Hybrid Repair of Large Crescent Rotator Cuff Tears Using a Modified SpeedBridge and Double-Pulley Technique

Abstract

An ideal rotator cuff repair maximizes the tendon-bone interface and has adequate biomechanical strength that can withstand a high level of demand. Arthroscopic transosseous-equivalent rotator cuff repairs have become popular and have been shown to be superior to many other methods of fixation. We present an alternative method of repair for large crescent rotator cuff tears that combines 2 well-known methods of fixation: modified SpeedBridge (Arthrex, Naples, FL) and double-pulley techniques. These 2 repair constructs were combined to provide the greatest amount of compression across the footprint while also providing rigid fixation. Ultimately, this can provide an optimal environment for healing in otherwise significant injuries.

Repairs of the rotator cuff tendons should maximize the tendon-bone interface, anatomically replicate the footprint area, and withstand high loads to failure to prevent gapping and optimize the healing process.¹ Arthroscopic transosseous-equivalent repairs using suture anchors have become popular and were first described by Park et al.² to maximize the footprint contact area, as well as avoid suture passage through the lateral aspect of the degenerated tendon. Such constructs have been shown to have a higher ultimate load to failure compared with other transosseous methods of repair.³ Clinically, transosseous-equivalent repairs were also shown to have a higher tendon healing rate based on ultrasound examination when compared with single-row repairs at 10 months after surgery.⁴ Many single-row and older double-row repair techniques did not achieve enough biomechanical compression and evenly distributed contact area over the majority of the footprint. Arrigoni et al.⁵ described an alternative double-row rotator cuff repair using medial-row anchors with an extracorporeal and static knot, termed the “double-pulley technique,” which was designed to help maximize medial footprint compression.

To address large crescent rotator cuffs, we have developed a modification of the transosseous-equivalent SpeedBridge (Arthrex, Naples, FL) repair and supplemented it with a double-pulley technique to achieve maximal compression across the footprint while adding stability to our repair construct (Video 1). This technique combines existing techniques in an effort to maximize security and tendon compression at the bone-tendon interface. The indications and contraindications for this technique are shown in Table 1.

Table 1.

Indications and Contraindications for Hybrid Rotator Cuff Technique

Indications	Contraindications
Crescent tears	U- or L-shaped tears; massive, immobile tears
>15 to 30 mm anterior-to-posterior tear dimensions	Degenerative tears with significant fatty atrophy of rotator cuff muscles
Adequate medial-to-lateral rotator cuff mobility	Subscapularis tendon tears requiring additional fixation
Medial rotator cuff flaring	Active or recent infections
Revision crescent tear repair	Advanced glenohumeral arthritis

Technique

Operating Room Setup

After induction of anesthesia (interscalene block v general anesthesia), the patient is placed in the lateral decubitus position with the operative extremity abducted to 30° in 10 lb of traction using a lateral traction arm sleeve and shoulder traction tower (Arthrex). All bony prominences are padded, and an axillary roll is placed under the contralateral arm. After standard sterile preparation and draping techniques, the anatomic landmarks are drawn on the shoulder.

Arthroscopic Portal Placement

A standard posterior viewing portal is established, and a diagnostic examination of the glenohumeral joint is performed. After appropriate pathology is managed in the glenohumeral joint, the subacromial space is accessed. A mid-lateral portal is created, and a working cannula is placed. We prefer to use a cannula with a deployable wing (Gemini Cannula; Arthrex) to allow for easy access to the rotator cuff without worrying about cannula instability. A thorough debridement of the subacromial bursa is performed to define the bursal side of the rotator cuff, and all sources of bleeding are coagulated with a radiofrequency ablator.

Surgical Technique

After adequate visualization of the rotator cuff, the anatomy of the tear is defined using both debridement and ablation. The tear is measured in an anterior-to-posterior direction with a measuring probe. A cuff grasper is used to assess the mobility of the cuff tear and manually assess the tension needed for lateral-row fixation (Fig 1). The described technique is best applied to larger (>15 mm to 30 mm) crescent-shaped tears with healthy tendon quality.

Fig 1.

Mobilization of rotator cuff tear. Large crescent rotator cuff tear (top) mobilized to the lateral margin of the greater tuberosity (bottom) with cuff grasper.

Anchor and Stitch Placement for Modified SpeedBridge Construct

The anteromedial and posteromedial margins of the bony footprint are prepared. Two anchors are placed along the medial row, adjacent to the articular margin. We use two 4.75-mm Bio-Composite SwiveLock anchors (Arthrex) loaded with FiberTape (Arthrex) and No. 2 FiberWire (Arthrex). The FiberWire comes as a “stay suture” as part of the anchor construct and will slide through the eyelet of the anchor. A self-retrieving suture passer (FastPass Scorpion; Arthrex) is loaded with either the tape or suture from the anteromedial anchor. This is shuttled through the rotator cuff in an inverted-mattress fashion. The final anterior-to-posterior positions of the suture and tapes are as follows: FiberWire-FiberTape-FiberWire. The tape can be placed first if this is easier, and then the sutures can be placed, 1 anterior and 1 posterior to the tape. This is repeated for the posteromedial anchor. In particular cases of larger tears, in which there may be flaring of the anterior or posterior corners (“dog-ears”), a FiberLink suture (Arthrex) can be placed at the anterior and posterior limbs of the crescent tear to aid in securing the tendon. A self-retrieving suture passer can be used to place the free end of the FiberLink through the dog-ear in an inverted-mattress fashion while the loop end is held in the other hand outside the cannula. A cinch loop can be made by passing the self-retrieved free end through the loop held by the other hand outside the cannula (Fig 2). Great care must be taken during these steps to label and identify the orientation of the sutures and tapes. Of note, the tapes have a single tail and must be released after passage through the tendon to create separate limbs.

Fig 2.

FiberLink dog-ear cinch loop, an optional step to reduce tendon edge flaring during repair. The FiberLink can be incorporated during anterolateral- or posterolateral-row fixation.

Lateral-Row Fixation of Modified SpeedBridge Construct

The bridging construct is created by taking 1 FiberTape limb from each of the medial anchors and loading it into an empty 4.75-mm Bio-Composite SwiveLock anchor. The anchor site is punched at least 1 cm distal to the lateral margin of the footprint and posteriorly on the tuberosity, in line with the posteromedial anchor. Subsequently, this process is repeated anterolaterally to complete the lateral-row fixation. If dog-ear sutures are used, these can be additionally loaded into each lateral-row anchor before fixation (Video 1). During lateral-row anchoring of the repair, it is imperative to make sure that the mattress sutures are not trapped underneath the tapes as they are passed through the cuff and subsequently brought to the lateral margin to be anchored.

Double-Pulley Technique

Next, attention is paid to the free FiberWire sutures, which are used for the double-pulley portion of the repair. Matching positional sutures from the anteromedial and posteromedial anchors are brought out from the mid-lateral portal. The other 2 free suture ends are brought out through the anterior portal. As described by Arrigoni et al.,⁵ an extracorporeal, 6-throw surgeon's knot is tied over a knot-pusher post (Video 1). The 2 free suture ends are then alternately toggled from the anterior portal to shuttle the extracorporeal knot down on the medial row from the mid-lateral portal (Video 1). After the extracorporeal knot has been secured, a static knot is tied with the free ends using a knot pusher.

The final repair construct (Fig 3) will consist of a transosseous-equivalent, knotless double-row construct that is then supplemented with the double-pulley technique to improve medial footprint compression and seal the joint from the footprint. The additional sutures secured to the anterior and posterior corners can reduce cuff edge flaring and be incorporated during lateral-row fixation, if needed. An abbreviated step-by-step summary of the entire technique is shown in Table 2.

Fig 3.

Two views of completed hybrid repair with double pulley overlying medial cuff.

Table 2.

Steps of Hybrid Rotator Cuff Repair (Modified SpeedBridge and Double-Pulley Technique)

1. Perform a thorough subacromial bursal debridement.

2. Assess cuff mobility in a medial-to-lateral direction.

3. Measure the anteroposterior distance of the rotator cuff tear.

4. Place 2 fully loaded (FiberTape and No. 2 FiberWire) 4.75-mm Bio-Composite SwiveLock anchors in the anteromedial and posteromedial rows, adjacent to the articular margin.

5. From anterior to posterior, place the FiberWire-FiberTape-FiberWire in an inverted-mattress fashion using a self-retrieving passer. Do this for the anterior and posterior limbs of the tear. When passing stitches, bring the tape and suture out through the anterior portal to manage the anterolateral-row fixation. Bring the tape and suture from the posterior limb out through the posterior viewing portal to manage posterolateral-row fixation.

6. Place a FiberLink cinch loop if there is cuff tendon flaring (dog-ears) present at the anterior and posterior edges of the rotator cuff tear (optional step).

7. Perform lateral-row modified SpeedBridge fixation.

A. Anterolateral-row fixation with anterior FiberLink (optional): Secure 1 FiberTape from the anteromedial anchor and 1 FiberTape from the posteromedial anchor into the anterolateral margin of the greater tuberosity with a 4.75-mm SwiveLock anchor.

B. Posterolateral-row fixation with posterior FiberLink (optional): Secure 1 FiberTape from the posteromedial anchor and 1 FiberTape from the anteromedial anchor into the posterolateral margin of the greater tuberosity using a 4.75-mm SwiveLock anchor.

8. Perform the double-pulley technique.

A. Bring 1 FiberWire from the anteromedial and posteromedial anchors through the mid-lateral portal. Slide the sutures back and forth to check for any entrapment of the suture underneath the FiberTape used during the SpeedBridge fixation.

B. Tie an extracorporeal knot over the post of the knot pusher with 6 throws of a surgeon's knot. Cut excess FiberWire on top of the knot.

C. Bring the remaining 2 free sutures out together from the anterior portal.

D. Toggle the 2 free sutures back and forth to slide the extracorporeal knot down onto the medial cuff.

E. Tie a static knot with the free suture.

Discussion

Arthroscopic rotator cuff repair can improve functional outcomes in most patients.⁶ Rotator cuff repairs should maximize the contact pressure across the footprint to optimize the environment for repair healing, as well as re-create anatomic stability to withstand the loading forces applied to the shoulder. In a biomechanical study assessing contact pressure, force, and area over time, a transosseous-equivalent repair (double-row suture bridge) was shown to have the highest contact pressure and force compared with other arthroscopic repairs.⁷ Another biomechanical study showed that a transosseous-equivalent suture bridge technique had the same initial fixation strength as a traditional transosseous repair.⁸ In a clinical study of 154 patients who underwent transosseous-equivalent repairs with a double-row suture bridge construct, the patients showed significant improvements in range of motion and subjective outcomes at a mean of 15 months' clinical follow-up.⁹

The described technique combines 2 techniques previously described: a knotless transosseous-equivalent repair (modified SpeedBridge) and a knotted double-pulley technique. The advantages of our repair include compression across the medial and lateral aspects of the footprint. In large crescent rotator cuff tears (anteroposterior measurement of approximately 15 to 30 mm), using this repair construct can maximize the contact pressure and area across the footprint and increase the overall mechanical strength with the addition of the double-pulley fixation. This repair can, in theory, seal the joint space from the repair site and minimize synovial fluid interposition at the bone-tendon interface where healing is desired. All these factors can help facilitate an optimal environment for healing.

The disadvantages of this repair include that it can be technically challenging. It requires meticulous placement of sutures and vigilance toward the orientation of the tapes and sutures to correctly anchor the SpeedBridge construct along the lateral margin. When the surgeon is securing the double-pulley repair, the suture ends must be free and located on top of the tapes or they will not be able to slide, preventing the surgeon from accomplishing the second stage of this hybrid repair. The key technical pearls and pitfalls are summarized in Table 3.

Table 3.

Pearls and Pitfalls

Pearls	Pitfalls
A thorough subacromial bursal debridement is necessary to clearly define the tear and allow for easier placement of suture and tape through the rotator cuff.	Vigilant suture and tape management is necessary throughout the case. If a thorough debridement is not performed, the suture and tape are more prone to become stuck in the soft tissues.
If the self-retrieving suture passer has difficulty passing either the suture or tape through thickened tendon on the anterior or posterior margins of the tendon, a tissue penetrator or suture lasso may need to be used.	After passing the tape, the surgeon must be sure to cut the end to free the 2 limbs that will be used for the bridging construct.
Additional fixation for anterior or posterior tendon flaring (dog-ears) can be managed with a FiberLink cinch loop.	When the surgeon is securing the lateral-row anchors, the sutures must be above the tape limbs to ensure that they are free to slide during the double-pulley step.

Overall, we believe that our repair provides an alternative method of repair that combines 2 well-known techniques to facilitate maximal compression across the footprint and, most importantly, allows the best possibility of improving the healing environment in patients with rotator cuff tears. Further studies are under way to assess the biomechanical characteristics of this repair, to quantify the medial joint sealing of the footprint from synovial fluid, and to determine any clinical advantage of this technique over other methods of double-row rotator cuff tear repair.

Supplementary Data

Video 1

Hybrid repair for large crescent tears of rotator cuff using 2 well-known techniques: modified SpeedBridge and double-pulley techniques.