Knotless Independent Double-Row Repair and Biceps Augmentation for Anterosuperior Rotator Cuff Tears

Summary

This is a technical note describing a cost-efficient, knotless, independent, double-row rotator cuff repair for medium to large anterosuperior rotator cuff tears with simultaneous biceps augmentation and subscapularis repair.

Abstract

Rotator cuff tears are frequent, mainly involving the anterosuperior shoulder tissue, such as the supraspinatus, subscapularis, and the long head of the biceps tendon (LHBT). The double-row repair was designed to provide better footprint coverage and a lower retear rate than a single-row repair for supraspinatus tears. Traditionally, a double-row repair needs two medial-row suture anchors and two lateral-row suture anchors to provide a wide compression area. However, the medical expenses associated with this technique are quite high. We developed a modified knotless independent double-row repair technique using only two suture anchors. This surgical technique presents a detailed procedure that includes patient positioning and preparation, creation of arthroscopic portals, assessment and confirmation of injuries, and repair of an anterosuperior cuff tear using one suture-loaded anchor for subscapularis repair, another suture-loaded anchor for LHBT tenodesis and medial row repair of supraspinatus, and one lateral row anchor to achieve a knotless, independent double-row repair. It serves as a cost-effective alternative to the traditional transosseous-equivalent suture bridge repair, which uses more anchors.

Introduction

An increasing number of orthopedic surgeons are performing arthroscopic rotator cuff tear (RCT) repair. Advancements in surgical principles, techniques, and instrumentation have enabled arthroscopic repair of rotator cuff tears across all sizes and tear patterns¹. RCTs are frequently involved in the anterosuperior part^2,3. While there are many techniques to repair the cuff arthroscopically, the double-row repair provides better coverage of the footprint^4,5 and a lower retear rate compared to a single-row repair⁶. Numerous authors have described and modified the double-row repair technique with promising clinical results^4,7.

The transosseous-equivalent suture bridge (TOE-SB) technique using four suture anchors offers a stable repair with predictable re-tear rates⁸. Colin et al. described the independent double-row repair, which entails the use of only two suture-loaded anchors at the medial and lateral row⁹, which has a similar retear rate compared with the traditional transosseous-equivalent suture bridge repair¹⁰. However, the knots in the independent double-row technique are kept in the subacromial space.

In our technique, we use one triple-loaded anchor to fix the medial part of the rotator cuff with knots. Further, we shuttle the remaining suture from the medial row, along with cut flat-braided suture tape from the knotless suture anchor, to the greater tuberosity, to complete a SpeedFix technique¹¹ using inverted mattress stitches that directly compress into the prepared bone socket without leaving knots in the subacromial space. The knotless, independent double-row (K-IDR) technique offers a greater area of footprint compression compared to the traditional independent double-row technique.

Protocol

This protocol was approved by the institution's Ethics Committee.

1. Patient selection

1. Set the following inclusion criteria: patients diagnosed with medium to large RCTs according to the Rodeo classification and less than Patte stage 3 tendon retraction¹² with at least 6 months of follow-up, acromiohumeral distance (AHD) > 7 mm on the anteroposterior radiograph in neutral rotation, and supraspinatus muscle fatty infiltration (FI) < Goutallier grade 3 (Figure 1).
2. Set the following exclusion criteria: subscapularis tear > Lafosse type 3, fractures, infection-related pathologies, partial or complete tear of LHBT, severe glenohumeral joint osteoarthritis, and deformity of the humeral head on preoperative X-ray.

2. Surgical procedure

1. Place the patient in a beach chair position under general anesthesia with an interscalene block. Traction the operative arm in an adjustable traction device.
2. Five portals are needed (posterior, anterior, lateral, anterolateral, and anteroinferior portal) (Figure 2). Perform diagnostic arthroscopy through the posterior portal and make a thorough examination of the RCT.
3. Identify the supraspinatus and subscapularis tears. Assess and classify the tear of the subscapularis according to the Lafosse classification (Figure 3A).
4. Use the motorized shaver to debride the subscapularis, the glenohumeral joint, and the supraspinatus footprint to create a bleeding bone bed for the repair .
5. Shift the arthroscope to the lateral subacromial portal. Assess the tear size and configuration according to Patte¹² and Burkart¹ and tendon reducibility to the footprint after a thorough release of the supraspinatus and subscapularis from all sides.
6. Shift the arthroscope back to the posterior portal for the subscapularis repair using a double-loaded suture anchor at the footprint of the subscapularis.
7. Perform lasso loop repair¹³ by parking the 1^st suture limb posterior to the SSC and retrieving it anteriorly with a retrograde retriever. Repeat this step on the next two limbs, while making a lasso-loop on the 4^th and final suture limb.
8. Create a mattress suture (blue sutures) and a lasso-loop (blue-and-white sutures) to secure the subscapularis (Figure 3C,D). Once the loop is secured, pull the free end of the lasso-loop limb to compress the tendon to the footprint and tie it down.
9. Compress the mattress suture to the tendon footprint by three half-hitches and four reverse half-hitches. Tie the lasso-loop down with standard three half-hitches and four reverse half-hitches (Figure 3E). The subscapularis repair is completed (Figure 3F).
10. Assess the integrity of the long head of the biceps tendon by pulling it into the joint space, allowing visualization along the bicipital groove to reveal any concealed lesions.
11. Repair the cuff tear using a triple-loaded suture-based anchor inserted just posterior (5 mm) to the long head of the biceps tendon at the bone cartilage junction. This anchor will also act as the medial row. Lasso-loop one limb of the triple-loaded anchor to re-route the biceps posteriorly to augment the cuff repair anteriorly (Figure 4A).
12. Create the lasso loop from one limb (black-white) of the triple-loaded anchor (Figure 4B). Pass the other suture limb (black-white) through the lasso (Figure 4C), providing a rip-stop configuration. Fix the LHBT with seven stitches (Figure 4D).
13. Cut the intra-articular part of the LHBT (Figure 4E). Leave a 5 mm LHBT remnant at the supraspinatus footprint's anterior edge, providing more soft tissue coverage at the anterior rotator cable¹⁴ (Figure 4F).
14. Shuttle the arthroscope back to the lateral subacromial portal. Repair the cuff by shuttling a free flat-braided suture tape from a 4.75 mm knotless suture anchor and one limb (green) from the previous medial row anchor into the joint through the defect (Figure 5A). Use a retrograde suture retriever to pierce the cuff at the musculotendinous junction in a posterior location via the posterior portal (Figure 5B).
15. Do not fully withdraw the green suture limb from the cuff. Instead, pass it through the previously created loop and retrieve it back, forming a secure looped construct¹⁵.
16. Park a second pair of differently colored suture limbs (green and blue/white) from the medial anchor in the joint. Use a bird beak to retrieve the sutures and pass them through the cuff at a location anterior to the initial suture pair (Figure 5E).
17. Shuttle the remaining blue/white suture limb from the medial anchor through the anterior cuff, along with the free end of the flat-braided suture tape (Figure 5F).
    NOTE: This establishes the anterior suture limb for the lateral row.
18. Tension the lasso-loop to compress the cuff toward the footprint. Once the loop is secured, tie it down to fix the construct (Figure 6A).
19. Cut one suture limb from the tied-down green and blue/white sutures. Retain the remaining limb for lateral row fixation (Figure 6B,C).
20. Confirm that the two mattress sutures from the medial row anchor (green and blue/white) and the flat-braided suture tape together form a reverse mattress suture configuration.
21. Shuttle all remaining medial row sutures (green and blue/white) and both ends of the flat-braided suture tape through the anteroinferior portal. Load them into a 4.75 mm knotless suture anchor and mallet it down into the greater tuberosity to complete the lateral row fixation (Figure 6D,E).
    NOTE: This step finalizes the knotless double-row construct.
22. Use the FiberWire suture from the knotless suture anchor to reduce any dog-ear deformity, if compression from the flat-braided suture tape and medial sutures is inadequate (Figure 6F). Review the final repair configuration, illustrated in schematic form (Figure 7A,B).
    NOTE: This represents the completed SpeedFix-style knotless double-row repair.

3. Postoperative protocol

1. Place the arm in an abduction brace for 6 weeks.
2. Initiate a self-directed, home-based rehabilitation program¹⁶ on postoperative day one, as prescribed by a sports physician.
3. Instruct patients to perform five cycles of five repetitions during exercises, tolerating low to moderate pain.
   NOTE: Activities must be non-pain provoking.
4. Restrict passive physical therapy and instrument-assisted strengthening for the first 3 months.
5. Allow formal supervised strengthening and return to sports only after 3 months.

Results

We retrospectively collected data on patients with medium to large RCTs who underwent a knotless, independent double-row repair from March 2023 to June 2024. Preoperative and postoperative 1 year follow-up radiographs, including AHD, Hamada classification, and ultrasound findings, were recorded. Outcomes were measured using the Subjective Shoulder Value (SSV)¹⁷, Constant Score¹⁸, and the American Shoulder and Elbow Surgeons (ASES) score¹⁹. Follow-up ...

Discussion

The K-IDR offers a cost-effective alternative to the traditional TOE-SB, like the conventional independent double-row technique using fewer anchors¹³. Unlike TOE-SB's four to five anchors, K-IDR uses only two anchors for supraspinatus repair and biceps tenodesis-one at the medial and one at the lateral row, comparable to that of a single-row repair but with the strength of a double-row repair⁹. The third anchor can be used to repair the subscapularis if needed. The K-ID...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
4.75 mm Swivelock anchor	Arthrex, Naples, FL		(knotless) suture anchor with one FiberTape and one Fiberwire, for rotator cuff repair.
FiberTape	Arthrex, Naples, F		flat-braided suture tape
Healicoil Regenesorb	Smith & Nephew, Andover, MA		Double-loaded absorbable suture anchors for rotator cuff repair.
SPSS software	IBM, Armonk, NY		version 25.0
Y-Knot RC All-suture anchor	ConMed Linvatec, Largo, FL		Triple-loaded all suture anchors for rotator cuff repair.