Abstract
The double-row suture technique and the suture-bridge technique have been used for rotator cuff repair to decrease the occurrence of retears. However, when only the degenerated tendon end is sutured, the risk of retear remains. The augmentation suture technique is a new procedure that connects the intact medial tendon to the lateral greater tuberosity, and this approach may protect the initial repair site. The procedures for this technique are as follows: 2 sutures are placed through the medial intact tendon, the cuff tear is repaired by the single-row technique, 2 sutures are pulled laterally over the single-row repair site, and 2 sutures are fixed at the lateral greater tuberosity with a push-in–type anchor. This technique is simple and easy and does not require special equipment. Moreover, this approach can augment the single-row repair technique without creating high tension at the cuff end.
To decrease the occurrence of retears after a single-row rotator cuff repair, double-row repair and suture-bridge repair procedures have been developed. These techniques have greater initial strength and a larger footprint area compared with single-row repair. However, it is doubtful whether these techniques lead to better biological healing compared with single-row repair. Unlike other tendon-bone repairs, a rotator cuff repair is performed for a chronic tear in which the tendon end is degenerated and weak. Using many sutures for the degenerated tendon will decrease the blood supply and cause tissue necrosis. In addition, pulling the tendon end more laterally to suture in 2 lines will cause too much tension at the tendon end. In fact, retear at the medial anchor after a double-row rotator cuff repair has been reported.1
One of the ideal techniques for rotator cuff repair is an augmentation of a single-row repair. An augmentation graft technique has been reported to have biomechanical and clinical advantages.2-4 This approach overlaps the single-row repair, connecting the medial tendon to the lateral greater tuberosity. The concept of augmentation grafting is sound; however, the procedure is technically difficult to perform for arthroscopic repairs. Moreover, mechanical properties, especially the elasticity of the graft, can affect the biomechanical results.
An augmentation suture technique uses sutures instead of a graft for the augmentation and connects the medial tendon and lateral greater tuberosity (Fig 1). This approach can augment the single-row repair without creating high tension at the tendon end.
Fig 1.
(A) Augmentation graft technique, in which a graft connecting the medial cuff to the lateral greater tuberosity overlaps the single-row repair. (B) Augmentation suture technique, in which the suture is used instead of the graft.
Technique
One or two augmentation sutures are used, depending on the tear size and shape. One augmentation suture is applied at the anterior margin of the supraspinatus tendon, and the other augmentation suture is applied posterior to the initial suture.
After mobilization of the end of the tear, an augmentation suture (No. 2 Hi-Fi High Strength Suture; ConMed Linvatec, Largo, FL) is passed through the medial tendon with a suture-passing device immediately lateral to the muscle-tendon junction. The same suture is again passed through the medial tendon approximately 10 mm from the initial suture. The suture is passed from the joint side to the subacromial side, and both ends of the suture are in the subacromial space. The augmentation suture is passed through the medial tendon with a horizontal mattress configuration (Fig 2A).
Fig 2.
(A) The augmentation sutures are passed through the medial cuff. (B) The cuff end is fixed to the footprint by the single-row repair. (C) The augmentation sutures are fixed at the lateral greater tuberosity with a push-in–type anchor.
After the surface of the footprint at the greater tuberosity is slightly decorticated, suture anchors (4.5-mm Healicoil PK Suture Anchors with 2 Ultrabraid sutures; Smith & Nephew, Andover, MA) are inserted into the bone. The sutures of the anchors are passed between the cuff end and the augmentation suture. The sutures are tied, and the cuff end is fixed to the footprint by use of the single-row technique (Fig 2B).
The augmentation sutures are pulled laterally over the single-row repair site. Then, the sutures are fixed at the lateral aspect of the greater tuberosity, approximately 20 mm inferior to the upper edge of the lateral aspect, with a push-in–type anchor (4.5-mm Footprint Ultra PK Suture Anchor; Smith & Nephew) (Fig 2C). To avoid too much tension at the medial tendon, the shoulder is positioned at 30° of abduction when the augmentation sutures are fixed by the lateral anchor (Video 1).
Discussion
The augmentation suture technique can augment a single-row repair by connecting the medial cuff to the lateral greater tuberosity. The risk of decreasing the blood supply and increasing the tension at the cuff end will be lower with this technique compared with double-row repair and suture-bridge repair, and better biological healing will be achieved. The concept of the augmentation suture is the same as that of the augmentation graft. However, no biomechanical assessments of the augmentation suture procedure have been performed, and future studies are required to confirm the advantages of this technique.
The augmentation suture procedure is simple and easy, does not require special devices, and can be useful, especially when the cuff end is degenerated and weak (Table 1).
Table 1.
Advantages and Limitations of Augmentation Suture Technique
| Advantages | Limitations |
|---|---|
| Augmentation of single-row repair without creating high tension at tendon end | No biomechanical assessments |
| Simple and easy procedure without special devices |
Footnotes
The authors report that they have no conflicts of interest in the authorship and publication of this article.
Supplementary Data
The patient is in the lateral decubitus position. A right shoulder with a large rotator cuff tear is shown from a lateral view. (1) An augmentation suture is passed through the medial tendon with a suture-passing device immediately lateral to the muscle-tendon junction. The same suture is again passed through the medial tendon approximately 10 mm from the initial suture. (2) Two augmentation sutures are used. One augmentation suture is applied at the anterior margin of the supraspinatus tendon, and the other augmentation suture is applied posterior to the initial suture. (3) After the surface of the footprint at the greater tuberosity has been decorticated, suture anchors are inserted into the bone. Two anchors with 4 sutures in total are used. The sutures of the anchors are passed through the tendon between the cuff end and the augmentation suture with a suture-passing device. After that, the sutures are tied, and the cuff end is fixed to the footprint by the single-row technique. (4) The augmentation sutures are pulled laterally and inferiorly. At the lateral aspect of the greater tuberosity, approximately 20 mm inferior to the upper edge of the lateral aspect, the augmentation sutures are fixed with a push-in–type anchor.
References
- 1.Trantalis J.N., Boorman R.S., Pletsch K., Lo I.K. Medial rotator cuff failure after arthroscopic double-row rotator cuff repair. Arthroscopy. 2008;24:727–731. doi: 10.1016/j.arthro.2008.03.009. [DOI] [PubMed] [Google Scholar]
- 2.Barber F.A., Herbert M.A., Boothby M.H. Ultimate tensile failure loads of a human dermal allograft rotator cuff augmentation. Arthroscopy. 2008;24:20–24. doi: 10.1016/j.arthro.2007.07.013. [DOI] [PubMed] [Google Scholar]
- 3.Barber F.A., Burns J.P., Deutsch A., Labbé M.R., Litchfield R.B. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012;28:8–15. doi: 10.1016/j.arthro.2011.06.038. [DOI] [PubMed] [Google Scholar]
- 4.Omae H., Steinmann S.P., Zhao C. Biomechanical effect of rotator cuff augmentation with an acellular dermal matrix graft: A cadaver study. Clin Biomech. 2012;27:789–792. doi: 10.1016/j.clinbiomech.2012.05.001. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The patient is in the lateral decubitus position. A right shoulder with a large rotator cuff tear is shown from a lateral view. (1) An augmentation suture is passed through the medial tendon with a suture-passing device immediately lateral to the muscle-tendon junction. The same suture is again passed through the medial tendon approximately 10 mm from the initial suture. (2) Two augmentation sutures are used. One augmentation suture is applied at the anterior margin of the supraspinatus tendon, and the other augmentation suture is applied posterior to the initial suture. (3) After the surface of the footprint at the greater tuberosity has been decorticated, suture anchors are inserted into the bone. Two anchors with 4 sutures in total are used. The sutures of the anchors are passed through the tendon between the cuff end and the augmentation suture with a suture-passing device. After that, the sutures are tied, and the cuff end is fixed to the footprint by the single-row technique. (4) The augmentation sutures are pulled laterally and inferiorly. At the lateral aspect of the greater tuberosity, approximately 20 mm inferior to the upper edge of the lateral aspect, the augmentation sutures are fixed with a push-in–type anchor.