Abstract
Although open transosseous repair was historically used as a gold-standard surgical solution for rotator cuff tears, this procedure was largely replaced by anchor-based techniques because of the advancement of arthroscopic surgery. However, the ability of anchor-based repair to achieve similar biomechanical fixation remains uncertain. Despite the proposals of numerous methods over the last decade, there remains demand for a standard, reliable technique that integrates the biomechanical advantages of transosseous fixation within the realm of arthroscopy. We describe a technique for transosseous rotator cuff repair using the Omnicuff, a needle-based transosseous suture-passing device that minimizes the risk of failure of suture passage between the bone tunnels. With potential advantages of this design including automated-assisted suture passage, improved bone-tendon healing, and anchorless fixation, surgeons may be inclined to consider these biomechanical and cost-saving benefits. Future studies are warranted to determine clinical outcomes of this technique and its suitability for tears of varying degrees and patterns.
Rotator cuff injury is a common cause of shoulder pain in people of all age groups, and its prevalence in cadaveric studies ranges from 5% to 40% of the population.1 In 1944, McLaughlin2 was the first to describe a transosseous rotator cuff repair, and this technique was considered the gold standard for repair of rotator cuff lesions until the end of the last century. The transosseous technique provided good clinical and biomechanical results but, for a long time, was feasible only with the open approach and, with the evolution of arthroscopic techniques, was replaced with arthroscopic suture anchor repair3
Suture anchor repair techniques have evolved from single-row to double-row to transosseous-equivalent repair in an attempt to improve the biomechanical properties of the repair.4 Nevertheless, a systematic review of 40 cadaveric studies evaluating the biomechanical properties of rotator cuff repairs in various constructs found no significant differences among single-row anchored, double-row anchored, transosseous equivalent, and transosseous repairs.5
Recently, new methods for arthroscopic transosseous repair have been developed.6,7 These techniques have been found to offer several potential advantages on anchor repair, including broad footprint coverage with no foreign body at the footprint area, lower risk of rotator cuff failure at the musculotendinous junction (type 2 failure),5 lower risk of type III Sugaya magnetic resonance imaging readings (insufficient thickness after repair),8 improved blood flow at the bone-tendon interface,9 and decreased pain with similar functional outcomes.10
Because arthroscopic transosseous technique usually requires manual passage of suture through intersecting bone tunnels, it can be more technically challenging than anchor-based repair.11 We describe a technique for transosseous rotator cuff repair using the Omnicuff (Mininvasive Ltd., Magal, Israel), a needle-based transosseous suture-passing device that minimizes the risk of failure of suture passage between the bone tunnels (Table 1).
Table 1.
Pearls and Pitfalls
| Pearls |
| The lateral portal should be placed 4 cm inferior to the lateral aspect of the acromion, 1-2 cm inferior to the commonly used lateral portal. |
| Perform adequate bursal debridement lateral to the greater tuberosity to allow visualization of the lateral cortex entry point. |
| Externally and internally rotate the arm in order to allow adequate space between bone tunnels. |
| Attach the sutures exiting the lateral cortex to the drapes to avoid suture unloading from tunnel during suture passage. |
| Pitfalls |
| Make sure the edge of the needle is in the prepunctured hole while drilling the lateral tunnel. |
| In case of severely osteoporotic bone, it is recommended to use suture tapes. |
| Use different color sutures to ease suture management. |
| If performing an X-box configuration, part of the knots can be made extra-articularly. |
Surgical Technique
The procedure can be performed with patients in both beach chair and lateral decubitus positions. A standard diagnostic arthroscopy of the glenohumeral joint is performed by use of a posterior viewing portal and an anterior portal through the rotator cuff interval lateral to the coracoid process. Once all glenohumeral joint pathology is evaluated and addressed, the arthroscope is introduced into the subacromial space. A 6-mm–long lateral portal is placed 4 cm inferior to the lateral aspect of the acromion, 1-2 cm inferior to the commonly used lateral portal (Fig 1). A thorough debridement of the subacromial bursa is performed. Subacromial decompression and lateral clavicular excision are performed if there is a clinical indication or intraoperative signs of impingement. The rotator cuff tear is identified, and soft tissue release is carried out as necessary for tissue mobilization. The rotator cuff footprint is then debrided.
Fig 1.
Clinical image of a right shoulder fully prepared and draped for an arthroscopic procedure. Patient is seated in a beach-chair position, and the shoulder is marked appropriately. The surgeon is creating a standard posterior viewing portal (white arrow), and a lower lateral portal for the use of the omnicuff is marked (black arrow).
At this stage the surgeon decides whether to use 1, 2, or 3 tunnels to repair the cuff according to the tear size and pattern. An accessory lateral portal is created off the anterolateral edge of the acromion, through which a dedicated punch is introduced to the shoulder, and the entry point of the transosseous tunnel location is marked on the medial aspect of the footprint. To create a pilot hole, use a mallet to tap the punch through the bone surface to the laser line on the punch (Fig 2). A drill bit adapter is attached to a surgical power drill, locking the adapter within the drill chuck. A drill bit is introduced into the working channel port in the Omnicuff device until a palpable indication of drill bit retention is felt.
Fig 2.
Diagram (A), clinical image (B), and intra-articular image viewed through a posterior portal (C) of a right shoulder of patient in beach chair position. The figure shows a mallet (black arrow) being applied to tap a punch tool (red arrow) through the bone surface to create a pilot hole (blue arrow).
The Omnicuff device is introduced through the lateral portal and approximated to the lateral cortex of the superior aspect of the greater tuberosity (Video 1). The lever of the device handle is squeezed twice to expose 6 mm of the needle from within the shaft. The exposed needle is introduced into the pilot hole, and the handle is lowered until the curved aspect of the shaft is nestled against the lateral cortex of the greater tuberosity. At this stage abduction and internal or external rotation might be needed to optimize the approximation of the device to the bone (Fig 3).
Fig 3.
Diagram (A), clinical image (B) and intra-articular image viewed through a posterior portal (C) of a right shoulder of patient in a beach chair position. The Omnicuff device (black arrow) is introduced through the lateral portal and approximated to the lateral cortex of the superior aspect of the greater tuberosity (red arrow) following shoulder manipulation.
While maintaining the needle in the pilot hole, a lateral bone tunnel is created using a surgical power drill by advancing the drill bit through the device. The drill bit is retracted from within the handle leaving a metal sleeve in the bone that creates a stable construct that prevents movements that might cause mismatch of the tunnels and failure of suture passing. A dedicated cartridge with a protected nitinol loop at its tip is introduced through the working channel (Fig 4).
Fig 4.
Diagram a right shoulder of a patient in a beach chair position, showing nitinol loop at its tip (black arrow) as it is introduced through the working channel (i.e. lateral tunnel) that was created using a surgical power drill advanced through Omnicuff.
The lever is slowly and repeatedly squeezed until the state Indicator on the top of the device's handle reaches its forward-most mark and the cartridge releases. When the cartridge releases, the nitinol wire at the end of the cartridge has been caught by the needle (Fig 5).
Fig 5.
Diagram (A) and intra-articular image viewed through a posterior portal (B) of a right shoulder of a patient in beach chair position. The images show the nitinol wire (black arrow) at the end of the cartridge being caught by the needle (red arrow) in preparation of being pulled all the way through the bone tunnel and out through the anterior portal.
The handle's direction is switched to the “down” position, and the lever arm is slowly and repeatedly squeezed until the state indicator on the top of the handle returns all the way to its initial position. The device is then withdrawn from the shoulder, leaving a nitinol wire loop that passed through the bone tunnel (Fig 6) that is used to shuttle up to five no. 2 sutures or three no. 2 suture tapes (Fig 7). Additional tunnels can be created in a similar fashion at this stage according to clinical need.
Fig 6.
Diagram (A), clinical image (B), and intra-articular image viewed through a posterior portal (C) of a right shoulder of patient in a beach chair position. The Omnicuff device is being withdrawn from the shoulder leaving a nitinol wire loop (red arrows) that passed through the bone tunnel, with one end exiting the lateral portal and the other end exiting the anterior portal, now both accessible by hand once the Omnicuff has been removed.
Fig 7.
Diagram (A) and clinical image (B) of a right shoulder of patient in a beach chair position. The diagram shows sutures (red arrows) passed through the wire loop (black arrow) in preparation to be passed through the bone tunnels, and the clinical image shows the sutures being passed through the bone tunnels by pulling the nitinol wire loop.
Sutures from the medial aspect of the tunnel are now passed through the cuff with dedicated devices (Figs 8 and 9) before tying the sutures to approximate the tendon to bone (Fig 10). The rotator cuff repair can be completed in various configurations (Fig 11), according to the tear pattern, size, and surgeon's preference.
Fig 8.
Diagram (A) and intra-articular image (B) viewed through the posterior portal of a right shoulder of patient in a beach chair position. The diagram illustrates a transtendinous needle (red arrow) inserted through the rotator cuff (black arrows) to pass the suture (blue arrows) through the tendon. The arthroscopic image shows a lasso-loop (red arrow) inserted through the tendon to retrieve the suture. Either technique may be used for this procedure.
Fig 9.
Intra-articular image viewed through the posterior portal of a right shoulder of patient in a beach chair position. The image shows all strands of suture (red arrows) that have been passed through the rotator cuff (black arrow) exiting through the secondary portal in preparation for suture tying.
Fig 10.
Diagram (A) and intra-articular image (B) viewed through the posterior portal of a right shoulder of patient in a beach chair position. The diagram shows a completed sliding knot followed by alternating half-hitches (red arrow) completed with application of the knot pusher (black arrow) to secure the tendon to its footprint. The intra-articular image shows the rotator cuff well-approximated with a secure knot.
Fig 11.
Diagram (A) and intra-articular image (B) of the completed repair viewed through the posterior portal of a right shoulder of patient in a beach chair position. The diagram shows the rotator cuff secured with three simple sutures (red circle) while the intra-articular image shows four simple sutures. An additional diagram (C) shows the tendon secured using an x-box technique (blue circle), which is also an appropriate method for fixation.
Discussion
We present a technique for transosseous arthroscopic rotator cuff repair using the Omnicuff, a device that uses a needle-retrieved wire loop to provide the surgeon with a more-efficient suture-passing method to set up the transosseous fixation. Although historically the gold standard for rotator cuff repair was performed as an open procedure with transosseous fixation by use of a needle or other curved device to pass the suture through the bone, anchor-based repair (i.e. single-row and double-row) grew in popularity with the expansion of arthroscopy. However, despite decades of strong clinical outcomes and a reproducible technique, anchor-based repair may still be limited in comparison to transosseous fixation. Biomechanical studies have demonstrated that arthroscopically placed anchors may be unable to replicate the same repair site integrity as the transosseous repair,4,5,9 and Randelli et al.10 showed in a prospective fashion that arthroscopic transosseous repair resulted in decreased postoperative pain. As a result, there is demand for standard, reliable, and practical arthroscopic transosseous techniques that enable surgeons to achieve better fixation and potentially better outcomes.
Multiple techniques have been described that aim to restore the biomechanical advantages of the transosseous technique in a completely arthroscopic fashion. Cicak et al.6 offered one of the first proposals in 2006, and since then several variations have attempted to create a standardized method. Garofalo et al.12 described a novel technique involving a 2-step process to recreate intersecting tunnels followed by manual suture passage. Kuroda et al.13 reported good clinical outcomes of arthroscopic transosseous repair with a single tunnel, which increased the appeal of this technique. Murphy et al.14 more recently also described transosseous repair with intersecting tunnels, but with an anchor used for fixation. The technique we describe offers an alternative approach that reduces the anchor burden even further by achieving fixation without implanted hardware while maintaining the surgical advantages of automated-assisted, needle-based suture passing through the bone.
There are several potential advantages of this technique to consider (Table 2). First, as mentioned, the suture-passing method is forgiving and versatile, which reduces the technical challenges traditionally associated with currently available arthroscopic transosseous devices. Additionally, the pure transosseous nature of the repair restores all of the biomechanical advantages associated with a more direct tendon-to-bone compression vector, leading to improved fixation and healing, broad footprint coverage with no foreign body at the footprint area, lower risk of rotator cuff failure at the musculotendinous junction (type 2 failure),5 lower risk of type III Sugaya magnetic resonance imaging readings (insufficient thickness after repair),8 improved blood flow at the bone-tendon interface9 and decreased pain with similar functional outcomes10 while reducing the risk of anchor dislodgement and overstuffing of the tuberosity in revision cases.
Table 2.
Advantages and Disadvantages
| Advantages |
| Enhanced vascularity at footprint |
| Less postoperative pain |
| No implant in rotator cuff footprint in revision settings |
| No foreign body at the footprint area |
| Biomechanical advantages of transosseous repair |
| Less musculotendinous junction failure |
| Fewer MRI findings of insufficient thickness after repair |
| Disadvantages |
| Learning curve linked to new device |
| Clinical outcomes currently limited |
| Potentially limited use in osteoporotic bone |
| Suture tying the medial row not recommended |
MRI, magnetic resonance imaging.
Although this procedure is appealing in its ability to achieve transosseous rotator cuff repair, it is not without limitations. An important consideration is that, unlike transosseous-equivalent repair, a suture-bridging technique using the medial row is not recommended in transosseous repair. This medial row technique has been described as advantageous to prevent “medial cuff failure” but may also lead to strangulation and quick necrosis of the cuff tendon.15, 16, 17 Additionally, transosseous anchorless repair has had limited described use in osteoporotic bone because of the risk of suture pull-out through the tunnels.18 Recently, however, Shi et al.19 have shown that using 2-mm suture tape instead of no. 2 sutures may improve the feasibility of transosseous repairs in an aging osteoporotic population. As with any new procedure, there is also a learning curve to consider for new users, and so training, guided assistance, or both may be needed to improve familiarity and comfort with the device, although the automated suture passage through the bone shortens the learning curve. Last, one of the main limitations is lack of reported clinical outcomes. Nevertheless transosseous repairs in general have demonstrated low re-tear rates, excellent function scores, and minimal complications.
In summary, this technique offers an anchorless alternative to achieve transosseous rotator cuff repair designed. Given the potential biomechanical and clinical benefits of transosseous fixation, it is an approach to consider for rotator cuff tears of all sizes and severity.
Footnotes
The authors report the following potential conflicts of interest or sources of funding: E.A. is a board member and consultant and receives royalties for Mininvasive Ltd. J.A.A. is a board member and consultant and receives royalties for Mininvasive Ltd. Full ICMJE author disclosure forms are available for this article online, as supplementary material.
Supplementary Data
We use standard arthroscopic portals to set up the procedure with the patient in the beach chair position. We typically identify the tear pattern and proceed to clean the greater tuberosity to prepare for insertion of our instrumentation for creating a transosseous bone tunnel. Here you can see us inserting our inserter needle attached to the gun, which allows us to insert the needle into the transosseous hole and the drill to make a bone tunnel across the tuberosity. Once the bone tunnel is made, we use a nitinol wire through a cartridge that is passed and captured by the needle in a predictable fashion. That nitinol wire is then retrieved out of the portal site. Once the wire is removed from the portal, there is now a wire transverse to the tuberosity, and that wire is loaded with suture. Various combinations of suture can be used, including heavy suture and various types of tape. Once the suture is passed through the bone tunnel, one portion is brought out anteriorly to maintain orientation of the sutures. Just as with any other repair, meticulous repair technique is important for execution of suture passage. I use a lasso technique to pass my suture, whereas others may use transtendinous needles. As we sequentially pass our sutures, the tear pattern becomes evident, and sutures are seen exiting the posterior portal. Then we sequentially retrieve our sutures, one from above the tendon and one from our bone tunnel on the lateral aspect of the greater tuberosity. Then we proceed to tie out sutures. I use half-hitch suture passage to tie the tendon back to the bone. As we start to the reduce the tear and reapproximate it to the bone and lock our suture, we pass our alternating half-hitches. We then cut the suture and do this over until we are finished with all our sutures we want to use. Anywhere between 1 to 4 tunnels can be used, depending on the size of the tear, size of the tuberosity, and suture configuration of choice. The finished product is a true transosseous repair of a rotator cuff tear well-approximated.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
We use standard arthroscopic portals to set up the procedure with the patient in the beach chair position. We typically identify the tear pattern and proceed to clean the greater tuberosity to prepare for insertion of our instrumentation for creating a transosseous bone tunnel. Here you can see us inserting our inserter needle attached to the gun, which allows us to insert the needle into the transosseous hole and the drill to make a bone tunnel across the tuberosity. Once the bone tunnel is made, we use a nitinol wire through a cartridge that is passed and captured by the needle in a predictable fashion. That nitinol wire is then retrieved out of the portal site. Once the wire is removed from the portal, there is now a wire transverse to the tuberosity, and that wire is loaded with suture. Various combinations of suture can be used, including heavy suture and various types of tape. Once the suture is passed through the bone tunnel, one portion is brought out anteriorly to maintain orientation of the sutures. Just as with any other repair, meticulous repair technique is important for execution of suture passage. I use a lasso technique to pass my suture, whereas others may use transtendinous needles. As we sequentially pass our sutures, the tear pattern becomes evident, and sutures are seen exiting the posterior portal. Then we sequentially retrieve our sutures, one from above the tendon and one from our bone tunnel on the lateral aspect of the greater tuberosity. Then we proceed to tie out sutures. I use half-hitch suture passage to tie the tendon back to the bone. As we start to the reduce the tear and reapproximate it to the bone and lock our suture, we pass our alternating half-hitches. We then cut the suture and do this over until we are finished with all our sutures we want to use. Anywhere between 1 to 4 tunnels can be used, depending on the size of the tear, size of the tuberosity, and suture configuration of choice. The finished product is a true transosseous repair of a rotator cuff tear well-approximated.