11 Transosseous Repair

J. Gabriel Horneff and Mark D. Lazarus


Transosseous rotator cuff repair remains the gold standard of repair. As arthroscopic techniques have evolved, the majority of repairs have been performed through the use of anchor-based techniques. This chapter describes an arthroscopic transosseous tunneling technique used to repair rotator cuff tears with no implant use that best recreates the ?gold standard? that was performed in the days of open rotator cuff repair. This technique requires careful suture management and familiarity with the use of a tunneler device but, ultimately, results in stronger, cheaper, and better repairs.

Keywords: arthroscopic cuff repair, posterosuperior cuff repair, rotator cuff repair, transosseous repair, tunneler

11.1 Patient Positioning

? The patient is placed in the beach chair position. This is our preference but a lateral decubitus position with 5 to 10 pounds of distraction on the operative arm is also acceptable depending on surgeon preference.

? The operative extremity is prepped and draped in the typical sterile fashion.

? A mechanical arm holder can be utilized to position the operative extremity in space (this is for our preferred beach chair positioning).

11.2 Portal Placement

? There are five main portals utilized for this approach to rotator cuff repair.

? Standard posterior portal.

? Created first in the posterior soft spot about 1?2 cm inferior and medial from the posterolateral edge of the acromion.

? Initial viewing portal for diagnostic scope of the glenohumeral joint and subacromial space.

? Serves as the retrieval portal for the posterior tunnel sutures.

? Serves as the portal for tying the medial limbs of the posterior tunnel horizontal mattress ?rip-stop? sutures.

? Standard anterior portal.

? Created second in the rotator interval under spinal needle localization.

? Serves as the initial working portal for use of the arthroscopic shaver and electrocautery.

? Serves as the retrieval portal for the anterior tunnel sutures.

? Serves as the portal for tying the medial limbs of the anterior tunnel horizontal mattress ?rip-stop? sutures.

? Lateral portal.

? Created third with spinal needle localization with the needle parallel to the horizontal of the floor. It is typically located in line with the anterior edge of the acromion.

? Serves as the main working portal for subacromial space.

? Enlarged for placement of the tunneling device for drilling of the lateral tunnels, shuttling of the sutures through the tendon edge, and lateral knot tying.

? Posterolateral portal.

? Typically created fourth for placement of the arthroscope during tunneling and suture management of the rotator cuff repair.

? Medial (acromial edge) portal.

? Used for spinal needle localization and drilling of the medial tunnel drill holes.

11.3 Surgical Technique (Step-by-Step Approach)

? Prior to incision, a surgical timeout should always be performed to correctly identify the patient, procedure, and correct operative limb.

? A standard posterior portal is created and the arthroscope is introduced into the glenohumeral joint. An anterior portal is immediately created in the rotator interval. A diagnostic arthroscopy is performed to assess the rotator cuff, labrum, articular surface, and remaining structures.

? If the subscapularis tendon is torn, this should be repaired as best as possible by the surgeon?s preferred technique.

? Once all intraarticular work is completed, the arthroscope should be redirected to the subacromial space.

? A lateral portal is created under spinal needle localization in line with the anterior border of the clavicle.

? A combination of arthroscopic shavers, burs, and electrocautery are used via the lateral portal to remove any debris from the undersurface of the acromion. Any large subacromial spurs can be smoothed. The arthroscopic tools can then also be used to remove any soft tissue attached to the exposed greater tuberosity footprint. The arthroscopic bur is used to lightly decorticate the greater tuberosity to encourage healing of the repaired cuff. An arthroscopic grasper can be brought in to ascertain the excursion and quality of the torn tendon tissue.

? The posterolateral portal is created for placement of the arthroscope for visualization during the repair.

? A spinal needle is brought into the shoulder off the lateral edge of the acromion to determine the number and spacing of the medial holes for tunnel placement. Once the proper localization is identified, a small portal is created and the medial row drill guide from the Tornier ArthroTunneler TunnelPro System (Wright Medical Group, Memphis, TN) is used to guide the placement of the medial holes with the drill.

? The medial holes for all the planned tunnels are drilled to the stop on the drill making sure to not violate the articular bone. The holes should be placed just adjacent to the lateral edge of the articular cartilage near the tuberosity.

? The holes are then smoothed with the medial row awl so as to remove any bony debris and prevent sharp edges of bone from cutting the sutures.

? The lateral portal is enlarged enough to allow for placement of the tunneling device. The medial hook on the tunneler is placed into a medial hole and the retractable lateral guide is positioned adjacent to the lateral portion of the greater tuberosity (the white pegs on the handle allow for retraction). Once in the proper position, the white pegs are held in place to ensure that the guide is firmly held to the lateral portion of the tuberosity and the blue switch is engaged in the forward position on the handle. This switch deploys the metal suture lasso that will capture the shuttling suture.

? The lateral drill bit is placed through the tunneler handle to drill the tunnel. The drill is removed and the metal shuttle suture passer is placed in the handle. The blue switch is then retracted as the suture passer is removed slowly to allow for capture of the shuttling suture. The tunneler is then removed from the lateral portal with the loop of the shuttling suture captured out of the medial tunnel.

? The loop of the shuttling suture is loaded with the appropriate number of repair sutures (three for outer tunnels and four for inner tunnels) and the free limbs of the shuttling suture are pulled through the lateral portal to load the sutures through the tunnel. Each of the sutures placed in the tunnel are of different type/color to allow for organization. The first two sutures are used for simple suture patterns while the third (and fourth sutures depending on number of tunnels) are used for horizontal mattress ?rip-stop? stitches that are tied to the same type of suture found in an adjacent tunnel.

? For anterior tunnel sutures, the medial and lateral suture limbs are brought out through the anterior portal and tagged outside of the shoulder with hemostats (one hemostat for medial limbs and two hemostats for lateral limbs). We have designed a color-coded hemostat system to help organize the suture limbs outside of the shoulder, which is described in the Tips and Tricks section.

? Only the most posterior tunnel will have its suture limbs brought out through the posterior portal and tagged with hemostats.

? A large working cannula is placed into the lateral portal.

? Starting posteriorly, each medial suture limb is separately retrieved through the lateral working cannula and passed through the rotator cuff tendon via a suture passing device. Once passed through the tendon, the limbs are retrieved out of their respective anterior or posterior portals and retagged with the appropriate hemostat.

? A small cannula is placed in the posterior portal and the corresponding medial limbs of horizontal mattress ?rip-stop? sutures from the most posterior tunnels are retrieved. These matching suture type/color medial limbs are then tied outside of the shoulder with a square knot and the excess suture is trimmed.

? The lateral limbs of these horizontal mattress sutures are then retrieved out of the lateral cannula. A grasper is used to reduce the cuff via the lateral portal as the lateral limbs are pulled taut. The horizontal mattress knot is visualized into placed and the grasper is removed. The lateral limbs are then tied in a nonsliding knot via alternating half hitches with an arthroscopic knot pusher.

? The medial and corresponding lateral limbs of the remaining sutures in the tunnels that just had a horizontal mattress tied are retrieved and tied sequentially from posterior to anterior in a simple suture pattern, with the lateral limbs serving as the post during arthroscopic knot tying.

? The small cannula is placed in the anterior portal and the process is repeated for the remaining tunnels with the horizontal mattress knots between adjacent tunnels tied first followed by the simple sutures.

? Remove all instrumentation from the shoulder and close the portal sites with a nonabsorbable suture and dress with sterile dressings to preference.

? The patient is placed in an abduction sling prior to awakening from anesthesia and then taken to the recovery room (? Video 11.1).


Video 11.1 Surgical demonstration of an arthroscopic transosseous rotator cuff repair technique.

11.4 Surgeon Tips and Tricks

? Larger tears often require more tunnels with most cases requiring anywhere between two and four tunnels. All peripheral tunnels are loaded with three sutures while inner tunnels (one tunnel in a three-tunnel repair and two tunnels in a four-tunnel repair) require four sutures.

? Suture management is the key to success with this technique. We use a color-coded hemostat system to organize suture limbs outside of the shoulder. Depending on how many tunnels are being used determines how many colors are involved. The following is our proposed color-coding scheme.

? Two tunnels:

? Tunnel 1 (anterior): three sutures ?medial (one red hemostat); lateral (one white hemostat).

? Tunnel 2 (posterior): three sutures ?medial (one black hemostat); lateral (one white hemostat).

? Three tunnels:

? Tunnel 1 (anterior): three sutures ?medial (one red hemostat); lateral (two red hemostats).

? Tunnel 2: four sutures ?medial (one white hemostat); lateral (two white hemostats).

? Tunnel 3 (posterior): three sutures ?medial (one blue hemostat); lateral (two blue hemostats).

? Four tunnels:

? Tunnel 1 (anterior): three sutures ?medial (one red hemostat); lateral (two red hemostats).

? Tunnel 2: four sutures ?medial (one white hemostat); lateral (two white hemostats).

? Tunnel 3: four sutures ?medial (one blue hemostat); lateral (two blue hemostats).

? Tunnel 4 (posterior): three sutures ?medial (one green hemostat); lateral (two green hemostats).

? We find that some abduction of the shoulder prior to drilling of the tunnels helps to engage stronger bone laterally.

? Suture placement through the cuff tendon should be carefully performed. For the simple sutures, the medial limbs should be placed into the tendon slightly anterior or posterior to the line of the tunnel and medial to the placement of the horizontal mattress suture limbs. The medial limbs of the horizontal mattress sutures are placed more in line with the tunnels (between the anterior and posterior simple suture limbs) and slightly more lateral. The purpose of this lateralization of the horizontal mattress sutures is so they serve as a ?rip-stop? to prevent cutout of the simple sutures through the tendon.

11.5 Pitfalls/Complications

? Usual possible risks that come along with arthroscopic shoulder surgery (i.e., infection, bleeding, wound healing, etc.).

? One concern with the use of transosseous tunnels is the potential for suture cutout if the bone quality is poor. To combat this, we will employ the use of tape-like sutures, which are less likely to cut through the bone. We also recommend making sure that the tunneler is completely seated before drilling the lateral hole to prevent a shallow tunnel in the weaker proximal bone of the greater tuberosity.

? Conversely, the bone can also cut sutures because of sharp edges near the tunnel holes. We recommend the use of the arthroscopic awl to help smooth the edges of the tunnel and, again, can use tape-like sutures, which are less likely to rupture.

? There have been studies showing that knot strength varies considerably among arthroscopic surgeons.1 One disadvantage of the transosseous technique is that it is heavily dependent upon the surgeon?s ability to tie secure knots. Therefore, one must be comfortable with the knot-tying technique.

11.6 Rehabilitation

? Weeks 0?6: Sling worn at all times. Portal sutures removed at the first postoperative visit. Passive range of motion (PROM) began with supine passive forward elevation to 90� and supine passive external rotation to 30�. This can be started as early as week 2 depending on tear size.

? Weeks 6?12: Discontinuation of the sling. Patient can actively use arm for light waist-level activity not heavier than a coffee cup. Continue PROM with elevation to 140� and external rotation to 40�. May also begin scapular strengthening and phase 1 cuff strengthening. Formal physical therapy (PT) is started with a concurrent home exercise program.

? Weeks 12?18: Add internal rotation stretches. Continue strengthening. No lifting greater than 10 pounds with both hands.

? Weeks 18?24: The PT regimen is advanced to full strengthening (phase 2) with transition to a home-based program. No lifting greater than 20 pounds with both hands.

? Week 24 and beyond: Can return to full activity with no weight restrictions. May begin sports-/work-specific strengthening if necessary.

11.7 Rationale and/or Evidence for Approach

? The use of transosseous tunnel repair significantly reduces the cost of rotator cuff surgery.2,3 Seidl et al found that the mean cost for rotator cuff repair was nearly $950 less when using a tunneler over arthroscopic anchors.2 This cost difference was magnified in the instances of larger tears where more anchors would need to be used.

? Transosseous repair has been shown to have a low re-tear rate of about 6% with minimal complications compared to anchor-based repair.3

? Patients undergoing transosseous repair have been found to have a faster decrease in their postoperative pain compared to anchor repair, which may be sign of improved repair.4

? The use of bone tunnels may improve blood flow to the repaired cuff tendon and contribute to better biological healing of the repair.5

? Instances of revision repair may be easier because no anchors have been used to limit the amount of bony purchase left available in the greater tuberosity footprint.


[1] Hanypsiak BT, DeLong JM, Simmons L, Lowe W, Burkhart S. Knot strength varies widely among expert arthroscopists. Am J Sports Med. 2014; 42(8):1978?1984

[2] Seidl AJ, Lombardi NJ, Lazarus MD, et al. Arthroscopic transosseous and transosseous-equivalent rotator cuff repair: An analysis of cost, operative time, and clinical outcomes. Am J Orthop. 2016; 45(7):E415?E420

[3] Kuroda S, Ishige N, Mikasa M. Advantages of arthroscopic transosseous suture repair of the rotator cuff without the use of anchors. Clin Orthop Relat Res. 2013; 471(11):3514?3522

[4] Randelli P, Stoppani CA, Zaolino C, Menon A, Randelli F, Cabitza P. Advantages of arthroscopic rotator cuff repair with a transosseous suture technique: A prospective randomized controlled trial. Am J Sports Med. 2017; 45(9):2000?2009

[5] Urita A, Funakoshi T, Horie T, Nishida M, Iwasaki N. Difference in vascular patterns between transosseous-equivalent and transosseous rotator cuff repair. J Shoulder Elbow Surg. 2017; 26(1):149?156