A Novel Arthroscopic Medial Knot-Tying Suture-Bridge Repair with Rip-Stop Technique for Rotator Cuff Tears

Summary

This protocol presents an optimized rotator cuff repair technique that combines the medial knot-tying suture-bridge repair with a rip-stop configuration, designed to enhance cuff healing and minimize the risk of retear.

Abstract

Rotator cuff tears remain one of the most common injuries encountered by shoulder surgeons. Although arthroscopic suture-bridge repair has demonstrated superior biomechanical properties and achieved promising clinical results, tendon retears remain a persistent challenge. To address this issue, we have introduced several refinements to optimize the existing repair techniques. One such refinement is the incorporation of a medial knot in the suture-bridge repair, which can decrease gap formation and enable a watertight repair, thereby improving tendon-bone healing. Another critical modification is the use of a rip-stop configuration in the medial row, which can reduce potential suture cut-out, strengthen the resistance of the suture-tendon interface, and lower the risk of type II retear. Therefore, we propose a novel hybrid repair technique that integrates medial knot-tying suture-bridge repair and rip-stop configuration into a single construct. Additionally, this new repair technique offers the benefit of reducing the number of suture passages and suture anchors required, thereby streamlining the repair process. In summary, this method represents a viable and effective alternative for the treatment of rotator cuff tears and may contribute to reducing the incidence of postoperative retears.

Introduction

Rotator cuff tears remain the most common pathologies encountered by shoulder surgeons, with their prevalence increasing with age^1,2,3,4. Arthroscopic suture-bridge repair has become a widely adopted technique for reattaching the torn cuff tendons to their anatomic footprints on the greater tuberosity of the proximal humerus^5,6,7. This technique not only exhibits superior biomechanical properties, but also achieves higher healing rates compared to traditional single- and double-row repairs^{7,8,9,10,11,12}.

Suture-bridge repair can be further categorized based on the presence of medial row knots. Previous studies have shown that the inclusion of medial knots significantly increases the footprint contact area and interface pressure, enhances load to failure strength, and provides greater stability and stiffness compared to knotless configurations^13,14,15. Despite these advantages, retear remains a common complication, with the majority occurring at the medial site (type 2 retear) in medial knot-tying suture-bridge repairs^5,7,16.

As the tendon-suture interface appears to be the weakest link in the repair construct, suture cut-out is believed to contribute significantly to type 2 retear^17,18,19. Given the poor functional outcomes and the complexity of revision surgery associated with type 2 retear, there is a pressing need to optimize the current medial knot-tying suture-bridge repair^5,20. The rip-stop configuration has demonstrated potential in mitigating suture cut-out, thereby improving the integrity of the suture-tendon interface^21,22,23. In light of this, we propose a new surgical technique that incorporates the rip-stop configuration into the medial knot-tying suture-bridge repair. This technique is designed to improve tendon healing and reduce the risk of retear in patients with small to massive, retractable rotator cuff tears and compromised tendon quality.

Protocol

Informed consent was obtained from the patient for publication, and the surgical protocol was approved by the institutional review board at our hospital (No. K2022-077-00).

NOTE: The inclusion and exclusion criteria are as follows:
Inclusion criteria include: (i) symptomatic full-thickness rotator cuff tears. (ii) failed conservative treatment. (iii) double-row repair. (iv) complete repair.
Exclusion criteria include: (i) irreparable rotator cuff tears. (ii) partial-thickness rotator cuff tears. (iii) Goutallier grade > 3. (iv) Arthritic changes of the glenohumeral joint. (v) neurologic involvement.

1. Surgical procedure

1. Patient positioning and portal placement
   1. After general analgesia and brachial plexus block, place the patient in the lateral decubitus position. Identify and mark the arthroscopic portals required (Figure 1A).
   2. Drape the patient in a sterile fashion. Apply a 6 kg weight to tract the affected shoulder (Figure 1B).
2. Diagnostic arthroscopy
   1. Introduce the arthroscope into the glenohumeral joint through the posterior portal.
   2. Create the anterior portal via the rotator cuff interval and perform a comprehensive examination of all intra-articular structures. Perform a biceps tenotomy or tenodesis, and repair the subscapularis at this stage if necessary.
   3. Switch the arthroscope to the subacromial space. Create the anterolateral and the posterolateral portals.
   4. Perform subacromial bursectomy and acromioplasty. Debride the tear margin to identify the tear pattern (Figure 2A).
   5. Use the suture retriever to temporarily reduce the torn cuff tendon. Assess the need for tendon release and select the most appropriate fixation method. (Figure 2B).
3. Medial suture anchor placement
   1. Prepare the bone bed and insert 2 double-loaded suture anchors (4.5 mm BR Anchor) at the articular margin of the greater tuberosity.
   2. Place the first anchor in the anteromedial aspect of the greater tuberosity near the biceps groove through the anterior portal.
   3. Place the second anchor 1.5 cm posterior to the first anchor through the posterolateral portal (Figure 3).
4. Suture passage
   1. Use a left/right curve suture hook (suture hooks, 45° curve) to pass one purple suture limb and one striped suture limb from the first anchor simultaneously through the anterior part of the supraspinatus about 2-3 mm lateral to the musculotendinous junction.
   2. Sequentially pass the other ends of the purple and striped sutures from the first anchor, from anterior to posterior, through the torn supraspinatus tendon at points posterior to the previous penetration site. Ensure that the suture limbs spread evenly across the anterior half of the torn tendon.
   3. Pass the suture limbs from the second anchor through the supraspinatus in a manner similar to the suture limbs from the anterior anchor. Ensure that the suture limbs spread evenly across the posterior half of the torn tendon (Figure 4).
5. Suture management
   1. Pull the two ends of the striped suture from the first anchor from the anterolateral portal and secure them with a sliding knot, positioning the knot at the penetration point of the posterior striped suture limb from the first anchor.
   2. Pull the two ends of the purple suture from the second anchor, tie them with a sliding knot, and place the knot at the penetration point of the anterior purple suture limb from the second anchor.
6. Lateral knotless suture anchor placement
   1. Punch a pilot hole on the lateral cortex of the greater tuberosity, aligning it with the first medial anchor.
   2. Thread 2 purple suture limbs and 1 striped suture limb from the first medial anchor, along with 1 purple suture limb from the second medial anchor, through the eyelet of the knotless anchor (4.75 mm Knotless BR Anchor).
   3. Ensure proper tensioning of the suture strands, and advance the knotless anchor into the prepared hole.
   4. Repeat the previous step to place a second knotless anchor (Figure 5).

2. Postoperative protocol

1. Rehabilitation
   1. Immobilize the shoulder in a sling for 6 weeks postoperatively.
   2. Initiate passive range of motion at 3 weeks after surgery and progress to active range of motion at 6 weeks after surgery.
   3. Start strengthening exercises 12 weeks after surgery.
2. Follow-up
   1. Routine follow-up visits allow the healthcare team to track the patient's recovery and provide guidance on rehabilitation.
   2. Evaluate shoulder function at 3, 6, and 12-month postoperatively, and perform an MRI examination to assess tendon healing at the 12-month follow-up.
      NOTE: On postoperative 1-year MRI, Sugaya types 1,2, and 3 were defined as tendon healing, whereas Sugaya types 4 and 5 were considered as retear²⁴. MRI was independently assessed by 2 musculoskeletal radiologists, and discrepancies were resolved by consensus.

Results

A 65-year-old female patient with a medium-sized rotator cuff tear in her right shoulder underwent the arthroscopic rotator cuff repair using the described technique, performed by a senior shoulder surgeon with over 20 years' clinical experience. At the 1-year follow-up, her Visual Analogue Scale (VAS) pain score improved significantly from 6 preoperatively to 0. The American Shoulder and Elbow Surgeons score (ASES) increased markedly from 53.33 to 91.67. The patient achieved full restoration of shoulder range of motion,...

Discussion

In recent years, the development of various suture-bridge repair techniques has significantly advanced the treatment of rotator cuff tears^5,6,7,11,12. Despite their clinical success, challenges persist in enhancing tendon-bone healing and reducing retear rates. A crucial factor for successful healing is achieving a watertight seal at the joint, which prevents ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
4.5 mm HEALIX ADVANCE BR ANCHOR	Depuy Mitek	222296	Medial anchor
4.75 mm HEALIX ADVANCE BR ANCHOR	Depuy Mitek	222330	Lateral anchor
Spectrum I Suture Hook, 45°Left Curve	Conmed	97.14115
Spectrum I Suture Hook, 45°Right Curve	Conmed	97.14215
Suture Retriever	Arthrex	AR-13971W