Advertisement

Arthroscopic Anchorless Transosseous Rotator Cuff Repair Produces Equivalent Clinical Outcomes and Imaging Results as a Standard Suture Bridge Technique with Anchors

Open AccessPublished:October 31, 2022DOI:https://doi.org/10.1016/j.asmr.2022.09.002

      Purpose

      To compare the clinical and imaging outcome of arthroscopic transosseous (TO)-equivalent rotator cuff repair (RCR) with anchors with arthroscopic anchorless TO RCR at a minimum of 2 years postoperatively.

      Methods

      The study population included patients who underwent RCR using either an anchorless TO technique with a TO suture passing device (group A) and those who were matched for tear size and underwent RCR using suture anchors for repair (group B). The inclusion criterion was an easily reducible rotator cuff tear with a sagittal extension of 2 to 4 cm. After a minimum of 2 years, clinical outcome scores and magnetic resonance imaging were obtained. Tendon quality and footprint integration were evaluated using the Sugaya classification.

      Results

      Seventy patients were included. A total of 45 were in group A and 25 were in group B. Group A had 2 bone tunnels and 4 sutures using an X-box configuration, and group B had a suture bridge construct of 4 anchors. Group A and B had identical anteroposterior tear size and were comparable for age. The Constant score improved from 50 ± 17.4 to 88 ± 8.6 in group A versus 48 ± 14.5 to 87 ± 7.2 in B. The Subjective Shoulder Value rose from 47 ± 19.1 to 95 ± 7.4 in group A vs from 47 ± 19.4 to 95 ± 7.6 in B. Neither the preoperative (P ≥ .502) nor postoperative scores (P ≥ .29) showed a significant difference. Magnetic resonance imaging showed 2 small retears in group A and one in B, resulting in an identical 4% retear rate. The mean Sugaya type was 2.02 versus 2.24 (P = .206) for groups A versus B.

      Conclusions

      Anchorless TO RCR is a valid alternative to suture anchor techniques. Clinical outcome data showed comparable results for both techniques after a follow-up of 2 years. The healing results as observed on magnetic resonance imaging were also equivalent for both groups.

      Level of Evidence

      Level III, retrospective comparative study.
      Historically, the gold standard of rotator cuff repair (RCR) has been open repair with transosseous (TO) sutures compressing the cuff to the bony footprint. This technique has proved to demonstrate convincing biomechanical properties
      • Apreleva M.
      • Ozbaydar M.
      • Fitzgibbons P.G.
      • Warner J.J.
      Rotator cuff tears: The effect of the reconstruction method on three-dimensional repair site area.
      ,
      • Park M.C.
      • Cadet E.R.
      • Levine W.N.
      • Bigliani L.U.
      • Ahmad C.S.
      Tendon-to-bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques.
      and to produce reliable healing results. In search of arthroscopic options, anchor fixation progressively emerged as the new gold standard,
      • Buess E.
      • Steuber K.U.
      • Waibl B.
      Open versus arthroscopic rotator cuff repair: A comparative view of 96 cases.
      evolving from single-row (SR) to double-row (DR) and transosseous-equivalent (TOE, i.e., suture-bridge) repair.
      • Burkhart S.S.
      • Lo I.K.
      Arthroscopic rotator cuff repair.
      ,
      • Park M.C.
      • ElAttrache N.S.
      • Tibone J.E.
      • Ahmad C.S.
      • Jun B.J.
      • Lee T.Q.
      Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique.
      The TOE technique was intended to mimic the classical open TO technique and has shown to produce broader footprint contact than SR and DR. In one study, TOE and DR techniques provided superior clinical and healing results than SR.
      • Xu C.
      • Zhao J.
      • Li D.
      Meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears.
      However, TOE anchor fixation seems to produce a greater number of type 2 failures, also termed “medial failures,” as opposed to type 1 or lateral failures at the footprint.
      • Cho N.S.
      • Yi J.W.
      • Lee B.G.
      • Rhee Y.G.
      Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique.
      Medial failures typically can present significant obstacles in the revision setting.
      • Groeger F.
      • Buess E.
      Failure to heal: Complication after arthroscopic rotator cuff repair. A treatment algorithm.
      Some other obstacles of anchor use have also remained, including knot impingement with prolonged postoperative pain, suture cut-through tendon,
      • Hayashida K.
      • Tanaka M.
      • Koizumi K.
      • Kakiuchi M.
      Characteristic retear patterns assessed by magnetic resonance imaging after arthroscopic double-row rotator cuff repair.
      anchor pull-out, cyst formation around anchors,
      • Ro K.
      • Pancholi S.
      • Son H.S.
      • Rhee Y.G.
      Perianchor cyst formation after arthroscopic rotator cuff repair using all-suture-type, bioabsorbable-type, and PEEK-type anchors.
      problems for additional anchor placement in revisions and high financial costs described by several authors.
      • Black E.M.
      • Austin L.S.
      • Narzikul A.
      • Seidl A.J.
      • Martens K.
      • Lazarus M.D.
      Comparison of implant cost and surgical time in arthroscopic transosseous and transosseous equivalent rotator cuff repair.
      Although rare, bone anchors also can be a source of infection.
      • Hughes J.D.
      • Hughes J.L.
      • Bartley J.H.
      • Hamilton W.P.
      • Brennan K.L.
      Infection rates in arthroscopic versus open rotator cuff repair.
      TO fixation, however, was not abandoned, and authors proposed completely arthroscopic techniques as early as 2002.
      • Fleega B.A.
      Arthroscopic transhumeral rotator cuff repair: Giant needle technique.
      A variety of techniques for arthroscopic TO RCR has been proposed in the literature, such as an anterior cruciate ligament tibial drill guide, a customized drill guide,
      • Kuroda S.
      • Ishige N.
      • Mikasa M.
      Advantages of arthroscopic transosseous suture repair of the rotator cuff without the use of anchors.
      or a variety of bone needles.
      • Cicak N.
      • Klobucar H.
      • Bicanic G.
      • Trsek D.
      Arthroscopic transosseous suture anchor technique for rotator cuff repairs.
      ,
      • Matis N.
      • Hubner C.
      • Aschauer E.
      • Resch H.
      Arthroscopic transosseous reinsertion of the rotator cuff.
      Subsequently, arthroscopic devices such as the ARTHROTUNNELER (Tornier/Wright, Memphis TN) were designed to allow the creation of intersecting bone tunnels
      • Garofalo R.
      • Castagna A.
      • Borroni M.
      • Krishnan S.G.
      Arthroscopic transosseous (anchorless) rotator cuff repair.
      (Fig 1). The purpose of the study was to compare the clinical and imaging outcome of arthroscopic TOE RCR with anchors with arthroscopic anchorless TO RCR at a minimum of 2 years postoperatively. We hypothesized, first, that anchorless repair of medium-to-large tears of the supra- and infraspinatus would lead to similar clinical outcomes as defined by the Constant score (CS), the Simple Shoulder Value (SSV), the Simple Shoulder Test, and a visual analog scale for pain, if compared with anchored repairs. Second, we hypothesized that the magnetic resonance imaging (MRI) results of TO RCR would be at least equal or superior to that of an anchor-based arthroscopic technique.

      Methods

      Study Design, Indications, Patient Selection, and Inclusion Criteria

      Board approval was obtained at the University of Vienna with the number EK 1369/2018. This was a comparative study of 2 cohorts of patients with traumatic or degenerative tears of the supra/infraspinatus (SSP/ISP) tendon unit who chose arthroscopic repair because of persisting pain and functional impairment. They all had MRI findings of a full-thickness rotator cuff tear with good tendon quality and no or minimal signs of muscle atrophy (Goutallier grade 0-1).
      The main inclusion criterion for the study was the anterior-to-posterior diameter of the tear after debridement measured intraoperatively with a hook probe. This diameter has previously been termed “exposed footprint” (EFP)
      • Buess E.
      • Waibl B.
      • Seidner R.
      • Werlen S.
      Outcome of arthroscopic rotator cuff repair in large tears: the exposed footprint.
      and is defined as a linear measurement of the extent of the tear. The tears were crescent-shaped, U-shaped, or (anteriorly or posteriorly) L-shaped. They were easily reducible to the footprint without extensive releases. We included patients with concomitant small partial tears of the subscapularis (SSC) type Lafosse I
      • Wirth B.
      • Kunz S.
      • Schwyzer H.K.
      • Flury M.
      • Lenz M.
      • Audige L.
      Repair of Lafosse I subscapularis lesions brings no benefit in anterosuperior rotator cuff reconstruction.
      that were repaired in situ with one anchor to prevent tear progression. Patients with biceps pathology needing tenotomy or tenodesis were included as well. Shoulders with a massive (i.e., EFP ≥4.5 cm) SSP/ISP tear, with more complex tear configurations, retracted SSC tears, retears, poor tendon quality, cartilage damage, and stiffness were excluded from this study.
      All patients with a full-thickness tear of SSP/ISP with an EFP of 2 to 4 cm and operated on using a TO X-box repair technique were prospectively included since January 14, 2014. The X-box configuration uses 2 bone tunnels and 4 suture strands, 2 of which run straight and the 2 others cross over from one tunnel to the other (Fig 2 A and B). All patients were operated by one single surgeon (E.B.). Until November 15, 2015, the number of TO cases reached 50 (cohort A). The results compared with 25 matched patients undergoing anchor-based TOE suture bridge technique by same surgeon using same indications from February 2012 to November 2013 (cohort B) (Appendix Fig 1, available at www.arthroscopyjournal.org).
      Figure thumbnail gr2
      Fig 2Transosseous repair (group A): Diagram showing right shoulder, lateral view. (A) Suture passing for TO RC repair with 2 bone tunnels and 4 color-coded sutures. Blue, straight sutures; green, box-suture; red, x-suture. (B) Final aspect of X-box repair configuration. (BT, biceps tendon; ISP, infraspinatus; SSP, supraspinatus.)

      Data Collection

      After a minimum of 2 years, 2 independent orthopaedic surgeons (H.B. and P.B.) collected patient-recorded outcomes and strength measurements, which were performed with the Isobex device (Cursor AG, Bern, Switzerland). An MRI was obtained at the 2-year follow-up and evaluated as described in the section to follow.

      MRI Evaluation

      An MRI (MAGNETOM Aera 1.5-T Scanner; Siemens Healthineers, Cary, NC) was performed to evaluate the structural integrity of the repaired cuff in all cases with the use of a dedicated shoulder coil (16-channel coil). The protocol included a three-plane localizing sequence (T1 turbo spin echo [TSE] axial blade resolution 448 × 448, proton density TSE fat-suppressed coronal blade resolution 320 × 320, proton density TSE fat-suppressed sagittal blade resolution: 384 × 384). The sequences were anonymized and analyzed separately by an independent radiologist (M.S.) and an independent orthopaedic surgeon (B.W.) not involved in the treatment. Both graded the images and classified independently according to Sugaya’s grading system (Table 1) and then compared their results. If the grading differed, they discussed their findings until reaching consensus. The same procedure was repeated a second time 2 months later. Only the result of the second course—likely more accurate and with a greater interrater reliability—was retained to calculate the results. The interrater reliability was 0.58 in the first and rose to 0.64 in the second course. Intraobserver reliability was 0.71 and 0.70, respectively.
      Table 1Sugaya Classification of the Repaired Cuff (2005)
      Type I: sufficient thickness compared with normal cuff with homogenously low intensity

      Type II: sufficient thickness (≥3mm) with partial high intensity areas

      Type III: thinned cuff with less than half of normal thickness without discontinuity (≤2.5mm)

      Type IV: minor discontinuity in only 1 or 2 slices on both oblique coronal and sagittal images

      Type V: major discontinuity observed in more than 2 slices on both oblique coronal and sagittal images

      Surgical Technique

      Patients were operated on in the beach-chair position using a custom-made soft-tissue traction system that maintains the arm in loose forward flexion of 30-40° and allows for free rotation and extension. Apart from the posterior standard portal, 3 other portals were established routinely: an anterosuperior, a lateral, and a posterolateral portal. Additional percutaneous portals were established as needed for suture management. The glenohumeral phase of the intervention included biceps tenodesis or tenotomy and repair of small subscapularis tears if indicated. Next, footprint preparation with an aggressive shaver to expose bleeding bone (anteroposterior diameter 2-4 cm) was accomplished, followed by bone marrow stimulation with a microfracture device. After performing an extended bursectomy and sparse acromioplasty, tear configuration and mobility were tested with a suture retriever.

      Anchorless TO Repair with the ARTHROTUNNELER (AT) Device

      In the prospective cohort A, tears were repaired using 2 bone tunnels and 4 high-strength sutures with the operative technique that has been previously described (Fig 2 A and B).
      • Steinitz A.
      • Buxbaumer P.
      • Hackl M.
      • Buess E.
      Arthroscopic transosseous anchorless rotator cuff repair using the X-box technique.
      Two medial tunnels 1.5 cm apart from each other and adjacent to the articular surface were created with a 2.9-cm trocar with the humerus in 2 different positions of abduction. The tip was inserted into the medial hole until the arch of the aiming device was in contact with the footprint. A lateral intersecting tunnel was drilled and a nitinol loop was passed to retrieve a FiberWire shuttling loop (Arthrex, Naples, FL) through the tunnel. A Clever hook (DePuy Mitek, Raynham, MA) was used to pass the anterior loop through the anterior cuff tissue first, and then, the posterior loop through the posterior cuff. With the help of the posterior loop, 3 color-coded high-strength sutures (FiberWire or ORTHOCORD [DePuy Synthes, Warsaw, IN]) were then shuttled through the posterior tunnel. A fourth high-strength suture was added before performing the shuttling maneuver anteriorly. The sutures were tightened over the cuff in an X-box configuration and all the knots placed onto the greater tuberosity.

      Anchor-Based Repair (SpeedBridge; Arthrex)

      In the retrospective comparative cohort B, the SSP/ISP tear was repaired with a typical 4-anchor construct (2 medial and 2 lateral SwiveLock anchors) and 4 limbs of suture tape (Fig 3 A and B). As a modification of the standard technique, one limb of the suture tape was pierced separately through the posterior and the anterior cuff by means of a suture hook and a polydioxanone shuttle. Furthermore, we connected the medial anchors with a double pulley suture (box suture) using the eyelet retention FiberWire sutures.
      Figure thumbnail gr3
      Fig 3Anchor-based repair (group B): Diagram showing right shoulder, lateral view. (A) Passage of the FiberTapes of the 2 medial anchors. One limb of each tape is pierced separately by means of a suture hook. Posteriorly the deep ISP layer is included. (B) Completed suture bridge repair with 2 lateral anchors and medial bridge using the eyelet retention sutures. (ISP, infraspinatus; SH, suture hook; SSP, supraspinatus.)

      Statistical Analysis

      Data collection and processing were carried out with SAS’s graphical statistic program JMP, version 16.0.0 (SAS Institute, Cary NC.). Statistical evaluation of the data was accomplished according to the distribution character of the data (normally distributed or non-normally distributed). In normally distributed data, univariate analysis of variance was the standard outcome evaluation tool. In non-normally distributed data, the nonparametric Wilcoxon/Kruskal–Wallis test was used to evaluate the significance levels, respectively. Significance level was set to P = .05. A post-hoc power analysis revealed for the CS a required sample size of 15 in each group to obtain a power of 0.8 with an alpha level of 0.05. For the SSV, a sample size of 96 and for the Sugaya score of 14 would be needed.

      Results

      As shown in Table 2, the 2 cohorts A and B had the same mean tear size of 2.9 cm, as expressed by the EFP (P = .73). Age did not show a significant difference (P = .035). There were more men in cohort B with 84% as compared with 49% in cohort A (P =. 003). Follow-up time was significantly longer for cohort B, as this was the control group operated during an earlier period (34 vs 29 months; P = .0002). Regarding the concomitant procedures for the biceps and the SSC, these were applied more frequently in cohort B (P = .03 and P = .02, respectively).
      Table 2Demographic and Intraoperative Patient Data for the Two Cohorts
      Group A
      Transosseous anchorless (TO).
      Group B
      Transosseous equivalent (TOE) with anchors.
      P Value
      Sample size4525
      Follow-up time, mo29 ± 5.2 (24-54)34 ± 6.8 (24-47).0002
      Age, y56 ± 9 (36-76)61 ± 8 (46-72).035
      Sex, male49%84%.003
      Side, right67%64%.82
      EFP, cm2.9 ± 0.5 (2-4)2.9 ± 0.4 (2-4).73
      SSC repair (in %)1336.03
      LHBT tenodesis/tenotomy (in %)5684.02
      NOTE. Data presented as mean ± standard deviation + range () or %.
      Significance levels were calculated via the Wilcoxon/Kruskal–Wallis test.
      EFP, exposed footprint; LHBT, long head of biceps tendon; SSC, subscapularis.
      Transosseous anchorless (TO).
      Transosseous equivalent (TOE) with anchors.
      The clinical results for both cohorts were almost identical with highly significant improvements for all scores (P < .01), as shown in Table 3 and Figure 4. Neither the pre- nor the postoperative scores showed a difference between the 2 techniques (P ≥ .502 and P ≥ .29, respectively). The postoperative results showed a final subjective shoulder value of 95% for both groups and an improvement of the CS of 38 and 39 points, respectively.
      Table 3Clinical Results
      Group A
      Transosseous anchorless (TO)
      (n = 45)
      Group B
      Transosseous equivalent (TOE) with anchors’
      (n = 25)
      PrePostPrePost
      Constant score50 ± 17.488 ± 8.648 ± 14.587 ± 7.2
       95% CI44-5585-9141-5584-90
      SSV47 ± 19.195 ± 7.447 ± 19.495 ± 7.6
       95% CI41-5293-9739-5592-98
      SST4.1 ± 2.511.5 ± .874.4 ± 3.211.6 ± .76
       95% CI3.4-4.911.2-11.83.0-5.711.3-11.9
      VAS6.8 ± 2.00.4 ± 1.16.4 ± 2.10.6 ± .9
       95% CI6.2-7.4.09-.725.5-7.3.18-.94
      NOTE. Data are presented as mean ± standard deviation and 95% CI.
      No significant difference in preoperative scores (P ≥ .502).
      All scores improved significantly from pre- to postoperative (P < .01).
      No significant difference in postoperative scores (P ≥ .29).
      CI, confidence interval; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; VAS, visual analog scale.
      Transosseous anchorless (TO)
      Transosseous equivalent (TOE) with anchors’
      Figure thumbnail gr4
      Fig 4Clinical scores. (CS, Constant score; SST, simple shoulder test; SSV, subjective shoulder value; TO, transosseous; TOE, transosseous equivalent; VAS, visual analog scale.)
      As to MRI results shown in Table 4 and Figure 5, structural tendon integrity was not statistically different (P = .206), and the retear rate was equal. We found 2 small retears classified as Sugaya type IV in cohort A and one in B resulting, which resulted in an identical retear rate of 4% for both cohorts. Type I and II combined added up to 80% in cohort A and 64% in B, whereas type III was less frequent in cohort A (16% vs 32%) (P = .145). See examples in Fig 6, Fig 7, Fig 8.
      Table 4Radiologic Results
      SugayaTypeIIIIIIIVV
      Group A TO (n = 45)22% (10)58% (26)16% (7)4% (2)0% (0)
      Group B TOE (n = 25)16% (4)48% (12)32% (8)4% (1)0% (0)
      NOTE. No significant difference regarding postoperative tendon integrity (Pz = .206).
      TO, transosseous; TOE, transosseous equivalent.
      A/TO combined I + II = 80% combined III + IV = 20%
      B/TOE combined I + II = 64% combined III + IV = 36%
      (P = .145).
      Figure thumbnail gr5
      Fig 5Tendon integrity according to Sugaya’s classification. (TO, transosseous; TOE, transosseous equivalent.)
      Figure thumbnail gr6
      Fig 6Example of coronal magnetic resonance imaging (right shoulder) 2 years after TO RC repair. The SSP tendon was graded Sugaya type I. The bone tunnel is clearly appreciated. (RC, rotator cuff; SSP, supraspinatus; TO, transosseous.)
      Figure thumbnail gr7
      Fig 7Example of coronal magnetic resonance imaging (right shoulder) of SSP tendon rated as Sugaya type II. (SSP, supraspinatus.)
      Figure thumbnail gr8
      Fig 8Example of coronal magnetic resonance imaging (right shoulder) of SSP tendon rated as Sugaya type III. (SSP, supraspinatus.)

      Discussion

      Comparison of the results of arthroscopic anchorless TO RCR with the results of a control group operated with an anchor-based repair construct showed no difference in improvement of clinical scores. The postoperative results can be rated excellent for both cohorts, with a final subjective shoulder value of 95% and an improvement of the CS of 38 versus 39 points from pre- to postoperative for the anchorless TO and the anchored TOE technique, respectively. Hence, our study shows that anchorless TO RCR leads to reliably good results with significant improvements in all clinical scores, low retear rates, and high patient satisfaction. We applied a standardized technique with an X-box suture configuration in all included cases.
      The structural healing rate was equal. However, the healing results on MRI after minimum of 2 years showed a greater percentage of type I and II healing (normal or near normal, Fig 6 and 7) in the anchorless TO group, whereas in the anchored TOE repairs intact but thinned cuffs graded Sugaya type III (Fig 8) were observed more frequently. The tendency toward slightly better tendon healing at the humeral footprint might be the result of enhanced blood flow from the bone tunnels.
      The hypothesis that both techniques would produce equivalent clinical results was confirmed. However, the assumption of better structural healing in the anchorless group failed to reach statistical significance.
      Randelli et al.,
      • Randelli P.
      • Stoppani C.A.
      • Zaolino C.
      • Menon A.
      • Randelli F.
      • Cabitza P.
      Advantages of arthroscopic rotator cuff repair with a transosseous suture technique: A prospective randomized controlled trial.
      in a randomized double blinded clinical trial (level I) comparing 31 arthroscopic anchorless TO vs 35 anchored SR repairs showed similar results for both techniques regarding MRI assessed tendon healing (87% vs 88% Sugaya type I-III 1 year after surgery) and shoulder function assessed by the CS and the QuickDASH. Srikumaran et al.
      • Srikumaran U.
      • Huish Jr., E.G.
      Shi BY, Hannan CV, Ali I, Kilcoyne KG. Anchorless arthroscopic transosseous and anchored arthroscopic transosseous equivalent rotator cuff repair show no differences in structural integrity or patient-reported outcomes in a matched cohort.
      compared 2 matched cohorts of 50 patients each using clinical scores and imaging with ultrasound. They found that TO and TOE techniques resulted in no difference for range of motion, American Shoulder and Elbow Surgeons scores, retear rates, and operating time. In their study, retear rates on ultrasound were 14% in both groups. Seidl et al.
      • Seidl A.J.
      • Lombardi N.J.
      • Lazarus M.D.
      • et al.
      Arthroscopic transosseous and transosseous-equivalent rotator cuff repair: An analysis of cost, operative time, and clinical outcomes.
      compared implant cost, operating time and patient based clinical scores of 2 cohorts of 21 patients each without imaging. While costs were lower in the anchorless TO group, operating time and the clinical scores showed no difference.
      Our study is in line with the previous comparative studies on anchorless vs anchored arthroscopic RCR. However, in our study an important improvement of the CS was found, while Randelli et al.
      • Randelli P.
      • Stoppani C.A.
      • Zaolino C.
      • Menon A.
      • Randelli F.
      • Cabitza P.
      Advantages of arthroscopic rotator cuff repair with a transosseous suture technique: A prospective randomized controlled trial.
      reported a surprisingly modest improvement of 6 and 7 points, respectively. The minimal clinically important difference for the CS in patients with RCR was calculated to be 10.4 points by Kukkonen et al.
      • Kukkonen J.
      • Kauko T.
      • Vahlberg T.
      • Joukainen A.
      • Aarimaa V.
      Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery.
      They also reported a greater retear rate of 13 versus 12% on MRI. The latter is also true for the comparative study of Srikumaran et al.
      • Srikumaran U.
      • Huish Jr., E.G.
      Shi BY, Hannan CV, Ali I, Kilcoyne KG. Anchorless arthroscopic transosseous and anchored arthroscopic transosseous equivalent rotator cuff repair show no differences in structural integrity or patient-reported outcomes in a matched cohort.
      with retear rates of 14% for both groups on ultrasound.
      Three studies from 2013 to 2016 describe case series of 31 to 384 cases of arthroscopic anchorless TO repair.
      • Kuroda S.
      • Ishige N.
      • Mikasa M.
      Advantages of arthroscopic transosseous suture repair of the rotator cuff without the use of anchors.
      ,
      • Black E.M.
      • Lin A.
      • Srikumaran U.
      • Jain N.
      • Freehill M.T.
      Arthroscopic transosseous rotator cuff repair: Technical note, outcomes, and complications.
      ,
      • Flanagin B.A.
      • Garofalo R.
      • Lo E.Y.
      • et al.
      Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair.
      They all obtained good results in American Shoulder and Elbow Surgeons or UCLA scores. Kuroda et al.,
      • Kuroda S.
      • Ishige N.
      • Mikasa M.
      Advantages of arthroscopic transosseous suture repair of the rotator cuff without the use of anchors.
      in the largest series of 384 patients, observed only 6% of retears on MRI, which is similar to our results. They used a customized drill guide and K-wires inserted in an angle of 55° from the lateral cortex of the greater tuberosity to the medial rotator cuff footprint and exiting percutaneously behind the acromioclavicular joint to pull the sutures through the cuff. Of note, they observed only 1 bone tunnel related issue intraoperatively and no axillary nerve damage in postoperative electromyography. Liu et al.,
      • Liu X.N.
      • Yang C.J.
      • Lee G.W.
      • Kim S.H.
      • Yoon Y.H.
      • Noh K.C.
      Functional and radiographic outcomes after arthroscopic transosseous suture repair of medium sized rotator cuff tears.
      in a study on patients with TO repairs of medium-sized rotator cuff tears, found a surprisingly high retear rate of 33% on MRI in a case series of 27 patients. The authors included the Sugaya type III cases in the anatomic failure group, which is unusual, as most authors consider only cuffs with a discontinuity a failure. In our own experience, patients with a type III cuff generally do clinically well and remain stable with a good shoulder function over time. Even including type III cuffs would result in a failure rate of only 21% in our own TO series.
      Cadaver laboratory studies showed mixed results of biomechanical testing. Salata et al.
      • Salata M.J.
      • Sherman S.L.
      • Lin E.C.
      • et al.
      Biomechanical evaluation of transosseous rotator cuff repair: Do anchors really matter?.
      in 2013 compared 4 techniques in regard to ultimate failure load and cyclic elongation on 28 specimens randomized in the 4 repair groups: TOE with 4 anchors, TO simple with 2 bone tunnels, AT simple, and AT X-box. The TOE-anchored construct performed best, with a maximum failure load of 558 N as compared with 291 to 388 N for the 3 anchorless techniques. The AT X-box (with 388 N) performed second best of the 4 constructs. In the same year, Kummer et al.
      • Kummer F.J.
      • Hahn M.
      • Day M.
      • Meislin R.J.
      • Jazrawi L.M.
      A laboratory comparison of a new arthroscopic transosseous rotator cuff repair to a double row transosseous equivalent rotator cuff repair using suture anchors.
      published a study on 6 pairs of cadaver shoulders comparing cuff edge displacement at 10,000 cycles and ultimate failure load for identical repair constructs as we have applied in our study. They found no statistical difference and concluded that an arthroscopic TO repair using an X-box configuration is similar in strength and stability to a TOE suture bridge-repair.
      Kilcoyne et al.
      • Kilcoyne K.G.
      • Guillaume S.G.
      • Hannan C.V.
      • Langdale E.R.
      • Belkoff S.M.
      • Srikumaran U.
      Anchored transosseous-equivalent versus anchorless transosseous rotator cuff repair: A biomechanical analysis in a cadaveric model.
      found that in 10 pairs of shoulders mean failure load was greater in the anchored TOE technique but also observed a greater incidence of type 2 failures at the musculotendinous junction as compared with the anchorless AT group (7/10 vs 4/10). They conclude that the potential benefit of greater stability might come at the cost of an unfavorable failure mode. Finally, Bronsnick et al.
      • Bronsnick D.
      • Pastor A.
      • Peresada D.
      • Amirouche F.
      • Solitro G.F.
      • Goldberg B.A.
      Is arthroscopic transosseous rotator cuff repair strength dependent on the tunnel angle?.
      were unable to demonstrate an influence of different tunnel angles and bone quality on the strength of the bone–suture interface by mechanical testing of 10 cadaver humeri.
      Urita et al.
      • Urita A.
      • Funakoshi T.
      • Horie T.
      • Nishida M.
      • Iwasaki N.
      Difference in vascular patterns between transosseous-equivalent and transosseous rotator cuff repair.
      published a basic science anatomic study in 2017: They compared the sequential blood flow as measured by contrast-enhanced ultrasound in 21 shoulders after arthroscopic cuff repair in a randomized study. The TO repair group showed greater blood flow inside the cuff and in the area of the bone tunnels than the TOE group. They concluded that bone tunnels might contribute to biological healing at the footprint by increasing blood flow at 1 to 3 months’ postoperatively.
      RCR has become increasingly frequent in the last 2 decades and so have concerns about its economic impact. Studies about its societal and economic value seem, however, to confirm its positive balance especially in patients younger than 61 years.
      • Mather 3rd, R.C.
      • Koenig L.
      • Acevedo D.
      • et al.
      The societal and economic value of rotator cuff repair.
      Several studies have focused on implant costs and operating times of anchorless and anchor-based repairs.
      • Black E.M.
      • Austin L.S.
      • Narzikul A.
      • Seidl A.J.
      • Martens K.
      • Lazarus M.D.
      Comparison of implant cost and surgical time in arthroscopic transosseous and transosseous equivalent rotator cuff repair.
      ,
      • Seidl A.J.
      • Lombardi N.J.
      • Lazarus M.D.
      • et al.
      Arthroscopic transosseous and transosseous-equivalent rotator cuff repair: An analysis of cost, operative time, and clinical outcomes.
      In our own environment, we found a difference of implant costs of 400 Euros in favor of the TO approach (770 vs 1170 Euros).
      Thickness of the rotator cuff on imaging is an important feature when applying the widely used Sugaya classification. As to normal thickness of the SSP tendon, there is no consensus in the literature, with different indications in MRI, ultrasound, and cadaver studies with a variance of 4 to 8 mm.
      • Karthikeyan S.
      • Rai S.B.
      • Parsons H.
      • Drew S.
      • Smith C.D.
      • Griffin D.R.
      Ultrasound dimensions of the rotator cuff in young healthy adults.
      • Morag Y.
      • Jacobson J.A.
      • Miller B.
      • De Maeseneer M.
      • Girish G.
      • Jamadar D.
      MR imaging of rotator cuff injury: What the clinician needs to know.
      • Sessions W.C.
      • Lawrence R.L.
      • Steubs J.T.
      • Ludewig P.M.
      • Braman J.P.
      Thickness of the rotator cuff tendons at the articular margin: an anatomic cadaveric study.
      As a compromise, the reviewers in our study chose to accept 2.5 mm as the threshold to define half of the thickness of a normal cuff. That means an intact cuff with ≥3 mm thickness would be rated type II, and if thickness was ≤2.5 mm, it was rated as a Sugaya type III. A location in the middle between the apex of the humeral head and the cartilage limit adjacent to the footprint was chosen to perform the before mentioned measurement.
      When comparing the 2 cohorts, we are aware of a lower percentage of additional procedures addressing the biceps and the subscapularis in the anchorless TO repair cohort. This might induce a bias towards potentially better clinical results because of a tendency of less complex tear patterns in this cohort. The greater percentage of male patients in the anchored TOE group might in part counterbalance this bias, as the literature reports generally better results for male patients than for women.
      • Frangiamore S.
      • Dornan G.J.
      • Horan M.P.
      • et al.
      Predictive modeling to determine functional outcomes after arthroscopic rotator cuff repair.

      Limitations

      There are limitations to this study. The results are a comparison from a prospective cohort versus a retrospective cohort, which could open it to selection bias. Second, this study is also limited by its sample size. While a post-hoc power analysis revealed sufficient power regarding the CS and Sugaya score results, a considerable greater sample size, which is not feasible in a single-center setting, would have been needed to detect significant differences regarding the SSV.

      Conclusions

      Anchorless TO RCR is a valid alternative to suture anchor techniques. Clinical outcome data showed comparable results for both techniques after a follow-up of 2 years. The healing results as observed on MRI were also equivalent for both groups.

      Appendix

      Figure thumbnail fx1
      Appendix Fig 1Flow chart of patient selection. (CS, Constant score; EFP, exposed footprint; FU, follow-up; ISP, infraspinatus; MRI, magnetic resonance imaging; pat., patients; SSC, subscapularis; SST, Simple Shoulder Test; SSV, Subjective Shoulder Value; TD, tendodesis; TO, transosseous; TOE, transosseous equivalent; TT, tenotomy; VAS, visual analog scale.

      Suppalementary Data

      References

        • Apreleva M.
        • Ozbaydar M.
        • Fitzgibbons P.G.
        • Warner J.J.
        Rotator cuff tears: The effect of the reconstruction method on three-dimensional repair site area.
        Arthroscopy. 2002; 18: 519-526
        • Park M.C.
        • Cadet E.R.
        • Levine W.N.
        • Bigliani L.U.
        • Ahmad C.S.
        Tendon-to-bone pressure distributions at a repaired rotator cuff footprint using transosseous suture and suture anchor fixation techniques.
        Am J Sports Med. 2005; 33: 1154-1159
        • Buess E.
        • Steuber K.U.
        • Waibl B.
        Open versus arthroscopic rotator cuff repair: A comparative view of 96 cases.
        Arthroscopy. 2005; 21: 597-604
        • Burkhart S.S.
        • Lo I.K.
        Arthroscopic rotator cuff repair.
        J Am Acad Orthop Surg. 2006; 14: 333-346
        • Park M.C.
        • ElAttrache N.S.
        • Tibone J.E.
        • Ahmad C.S.
        • Jun B.J.
        • Lee T.Q.
        Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique.
        J Shoulder Elbow Surg. 2007; 16: 461-468
        • Xu C.
        • Zhao J.
        • Li D.
        Meta-analysis comparing single-row and double-row repair techniques in the arthroscopic treatment of rotator cuff tears.
        J Shoulder Elbow Surg. 2014; 23: 182-188
        • Cho N.S.
        • Yi J.W.
        • Lee B.G.
        • Rhee Y.G.
        Retear patterns after arthroscopic rotator cuff repair: single-row versus suture bridge technique.
        Am J Sports Med. 2010; 38: 664-671
        • Groeger F.
        • Buess E.
        Failure to heal: Complication after arthroscopic rotator cuff repair. A treatment algorithm.
        Arthroskopie. 2020; 33: 176-182
        • Hayashida K.
        • Tanaka M.
        • Koizumi K.
        • Kakiuchi M.
        Characteristic retear patterns assessed by magnetic resonance imaging after arthroscopic double-row rotator cuff repair.
        Arthroscopy. 2012; 28: 458-464
        • Ro K.
        • Pancholi S.
        • Son H.S.
        • Rhee Y.G.
        Perianchor cyst formation after arthroscopic rotator cuff repair using all-suture-type, bioabsorbable-type, and PEEK-type anchors.
        Arthroscopy. 2019; 35: 2284-2292
        • Black E.M.
        • Austin L.S.
        • Narzikul A.
        • Seidl A.J.
        • Martens K.
        • Lazarus M.D.
        Comparison of implant cost and surgical time in arthroscopic transosseous and transosseous equivalent rotator cuff repair.
        J Shoulder Elbow Surg. 2016; 25: 1449-1456
        • Hughes J.D.
        • Hughes J.L.
        • Bartley J.H.
        • Hamilton W.P.
        • Brennan K.L.
        Infection rates in arthroscopic versus open rotator cuff repair.
        Orthop J Sports Med. 2017; 52325967117715416
        • Fleega B.A.
        Arthroscopic transhumeral rotator cuff repair: Giant needle technique.
        Arthroscopy. 2002; 18: 218-223
        • Kuroda S.
        • Ishige N.
        • Mikasa M.
        Advantages of arthroscopic transosseous suture repair of the rotator cuff without the use of anchors.
        Clin Orthop Relat Res. 2013; 471: 3514-3522
        • Cicak N.
        • Klobucar H.
        • Bicanic G.
        • Trsek D.
        Arthroscopic transosseous suture anchor technique for rotator cuff repairs.
        Arthroscopy. 2006; 22: 565.e1-565.e6
        • Matis N.
        • Hubner C.
        • Aschauer E.
        • Resch H.
        Arthroscopic transosseous reinsertion of the rotator cuff.
        Oper Orthop Traumatol. 2006; 18: 1-18
        • Garofalo R.
        • Castagna A.
        • Borroni M.
        • Krishnan S.G.
        Arthroscopic transosseous (anchorless) rotator cuff repair.
        Knee Surg Sports Traumatol Arthrosc. 2012; 20: 1031-1035
        • Buess E.
        • Waibl B.
        • Seidner R.
        • Werlen S.
        Outcome of arthroscopic rotator cuff repair in large tears: the exposed footprint.
        Acta Orthop Belg. 2011; 77: 743-750
        • Wirth B.
        • Kunz S.
        • Schwyzer H.K.
        • Flury M.
        • Lenz M.
        • Audige L.
        Repair of Lafosse I subscapularis lesions brings no benefit in anterosuperior rotator cuff reconstruction.
        Knee Surg Sports Traumatol Arthrosc. 2019; 27: 4021-4031
        • Steinitz A.
        • Buxbaumer P.
        • Hackl M.
        • Buess E.
        Arthroscopic transosseous anchorless rotator cuff repair using the X-box technique.
        Arthrosc Tech. 2019; 8: e175-e181
        • Randelli P.
        • Stoppani C.A.
        • Zaolino C.
        • Menon A.
        • Randelli F.
        • Cabitza P.
        Advantages of arthroscopic rotator cuff repair with a transosseous suture technique: A prospective randomized controlled trial.
        Am J Sports Med. 2017; 45: 2000-2009
        • Srikumaran U.
        • Huish Jr., E.G.
        Shi BY, Hannan CV, Ali I, Kilcoyne KG. Anchorless arthroscopic transosseous and anchored arthroscopic transosseous equivalent rotator cuff repair show no differences in structural integrity or patient-reported outcomes in a matched cohort.
        Clin Orthop Relat Res. 2020; 478: 1295-1303
        • Seidl A.J.
        • Lombardi N.J.
        • Lazarus M.D.
        • et al.
        Arthroscopic transosseous and transosseous-equivalent rotator cuff repair: An analysis of cost, operative time, and clinical outcomes.
        Am J Orthop (Belle Mead NJ). 2016; 45: E415-E420
        • Kukkonen J.
        • Kauko T.
        • Vahlberg T.
        • Joukainen A.
        • Aarimaa V.
        Investigating minimal clinically important difference for Constant score in patients undergoing rotator cuff surgery.
        J Shoulder Elbow Surg. 2013; 22: 1650-1655
        • Black E.M.
        • Lin A.
        • Srikumaran U.
        • Jain N.
        • Freehill M.T.
        Arthroscopic transosseous rotator cuff repair: Technical note, outcomes, and complications.
        Orthopedics. 2015; 38: e352-e358
        • Flanagin B.A.
        • Garofalo R.
        • Lo E.Y.
        • et al.
        Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair.
        Int J Shoulder Surg. 2016; 10: 3-9
        • Liu X.N.
        • Yang C.J.
        • Lee G.W.
        • Kim S.H.
        • Yoon Y.H.
        • Noh K.C.
        Functional and radiographic outcomes after arthroscopic transosseous suture repair of medium sized rotator cuff tears.
        Arthroscopy. 2018; 34: 50-57
        • Salata M.J.
        • Sherman S.L.
        • Lin E.C.
        • et al.
        Biomechanical evaluation of transosseous rotator cuff repair: Do anchors really matter?.
        Am J Sports Med. 2013; 41: 283-290
        • Kummer F.J.
        • Hahn M.
        • Day M.
        • Meislin R.J.
        • Jazrawi L.M.
        A laboratory comparison of a new arthroscopic transosseous rotator cuff repair to a double row transosseous equivalent rotator cuff repair using suture anchors.
        Bull Hosp Jt Dis (2013). 2013; 71: 128-131
        • Kilcoyne K.G.
        • Guillaume S.G.
        • Hannan C.V.
        • Langdale E.R.
        • Belkoff S.M.
        • Srikumaran U.
        Anchored transosseous-equivalent versus anchorless transosseous rotator cuff repair: A biomechanical analysis in a cadaveric model.
        Am J Sports Med. 2017; 45: 2364-2371
        • Bronsnick D.
        • Pastor A.
        • Peresada D.
        • Amirouche F.
        • Solitro G.F.
        • Goldberg B.A.
        Is arthroscopic transosseous rotator cuff repair strength dependent on the tunnel angle?.
        Orthop J Sports Med. 2019; 72325967119848667
        • Urita A.
        • Funakoshi T.
        • Horie T.
        • Nishida M.
        • Iwasaki N.
        Difference in vascular patterns between transosseous-equivalent and transosseous rotator cuff repair.
        J Shoulder Elbow Surg. 2017; 26: 149-156
        • Mather 3rd, R.C.
        • Koenig L.
        • Acevedo D.
        • et al.
        The societal and economic value of rotator cuff repair.
        J Bone Joint Surg Am. 2013; 95: 1993-2000
        • Karthikeyan S.
        • Rai S.B.
        • Parsons H.
        • Drew S.
        • Smith C.D.
        • Griffin D.R.
        Ultrasound dimensions of the rotator cuff in young healthy adults.
        J Shoulder Elbow Surg. 2014; 23: 1107-1112
        • Morag Y.
        • Jacobson J.A.
        • Miller B.
        • De Maeseneer M.
        • Girish G.
        • Jamadar D.
        MR imaging of rotator cuff injury: What the clinician needs to know.
        Radiographics. 2006; 26: 1045-1065
        • Sessions W.C.
        • Lawrence R.L.
        • Steubs J.T.
        • Ludewig P.M.
        • Braman J.P.
        Thickness of the rotator cuff tendons at the articular margin: an anatomic cadaveric study.
        Iowa Orthop J. 2017; 37: 85-89
        • Frangiamore S.
        • Dornan G.J.
        • Horan M.P.
        • et al.
        Predictive modeling to determine functional outcomes after arthroscopic rotator cuff repair.
        Am J Sports Med. 2020; 48: 1559-1567