Most rotator cuff tears occur in individuals older

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1 A Load-Sharing Rip-Stop Fixation Construct for Arthroscopic Rotator Cuff Repair Patrick J. Denard, M.D., and Stephen S. Burkhart, M.D. Abstract: Despite advancements in arthroscopic rotator cuff repair techniques, achieving tendonto-bone healing can be difficult in the setting of poor-quality tendon. Moreover, medial tendon tears or tears with lateral tendon loss may preclude standard techniques. Rip-stop suture configurations have been shown to improve load to failure compared with simple or mattress stitch patterns and may be particularly valuable in these settings. The purpose of this report is to describe a technical modification of a rip-stop rotator cuff repair that combines the advantages of a rip-stop suture (by providing resistance to tissue cutout) and a double row of load-sharing suture anchors (minimizing the load per anchor and therefore the load per suture within each anchor). Most rotator cuff tears occur in individuals older than 60 years of age. 1,2 Increasingly, these individuals are remaining active and demanding rotator cuff repair. However, several studies have shown that the rate of healing in these individuals is less than desirable by standard techniques. 3-5 In a recent report, for instance, the rate of healing after single-row arthroscopic rotator cuff repair (ARCR) was 43% for individuals older than 65 years compared with 95% for individuals younger than 55 years. 3 The lower healing rate observed in older adults is likely related to decreased biologic healing potential. Independent of age, poor tissue quality of the rotator cuff has also been associated with a 3-fold increase in the risk for From Southern Oregon Orthopedics (P.J.D.), Medford, Oregon; the Department of Orthopaedics and Rehabilitation, Oregon Health & Science University (P.J.D.), Portland, Oregon; The San Antonio Orthopaedic Group (S.S.B.); and the Department of Orthopaedic Surgery, University of Texas Health Science Center at San Antonio (S.S.B.), San Antonio, Texas, U.S.A. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received November 17, 2011; accepted December 28, Address correspondence to Stephen S. Burkhart, M.D., 150 E Sonterra Blvd, Ste 300, San Antonio, TX ssburkhart@msn.com 2012 by the Arthroscopy Association of North America. Open access under CC BY-NC-ND license /11764 doi: /j.eats recurrence after ARCR. 4 Strikingly, poor tissue quality may be encountered in approximately one-third of ARCRs. 4 Whereas biologic advancements will likely be improving healing rates in the future, to date, these efforts (e.g., rotator cuff patches and platelet-rich plasma) have not been proven effective. 6,7 Thus the technical goal of any rotator cuff repair remains maximizing fixation strength. Several techniques can be used to accomplish this goal, such as obtaining multiple fixation points, performing suture-bridging double-row repairs, and altering stitch configuration. 8 Most rotator cuff tears occur at the tendon-bone insertion and are amenable to a suture-bridging doublerow repair, which restores the anatomic footprint, maximizes biomechanical strength, and clinically, leads to high healing rates However, at times, a tear can occur more medially 12,13 or be accompanied by lateral tendon loss and preclude the ability to perform a double-row repair. Rip-stop suture configurations have been shown to improve load to failure compared with simple or mattress stitch patterns and may be particularly valuable in the aforementioned setting. 14,15 The purpose of this report is to describe a new technique with a load-sharing rip-stop suture that may be used during ARCR to combine the advantages of a rip-stop suture with the load-sharing properties provided by additional anchors. Arthroscopy Techniques, Vol 1, No 1 (September), 2012: pp e37-e42 e37

2 e38 P. J. DENARD AND S. S. BURKHART TECHNIQUE In this technique a suture tape (FiberTape; Arthrex, Naples, FL) rip-stop suture is placed medially in an inverted mattress configuration and secured laterally to BioComposite SwiveLock C anchors (Arthrex). FiberTape is a nonabsorbable 2-mm suture tape with a similar polyethylene structure to No. 2 FiberWire (Arthrex). FiberTape is thicker centrally and broader than FiberWire and therefore less likely to pull through rotator cuff tissue. 16 The ends of FiberTape are composed of FiberWire leaders, which allow the suture to be passed through tissue with standard arthroscopic instruments. Sutures from medial row anchors (BioComposite Corkscrew FT; Arthrex) are passed in a simple stitch configuration medial to the suture tape ripstop. Unlike previous descriptions in which the mattress stitch and simple stitch are based off the same anchor, 17,18 in our technique, the rip-stop suture is independently secured so that it not only provides resistance to tissue cutout for the simple sutures but also enhances load distribution. FIGURE 1. Anchor-based rip-stop rotator cuff repair for rotator cuff tear that has loss of significant portion of lateral tendon (left shoulder, lateral-to-medial view). (A) In this rotator cuff tear with lateral tendon loss, there is limited space to achieve fixation in the remaining medial tendon. (B) A suture tape rip-stop has been placed as an inverted mattress stitch in the rotator cuff. (C) Two medial anchors are placed approximately 5 mm lateral to the articular margin. (D) The sutures from these anchors are passed medial to the suture tape rip-stop stitch (arrows). (E) Before sutures from the medial anchors are tied, the suture tape rip-stop stitch is secured to bone with 2 lateral knotless anchors. (F) Tying the suture limbs from the medial anchors completes the repair. It should be noted that tying the medial suture limbs must be delayed until after the rip-stop suture has been secured.

3 RIP-STOP FIXATION FOR ROTATOR CUFF REPAIR e39 The tear margin is debrided, the bone bed is prepared, and the tear pattern and mobility are assessed in the standard fashion. The first step is placement of rip-stop sutures. While the surgeon is viewing from a posterior portal, a suture tape is passed through the rotator cuff as an inverted mattress stitch placed 3 mm lateral to the musculotendinous junction. The suture tape is typically passed in an antegrade technique (Scorpion FastPass; Arthrex) to directly pass the FiberWire leaders through the rotator cuff. If necessary, a retrograde pass can also be performed by use of a hand-off technique. Typically, we recommend placing 1 suture tape rip-stop suture per tendon that is torn; for an isolated supraspinatus tendon tear, 1 suture tape is used, whereas 2 are used for a combined supraspinatus and infraspinatus tendon tear. In either case, the rip-stops are placed so that they span the entire anterior-to-posterior dimension of the rotator cuff tear. The rip-stop suture limbs are retrieved out of accessory portals and stored for FIGURE 2. Dual rip-stop rotator cuff repair (left shoulder, lateral-to-medial view). Two rips-stops are typically used if there is a 2-tendon tear. (A) In this rotator cuff tear with lateral tendon loss, there is limited space to achieve fixation in the medial tendon. (B) Two suture tape rip-stop sutures are placed 3 mm lateral to the musculotendinous junction as inverted mattress stitches. (C) Two medial anchors are placed in the greater tuberosity bone bed, approximately 5 mm lateral to the articular margin. (D) Suture limbs from the medial anchors are passed medial to the rip-stop stitches (arrows). (E) The suture tape rip-stop sutures are secured laterally with 2 knotless anchors (arrows). During this step, it is important to retrieve the rip-stop sutures so that they surround the lateral suture limbs from the medial anchors. (F) The repair is completed by tying the suture limbs from the medial anchors.

4 e40 P. J. DENARD AND S. S. BURKHART Steps of Rotator Cuff Repair With Load-Sharing Rip-Stop Suture Tape TABLE Place a suture tape rip-stop as a free inverted mattress stitch in the rotator cuff 3 mm lateral to the musculotendinous junction. 2. Place medial anchors in the greater tuberosity. 3. Place sutures from the anchors as simple stitches that pass medial to the rip-stop suture. 4. Retrieve the suture tape rip-stop to encircle the rotator cuff sutures. a. Retrieve the anterior limb of the rip-stop anterior to the rotator cuff suture limbs. b. Retrieve the posterior limb of the rip-stop posterior to the rotator cuff suture limbs. 5. Secure the anterior and posterior limbs of the suture tape to the lateral anchor(s). 6. Tie the rotator cuff sutures, which pass medial to the rip-stop. later fixation. These rip-stop suture tapes must not be tensioned and repaired to bone until after the sutures from the medial anchors have been passed circumferentially around them. Next, 2 double-loaded suture anchors are placed anteromedially and posteromedially, adjacent to the articular margin. Beginning posteriorly, the sutures from the medial anchors are retrieved and passed as simple stitches that penetrate the rotator cuff medial to the rip-stop suture, 2 to 3 mm lateral to the musculotendinous junction. In most cases, there is lateral tendon loss, and a chronic degenerative tendon stump will have been debrided from the greater tuberosity to prepare the bone bed before anchor placement. However, in the setting of an acute medial tear with a viable lateral tendon stump (usually in a younger patient), consideration can be given to passing the opposite ends of the suture limbs through the lateral tendon stump. In either case, knot tying is delayed at this point, and the suture limbs are held in accessory portals. Once the medial stitches are passed, the suture tape rip-stop stitches are retrieved and secured laterally with 2 BioComposite SwiveLock C anchors. In this step the rip-stop limbs are retrieved so that they encircle the simple sutures from the medial anchors. If only 1 rip-stop is used, the posterior suture tape limb is retrieved posterior to the simple stitches and secured with a posterolateral anchor. Then, the anterior suture tape limb is retrieved anterior to the simple stitches and secured with an anterolateral SwiveLock anchor. If 2 equally spaced rip-stop sutures have been placed, each must encircle the corresponding medial anchor sutures; for example, the anterior limb of the anterior rip-stop stitch is retrieved so that it passes in front of the sutures from the anteromedial anchor, and the posterior limb of the anterior rip-stop stitch is retrieved so that it passes behind the sutures from the anteromedial anchor. As opposed to the single rip-stop technique in which the anterior and posterior suture tape limbs are secured with separate lateral anchors, in the case of 2 rip-stops, the anterior rip-stop is secured with a single anterolateral anchor and the posterior rip-stop is secured with a single posterolateral anchor. After the rip-stop stitches have been secured, the FiberWire simple stitches from the medial anchors are retrieved and static knots are tied with a doublediameter knot pusher (Surgeon s Sixth Finger Knot Pusher; Arthrex). It is important to delay knot tying until after the rip-stop is secured to have a firm, taut rip-stop. The suture tape rip-stop not only prevents cutout like a standard rip-stop but also serves to unload the medial sutures because the rip-stop is tensioned laterally to an anchor. Therefore the medial sutures should not be tied until the rip-stop suture is secured (Figs 1 and 2, Table 1, Videos 1 and 2). DISCUSSION To minimize failure of suture cutting through the tendon, various grasping-type suture techniques have been proposed. Gerber et al. 19 reported that a modified Mason-Allen stitch was the strongest of 9 different stitch patterns. However, the complex weaving pattern of this stitch is difficult to perform arthroscopically. Furthermore, weaving suture patterns such as the modified Mason-Allen may be prone to early failure by loss of loop security (i.e., early gap formation). 20 During cyclic loading, the suture weave within the tendon tightens on itself and the suture loop becomes larger (Fig 3). The result is a loss of loop security and thus a loss of tendon-bone contact. The most efficient way to minimize cinching is to use a single loop of suture a simple stitch. A rip-stop suture is an effective method of avoiding cinching while improving resistance to suture cutout. An anterior-to-posterior mattress stitch (placed independently or originating from an anchor) can be placed through the rotator cuff and tied on itself. Subsequently, simple sutures from an anchor are passed medial to the rip-stop suture, which distributes the medial-to-lateral tensile forces and effectively decreases the chance of suture cutout (Fig 4). Such a rip-stop suture may be placed as an isolated suture or with the use of a double- or triple-loaded anchor. In

5 RIP-STOP FIXATION FOR ROTATOR CUFF REPAIR e41 FIGURE 3. Modified Mason-Allen stitch. Although this stitch pattern has a high load to failure, it has poor loop security under load. (A) A modified Mason-Allen stitch based off an anchor has been woven through the rotator cuff. (B) Under a medial tensile load (arrow), the complex weave cinches on itself, resulting in loss of loop security and thus medial displacement of the rotator cuff. (F, force from rotator cuff.) the case of an anchor, the first set of anchor sutures is used to create a mattress stitch and the remaining sutures are passed medial to lateral in a simple pattern. Ma et al. 14 showed that a rip-stop suture with a double-loaded anchor had a load to failure equivalent to a modified Mason-Allen stitch. Both techniques showed significantly increased load to failure (233 N and 246 N, respectively) compared with a simple stitch (72 N) or a mattress stitch (77 N) (P.05). Other studies have confirmed this observation. 15,21 In another study by Ma et al., 22 it was reported that a triple-loaded anchor with a horizontal rip-stop stitch and 2 simple stitches enhanced fixation properties beyond the double-loaded anchor technique. With this modification, elongation with cyclic loading (i.e., maintained loop security) was decreased (1.1 mm v 1.5 mm) and higher ultimate load to failure (250 N v 212 N) was achieved. Notably, however, the highest load to failure (287 N) and lowest elongation (1.1 mm) were observed with a double-row repair, showing that the load sharing achieved with additional anchors is also important for improving fixation. Another factor to consider in improving fixation strength is the suture material itself. In recent years several polyblend polyethylene sutures have been developed (e.g., FiberWire [Arthrex] and Orthocord FIGURE 4. Rip-stop stitch. This stitch pattern increases pullout and maximizes loop security by using only simple loops of suture. (A) A mattress stitch is placed from anterior to posterior through the rotator cuff perpendicular to the rotator cuff fibers. Then, a simple stitch from a suture anchor is passed medial to the rip-stop stitch. This technique can be performed as illustrated or with both sutures based off the anchor (i.e., with 1 of the sutures from the anchor passed as a rip-stop mattress stitch and the other anchor suture passed as a simple stitch medial to the rip-stop). (B) Under a tensile load (arrow), the rip-stop stitch resists cutout of the simple stitch. (F, force from rotator cuff.)

6 e42 P. J. DENARD AND S. S. BURKHART [DePuy Mitek, Raynham, MA]). These sutures show improved load to failure and abrasion resistance compared with braided polyester sutures (e.g., Ethibond [Ethicon, Somerville, NJ]) or absorbable monofilament polydioxanone sutures (e.g., PDS II [Ethicon]). 23,24 More recently, a 2-mm polyblend tape (FiberTape) has been shown to have even greater load to failure compared with FiberWire both in isolation (937 N v 349 N, P.001) and in tendon specimens (184 N v 168 N, P.046). 16 On the basis of this study, we believe that the suture tape rip-stop used in the current technique is advantageous compared with a standard polyblend suture, particularly in poorquality tissue. The rip-stop rotator cuff repair technique that we have described combines the advantages of a rip-stop suture (by providing resistance to tissue cutout) and a double-row repair (by increasing load-sharing properties). In addition, our technique uses a suture tape that has shown improved biomechanical properties compared with standard high-strength sutures. In our opinion this technique is particularly useful for cases in which there is limited medial tendon that precludes a suture-bridging double-row repair. REFERENCES 1. Sher JS, Uribe JW, Posada A, Murphy BJ, Zlatkin MB. Abnormal findings on magnetic resonance images of asymptomatic shoulders. J Bone Joint Surg Am 1995;77: Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am 2006;88: Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal? J Bone Joint Surg Am 2005;87: Nho SJ, Brown BS, Lyman S, Adler RS, Altchek DW, MacGillivray JD. 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