Rotator cuff pathology is a common cause of shoulder pain in the athletic and general population. Partial-thickness rotator cuff tears (PTRCT) are commonly encountered and can be bursal-sided, articular-sided, or intratendinous. Various techniques exist for the repair of bursal-sided PTRCTs. The 2 main distinctions when addressing these lesions include tear completion versus preservation of the intact fibers, and single- versus double-row suture anchor fixation. We present our method for addressing bursal-sided PTRCTs using an in situ repair technique with double-row suture anchors. © 2017 Arthroscopy Association of North Americ

Carter, MD, Aaron

Freedman, Kevin

Salem, Hytham

Tjoumakaris, Fotios

English

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Orthopaedic Surgery Faculty Papers Department of Orthopaedic Surgery3-1-2018Double-Row Repair Technique for Bursal-SidedPartial-Thickness Rotator Cuff TearsHytham SalemThomas Jefferson UniversityAaron Carter, MDThomas Jefferson University, aaron.carter@jefferson.eduFotios TjoumakarisThomas Jefferson University, Fotios.Tjoumakaris@jefferson.eduKevin FreedmanThomas Jefferson University, kevin.freedman@jefferson.eduLet us know how access to this document benefits youFollow this and additional works at: https://jdc.jefferson.edu/orthofpPart of the Orthopedics CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Orthopaedic Surgery Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For more information, pleasecontact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationSalem, Hytham; Carter, MD, Aaron; Tjoumakaris, Fotios; and Freedman, Kevin, "Double-RowRepair Technique for Bursal-Sided Partial-Thickness Rotator Cuff Tears" (2018). Department ofOrthopaedic Surgery Faculty Papers. Paper 111.https://jdc.jefferson.edu/orthofp/111Technical NoteDouble-Row Repair Technique for Bursal-SidedPartial-Thickness Rotator Cuff TearsHytham Salem, B.A., Aaron Carter, M.D., Fotios Tjoumakaris, M.D., andKevin B. Freedman, M.D.Abstract: Rotator cuff pathology is a common cause of shoulder pain in the athletic and general population. Partial-thickness rotator cuff tears (PTRCT) are commonly encountered and can be bursal-sided, articular-sided, or intra-tendinous. Various techniques exist for the repair of bursal-sided PTRCTs. The 2 main distinctions when addressing theselesions include tear completion versus preservation of the intact ﬁbers, and single- versus double-row suture anchorﬁxation. We present our method for addressing bursal-sided PTRCTs using an in situ repair technique with double-rowsuture anchors.Shoulder pain is the third most common musculo-skeletal complaint in the adult population, andpatients seeking medical care for shoulder pain aremost likely to be suffering from rotator cuff pathology.1Tears of the rotator cuff may be full- or partial-thickness, with partial-thickness rotator cuff tears(PTRCTs) further divided into bursal surface, articularsurface, and intratendinous tears. Although the indi-cation for surgical treatment of PTRCTs has not beenclearly established, arthroscopic or open repair isgenerally recommended in active patients that exhibitpain and weakness refractory to conservative treat-ment, and in tears that involve more than 50% oftendon thickness or are greater than 2 cm in diameter.2The surgical treatment of PTRCTs differs on the basisof whether the intact portion of the tendon is preservedor sacriﬁced. In the latter method, the partial tear isconverted to a full-thickness tear and then anchored tothe original footprint. Alternatively, an in situ repairtechnique involves the ﬁxation of the torn cuff tissue tothe footprint whereas the intact portion and itsattachment are preserved. Various techniques havebeen employed in an attempt to preserve intact artic-ular tendon ﬁbers while repairing bursal cuff tissue.3,4We present our method for addressing bursal-sidedPTRCTs using an in situ repair technique with double-row suture anchors.TechniqueThe following surgical technique can be performedwith the patient in either a beach chair or lateral de-cubitus position. After the operative shoulder isappropriately prepped and draped, a timeout is per-formed to conﬁrm the operative site. A standard pos-terior viewing portal is established and the arthroscopeis introduced into the shoulder. The anterior portal isthen established in the rotator interval and any intra-articular pathology is addressed. The articular-sidedrotator cuff insertion is carefully examined with thearm in abduction and external rotation from the pos-terior viewing portal.Once the articular-sided cuff insertion is conﬁrmed tobe intact, the arthroscope is transitioned to the sub-acromial space. A direct lateral viewing portal is used,and a complete bursectomy is performed. In addition,since most bursal sided rotator cuff tears are associatedwith impingement, an arthroscopic acromioplasty isperformed with a motorized burr using a cutting blocktechnique. An additional anterolateral portal just off theacromial border is then established with an 8.25-mmcannula to serve as the primary working portal toFrom the Rothman Institute, Department of Orthopaedic Surgery, ThomasJefferson University, Philadelphia, Pennsylvania, U.S.A.The authors report the following potential conﬂicts of interest or sources offunding: K.B.F. is a paid consultant for J&J Mitek Sports Medicine. FullICMJE author disclosure forms are available for this article online, assupplementary material.Received June 29, 2017; accepted August 16, 2017.Address correspondence to Kevin B. Freedman, M.D., Medical ArtsPavilion, Suite 200, 825 Old Lancaster Rd, Bryn Mawr, PA 19010, U.S.A.E-mail: Kevin.Freedman@rothmaninstitute.com 2017 by the Arthroscopy Association of North America. Published byElsevier. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).2212-6287/17815https://doi.org/10.1016/j.eats.2017.08.068Arthroscopy Techniques, Vol 7, No 3 (March), 2018: pp e199-e203 e199accommodate anchor placement and passage of sutures.The footprint of the rotator cuff is probed and carefullydebrided to avoid any damage to intact ﬁbers of the cuffinsertion (Fig 1). Through the anterolateral portal,microfracture of the tuberosity is typically performed tocreate a bleeding surface to promote healing. A triple-loaded Healix Advance 5.5-mm Peek Suture Anchorwith Orthocord (DePuy Mitek, Raynham, MA) is thenplaced at the most medial margin of the exposedfootprint to create themedial row (Fig 2). An ExpresSewII (DePuy Mitek) ﬂexible suture passer or Spectrum II(ConMed Linvatec, Utica, NY) is then used to pass theindividual suture limbs of the same color through therotator cuff ﬂap in a horizontal mattress fashion. Thisstep is repeated for each of the color-coded limbs of thesuture anchor. Careful attention is focused on the spreadof suture limbs across the cuff tear to ensure adequateFig 1. With the patient in the beach chair position,arthroscopic imaging from the lateral viewing portal shows apartial-thickness bursal-sided rotator cuff tear of the leftsupraspinatus tendon after debridement.Fig 2. With the patient in the beach-chair position, arthro-scopic imaging from the lateral viewing portal shows theplacement of a triple-loaded Healix Advance 5.5-mm PeekSuture Anchor with Orthocord (DePuy Mitek) placed at themost medial margin of the intact supraspinatus tendoninsertion to create the medial row.Fig 3. Arthroscopic imaging of the left shoulder from thelateral viewing portal shows the placement of 3 individualhorizontal mattress sutures placed through the rotator cufftissue.Fig 4. Arthroscopic imaging of the left shoulder from thelateral viewing portal shows the placement of a lateral-rowanchor with an additional suture incorporated into thelateral-row anchor at the time of insertion to further reducethe cuff tissue to the footprint.e200 H. SALEM ET AL.reduction (Fig 3). The medial row is then tied with asliding knot and alternating half hitches. Once themedial-row sutures are tied, one limb from each hori-zontal mattress suture is loaded through the end of aFootprint Ultra PK 4.5-mm Suture Anchor (Smith &Nephew, Andover, MA). A pilot hole is prepared at thelateral edge of the greater tuberosity through the ante-rolateral portal. The Footprint anchor is advancedthrough the pilot hole completing the lateral row andreducing the cuff tear. Each suture limb can be individ-ually tensioned. Of note, an additional suture can beincorporated into the lateral-row anchor prior to inser-tion at the surgeon’s discretion (Fig 4). This suture canthen be passed through cuff tissue and tied with a simpleknot to further reduce any cuff tissue to the footprint(Table 1). For most repairs, a single lateral-row anchor isusedwith themedial-row sutures forming a “parachute”over the tendon edge (Fig 4). If 2 lateral-row anchors areto be used, the remaining limbs from each mattress su-ture are incorporated into the additional anchor andplaced into the greater tuberosity (Fig 5). If a singlelateral-row anchor is used, each of the remaining singlemattress sutures from the medial row can be cut (Fig 6).RehabilitationPostoperative rehabilitation protocol involves a briefperiod of immobilization followed by gradual progres-sion of motion and strength, with eventual return tofull activity and sport. During the ﬁrst phase(0-4 weeks), the arm is placed in a sling with a sup-portive abduction pillow. Range of motion during thisphase is limited to passive motion as tolerated by thepatient, and therapeutic exercises include Codman’sexercise, grip strengthening, and isometric scapularstabilization. In the second phase (4-8 weeks), theimmobilizer is discontinued and gentle passive stretch-ing is progressed to 160 of forward ﬂexion, 60external rotation with arm adducted, and abduction to60 to 80. Range of motion can be increased graduallyas tolerated until 8 weeks postoperatively. Therapeuticexercises in phase II include gentle active exercises at 4to 6 weeks with the commencement of deltoid andbiceps strengthening at 6 to 8 weeks. At phase III (8-12 weeks), range of motion is progressed to full motionwithout discomfort. Scapular strengthening exercisesare continued and internal/external strengtheningexercises are begun. In the fourth and ﬁnal phase(12-20 weeks), phase III exercises are advanced, andsport-speciﬁc activities are begun with an emphasis onthe maintenance of ﬂexibility and the increase ofmotion velocity (Table 2).DiscussionWith current methods for the surgical repair of rotatorcuff tears trending away from open procedures andtoward arthroscopy, the ideal arthroscopic techniquefor restoring anatomy of the footprint and optimizingFig 5. Arthroscopic imaging of the left shoulder from thelateral viewing portal shows the completed repair of a partial-thickness bursal-sided rotator cuff tear with 2 lateral anchors.Fig 6. Arthroscopic imaging of a right shoulder from thelateral viewing portal shows the completed repair of a partial-thickness rotator cuff tear with a single lateral-row sutureanchor.Table 1. Pearls and PitfallsPearls PitfallsA An extra suture can beincorporated into lateral-rowanchors to further reducerotator cuff tissueA Careful attention must be paidduring debridement to avoiddamage to intact articular ﬁbersA Careful attention should befocused on the spread ofmedial-row suture limbs acrosscuff tear to ensure adequatereductionPARTIAL THICKNESS REPAIR TECHNIQUE e201clinical outcomes is worthy of investigation. Currently,there is still debate regarding the best method to treatpartial-thickness rotator cuff tears.Shin5 found that the tear completion method leads tofaster recovery of function and range of motion butdiminished tendon integrity as evidenced by magneticresonance imaging ﬁndings. Conversely, the in situmethod in which the intact portion of the tendon is leftundisturbed maintains the anatomic tendon footprintwithout disrupting the biomechanics of the rotatorcuff.5 A recent prospective study by Kim et al.6 evalu-ated the outcomes of in situ repair versus tearcompletion repair for PTRCTs. In their technique,mattress sutures were passed through both bursal cufftissue as well as the intact tendon ﬁbers prior to anchorﬁxation. The in situ technique resulted in a lower retearrate among patients with bursal-sided PTRCTscompared with the tear completion method. Ourdescribed technique employs mattress sutures throughonly the bursal cuff tissue with the medial-row anchorplaced adjacent to the remaining footprint. This furtherlimits the disruption of intact cuff ﬁbers and, possibly,alteration of their biomechanics.Anatomic studies have revealed that the placement ofa lateral-row anchor further reinforces this construct.Tuoheti et al.7 found that double-row repairs lead to60% greater contact area than single-row constructs,thereby promoting a better environment for tendonhealing (Table 3). In a cadaveric study by Mazzoccaet al.,8 a signiﬁcantly greater supraspinatus footprintwidth was observed with double-row techniquescompared with single-row repair.In conclusion, an in situ repair technique withdouble-row suture anchors is our preferred method ofaddressing bursal-sided partial-thickness rotator cufftears (Video 1). It provides excellent ﬁxation of therotator cuff tissue while preserving the anatomy of themedial footprint.References1. Urwin M, Symmons D, Allison T, et al. Estimating theburden of musculoskeletal disorders in the community:The comparative prevalence of symptoms at differentanatomical sites, and the relation to social deprivation. AnnRheum Dis 1998;57:649-655.2. Fukuda H. The management of partial-thickness tears ofthe rotator cuff. J Bone Joint Surg Br 2003;85:3-11.3. Kim KC, Rhee KJ, Shin HD, Kim DK. Mattress suture-bridge technique for bursal-side partial-thickness rotatorcuff tears. Arch Orthop Trauma Surg 2010;130:407-411.4. Yoo JC, Ahn JH, Lee SH, Kim JH. Arthroscopic full-layerrepair of bursal-side partial-thickness rotator cuff tears:A small-window technique. Arthroscopy 2007;23:903.e901-903.e904.Table 2. Rehabilitation Program After RepairRange of Motion Immobilizer Therapeutic ExercisePhase I (0-4 weeks) Passive range onlydto tolerance Sling with supportingabduction pillow tobe worn at all timesexcept for hygiene andtherapeutic exerciseCodman’s, elbow/wrist/hand ROM,grip strengthening, isometricscapular stabilizationPhase II (4-8 weeks) 4-6 weeks: Gentle passive stretchto 160 of forward ﬂexion, 60external rotation at side, andabduction to 60-80None 4-6 weeks: Begin gentle activeassistive/active exercises,begin gentle joint mobilizations(grade I and II), continue withphase I exercises6-8 weeks: increase ROMto tolerance6-8 weeks: Begin active exercisesand deltoid/biceps strengtheningPhase III (8-12 weeks) Progress to full motion withoutdiscomfortNone Continue with scapular strengthening,progress exercises in phase II, begininternal/external rotation isometrics,stretch posterior capsule when armis warmed upPhase IV (12 weeks-5 months) Full motion without discomfort None Advance exercises in phase III, beginsport-speciﬁc activities, maintainﬂexibility, increase velocity of motion,return to sport activitiesTable 3. Advantages and DisadvantagesAdvantages DisadvantagesA Greater tendon-bone contactarea is achieved with adouble-row techniquecompared with single-rowconstructsA Entire thickness of cuff tissuenot incorporated into repairwith our proposed techniqueA Preserved integrity ofanatomic footprint with an insitu method compared withthe tear-completion methodA May be more technicallydemanding than the tearcompletion methode202 H. SALEM ET AL.5. Shin SJ. A comparison of 2 repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy2012;28:25-33.6. Kim YS, Lee HJ, Bae SH, Jin H, Song HS. Outcome com-parison between in situ repair versus tear completion repairfor partial thickness rotator cuff tears. Arthroscopy 2015;31:2191-2198.7. Tuoheti Y, Itoi E, Yamamoto N, et al. Contact area,contact pressure, and pressure patterns of the tendon-bone interface after rotator cuff repair. Am J Sports Med2005;33:1869-1874.8. Mazzocca AD, Millett PJ, Guanche CA, Santangelo SA,ArcieroRA.Arthroscopic single-rowversus double-row sutureanchor rotator cuff repair.AmJ SportsMed2005;33:1861-1868.PARTIAL THICKNESS REPAIR TECHNIQUE e203

Double-Row Repair Technique for Bursal-Sided Partial-Thickness Rotator Cuff Tears

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Double-Row Repair Technique for Bursal-Sided Partial-Thickness Rotator Cuff Tears

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