An Arthroscopic Technique for Hybrid Double‐Row Repair Using a Cancellous Screw and Washer for Enhanced Lateral‐Row Fixation in Osteoporotic Massive Rotator Cuff Tears With Long‐Head Biceps Augmentation

Abstract

Massive rotator cuff tears in osteoporotic bone often fail because of many factors, including poor anchor fixation. We present an arthroscopic hybrid double‐row repair technique using a unicortical cancellous screw and washer for lateral‐row fixation, combined with biceps superior capsular reconstruction. This method secures multiple suture limbs through a single screw, ensures dependable bone purchase, and maintains footprint compression in fragile bone. Offering a cost‐effective and practical alternative to conventional anchors, this technique is well suited for managing massive rotator cuff tears in osteoporotic patients.

Massive rotator cuff tears (MRCTs) involve 2 or more rotator cuff tendons and are associated with poor tendon quality, muscle atrophy, and fatty infiltration, often resulting in suboptimal surgical outcomes. ¹ These tears can lead to chronic shoulder pain and dysfunction, affecting patients’ quality of life and their ability to perform daily activities. ² Osteoporosis poses a significant challenge in rotator cuff repair because compromised bone quality increases the risk of anchor failure, impairs tendon‐to‐bone healing, and disrupts normal bone metabolism, ultimately compromising surgical outcomes. ³ These challenges are further amplified in the setting of MRCTs, which are inherently associated with poor tendon quality, muscle atrophy, and fatty infiltration, making secure fixation and durable repair particularly difficult in osteoporotic bone. ¹ , ⁴ To address these limitations, we describe an arthroscopic hybrid double‐row repair technique that uses a cancellous screw with a washer for lateral‐row fixation in patients with MRCTs and osteoporosis. This construct provides improved bone purchase and higher pullout strength than suture anchors while also offering a cost‐effective, readily available solution for fixation in osteoporotic bone. ⁵

SURGICAL TECHNIQUE

Preoperative Imaging Evaluation

Preoperative magnetic resonance imaging of the shoulder was reviewed to assess tear configuration, tendon retraction, muscle quality, and associated pathology. Coronal and sagittal T2‐weighted images showed a massive posterosuperior rotator cuff tear with retraction of the supraspinatus tendon to the glenoid (Figure 1A and B). Axial T2‐weighted images showed a full‐thickness tear of the subscapularis tendon (Figure 1C).

FIGURE 1.

Preoperative MRI of the right shoulder. (A) Coronal T2‐weighted MRI showing a full‐thickness tear of the supraspinatus tendon with retraction to the level of the glenoid. (B) Sagittal T2‐weighted MRI showing a massive posterosuperior rotator cuff tear. (C) Axial T2‐weighted MRI showing a full‐thickness tear of the subscapularis tendon. (MRI, magnetic resonance imaging.)

Patient Positioning and Anesthesia

The complete technique is shown in the supplemental video (Video 1). The patient undergoes an interscalene brachial plexus block with endotracheal intubation. The patient was placed in a modified semilateral decubitus position. ⁶ All bony prominences are padded. The operative shoulder is secured to a hand‐holder traction attachment (Arthrex, Naples, FL) and positioned in approximately 45° of abduction and 30° of forward elevation.

VIDEO 1.

Download video file ^{(47.2MB, mp4)}

The patient was placed in a modified semilateral decubitus position. Intra‐articular examination viewed from the posterior portal revealed a full‐thickness tear of the subscapularis tendon, accompanied by a large tear of the posterosuperior rotator cuff. Capsular release was performed using a radio‐frequency ablator. Single‐row repair of the subscapularis tendon was performed using a double‐loaded suture anchor, which aided in the reduction of the posterosuperior rotator cuff for subsequent repair. Subacromial viewing showed a posterosuperior rotator cuff tear, with the supraspinatus tendon retracted to the glenoid. Rotator cuff mapping revealed cuff mobilization to the footprint facilitated by biceps tendon transposition. Two triple‐loaded suture anchors were inserted at the anterior and posterior aspects of the rotator cuff footprint. Four suture limbs from 2 sutures of the posterior anchor were shuttled through the infraspinatus tendon, and the sutures were then tied. Sutures from the anterior anchor were passed through the long head of the biceps tendon and the supraspinatus tendons. The long head of the biceps tendon was tenotomized after the sutures were passed. The sutures passed through the long head of the biceps tendon were tied. Six sutures were retrieved through the cannula for lateral‐row fixation. A Kirschner wire was initially placed to confirm a safe trajectory away from the axillary nerve, followed by a skin incision for a cancellous screw insertion as lateral‐row fixation. Lateral‐row fixation was performed using a 6.5‐mm partially threaded cancellous screw with a washer. Three sutures were initially passed through the washer, and after the screw was fully tightened, each suture that had not passed through the washer was paired and tied with a suture that had passed through the washer, completing the final repair. The postoperative radiograph reveals appropriate positioning of the cancellous screw with washer. The surgical incision for lateral‐row fixation with a cancellous screw is shown here. Video content can be viewed at https://doi.org/10.1002/atn2.70299.

Diagnostic Glenohumeral Arthroscopy and Subscapularis Repair

The surgical site is prepared and draped in a sterile fashion, and bony landmarks are identified and marked. A standard posterior portal is established for diagnostic glenohumeral arthroscopy, followed by creation of an anterior working portal using an outside‐in technique. The size and extent of the rotator cuff tear are assessed, along with the integrity of the long head of the biceps tendon (LHBT). Capsular release was performed using a radio‐frequency ablator (Super Turbovac Coblation Wand, ArthroCare, Austin, TX). When a subscapularis tendon tear is identified, repair of the subscapularis tendon is performed first because it facilitates subsequent repair of the posterosuperior rotator cuff. The subscapularis tendon is repaired using a single‐portal technique. ⁷ A 2.6‐mm double‐loaded suture anchor (Genesys PressFT; ConMed, Utica, NY) is inserted at the lesser tuberosity footprint. A single‐row repair was performed by shuttling sutures using a 45° left‐curved suture passer (Spectrum; ConMed Linvatec, Largo, FL) loaded with No. 1 polydioxanone (Ethicon, Somerville, NJ) (Figure 2A).

FIGURE 2.

Arthroscopic views of the right shoulder in a modified semilateral decubitus position, viewed from the posterolateral portal, before repair of a massive posterosuperior rotator cuff tear. (A) After single‐row repair of the SSc using a double‐loaded suture anchor. (B) Massive posterosuperior rotator cuff tear with retraction of the SSp to the G. (C) Rotator cuff mapping to assess the degree to which the rotator cuff can be mobilized to the footprint. (D) Evaluation of the optimal position for long head of the biceps tendon transposition for superior capsular reconstruction. White arrow, suture knot. (B, long head of the biceps tendon; G, glenoid; H, humerus; ISp, infraspinatus tendon; SSc, subscapularis tendon; SSp, supraspinatus tendon.)

Posterosuperior Rotator Cuff Repair With Biceps Superior Capsular Reconstruction

The arthroscope is advanced into the subacromial space through the posterior portal. An anterolateral portal is established, through which bursectomy and acromioplasty are performed as needed. A posterolateral portal is subsequently created and used as the primary viewing portal for posterosuperior rotator cuff repair. The posterosuperior rotator cuff tear is assessed for size and degree of retraction (Figure 2B). Rotator cuff mapping is performed to assess the degree to which the rotator cuff can be mobilized to cover the footprint (Figure 2C). The LHBT is evaluated and mobilized to determine the optimal position for transposition in superior capsular reconstruction (SCR) (Figure 2D). Two triple‐loaded suture anchors are placed at the anterior and posterior aspects of the rotator cuff footprint (Figure 3A). The sutures from the posterior anchor are passed through the infraspinatus tendon and the posterior portion of the supraspinatus tendon. The 2 suture pairs passed through the infraspinatus tendon are then tied, and each limb is subsequently cut (Figure 3B). The LHBT is transposed to the anterior aspect of the greater tuberosity. Each limb of the sutures from the anterior anchor is passed through the LHBT, with the corresponding opposing limb passed through the rotator cuff tendon, and the sutures are then tied in a side‐to‐side fashion (Figure 3C). After knot tying, the sutures are cut, leaving 2 suture limbs, which, together with 4 limbs from the posterior anchor, result in a total of 6 suture limbs used for lateral‐row fixation with a cancellous screw and washer (Figure 3D).

FIGURE 3.

Arthroscopic views of the right shoulder in a modified semilateral decubitus position, viewed from the posterolateral portal, during repair of a massive posterosuperior rotator cuff tear. (A) Two triple‐loaded suture anchors placed at the anterior and posterior aspects of the rotator cuff footprint. (B) After knot tying of 2 sutures from the posterior anchor in the ISp. (C) Sutures from the anterior anchor are passed through the long head of the biceps tendon and the rotator cuff tendon and tied in a side‐to‐side fashion. (D) Six suture limbs used for lateral‐row fixation with a cancellous screw and washer. White arrow, suture knot; white arrowhead, suture anchor placement. (B, long head of the biceps tendon; H, humerus; ISp, infraspinatus tendon; SSp, supraspinatus tendon.)

Lateral‐Row Fixation Using a Cancellous Screw With a Washer

The 6 suture limbs are retrieved through the cannula via the anterolateral portal. The K‐wire is drilled for the optimal position for the screw insertion, which is located just below the transitional zone of the metaphysis‐diaphysis of the humerus. The drill is aimed at the medial calcar of the proximal humerus to achieve the longest screw purchase to the proximal humerus (Figure 4A). After, a miniopen incision is then created by extending the incision at the anterolateral portal, which should not violate the axillary nerve from the preoperative skin marking (Figure 4B and C).

FIGURE 4.

Lateral‐row fixation using a cancellous screw with a washer. (A) Postoperative anteroposterior radiograph of the right shoulder showing recommended screw trajectory toward the medial calcar of the proximal humerus (white arrowhead) to achieve maximal purchase. (B) Preoperative skin marking for lateral‐row fixation using a cancellous screw with a washer to identify the location of the axillary nerve (white arrowhead). (C) Miniopen incision created by extending the anterolateral portal after optimal K‐wire placement for screw insertion (white arrowhead). (D) Diagram illustrating the positions of the suture anchors, suture passage through the posterosuperior rotator cuff tendon and the long head of the biceps tendon, and lateral‐row fixation using a cancellous screw with a washer securing 6 suture limbs. (E) Diagram illustrating lateral‐row fixation using a cancellous screw with a washer. Three suture limbs are passed through the washer and tensioned before final screw seating, after which the remaining suture limbs are paired and tied to complete lateral‐row fixation. (F) The right shoulder displays a surgical scar from lateral‐row fixation. (B, long head of the biceps tendon; ISp, infraspinatus tendon; SSp, supraspinatus tendon.)

The cannula is then removed, and a 6.5‐mm partially threaded cancellous screw with a washer (Synthes, Oberdorf, Switzerland) is inserted but not fully seated. Three suture limbs are passed through the washer and tightened before final seating of the screw. After the screw is fully tightened, each suture limb not passed through the washer is paired and tied to a corresponding suture limb that has been passed through the washer, completing the lateral‐row fixation (Figure 4D and E). The right shoulder displays a surgical scar from lateral‐row fixation (Figure 4F).

DISCUSSION

Adequate lateral‐row fixation is essential to maintain compression of the repaired tendon onto the footprint, maximize contact area, and reduce gap formation under cyclic loading. ⁸ However, in the osteoporotic bone, conventional suture anchors may have compromised pullout strength, increasing the risk of fixation failure. ⁹ To address this limitation, we proposed a technique using a cancellous screw with a washer as an alternative lateral‐row fixation method, providing secure purchase of cancellous bone and reliable load distribution. This construct also allows fixation of multiple suture limbs by pairing a suture limb passed through the washer with a corresponding limb not passed through the washer for knot tying while preserving footprint compression even in poor‐quality bone. In combination with biceps SCR, this technique facilitates secure repair of the posterosuperior cuff and may be a reliable option for treating MRCTs in osteoporotic patients.

A cancellous screw with a washer is used for lateral‐row fixation in this technique. The washer functions as an anchor through which the sutures can be passed, providing a secure fixation point. ⁵ Unlike previously published techniques that use a cancellous screw with a washer for a suture‐to‐post construct, in which the sutures loop underneath the washer before knot tying, our technique passes half of the suture limbs through the washer to serve as the fixation point, whereas the remaining half are paired for knot tying. ¹⁰ , ¹¹ In this case, 3 of the 6 suture limbs were passed through the washer; therefore, the sutures were tied as 3 separate knot pairs. The sutures that pass through the washer must be tensioned before the screw is fully tightened. Therefore, the tension of the sutures routed through the washer is adjusted first, followed by tensioning the remaining sutures before knot tying. Once completed, all suture limbs achieve the desired tension, providing an effect comparable to that of a lateral‐row fixation using an absorbable screw. This technique offers several advantages. The use of a washer allows multiple sutures to be passed through it, enabling lateral‐row fixation with several suture limbs using only a single screw. A cancellous screw provides good purchase in cancellous bone, and studies have shown that its pullout strength and stiffness are comparable to those of bioabsorbable screws. ¹² , ¹³ The configuration enables maintenance of adequate footprint compression with uniform load distribution across the repair construct. Suture tensioning can be controlled, thereby optimizing the biomechanics of the repair. In addition, cancellous screws are inexpensive and widely available in most health care settings, making them a practical option in resource‐limited situations.

Use of the LHBT as an augmentation technique has gained popularity in recent years because of its biological advantages. ¹⁴ , ¹⁵ , ¹⁶ , ¹⁷ When used for SCR, the LHBT adheres to the fundamental principles of restoring the superior capsular restraint, thereby contributing to the stabilization of the humeral head. ¹⁸ The advantages of using the LHBT as an autograft include the ability to perform the procedure without placing anchors in the glenoid, without requiring additional incisions for graft harvest, without donor‐site morbidity, and without additional costs associated with dermal allografts. ¹⁹ In the authors’ technique, the LHBT is first rerouted and secured with sutures prior to performing the tenotomy. The advantage of this sequence is that it allows the surgeon to select the optimal portion of the LHBT for suture passage while preventing tendon movement during suturing. The authors aim to position the biceps tendon over the anterior aspect of the greater tuberosity footprint to augment the region corresponding to the anterior cable of the rotator cuff, which is believed to improve repair strength, enhance clinical outcomes, and reduce the risk of failure. ²⁰ , ²¹

This technique is not without limitations. It requires an extended incision and muscle retraction to insert the screw. Marking the axillary nerve landmark in the lateral arm before arthroscopy is recommended to prevent iatrogenic injury. The cancellous screw must be placed unicortically because of the risk of intra‐articular penetration. Passing sutures through a washer can be technically challenging. Additionally, the use of a screw and washer introduces a potential risk of local soft‐tissue irritation and hardware‐related complications, although these events are expected to be uncommon. The pearls and pitfalls of this technique are summarized in Table 1, and the advantages and disadvantages are summarized in Table 2.

TABLE 1.

Pearls and Pitfalls

Pearls
The subscapularis tendon tear should be repaired first to facilitate the mobilization of the posterosuperior cuff
Reroute and pass sutures through the LHBT prior to tenotomy to help select the optimal tendon segment for suture passage and prevent tendon displacement during the procedure
Position the LHBT on the anterior portion of the greater tuberosity to provide augmentation of the anterior rotator cuff cable
Before arthroscopy, mark the planned incision for cancellous screw fixation and the axillary nerve landmark to prevent iatrogenic injury
The cancellous screw should be placed unicortically and aimed at the medial calcar of the proximal humerus
Adjust the tension of the sutures passed through the washer before fully tightening the screw
Knot tying of the lateral‐row cancellous screw with washer fixation should be performed using a knot pusher

Pitfalls
The use of the LHBT for SCR is not suitable in patients with a ruptured LHBT, previous tenodesis, or LHBT tendinopathy
Lateral fixation using a cancellous screw with a washer requires an extended incision and meticulous deltoid muscle retraction
Failing to identify and mark the axillary nerve can increase the risk of nerve injury
Placing the screw bicortically can risk intra‐articular penetration
Poor suture management during lateral‐row fixation may lead to suture entanglement and premature knotting
Failure to tension the sutures passing through the washer before fully tightening the cancellous screw may result in laxity of the sutures

LHBT, long head of the biceps tendon; SCR, superior capsular reconstruction.

TABLE 2.

Advantages and Disadvantages of the Technique

Advantages
Cancellous screws provide strong fixation in osteoporotic bone by achieving adequate purchase
The screw‐washer construct enables secure lateral‐row fixation by allowing the use of multiple sutures
Adequate footprint compression and uniform load distribution are maintained across the construct
The technique allows controlled tensioning of sutures, optimizing repair biomechanics
The technique offers a cost‐effective and widely available alternative to conventional suture anchors

Disadvantages
Adequate exposure for screw insertion requires an extended incision and muscle retraction
The procedure carries a risk of axillary nerve injury, necessitating careful preoperative marking and surgical technique
Misdirected screw placement carries a risk of intra‐articular penetration
Technical difficulty may be encountered when passing multiple sutures through the washer
The screw and washer may cause hardware‐related complications

DISCLOSURES

The authors (P.C., B.C., M.M., P.P., P.G.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.