TECHNIQUE

Double-Row, Transosseous-Equivalent Suture-Bridge Repair

for Supraspinatus Tears: Power Up the Healing
Chris R. Mellano, MD, Kirk A. Campbell, MD,
Anthony A Romeo, MD, and Brian J. Cole, MD, MBA

equivalent (TOE) or suture-bridge repair techniques.1–4,11 This

Abstract: Arthroscopic rotator cuff repair is one of the most com- construct uses 2 rows of suture anchors to recreate the favor-
monly performed surgeries in orthopedics. The primary goal of this able biomechanics, especially the improved tendon-to-bone
procedure is to reduce shoulder pain and restore its function so that contact and compression over the anatomic footprint, found in
patients may return to some of their preinjury activities. Arthroscopic the original open transosseous rotator cuff repairs.1,4,12
double-row transosseous-equivalent or suture-bridge repair techniques The double-row TOE/suture-bridge rotator cuff repair has
have become increasingly popular over the last decade. This repair been shown to lead to several biomechanical advantages over
technique, which uses 2 rows of suture anchors to recreate a bio- the standard single-row repair. These include improved foot-
mechanically favorable healing environment at the anatomic footprint print coverage, greater load to failure, increased contact pres-
of the rotator cuff, produces a strong fixation construct with improved sure at the tendon footprint, decreased motion at the tendon-
tendon-to-bone contact and compression over the anatomic footprint. bone footprint interface, and increased resistance to rotational
The addition of this technique to one’s armamentarium has the forces, which should all theoretically lead to improved tendon
potential to lead to improved patient outcomes after rotator cuff repair. healing to bone.1–4,12–14 However, these excellent bio-
In this review, we will detail some of the technical pearls on how to mechanical characteristics do not always translate into clinical
perform a double-row transosseous-equivalent repair and power up the improvements in the rotator cuff healing rate or functional
healing of rotator cuff tears involving the supraspinatus. outcomes in the literature.9,15,16 Controversy still exists as to
Key Words: rotator cuff tear, double-row repair, transosseous equiv- whether single-row or double-row rotator cuff repairs lead to
alent, suture bridge, double-row TOE better outcomes.9,15,16 Recent clinical trials have shown that
double-row repairs lead to improved postoperative strength
(Tech Should Elb Surg 2016;17: 49–57)
and decreased retear rate when compared with single-row
repairs.17,18 Furthermore, a recent systematic review of over-
lapping meta-analyses of the highest quality studies available

T he main goals of rotator cuff repair surgery are to reduce

pain and to restore shoulder function. These goals are
typically achieved by carrying out a repair that has some of the
showed that double-row rotator cuff repair resulted in superior
structural healing when compared with single-row repair.9
The short-term clinical and structural integrity outcomes
following characteristics: restoration of the rotator cuff ana- of double-row TOE repair have compared favorably with those
tomic footprint, high initial fixation strength, minimum gap reported for double-row repair of rotator cuff tears.10,12,15,19,20
formation with cyclic loading, and broad tendon-to-bone A small randomized controlled trial of double-row TOE versus
contact to promote biological healing of the rotator cuff to the single-row rotator cuff repair techniques for full-thickness
bone.1–4 Traditionally, rotator cuff surgery was performed supraspinatus tears used ultrasound evaluation to show that
through an open approach and it was repaired in a transosseous double-row TOE repair resulted in a 93% healing rate versus
manner. However, with continued improvements in surgical
instrumentation and techniques, these repairs have transitioned
from open, to mini open, to now all-arthroscopic procedures.
Although the underlying goals of surgery have remained
the same, the transition to an all-arthroscopic procedure led to
a move away from the transosseous repair to the adaption of
simpler repair configurations, such as a single-row repair.
Unfortunately, the high-failure rates that were found to range
from 5% to 94% led to a search for improved arthroscopic
repair techniques.1,5–10 Further advances in instrumentation
and technique then led to double-row rotator cuff repair and
then in an attempt to recreate the favorable biomechanical
characteristics of the original transosseous repair, there has
been a recent move toward the double-row transosseous-

From the Department of Orthopaedic Surgery, Rush University Medical PHOTO 1. Portal locations. Right shoulder beach-chair position.
Center, Chicago, IL. Portals include: (A) Standard posterior portal. (B) Anterior rotator
B.J.C. receives support from Arthrex, Carticept, Regentis, Zimmer, interval portal created during the glenohumeral joint diagnostic
Medipost, National Institutes of Health, DJ Orthopaedics, Athletico, arthroscopy. (C) Lateral viewing portal typically created 2 finger
Ossur, Smith & Nephew, and Tornier. A.A.R. receives support from breadths lateral to the lateral acromial edge and in-line with the
Arthrex, DJO Surgical, Smith & Nephew, and Ossur. The other authors
posterior aspect of the distal clavicle. (D) Anterolateral working
declare no conflict of interest.
Reprints: Kirk A. Campbell, MD, Midwest Orthopedics at Rush University portal, this portal location is optimized with a spinal needle to
Medical Center, 1611 W. Harrison Suite 300, Chicago, IL 60610 provide unimpeded access to the cuff tear and anticipated
(e-mail: [email protected]). anchor insertion sites without crowding the lateral viewing
Copyright r 2015 Wolters Kluwer Health, Inc. All rights reserved. portal. A 6 mm cannula is placed through this portal.

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Mellano et al Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016

FIGURE 1. A, Right shoulder view from posterior. A tear of the supraspinatus is present. While visualizing through the lateral portal the
surgeon should localize the anterolateral working portal with a spinal needle. This portal should allow unimpeded access to the cuff tear
and eventual anchor locations. Care should be taken to avoid crowding the anterolateral working portal with the lateral viewing portal.
Next, the surgeon must introduce a grasping device through the anterolateral working portal to assess the tendon quality and tear
pattern. (Note that the separation between the supraspinatus and infraspinatus is depicted for illustration purpose only and does not
represent the arthroscopic appearance of the supraspinatus and infraspinatus in vivo.). B, Supraspinatus tear viewed from the lateral
portal.

75% for single-row repair.13 However, when the 3 most goals of rotator cuff surgery: pain reduction and restoration of
common arthroscopic techniques (single row, double row, and shoulder functionality.
double-row TOE repairs) for repairing supraspinatus tears
were compared, it was found that all 3 techniques resulted in SURGICAL TECHNIQUE
clinical and statistically significant improvements in subjective
and objective outcomes at a minimum 2-year follow-up. Step 1: Prepare the Subacromial Space
Interestingly, they noted a decrease in the rate of retears based A thorough bursectomy must be accomplished to create a
on the technique used: 22% for single row, 18% for double space to work. Please see the article on how to perform a
row, and 11% for double-row TOE; however, this was not subacromial bursectomy, with or without an acromioplasty, for
statistically significant.15 more detailed description of how to prepare the subacromial
Although larger randomized controlled trials are needed space.
to determine the long-term outcomes of double-row TOE, the
biomechanical and early short-term clinical results have been Step 2: Establish Proper Portal Positioning.
very promising. This technique is an advance in rotator cuff In addition to the standard posterior viewing portal,
surgery and will help to facilitate the achievement of the main anterior rotator interval portal, and lateral viewing portal, an

FIGURE 2. A, Insertion of the medial-row posterior anchor. After the supraspinatus footprint on the greater tuberosity is decorticated
with a burr, the posterior-medial anchor is typically placed first. A tap is used first to create a hole typically 2 mm lateral to the articular
surface and aimed slightly medial to create an appropriate “dead-man’s” angle. This particular anchor (SwivelLock; Arthrex) is loaded
with a 2 mm broad suture (FiberTape; Arthrex). Depending on the necessary trajectory, this anchor can either be placed into the hole
through the anterolateral working portal (as shown here) or through a percutaneous incision. B, The posterior anchor of the medial row
after insertion.

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Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016 DR TOE Repair

FIGURE 3. Retrograde suture shuttling of the medial-row posterior

anchor sutures. While visualizing through the lateral portal, a
curved suture-passing device (Spectrum; Linvatec) is placed
through the posterior portal and used to pass a #1 PDS suture FIGURE 5. Insertion of the medial-row anterior anchor. While
through the supraspinatus tendon just lateral to the MTJ medial to both tails of the medial-row posterior anchor are “parked” out of
the posterior portion of the tear. A suture retriever is inserted in the the posterior portal the process is repeated for the medial-row
anterolateral working portal and retrieves the #1 PDS suture anterior anchor. The tap is used to create a hole 2 mm off the
through the tear. The #1 PDS is tied around both suture tails. The articular surface in a dead-man’s trajectory. The anchor
#1 PDS is then pulled back through the posterior portal to pass the (SwivelLock; Arthrex) loaded with a broad 2 mm suture
2 suture tails through the tendon together. Alternatively, each of (FiberTape; Arthrex) is inserted, either through the anterolateral
the suture tails could be passed independently through 2 different working portal (as shown here) or through a percutaneous
locations in the tendon requiring 2 passes. incision.

FIGURE 6. Retrograde suture shuttling of the medial-row

anterior anchor sutures. While visualizing through the lateral
portal, the curved suture-passing device (Spectrum; Linvatec) is
used through the anterior portal (as shown here) or through the
FIGURE 4. Retrograde suture shuttling of the medial-row posterior posterior portal based on ease of access. The suture passer
anchor sutures. While visualizing through the lateral portal, a penetrates the tendon just lateral to the MTJ in the anterior
curved suture-passing device (Spectrum; Linvatec) is placed aspect of the tear and passes a #1 PDS suture. A suture retriever is
through the posterior portal and used to pass a #1 PDS suture inserted in the anterolateral working portal and retrieves the #1
through the supraspinatus tendon just lateral to the MTJ medial to PDS suture through the tear. The #1 PDS is tied around both
the posterior portion of the tear. A suture retriever is inserted in the suture tails of the anterior anchor. The #1 PDS is then pulled back
anterolateral working portal and retrieves the #1 PDS suture through the anterior portal to pass the 2 suture tails through the
through the tear. The #1 PDS is tied around both suture tails. The tendon together (alternatively each tail can be passed
#1 PDS is then pulled back through the posterior portal to pass the independently through 2 different locations in the tendon
2 suture tails through the tendon together. Alternatively, each of requiring 2 passes). The 2 suture tails from the medial-row
the suture tails could be passed independently through 2 different anterior anchor are “parked” out of the anterior portal (as shown)
locations in the tendon requiring 2 passes. or the posterior portal based on surgeon preference.

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Mellano et al Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016

FIGURE 9. Insertion of the lateral-row posterior anchor. Using a

FIGURE 7. Retrograde suture shuttling of the medial-row suture retriever a single suture limb is retrieved from both medial-
anterior anchor sutures. While visualizing through the lateral row anchors (posterior and anterior). These 2 limbs are inserted
portal, the curved suture-passing device (Spectrum; Linvatec) is into the lateral-row anchor (SwivelLock; Arthrex) outside of the
used through the anterior portal (as shown here) or through the anterolateral working portal. Next, the anchor, now loaded with
posterior portal based on ease of access. The suture passer the 2 suture limbs from the medial-row anchors, is inserted into
penetrates the tendon just lateral to the MTJ in the anterior the lateral-row hole created by the tap. Before final seating of the
aspect of the tear and passes a #1 PDS suture. A suture retriever is lateral anchor posterior anchor, the surgeon should remove all of
inserted in the anterolateral working portal and retrieves the #1 the slack from the sutures to create a rigid fixation construct. Pay
PDS suture through the tear. The #1 PDS is tied around both attention to the proprioception of the anchor seating as abrupt
suture tails of the anterior anchor. The #1 PDS is then pulled back “giving-way” may mean the anchor has skived out the cortex.
through the anterior portal to pass the 2 suture tails through the Once the posterior anchor is appropriately seated the suture
tendon together (alternatively each tail can be passed cutter is used directly on top of the anchor.
independently through 2 different locations in the tendon
requiring 2 passes). The 2 suture tails from the medial-row
anterior anchor are “parked” out of the anterior portal (as shown)
or the posterior portal based on surgeon preference.

FIGURE 8. Lateral-row posterior anchor. While the sutures from

the medial anchor are “parked” out of the posterior and anterior FIGURE 10. Insertion of the lateral-row posterior anchor. Using a
cannula the lateral-row anchor insertion sites are planned. The suture retriever a single suture limb is retrieved from both medial-
ideal position of the lateral-row posterior anchor can be row anchors (posterior and anterior). These 2 limbs are inserted
evaluated by performing a “lateral-row trial reduction.” This is into the lateral-row anchor (SwivelLock; Arthrex) outside of the
performed by using a grasper through the anterolateral working anterolateral working portal. Next, the anchor, now loaded with
portal to pull the medial-row sutures over to the lateral aspect of the 2 suture limbs from the medial-row anchors, is inserted into
the greater tuberosity and determining which posterior anchor the lateral-row hole created by the tap. Before final seating of the
location gives the best footprint restoration. If a potential “dog- lateral anchor posterior anchor, the surgeon should remove all of
ear” is noticed posteriorly during the trial reduction then the the slack from the sutures to create a rigid fixation construct. Pay
surgeon can consider incorporating a cinch-stitch into the lateral attention to the proprioception of the anchor seating as abrupt
row (see below). When using the tap to create a hole for the “giving-way” may mean the anchor has skived out the cortex.
lateral-row posterior anchor be careful to avoid skiving off the Once the posterior anchor is appropriately seated the suture
cortex. cutter is used directly on top of the anchor.

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Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016 DR TOE Repair

FIGURE 13. Insertion of the lateral-row anterior anchor. A suture

retriever is used to retrieve both remaining medial-row sutures.
FIGURE 11. Lateral-row anterior anchor. The ideal position of the These 2 limbs are inserted into the lateral-row anterior anchor
lateral-row anterior anchor can also be evaluated by performing a (SwivelLock; Arthrex) outside of the anterolateral working portal.
“lateral-row trial reduction.” Using a grasper through the Next, the anchor, now loaded with the 2 suture limbs from the
anterolateral working portal, pull the remaining 2 medial-row medial-row anchors, is inserted into the lateral-row anterior hole
sutures over to the lateral aspect of the greater tuberosity and created by the tap. Before final seating of the lateral-row anterior
determining which location anterior to anchor insertion site gives anchor, the surgeon should remove all of the slack from the 2
the best footprint restoration. If a potential “dog-ear” is noticed sutures to create a rigid fixation construct. Again, pay attention
anteriorly during the trial reduction then the surgeon can to the proprioception of the anchor seating as abrupt “giving-
consider incorporating a cinch-stitch into the lateral row (see way” may mean the anchor has skived out the cortex. Once the
below). When using the tap to create a hole for the lateral anchor anterior anchor is appropriately seated the suture cutter is used in
anterior the surgeon must be careful to avoid skiving off the a similar manner.
anterior cortex, which is more likely than the posterior anchor.
anterolateral working portal is used for instrument access to
the cuff tear (Photo 1).

Step 3: Evaluate the Cuff Tear and Plan the

Repair Construct
A grasping device can be used to evaluate the tendon to
assess the tendon quality and mobility. This is a necessary step
to understand the tear pattern and plan the repair configuration,
including how many anchors, where to put the anchors, where
to pass the sutures through the tendon, and what sequence to
fix the sutures (Fig. 1).

Step 4: Prepare the Anatomic Footprint

The footprint of the torn supraspinatus tendon can be
prepared with a high-speed burr. Gentle decortication of the
footprint is thought to access mesenchymal stem cells within
the cancellous bone. This step is performed to improve tendon
healing to bone.

Step 5: Insert Medial-Row Posterior Anchor

For suture management purposes, it is easier to work from
FIGURE 12. Insertion of the lateral-row anterior anchor. A suture posterior to anterior beginning with the medial-row posterior
retriever is used to retrieve both remaining medial-row sutures. anchor (Fig. 2).
These 2 limbs are inserted into the lateral-row anterior anchor
(SwivelLock; Arthrex) outside of the anterolateral working portal. Step 6: Pass the Medial-Row Posterior Anchor
Next, the anchor, now loaded with the 2 suture limbs from the Sutures Through the Tendon
medial-row anchors, is inserted into the lateral-row anterior hole This step can be performed with a variety of suture-
created by the tap. Before final seating of the lateral-row anterior passing devices in either an antegrade or retrograde direction.
anchor, the surgeon should remove all of the slack from the 2
sutures to create a rigid fixation construct. Again, pay attention
A retrograde suture-passing device is 1 option (Figs. 3, 4).
to the proprioception of the anchor seating as abrupt “giving-
way” may mean the anchor has skived out the cortex. Once the Step 7: Insert Medial-Row Anterior Anchor
anterior anchor is appropriately seated the suture cutter is used in This step is performed in a similar manner to insertion of
a similar manner. the medial-row posterior anchor (Fig. 5).

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Mellano et al Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016

FIGURE 14. A and B, Final appearance of a double-row, transosseous-equivalent, suture-bridge, knotless fixation construct. Some
surgeons may prefer to secure the medial-row fixation by tying knots (not pictured) after passing the sutures from the 2 medial anchors.
After tying the knots of your choice, such as alternating half hitches, the sutures would then be passed and used for the lateral-row
fixation and steps 9 to 12 would then be completed.

Step 8: Pass the Medial-Row Anterior Anchor Cinch-Stitch Step 2: Create the Cinch-Stitch
Sutures Through the Tendon The free suture has been passed through the tendon and
This step is performed similar to the posterior anchor now the 2 free tails are pulled through the loop end to create a
suture passage using a curved suture-passing retrograde device. cinch-stitch, or luggage-tag, configuration (Figs. 16, 17).
This can be performed through either the posterior or anterior
portal (Figs. 6, 7). Cinch-Stitch Step 3: Incorporate the Cinch-Stitch
Into a Single Lateral-Row Anchor
Unlike the double-row suture-bridge configuration, the
Step 9: Perform a Trial Reduction of the Lateral cinch-stitch is only incorporated into a single lateral anchor
Row that is closest in location to the cinch-stitch (Figs. 18, 19).
This step will allow the surgeon to understand where best
to place the lateral-row anchors and identify any potential dog- Cinch-Stitch Step 4: Tighten the Cinch-Stitch
ears (Fig. 8). Before Final Insertion of Lateral-Row Anchor
Similar to removing slack from the double-row suture-
Step 10: Insert the Lateral-Row Posterior Anchor bridge configuration before lateral-row fixation, to avoid slack
Take 1 suture from each of the medial-row anchors and in the cinch-stitch, it is necessary to “take up the slack” in the
incorporate into the lateral-row posterior anchor (Figs. 9, 10).

Step 11: Lateral-Row Anterior Anchor

With the remaining 2 limbs of the medial anchor, the
surgeon can perform another “trial reduction” of the sutures to
locate the optimal position of the lateral-row anterior anchor.
Be careful of skiving with the tap near the anterior cortex
(Fig. 11).

Step 12: Insert Lateral-Row Anterior Anchor

Take the 2 remaining sutures from each of the medial-row
anchors and incorporate into the lateral-row anterior anchor
(Figs. 12, 13).

Step 13: Assess Final Repair Integrity

The arm can be manually rotated to assess for repair
integrity (Figs. 14A, B). FIGURE 15. Pass cinch-stitch with retrograde suture passer.
Before performing the lateral-row fixation, a “trial reduction” may
demonstrate a possible dog-ear either anterior or posterior. To
Cinch-Stitch Step 1: Identify Dog-Ears and Pass avoid leaving a dog-ear the surgeon can incorporate a cinch-
Free Suture Through Tendon stitch (luggage-tag suture configuration) into the lateral row. A
Before performing the lateral-row repair, a “trial reduc- curved retrograde suture-passer device is passed through either
the posterior or anterior portal depending on the location of the
tion” can demonstrate dog-ears in the repair configuration. A dog-ear. The suture passer passes a #1 PDS suture through the
cinch-stitch (luggage-tag suture configuration) can be incor- tendon behind the dog-ear. A suture retriever then retrieves the
porated into the lateral row to help reduce dog-ears. A cinch- #1 PDS suture out of the anterolateral working portal. A free
stitch requires the use of a free suture and a suture passer suture (Fiberwire, Naples, FL) is doubled in half and the #1 PDS is
(Fig. 15). tied over both halves of the suture (see inset figure).

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Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016 DR TOE Repair

FIGURE 16. Create the cinch-stitch (luggage tag) suture

configuration. Once the #1 PDS is tied around both halves of the FIGURE 18. Incorporation of the cinch-stitch into the lateral row.
free suture then the #1 PDS is pulled back through the portal Both limbs of the cinch-stitch are incorporated into the same
bringing the 2 tail ends of the suture through the tendon behind lateral-row anchor. If the cinch-stitch is posterior (as shown here),
the dog-ear. The loop end of the suture is not pulled through the both limbs will be incorporated into the lateral-row posterior
tendon. Next, the 2 tail ends, which have now passed through anchor along with 1 limb from either medial anchor for a total of
the tendon, are pulled back through the loop end to create the 4 suture limbs in the lateral-row posterior anchor. If the cinch-
cinch-stitch configuration. This step can be performed using a stitch is anterior then the same process would be performed for
suture retriever in 2 different ways, either outside the cannula the lateral-row anterior anchor.
(inset figure) or arthroscopically (main figure). The suture
retriever is passed through the loop, then retrieves the 2 tail ends TECHNICAL PEARLS
out of the loop. Once the 2 tail ends are passed through the loop (1) Have a clear understanding of rotator cuff footprint
the 2 tails are pulled to reduce and tighten the cinch-stitch to the anatomy and common tear patterns.21–23
tendon.
(2) Do not skimp on exposure. Maximize visualization by
performing a thorough bursectomy ( ± acromioplasty when
cinch-stitch sutures before final lateral-row anchor seating. Once indicated) before rotator cuff repair. If planning a double-
the final repair construct is created, its integrity can be assessed row repair then perform a bursectomy in the location of the
with gentle range of motion (cinch-stitch Figs. 20A, B). anticipated lateral-row anchor sites as well.
(3) Optimize your portal locations. Triangulate with a spinal
needle first. Do not crowd your lateral visual portal and
anterolateral working portal.

FIGURE 17. Create the cinch-stitch (luggage tag) suture

configuration. Once the #1 PDS is tied around both halves of the
free suture then the #1 PDS is pulled back through the portal
bringing the 2 tail ends of the suture through the tendon behind
the dog-ear. The loop end of the suture is not pulled through the
tendon. Next, the 2 tail ends, which have now passed through the FIGURE 19. Incorporation of the cinch-stitch into the lateral row.
tendon, are pulled back through the loop end to create the cinch- Both limbs of the cinch-stitch are incorporated into the same
stitch configuration. This step can be performed using a suture lateral-row anchor. If the cinch-stitch is posterior (as shown here),
retriever in 2 different ways, either outside the cannula or both limbs will be incorporated into the lateral-row posterior
arthroscopically. The suture retriever is passed through the loop, anchor along with 1 limb from either medial anchor for a total of
then retrieves the 2 tail ends out of the loop. Once the 2 tail ends 4 suture limbs in the lateral-row posterior anchor. If the cinch-
are passed through the loop the 2 tails are pulled to reduce and stitch is anterior then the same process would be performed for
tighten the cinch-stitch to the tendon. the lateral-row anterior anchor.

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Mellano et al Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016

FIGURE 20. A and B, Final appearance of double-row, transosseous-equivalent, suture-bridge with posterior cinch-stitch (blue)
incorporated into the lateral-row posterior anchor.

(4) Take time to evaluate the tendon quality and understand rotator interval, must be reduced and fixed properly to
the tear pattern as crescent, L-shaped, reverse L-shaped, create the optimal mechanical repair construct. Avoid
complex, or type II (musculotendinous junction) by “overreducing” the posterior aspect of the tear first which
performing a “trial reduction” with the use of a grasping may tether the tendon excursion anteriorly and lead to an
device. Not all tears, especially L-shaped tears, are inadequate reduction of the anterior rotator cable or create
properly repaired by pulling the tendon directly medial to a repair under high tension. Consider reducing and fixing
lateral. You must understand how the tendon is supposed the anterior rotator cable first before fixation of the
to reduce to avoid creating a high-tension, nonanatomic posterior half of the tear.
repair with high likelihood of failure. Plan the locations to (10) Understand that a double-row TOE repair can be
pass each suture through the tendon based on the successfully performed with different anchors, sutures,
reduction vectors need to properly reduce the tear. or suture-passing devices than depicted in this article.
(5) Do not ignore or miss a tear that extends into the Adherence to the principles, and not necessarily the
infraspinatus as this will lead to predictably poor clinical specific implants, described here will assure the greatest
outcomes. If the tear extends into the infraspinatus, in possibility for successful double-row TOE repair.
general, this should be repaired first.
(6) Be comfortable with a variety of suture-passing devices.
Antegrade suture-passing devices such as the Scorpion
(Arthrex, Naples, FL) may be easy to use in large tears REFERENCES
but in small tears antegrade suture passers may be more 1. Park MC, Elattrache NS, Ahmad CS, et al. “Transosseous-equivalent”
difficult to maneuver and cause frustration. Retrograde rotator cuff repair technique. Arthroscopy. 2006;22:1360.e1–1360.e5.
passers such as the Spectrum (Linvatec, Largo, FL) or 2. Park MC, ElAttrache NS, Tibone JE, et al. Part I: Footprint contact
Penetrator (Arthrex) may work best in small spaces. characteristics for a transosseous-equivalent rotator cuff repair tech-
(7) Anticipate “dog-ears” in the DR TOE repair construct. nique compared with a double-row repair technique. J Shoulder Elbow
This can be done by performing a “double-row trial Surg. 2007;16:461–468.
reduction” of the medial sutures over the cuff with the use
3. Park MC, Tibone JE, ElAttrache NS, et al. Part II: Biomechanical
of a grasper before inserting lateral anchors. Consider
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incorporating a cinch-stitch into the lateral-row anchors cuff repair technique compared with a double-row repair technique.
to properly reduce the dog-ears. J Shoulder Elbow Surg. 2007;16:469–476.
(8) When placing the lateral-row anchors avoid skiving
through the cortex, especially anterior. This can be 4. Cole BJ, ElAttrache NS, Anbari A. Arthroscopic rotator cuff repairs:
an anatomic and biomechanical rationale for different suture-anchor
avoided by understanding the osseous anatomy and
repair configurations. Arthroscopy. 2007;23:662–669.
paying attention to the proprioceptive feedback during
anchor insertion. If you feel a sudden give during 5. Galatz LM, Ball CM, Teefey SA, et al. The outcome and repair
insertion of the lateral-row anterior anchor, you must integrity of completely arthroscopically repaired large and massive
evaluate closely for the anchor skiving out the anterior rotator cuff tears. J Bone Joint Surg Am. 2004;86-A:219–224.
cortex. 6. Boileau P, Brassart N, Watkinson DJ, et al. Arthroscopic repair of full-
(9) If the tear of the supraspinatus extends anterior into the thickness tears of the supraspinatus: does the tendon really heal?
rotator interval then priority should be given to repair the J Bone Joint Surg Am. 2005;87:1229–1240.
anterior aspect of the supraspinatus, which includes the 7. Bishop J, Klepps S, Lo IK, et al. Cuff integrity after arthroscopic
rotator cable. The anterior rotator cable, which runs versus open rotator cuff repair: a prospective study. J Shoulder Elbow
through the anterior aspect of the supraspinatus and Surg. 2006;15:290–299.

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Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016 DR TOE Repair

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15. McCormick F, Gupta A, Bruce B, et al. Single-row, double-row, and 22. Curtis AS, Burbank KM, Tierney JJ, et al. The insertional footprint of
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tears with minimal atrophy: a retrospective comparative outcome and 23. Millett PJ, Warth RJ. Posterosuperior rotator cuff tears: classification,
radiographic analysis at minimum 2-year followup. Int J Shoulder pattern recognition, and treatment. J Am Acad Orthop Surg. 2014;
Surg. 2014;8:15–20. 22:521–534.

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