ARTHROSCOPIC TRANSOSSEOUS

(No implant) ROTATOR CUFF REPAIR

Sai Institute of Sports Injury & Arthroscopy Shoulder & Knee Specialty Centre, Hyderabad

Dr. Raghuveer Reddy. K

IAS 2014

I am Thankful to Dr. Sumant G. Krishnan

for providing with Biomechanical work

& Clinical outcome statistics of his

study done in U.S.

History

Cycle of Rotator Cuff Repair

Open Transosseous

Mini-Open Transosseous

Mini-Open with Anchors

Arthroscopic with Anchors

SR vs DR vsTOE

Arthroscopic Transosseous

The Perfect RCR

Large Contact Area

High Initial Fixation Strength

Stable Construct

Biology

High Contact Pressure

Low Tension Repair

Mechanical fixation Biological healing

Suture strength

Multiple sutures

Suture configuration

Suture anchors

Transosseous Equivalent

Transosseous Repair

Prepare bone foot print

? Acromioplasty??

• Collagen coated suture

Growth Factors ( PRP)

Stem Cells

ECM Grafts

Biologic Scaffolds

Graft Jacket

Cuff Healing - Stimulation

Cyclic Testing

Tunnel: Bone Failure

Anchors: Tendon Failure

Burkhart et al Arthroscopy 1997

Design Arthrotunneller

Arthroscopic Transosseous RCRHISTORICAL PERSPECTIVE

Fleega 2002

“Giant Needle”

Krishnan 2002

All-Arthroscopic

Transosseous

Lu 2005

ACL Guide

Beauchamp 2007

Curved passers

Resch 2009

Curved hollow needle

Castagna 2012

Taylor Stitch

Kuroda 2013

Customized drill guide

ATRCRThe Surgical Technique

ARTHROSCOPIC TRANSOSSEOUS (ANCHORLESS) ROTATOR CUFF REPAIR

ARTHROSCOPIC TRANSOSSEOUS (ANCHORLESS) ROTATOR CUFF REPAIR

Surgical Technique –

Any suture configuration possible

Simple (medial)

Mattress (ant/post)

Bridges

ARTHROSCOPIC TRANSOSSEOUS (ANCHORLESS) ROTATOR CUFF REPAIR

Single Tunnel

ARTHROSCOPIC TRANSOSSEOUS (ANCHORLESS) ROTATOR CUFF REPAIR

Two Tunnel

ATRCRThe Science

BIOMECHANICAL EVALUATION

Ideal Rotator Cuff Repair

● High initial fixation strength

● Minimal gap formation

● Mechanical stability till tendon bone healing

Gerber JBJS (Br) 1994

Sugaya JBJS 2007

Arthroscopic Transosseous RCRREVISITING HISTORY

● Burkhart et al. - Arthroscopy, 2000

● Barber et al. - Arthroscopy, 2010

● Jost et al. - JBJS, 2012

“Increasing the number of sutures crossing the repair

site increases the load to failure and decreases gap

formation under cyclic loading”

ATRCRThe Outcomes of

Our Prospective Clinical Study &

Sumant’s Randomized Study

My Experience

PROSPECTIVE CLINICAL STUDY

Material 2013 - 14 20 cases

Our Prospective Clinical Study

Primary 18, Revision 2

Posterior superior tears 14, Superior 6 tears

Single tunnel 11Pts. Simple Suture

Two tunnel 9Pts. Mattress Suture

10 Cases evaluated. 6 - 12 months follow up

Functional evaluation (VAS, ASES)One pt. Had ASES < 70

MRI Evaluation – Sugaya criteria for cuff healing5 pts. Type I Three pts , Type II Two pts

MRI evaluation using Sugaya

Criteria for Cuff Healing Arthroscopy 2005

Type I: Sufficient thickness with homogeneously low intensity

Type II: Sufficient thickness with partial high intensity

Type III: Insufficient thickness without discontinuity

Type IV: Presence of a minor discontinuity

Type V: Presence of a major discontinuity

Case 1 Post op MRI

Type I: Sufficient thickness with homogeneously low intensity

Type II: Sufficient thickness with partial high intensity

Type III: Insufficient thickness without discontinuity

Type IV: Presence of a minor discontinuity

Type V: Presence of a major discontinuity

Case 2 Post op MRI

Type I: Sufficient thickness with homogeneously low intensity

Type II: Sufficient thickness with partial high intensity

Type III: Insufficient thickness without discontinuity

Type IV: Presence of a minor discontinuity

Type V: Presence of a major discontinuity

Case 3 Post op MRI

Type I: Sufficient thickness with homogeneously low intensity

Type II: Sufficient thickness with partial high intensity

Type III: Insufficient thickness without discontinuity

Type IV: Presence of a minor discontinuity

Type V: Presence of a major discontinuity

Posterosuperior rotator cuff tear amenableto GT footprint repair without tension (L , Crescent, reverse L)

• No subscapularis tendon involvement

• Grade I, II, III (Goutallier) FI

• One single surgeon

• Prospective Randomized allocation

• MRI evaluation at 1 year postop from 3 independent radiologists using SugayaCriteria for cuff healing

Prospective Randomized Study - Sumant

INCLUSION CRITERIA

TECHNIQUE AT SUTURE ANCHORS

N cases 28 24

Retear (NH) 4 (14%) 4 (16%)

Grade I 10 (38%) 6 (26%)

Grade II 13 (48%) 8 (34%)

Grade III (PT) 1 (3%) 6 (26%)

OVERALL 86% 84%

Type I healing Type III healing

Type I: Sufficient thickness with homogeneously low intensity

Type II: Sufficient thickness with partial high intensity

Type III: Insufficient thickness without discontinuity

Type IV: Presence of a minor discontinuity

Type V: Presence of a major discontinuity

Arthroscopic Transosseous Repair Integrity

Various Centers

LOCATION STRUCTURAL INTEGRITY# OF CASES TO DATE

Krishnan ASES 2010 82% (49/60) MRI 1350

Mozes ISRAEL 2011 96% (48/50) U/S 98

Brassart FRANCE 2011 86% (33/38) U/S 241

Mikek SECEC 2011 95% (56/59) U/S 175

OVERALL 86% (214/239) >2000

Study Overall Integrity TypeSugaya JBJS 2007 83% ( 71 / 86 ) DR SA

DeBeer JBJS 2007 83% ( 174 / 210 ) DR SA

LaFosse JBJS 2007 89% (93 / 105 ) DR SA

ElAttrache AJSM 2008 88% (22 /25) TOE/Suture bridge

Gartsman ASES 2010 94% (44 / 47) TOE/Suture bridge

Volgt AJSM 2010 71% ( 32 / 45) TOE/Suture bridge

Boileau Nice 2010 72% (28 / 39) TOE/Suture bridge

Sethi JSES 2010 83% (33 / 40) TOE/Suture bridge

Toussaint AJSM 2011 86% (132 / 154) TOE/Suture bridge

Rhee AJSM 2011 67% (58 / 87) TOE/Suture bridge

Kim JBJS 2012 85% (62 / 73) TOE/Suture bridge

OVERALL 82% (749 / 911)

Double Row & TOE Repair Integrity

Requirement Transosseous

RCR

Suture Anchor

RCR

Contact Area X X

Initial Strength X X

Contact Stability X X

Gap Formation X X

Mechanical Stability X X

Biology X

No Implants in Bone X

Ideal Rotator Cuff Repair

Transosseous repairs10,000+ cases worldwide

Bone Tunnel Placement

Bone Quality

Overtensioning

Of repair

Number of Tunnels

Arthroscopic Transosseous RCRWHAT ARE THE CONCERNS AND RISK?

Arthroscopic Transosseous RCRREVISITING HISTORY

Tunnel Augmentation

Warner JP, Piza P

Warren Alpert Medical School 2012

Bone “Tunnel Protection”

Courtesy: Warner JP

Arthroscopic Transosseous RCRASSESS THE TEAR AND AVOID OVERTENSIONING

Shorter tendon = increased tension if pulled to normal length

Some cuffs cannot be pulled all the

way out to cover the old footprint

Myotendinous Junction Retears

Tight Cuff Tears

• Covers the footprint as much as possible and

remaining with suture

• Auto adjusts the tension – Spiral Binding

• Less over tensioning when compared to DR/ TOE

Arthroscopic Transosseous RCR

ComparisonARTHROTUNNELER Vs ANCHORS

Implant ARTHROTUNNELER

No Implant

ANCHORS

Implant Present

Small Tears

Single tunnel

Expensive Cheap

Large Tears

Two or three tunnel

Cheap Expensive

Technique Simple suture - Easy SR - Easy

Mattress suture - Demanding DR - Demanding

TOE - Easy

Biology Bone marrow from tunnel - More Less in vented anchors

Re tear Easy Re -operation Difficult

● Equivalent to Current Methods

● Repair Integrity

● Biomechanical Strength

● Reliable/Reproducible Technique

● Multiple Sutures

● Bone Tunnel Augmentation

● Assess the lesion

● Anatomic repair and avoid over tensioning

● More easy reoperation in case of Re-tear

● Biology

● Marrow elements from bone tunnels

Arthroscopic Transosseous RCRCONCLUSIONS

ARTHROSCOPIC TRANSOSSEOUS

(ANCHORLESS) ROTATOR CUFF REPAIR

Sai Institute of Sports Injury & Arthroscopy Shoulder & Knee Specialty Centre, Hyderabad

Dr. Raghuveer Reddy. K

IAS 2014

06 Hrs

Recent Advances

Rotator Cuff Repair

ARTHROSCOPIC TRANSOSSEOUS

(ANCHORLESS) ROTATOR CUFF REPAIR

Sai Institute of Sports Injury & Arthroscopy Shoulder & Knee Specialty Centre, Hyderabad

Dr. Raghuveer Reddy. K

OASIS 2014

TOE ConcernsMyotendinous Junction Retears

Lill, et al. Arthroscopic Supraspinatus Tendon Repair with

Suture Bridging Technique: Functional Outcome

and MRI. - AJSM 2010

Retear rate by MRI at 12 mos: 28.9%

Cho, et al. Retear Patterns After Arthroscopic Cuff Repair:

Single Row vs. Suture Bridge Technique. - AJSM

2010

27 cases of failed suture bridge technique74% failure at myotendinous junction

Gerhardt et

al.

Arthroscopic Single-Row Modified Mason-Allen

Repair vs. Double-Row SutureBridge

Reconstruction for Supraspinatus Tendon Tears -

AJSM Dec. 2012

20 patients/5 retears80% retears at myotendinous junction

TOE Concerns

Myotendinous Junction Retears

Hayashida et al. Characteristic re-tear pattern after arthroscopic double-row

repair. Arthroscopy, 2012

15% retear rate at myotendinous junction

Conclusion:

“A new repair method, which achieves a wide

footprint, a good initial fixation strength, and

avoids re-tearing around the proximal suture

anchors should be developed to obtain better

cuff integrity and clinical results.”