Authors:
Gilberto A. Herrera H. MD,
Paulo J. Llinás H. MD,
Gustavo A. Gil N. MD.*
Corresponding author.: E-mail: gustavo.gil@fvl.org.co
* The main author declares no conflict of interest for this article
INTRODUCTION
Massive, traumatic rotator cuff tears present a challenges in shoulder surgery due to its high re-tear rates (1). Traditional single-row repair techniques, although effective, have shown limitations in achieving optimal tendon-to-bone healing and biomechanical stability. Double-row repair techniques have emerged as an alternative, aimed at improving tendon healing by increasing the contact area and providing greater mechanical stability.
DESCRIPTION OF THE TECHNIQUE
After dealing with the biceps and subscapularis tendon, the postero-superior rotator cuff tear is evaluated, revealing a large, potentially massive tear depending on definitions, but deemed not massive due to minimal retraction and lack of fatty infiltration. A double-row repair is chosen for optimal fixation and tendon-to-bone contact pressure. The first step involves debriding the greater tuberosity footprint using a shaver. Two all-suture, triple-loaded anchors are then placed, one at the anterior border and the other at the posterior border of the footprint. Using a suture passer, sutures are passed through the tendon from anterior to posterior in a mattress configuration. Given the posterior location, multiple instruments may be required for this step. The sutures are then knotted to approximate the tendon to the tuberosity, and the knotted sutures are retrieved through a cannula.
The second row aims to cross sutures over the tendon, enhancing tissue-bone contact pressure. The lateral cortex of the humerus is identified at the end of the footprint, and insertion points for anterior and posterior knotless anchors are determined. Sutures from each mattress knot are retrieved and secured to the first anchor at the posterior border, followed by securing remaining sutures to the anterior border with a second knotless anchor. Sutures are pulled individually to ensure even tensioning before anchor positioning is completed with screws.
The final construct shows sutures crossing over the tendon, providing adequate contact and tension, ensuring a robust and reliable repair. The goal is to maintain tendon integrity and promote healing by maximizing tissue-bone contact and stability.
RESULTS
Studies have demonstrated that double-row repair techniques result in superior clinical outcomes compared to single-row methods, particularly in large and massive tears. Randomized controlled trials reported that patients undergoing double-row repairs experienced significant improvements in pain reduction and functional scores in the setting of >3cms tears. (2) Biomechanical studies have consistently shown that double-row repairs offer enhanced stability, leading to better structural integrity and lower re-tear rates (3)(4). For instance, Sugaya et al found that double-row repairs resulted in a higher rate of tendon healing, as evidenced by MRI assessments (5). Similarly, Lafosse et al observed that patients with intact double-row repairs had better postoperative strength and range of motion (6). Clinical scores, such as the Constant score and the American Shoulder and Elbow Surgeons (ASES) score, were significantly higher in patients treated with double-row techniques, indicating improved shoulder function and patient satisfaction (7,8)
DISCUSSION
The double-row repair technique for massive rotator cuff tears provides significant advantages in terms of biomechanical stability and clinical outcomes. By distributing forces across a larger footprint, double-row repairs reduce the risk of re-tear and enhance tendon healing. This technique is particularly beneficial for large and massive tears, where traditional single-row repairs may not provide sufficient stability. The superior biomechanical properties of double-row repairs, including increased load to failure and reduced gap formation, contribute to improved functional outcomes and patient satisfaction. However, double-row techniques are more technically demanding and may require longer surgical times and higher costs. Despite these challenges, the long-term benefits of reduced re-tear rates and better functional recovery make double-row repairs a preferable option for managing massive, traumatic rotator cuff tears.
REFERENCIAS
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