A Modified SpeedBridge Technique for Retracted or Delaminated Rotator Cuff Repairs

Abstract

Treatment of full-thickness rotator cuff tears vary in surgical technique dependent on the amount of retraction of the rotator cuff and/or delamination of the soft tissue. The described technique addresses both of those concerns. We present a modification of the SpeedBridge technique used to address retracted or delaminated repairs and effectively expand the indications for use of the double-row knotless technique. In this modification, the reduction is performed by an initial anchor with several stay sutures providing provisional reduction of the tissue in a controlled fashion. This is followed by compression through a standard double-row technique.

Risks of the procedure are the increased operative time and the increased number of anchors placed laterally in the greater tuberosity. This could cause potential difficulties in a revision setting where limited bone stock remained for placement of additional fixation. Potential complications are suture cut out in poor quality tissue or overtensioning, which could lead to failure of repair or tissue strangulation. In conclusion, we describe a modification of a well-established technique that allows for controlled provisional reduction of the rotator cuff tissue and for repair of the superior capsule as a separate layer if desired.

Knotless self-reinforcing transosseous equivalent double-row rotator cuff repair with suture tapes, also known as SpeedBridge, is an accepted treatment option for full-thickness rotator cuff tears, with good clinical outcomes reported.1, 2 The technique has some limitations, however. Specifically, reduction is performed during placement of the lateral anchors and can be difficult if there is significant retraction of the rotator cuff tissue. Furthermore, delaminated tissue is repaired en masse and cannot easily be independently tensioned to create an anatomic repair. In our technique, we present a modification of the SpeedBridge technique used to address retracted or delaminated repairs and effectively expand the indications for use of the double-row knotless technique. In this modification, the reduction is performed by an initial anchor with several stay sutures providing provisional reduction of the tissue in a controlled fashion. This is followed by compression through a standard double-row technique.

Surgical Technique

Positioning, Diagnostic Arthroscopy, and Cuff Tear Evaluation

The surgical technique is demonstrated in Video 1. The patient is placed in the beach chair position, and a diagnostic arthroscopy of the shoulder is performed. The rotator cuff is evaluated for tissue quality, retraction, and delamination (Fig 1 A and B; still images, delaminated rotator cuff injury). The amount of excursion of the rotator cuff is determined after full mobilization, release of the rotator interval, and release of the posterior interval as needed (Fig 1 A and B).

Fig 1.

Arthroscopic view (A) and schematic (B) of superior lateral view of delaminated rotator cuff demonstrating separation of the superficial and deep layers in a right shoulder. Superficial layer being composed of supraspinatus tendon, and deep layer consisting of the rotator cuff deep layer and superior capsule.

Portals and Cannulas

Once the decision to proceed with rotator cuff repair is confirmed, portals are created and cannulas are placed (Fig 2; still image, portals and cannulas in) Standard cannulas include a Gemini (Arthrex, Naples, FL) in the lateral portal, 8 mm × 3 mm Passport (Arthrex) in the anterior superior lateral portal, and an 8 mm × 4 mm Passport cannula placed in the posterior lateral portal. Standard posterior and anterior portals provide good trajectories for use of the 90° suture lasso and do not need cannulas, as they are primarily used for suture passing and docking. Cannulas and portals are demonstrated in Figure 2.

Fig 2.

External view from superior, right shoulder, demonstrating arthroscopic portal placement and corresponding cannulas. Anterior is to the right of the image. Passport cannulas are in the posterior lateral and anterior lateral portals and a Gemini cannula is in the lateral portal. Suture is docked in the anterior and posterior portals without cannulas.

Placement of Medial Row Anchors and Passing of Compression Tapes

The articular margin is identified and the decision for number of medial row anchors (2 or 3) is determined based on available area within the torn tendon footprint. In our experience, this is a factor of the size of the tear and the size of the footprint. The first anchor is placed approximately 2 mm lateral to the articular margin, near the anterior margins of the rotator cuff tear (just posterior to the long head of the biceps tendon). A minimum of 5 to 6 mm of intact bone between adjacent anchors in the medial row should be maintained. 4.75 mm Bio-composite, Vented, SwiveLock Anchors (Arthrex) loaded with FiberTape (Arthrex) are used. Use of FiberTape provides a larger surface area for compressive force distribution. Coloring of the awl with a surgical marker can aid in locating the anchor sites. A tap is occasionally used if the bone quality is especially dense. After placement of each anchor, a 90°SutureLasso (Arthrex) is used to shuttle the FiberTape through the rotator cuff tendon. The aim is to place the SutureLasso through the tissue at a point just lateral to the myotendinous junction and in line with the corresponding anchor. Toggling of the FiberTape during transit through the cuff can help identify and avoid twists or soft-tissue entrapment (Fig 3).

Fig 3.

Schematic superior subacromial view, right shoulder, demonstrating the placement of the anterior (blue) and posterior (red) suture tapes in the medial row of anchors in preparation for a SpeedBridge repair. Suture tape is passed with either a suture passer or scorpion before being anchored.

Placement of Reduction Sutures

Reduction sutures are then placed using a Scorpion Suture Passer through the lateral portal. Visualization is best from the posterior lateral portal for placement of anterior sutures and from the anterior lateral portal for placement of posterior sutures. #2 FiberLink sutures (Arthrex) are used (Fig 4). Efficiency can be increased by placing the arm of the Scorpion through the FiberLink loop before introducing into the shoulder, allowing for automatic cinching when the Scorpion is removed. The number of links required is dependent upon tear morphology and the degree of retraction. When using the Scorpion to cinch these FiberLinks, care should be made not to inadvertently lacerate the suture tapes. At least 3 central reduction sutures approximately 3 mm lateral to the medial row FiberTape sutures are routinely used. During placement, these cinched sutures are docked in the anterior lateral portal.

Fig 4.

Schematic superior subacromial view, right shoulder. Reduction sutures are passed through the cuff along the tear margin using a suture passer, or scorpion and fastened in cinched loops.

Preparation of the Footprint

The greater tuberosity is prepared by removing residual rotator cuff or fibrous tissue. Microfracture of the footprint is performed with a 30° PowerPick (Arthrex) just before lateral row fixation (Fig 5).

Fig 5.

Arthroscopic view, right shoulder subacromial space from anterior superior portal demonstrating a footprint that has been prepared to a smooth surface accompanied by microfracture with a PowerPick (Arthrex) before the reduction sutures are reduced and anchored into place.

Provisional Reduction and Fixation of Reduction Sutures

Fixation of the cuff starts by first anchoring the central reduction sutures. These are retrieved through the lateral cannula. While holding tension on these reduction sutures, the inner cannula of the Gemini retractor can be pushed forward to determine tension and avoid malreduction (Fig 6). Once the location of the reduction anchor is determined, a punch is used for a 4.75 SwiveLock. Again, marking the punch tip with a surgical marker can aid in relocating the precise position after punch removal. The reduction sutures are then loaded into the eyelet of the 4.75 SwiveLock anchor. Sutures are then individually pretensioned before seating and screwing in the anchor (Fig 7). Care should be made not to overtension or undertension these sutures. Overtensioning can lead to bone or tissue cutout near the anchor and compromise tissue/suture security ultimately compromising healing. Undertensioning can result in suboptimal cuff reduction and footprint contact area.

Fig 6.

Schematic (A) and arthroscopic view (B) of anterior superior subacromial view of right shoulder. Reduction sutures are gathered together in the Gemini cannula, allowing for medial reduction of tear margin and individual tensioning before anchoring.

Fig 7.

Schematic of right shoulder, superior subacromial view, showing the positioning of central reduction anchor. Anchor is placed in the humerus at midline to the tear itself between medial and lateral row of suture tapes.

Alternatively, these reduction sutures may be placed only in the inferior leaflet of retracted tissue, which commonly represents the superior capsular tissue. This layer may be then be reduced anatomically to its attachment at the articular margin of the footprint creating an anatomic 2-layered repair in the setting of a delaminated tear.

Fixation of Compression FiberTape Sutures

The remainders of the lateral row anchors are then placed. Starting with the anterior lateral anchor, this includes the FiberTapes from the medial row anchors (blue and purple). The final lateral row anchor includes the last 2 FiberTape sutures. In the case of 3 medial row anchors, 3 lateral row anchors are used. Care should be made when placing these anchors, to avoid skiving in either the anterior or posterior directions. Internal and external rotation of the arm can help with ideal anchor trajectory (which should be directed centrally).

In addition, peripheral reduction cinched FiberLink sutures (not incorporated into the central reduction anchor can be used to augment strength of the repair and to prevent “dog ears” at the peripheral margins of the tear. An example of the completed construct is demonstrated in Figures 8 and 9. Pearls and Pitfalls of the procedure are listed in Table 1.

Fig 8.

Schematic superior subacromial view, right shoulder, demonstrating a suture tape (red) from the posterior medial anchor and a suture tape (blue) from the anterior medial anchor. These are secured to lateral anchors which are demonstrated on the exposed greater tuberosity. Reduction sutures (white), a total of 5 in this example, are placed in the rotator cuff tissue and secured to a central reduction anchor.

Fig 9.

Arthroscopic view of completed construct, posterior lateral view, and right shoulder. In this example, an expanded SpeedBridge is demonstrated with three medial anchors, three central reduction suture links, and three lateral row anchors.

Table 1.

Pearls and Pitfalls

Pearls

• Ensure even spacing of reduction sutures to prevent uneven buckling of the tissue.

• Reduction sutures should be passed closer to the free edge of the tissue than the passage of medial row sutures for the SpeedBridge component of the repair.

• Free sutures can be passed in simple fashion at the far anterior and posterior edges of the repair and secured with the lateral row anchors to prevent dog ear formation.

• FiberLink reduction sutures may be used to reduce the superior capsule or a deep delaminated layer of rotator cuff tissue independently of the more superficial cuff tissue creating a more anatomic repair construct.

Pitfalls

• Uneven placement or tensioning of the reduction sutures may lead to uneven reduction or excess suture material which is not secured appropriately. Direct visualization of the looped sutures passing through the anchor eyelet can prevent this problem.

• Careful planning should be used in noncrescent-type patterns to prevent uneven tensioning and anatomic repair.

• Passing sutures too narrowly can create crowding between the lateral row anchors and the central reduction anchor. Placement of the central reduction anchor slightly more medially can prevent this problem.

• Over-reduction of the tissue with the single central reduction anchor may cause failure of this anchor. Use of a larger 5.5-mm anchor or punching without tapping may reduce the risk of loss of fixation in osteopenia bone.

Discussion

Delaminated and retracted rotator cuff tears are more likely to fail nonoperative management and are more technically challenging to treat arthroscopically.³ Nonetheless, these findings are both common and often concurrent conditions with reported rates as high as 80%.4, 5

Recently, increasing attention has been given to the superior capsule, its function, and its potential role in the pathogenesis of rotator cuff tears.⁶ While repair of both the superior capsule and the rotator cuff tissue leads to superior footprint restoration in biomechanical models, clinical results have not shown a reproducibly significant benefit to repair of both layers.7, 8, 9, 10 This could be due to problems in controlling the tension of the torn superior capsule during repair.

The primary goal of rotator cuff repair is to achieve secure fixation and increased contact pressure with the anatomic footprint site.¹¹ The development of new techniques for rotator cuff repair have revealed an effort toward increased footprint surface contact, leading from the single-row technique to the double-row technique, and from there to the interosseous equivalent, or suture bridge technique.11, 12, 13 A wide variety of modifications have been proposed to these techniques, including the rip-stop suture bridge,¹⁴ the tension-band suture technique,¹⁵ the roman bridge technique,¹⁶ the hybrid technique,¹⁷ and a technique combining a modified SpeedBridge with the double pulley technique.¹⁸ One factor these modifications are not well equipped to address is the tensioning of an inferior layer in a delaminated lesion and “dog earing,” which can arise during repair of a larger or retracted tear.

The primary advantage in the technique is the ability to control tension on the capsule leading to better restoration of the anatomy at the medial edge of the anatomic footprint, or in other cases, to reduce tension provisionally in the setting of a large or massive tear. Instead of reducing tendon tissue en masse, this modification addresses reduction and compression independently using a combination of cinched reduction sutures to reduce the tear medially before placing the compression sutures of a standard modified SpeedBridge.

Risks of the procedure are the increased operative time and the increased number of anchors placed laterally in the greater tuberosity. This could cause potential difficulties in a revision setting where limited bone stock remained for placement of additional fixation. Potential complications are suture cut out in poor quality tissue or overtensioning, which could lead to failure of repair or tissue strangulation.

In conclusion, we describe a modification of a well-established technique that allows for controlled provisional reduction of the rotator cuff tissue and for repair of the superior capsule as a separate layer if desired.

Supplementary Data

Video 1

An example of the surgical technique is demonstrated. Right shoulder, patient in beach chair position, posterior viewing portal.