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

The patient is placed in a beach chair position under general anesthesia. Five portals are needed, posterior, lateral, anterolateral, anterointeferior, and lateral portals. Diagnostic arthroscopy is started from the posterior portal.

Identify the supraspinatus and subscapularis tears then classify the subscap tear according to the Lafosse classification. The radio frequency ablator and shaver is used to debride the subscapularis, the glenohumeral joint, and the supraspinatus footprint, to create a healthy bone bed for the repair. Shift the arthroscope to the lateral subacromial portal.

Assess the tear size configuration according to Patte and Burkhart, and the tendon reducibility to the footprint after the release of the supraspinatus and subscapularis. Shift the arthroscope back to the posterior portal for the subscapularis repair using a double loaded suture anchor at the footprint of the subscap. A lasso-loop repair is done by parking the first suture limb posterior to the subscapularis and retrieving it anteriorly with a retrograde retriever.

This step is repeated on the next two limbs while making a lasso loop on the fourth and final suture limb. Once secured, pull the free end of the lasso limb to compress the tendon to the footprint and tie it down. The remaining limbs are tied in the same way.

The subscapularis repair is completed. The cuff is repaired using a triple-loaded suture anchor inserted just posterior to the long head of the biceps tendon at the bone cartilage junction. Lasso loop one limb of the triple-loaded anchor to reroute the biceps posteriorly to augment the anterior cuff.

Pass the other suture limb through the lasso to provide a rip-stop construct, and tie the biceps down. Pierce the cuff at the musculotendinous junction from the posterior portal, using a retrograde retriever, after shuttling a free suture tape and one limb from the previous medial row anchor into the joint defect. Do not fully withdraw the green suture limb from the cuff, and instead pass it through the previously created loop and retrieve it back to form a loop construct.

Park a second pair of different colored suture limbs from the medial anchor into the joint. Use a retrograde suture retriever, and pass them through the cuff at a location anterior to the first pair of sutures. Shuttle the remaining suture limb from the medial row anchor with the free end of the flat-braided suture tape through the anterior cuff.

Tension the lasso loop to compress the cuff towards the footprint. Tie it down to fix the construct. The other suture limb from the medial row anchor is also tied down.

Cut only one suture limb from the tied down sutures for the lateral row fixation. Shuttle all remaining medial row sutures and both ends of the suture tape through the anteroinferior portal. Load them into a 4.75 millimeter knotless suture anchor and mallet it down towards the greater tuberosity to complete the lateral row fixation.

The fiberwire suture from the knotless suture anchor can be used to reduce any dog-ear deformity of the cuff. This completes the speed-fix style knotless double-row repair.