7 Two-Anchor, Double-Row Rotator Cuff Repair with Incorporated Biceps Tenodesis

Michael J. O?Brien and Felix H. Savoie


The two-anchor, double-row rotator cuff repair is a surgical technique to repair large and massive rotator cuff tears with fewer anchors to limit anchor material in the bone and maximize the contact area between tendon and bone. Recurrent rotator cuff tears are a devastating outcome to patients. One common reason for recurrent tears is failure of the primary repair to heal. The rotator cuff insertion on the greater tuberosity footprint occupies a limited surface area of the bone. Use of multiple anchors may fill this finite space with anchor material, limiting the contact area between tendon and bone, which is necessary for healing to occur. For this reason, we have developed a two-anchor, double-row rotator cuff repair technique for large and massive tears. This technique can be utilized on large and massive tears to facilitate healing by providing excellent footprint coverage with limited anchor material to maximize contact area between the tendon and greater tuberosity bone while also being able to tenodese the biceps tendon at the rotator cuff repair site.

Keywords: double-row, footprint coverage, healing, rotator cuff repair, two-anchor

7.1 Patient Positioning

? Rotator cuff repair surgery may be performed in either the beach chair or lateral decubitus position.

? The patient position is largely surgeon-dependent based on experience and comfort level.

7.2 Portal Placement

? Standard shoulder arthroscopy portals are utilized.

? The procedure begins with a standard posterior viewing portal, placed in the soft spot of the raphe of the infraspinatus.

? An anterior portal is established in the rotator interval, in line with the acromioclavicular joint, using an outside-in technique with a spinal needle.

? The portal is placed just cephalad to the subscapularis, in a position where a lesser tuberosity anchor may be inserted if necessary.

? A lateral portal is created 3?4 cm off the anterolateral edge of the acromion.

? Accessory anterolateral and posterolateral portals are established in line with the standard lateral portal.

? These portals are utilized for performing anterior and posterior releases, manipulating the rotator cuff tendons with a grasper, reducing the rotator cuff to the greater tuberosity footprint, and suture passage.

7.3 Surgical Technique (Step-by-Step Approach)

7.3.1 Posterior Viewing Portal

? A posterior portal is established for the arthroscope. The scope is introduced into the glenohumeral joint and diagnostic arthroscopy is performed.

? Using an outside-in technique with a spinal needle, an anterior portal is established in the rotator interval, in line the with acromioclavicular joint.

? All intraarticular pathology is addressed as indicated.

? The rotator cuff tear is identified from inside the joint.

? In the setting of a massive retracted rotator cuff tear, a 360� capsular release is performed to allow the humeral head to drop to a reduced position in the glenohumeral joint and facilitate reduction of the rotator cuff tear.

? Once all intraarticular pathology has been addressed, the blunt trocar is used to advance the arthroscope into the subacromial space.

? Using a spinal needle with an outside-in technique, a lateral portal is established 3?4 cm off the anterolateral corner of the acromion.

? The motorized shaver is introduced through the lateral portal.

? A limited bursectomy is performed to allow visualization of the rotator cuff tear. A complete bursectomy is not performed as this decreases blood supply to the rotator cuff.

? If a lateral overhang is present on the acromion, it is resected now with the shaver or bur.

? The greater tuberosity footprint is lightly decorticated.1,2

? Care is taken not to remove the cortical layer of bone on the greater tuberosity, as this may weaken the suture anchor attachment.

7.3.2 Lateral Viewing Portal

? The arthroscope is then moved to a lateral viewing portal.

? It is the authors? observation that the rotator cuff tear is best appreciated viewing from the lateral portal (? Fig. 7.1).

? The rotator cuff tear pattern can be identified: crescent-shaped, V-shaped, L-shaped, reverse-L-shaped.

? Laminations in the tear can be visualized.

? Sutures can be placed accurately in the tendon for an anatomic repair.

? Accessory anterolateral portals and posterolateral portals can be established with a spinal needle.

? The accessory lateral portals can be used to:

? Secure the tear edges with a grasper to identify the tear pattern.

? Assess tear retraction and mobility.

? Perform anterior and posterior releases.

? Reduce the tendon to the greater tuberosity footprint.

? The tendon edges are lightly debrided, and the greater tuberosity footprint is lightly decorticated.

? An acromioplasty is performed at the discretion of the surgeon (? Fig. 7.2).

? Acromioplasty may be beneficial to improve visualization, increase the working space, remove osteophytes that may cause external impingement, and create a bleeding acromion bed to bathe the rotator cuff repair site.


Fig. 7.1 Viewing from the lateral portal in a right shoulder in the beach chair position, a reverse-L-shaped full-thickness supraspinatus tear can be visualized. The tear can be manipulated with a grasper to determine tear pattern, check tendon mobility, and reduce the tendon to the greater tuberosity.


Fig. 7.2 A view from the lateral portal in a right shoulder after completion of acromioplasty. We routinely perform acromioplasty to improve visualization, create more working space, remove any sources of external impingement, and create a bleeding acromion bed to bathe the rotator cuff repair site.

7.3.3 Repair

? A triple-loaded anchor is placed into the greater tuberosity footprint just lateral to the articular cartilage margin (? Fig. 7.3).

? We prefer an open architecture anchor, such as the Healicoil (Smith & Nephew, Andover, MA), to allow bone marrow and blood products to flow out of the marrow canal and bathe the repair site to promote healing (? Video 7.1).

? A small awl or punch is used to microfracture the greater tuberosity footprint.

? Microfracture allows bone marrow contents to bathe the repair site and facilitate healing.3,4

? Avoid microfracture in osteopenic bone, as this may compromise anchor purchase.

? A grasper can be utilized, if necessary, though an anterior portal to reduce the rotator cuff tendon during suture passage.

? A retrograde suture passer is placed percutaneously to pass and retrieve sutures through the rotator cuff tendons.


Fig. 7.3 A motorized shaver is used to create a bleeding trough of bone in the medial tuberosity, and a triple-loaded, medial-row anchor is placed just lateral to the articular cartilage margin.


Video 7.1 This video demonstrates an arthroscopic rotator cuff repair and biceps tenodesis in a right shoulder in the beach chair position, utilizing a two-anchor double-row rotator cuff repair with incorporated biceps tenodesis.

? We prefer to pass sutures with the IDEAL Suture Grasper (Mitek Sports Medicine, DePuy Synthes, Raynham, MA).

? Sutures are place in mattress fashion, evenly spaced across the tear (? Fig. 7.4).

? Care is taken to place the sutures in the tendon, and not at the muscle?tendon junction.

? Overtensioning of the medial row sutures may lead to a type-II failure.

? If a biceps tenodesis is also to be performed, the anterior suture can also be passed through the long head of the biceps tendon.

? The suture grasper is passed through the rotator cuff tendon, and then through the biceps tendon, before retrieving the suture.

? The biceps tenodesis is performed to the greater tuberosity anchor, and the biceps tendon sits between the rotator cuff tendon and greater tuberosity bone.

? The three mattress sutures are tied, leaving all suture tails long.

? For the lateral row anchor, either both limbs from each mattress (six limbs) or one limb from each mattress (three limbs) can be incorporated into the anchor, depending on the anchor type and how many sutures it can accommodate.

? The remaining sutures are then incorporated into one lateral row anchor. The anchor is placed into an anatomic location to decrease tension on the repair.

? The lateral row anchor is impacted, tensioned, and deployed (? Fig. 7.5).


Fig. 7.4 Three mattress sutures are placed evenly across the torn tendon. Take great care not to place sutures too medial at the muscle?tendon junction, as overtensioning of the repair may cause a type-II failure with tearing at the muscle?tendon junction.