Transosseous and anchor-based cuff repair methods each have specific technical advantages, which can be used synergistically in rotator cuff repair, like two sides of the same coin. Transosseous fixation offers double-row, 2-point fixation per tunnel, small diameter marrow vents, multiple sutures per tunnel, and unlimited fixation points per case with no cost ceiling. Anchors may have improved biomechanics in some settings and offer knotless fixation, which may be used in conjunction with transosseous approaches. Clinical literature has never demonstrated a fundamental difference in healing rates between the two methods. This chapter discusses a novel hybrid technique to provide double-row, anatomic footprint reconstruction at the healing interface of the rotator cuff with no inert anchor burden to the tuberosity, while capitalizing on biomechanical advantages of a single knotless lateral row anchor, which also serves to independently tighten and backup primary transosseous fixation. This construct allows for a high fixation point per surface area repair, excellent access to biologically active marrow elements, no inert material in the footprint to consider in the revision setting, and redundant high-strength fixation. Moreover, cost reproducibility may be achieved regardless of tear size in the value-based era of surgery. This chapter describes an all-arthroscopic technique for ?true? transosseous rotator cuff repair, utilizing a gold standard technique with five fixation points, but only one anchor. This repair combines many desirable qualities namely double-row fixation excellent biological considerations with bone marrow vents accessing repair site, dense fixation point per surface area repair, independent fixation, and cost reduction per fixation point.
Keywords: hybrid rotator cuff repair, rotator cuff repair, transosseous, true transosseous hybrid rotator cuff repair, value-based medicine
The patient may be positioned in either beach chair or lateral decubitus position. We prefer a beach chair with a mechanical arm holder, especially to allow for controlled rotation and forward flexion of the arm during biceps tenodesis.
The standard posterior portal and anterior superior portal are utilized. Specific portals for the technique include (see ? Fig. 12.1):
? Low anterolateral portal for introduction of tunneling device during cuff repair and biceps tenodesis.
? Midlateral portal v. in ? Fig. 12.1. for viewing during biceps tenodesis.
? Accessor anterior?inferior instrumentation portal iii in ? Fig. 12.1 to aid in suture passage through the biceps portal iv in ? Fig. 12.1.
Fig. 12.1 Portals for transosseous cuff repair and biceps tenodesis. i. standard anterosuperior portal; ii. standard posterior portal; iii. midlateral viewing portal; iv. accessory anterior-inferior instrumentation portal; v. low anterolateral working portal.
Video 12.1 True transosseous hybrid arthroscopic cuff repair of a right shoulder is shown in the beachair position. This technique offers triple row fixation, no inert material at the healing interface, decreased cost per fixation point, cortical augmentation, and the chance to retension the construct at the final step.
? The cuff tear pattern is mobilized and assessed in the standard fashion (? Video 12.1).
? Footprint preparation: The footprint surface is prepared with a shaver to optimize healing. The geometry of the footprint reconstruction and placement of the fixation points are planned at this phase.
? Medial fixation points: A 2.9 mm awl is placed through an accessory portal just lateral to the acromion to create two medial fixation points just adjacent to the articular surface of the humeral head. These would be in the location of a medial row anchor. While the awl is in the subacromial space, the tuberosity may be microfractured to create more bone marrow vents to aid in ingress of biologically active marrow cells.
? Tunnel creation: The low anterolateral portal is localized by placing a spinal needle just above the tuberosity. The TransOs tunneler is introduced in an inverted fashion, penetrating the subdeltoid fascia low on the tuberosity. The tip is then rotated up into the previously created medial fixation point. Simultaneous tunnel creation and shuttle suture delivery are performed with the reusable tunneling device (TransOs, Tensor Surgical, Chattanooga, TN).
? Suture passage: The doubled suture is pulled through the superior awl portal and used to shuttle three high-strength sutures of different color through the tunnel for this ?Xbox? style repair. The inferior tails of the sutures are clipped to the surgical drapes to prevent them from sliding or unloading. The sutures may now be managed intraarticularly, similar to an anchor-based repair.
? The previous two steps are repeated for the second, posterior tunnel. There are now two tunnels with three sutures (referred to as ?triplets?) in each tunnel.
? Suture passage through the tendon: Simple sutures are passed through the tendon with standard antegrade or retrograde techniques. They are stored in the anterior or superior portals.
? Creation of mattress, or ?box? stitch: A different-colored medial suture tail from the anterior and posterior tunnel are retrieved from the lateral cannula and tied together outside the cannula. The inferior tails are used to slide the knot back into the joint and position the knot where it is most advantageous for the repair. This creates the medial mattress limb that compresses the tendon between the two tunnels and excludes synovial fluid from the repair. The lateral limbs of the box are left untied.
? Creation of ?X? stitch: A superomedial tail from the posterior tunnel and an inferolateral tail from the anterior tunnel are retrieved through the lateral cannula and tied together. Pulling on the posterior inferolateral tail of the posterior tunnel and the superomedial tail of the anterior tunnel will reduce the knot into the joint at the medial footprint of the cuff wherever it is desired by the surgeon. The tails are left untied.
? Tying the simple sutures: Both tails of the anterior tunnel simple suture are retrieved through the lateral cannula and tied with a locking, sliding knot, using a lateral post based on the inferolateral tuberosity. The posterior simple stitch is then tied in the same manner. This step will reduce the cuff to its anatomic footprint by circumferential transosseous compression.
? Tying the mattress and crossing ?X? stitch: The remaining tails of these two sutures are then tied lateral on the tuberosity. At this phase, the medial tails that have been left long can be positioned between the tunnel fixation points, optimizing cuff surface area compression from the lateral anchor. The lateral sutures of these limbs may be tied and cut.
? Anchor placement: The repair is now fully complete as a transosseous repair, which could be used as a stand-alone repair. However, the long medial tails offer an extra opportunity to independently and mechanically back up the construct with a single cost-effective anchor and also provide final tightening of the construct. The medial tails are brought through the lateral cannula and a knotless anchor is used to place them below the mattress stitch on the inferior portion of the tuberosity, creating a self-reinforcing construct based in the harder bone of the lower portion of the tuberosity. If dog-ears in the cuff are present, additional sutures may be incorporated to reduce them with the lateral anchor at this time.
? Keep the portal more inferior than an anchor portal by localizing a spinal needle just over the greater tuberosity. This angle makes it easier to achieve a large bone bridge in the hardest bone and works with the force of the deltoid to rotate the device lower on the humerus.
? Techniques may be used with simple sutures alone or knotless lateral row anchors early in the learning curve.
? Snap the inferior limbs of the sutures to the drapes to ease suture management in the suture passing step and prevent inadvertent unloading of the tunnel.
? Use sutures of different colors to ease suture management.
? If a suture unloads, more can be shuttled into the tunnel if there are any sutures left in the tunnel, or it may be retunneled. Unloading of a tunnel does not destroy the anchor point as does an unloaded anchor in the same position. This fact holds true for revision cases as well.
? Any tunnel can be substituted for an anchor if there is concern over soft bone with no repercussions. The 2.9/5.5 diameter mismatch will give the anchor higher torque in soft bone. If the awl can be inserted without the use of a mallet, we consider anchor augmentation; otherwise, transosseous fixation is sufficient for mechanical stability.
? Tapes may be used in the tunnel for the simple stitches to decrease plastic deformation of the bone and provide higher surface area compression.
? The anterior two-thirds of the proximal humerus may be tunneled from the anterior lateral portal; if a posterior tunnel is desired for a three-tunnel massive tear, the posterolateral portal is utilized to place the tunnel.
? Suture cutting through soft bone: In our experience, this rarely happens with modern indications and instrumentation that avoids drilling and removing bone. If a tunnel does cut through intraoperatively, any other feasible fixation paradigm may be used as the diameters of the tunnels are small and bone-conserving. Lateral row anchors, buttons, screws, and tapes are all options for fixation in osteoporotic bone. Unlike loose hardware, fixation loss from suture cut through in the post-op phase would not necessarily result in revision surgery.
? Suture management: Suture management is facilitated by colored sutures, controlling/organizing the sutures on the field, and placing a cannula in the instrumentation portal, which serves to stabilize the inferior sutures.
? Revision concerns: Hybrid techniques are easily revised, as the tuberosity bone is conserved. Anchors may be placed into previous tunnels, or they may be retunneled. Revision of a tunneled repair is usually a type 1 failure, which conserves tendon substance. In severe bone defects, additional support can be achieved with screw fixation distally.
? Rehabilitation: No active motion for 6 weeks. Elbow range of motion and pendulums only. A graduated stretching and strengthen program are then implemented.
? Arthroscopic methods to achieve the gold standard transosseous cuff repair have now been described, which have similar biomechanics and clinical results, but decreased implant burden relative to anchor-based techniques.1,2,3,4,5,6,7,8,9,10,11,12 Anchor-based and transosseous techniques for cuff repair may be used synergistically in the surgeon?s armamentarium to treat complicated rotator cuff tears in the value-based era of medicine.13,14,15,16,17 This hybrid approach is designed to maximize the number of fixation points per repair while minimizing complications and cost.18,19,20,21,22,23
? Basic science has supported several principles for rotator cuff repair: high initial fixation strength, adequate resistance to cyclic loading, and anatomic footprint reconstruction with crossing sutures meant to provide compression and decrease shear forces at the tendon?bone interface.24,25,26,27,28 Transosseous-equivalent techniques use anchors to mimic the desirable cerclage effect about the footprint created by true transosseous repair29. Because one anchor per fixation point is necessary, multiple anchors must be used to achieve this goal, increasing cost in the episode of care and potential hardware problems in the greater tuberosity. Many anchors achieve high strength and stiffness in adequate bone. However, some potential concerns regarding anchor fixation are tissue strangulation,30 stress concentration,31,32,33,34 and modulus mismatch at the anchor?suture?tendon interface. As the rotator cuff tissue is typically the weak link in the repair construct, certain very rigid anchor constructs may create an abrupt stress and strain transition that could lead to tendon transection at the medial anchor. Previous authors have described this ?type 2? failure mode to be associated with, if not unique to, anchor constructs.26,27 Transosseous techniques offer the advantage of high-density, doublerow fixation points within a repair, excellent access to biologically active marrow elements through small diameter marrow vents, satisfactory biomechanics, and lower implant burden. A true transosseous, single-anchor hybrid technique could offer the clinical advantages of both paradigms to a maximal degree while achieving cost reproducibility in the episode of care. While the exact interplay of tension, vascularity, stiffness, ultimate failure strength, and other variables necessary in a rotator cuff repair remain unknown, it may be inferred that delivering a sufficiently strong biologically active repair in a sustainable manner is a key concern.
 Garrigues GE, Lazarus MD. Arthroscopic bone tunnel augmentation for rotator cuff repair. Orthopedics. 2012; 35(5):392?397
 Cicak N, Klobucar H, Bicanic G, Trsek D. Arthroscopic transosseous suture anchor technique for rotator cuff repairs. Arthroscopy. 2006; 22(5):565.e1?565.e6
 Kim KC, Rhee KJ, Shin HD, Kim YM. Arthroscopic transosseous rotator cuff repair. Orthopedics. 2008; 31(4): 327?330
 Garofalo R, Castagna A, Borroni M, Krishnan S. Arthroscopic transosseous (anchorless) rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 201 2; 20(6):1031?1035
 Fox MP, Auffarth A, Tauber M, Hartmann A, Resch H. A novel transosseous button technique for rotator cuff repair. Arthroscopy. 2008; 24(9):1074?1077
 Burkhart SS, Nassar J, Schenck RC, Jr, Wirth MA. Clinical and anatomic considerations in the use of a new anterior inferior submaxillary nerve portal. Arthrsocopy. 1996; 12(5):634?637
 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
 Nho SJ, Shindle MK, Sherman SL, Freedman KB, Lyman S, MacGillivray JD. Systematic review of arthroscopic rotator cuff repair and mini-open rotator cuff repair. J Bone Joint Surg Am. 2007; 89 Suppl 3:127?136
 Black EM, Lin A, Srikumaran U, Jain N, Freehill MT. Arthroscopic transosseous rotator cuff repair: Technical note, outcomes, and complications. Orthopedics. 2015; 38(5):e352?e358
 Sanders B. Novel reusable transosseous tunnel based soft tissue repair techniques about the shoulder: A rational, value-based approach. Ortho Rheumatol. 2016; 5(1):00164
 Srikumaran U, et al. Arthroscopic transosseous anchorless vs anchored rotator cuff repair: A comparison of clinical and patient reported outcomes, structural integrity, and costs. Arthroscopy. 2016; 32(6):e22?e23
 Flanagin BA, Garofalo R, Lo EY, et al. Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair. Int J Shoulder Surg. 2016; 10(1):3?9
 Churchill RS, Ghorai JK. Total cost and operating room time comparison of rotator cuff repair techniques at low, intermediate, and high volume centers: Mini-open versus all-arthroscopic. J Shoulder Elbow Surg. 2010; 19(5):716?721
 Genuario JW, Donegan RP, Hamman D, et al. The cost-effectiveness of single-row compared with double-row arthroscopic rotator cuff repair. J Bone Joint Surg Am. 2012; 94(15):1369?1377
 Adla DN, Rowsell M, Pandey R. Cost-effectiveness of open versus arthroscopic rotator cuff repair. J Shoulder Elbow Surg. 2010; 19(2):258?261
 Vitale MA, Vitale MG, Zivin JG, Braman JP, Bigliani LU, Flatow EL. Rotator cuff repair: An analysis of utility scores and cost-effectiveness. J Shoulder Elbow Surg. 2007; 16(2):181?187
 Narvy SJ, Ahluwalia A, Vangsness CT, Jr. Analysis of direct cost of outpatient arthroscopic rotator cuff repair. Am J Orthop. 2016; 45(1):E7?E11
 Jost PW, Khair MM, Chen DX, Wright TM, Kelly AM, Rodeo SA. Suture number determines strength of rotator cuff repair. J Bone Joint Surg Am. 2012; 94(14):e100
 Kummer FJ, Hahn M, Day M, Muslin RJ, Jazrawi LM. Laboratory comparison of a new arthroscopic transosseous rotator cuff repair technique to a double row transosseous equivalent repair using anchors. Bull Hosp Jt Dis. 2013; 71(2):128?131
 Bisson LJ, Manohar LM. A biomechanical comparison of transosseous-suture anchor and suture bridge rotator cuff repairs in cadavers. Am J Sports Med. 2009; 37(10):1991?1995
 Srikumaran U, Hannan C, Kilcoyne K, Petersen S, Mcfarland E, Zikria B. Arthroscopic anchored versus transosseous cuff repair: A comparison of clinical outcomes and structural integrity. Arthroscopy. 2016; 32(6):e22
 Russell RD, Knight JR, Mulligan E, Khazzam MS. Structural integrity after rotator cuff repair does not correlate with patient function and pain: A meta-analysis. J Bone Joint Surg Am. 2014; 96(4):265?271
 Kilcoyne KG, Guillaume SG, Hannan CV, Langdale ER, Belkoff SM, Srikumaran U. Anchored transosseous-equivalent versus anchorless transosseous rotator cuff repair: A biomechanical analysis in a cadaveric model. Am J Sports Med. 2017; 45(10):2364?2371
 Jo CH, Shin JS, Park IW, Kim H, Lee SY. Multiple channeling improves the structural integrity of rotator cuff repair. Am J Sports Med. 2013; 41(11):2650?2657
 Milano G, Saccomanno MF, Careri S, Taccardo G, De Vitis R, Fabbriciani C. Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study. Arthroscopy. 2013; 29(5): 802?810
 Cho NS, Yi JW, Lee BG, Rhee YG. Retear patterns after arthroscopic rotator cuff repair: Single-row versus suture bridge technique. Am J Sports Med. 2010; 38(4):664?671
 Trantalis JN, Boorman RS, Pletsch K, Lo IK. Medial rotator cuff failure after arthroscopic double-row rotator cuff repair. Arthroscopy. 2008; 24(6):727?731
 Lee TQ. Current biomechanical concepts for rotator cuff repair. Clin Orthop Surg. 2013; 5(2):89?97
 Franceschi F, Papalia R, Franceschetti E, et al. Double-row repair lowers the retear risk after accelerated rehabilitation. Am J Sports Med. 2016; 44(4):948?956
 Christoforetti JJ, Krupp RJ, Singleton SB, Kissenberth MJ, Cook C, Hawkins RJ. Arthroscopic suture bridge transosseus equivalent fixation of rotator cuff tendon preserves intratendinous blood flow at the time of initial fixation. J Shoulder Elbow Surg. 2012; 21(4):523?530
 Panella A, Amati C, Moretti L, Damato P, Notarnicola A, Moretti B. Single-row and transosseous sutures for supraspinatus tendon tears: A retrospective comparative clinical and strength outcome at 2-year follow-up. Arch Orthop Trauma Surg. 2016; 136(11):1507?1511
 McCarron JA, Derwin KA, Bey MJ, et al. Failure with continuity in rotator cuff repair ?healing.? Am J Sports Med. 2013; 41(1):134?141
 Sano H, Yamashita T, Wakabayashi I, Itoi E. Stress distribution in the supraspinatus tendon after tendon repair: Suture anchors versus transosseous suture fixation. Am J Sports Med. 2007; 35(4):542?546
 Sanders B, Lavery KP, Pennington S, Warner JJP. Clinical success of biceps tenodesis with and without release of the transverse humeral ligament. J Shoulder Elbow Surg. 2012; 21(1):66?71