Double Row Knotted "Trident": 1 Suture Technique for Superior to Posterosuperior Small Cuff Tear

Abstract

Many arthroscopy suture techniques have been described for small rotator cuff tears, but there is no consensus. The aim of this study is to describe a double-row knot technique, which we call a “trident point,” for the superior and posterosuperior small cuff tear that is easily reproducible and has a fast learning curve. This knot takes into account the excess of tendon tissue on the foot print after a cuff suture, called a “dog-ear deformity.” However clinical, ultrasound, and biomechanical evaluation with follow-up remains necessary to validate the sustainability of this arthroscopy technique.

Technique Video

Video 1

The trident double row knotted technic for a small posterosuperior cuff tear repair in a left shoulder in beach chair position is shown, with narration.

Cuff tear surgery has evolved in recent decades from a classical open approach to arthroscopy. The quality of a rotator cuff repair depends on both the strength of the anchorage and the tendon-bone contact, which ensures good healing.¹

The aim of repairing rotator cuff tear (RCT) is to restore the normal anatomy of the footprint. Even though many suture techniques have been described, none has shown clinical superiority so far.²

The evolution of these surgical techniques, the new imaging technologies, and the aging of the population lead surgeons of the shoulder to operate on more and more small ruptures.

For superior posterosuperior small (<1.5 cm) cuff tears, the double-row knotted “trident” technique is reliable and easily reproducible and requires the establishment of only two anchors.

Surgical Technique

Preoperative Evaluation

A medical-surgical history, a complete clinical examination with an evaluation of the range of motion, a testing of the cuff are performed.

A classic imaging assessment including plain radiographs (face 3 rotations and Lamy’s profile). Magnetic resonance imaging or injected computed tomography scanning is performed to analyze more precisely the cuff tear and to evaluate muscular atrophy and fatty infiltration using the Goutallier classification. A fatty infiltration >2 of the Goutallier classification, tear >1.5 cm in length or width are contraindications for the “trident” suture.

Anesthesia and Patient Positioning

An interscalene block is performed. After induction of general anesthesia, the patient is placed in the beach chair position. The affected arm is flexed 30° to 40° and placed in neutral rotation. Longitudinal traction (3-4 kg) is used (Fig 1).

Fig 1.

The patient is placed in the beach chair position. The right arm is flexed at 30° with longitudinal traction.

Standard Portal Placement

The acromion, coracoid, acromioclavicular joint, coracoacromial ligament, and the different portals are marked (Fig 2). First, an entry mark by the soft point allows an intra-articular look to evaluate the different lesions. An anterior pathway in the rotator interval is created using the "outside-in technique" (the locating of the interval by a 14-gauge needle), and, if necessary, tenotomy or tenodesis of the long biceps is performed. The arthroscope is removed from the glenohumeral joint to the subacromial space by the soft point to perform an enlarged bursectomy and visualize the rupture with an extra articular view. An anterolateral portal is performed at the anterior border of the acromion, 2 fingertips away from the anterior portal, after locating the RCP with a needle. A third lateral portal is done, to obtain a good triangulation. A bursectomy is performed with an electrocautery system ± associated with debridement, using a 4-mm shaver cuff. The section of the coracoacromial ligament is practiced with an electrocautery system. A complete debridement of any tissues preventing the good visualization and the good mobilization of the rupture must be performed, as well as a total excision of the subacromial bursa.

Fig 2.

The acromion, coracoid, acromioclavicular joint, coracoacromial ligament, and portals are drawn on this right shoulder before the beginning of the surgery. (A, soft point; B, lateral; C, anterior lateral; D, rotator interval).

Suture Technique

Pearls and pitfalls of the trident technique are summarized in Table 1. The procedure is performed with a 30 ° arthroscope, after intra- and extra-articular analysis of the RCT. The preparation of the footprint is done with the arthroscope in lateral portal. The electrocautery system and the shaver are positioned in the anterolateral portal (Fig 3).

Table 1.

Pearls and Pitfalls

Pearls

For best visualization, use the midlateral portal as the primary viewing portal.

Use the anterolateral portal as the primary working portal, and anterior and posterior (i.e., soft point), for suture management.

If it possible, use a blue suture as anterior and posterior suture, easier to fine in the bursa.

Perform an acromioplasty to improve the space needed for repair.

Perform a large bursectomy to clearly see and understand the rupture.

Pitfalls

Failure to remove all the soft tissue and the bursa will impede visualization and increase surgical time.

This technique must be used only for small rupture. In case of medium to large rupture, a 2-anchor technique is better for apply the rotator cuff on the footprint.

There may be a learning curve if prior practice has been limited to viewing the rotator cuff from posterior portal.

Fig 3.

Intraoperative arthroscopic image of the left shoulder in beach chair position in lateral view portal in the sub acromial space after the bursectomy. Abrasion of the footprint (star) with the shaver after having spotted the tear. (A, anterior; P, posterior).

Debridement and abrasion with the shaver of the foot print at the cartilage-bone junction allow the setting in place of an anchor in the center the rupture in the axis of the anatomic neck (Y-knot RC all-suture anchor; ConMed, Largo, FL; Fig 4). The size of the anchor (max 15 × 15 mm) and the reparability are previously evaluated using a clamp. Of note is that most rotator cuff suture anchors can be used for this technique.

Fig 4.

Intraoperative arthroscopic image of the left shoulder in beach chair position in lateral view portal in the subacromial space showing the placement of the first anchor (4 strands) at the cartilage-bone junction (arrow). (A, anterior; P, posterior).

Two different sutures are passed on each side of the tear using a Spectrum ™ type wire hook (Video 1). This ensures a “soft tissue friendly” technique for the rotator cuff, because it preserves the blood supply for healing (Fig 5).

Fig 5.

Intraoperative arthroscopic image of the left shoulder in beach chair position in lateral view portal in the sub acromial space showing the passage of two strands over the anterior part of the tear. (A, anterior; P, posterior).

We tie the U-shaped center point with a Nicky's knot. The four strands are retrieved by the anterolateral path. A punched hole with a mallet 2 cm away from the upper edge of the trochiter and in the vertical axis of the first anchor is made to set up a BioComposite SwiveLockC anchor, closed eyelet 4.75 (Arthrex), to obtain a double row (Fig 6).

Fig 6.

Intraoperative arthroscopic image of the left shoulder in beach chair position in lateral view portal in the sub acromial space showing final assembly, after placing the second row, with a U-shaped center point (star) and the two strands knotless making a trident shape. (A, anterior; P, posterior).

The central knot provides a good fixation of the RCT on the footprint, and the lateral suture fixes the dog-ear deformity and increases tendon-bone contact (Fig 7).

Fig 7.

Drawing summarize the stages of the trident point. A, Schema of a posterosuperior rotator cuff tear. B, Schema showing the positioning of the anchor and the passage of the strands each side of the cuff. C, Layout of the trident point with the second row.

Postoperative Rehabilitation

The patient is immobilized in an antalgic sling for about 10 days. The protocol of 5 times/5 minutes a day self–re-education begins at day 3 to 5 after surgery, in association with physiotherapy. The mobilization of the shoulder is possible for the gestures of daily living without pain. The focus is based on relaxation, with the goal of a free range of motion of the shoulder at 3 months and activities in force at 6 months.

Discussion

Several biomechanical studies have shown that the double row allows better coverage of the footprint after rotator cuff surgery.^3,4 Clinical studies and review show no significant difference between single and double row.^5,6

As far as the double row is concerned, several techniques have been described, including the “suture bridge” technique, which crosses the suture limb of the second row, allowing a more anatomical reapplication of the cuff on the footprint. From an anatomic point of view, the vascularization of the tendon is medial to lateral, making this technique risky in terms of possible vascular complications.⁷

The Trident double row technique, detailed in this article, provides many advantages, especially on the healing potential of the cuff (Table 2).

Table 2.

Advantages and Risks or Limitations

Advantages

Linearly oriented suture limbs do not cross radial blood supply of rotator cuff

Allows a good correction of dogear deformities

Trident technique using in the same time a knot-tying and knotless structure

Failure of the lateral-row anchor will not cause failure of entire construct

Risks or Limitations

No biomechanical data are available for this particular technique

Available only for small tear of superior and posterosuperior rotator cuff tear

Managing the excess of tendon tissue after a cuff suture, called the “dog-ear deformity,” has been a real challenge for years.

Redler et al.⁸ showed that reducing these ears creates a favorable biodynamic and organic environment, by preventing the escaping of synovial fluid from inhibiting the healing of the tendon. In this Technical Note, the authors consider that these deformities were frequent and more important for small tears and that the passage of a single point is the first step necessary to reduce these ears to restore a more anatomic footprint.

The knotted double-row technique is a technique that is easy with a fast learning curve and high reproducibility. Its cost is low, and it only requires two anchors with no additional instrumentation. In this technique, only one knot is knotted, leading to a shortening of the surgical time.

Conclusion

The double-row "trident" technique has several advantages in the management of superior-to-posterosuperior small ruptures with an optimal reduction, while limiting the cost and the duration of the procedure.

Supplementary Data

Video 1

The trident double row knotted technic for a small posterosuperior cuff tear repair in a left shoulder in beach chair position is shown, with narration.