Arthroscopic Lamina-Specific Double-Row Fixation for Large Delaminated Rotator Cuff Tears Daisuke Mori, M.D., Noboru Funakoshi, M.D., and Fumiharu Yamashita, M.D.
Abstract: Delamination is a commonly observed finding at the time of rotator cuff repair, but few studies have described the surgical techniques used for delaminated rotator cuff tears (RCTs) or their clinical outcomes. We developed a technique using a combination of a double row and an additional row, which we call lamina-specific double-row fixation, for large delaminated RCTs. The lamina-specific double-row technique is performed using an additional row (lamina-specific lateral row) of suture anchors placed between the typical medial and lateral rows of suture anchors. The technique is performed as follows: (1) medial-row sutures are passed through the inferior (articular-side) and superior (bursal-side) layers in a mattress fashion; (2) lamina-specific lateral-row simple sutures are passed through the inferior layer; and (3) lateral-row simple sutures are passed through the superior layer. We believe that this technique offers the following advantages: (1) creation of a larger area of contact between the inferior layer and the footprint, (2) higher initial fixation strength of the articular-side components of the repaired rotator cuff tendon, and (3) an adaptation between the superficial and inferior layers. This technique represents an alternative option in the operative treatment of large delaminated RCTs.
D
elamination is a commonly observed finding at the time of rotator cuff repair,1-6 and some clinical studies have reported it as a negative prognostic factor in rotator cuff healing.1,2 Although the definitive diagnosis of delamination mainly depends on operative findings, little information is available about the histologic and anatomic analysis of delamination, and few studies have described the surgical techniques used for delaminated rotator cuff tears (RCTs) or their clinical outcomes. The repair of delaminated RCTs is more complex than that of non-delaminated RCTs and requires a special technique, mainly because the margin of the inferior (articular-side) layer in delaminated RCTs is usually more retracted than that of the superior (bursal-side) layer.4,7-9 Sugaya et al.8,9 reported the “double-row” technique for delaminated RCTs, which involves the repair of each layer separately. However, they did not describe the clinical outcomes of delaminated RCTs in
From the Department of Orthopaedic Surgery, Kyoto Shimogamo Hospital, Kyoto, Japan. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 27, 2014; accepted August 20, 2014. Address correspondence to Daisuke Mori, M.D., Kyoto Shimogamo Hospital, 17 Shimogamo Higashimorigamaecho, Sakyo-ku, Kyoto 606-0866, Japan. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 2212-6287/14450/$36.00 http://dx.doi.org/10.1016/j.eats.2014.08.004
conjunction with structural results. Moreover, Sonnabend et al.5,7 and MacDougal and Todhunter6 reported that delaminated components were curetted at the time of surgery and that their presence had no effect on the clinical outcome of rotator cuff repair. Because it appears that there are different ways to address the effective treatment of delaminated RCTs, an effective operative technique should be established on the basis of clinical and structural results. We considered that components of the inferior layer in delaminated RCTs are part of the rotator cuff tissue when the inferior layer is retracted, and they can be pulled laterally to the footprint at the time of surgery (Fig 1). Moreover, we believed that a higher initial fixation strength for inferior layer components and a more anatomic repair would provide more secure tendon healing, with associated improved clinical outcomes. We developed a technique using a combination of a double row and an additional row (lamina-specific lateral row), which we call lamina-specific double-row fixation (Fig 2, Video 1), for delaminated large RCTs. The purpose of this article is to describe the operative technique of arthroscopic lamina-specific double-row fixation (Tables 1 and 2).
Surgical Technique The patient is placed in the beach-chair position under general anesthesia. A posterior portal is established for initial assessment of the glenohumeral joint.
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Fig 1. The inferior layer in delaminated RCTs can be grasped and pulled laterally to the footprint using a tendon grasper with a 7-mm bite after capsular release.
Typically, the surgeon uses 5 portals: posterior, anterior, anterolateral, Neviaser,10 and posterolateral. If necessary, additional portals are used to obtain an optimal insertion angle for the suture anchors, as well as to release adhesions. The status and mobility of the torn, retracted tendon and the presence and pattern of delamination are carefully evaluated (Figs 1 and 2A). The posterolateral portal is mainly used as the viewing portal. The anterolateral portal is also used as the viewing portal to prevent the surgeon from overlooking posterior delamination.3 Delamination is evaluated by pulling the torn superior and inferior layers laterally to the footprint using a tendon grasper with a 7-mm bite (Fig 1). If the edge of the inferior layer can be grasped and pulled laterally to the footprint with the grasper, we regard this inferior layer as thick and tough tissue. We performed lamina-specific double-row fixation for delaminated RCTs with such inferior layers. If the inferior layer tissue is torn and fragile at the time of evaluation, standard double-row fixation should be performed. Tendon-to-bone repair is performed with doubleloaded metal suture anchors (TwinFix, 5.0 mm or 6.5 mm, with No. 2 UltraBraid [Smith & Nephew, Andover, MA] and Fastin RC, 5.0 mm, with No. 2 Ethibond [DePuy Mitek, Norwood, MA]) in the greater tuberosity. The number of suture anchors varies according to the size and configuration of the delamination. The surgeon should pay special attention when inserting the suture anchors because of the high risk of anchor pullout. We recommend that the surgeon ascertain the safety of the anchors by pulling the sutures at the time of anchor insertion. If the anchor pulls out of the greater tuberosity after traction of the sutures, this technique should be avoided. The goal is to achieve balanced anatomic repair,11 including insertion
of the infraspinatus tendon into the middle facet and the posterolateral third of the superior facet of the greater tuberosity. Therefore we do not use margin convergence.11 All repairs are performed with the arm in approximately in 30 of abduction and external rotation to avoid undue tension on the repaired tendon after surgery. To perform our technique, the medial row of anchors is inserted at the articular margin. No. 2 permanent sutures of medial-row anchors are placed through the inferior and superior layers in a mattress fashion using an Ideal Suture Grasper (DePuy Mitek). First, the anterior medial-row anchor is inserted into the greater tuberosity. The suture grasper is introduced through the Neviaser or posterior portal. Special care is taken with suture placement in the mattress fashion by pulling and lifting up the inferior and superior layers with the tendon grasper to make a vertical path for the suture grasper through the superior and inferior layers in the bursal-to-articular direction. Suture placement of the tendon is slightly lateral to the cleavage between the inferior and superior layers. The point through the inferior layer is ideally 7 mm medial to its edge. The reaming sutures are repeated to achieve placement in a mattress fashion. The limbs of the sutures are retrieved through the anterior, Neviaser, or posterior portal for improved visualization. We think that placing sutures in the mattress fashion allows for layered closure and adaptation between the inferior and superior layers. Next, we determine whether to insert a posterior medial-row or lamina-specific lateral-row anchor. This depends on the size of the delaminated RCT. Suture management of the posterior medial-row anchor is identical to the anterior medial-row anchor. The inferior layer is reduced to the footprint with the tendon grasper, and we determine an appropriate placement for the lamina-specific lateral-row anchor. The pilot hole for this is approximately 5 mm lateral to the edge of the articular cartilage and the inserted medial-row anchors in the middle portion of the footprint. The surgeon prevents the pilot hole from overlapping with the medial-row anchor hole. Simple sutures of the lamina-specific lateral row are placed approximately 5 mm from the edge of the inferior layer using the suture grasper or a Caspari punch (Linvatec, Largo, FL) loaded with a looped No. 2-0 nylon suture. A suture relay with the nylon suture is undertaken intra-articularly. After all mattress repair sutures of the medial row and simple repair sutures of the lamina-specific lateral row are placed, knot tying for the laminaspecific lateral-row sutures is performed (Fig 2B). Two anchors are inserted in the medial row, and 1 or 2 anchors are inserted in the lamina-specific lateral row. A lateral row of anchors is inserted at the lateral margin of the rotator cuff tendon footprint to reduce the superior layer anatomically without undue tension
LAMINA-SPECIFIC DOUBLE-ROW FIXATION
Fig 2. A right shoulder with large delaminated RCTs that underwent laminaspecific double-row fixation, as viewed from the posterolateral portal. (A) The edge of the inferior layer is retracted to the level of the glenoid. (B) Sutures of the medial row are placed through the inferior and superior layers in a mattress fashion. Simple sutures of the lamina-specific lateral row are placed through the inferior layer. (C) Knot tying for the lamina-specific lateral row is performed, and simple sutures of the lamina-specific lateral row are then placed through the superior layer. (D) Knot tying for the lateral simple sutures attached to the superior layer is performed, followed by knot tying for the medial row in a mattress fashion.
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Table 1. Indications and Relative and Absolute Contraindications Indications Delaminated RCTs Inferior layer retracted medial to glenoid Size of inferior layer 10 mm Complete footprint coverage with subtotal removal of subacromial bursa and tendon mobilization technique such as partial capsulotomy, as well as coracohumeral ligament release
Relative Contraindications Osteoporosis Women aged >70 yr Prior shoulder surgery
on the superior layer. Simple sutures of the lateral row are then placed through the superior layer (Fig 2C). Knot tying for the lateral-row simple sutures attached to the superior layer is performed first, followed by knot tying for the medial-row anchor in a mattress fashion (Fig 2D, Video 1).
Discussion We chose not to perform a single- or double-row fixation for large delaminated RCTs but instead carried out lamina-specific double-row fixation. This was because we believed that secure repair of the inferior layer would result in improved tendon healing because the layer of a large delaminated RCT is part of the Table 2. Key Technical Pearls and Pitfalls of Arthroscopic Lamina-Specific Double-Row Fixation Pearls 1. The status and mobility of the torn, retracted tendon and the presence and pattern of delamination should be carefully evaluated. 2. The anterolateral and posterolateral portals should be used as the viewing portals to prevent the surgeon from overlooking posterior delamination. 3. The Neviaser portal is useful for suture management. 4. The medial anchor’s suture placement is slightly lateral to the cleavage between the inferior and superior layers. The point through the inferior layer is ideally 7 mm medial to its edge. 5. The simple sutures of the lamina-specific lateral row are placed approximately 5 mm from the edge of the inferior layer. 6. Lifting up the superior and inferior layer is helpful for suture placement. 7. The suture limbs should be retrieved through the anterior, Neviaser, or posterior portal for better visualization before knot tying. Pitfalls 1. If the inferior layer is thin and fragile, this procedure should be avoided. 2. Anchor holes should be kept at a distance >5 mm to prevent anchor problems such as pullout. 3. The surgeon should ascertain anchor security by pulling the suture anchors to prevent anchor pullout. 4. Careful attention should be paid to knot tying so that anchor pullout is not missed. If the surgeon finds the possibility of anchor pullout intraoperatively, radiographs should be taken to ascertain the possibility quickly.
Absolute Contraindications Friable inferior and superior layer tissue Non-retracted inferior layer
rotator cuff tissue. The lamina-specific double-row technique was therefore expected to (1) create a larger area of contact between the inferior layer and the footprint, (2) lead to higher initial fixation strength of the articular-side components of the repaired rotator cuff tendon, and (3) form an adaptation between the superficial and inferior layers. We believed that these effects would be more beneficial in terms of operative essence for robust initial fixation when compared with the single-row or standard double-row techniques, thus minimizing the recurrence of retears of large delaminated RCTs. However, there are some potential disadvantages, risks, and limitations when compared with single-row or standard double-row fixation. These include higher cost, prolonged operative time, and the difficulty of revision surgery because of large numbers of suture anchors. Moreover, the many knots used for the medial and lamina-specific lateral rows have the potential to cause strangulation and necrosis of rotator cuff tendons.12 Some additional high risks and limitations are also present for the following patients because of their potentially lower bone quality in the greater tuberosity: (1) patients with osteoporosis, (2) women aged older than 70 years, and (3) patients who have undergone previous shoulder surgery on the affected side. Thus the final decision of whether to perform this technique in these patients was made at the time of surgery. Nevertheless, we believe that this technique could be used as an alternative option for repairing retracted large delaminated RCTs. However, clinical and structural studies are required to confirm this.
Acknowledgment The authors thank Mutsumi Nishida, Ph.D., for his valuable discussion.
References 1. Boileau P, Brassart N, Watkinson DJ, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal? J Bone Joint Surg Am 2005;87:1229-1240. 2. Frurin PH, Landreau P, Gregory T, et al. Cuff integrity after arthroscopic rotator cuff repair: Correlation with clinical results in 576 cases. Arthroscopy 2007;23:340-346.
LAMINA-SPECIFIC DOUBLE-ROW FIXATION 3. Han Y, Shin JH, Seok CW, Lee CH, Kim SH. Is posterior delamination in arthroscopic rotator cuff repair hidden to the posterior viewing portal? Arthroscopy 2013;29:1740-1747. 4. Matuski K, Murata R, Ochiai N, Ogino S, Fujita K, Ishige N. Delamination observed in full-thickness rotator cuff tears. Shoulder Joint (Katakansetsu) 2005;29:603-606 [in Japanese]. 5. Sonnabend DH, Watson EM. Structural factors affecting the outcome of rotator cuff tears. J Shoulder Elbow Surg 2002;11:212-218. 6. MacDougal GA, Todhunter CR. Delamination tearing of the rotator cuff: Prospective analysis of the influence of delamination tearing on the outcome of arthroscopically assisted mini open rotator cuff repair. J Shoulder Elbow Surg 2010;19:1063-1069. 7. Sonnabend DH, Yu Y, Howlett CR, Harper GD, Walsh WR. Laminated tears of the human rotator cuff: A histologic and immunochemical study. J Shoulder Elbow Surg 2001;10:109-115.
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8. Sugaya H, Maeda K, Matsuki K, Moriishi J. Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: Single-row versus dual-row fixation. Arthroscopy 2005;21:1307-1316. 9. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg Am 2007;89:953-960. 10. Neviaser TJ. Arthroscopy of the shoulder. Orthop Clin North Am 1987;18:361-372. 11. Mochizuki T, Sugaya H, Uomizu M, et al. Humeral insertion of the supraspinatus and infraspinatus. New anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg Am 2008;90: 962-969. 12. Rhee YG, Cho NS, Parke CS. Arthroscopic rotator cuff repair using modified Mason-Allen medial row stitch: Knotless versus knot-tying suture bridge technique. Am J Sports Med 2012;40:2440-2447.
Abstract: Delamination is a commonly observed finding at the time of rotator cuff repair, but few studies have described the surgical techniques used for delaminated rotator cuff tears (RCTs) or their clinical outcomes. We developed a technique using a combination of a double row and an additional row, which we call lamina-specific double-row fixation, for large delaminated RCTs. The lamina-specific double-row technique is performed using an additional row (lamina-specific lateral row) of suture anchors placed between the typical medial and lateral rows of suture anchors. The technique is performed as follows: (1) medial-row sutures are passed through the inferior (articular-side) and superior (bursal-side) layers in a mattress fashion; (2) lamina-specific lateral-row simple sutures are passed through the inferior layer; and (3) lateral-row simple sutures are passed through the superior layer. We believe that this technique offers the following advantages: (1) creation of a larger area of contact between the inferior layer and the footprint, (2) higher initial fixation strength of the articular-side components of the repaired rotator cuff tendon, and (3) an adaptation between the superficial and inferior layers. This technique represents an alternative option in the operative treatment of large delaminated RCTs.
D
elamination is a commonly observed finding at the time of rotator cuff repair,1-6 and some clinical studies have reported it as a negative prognostic factor in rotator cuff healing.1,2 Although the definitive diagnosis of delamination mainly depends on operative findings, little information is available about the histologic and anatomic analysis of delamination, and few studies have described the surgical techniques used for delaminated rotator cuff tears (RCTs) or their clinical outcomes. The repair of delaminated RCTs is more complex than that of non-delaminated RCTs and requires a special technique, mainly because the margin of the inferior (articular-side) layer in delaminated RCTs is usually more retracted than that of the superior (bursal-side) layer.4,7-9 Sugaya et al.8,9 reported the “double-row” technique for delaminated RCTs, which involves the repair of each layer separately. However, they did not describe the clinical outcomes of delaminated RCTs in
From the Department of Orthopaedic Surgery, Kyoto Shimogamo Hospital, Kyoto, Japan. The authors report that they have no conflicts of interest in the authorship and publication of this article. Received May 27, 2014; accepted August 20, 2014. Address correspondence to Daisuke Mori, M.D., Kyoto Shimogamo Hospital, 17 Shimogamo Higashimorigamaecho, Sakyo-ku, Kyoto 606-0866, Japan. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 2212-6287/14450/$36.00 http://dx.doi.org/10.1016/j.eats.2014.08.004
conjunction with structural results. Moreover, Sonnabend et al.5,7 and MacDougal and Todhunter6 reported that delaminated components were curetted at the time of surgery and that their presence had no effect on the clinical outcome of rotator cuff repair. Because it appears that there are different ways to address the effective treatment of delaminated RCTs, an effective operative technique should be established on the basis of clinical and structural results. We considered that components of the inferior layer in delaminated RCTs are part of the rotator cuff tissue when the inferior layer is retracted, and they can be pulled laterally to the footprint at the time of surgery (Fig 1). Moreover, we believed that a higher initial fixation strength for inferior layer components and a more anatomic repair would provide more secure tendon healing, with associated improved clinical outcomes. We developed a technique using a combination of a double row and an additional row (lamina-specific lateral row), which we call lamina-specific double-row fixation (Fig 2, Video 1), for delaminated large RCTs. The purpose of this article is to describe the operative technique of arthroscopic lamina-specific double-row fixation (Tables 1 and 2).
Surgical Technique The patient is placed in the beach-chair position under general anesthesia. A posterior portal is established for initial assessment of the glenohumeral joint.
Arthroscopy Techniques, Vol 3, No 6 (December), 2014: pp e667-e671
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Fig 1. The inferior layer in delaminated RCTs can be grasped and pulled laterally to the footprint using a tendon grasper with a 7-mm bite after capsular release.
Typically, the surgeon uses 5 portals: posterior, anterior, anterolateral, Neviaser,10 and posterolateral. If necessary, additional portals are used to obtain an optimal insertion angle for the suture anchors, as well as to release adhesions. The status and mobility of the torn, retracted tendon and the presence and pattern of delamination are carefully evaluated (Figs 1 and 2A). The posterolateral portal is mainly used as the viewing portal. The anterolateral portal is also used as the viewing portal to prevent the surgeon from overlooking posterior delamination.3 Delamination is evaluated by pulling the torn superior and inferior layers laterally to the footprint using a tendon grasper with a 7-mm bite (Fig 1). If the edge of the inferior layer can be grasped and pulled laterally to the footprint with the grasper, we regard this inferior layer as thick and tough tissue. We performed lamina-specific double-row fixation for delaminated RCTs with such inferior layers. If the inferior layer tissue is torn and fragile at the time of evaluation, standard double-row fixation should be performed. Tendon-to-bone repair is performed with doubleloaded metal suture anchors (TwinFix, 5.0 mm or 6.5 mm, with No. 2 UltraBraid [Smith & Nephew, Andover, MA] and Fastin RC, 5.0 mm, with No. 2 Ethibond [DePuy Mitek, Norwood, MA]) in the greater tuberosity. The number of suture anchors varies according to the size and configuration of the delamination. The surgeon should pay special attention when inserting the suture anchors because of the high risk of anchor pullout. We recommend that the surgeon ascertain the safety of the anchors by pulling the sutures at the time of anchor insertion. If the anchor pulls out of the greater tuberosity after traction of the sutures, this technique should be avoided. The goal is to achieve balanced anatomic repair,11 including insertion
of the infraspinatus tendon into the middle facet and the posterolateral third of the superior facet of the greater tuberosity. Therefore we do not use margin convergence.11 All repairs are performed with the arm in approximately in 30 of abduction and external rotation to avoid undue tension on the repaired tendon after surgery. To perform our technique, the medial row of anchors is inserted at the articular margin. No. 2 permanent sutures of medial-row anchors are placed through the inferior and superior layers in a mattress fashion using an Ideal Suture Grasper (DePuy Mitek). First, the anterior medial-row anchor is inserted into the greater tuberosity. The suture grasper is introduced through the Neviaser or posterior portal. Special care is taken with suture placement in the mattress fashion by pulling and lifting up the inferior and superior layers with the tendon grasper to make a vertical path for the suture grasper through the superior and inferior layers in the bursal-to-articular direction. Suture placement of the tendon is slightly lateral to the cleavage between the inferior and superior layers. The point through the inferior layer is ideally 7 mm medial to its edge. The reaming sutures are repeated to achieve placement in a mattress fashion. The limbs of the sutures are retrieved through the anterior, Neviaser, or posterior portal for improved visualization. We think that placing sutures in the mattress fashion allows for layered closure and adaptation between the inferior and superior layers. Next, we determine whether to insert a posterior medial-row or lamina-specific lateral-row anchor. This depends on the size of the delaminated RCT. Suture management of the posterior medial-row anchor is identical to the anterior medial-row anchor. The inferior layer is reduced to the footprint with the tendon grasper, and we determine an appropriate placement for the lamina-specific lateral-row anchor. The pilot hole for this is approximately 5 mm lateral to the edge of the articular cartilage and the inserted medial-row anchors in the middle portion of the footprint. The surgeon prevents the pilot hole from overlapping with the medial-row anchor hole. Simple sutures of the lamina-specific lateral row are placed approximately 5 mm from the edge of the inferior layer using the suture grasper or a Caspari punch (Linvatec, Largo, FL) loaded with a looped No. 2-0 nylon suture. A suture relay with the nylon suture is undertaken intra-articularly. After all mattress repair sutures of the medial row and simple repair sutures of the lamina-specific lateral row are placed, knot tying for the laminaspecific lateral-row sutures is performed (Fig 2B). Two anchors are inserted in the medial row, and 1 or 2 anchors are inserted in the lamina-specific lateral row. A lateral row of anchors is inserted at the lateral margin of the rotator cuff tendon footprint to reduce the superior layer anatomically without undue tension
LAMINA-SPECIFIC DOUBLE-ROW FIXATION
Fig 2. A right shoulder with large delaminated RCTs that underwent laminaspecific double-row fixation, as viewed from the posterolateral portal. (A) The edge of the inferior layer is retracted to the level of the glenoid. (B) Sutures of the medial row are placed through the inferior and superior layers in a mattress fashion. Simple sutures of the lamina-specific lateral row are placed through the inferior layer. (C) Knot tying for the lamina-specific lateral row is performed, and simple sutures of the lamina-specific lateral row are then placed through the superior layer. (D) Knot tying for the lateral simple sutures attached to the superior layer is performed, followed by knot tying for the medial row in a mattress fashion.
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Table 1. Indications and Relative and Absolute Contraindications Indications Delaminated RCTs Inferior layer retracted medial to glenoid Size of inferior layer 10 mm Complete footprint coverage with subtotal removal of subacromial bursa and tendon mobilization technique such as partial capsulotomy, as well as coracohumeral ligament release
Relative Contraindications Osteoporosis Women aged >70 yr Prior shoulder surgery
on the superior layer. Simple sutures of the lateral row are then placed through the superior layer (Fig 2C). Knot tying for the lateral-row simple sutures attached to the superior layer is performed first, followed by knot tying for the medial-row anchor in a mattress fashion (Fig 2D, Video 1).
Discussion We chose not to perform a single- or double-row fixation for large delaminated RCTs but instead carried out lamina-specific double-row fixation. This was because we believed that secure repair of the inferior layer would result in improved tendon healing because the layer of a large delaminated RCT is part of the Table 2. Key Technical Pearls and Pitfalls of Arthroscopic Lamina-Specific Double-Row Fixation Pearls 1. The status and mobility of the torn, retracted tendon and the presence and pattern of delamination should be carefully evaluated. 2. The anterolateral and posterolateral portals should be used as the viewing portals to prevent the surgeon from overlooking posterior delamination. 3. The Neviaser portal is useful for suture management. 4. The medial anchor’s suture placement is slightly lateral to the cleavage between the inferior and superior layers. The point through the inferior layer is ideally 7 mm medial to its edge. 5. The simple sutures of the lamina-specific lateral row are placed approximately 5 mm from the edge of the inferior layer. 6. Lifting up the superior and inferior layer is helpful for suture placement. 7. The suture limbs should be retrieved through the anterior, Neviaser, or posterior portal for better visualization before knot tying. Pitfalls 1. If the inferior layer is thin and fragile, this procedure should be avoided. 2. Anchor holes should be kept at a distance >5 mm to prevent anchor problems such as pullout. 3. The surgeon should ascertain anchor security by pulling the suture anchors to prevent anchor pullout. 4. Careful attention should be paid to knot tying so that anchor pullout is not missed. If the surgeon finds the possibility of anchor pullout intraoperatively, radiographs should be taken to ascertain the possibility quickly.
Absolute Contraindications Friable inferior and superior layer tissue Non-retracted inferior layer
rotator cuff tissue. The lamina-specific double-row technique was therefore expected to (1) create a larger area of contact between the inferior layer and the footprint, (2) lead to higher initial fixation strength of the articular-side components of the repaired rotator cuff tendon, and (3) form an adaptation between the superficial and inferior layers. We believed that these effects would be more beneficial in terms of operative essence for robust initial fixation when compared with the single-row or standard double-row techniques, thus minimizing the recurrence of retears of large delaminated RCTs. However, there are some potential disadvantages, risks, and limitations when compared with single-row or standard double-row fixation. These include higher cost, prolonged operative time, and the difficulty of revision surgery because of large numbers of suture anchors. Moreover, the many knots used for the medial and lamina-specific lateral rows have the potential to cause strangulation and necrosis of rotator cuff tendons.12 Some additional high risks and limitations are also present for the following patients because of their potentially lower bone quality in the greater tuberosity: (1) patients with osteoporosis, (2) women aged older than 70 years, and (3) patients who have undergone previous shoulder surgery on the affected side. Thus the final decision of whether to perform this technique in these patients was made at the time of surgery. Nevertheless, we believe that this technique could be used as an alternative option for repairing retracted large delaminated RCTs. However, clinical and structural studies are required to confirm this.
Acknowledgment The authors thank Mutsumi Nishida, Ph.D., for his valuable discussion.
References 1. Boileau P, Brassart N, Watkinson DJ, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal? J Bone Joint Surg Am 2005;87:1229-1240. 2. Frurin PH, Landreau P, Gregory T, et al. Cuff integrity after arthroscopic rotator cuff repair: Correlation with clinical results in 576 cases. Arthroscopy 2007;23:340-346.
LAMINA-SPECIFIC DOUBLE-ROW FIXATION 3. Han Y, Shin JH, Seok CW, Lee CH, Kim SH. Is posterior delamination in arthroscopic rotator cuff repair hidden to the posterior viewing portal? Arthroscopy 2013;29:1740-1747. 4. Matuski K, Murata R, Ochiai N, Ogino S, Fujita K, Ishige N. Delamination observed in full-thickness rotator cuff tears. Shoulder Joint (Katakansetsu) 2005;29:603-606 [in Japanese]. 5. Sonnabend DH, Watson EM. Structural factors affecting the outcome of rotator cuff tears. J Shoulder Elbow Surg 2002;11:212-218. 6. MacDougal GA, Todhunter CR. Delamination tearing of the rotator cuff: Prospective analysis of the influence of delamination tearing on the outcome of arthroscopically assisted mini open rotator cuff repair. J Shoulder Elbow Surg 2010;19:1063-1069. 7. Sonnabend DH, Yu Y, Howlett CR, Harper GD, Walsh WR. Laminated tears of the human rotator cuff: A histologic and immunochemical study. J Shoulder Elbow Surg 2001;10:109-115.
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8. Sugaya H, Maeda K, Matsuki K, Moriishi J. Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: Single-row versus dual-row fixation. Arthroscopy 2005;21:1307-1316. 9. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg Am 2007;89:953-960. 10. Neviaser TJ. Arthroscopy of the shoulder. Orthop Clin North Am 1987;18:361-372. 11. Mochizuki T, Sugaya H, Uomizu M, et al. Humeral insertion of the supraspinatus and infraspinatus. New anatomical findings regarding the footprint of the rotator cuff. J Bone Joint Surg Am 2008;90: 962-969. 12. Rhee YG, Cho NS, Parke CS. Arthroscopic rotator cuff repair using modified Mason-Allen medial row stitch: Knotless versus knot-tying suture bridge technique. Am J Sports Med 2012;40:2440-2447.
