Various surgical techniques have been described in arthroscopic rotator cuff repair. Traditional single row repairs were initially reported and were then followed by double row repairs in an effort to improve fixation. However, concerns arose with the double row technique. In particular, the placement of medial row sutures led to cases of failure at this fixation point. When medial row failure occurred, the resultant segment of tendon available for revision repair was often very short and nearly at the musculotendinous junction. To address this concern, the double-row transosseous equivalent (TOE) repair was developed. This technique has the advantage of the double-row repair in that the sutures provide compression across the entire rotator cuff footprint. However, it mitigates concerns about medial row failure because two rows of fixation are not employed. This chapter will describe the operative technique employed at our center for this repair.
Keywords: beach chair position, rotator cuff repair, traction, transosseous equivalent
? Beachchair position.
? When sitting the patient up to the beachchair position, we take care to control the chin for proper head positioning.
? In the coronal plane, check carefully to keep the nose, chin, and sternum in line before securing the head.
? Avoid neck extension. If any is noted, apply gentle pressure to the chin to bring the neck into neutral flexation.
? 12 lb of traction are placed to distract the joint and to facilitate visualization.
? We use a pulley kit for traction similar to what is used for the arthroscopy in the lateral decubitus position.
Video 8.1 This video details the surgical technique of arthroscopic single row, transosseous equivalent (tension band) rotator cuff repair.
Fig. 8.1 12 lb of traction are applied to the shoulder through a suspension kit to improve arthroscopic visualization.
? The pole and pulley are attached with standard clamps to the operating room table (? Fig. 8.1).
? We avoid prolonged traction more than 90?120 minutes.
? Our working viewing portal is the posterior portal.
? A posterolateral viewing portal through the subacromial space may be used and is helpful for small, anterior supraspinatus tears.
? We use an anterior working portal for intraarticular work such as biceps tenodesis and debridement.
? The lateral or anterolateral working portal is used with an 8 mm cannula for most subacromial procedures.
? Subacromial debridement.
? Suture placement.
? Subacromial decompression.
? We use a superior working portal just off the lateral acromial edge as an accessory portal.
? Suture anchor placement.
? Suture storage.
? Subacromial debridement.
? We establish a lateral portal and perform a thorough bursectomy with electrocautery.
Fig. 8.2 Standard arthroscopic portals are utilized for transosseous equivalent RCR. In particular, the anterosuperior portal functions well for suture storage and allows suture anchor placement at the optimal angle of insertion.
? Once the bursa is cleared, electrocautery is used to outline the anterior and lateral edges of the acromion. It is then examined for any evidence of subacromial spurring or impingement lesion.
? We do not perform a full release of the coracoacromial ligament.
? After the bony exposure is completed, we then identify the rotator cuff tear margins and establish the tear shape.
? Rotator cuff repair (transosseous equivalent, inverted mattress, lateral row with tape suture).
? We enlarge the lateral portal and place an 8 mm cannula. Using electrocautery and shaver, the greater tuberosity is debrided to create a bony bed for healing.
? Superficial and deep releases of any adhesions around the rotator cuff are performed as needed to mobilize it for repair.
? A suture passer is used to place two inverted mattress stitches using tape suture.
? The anterosuperior portal is established by needle localization to identify anchor sites. The sutures are retrieved and stored through this portal.
? The middle two limbs are then crossed to create a tension band, transosseous equivalent construct.
? The suture anchors are placed through the anterosuperior portal.
? We aim for at least a 1 cm bone bridge between anchors.
? We attempt to place anchors at 45?60 angle for optimal fixation.
? Subacromial decompression (optional).
? Thorough bursectomy.
? We pay special attention to the lateral bursa, which can interfere with suture passage and cannula placement if not thoroughly cleared.
? Suture management.
? The anterosuperior portal can function as a waiting room portal for previously placed sutures.
? Portal placement.
? We carefully study the sagittal images on the preoperative magnetic resonance imaging to identify the location of the rotator cuff tear. We use that information to establish our lateral portal to ensure that our suture passer can access the entire width of the tear.
? We use needle localization to ensure that the superior portal can place both suture anchors with an appropriate bone bridge between them.
? Inadequate bursectomy will interfere with visualization, suture passage, and anchor placement.
? Avoid suture tangles by using the anterosuperior portal for suture storage.
? If the anterosuperior portal is not placed correctly, it can interfere with suture anchor placement. This in turn may result in an inadequate bony bridge between anchors, which place the construct at risk for fracture.
? Repair failure.
? Our program is based on the premise that the repair is at risk for re-tear up to 6 months following surgery.
? First 2 weeks.
? Sling immobilization and Codman?s exercises only.
? Weeks 2?6.
? The patient continues wearing a sling at all times when not in physical therapy.
? We begin formal physical therapy with active assisted range of motion (AAROM) and passive range of motion (PROM) up to 90of forward elevation and external rotation to 30.
? Weeks 6?12.
? The patient comes out of the sling for daily activities in front of the body.
? Light activities such as driving and desk work are permitted.
? Physical therapy continues with advancement of AAROM and PROM to full forward elevation and external rotation.
? Weeks 12?24.
? The patient is out of the sling full time with a 10 lb weight limit for daily activities.
? Physical therapy continues with advancement of active range of motion and PROM in all planes. Isometric strengthening with a 10 lb limit is initiated.
? Week 24.
? The patient is released to unrestricted activities.
? Biomechanics of transosseous equivalent (TOE) repair are favorable to single- and double-row repairs.
? These studies indicate that TOE provides repair ?self-reinforcement.?1,2
? TOE has been reported to have a lower re-tear rate than single- and double-row repairs. However, this difference was not statistically significant.3
? Knotless and knotted TOE constructs have both been studied with good outcomes. However, a lower re-tear rate was noted after knotless repair.4
? Rotator cuff repairs are at risk for re-tear up to 6 months after surgery. But re-tears are uncommon thereafter.5
 Park MC, Mc Garry MH, Gunzenhauser RC, Benefiel MK, Park CJ, Lee TQ. Does transosseous-equivalent rotator cuff repair biomechanically provide a ?self-reinforcement? effect compared with single-row repair? J Shoulder Elbow Surg. 2014; 23(12):1813?1821
 Park MC, Peterson AB, Mc Garry MH, Park CJ, Lee TQ. Knotless transosseous-equivalent rotator cuff repair improves biomechanical self-reinforcement without diminishing footprint contact compared with medial knotted repair. Arthroscopy. 2017; 33(8):1473?1481
 Mc Cormick F, Gupta A, Bruce B, et al. Single-row, double-row, and transosseous equivalent techniques for isolated supraspinatus tendon tears with minimal atrophy: A retrospective comparative outcome and radiographic analysis at minimum 2-year followup. Int J Shoulder Surg. 2014; 8(1):15?20
 Millett PJ, Espinoza C, Horan MP, et al. Predictors of outcomes after arthroscopic transosseous equivalent rotator cuff repair in 155 cases: A propensity score weighted analysis of knotted and knotless self-reinforcing repair techniques at a minimum of 2 years. Arch Orthop Trauma Surg. 2017; 137(10):1399?1408
 Iannotti JP, Deutsch A, Green A, et al. Time to failure after rotator cuff repair: A prospective imaging study. J Bone Joint Surg Am. 2013; 95(11):965?971