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Thank you for your interest in our technique, as well as your kind words. We would like to answer your second question first: To reduce the tendon to its footprint, you need a construct that will slide through the tendon. In this construct, the lasso loop locks the tendon up, thus preventing the stitch from sliding through the tendon. Because the suture is not fixed within the anchor, the anchor acts like a pulley and pulls the medial-row tendon down to the anchor when the simple limb is tensioned (as shown in parts G and J of our figure).¹ Although you make a good point about cut-through, we cannot envision a way to repeat this reduction maneuver with a combination of a simple limb and a lasso-loop limb stitch in each of the lateral-row anchors. The lasso loop is important because it prevents suture cut-through when you pull on the sliding simple limb. This is the key to this technique. We believe that the lasso loop allows sufficient and strong tissue grip for medial-row reduction. We do not believe it is prudent to be aggressive with tensioning the lateral-row anchors. The lateral-row anchors (and the suture limbs) provide an extra element of tendon-to-bone compression. The key is adequately reducing the medial row (which the lasso-loop stitch is helpful with). In the article of Busfield et al.,² the suture bridge is knotless and has no effective way to “grip” the medial row. In this scenario, suture cut-through would be more problematic. Your point about double-loaded suture anchors is interesting. If we understand your concept correctly, you want to increase the number of lasso loops in the tendon in the medial row so that you can have simple-suture limbs combined with lasso-loop limbs laterally. This may be a useful concept but, as you suggest, may also be technically difficult. Furthermore, it might put the tendon at greater risk of vascular injury. We agree that further testing on this construct should be pursued. We hope to have greater than a 2-year clinical follow-up soon.

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References 

1. Toussaint B, Schnaser E, Lafosse L, Bahurel J, Gobezie R. A new approach to improving the tissue grip of the medial-row repair in the suture-bridge technique: The “modified lasso-loop stitch.”. Arthroscopy. 2009;25:691–695
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2. Busfield BT, Glousman RE, McGarry MH, Tibone JE, Lee TQ. A biomechanical comparison of 2 technical variations of double-row rotator cuff fixation: The importance of medial row knots. Am J Sports Med. 2008;36:901–906
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