5 Double Row with ?Rip-Stop? Rotator Cuff Repair

Mark R. Wilson, Eric D. Field, and Larry D. Field

Summary

Double-row repairs as well as rip-stop configurations have been proposed to limit failures found after arthroscopic rotator cuff repairs. A type II rotator cuff repair failure is encountered when the rotator cuff tendon detaches from the medial fixation row, which is often located at the musculotendinous junction. Rip-stop techniques have been shown to effectively reduce suture tendon pullout when compared to traditional transosseous double-row repairs in biomechanical studies. If an additional horizontal ?rip-stop? suture can be added to previously described techniques designed to restore a secure tendon?bone interface, a higher incidence of rotator cuff healing can potentially be achieved. This technique is commonly employed by the authors to secure rotator cuff tears and allows not only for double-row fixation but also an interlocking double-row suture construct that improves security and fixation strength.

Keywords: double-row repair, interlocking double-row suture construct, rip-stop, rotator cuff repair, suture tendon pullout

5.1 Patient Positioning

Beach chair or lateral decubitus positions are both acceptable.

5.2 Portal Placement

? Standard posterior portal placed initially for diagnostic arthroscopic evaluation.

? Anterior and lateral portals placed for working portals.

? Anterolateral and posterolateral subacromial accessory portals as needed.

5.3 Surgical Technique

? The surgical technique described is indicated for large, multitendon tears with adequate rotator cuff tendon mobility to allow for near anatomic reduction to the tuberosity footprint (? Fig. 5.1, ? Fig. 5.2).

? With the patient positioned in the beach chair position and following induction of anesthesia, the operative arm is prepped and draped in sterile fashion.

? A diagnostic arthroscopy using a 30� arthroscope is performed using a standard posterior portal.

? In the video provided (? Video 5.1), a partial subscapularis tendon tear is identified and repaired prior to introduction of the arthroscope into the subacromial space. Once all glenohumeral joint pathology is adequately addressed, the arthroscope is introduced into the subacromial space.

? In the video provided (? Video 5.1), one can see a large tear involving both the supraspinatus and infraspinatus tendons being reduced with aid of a grasper to their respective bony attachments prior to anchor placement.

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Fig. 5.1 A tear involving the rotator cuff can be seen from the lateral portal in a left shoulder in the beach chair position. Biceps tendon is in view anteriorly. The rotator tendon is elevated using a grasper showing the humeral footprint insertion.

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Fig. 5.2 The rotator cuff tear is reduced using a grasper as seen from the lateral portal in a left shoulder with beach chair positioning. The grasper seen is inserted using an accessory anterolateral portal. The biceps tendon may be seen crossing through the biceps interval.

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Video 5.1 Surgical demonstration of a double row with ?Rip-Stop? Rotator Cuff Repair.

? Using the described technique, two double-loaded biocomposite anchors (Healicoil Regenesorb 5.5 mm, Smith & Nephew, Andover, MA) are placed at the most medial aspect of the rotator cuff footprint adjacent to the humeral head articular cartilage.

? As seen in the video and viewed through the lateral portal, each limb of alternating sutures from the anterior double-loaded anchor is passed through the rotator cuff tendon in a horizontal mattress configuration (? Fig. 5.3) using a 60� retrograde suture passer through the anterior portal (IDEAL Suture Grasper, Mitek Sports Medicine, DePuy Synthes, Raynham, MA).

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Fig. 5.3 The first anchor of two medial row anchors is viewed from the lateral portal in a left shoulder in the beach chair position. All four sutures have been passed in a horizontal mattress configuration through the cuff tissue. A grasper can be seen positioned through an accessory anterolateral portal, and an outflow cannula is positioned in the anterior portal.

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Fig. 5.4 (a) Two medial row anchors can be seen from the lateral portal in a left shoulder in the beach chair position. The four exiting suture limbs are marked with arrows passing through the tendon of the infraspinatus in horizontal mattress configuration. (b) An illustration of a left shoulder during the first step of the double-row, rip-stop technique includes the passing of two double-loaded medial anchors in the horizontal mattress configuration.

? The posterior anchor sutures are then passed and retrieved in a similar fashion, utilizing a posterior portal (? Fig. 5.4a). Of note, it is advisable that these sutures broadly incorporate all detached rotator cuff tissue to maximize the tendon?bone interface during the subsequent steps (? Fig. 5.4b).

? Once all medial row sutures have been passed, a third triple-loaded anchor (Healicoil Regenesorb) is placed into the lateral border of the greater tuberosity footprint. As seen in the video provided (? Video 5.1) and viewed through the lateral portal, each of the three lateral row sutures are passed and retrieved in a simple orientation medial to the medial row horizontal mattress sutures (? Fig. 5.5a).

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Fig. 5.5 (a) As viewed from the lateral portal in a left shoulder in the beach chair position, three limbs of each suture from the lateral row triple-loaded anchor have been passed through the cuff tissue medial to the rip-stop horizontal mattress sutures from both medial row anchors. A grasper is utilized through an accessory anterolateral portal to manipulate the rotator cuff tissue. (b) An illustration of a left shoulder during the second step of the double-row, rip-stop technique includes passing lateral double-row anchor sutures in simple fashion medial to horizontal mattress suture configuration of the medial anchors. A grasper is illustrated and is used to manipulate the rotator cuff tissue.

? ? Fig. 5.5b illustrates utilization of a grasper during this step to lateralize the rotator cuff tissue and facilitate placement of lateral row sutures.

? Following placement of all sutures, the medial row horizontal mattress sutures are securely tied prior to tying the lateral row anchor sutures so that the medial row sutures act as a ?rip-stop? for these lateral row sutures and thus effectively increasing the strength of this double-row configuration (? Fig. 5.6).

? In the video provided, all lateral row sutures are tied in sequential order, creating the double-row repair (? Fig. 5.7a, b).

? After final arthroscopic photos are taken, a sterile dressing is applied, and the patient is placed in a shoulder abduction brace (? Video 5.1).

5.4 Surgeon Tips and Tricks

? Use the lateral or accessory lateral subacromial portal for visualization using the arthroscope. Visualizing from a lateral access site maximizes the opportunity to recognize the rotator cuff tear pattern and reducibility as well as better identify and incorporate lamination of rotator cuff tissue into the repair.

? Adequate mobilization of the rotator cuff tissue prior to anchor placement allows for better planning of medial and lateral row placement and reduces tension on this double-row repair construct and rotator cuff tissue.

? A grasper can be used through an accessory lateral portal to thoroughly assess the most anatomic and desirable position to reduce the rotator cuff to the tuberosity with the most appropriate degree of repair tension.

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Fig. 5.6 As viewed from the lateral portal in a left shoulder in the beach chair position, three limbs of each suture from the lateral row triple-loaded anchor have been passed through the cuff tissue medial to the rip-stop horizontal mattress sutures from both medial row anchors. A medial row rip-stop suture is seen tied, reducing the rotator cuff tissue. A posterior cannula is seen with the one of the three limbs from the lateral anchor.