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Single- Versus Double-Row Arthroscopic Rotator Cuff Repair: The Complexity Grows

2012; Elsevier BV; Volume: 28; Issue: 9 Linguagem: Inglês

10.1016/j.arthro.2012.06.006

1526-3231

James H. Lubowitz, Matthew T. Provencher, Gary G. Poehling,

Shoulder and Clavicle Injuries

The controversy continues over the single-row versus double-row arthroscopic rotator cuff repair techniques.1Mazzocca 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.Am J Sports Med. 2005; 33: 1861-1868Crossref PubMed Scopus (307) Google Scholar, 2Lubowitz J.H. McIntyre L.F. Provencher M.T. Poehling G.G. AAOS rotator cuff clinical practice guideline misses the mark.Arthroscopy. 2012; 28: 589-592Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar, 3Lubowitz J.H. Provencher M.T. Poehling G.G. Single-row versus double-row rotator cuff repair: The controversy continues.Arthroscopy. 2011; 27: 880-882Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar, 4Lubowitz J.H. Poehling G.G. Rotator cuff repair: Obviously.Arthroscopy. 2010; 26: 293-294Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar, 5Lubowitz J.H. Poehling G.G. Shoulder arthroscopy: Evolution of the revolution.Arthroscopy. 2009; 25: 823-824Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 6Lubowitz J.H. Poehling G.G. Clinical relevance: Eight shoulders and a knee.Arthroscopy. 2009; 25: 571-572Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 7Lubowitz J.H. Poehling G.G. Keeping it short: Evidence-based international systematic reviews, rotator cuff, knee posterolateral corner, and bupivacaine chondrocytotoxicity.Arthroscopy. 2009; 25: 223Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 8Lubowitz J.H. Poehling G.G. Two on the fast track: Arthroscopic rotator cuff repair and subacromial decompression with coracoacromial ligament excision.Arthroscopy. 2009; 25: 2-3Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar, 9Lubowitz J.H. Poehling G.G. Arthroscopic rotator cuff repair: Onward the row.Arthroscopy. 2007; 23: 571-572Abstract Full Text Full Text PDF Scopus (3) Google Scholar Double-row has biomechanical advantages, but early reports have suggested the risk of a new mode of failure at the medial row at the musculotendinous junction, which is very hard to revise.10Trantalis J.N. Boorman R.S. Pletsch K. Lo I.K.Y. Medial rotator cuff failure after arthroscopic double-row rotator cuff repair.Arthroscopy. 2008; 24: 727-731Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar, 11Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar, 12Burks R. Study of rotator cuff repair techniques: We really are trying.Arthroscopy. 2010; 26 (letter): 1013-1015Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, 13Wall L.B. Keener J.D. Brophy R.H. Clinical outcomes of double-row versus single-row rotator cuff repairs.Arthroscopy. 2009; 25: 1312-1318Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar, 14Brady P.C. Arrigoni P. Burkhart S.S. Evaluation of residual rotator cuff defects after in vivo single- versus double-row rotator cuff repairs.Arthroscopy. 2006; 22: 1070-1075Abstract Full Text Full Text PDF PubMed Scopus (107) Google Scholar However, not all double-row techniques are the same. Transosseous equivalents are in vogue, but there are so many variations it's hard to generalize.15Kaplan K. ElAttrache N.S. Vazquez O. Chen Y.-J. Lee T. Knotless rotator cuff repair in an external rotation model: The importance of medial-row horizontal mattress sutures.Arthroscopy. 2011; 27: 471-478Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar, 16Ko S.-H. Lee C.-C. Friedman D. et al.Arthroscopic single-row supraspinatus tendon repair with a modified mattress locking stitch: A prospective, randomized controlled comparison with a simple stitch.Arthroscopy. 2008; 24: 1005-1012Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 17Leek B.T. Robertson C. Mahar A. Pedowitz R.A. Comparison of mechanical stability in double-row rotator cuff repairs between a knotless transtendon construct versus the addition of medial knots.Arthroscopy. 2010; 26: S127-S133Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 18Spang J.T. Buchmann S. Brucker P.U. et al.A biomechanical comparison of 2 transosseous-equivalent double-row rotator cuff repair techniques using bioabsorbable anchors: Cyclic loading and failure behavior.Arthroscopy. 2009; 25: 872-879Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 19Burkhart S.S. Adams C.R. Burkhart S.S. Schoolfield J.D. 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: 274-281Abstract Full Text Full Text PDF PubMed Scopus (89) Google Scholar, 20Park M.C. ElAttrache N.S. Ahmad C.S. Tibone J.E. “Transosseous-equivalent” rotator cuff repair technique.Arthroscopy. 2006; 22: 1360.e1-1360.e5Abstract Full Text Full Text PDF PubMed Scopus (286) Google Scholar, 21Voigt C. Bosse C. Vosshenrich R. Schulz A.P. Lill H. Arthroscopic supraspinatus tendon repair with suture-bridging technique Functional outcome and magnetic resonance imaging.Am J Sports Med. 2010; 38: 983-991Crossref PubMed Scopus (123) Google Scholar, 22Nho S.J. Yadav H. Pensak M. et al.Biomechanical fixation in arthroscopic rotator cuff repair.Arthroscopy. 2007; 23: 94-102.e1Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 23Lo I.K.Y. Burkhart S.S. Transtendon arthroscopic repair of partial-thickness, articular surface tears of the rotator cuff.Arthroscopy. 2004; 20: 214-220Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar, 24Grimberg J. Diop A. Kalra K. et al.In vitro biomechanical comparison of three different types of single- and double-row arthroscopic rotator cuff repairs: Analysis of continuous bone-tendon contact pressure and surface during different simulated joint positions.J Shoulder Elbow Surg. 2010; 19: 236-243Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar, 25Park M.C. ElAttrache N.S. Tibone J.E. et al.Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique.J Shoulder Elbow Surg. 2007; 16: 461-468Abstract Full Text Full Text PDF PubMed Scopus (320) Google Scholar, 26Leek B.T. Robertson C. Mahar A. Pedowitz R.A. Comparison of mechanical stability in double-row rotator cuff repairs between a knotless transtendon construct versus the addition of medial knots.Arthroscopy. 2012; 26: S127-S133Google Scholar, 27Denard P.J. Burkhart S.S. Techniques for managing poor quality tissue and bone during arthroscopic rotator cuff repair.Arthroscopy. 2011; 27: 1409-1421Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Theoretically, biomechanically strong repair could overdo things and strangulate rather than recreate tissue healing. This could be associated with failure of arthroscopic rotator cuff repair. Alan Barber, journal Associate Editor emeritus, has published strong evidence in support of single-row repair using multiply loaded, particularly triple-loaded, anchors.28Barber F.A. Hapa O. Bynum J.A. Comparative testing by cyclic loading of rotator cuff suture anchors containing multiple high-strength sutures.Arthroscopy. 2010; 26: S134-S141Abstract Full Text Full Text PDF PubMed Scopus (32) Google Scholar, 29Barber F.A. Herbert M.A. Beavis R.C. Cyclic load and failure behavior of arthroscopic knots and high strength sutures.Arthroscopy. 2009; 25: 192-199Abstract Full Text Full Text PDF PubMed Scopus (98) Google Scholar However, in this issue, Barber and Drew report that arthroscopic double-row rotator cuff repair is better than single-row repair with triple-loaded anchors.30Barber F.A. Drew O.R. A biomechanical comparison of tendon-bone interface motion and cyclic loading between single-row, triple-loaded cuff repairs and double-row, suture-tape cuff repairs using biocomposite anchors.Arthroscopy. 2012; 28: 1197-1205Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Or maybe that is not what Dr. Barber is reporting. We have to be careful not to get confused.31Barber F.A. Aziz-Jacobo J. Rapley J.H. Herbert M.A. Schroeder F.A. Mays M.M. Authors' reply to letter from Park et al.Arthroscopy. 2010; 26: 874-876Abstract Full Text Full Text PDF Scopus (4) Google Scholar Specifically, in this new article “A Biomechanical Comparison of Tendon-Bone Interface Motion and Cyclic Loading Between Single-Row, Triple-Loaded Cuff Repairs and Double-Row, Suture-Tape Cuff Repairs Using Biocomposite Anchors,”30Barber F.A. Drew O.R. A biomechanical comparison of tendon-bone interface motion and cyclic loading between single-row, triple-loaded cuff repairs and double-row, suture-tape cuff repairs using biocomposite anchors.Arthroscopy. 2012; 28: 1197-1205Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar Barber and Drew conclude that “The suture-tape, rip-stop, double-row repair had greater footprint coverage, less rotational footprint displacement, and greater mean ultimate failure load than a triple-loaded, single-row repair in mechanical testing. No constructs demonstrated 5 mm of displacement after 100 cycles.” In the abstract, they state the clinical relevance as “Differences in cuff fixation influence rotational tendon movement and may influence postoperative healing. Stronger repair constructs still fail at the suture tendon interface.” Does this indicate that Barber believes double-row repair is better? Or does he believe single-row triple-loaded anchors are better? What does Dr. Barber really mean? We decided to ask him. The Editors: We really like your article “A Biomechanical Comparison of Tendon-Bone Interface Motion and Cyclic Loading Between Single-Row, Triple-Loaded Cuff Repairs and Double-Row, Suture-Tape Cuff Repairs Using Biocomposite Anchors”30Barber F.A. Drew O.R. A biomechanical comparison of tendon-bone interface motion and cyclic loading between single-row, triple-loaded cuff repairs and double-row, suture-tape cuff repairs using biocomposite anchors.Arthroscopy. 2012; 28: 1197-1205Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar and have some questions for the September 2012 Editorial: Can you make specific clinical recommendations? What are the limitations of the research? How does time zero biomechanical analysis apply to healing? What is the clinical importance of complete versus incomplete healing after rotator cuff repair? What other analyses are required to fully solve the question about the best manner to achieve tendon-bone healing? Failure at the suture-tendon interface was most common; can failure at the suture-tendon interface be prevented? What were other modes of failure, and why and when is the mode different? What is your preferred technique, and why? Dr. Barber: This test was performed to address the pertinent and well-reasoned argument that larger, stronger suture constructs, such as using suture tape or chain-link suture,11Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar would perform differently than the “classic” double-row constructs and the triple-loaded constructs that were compared previously.32Barber F.A. Herbert M.A. Schroeder F.A. Aziz-Jacobo J. Mays M.M. Rapley J.H. Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs.Arthroscopy. 2010; 26: 316-323Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar A concern raised in several point-counterpoint debates at AANA meetings is that the crossing sutures of a double-row repair may place sufficient pressure on the already degenerative rotator cuff tendon to compromise the vascular supply to some areas of the tendon. Could such crossing sutures actually strangulate the tissue and be harmful? The data are not available to answer that question. We read with interest the study by Kaplan et al.15Kaplan K. ElAttrache N.S. Vazquez O. Chen Y.-J. Lee T. Knotless rotator cuff repair in an external rotation model: The importance of medial-row horizontal mattress sutures.Arthroscopy. 2011; 27: 471-478Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar who looked at a double-row, suture tape construct and sought to evaluate it in comparison with a triple-loaded single-row repair. Our study construct differed from Kaplan's because we sought to maximize the holding power of the construct by tying the mattress suture under the two suture tapes to create a ripstop effect. Since our prior study32Barber F.A. Herbert M.A. Schroeder F.A. Aziz-Jacobo J. Mays M.M. Rapley J.H. Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs.Arthroscopy. 2010; 26: 316-323Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar that compared the “classic” double-row and the suture crossing, double-row constructs with a triple-loaded single-row showed that the triple-loaded single-row had less displacement, we wanted to compare the triple-loaded single-row with the suture bridge created by suture tape. Our previous studies have shown a direct correlation between the number of sutures in a single anchor and the tissue holding strength. Specifically, 3 sutures in a single anchor are stronger than 2 sutures in a single anchor which are stronger than 1 suture. It follows that increasing the number of sutures and the strength of those sutures will continue to increase the repair strength until the weakest link in the repair is the tissue and not the suture. How much is enough? At some point, you can have so much suture in the tissue that the result is overkill. Is a comparison between 2 triple-loaded single-row anchors with 6 sutures and 4 anchors creating a double row with a total of 8 sutures (4 of which are 2-mm tapes) a fair match up? Does it have clinical relevance? Clearly, introducing more and more suture material into a repair may reach the point where the increased strength is irrelevant and quite possibly the physiology of healing is impaired. That is especially germane if one gives credence to the arguments on compromising tissue vascularity. Clinically, stronger may not mean better. There is increasing recognition that holding the rotator cuff tendon footprint fixed over a greater area seems to lead to musculotendinous junction failure in cuff muscles with less fatty degeneration or muscle atrophy. Two rotator cuff repair failure modes exist: Cho type 1 (failure at the original repair site) and Cho type 2 (failure around the medial row).33Cho N.S. Lee B.G. Rhee Y.G. Arthroscopic rotator cuff repair using a suture bridge technique: Is the repair integrity actually maintained?.Am J Sports Med. 2011; 39: 2108-2116Crossref PubMed Scopus (185) Google Scholar While failure at the musculotendinous junction has been previously identified by Voigt et al.,21Voigt C. Bosse C. Vosshenrich R. Schulz A.P. Lill H. Arthroscopic supraspinatus tendon repair with suture-bridging technique Functional outcome and magnetic resonance imaging.Am J Sports Med. 2010; 38: 983-991Crossref PubMed Scopus (123) Google Scholar it is of special concern that this Cho type 2 failure (musculotendinous junction tear) occurred with double-row repairs in 59% of Cho's failure cases. It is also interesting that the percentage of the Cho type 1 retear increased with the severity of fatty degeneration or muscle atrophy. This suggests that the healthier tissue may be more likely to tear in the more catastrophic Cho type 2 manner (at the musculotendinous junction). More needs to be known about the effects of multiple crossing sutures on the potential for tendon vascular compromise. At this point, I believe that the single-row, triple-loaded repair has advantages over a double-row repair because it does not cut off circulation to cuff tissue or overtension the repair, and it avoids repair failure at the musculotendinous junction, is quicker to perform, and costs less. How does time-zero biomechanical analysis apply to healing? There is no direct correlation. Nothing studied in any biomechanical test can be directly applied to healing. Information derived from a biomechanical test may suggest that rotation of the arm after tendon repair may be more likely to expose bone under the tendon with a single-row repair than a double-row repair, but this does not mean that there is an effect on healing. This is a clinical condition and requires a clinical test. It may be that the postoperative rehabilitation program, the patient's behavior (e.g., smoking, compliance with a program), or physiology may have a more significant effect. What is the clinical importance of complete versus incomplete healing after rotator cuff repair? Good question! What is meant by incomplete healing and how is it measured? Is it defined by the lack of “maturity” seen on a postoperative MRIs of repaired cuff tendon, the footprint area size, or the repaired tendon thickness? Or, is it judged solely on whether or not there is a still a complete cuff tear at whatever time the repeat imaging is performed? Also, what form of assessment or imaging is used: ultrasound or MRI? At the 2011 annual AANA meeting, Don Buford presented his data on the use of ultrasound to track rotator cuff tendon healing. He feels that 4 or 5 months is required before ultrasound can effectively show cuff healing. In contrast, some authors have published reports based on 6-week and 12-week ultrasound data.34Rodeo S.A. Delos D. Williams R.J. Adler R.S. Pearle A. Warren R.F. The effect of platelet-rich fibrin matrix on rotator cuff tendon healing: A prospective, randomized clinical study.Am J Sports Med. 2012; 40: 1234-1241Crossref PubMed Scopus (279) Google Scholar Clearly, incomplete healing needs to be specifically defined, especially considering that not all partial-thickness tears are surgically repaired. Would a 20% thickness PASTA tear present 12 months after rotator cuff repair be considered a failure? What does our Academy have to say on this subject? Their recent statement seems to have confused the situation. As the editors of Arthroscopy wrote in the May issue,2Lubowitz J.H. McIntyre L.F. Provencher M.T. Poehling G.G. AAOS rotator cuff clinical practice guideline misses the mark.Arthroscopy. 2012; 28: 589-592Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar the Academy's Clinical Practice Guideline on “Optimizing the Management of Rotator Cuff Problems”35Pedowitz R.A. Yamaguchi K. Ahmad C.S. et al.American Academy of Orthopaedic Surgeons Optimizing the management of rotator cuff problems: Guideline and evidence report.J Bone Joint Surg Am. 2012; 94: 163-167Crossref PubMed Scopus (5) Google Scholar listed inconclusive recommendations and offered little evidence to support repairs of rotator cuff pathology. The editors indicate that these non-guidelines seem to miss the mark or at the very least are not helpful to the surgeon.2Lubowitz J.H. McIntyre L.F. Provencher M.T. Poehling G.G. AAOS rotator cuff clinical practice guideline misses the mark.Arthroscopy. 2012; 28: 589-592Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar You asked me to describe my current, preferred technique. I am involved in a prospective, randomized study comparing triple-loaded, single-row repairs with double-loaded, double-row repairs, both augmented by platelet-rich plasma fibrin membrane (PRPFM). Previous research has convinced me of the benefit of this type of platelet-rich plasma augmentation for tears less than 3 cm in anteroposterior diameter.36Barber F.A. Hrnack S.A. Snyder S.J. Hapa O. Rotator cuff repair healing influenced by platelet-rich plasma construct augmentation.Arthroscopy. 2011; 27: 1029-1035Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar, 37Visser L.C. Arnoczky S.P. Caballero O. Gardner K.L. Evaluation of the use of an autologous platelet-rich fibrin membrane to enhance tendon healing in dogs.Am J Vet Res. 2011; 72: 699-705Crossref PubMed Scopus (25) Google Scholar The double-row technique uses a conventional suture bridge without a ripstop stitch. The medial row sutures are knotted securely and then knotless anchors are used to secure the lateral row. The single-row technique is a standard triple-loaded (no ripstop) suture anchor repair. Marrow vents are placed in the greater tuberosity. In both repairs the PRPFM is secured with suture in the interval between the tendon and the greater tuberosity. Thanks for your interest! The Editors' final comment: Thanks, Alan. This is an honest and evidence-based expert opinion, but as you indicate, others disagree or argue with your hypotheses. Therefore, we hereby solicit all experts to voice their opinion on the topic of rotator cuff repair. Send us your letters. We think the jury is still out on this issue.