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Editorial Commentary: Biology and Biomechanics Must Be Carefully Balanced for a Durable Rotator Cuff Repair

      Abstract

      Arthroscopic rotator cuff repair strategies have evolved over 3 decades, but suture anchor design, anchor configuration, and stitches have been largely driven by repair biomechanics. In recent years there has been a shift toward repair strategies that enhance the biology of tendon repair. Double-row and transosseous equivalent suture anchor repair constructs demonstrate excellent time zero mechanical properties, but the resulting increased repair tension and tendon compression may compromise tendon healing. Modern single-row repairs employing medialized triple-loaded suture anchors, simple stitches, and lateral marrow venting avoid some of the problems associated with double-row repairs and demonstrate excellent short-term healing and clinical results. The most robust repair fails if the tendon does not heal. Biology and biomechanics must be carefully balanced.
      The history of arthroscopic rotator cuff repair is approximately 30 years old. When I entered orthopaedic residency in 1994, only Drs. Snyder and Altchek had presented, separately, on the outcomes of all arthroscopic rotator cuff repair.
      • Palette G.A.
      • Warner J.J.P.
      • Altchek D.W.
      Arthroscopic rotator cuff repair: Evaluation of results and a comparison of techniques.

      Snyder SJ, Bachner EJ. Arthroscopic fixation of rotator cuff tears: a preliminary report. Paper presented at the 12th Annual Meeting of the Arthroscopy Association of North America, Palm Desert, CA, 1993.

      Bachner EJ, Snyder SJ. Arthroscopic fixation of the torn rotator cuff tendon using suture anchors and permanent mattress sutures: A preliminary report. Presented at the Arthroscopy Association of North America, 1994 Specialty Day Meeting, New Orleans, LA, February 27, 1994.

      • Randelli P.
      • Cucchi D.
      • Ragone V.
      • de Girolamo L.
      • Cabitza P.
      • Randelli M.
      History of rotator cuff surgery.
      A handful of other surgeons had performed arthroscopic rotator cuff repair previously but had not reported on their results. Since then, there has been a proliferation of arthroscopic techniques and strategies to effect tendon to bone repair, including various indirect and direct suture passing techniques, sutures and tapes, stitches, suture anchors, and anchor configurations.
      In the 1990s and early 2000s, arthroscopic rotator cuff repair employed a single row (SR) of double-loaded suture anchors and simple stitches. Anchors were often placed laterally, so that if there was gapping at the repair and the tendon slid a few millimeters away from the anchor, the rotator cuff tendon could still contact the bony footprint, resulting in potential for healing.
      • Gartsman G.M.
      • Hammerman S.M.
      Full-thickness tears: Arthroscopic repair.
      • Burkhart S.S.
      • Diaz Pagàn J.L.
      • Wirth M.A.
      • Athanasiou K.A.
      Cyclic loading of anchor-based rotator cuff repairs: Confirmation of the tension overload phenomenon and comparison of suture anchor fixation with transosseous fixation.
      • Hasan S.S.
      • Gartsman G.M.
      Pearls and pitfalls of arthroscopic rotator cuff repair.
      Subsequently, concerns over the limited tendon-to-footprint contact motivated the development of unlinked double-row (DR) techniques
      • Lo I.K.
      • Burkhart S.S.
      Double-row arthroscopic rotator cuff repair: Re-establishing the footprint of the rotator cuff.
      employing a second row of medially placed anchors with mattress stitches placed medially through the tendon in addition to the lateral row anchors with simple stitches placed through the tendon more laterally. These techniques demonstrated superior restoration of footprint contact compared with SR techniques.
      • Mazzocca A.D.
      • Millett P.J.
      • Guanche C.A.
      • Santangelo S.A.
      • Arciero R.A.
      Arthroscopic single-row versus double-row suture anchor rotator cuff repair.
      These unlinked DR constructs remained popular for several years, but concerns arose regarding the nonuniform footprint contact as well as the cumbersome technique and potential for suture abrasion and crepitus resulting from medially placed knot stacks. In 2005, Park et al.
      • Park M.C.
      • Elattrache N.S.
      • Ahmad C.S.
      • Tibone J.E.
      "Transosseous-equivalent" rotator cuff repair technique.
      reported on a transosseous equivalent (TOE) technique consisting of 2 rows connected by the sutures bridging the rotator cuff, otherwise referred to as a linked DR repair.
      • Maassen N.H.
      • Somerson J.S.
      A majority of single versus double-row rotator cuff repair comparisons fail to consider modern single-row techniques: A systematic review.
      Biomechanical studies also demonstrated that TOE repairs improved tendon-to-bone contact and durability compared to SR repairs.
      • Park M.C.
      • El Attrache N.S.
      • Tibone J.E.
      • Ahmad C.S.
      • Jun B.J.
      • Lee T.Q.
      Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique.
      ,
      • Mazzocca A.D.
      • Bollier M.J.
      • Ciminiello A.M.
      • et al.
      Biomechanical evaluation of arthroscopic rotator cuff repairs over time.
      The technique was simplified further by replacing suture with tape for knotless repairs. Collectively, these TOE techniques remain very popular today, although different repair strategies are often employed according to tear size, geometry, retraction, and tissue quality.
      • Cole B.J.
      • ElAttrache N.S.
      • Anbari A.
      Arthroscopic rotator cuff repairs: an anatomic and biomechanical rationale for different suture-anchor repair configurations.
      Over time, concerns have been raised regarding the potential consequences of TOE repairs. One concern relates to the tendon compression caused by the bridge of sutures and its effect on rotator cuff vascularity.
      • Urita A.
      • Funakoshi T.
      • Horie T.
      • Nishida M.
      • Iwasaki N.
      Difference in vascular patterns between transosseous-equivalent and transosseous rotator cuff repair.
      Another, possibly related, concern are the repair failures that arise medial to the TOE construct, also referred to as a Cho type 2 failure.
      • Cho N.S.
      • Yi J.W.
      • Lee B.G.
      • Rhee Y.G.
      Retear patterns after arthroscopic rotator cuff repair: Single-row versus suture bridge technique.
      These failures near the muscle tendon junction leave a short medial tendon stump that is challenging to repair and heal. Another important concern in this era of value-based care relates to the fact that DR and TOE repairs require more time and more implants and therefore are more costly that SR repairs.
      • Genuario J.W.
      • Donegan R.P.
      • Hamman D.
      • et al.
      The cost effectiveness of single-row compared with double-row arthroscopic rotator cuff repair.
      Over 2 decades in clinical practice, I have observed a gradual but relentless movement away from prioritizing above all else the strength and mechanical durability of the repair construct toward an emphasis on optimizing both repair biomechanics and biology of tendon healing following repair. We currently employ suture anchors with substantial pull-out strength, ultra-high strength sutures, and stitch redundancy or suture bridging to effect a strong repair that withstands early loading. Yet the most robust repair fails if the tendon does not heal. We do not typically encounter dislodged anchors and unraveled knots at the time of revision repair but rather suture cutout through the tendon or a new tear arising medial to the previous repair. If durable tendon healing and restoration of comfort, strength, and function are the goals of rotator cuff repair, then we should not aim for the strongest time zero repair construct if it strangles the tendon or is otherwise tensioned excessively.
      A recent systematic review summarized the results of several early comparative studies that demonstrated better healing rates and/or outcomes with DR or TOE repairs compared with traditional SR repairs employing double-loaded suture anchors typically placed away from the articular margin without any adjunctive intervention to promote healing.
      • Maassen N.H.
      • Somerson J.S.
      A majority of single versus double-row rotator cuff repair comparisons fail to consider modern single-row techniques: A systematic review.
      However, modern SR repairs employing complex stitches and/or triple-loaded anchors have been shown to biomechanically outperform repairs using double-loaded anchors and simple or horizontal mattress stitches.
      • Maassen N.H.
      • Somerson J.S.
      A majority of single versus double-row rotator cuff repair comparisons fail to consider modern single-row techniques: A systematic review.
      ,
      • Coons D.A.
      • Barber F.A.
      • Herbert M.A.
      Triple loaded single-anchor stitch configurations: An analysis of cyclically loaded suture-tendon interface security.
      ,
      • Perser K.
      • Godfrey D.
      • Bisson L.
      Meta-analysis of clinical and radiographic outcomes after arthroscopic single-row versus double-row rotator cuff repair.
      In the paper “Arthroscopic Repair of Medium to Large Rotator Cuff Tears with a Triple-Loaded Medially Based Single-Row Technique Augmented With Marrow Vents” by Dierckman, Frousiakis, Burns, Barber, Wodicka, Getelman, Karzel, and Snyder,
      • Dierckman B.D.
      • Frousiakis P.
      • Burns J.P.
      • et al.
      Arthroscopic repair of medium to large rotator cuff tears with a triple-loaded medially based single-row technique augmented with marrow vents.
      the authors report on the outcomes of a modern SR repair strategy for medium-to-large rotator cuff tears 2 to 4 cm in length.
      • Dierckman B.D.
      • Frousiakis P.
      • Burns J.P.
      • et al.
      Arthroscopic repair of medium to large rotator cuff tears with a triple-loaded medially based single-row technique augmented with marrow vents.
      They employ a consistent technique featuring triple-loaded suture anchors placed medially, only 3 to 5 mm lateral to the articular margin. In addition, the authors employ bone marrow vents placed lateral on the footprint to improve the vascularity of the healing rotator cuff tendon and to augment the local biologic environment to promote healing.
      • Snyder S.
      • Burns J.
      Rotator cuff healing and the bone marrow “crimson duvet.” From clinical observations to science.
      It is possible that DR or TOE repairs employing vented anchors might fulfill that role, although the authors employ numerous closely spaced narrow punch holes rather than 4 or 5 larger holes for venting.
      The rationale underlying the authors’ repair strategy is to minimize repair tension by using medial-row anchors and simple stitches and maximize healing potential by using bone marrow vents rather than a TOE construct that optimizes footprint contact at expense of increased repair tension and the potential for tendon strangulation. Previous study has demonstrated that repairs requiring greater tension for tendon reduction to the footprint had significantly inferior outcomes scores.
      • Davidson P.A.
      • Rivenburgh D.W.
      Rotator cuff repair tension as a determinant of functional outcome.
      However, one should not deduce from the authors’ preference for a medial-based repair that large, retracted rotator cuff tears should be summarily reduced to the medial footprint without first releasing, meticulously and systematically, any dense bursal and articular sided adhesions
      • Hasan S.S.
      • Gartsman G.M.
      Pearls and pitfalls of arthroscopic rotator cuff repair.
      to minimize repair tension.
      One of the authors of this paper, Dr. Snyder, has described several SR repair techniques, including one that employs triple-loaded anchors and simple stitches placed medial to a broad lateral mattress stitch that acts as a rip-stop.
      • Castagna A.
      • Garofalo R.
      • Conti M.
      • Borroni M.
      • Snyder S.J.
      Arthroscopic rotator cuff repair using a triple-loaded suture anchor and a modified Mason-Allen technique (Alex stitch).
      More recently, he and his colleagues have demonstrated that even with a medially based SR repair, the footprint is able to reconstitute itself from the “super clot”
      • Dierckman B.D.
      • Frousiakis P.
      • Burns J.P.
      • et al.
      Arthroscopic repair of medium to large rotator cuff tears with a triple-loaded medially based single-row technique augmented with marrow vents.
      or ‘‘crimson duvet’’ created by these bone marrow vents.
      • Snyder S.
      • Burns J.
      Rotator cuff healing and the bone marrow “crimson duvet.” From clinical observations to science.
      ,
      • Faulkner N.D.
      • Getelman M.H.
      • Burns J.P.
      • Bahk M.S.
      • Karzel R.P.
      • Snyder S.J.
      Regarding "meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears".
      This technique also has been used to promote graft incorporation after dermal allograft reconstruction of irreparable rotator cuff tears.
      • Bond J.L.
      • Dopirak R.M.
      • Higgins J.
      • Burns J.
      • Snyder S.J.
      Arthroscopic replacement of massive, irreparable rotator cuff tears using a GraftJacket allograft: Technique and preliminary results.
      Dierckman et al.
      • Dierckman B.D.
      • Frousiakis P.
      • Burns J.P.
      • et al.
      Arthroscopic repair of medium to large rotator cuff tears with a triple-loaded medially based single-row technique augmented with marrow vents.
      have employed a consistent technique and robust magnetic resonance imaging (MRI) follow to demonstrate excellent outcomes. They report 91% patient satisfaction, 92% healing by high-field MRI, and low complication and reoperation rates that represent excellent results for repair of medium-to-large rotator cuff tears.
      • Dierckman B.D.
      • Frousiakis P.
      • Burns J.P.
      • et al.
      Arthroscopic repair of medium to large rotator cuff tears with a triple-loaded medially based single-row technique augmented with marrow vents.
      The low re-tear rate confirms that excessive gap formation preventing tendon to footprint healing does not occur in the early postoperative period. Triple-loaded anchors help in this regard because these maximize the number of sutures spanning the repair, which is a critical determinant of repair construct strength.
      • Burkhart S.S.
      A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles.
      ,
      • Jost P.W.
      • Khair M.M.
      • Chen D.X.
      • Wright T.M.
      • Kelly A.M.
      • Rodeo S.A.
      Suture number determines strength of rotator cuff repair.
      Several recent studies have demonstrated equivalent results comparing modern SR and TOE repairs for tears 3 cm in length or smaller, as compared with the 2- to 4-cm tears in the study by Dierckman et al. Barber
      • Barber F.A.
      Triple-loaded single-row versus suture-bridge double-row rotator cuff tendon repair with platelet-rich plasma fibrin membrane: A randomized controlled trial.
      published a level I study comparing SR and TOE repairs, augmented with platelet-rich plasma, and demonstrated 85% healing rates in both groups. In addition, all failures in the TOE group were Cho type 2 and all failures in the SR group were type 1.
      • Barber F.A.
      Triple-loaded single-row versus suture-bridge double-row rotator cuff tendon repair with platelet-rich plasma fibrin membrane: A randomized controlled trial.
      In a retrospective cohort study comparing medial SR and TOE repairs, Tashjian et al.
      • Tashjian R.Z.
      • Granger E.K.
      • Chalmers P.N.
      Healing rates and functional outcomes after triple-loaded single-row versus transosseous-equivalent double-row rotator cuff tendon repair.
      demonstrated similar re-tear rates and outcomes in both groups, except for a greater improvement in patient reported outcomes among patients undergoing SR repair. Jeong et al.
      • Jeong H.Y.
      • Kim H.J.
      • Jeon Y.S.
      • Rhee Y.G.
      Factors predictive of healing in large rotator cuff tears: Is it possible to predict retear preoperatively?.
      reported equivalent clinical outcomes and re-tear rates in their retrospective cohort study of the 2 repair constructs.
      Recently, Yamakado
      • Yamakado K.
      A prospective randomized trial comparing suture bridge and medially based single-row rotator cuff repair in medium-sized supraspinatus tears.
      compared the clinical and imaging outcomes for TOE and medial SR repairs and found no significant differences across range of motion and outcomes measures at final follow-up. Cho type 2 failures were observed only following TOE repair, but only 6.5% of patients with TOE and 2.1% of patients with medial SR demonstrated a re-tear.
      • Yamakado K.
      A prospective randomized trial comparing suture bridge and medially based single-row rotator cuff repair in medium-sized supraspinatus tears.
      The author observed regeneration of the lateral rotator cuff tendon in 93% of patients with medial SR, echoing the observations in the study by Dierckman et al. Writing the Editorial Commentary for the study by Yamakado, Chalmers
      • Chalmers P.N.
      Editorial Commentary: Does a medialized repair allow single-row to outperform double-row rotator cuff repair?.
      concluded that “footprint coverage may be less important than previously thought regarding restoration of a full tendon attachment.”
      However, the study does have some important limitations, many of which the authors acknowledge. Despite the robust clinical and MRI follow-up with low patient attrition, the study is retrospective and lacks a control group. In addition, the authors employed a validated patient reported condition-specific outcomes tool, the Western Ontario Rotator Cuff score,
      • Kirkley A.
      • Alvarez C.
      • Griffin S.
      The development and evaluation of a disease-specific quality-of-life questionnaire for disorders of the rotator cuff: The Western Ontario Rotator Cuff Index.
      as the secondary outcomes measure, but they did not complement this score with any objective assessment of active shoulder range of motion and rotator cuff strength.
      The authors employ MRI to assess rotator cuff healing according to the method of Sugaya et al.,
      • Sugaya H.
      • Maeda K.
      • Matsuki K.
      • Moriishi J.
      Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study.
      but they did not specifically study the influence of tendon length and muscle–tendon junction position on healing. Tashjian et al.
      • Tashjian R.Z.
      • Hung M.
      • Burks R.T.
      • Greis P.E.
      Influence of preoperative musculotendinous junction position on rotator cuff healing using single-row technique.
      previously correlated tendon length and muscle–tendon junction position with healing following SR repair. They opined that in chronic retracted tears, muscle elongation may be limited, and the native tendon may be short because of tendon loss. Furthermore, if healing is to occur, then tendon lengthening with scar in continuity may be necessary to fill the defect.
      • Tashjian R.Z.
      • Hung M.
      • Burks R.T.
      • Greis P.E.
      Influence of preoperative musculotendinous junction position on rotator cuff healing using single-row technique.
      Further studies are clearly needed to better understand the elasticity of the muscle–tendon unit and its correlation with healing as well as the tendon lengthening that occurs during healing.
      Most tears occur in the hypovascular region of the tendon, 5 to 15 mm medial from the tuberosity,
      • Meyer D.C.
      • Farshad M.
      • Amacker N.A.
      • Gerber C.
      • Wieser K.
      Quantitative analysis of muscle and tendon retraction in chronic rotator cuff tears.
      so that reattaching a shortened tendon to the medial footprint is more anatomic than extending the repair across the entire footprint. Dierckman et al.
      • Dierckman B.D.
      • Frousiakis P.
      • Burns J.P.
      • et al.
      Arthroscopic repair of medium to large rotator cuff tears with a triple-loaded medially based single-row technique augmented with marrow vents.
      describe clearing all soft tissues to expose the entire footprint for bone marrow venting, including any residual tendon stump off the anatomic footprint on the grounds that the stump is avascular. However, triple-loaded anchors also facilitate the incorporation of a thick lateral tendon stump whenever present, so it is unclear if repairs that incorporate the tendon stump, especially using vented anchors, would heal just as predictably.
      The authors present their findings at a median follow-up of 32 months (range 24-48 months) so longer follow-up is clearly needed. A recent study reporting on rotator cuff healing following SR repair at minimum 10-year follow-up revealed a complete re-tear in one-half of all cases
      • Heuberer P.R.
      • Smolen D.
      • Pauzenberger L.
      • et al.
      Longitudinal long-term magnetic resonance imaging and clinical follow-up after single-row arthroscopic rotator cuff repair: Clinical superiority of structural tendon integrity.
      and another recent study comparing healing and clinical outcomes following SR and DR repairs at minimum 10-year follow-up revealed that DR repairs were more durable but clinical outcomes were similar with the numbers available.
      • Plachel F.
      • Siegert P.
      • Rüttershoff K.
      • et al.
      Long-term results of arthroscopic rotator cuff repair: A follow-up study comparing single-row versus double-row fixation techniques.
      It follows that Dierckman et al. should aim to follow their study patients long-term to determine whether the excellent short-term results obtained with their modern SR repair techniques hold up over time.
      Overall, the study by Dierckman et al. demonstrates the short-term effectiveness of modern SR rotator cuff repair. It highlights many of the contributions of Dr. Snyder and his colleagues to the art and science of arthroscopic rotator cuff repair. The authors are to be commended for following their patients, closely and with imaging, nearly 30 years after Dr. Snyder’s early reports helped usher in the era of arthroscopic rotator cuff repair. However, a long-term comparative study between various DR and TOE repairs and modern SR repair is needed to determine which strategy provides the more durable and optimal clinical result.

      Supplementary Data

      References

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        • Warner J.J.P.
        • Altchek D.W.
        Arthroscopic rotator cuff repair: Evaluation of results and a comparison of techniques.
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