Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 25, Issue 11 , Pages 1201-1202, November 2009

Regarding the “Modified Lasso-Loop Stitch”

Article Outline

 

To the Editor:

I read with interest the Technical Note by Toussaint et al.1 in the June 2009 issue. Knotless approaches to rotator cuff repair represent advancements, arguably as long as biomechanical properties are maintained and clinical outcomes are not compromised. The technique described highlights an efficient way to purchase tissue without having to tie knots during rotator cuff repair, although it does not reduce the number of suture passes required for a simple mattress stitch.

The suture-bridge, or “transosseous-equivalent,” construct for rotator cuff footprint restoration has been shown to have favorable characteristics in the laboratory, as well as clinically.2, 3, 4, 5, 6 The ability to share load between anterior and posterior anchors represents an inherent characteristic to the construct as originally described.7 The concern I have is with Fig 1L in the article. In this schematic, both suture limbs from the lasso loop are fixed anterolaterally, and both simple stitches are anchored posterolaterally. In the context of the concept of “interconnectivity” between anchors and sharing load,6 perhaps a better method would be to fix the posterior lasso-loop end with the anterior simple-stitch end posterolaterally and to do the same for the anterior anchor anterolaterally. As depicted, should the posterolateral fixation become compromised (both simple stitches fixed posterolaterally), both lasso loops would be compromised anteriorly and posteriorly. This is best illustrated in their Fig 1J, in which both simple-stitch ends are used to reduce the lasso-loop ends. If any simple-stitch end is compromised, then the lasso-loop end, although self-locking relative to the tendon, will be compromised relative to the reduction to bone. This reminds me of a recent study in which knotless medial fixation for the transosseous-equivalent repair did not perform as well biomechanically because the suture would cut through the tendon.8 Should either simple-stitch end cut through, even partially, the corresponding lasso-loop end will lose some degree of security to the footprint. Perhaps with symmetric lateral fixation (lasso loop and simple stitch fixed to the same anchor laterally), this potential problem will be less likely with respect to the overall construct. What do the authors think about lasso loops at both ends? Would this compromise the reduction maneuver? Although technically demanding, what about repeating the construct with double-loaded anchors (without doubling the number of lateral anchors) for the construct described, thus augmenting the posterolateral fixation?

  • View full-size image.
  • Figure 1. 

    (L) The anterolateral anchor is in place, and the suture-bridge repair is complete. This is a representation of a right shoulder with the patient in the beach-chair position with 3 to 5 ports placed posteriorly, posterolaterally, laterally, anterolaterally, and anteriorly as needed for appropriate instrumentation. (J) The cuff is reduced and the post is created with the simple stitch. The arrows show the reduction maneuver.

The authors should be commended for improving on stitch configuration, because this is potentially the simplest, most efficient way to improve different rotator cuff repair constructs. I would encourage a laboratory study to delineate the biomechanical effect of such a configuration in this setting, and a report on the authors' clinical series would be most appreciated.

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References 

  1. Toussaint B, Schnaser E, Lafosse L, Bahard 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
  2. Burkhart SS, Adams CR, Burkhart SS, et al. A biomechanical comparison of 2 techniques of footprint reconstruction for rotator cuff repair: The SwiveLock-FiberChain construct versus standard double-row repair. Arthroscopy. 2009;25:274–281
  3. Frank JB, ElAttrache NS, Dines JS, et al. Repair site integrity after arthroscopic “transosseous-equivalent/suture-bridge” rotator cuff repair. Am J Sports Med. 2008;36:1496–1503
  4. Park MC, Idjadi JA, ElAttrache NS, et al. The effect of dynamic external rotation comparing 2 footprint-restoring rotator cuff repair techniques. Am J Sports Med. 2008;36:893–900
  5. Park MC, Pirolo JM, Park CJ, Tibone JE, McGarry MH, Lee TQ. The effect of abduction and rotation on footprint contact for single-row, double-row, and modified double-row rotator cuff repair techniques. Am J Sports Med. 2009;37:1599–1608
  6. Park MC, Tibone JE, ElAttrache NS, et al. Part II: Biomechanical assessment for a footprint-restoring arthroscopic transosseous-equivalent rotator cuff repair technique compared to a double-row technique. J Shoulder Elbow Surg. 2007;16:469–476
  7. Park MC, ElAttrache NS, Ahmad CS, et al. “Transosseous-equivalent” rotator cuff repair technique. Arthroscopy. 2006;22:1360.e1–1360.e5www.arthroscopyjournal.org
  8. Busfield BT, Glousman RE, McGarry MH, et al. 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

PII: S0749-8063(09)00695-1

doi:10.1016/j.arthro.2009.08.003

Refers to article:

  • A New Approach to Improving the Tissue Grip of the Medial-Row Repair in the Suture-Bridge Technique: The “Modified Lasso-Loop Stitch” , 02 February 2009

    Bruno Toussaint, Erik Schnaser, Laurent Lafosse, Jerome Bahurel, Reuben Gobezie
    Arthroscopy: The Journal of Arthroscopic and Related Surgery June 2009 (Vol. 25, Issue 6, Pages 691-695)

  • Author's Reply

    Erik Schnaser, Bruno Toussaint, Reuben Gobezie
    Arthroscopy: The Journal of Arthroscopic and Related Surgery November 2009 (Vol. 25, Issue 11, Page 1202)

Arthroscopy: The Journal of Arthroscopic and Related Surgery
Volume 25, Issue 11 , Pages 1201-1202, November 2009