Massive rotator cuff tears associated with poor tendon quality remains a challenging condition. While double-row suturing bridging repairs have improved biomechanical strength, this technique may not be possible in the setting of tendon loss or limited tendon mobility. Single-row repairs are frequently performed in these settings, but re-tear rates have been reported up to 94% in massive rotator cuff tears. Therefore, alternative repair constructs must be sought. A loading?sharing rip-stop (LSRS) suture technique combines the advantages of a rip-stop suture tape and load-sharing properties of a double-row repair. Biomechanically, the LSRS construct has superior properties compared to a single-row repair, and clinically the repair has demonstrated promising initial results. A variation of this technique is to perform a knotless rip-stop (KRS) repair with only two suture anchors. This technique eliminates knot tying and decreases the anchor burden, while still maintaining the benefit of 2-mm suture tape. This chapter describes the authors? technique for the LSRS and KRS repair for massive rotator cufftears in which a double-row repair is not achievable.
Keywords: knotless rip-stop, load-sharing rip-stop, rotator cuff, single-row
? The patient is placed in the lateral decubitus position and secured with a beanbag. An axillary role is used to protect the brachial plexus. Pillows are placed underneath the fibular head of the down leg to protect the peroneal nerve and between the legs.
? The arm is held in 20 to 30 of abduction combined with 20 forward flexion utilizing an articulated electrically powered arm holder (Spider2, Smith & Nephew, Memphis, TN).
? An arthroscopic pump (Arthrex, Naples, FL) is used starting at 40 mm Hg and using fluid with added epinephrine to each bag to minimize bleeding, utilizing a standard dose (1 mg epinephrine per 3-Lsaline bag).
A posterior glenohumeral viewing portal is established in the posterior ?soft spot.? We palpate the ?soft spot? created by the glenoid medially and humeral head laterally.
An anterosuperolateral portal is established 1?2 cm lateral and distal to the anterolateral corner of the acromion with a 5?10 angle of approach to the lesser tuberosity. A threaded cannula is placed in this portal. Biceps tenodesis, subscapularis repair, and coracoplasty (if indicated) are performed through this working portal. Note that the repair of the subscapularis must precede repair of the posterosuperior rotator cuff to have success in repair of massive rotator cuff tears. Then, the scope is redirected from the joint into the subacromial space.
A lateral portal is established in the mid tuberosity, approximately 3?4 cm lateral to the acromion. A limited subacromial decompression that preserves the coracoacromial arch is performed through this portal. After the decompression, bony landmarks (scapular spine and undersurface of acromioclavicular [AC] joint) are dissected so that they are fully visualized. Good visualization of the scapular spine is particularly important to see the raphe between the supraspinatus and the infraspinatus. Every effort is made to obtain a complete repair of the cuff, including careful excavation of the cuff, excision of bursal leaders, and interval slides when indicated. During this phase of the procedure, we have found that a 70 arthroscope is particularly useful because of the expanded field of view that it offers. Once mobilization is complete, a threaded cannula is placed in this portal for suture placement and lateral anchor placement.
Percutaneous portals are used as necessary for placement of anchors. These are established as 5?10 mm stab incisions just off the lateral edge of the acromion and are used for placement of anchors placed adjacent to the articular margin.
? An antegrade suture passer is used to pass a 2-mm suture (FiberTape, Arthrex) through the rotator cuff as an inverted mattress stitch; the suture is placed 5?10 mm lateral to the tendon edge depending on remaining tendon length.
? If the tear has a large anterior-to-posterior dimension, then a second FiberTape may be placed in similar fashion. These rip-stop suture tapes must not be tensioned and repaired to bone until after the sutures from the medial anchors have been passed.
? Next, two double-loaded 5.5 mm anchors (Bio Composite Corkscrew, Arthrex) are placed anteromedially and posteromedially, along the articular margin. Beginning posteriorly, the sutures are passed from the medial anchors as simple stiches that penetrate the rotator cuff about 1 mm medial to the rip-stop suture.
? Once the medial sutures are passed, the FiberTape rip-stop sutures are retrieved from an accessory portal and secured laterally with two knotless suture anchors, making sure they encircle the sutures from the medial anchors.
? Finally, simple sutures from the medial anchors are retrieved and static knots are tied (? Fig. 32.1, ? Video 32.1).
Fig. 32.1 Schematic illustrations of an anchor-based rip-stop rotator cuff repair for a rotator cuff tear with lateral tendon loss. (a) A FiberTape (Arthrex, Naples, FL) suture has been placed as an inverted mattress stitch in the rotator cuff. Two medial anchors (Bio Composite Corkscrew, Arthrex) have also been placed and sutures from these anchors are passed medial to the rip-stop stitch. (b) Prior to tying the sutures from the medial Corkscrew anchors, the rip-stop stitch is secured to bone with two lateral Bio Composite SwiveLock C anchors (Arthrex). (c) Tying the suture limbs from the Corkscrew anchors completes the repair.(Reprinted with permission from Burkhart et al 2012.)
? In the knotless rip-stop (KRS) repair, two knotless constructs are created. This technique is similar in concept to the loading?sharing rip-stop (LSRS) repair but is simpler to perform.
? As in the LSRS repair, this repair begins by placing a 2-mm suture tape (FiberTape, Arthrex) as an inverted mattress stitch in the rotator cuff, 5?10 mm medial to the lateral tendon edge. The suture is passed with 1 cm of spacing between the suture limbs.
? Next, a #2 suture with a free end on one end and a loop on the other end (FiberLink; Arthrex) is passed just medial to the mattress suture. The free end is passed through the loop to create a cinch stitch.
? A second KRS construct is then placed.
? A small punch is used to create bone vents adjacent to the articular margin to open the marrow elements and facilitate healing of the tendon to bone.
? Each KRS construct is secured in the lateral greater tuberosity with a knotless anchor (5.5 mm Bio Composite SwiveLock C, Arthrex) for a total of two anchors.
? Beginning posteriorly, the suture limbs of one construct are retrieved out the lateral portal cannula. The free limbs of the sutures are threaded through the eyelet of the knotless anchor, slack is removed, the anchor is placed in a pre-placed bone socket, and the suture limbs are cut to complete the KRS.
? The anterior construct is then secured in an identical fashion (? Fig. 32.2, ? Video 32.2).
Fig. 32.2 Schematic illustrations of a knotless rip-stop technique. (a) Two 2-mm suture tapes (FiberTape, Arthrex, Naples, FL) are placed as an inverted mattress stitches in the rotator cuff, 1 cm medial to the lateral tendon edge. (b) Next, a cinch suture (FiberLink, Arthrex) is passed just medial to the inverted mattress suture tape. (c) Each suture tape/cinch loop construct is secured independently with two knotless anchors (5.5 mm Bio Composite SwiveLock C, Arthrex). (d) Final illustration demonstrating knotless rip-stop repair.
? We routinely use a 70 scope during the rotator cuff repair portion of the procedure, which we have found particularly useful for the expanded field of view that it offers. Use of this scope from the posterior portal facilitates triangulation with a lateral working portal and also makes lateral row anchor placement easier.
? 8.25 or 8.5 threaded mm cannulas are routinely placed in the anterosuperolateral and lateral portals and are used as the main working portals during the procedure.
? Accessory percutaneous portals are created as needed for anchor placement or suture management.
? An antegrade suture passer that is self-retrieving (Scorpion FastPass, Arthrex) facilitates suture passage.
? For the LSRS, it is important to delay knot tying until after the rip-stop stitch is secured laterally for two reasons. First, it is important to have a firm, taut rip-stop. Second, the FiberTape serves to unload the medial sutures as the rip-stop construct is secured laterally to an anchor.
? Suture management during the LSRS is facilitated by retrieving sutures from the medial anchors out of the same percutaneous portals used for anchor placement; this is done after each pass.
? For the KRS, the anchors are placed in the tuberosity, positioned in the same location normally used for the lateral row of a double-row repair, which is about 1 cm lateral to the tuberosity edge. This placement drapes the tendon over the bone vents in the tuberosity. However, as such, it is important to not overtension the rotator cuff when securing the construct.
? We try to take advantage of biology. In the LSRS, the medial anchors are cannulated and vented. In the KRS construct, bone vents are used medially to encourage healing (i.e., reverse ?crimson duvet?).
? Rehabilitation after this type of repair should be slow given the poor-quality tissue. We avoid motion until 6 weeks and delay strengthening until 12 weeks.
? Anchor failure is uncommon with threaded anchors. But we have seen pullout with smaller anchors (4.5 or 4.75 mm) in these types of repairs and only use larger anchors laterally (5.5 mm) given that many of these patients have poor bone quality.
? Re-tear is lowered with these types of repairs but can still occur. Our healing rates are outlined in the literature.1
Postoperatively, patients undergo immobilization in a sling for 6 weeks with basic hand, elbow, and wrist exercises started immediately. If a concomitant subscapularis repair is performed, we limit external rotation to neutral. Otherwise, if no repair was performed, external rotation to 30 is allowed. After 6 weeks, the sling is discontinued and passive forward elevation along with table slides are allowed. At 3 months postoperatively, strengthening is initiated.
Rip-stop sutures are used to limit tendon cut through given that the majority of rotator cuff failures occur at the suture?tendon interface. Ma et al demonstrated that a rip-stop suture with a double-loaded anchor had load to failure equivalent to a modified Mason?Allen stitch.2 This construct is particularly useful for cases in which there is limited medial tendon that precludes a standard double-row repair.
The LSRS technique was first reported by Denard and Burkhart.3 This technique combines the advantages of a wide rip-stop suture tape and load-sharing properties of a double-row repair. A biomechanical study performed by Burkhart et al compared the LSRS to a standard single-row repair.4 The mean load to failure for LSRS was nearly twice that for a single-row repair construct(616 N vs. 371 N; P =0.031). Notably, in the single-row group, four of six failures occurred at the suture tendon interface (suture cutout) versus only one failure in the LSRS group. In a recent clinical study, Noyes et al evaluated the functional outcomes and healing rates for large and massive rotator cuff tears repaired with an LSRS construct.5 Postoperative ultrasound evaluation demonstrated complete healing in 53% and partial healing in 29% of the cohort. Mean supraspinatus strength improved by one grade and 82% of patients were satisfied at their final follow-up. These results are promising considering the difficult patient population.
We are not aware of any clinical data on the KRS at this time. We performed a biomechanical investigation comparing the KRS to a single-row repair with triple-loaded anchors (submitted). The mean load to failure for triple-loaded anchors compared to KRS was equivalent (438 N vs. 457 N; P = 0.582). Interestingly, the triple-loaded anchor group had two tendon tears (type 1 failures) as a mode of failure while the KRS group had no tendon tears.
 Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004; 86(2):219?224
 Ma CB, MacGillivray JD, Clabeaux J, Lee S, Otis JC. Biomechanical evaluation of arthroscopic rotator cuff stitches. J Bone Joint Surg Am. 2004; 86(6):1211?1216
 Denard PJ, Burkhart SS. A load-sharing rip-stop fixation construct for arthroscopic rotator cuff repair. Arthrosc Tech. 2012; 1(1):e37?e42
 Burkhart SS, Denard PJ, Konicek J, Hanypsiak BT. Biomechanical validation of load-sharing rip-stop fixation for the repair of tissue-deficient rotator cuff tears. Am J Sports Med. 2014; 42(2):457?462
 Noyes MP, Ladermann A, Denard PJ. Functional outcome and healing of large and massive rotator cuff tears repaired with a load-sharing rip-stop construct. Arthroscopy. 2017; 33(9):1654?1658
Burkhart SS, Lo IK, Brady PC, Denard PJ. The Cowboy?s Companion. Philadelphia, PA: Lippincott Williams & Wilkins; 2012