9 Arthroscopic Double-Row Transosseous Equivalent Repair of Large Rotator Cuff Tears

Ajay S. Padaki, Daniel J. Song, Pinkawas Kongmalai, and William N. Levine


Operative treatment of rotator cuff tears has increased in the past several decades in response to biomechanical and clinical evidence, supporting repair of symptomatic full-thickness tears in patients who have failed nonoperative management. As our understanding of rotator cuff anatomy, biology, pathophysiology, and biomechanics improves along with the technological advances in orthopedic biologics, implant material, and design, there is constant evolution in the surgical treatment of rotator cuff tears. Although the arthroscopic approach is most commonly used today, the traditional open or mini-open rotator cuff repair remains a viable approach to rotator cuff repairs. Technological advances have provided orthopedic surgeons with a variety of surgical techniques to repair rotator cuff tears. Surgical techniques should be carefully selected and used after evaluating patient factors, tear size, tear pattern, tissue pathology, and surgeon experience to create the optimum repair construct. The arthroscopic, double-row transosseous-equivalent repair of rotator cuff tears is a commonly used technique for rotator cuff tears that allows anatomic repairs with a large tendon to a bone interface that is theoretically and biomechanically superior to other rotator cuff repair techniques. This chapter will provide a concise, easy-to-follow approach, high-lighting the pearls and pitfalls of the technique.

Keywords: double row repair, rotator cuff, shoulder surgery, transosseous equivalent

9.1 Patient Positioning

9.1.1 Standard Supine Beach Chair Positioning

? Preparation.

? Bilateral venodynes for deep vein thrombosisprophylaxis; leg ramp.

? Ensure neutral neck alignment following intubation.

? Perform exam under anesthesia.

? Assemble limb positioner of choice at ipsilateral hip.

? Hang extremity; soap scrub followed by chlorhexidine scrub.

? Sterile draping per institutional protocol and limb positioner attachment.

? Mark the posterolateral and anterolateral acromial border, coracoid, and acromioclavicular joint.

9.2 Portal Placement

9.2.1 Posterior

? Inject wheal into all portal sites with lidocaine with 1% epinephrine.

? Palpate soft spot 1 cm medial and 2 cm posterior to posterolateral acromion.

? 1 cm scalpel incision through skin only.

? Trocar through deltoid with fleck of glenoid before insertion toward coracoid. 58

9.2.2 Anterior

? Under direct visualization, place an 18G spinal needle 1 cm lateral to lateral coracoid through the rotator interval.

? 1 cm scalpel incision through skin only.

? Switching stick, dilator, and cannula placement.

9.2.3 Lateral

? Mark two to three fingerbreadths lateral to the lateral acromion.

? Insert an 18G spinal needle under direct visualization after transition to subacromial space.

9.3 Surgical Technique (Step-by-Step Approach)

9.3.1 Diagnostic Arthroscopy from the Posterior Portal

? Insert probe into anterior portal.

? Assess integrity of superior labrum with probe.

? Move probe superior to biceps tendon and pull traction with probe to examine biceps tendon for tear, tendinitis, and instability.

? Examine humeral head cartilage laterally and glenoid cartilage medially.

? Visualize middle glenohumeral ligament and subscapularis at humerus.

? Rotate inferiorly and examine inferior glenohumeral ligamentand inferior labrum.

? Assess capsular ligament insertions along the humerus before traversing inferior pouch and ruling out the presence of loose bodies.

? Gently rotate to visualize posteroinferior labrum and posterosuperior labrum.

? Place the arm in slight abduction and external rotation and evaluate rotator cuff for tears.

? Address labral, cartilage, and biceps pathology as indicated.

9.3.2 Subacromial Space

? Remove posterior scope and place trocar directly under acromion.

? Sweep trocar medially and laterally to improve visualization before placing the trocar at the coracoacromial (CA) ligament.

? Establish lateral portal as delineated above, then insert a 7 mm cannula.

? Identify anterolateral acromial edge.

? Debride bursa with combination of shaver and electrocautery to optimize visibility while alternating visualization between the posterior and lateral portals.

? Perform acromioplasty if needed to help visualization of rotator cuff.

? Visualizing from the lateral portal, evaluate the rotator cuff tear including tear pattern, mobility, and reducibility.

? Visualizing from the posterior portal, debride adhesions to rotator cuff as needed to gain sufficient excursion to reapproximate the anatomic footprint.

? Prepare the rotator cuff footprint until cancellous bone is visible to maximize healing potential.

? Insert the spinal needle directly adjacent to the acromion to assess the angle of medial suture anchor placement.


Video 9.1 Surgical demonstration of an arthroscopic double row transosseous equivalent repair of a large rotator cuff tear.

? Create a small incision to place anterior and posterior medial anchors just off the articular margin.

? Pass sutures starting from anterior to posterior utilizing the Scorpion suture passing device.

? Pass one limb each from the anterior and posterior suture anchor out of the lateral portal.

? Load these sutures into a Swive Lock suture anchor.

? Using electrocautery, remove soft tissue off the lateral greater tuberosity to ensure ease of anchor placement.

? Tap into desired lateral row anchor and place suture anchor with appropriate tension using the cannula as a guide.

? Cut suture limbs flush.

? Repeat this process for the remaining two sutures from the medial row anchors.

? Evaluate for additional tears or ?dog-ears? anterior or posterior to the repair and utilize sutures from the lateral anchors to further repair or reduce the rotator cuff.

? Perform acromioplasty as indicated.

? Close skin with 4?0 subcutaneous Biosyn (? Video 9.1).

9.4 Surgeon Tips and Tricks (Use of Specific Instrumentation)

? Place 0 Prolene through suspected or partial rotator cuff tear from the glenohumeral space to ease localization in the subacromial space.

? Perform thorough subacromial bursectomy and possible acromioplasty to ensure adequate visualization of the entire rotator cuff tearthroughout the case.

? Maintain hemostasis throughout the case.

? Ensure optimal suture management at all times with specific protocol.

? Hold cannula directly over the awl so swivel lock placement is not difficult.

? After repair, ensure footprint restored from glenohumeral joint.

9.5 Pitfalls/Complications

? Inadequate visualization of rotator cuff tear secondary to inadequate subacromial bursectomy.

? Poor suture management.

? Inappropriate tension (under- and overtensioning).

9.6 Rehabilitation

? Remain non-weight-bearing on the operative arm for 6 weeks in a pad sling.

? Pendulum exercises with no other shoulder range of motion (ROM) during this 6-week period.

? Active-assisted ROM with physical therapy at weeks 6?12.

? Active ROM and strengthening at weeks 12?20.

? Continued strengthening and home exercise program at weeks 20 and beyond.

? 2-week follow-up for wound inspection, 6-week follow-up to initiate physical therapy, and 3- and 6-month follow-ups to evaluate for rotator cuff integrity and progress with physical therapy.

9.7 Rationale and/or Evidence for Approach

9.7.1 Repair Technique

? The authors prefer double-row repair because double-row rotator cuff repair increases the bone?tendon interface.1

? The double-row repair also has been shown to increase fixation strength of the tendon2 with less gapping.3

? Anatomic restoration of the footprint is critical for rotator cuff repair, and double-row repair best reapproximates the footprint.4,5,6

? While not clinically significant, double-row repair has demonstrated greater tendon healing on magnetic resonance imaging than the single-row technique.7

? Despite these cadaveric studies, however, clinical investigations show marginal, if any, benefit of double-row repair.8,9

9.7.2 Postoperative Therapy

? Despite protocols10 advocating for early ROM, the authors recommend 4?6 weeks of immobilization to minimize gapping following repair.11

? While accelerated early movement may increase short-term results, no long-term effects have been demonstrated.12,13,14

? Standard immobilization after surgery also may increase early tendinous strength.15

? Rate of re-tear has been shown to be equivocal between the two groups with some studies showing a nonsignificant trend in increased re-tears in the early movement cohort.12,15


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