACS score 10.5 ± 1) and were analyzed. Studies varied in the number and type of anchors and construct technique (1-2 anchors single-row; 3-4 anchors double-row; bioabsorbable or titanium anchors) and suture(s) used (no. 2 FiberWire or FiberTape), subscapularis tear type (25%, 33%, 50%, or 100% tear), and whether a knotless or knotted fixation was used. In studies that created full-thickness, upper subscapularis tears (Fox-Romeo II/III or Lafosse II), no significant differences were seen in ultimate load, gap formation, and stiffness for knotted versus knotless single-row repair (2 studies) and single-row versus double-row repair (1 study). Double-row repair of complete subscapularis tears demonstrated higher ultimate load, stiffness, and lower gap formation in 1 study. Ultimate load differed between the studies and constructs (single-row: range, 244 N to 678 N; double-row: range 332 N to 508 N, transosseous: 453 N). Suture cutout was the most common mode of failure (59%).

Conclusion

Because of the limited number of studies and varying study designs in examining the biomechanical properties of repair constructs used for subscapularis tears, there is inconclusive evidence to determine which construct type is superior for repairing subscapularis tears.

Clinical Relevance

Results from biomechanical studies of clinically relevant subscapularis repair constructs are important to guide decision-making for choosing the optimal construct for patients with subscapularis tears.

Comparison of Biomechanical Failure Loads Between Tape-Type and Conventional Sutures in Internal Knotless Anchor–Based Constructs

Background:

Despite the increasing prevalence of tape-type sutures, whether internal knotless anchors can consistently affix tape-type sutures has not been thoroughly investigated.

Purpose:

To evaluate whether substituting tape-type sutures for conventional sutures influences the suture-holding strength of internal knotless anchors.

Study Design:

Controlled laboratory study. Level of evidence, 5.

Methods:

A total of 3 internal knotless anchors were tested: a spiral core clamping anchor (Footprint Ultra PK), a winged clamping anchor (PopLok), and a spooling anchor (ReelX STT). Four constructs were compared for each type of anchor, with the anchor double or quadruple loaded with tape-type sutures or conventional sutures. The testing protocol comprised preloading suture tension to 10 N; cyclic loading, in which tension increased in increments of 10 N from 10 to 90 N; and a load-to-failure stage set at a speed of 0.5 mm/s. The clinical failure load (CFL) was defined as suture slippage of ≥3 mm. Also, 1-way analysis of variance and power analysis were used to compare the CFLs of the constructs.

Results:

For the quadruple-loaded spiral core clamping anchors, a significant reduction in CFLs was seen with conventional sutures over tape-type sutures (138.10 ± 4.73 vs 80.00 ± 12.25 N, respectively; P < .001). This reduction was not observed under the double-loaded condition (conventional vs tape type: 76.00 ± 5.48 vs 80.00 ± 10.00 N, respectively). Substitution of the suture materials did not significantly reduce the CFLs for the winged clamping anchors (conventional vs tape type: 40.00 ± 10.00 vs 30.00 ± 7.07 N for double loaded, respectively, and 64.00 ± 13.41 vs 50.00 ± 10.00 N for quadruple loaded, respectively) or the spooling anchors (conventional vs tape type: 62.00 ± 19.23 vs 56.32 ± 20.20N for double loaded, respectively, and 72.00 ± 21.68 vs 84.00 ± 13.42 N for quadruple loaded, respectively).

Conclusion:

Substituting tape-type sutures for conventional sutures increased the CFLs of some internal knotless anchors. With specific suture-anchor combinations, quadruple-loaded conventional suture anchors had CFLs higher than those of double-loaded conventional suture anchors.

Clinical Relevance:

When multiple tape-type sutures are used in conjunction with a clamping anchor, clinicians should note a possible reduction in CFLs and resultant early suture slippage.

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.

Optimizing Fixation for Distal Biceps Tendon Repairs: A Systematic Review and Meta-regression of Cadaveric Biomechanical Testing

BACKGROUND

Various surgical techniques can be used to repair acute distal biceps tendon (DBT) tears; however, it is unknown which type of repair or implant has the greatest biomechanical strength and presents the lowest risk of type 2 failure.

PURPOSE

To identify associations between the type of implant or construct used and the biomechanical performance of DBT repairs in a review of human cadaveric studies.

STUDY DESIGN

Systematic review and meta-regression.

METHODS

We systematically searched the EMBASE and Medline (PubMed) databases for biomechanical studies that evaluated DBT repair performance in cadaveric specimens. Two independent reviewers extracted data from 14 studies that met our inclusion criteria. The pooled data set was subjected to meta-regression with adjusted failure load (AFL) as the primary outcome variable. Procedural parameters, such as number of sutures, cortices, locking stitches, and whipstitches, served as covariates. Adjusted analysis was performed to determine the differences among implant types. The alpha level was set at .05.

RESULTS

When using no implant (bone tunnels) as the referent, no fixation type or procedural parameter was significantly better at predicting AFL. Cortical button fixation had the highest AFL (370 N; 95% CI, -2 to 221). In an implant-to-implant comparison, suture anchor alone was significantly weaker than cortical button (154 N; 95% CI, 30 to 279). Constructs using a cortical button and interference screw were not stronger (as measured by AFL) than those using a cortical button alone. The presence of a locking stitch added 113 N (95% CI, 29 to 196) to the AFL. The use of cortical button instead of interference screws or bone tunnels was associated with lower odds of type 2 failure. Avoiding locking stitches and using more sutures in the construct were also associated with lower odds of type 2 failure.

CONCLUSION

Cortical button fixation is associated with greater construct strength than is suture anchor repair and a lower risk of type 2 failure compared with interference screw fixation or fixation without implants. The addition of an interference screw to cortical button fixation was not associated with increased strength. The presence of a locking stitch added 113 N to the failure load but also increased the odds of type 2 failure.

Editorial Commentary: Causes of Failure After Arthroscopic Rotator Cuff Repair

Causes of failure after arthroscopic rotator cuff repair include patient factors, tear factors, and surgical factors. Failure may occur at the suture-tendon interface, the bone-tendon interface, or the bone-anchor interface. Low bone mineral density (BMD) in the greater tuberosity has been reported as a prognostic factor for recurrent tears following rotator cuff repair, and although most studies suggest the tendon-to-suture interface as the "weakest link," patients with low BMD may have lower suture anchor pull-out strength. A potential alternative cause of failure is the suture cutting through the greater tuberosity bone in patients with low BMD. Knotless suture bridge constructs or single-row constructs may be more susceptible to a suture cutting through the bone. The knotted suture bridge technique, wherein the medial mattress sutures are tied, may to some extent "shield" against complete cut-through. When bone quality appears poor, a common response is to change the type of anchor, size of anchor, or the location of the anchor. Other factors, such as bone preparation, suture type, suture tensioning, and anchor type (e.g., internal vs external locking), may all potentially affect suture cutting through weak bone.

Intratendinous Strain Variations of the Supraspinatus Tendon Depending on Repair Technique: A Biomechanical Analysis Regarding the Cause of Medial Cuff Failure

BACKGROUND

Double-row (DR) and transosseous-equivalent (TOE) techniques for rotator cuff repair offer more stability and promote better tendon healing compared with single-row (SR) repairs and are preferred by many surgeons. However, they can lead to more disastrous retear patterns with failure at the medial anchor row or the musculotendinous junction. The biomechanics of medial cuff failure have not been thoroughly investigated thus far.

PURPOSE

To investigate the intratendinous strain distribution within the supraspinatus tendon depending on repair technique.

STUDY DESIGN

Controlled laboratory study.

METHODS

Twelve fresh-frozen cadaveric shoulders were used. The intratendinous strain within the supraspinatus tendon was analyzed in 2 regions-(1) at the footprint at the greater tuberosity and (2) medial to the footprint up to the musculotendinous junction-using a high-resolution 3-dimensional camera system. Testing was performed at submaximal loads of 40 N, 60 N, and 80 N for intact tendons, after SR repair, after DR repair, and after TOE repair.

RESULTS

The tendon strain of the SR group differed significantly in both regions from that of the intact tendons and the TOE group at 40 N (P≤ .043) and from the intact tendons, the DR group, and the TOE group at 60 N and 80 N (P≤ .048). SR repairs showed more tendon elongation at the footprint and less elongation medial to the footprint. DR and TOE repairs did not provide significant differences in tendon strain when compared with the intact tendons. However, the increase in tendon strain medial to the footprint from 40 N to 80 N was significantly more pronounced in the DR and TOE group (P≤ .029).

CONCLUSION

While DR and TOE repair techniques more closely reproduced the strains of the supraspinatus tendon than did SR repair in a cadaveric model, they showed a significantly increased tendon strain at the musculotendinous junction with higher loads in comparison with the intact tendon.

CLINICAL RELEVANCE

DR and TOE rotator cuff reconstructions lead to a more anatomic tendon repair. However, their use has to be carefully evaluated whenever tendon quality is diminished, as they lead to a more drastic increase in tendon strain medial to the footprint, putting these repairs at risk of medial cuff failure.

Needle-Based Arthroscopic Transosseous Rotator Cuff Repair: A Short-Term Outcomes Analysis

Introduction Given the limitations of anchor-based rotator cuff repair, surgeons have considered and investigated the use of an arthroscopic transosseous repair technique using only sutures to repair tendon tissue. Returning full circle to the gold standard of transosseous repair, but with the modern adaptation of arthroscopy, advocates of arthroscopic transosseous rotator cuff repair believe that many of the risks associated with suture anchors can be avoided. The purpose of this study was to examine the capabilities of a novel needle-based arthroscopic transosseous tunneling device (OmniCuff™ arthroscopic transosseous device, MinInvasive Ltd., Magal, Israel) and evaluate the short-term clinical outcomes and patient satisfaction of patients treated with this technique. Materials and methods This study was a prospective, single-arm, multi-center study performed on patients from January 2014 to March 2015. During the study period, thirty-two patients underwent arthroscopic transosseous rotator cuff repair using the OmniCuff™ arthroscopic transosseous device. Results The average age of patients was 58.2 years (range, 44 to 80 years). The sizes of the tears were as follows: seven small, 18 medium, four large, and three massive. The average number of tunnels used per repair was 1.9 with the following breakdown: six one-tunnel repairs, 22 two-tunnel repairs, and four three-tunnel repairs. The mean American Shoulder and Elbow Surgeon (ASES) score improved from 45.1 to 87.7, the mean Simple Shoulder Test (SST) score improved from 42.6 to 92. Overall patient satisfaction was high with an average Likert scale of 4.6. Conclusion Our study demonstrated significantly improved outcomes for patients undergoing arthroscopic transosseous rotator cuff repair using the needle based Omnicuff device. Patients were overall very satisfied with the outcome of their surgery and their ASES and SST scores demonstrated this appropriately.

Improved Rotator Cuff Footprint Contact Characteristics With an Augmented Repair Construct Using Lateral Edge Fixation

BACKGROUND

The transosseous-equivalent (TOE) rotator cuff repair construct has become the gold standard for the repair of medium and large rotator cuff tears. Repair failure, however, continues to be a problem. One contributing factor may be the inability of the TOE repair to replicate the native footprint contact characteristics during shoulder movement, especially in rotation. This results in higher strain across the repair, which leads to gapping and predisposes the construct to failure. In an effort to better reproduce the native compression forces throughout the footprint, an augmented TOE construct supplemented with lateral edge fixation is proposed, and the contact characteristics were compared with those of the gold standard TOE construct.

HYPOTHESIS

The augmented TOE repair will demonstrate improved footprint contact characteristics when compared with the classic TOE repair.

STUDY DESIGN

Controlled laboratory study.

METHODS

Ten fresh-frozen cadaveric shoulders underwent supraspinatus repair using both the classic TOE double-row construct and the augmented TOE repair. For the augmented repair, 2 luggage tag sutures were used to secure the lateral edge and incorporated into the lateral row anchors. A Tekscan pressure sensor (Tekscan Inc) placed under the repaired tendon was used to collect footprint contact area, force, peak pressure, and contact pressure data for each construct.

RESULTS

The augmented construct demonstrated significantly greater contact forces (average difference, 4.9 N) and significantly greater contact pressures (average difference, 23.1 kPa) at all degrees of abduction and all degrees of rotation. At 30° of internal and 30° of external rotation at both 0° and 30° of shoulder abduction, the augmented construct demonstrated significantly greater peak contact pressures.

CONCLUSION

The augmented construct showed superior contact characteristics when compared with the classic TOE technique. The addition of lateral edge fixation to the classic TOE repair significantly improves bone-tendon contact characteristics with minimal additional surgical effort.

CLINICAL RELEVANCE

The results of this study indicate that lateral augmentation of the classic TOE repair produces a biomechanically superior construct that may optimize tendon healing.

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.

Arthroscopic Rotator Cuff Repair in 2019: Linked, Double Row Repair for Achieving Higher Healing Rates and Optimal Clinical Outcomes

The primary aim of rotator cuff repair surgery is to restore the musculotendinous units by creating a complete, tension-free repair construct that optimizes conditions for tendon-to-bone healing. There are many factors outside the control of the surgeon that are capable of affecting the healing process; however, there are also a number of important technical considerations that the surgeon can control, including familiarity with methods to deal with immobile tissues and techniques to perform novel repair constructs. It is clear that linked double row repairs are more likely to heal, and healed rotator cuff repairs best restore shoulder strength, improve patients' satisfaction, and maximize functional outcomes.