The transosseous rotator cuff repair has been the gold standard since the very beginning of the open surgery. This chapter describes a fully arthroscopic transosseous procedure for small and medium-sized rotator cuff tears and highlights the above key elements (tips and tricks) as part of the repair. No anchors are implanted; therefore, there is no risk of implant loosening. There is no medial row; therefore, there is less risk of tendon necrosis or re-tear. We also describe the standard portals and rehabilitation process and typical timeline.
Keywords: rotator cuff repair, rotator cuff tear, transosseous suture
Under general anesthesia supplemented by local nerve block for better postoperative analgesia in the beach chair position with the arm in a pneumatic arm holder (Spider, Smith & Nephew), a U-drape is placed around the shoulder starting from the neck. A rectangular drape is applied above the shoulder to connect legs of the U-drape, and, finally, arthroscopy drapes are placed. The following portals are used (see ? Fig. 14.1, ? Fig. 14.2, ? Fig. 14.3):
? The posterior (A): palpate the soft spot created by glenoid medially, the humeral head laterally and the rotator cuff superiorly. A general arthroscopic examination is done to assess the GH joint, address the rotator cuff tears and to manage biceps pathology.
? The anterolateral (B): 1 cm lateral to the anterolateral corner of the acromion, frontal to the AC joint. The long head biceps tenotomy (or tenodesis) is done with refreshment of the footprint of the supraspinatus. A bursoscopy, a debridement, and an acromioplasty (with resection of the coracoacromial ligament) are performed.
? Lateral portal (C): 4 cm lateral to the acromion in line with the posterior aspect of the clavicle. This portal shall create a parallel access to the footprint area. Draw an equilateral triangle at the base of the lateral edge of the acromion as from figure. Insert a smooth 8 mm clear cannula with a tapered obturator for an Express view grasper (Smith & Nephew).
Fig. 14.1 Portals. ?A? Soft point. ?B? Anterosuperior portal (debridement and acromioplasty). ?b? Superior working portal (Taylor Stitcher entry). Frontal to the AC joint. ?C? Lateral portal (scope position, frontal to the cuff tear). ?F? Shuttle-retrieving portal.
Fig. 14.2 Superior view. The switching stick is inserted through portal ?b? and aligned with the humeral shaft while the suture grasper comes from portal ?B? and arrives tangent to the footprint.
Fig. 14.3 Knots are tightening through the most distal portal ?F? to prevent any bone-cutting fracture and to optimize the cuff reduction.
? The superior anteromedial portal (b): superior working portal (Taylor Stitcher entry). Frontal to the AC joint.
? The posterolateral (F): in line with B (see ? Fig. 14.1), three fingers distally. Use this portal to retrieve sutures.
? Portal P: in line with B (see ? Fig. 14.1), two fingers distally. Use this portal to tie knots.
? Before inserting, check for the lateral aspect of the tuberosity. A working volume on the side is needed for a clear view and management of the sutures. (Place the shoulder at 20?30 of abduction and 15?20 of forward flexion.)
Fig. 14.4 (a, b) Insert the instrument main cannula through this above-mentioned portal ?b? (superior anteromedial) and align it with the diaphysis (humeral shaft and long axis of the device must be as parallel as possible).
? Retract the superelastic transosseus needle (STN) needle by turning counterclockwise the gray knob in the tail of the Taylor Stitcher. Check for the correct STN tip exposure once completely within the cannula. Insert a shuttle (e.g., pds size 1) or directly load sutures.
? Use a needle to identify the superior anteromedial portal (?B?), frontal to the AC joint, to ascertain the long axis of the humeral shaft and simultaneously to be as perpendicular as possible to the supraspinatus footprint and close to the cartilage (? Fig. 14.4a,b).
? The rotator cuff tissue is evaluated for quality and mobility. How well it can be brought laterally without undue tension is assessed with a grasper. The natural tension of the rotator cuff tissue is respected. Ideally, the rotator cuff is supposed to be anatomically reduced onto its footprint. Gentle releases may be performed, especially release of the coracohumeral ligament from the superior edge of the coracoid process to help mobilize the rotator cuff reduction and decrease its tension after the repair.
? A starter punch is placed in the chosen tunnel position close to the cartilage of the humeral head.
? If needed, a second tunnel is placed depending on the size of the tear.
? Insert the instrument main cannula through this above-mentioned portal (superior anteromedial) and align it with the diaphysis (humeral shaft and long axis of the device must be as parallel as possible).
? Note: you may or may not use the targeting device. The punch included in the instrument kit can be used to create a pre-hole in the footprint area (optional).
? Check the laser mark on the flat surface of the guide containing the STN needle and orient this in the exit direction.
? Prepare to deploy the needle by gently taping the posterior part of the piston until the STN tip emerges in the lateral aspect of the tuberosity at 15?20 mm distally. Be careful to keep the guide in contact with the bone, avoiding being rejected and displaced during STN deployment.
? Once the STN needle emerges on the lateral side, act on the gray knob to slightly retrieve the STN needle and fold the shuttle. Grab the shuttle with a grasper by entering a distal and lateral portal (F) and completely retract the STN needle in the stainless-steel cannula (by turning the knob clockwise). Tighten knots from this distal and lateral portal (P) to prevent any bone cutting.
? Number of tunnels and sutures adopted depend on the lesion type, tear size, grade of retraction, elasticity and quality of the tissues, and type of repair configuration.
? Proper portal placement is important to optimizing a successful surgery. The lateral portal in the subacromial space placed at the midpoint of the rotator cuff tear ensures good visualization of the rotator cuff repair.
? Knots are tightening through the most distal portal (F) to prevent any bone-cutting fracture and to optimize the cuff reduction.
? Sutures are supposed to be convergent from medial to lateral, in the direction of the tunnel entry, reproducing the natural anatomy of the cuff.
? Before tying a sliding suture knot, take a suture grasper to reduce the cuff and slide both limbs of the sutures fully back.
In case of soft bone with fracture while tightening sutures, we suggest using a double row knotless implant more laterally.
? The first goal is to protect the repair during the first 4 weeks to allow the repaired tissue to heal. Immobilization using an abduction sling will help accomplish this goal by allowing tension-free healing. The sling is worn 23?24 hours a day with gentle daily passive and pendular mobilization.
? After 4 weeks, active mobilization may be initiated with strengthening, typically 2?4 months after surgery depending on the patient recovery.
? Arthroscopic single-row rotator cuff repairs demonstrated a failure to heal of 20% to 30%.1,2 It can restore only 67% of the anatomic surface of the footprint.3
? Arthrocopic double-row repair techniques were described to restore the native anatomy of the footprint4 and biomechanical studies tend to prove a better and stronger coverage footprint fixation to improve healing rates.5,6 The rate of cuff healing seems superior to the single-row technique.7,8
? However, multiple level I and II studies fail to demonstrate a difference in clinical outcomes and re-tear rates when comparing the two techniques.9,10
Video 14.1 Surgical demonstration of fully arthroscopic transosseous rotator cuff repair: a reverse-guided technique.
? Moreover, double-row short-term results have shown a high rate of re-tear larger than the primary lesion, probably because contact pressure that is too high with the medial-row mattress sutures induce which may a possible necrosis of the cuff tendon.
? Measurement of bone?tendon contact pressure in a continuous way with piezoelectric pressure gauges have shown that ideal pressure should be homogeneously spread onto the footprint.11
? Based on the aforementioned studies, Garofalo et al have strongly encourage a low tension repair performed best with a transosseous suture.12 They try to (arthroscopically) reproduce the previous (open) gold standard techniques described by Codman, McLaughlin, Neer, De Palma, Rowe, Hawkins, and Graig.
? We describe a modification of the original Garofalo technique with a reverse guided transosseous technique (? Video 14.1).
If the cuff is anatomically reducible without any tension onto its footprint, we propose our aforementioned transosseous suture technique instead of a classical double-row technique. If the cuff is not anatomically reducible, we propose a classical single-row technique, as tension that is too high could induce tendon cuff necrosis and a larger retear than the primary lesion. If there are only tendons with a fatty muscle belly infiltration, we propose a fully arthroscopic latissimus dorsi tendon transfer.13
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 Flurin PH, Landreau P, Gregory T, et al. Cuff integrity after arthroscopic rotator cuff repair: Correlation with clinical results in 576 cases. Arthroscopy. 2007; 23:340?346
 Apreleva M, zbaydar M, Fitzgibbons PG, Warner JJ. Rotator cuff tears: The effect of the reconstruction method on three-dimensional repair site area. Arthroscopy. 2002; 18(5):519?526
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 Hantes ME, Ono Y, Raoulis VA, et al. Arthroscopic single-row versus double-row suture bridge technique for rotator cuff tears in patients younger than 55 years: A prospective comparative study. Am J Sports Med. 2018; 46(1):116?121
 Wade R, Salgar S. Clinico-radiological evaluation of retear rate in arthroscopic double row versus single row repair technique in full thickness rotator cuff tear. J Orthop. 2017; 14(2):313?318
 Spiegl UJ, Euler SA, Millett PJ, Hepp P. Summary of meta-analyses dealing with single-row versus doublerow repair techniques for rotator cuff tears. Open Orthop J. 2016; 10:330?338
 Nicholas SJ, Lee SJ, Mullaney MJ, et al. Functional outcomes after double-row versus single-row rotator cuff repair: A prospective randomized trial. Orthop J Sports Med. 2016; 4(10):2325967116667398
 Grimberg J, Diop A, Kalra K, Charousset C, Duranthon LD, Maurel N. In vitro biomechanical comparison of three different types of single- and double-row arthroscopic rotator cuff repairs: Analysis of continuous bone-tendon contact pressure and surface during different simulated joint positions. J Shoulder Elbow Surg. 2010; 19(2):236?243
 Garofalo R, Castagna A, Borroni M, Krishnan SG. Arthroscopic transosseous (anchorless) rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2012; 20(6):1031?1035
 Kany J, Anis H, Werthel JD. Massive irreparable rotator cuff tears: Treatment options, indications, and role of fully arthroscopic latissimus dorsi transfer. Obere Extremitt. 2018; 13(89)