Paper 06

Abstract Title: Shoulder Injection Prior to Rotator Cuff Repair is Associated with Increased Risk of
Subsequent Surgery

Authors:
Sophia A. Traven, MD, Daniel Brinton, MHA, MAR, Kit Simpson, DrPH, Zachary Adkins, MD, Alyssa
Althoff, BS, John Andrew Palsis, MD, William Ashford, MD, Harris Slone, MD.
Medical University of South Carolina, Charleston, SC, USA.

Objectives: Corticosteroid injections (CSI) are frequently utilized in the nonoperative management of
rotator cuff tears. However, recent literature suggests that injections may reduce biomechanical
strength of tendons and ligaments in animal models and increase the risk of postoperative infections
following surgery. The goal of this study was to determine if the timing of CSI is associated with an
increased risk of reoperation following primary rotator cuff repair (RCR).

Methods: A retrospective analysis of claims data of privately-insured subjects from the MarketScan®
database for the years 2010-2014 was conducted. A cohort of subjects aged 18-64 who were diagnosed
with a rotator cuff tear and underwent repair in 2011 was identified. Multivariable logistic regression
models were used to compare the odds of reoperation between groups.

Results: A total of 4,959 subjects with an arthroscopic RCR were identified. Of this, 553 subjects
required reoperation within the following 3 years (Table 1). Patients who had a CSI within 6 months
preceding the RCR were at a much higher risk of undergoing reoperation (Figure 1): 0-3 months prior,
AOR 1.536 (95% CI: 1.201-1.965); 3-6 months, AOR 1.843 (95% CI: 1.362-2.494); and 6-12 months AOR
1.339 (95% CI: 0.914-1.962). Of those patients that underwent a reoperation, the most common surgery
performed was revision rotator cuff repair followed by arthroscopic debridement (48.5% versus 38.9%
respectively).

Conclusion: Patients who had received a CSI within 6 months prior to RCR were much more likely to
undergo a subsequent reoperation within the following 3 years. These odds diminished as more time
passed between CSI and primary repair. Consideration should therefore be given to delaying primary
rotator cuff repair for 6 months following injection.
Paper 07

Abstract Title: Superior Capsule Reconstruction for Reinforcement Before Arthroscopic Rotator Cuff
Repair Improves Cuff Integrity

Authors:
Teruhisa Mihata, MD, PhD,1, Thay Q. Lee, PhD2, Kunimoto Fukunishi, MD3, Takeshi Kawakami, MD,
PhD4, Yukitaka Fujisawa, MD1, Yasuo Itami, MD1, Mutsumi Ohue, MD5, Masashi Neo, MD, PhD1.
1
Osaka Medical College, Takatsuki, Japan, 2VA Long Beach Healthcare System, Long Beach, CA, USA,
3
Rakusai Shimizu Hospital, Kyoto, Japan, 4Towakai Hospital, Takatsuki, Japan, 5Katsuragi Hospital,
Kishiwada, Japan.

Objectives: We developed the superior capsule reconstruction (SCR) technique for surgical treatment of
irreparable rotator cuff tears. In these patients, SCR restores shoulder stability and muscle balance,
consequently improving shoulder function and relieving pain. In this study, we evaluated whether SCR
for reinforcement before arthroscopic rotator cuff repair (ARCR) improves cuff integrity, especially in the
case of severely degenerated supraspinatus tendon.

Methods: A series of 32 consecutive patients (mean age, 69.0 years) with severely degenerated but
reparable rotator cuff tears (medium size: 1-3 cm, and large size: 3-5 cm) underwent SCR using fascia
lata autografts for reinforcement before ARCR. To determine the indications for SCR for reinforcement,
the severity of degeneration in the torn supraspinatus tendon was assessed. We evaluated fatty
degeneration in the muscle by using the Goutallier grade; we also scored retraction of the torn tendon
(grade 0: no retraction; grade 1: torn edge on the greater tuberosity; grade 2: torn edge on the lateral
half of the humeral head; grade 3: torn edge on the medial half of the humeral head; grade 4: torn edge
on the glenoid) and tendon quality (grade 0: normal; grade 1: slightly thin, or slight fatty degeneration in
the tendon part; grade 2: severely thin, or severe fatty degeneration in the tendon part; grade 3:
severely thin, and severe fatty degeneration in the tendon part; grade 4: no tendon). In patients
classified with grade 3 or 4 in at least two of these three categories, arthroscopic SCR was performed for
reinforcement, after which the torn tendon was repaired over the fascia lata graft. To assess the benefit
of SCR for reinforcement, the results from these 32 patients were compared with those after ARCR
alone in 91 consecutive patients with medium (1-3 cm) to large (3-5 cm) rotator cuff tears (mean age,
66.7 years). Torn tendons were repaired by using double-row suture-bridges with and without SCR for
reinforcement. By using t- and chi-square tests, we compared the American Shoulder and Elbow
Surgeons (ASES) score, active shoulder range of motion (ROM), and cuff integrity (Sugaya MRI
classification) between ARCR with and without SCR as well as between before surgery and at final
follow-up (mean, 19 months; 12 to 40 months). A significant difference was defined as P < 0.05.

Results: All 32 patients who underwent SCR before ARCR had no postoperative re-tear and
demonstrated type I cuff integrity (sufficient thickness with homogeneously low intensity), whereas
those treated with ARCR without SCR had a 5.5% incidence (5/91 all patients) of postoperative re-tear,
and 22.1% (19/86 healed patients) had type II (partial high-intensity area) or III (insufficient thickness)
cuff integrity. ASES score, active elevation, active external rotation, and active internal rotation
increased significantly after ARCR both with and without SCR (P < 0.001) (Table). Postoperative ASES
score and active ROM did not differ significantly between ARCR with and without SCR, but the Goutallier
grade of the supraspinatus was significantly higher for ARCR with SCR (mean, 2.8) than for ARCR alone
(mean, 2.1) (P < 0.0001).

Conclusion: SCR for reinforcement prevented postoperative re-tear after ARCR and improved the quality
of the repaired tendon on MRI. Furthermore, postoperative functional outcomes were similar in
patients who underwent ARCR alone and those who also underwent SCR, even though degeneration of
the torn tendons was greater in the latter group.

Table
ASES ASES Active Active External External
Internal Internal
score score elevation elevation rotation rotation
rotation rotation
(points) (points) (degrees) (degrees) (degrees) (degrees)
Before After Before After Before After Before After
ARCR
with
45.1 88.2 133 161 38 49 L4 L1
SCR
(n=32)
ARCR
alone 34.4 90.6 133 169 52 58 L2 T11
(n=91)
 5 Pearls to Make Your Life Easier for Rotator Cuff Repair

William N. Levine, MD
Frank E. Stinchfield Professor and Chairman
Department of Orthopedic Surgery
NYP/Columbia University Medical Center
New York, NY
Email: wnl1@[Link]

I. Pre-operative evaluation – avoid the inevitable…

II. Tear recognition – is it an L or a U?
III. Strategy for suture management/repair – “been there, done that!”
IV. Biologic augmentation – “I need some healing help”
V. Know your limits and the patient’s – “Maybe I should not be here right now!”

I. Pre-operative Evaluation
A. Physical examination
1. Active range of motion
2. Pseudoparalysis
3. Cuff-specific tests
a. Subscapularis
i. Lift-off test
ii. Belly-press
iii. Internal rotation lag sign
b. Supraspinatus
i. Jobe drop-arm
c. Infraspinatus
i. ER lag sign
ii. ER at the side weakness
d. Teres Minor
i. Hornblower’s

B. Radiographic Evaluation
1. Humeral head relationship to glenoid
a. Proximal migration (lack of posterosuperior cuff)
b. Anterior subluxation (lack of subscap)
2. Arthrosis – “cuff tear arthropathy”
3. Signs of chronicity (do NOT occur with acute, even massive, tears
a. Complete proximal humeral migration (“anterior escape”)
b. Significant anterior subluxation (axillary radiograph)
c. “Acetabularization” of acromion
d. “Femoralization” of humeral head

C. MRI Evaluation
1. 1st question – is it acute, chronic, or acute-on-chronic?
 2. Acute
a. No significant muscle atrophy (Goutallier 2 or less)
b. Retraction typically not as severe
c. No proximal migration
d. No anterior subluxation
3. Chronic
a. Significant atrophy (Goutallier 3 or higher)
b. Significant retraction
c. Poor quality tissue
D. Patte Classification (Patte; Clin Orthop 254: 81-86; 1990)
1. Extent of tear
a. Group I: Partial tears or full tears <1cm
b. Group II: Full thickness tear of entire supraspinatus
c. Group III: Full thickness tears involving more than 1 tendon
d. Group IV: Massive tears with 2° DJD
2. Topography of Tear – Sagittal Plane
a. Subscapularis tear
b. Coracohumeral ligament tear
c. Isolated supraspinatus tear
d. Tear of entire supra and ½ of infraspinatus
e. Tear of supra and infra
f. Tear of subscapularis, supraspinatus, and infraspinatus
3. Topography of Tear – “Frontal” Plane – 3 stages
a. Stage 1 – Proximal stump close to bony insertion
b. Stage 2 – Proximal stump at level of humeral head
c. Stage 3 – Proximal stump at level of glenoid
4. Quality of Muscle
5. State of the Long head of biceps
E. Goutallier Classification (Goutallier et al; Clin Orthop ’94; 304: 78-83)
1. Stage 0 – Normal muscle without fatty streaks
2. Stage 1 – Some fatty streaks
3. Stage 2 – More muscle than fat
4. Stage 3 – Equal amount of fat and muscle
5. Stage 4 – More fat than muscle

II. Tear Recognition (Millett et al; JAAOS August 2014: 22(8): 521-534)
A. Crescent tears
1. ~40% of tears
2. Mobilize medial to lateral
3. Typically “reparable”
4. Avulsion from tuberosity
5. Do NOT extend into rotator interval
B. U or V Tears
1. ~15% of tears
2. Apex extends much further medially than crescent
3. CANNOT bring apex to bone
 4. Adequate AP mobility allows side to side (“margin convergence” –
McLaughlin; Burkhart)
5. Fix free margins together first and apex converting U/V to small crescent
C. L- and Reverse-L Tears
1. ~30% of tears
2. Transverse and longitudinal components
3. L tears propagate along interval between supra and infra
4. Reverse-L propagate along through rotator interval
5. Key is to view from lateral portal to ensure anatomic reduction
D. Massive, contracted, Immobile Tears (“Irreparable”)
1. Anterior interval slide (release coracohumeral ligament)
2. Posterior interval slide (cut between supra and infra tendons) – controversial
3. May have to resort to partial repair

III. Strategy for Suture Management/Mental Rehearsal (Skill, Christopher Ahmad, MD –

Amazon)
A. Subscapularis
1. Single row
2. Double row
3. Biceps – leave, tenotomize, tenodese
B. Biceps tendon
1. Soft tissue tenodesis (“PITT” technique)
2. Incorporate into subscap repair with accessory suture from lateral row anchor
3. Separate suture anchor
C. Posterosuperior Tear
1. Single row
2. Double row
3. Double row transosseous equivalent
D. Develop a routine
1. John Richmond (one of my mentors) – “we do it the same way every time”…
2. Incorporate the scrub tech/nurse into your team
3. Write down you repair strategy and give it to your team (residents, fellows,
surgical first assistants)
4. Try to avoid “reinventing the wheel” every time you do a rotator cuff repair
5. Start with “big” 30,000 foot principle and then work down from there

IV. Biologic Augmentation (Patel et al, J Orthop Res 2017. Doi: 10.1002/jor. 23810. [Epub
ahead of print].
A. Know the current options
B. Determine if you are a “believer”
C. Resorbable options
D. Permanent options
E. Primary vs revision
F. Cost/benefit
G. Risk profile

V. Know Your Limits and the Patient’s

A. Surgical Skill
B. Surgical Techniques (do you know all the tricks necessary)
C. Surgical tools
D. Plan B, C and D
1. Partial repairs
2. Margin convergence
3. Biologic augmentation
a. Dermal allograft
b. Resorbable scaffold
4. Superior capsular reconstruction
5. Reverse total shoulder replacement
E. Can the patient do the rehab necessary to regain function, strength, and use of the arm?
 Use of Biologics in
Rotator Cuff Repair

Jason L. Dragoo, MD
Associate Professor
Department of Orthopaedic Surgery
 I (and/or my co-authors) have something to
disclose.
Detailed disclosure information is available via:

Printed Final Program

Meeting Handout Website

[Link]
or
AAOS Orthopaedic Disclosure Program on the AAOS website at
[Link]
 Biologics in RTC Repair

•  Much attention has been given to optimizing:

ü Implant design
ü Suture configuration
ü Suture material

•  Biological augmentation may enhance local healing

•  Biologics can be divided into the following groups:

•  Autologous Growth factors (PRP)
•  Cellular agents (Stem cell therapy)
•  Tissue therapy (Scaffolds)
JSES Dec 2015

•  All randomized trials published before 1/2015

•  5 articles met inclusion criteria
•  No difference with or w/o PRP: Constant, UCLA,
Simple Shoulder Test, ASES
•  Failure rate decreased in PRP group when used to
treat small-to-medium tears (no difference in
massive tears)
Arthroscopy
Dec 2015

•  Included all Meta-analyses before 1/2015

•  7 meta-analyses with 3,193 patients
•  PRP did not improve clinical outcome or lower re-
tear rate
•  Subgroup analysis: some evidence of outcomes:
•  Smaller and medium-sized tears
•  Double-row fixation techniques
•  PRP clot injected at bone-tendon interface
 Recent RCTs RTC Repair + PRP
Study Journal Disease Treatment No. of Follow- Outcome Findings
(year) patients up Measures

Malavolta AJSM Complete Single-row 54 (27 per 24 mths •Constant No

(2014) supraspinatus repair group) •UCLA difference
tears •VAS pain
Liquid PRP •MRI
vs. control
Wang (2015) AJSM Full-thickness Double-row 60 (30 per 16 weeks •Oxford No
supraspinatus repair group) Shoulder difference
tears Score
2 post-op •QuickDASH
PRP inj vs. •VAS pain
control •MRI

Jo (2015) AJSM Medium-to- Suture- 74 (37 per 12 mths •Constant No

large RTC bridge repair group) •VAS pain difference
*NON- tears •MRI
BLINDED PRP vs.
control
 Recent RCTs RTC Repair + PRP
Study Journal Disease Treatment No. of Follow- Outcome Findings
(year) patien up Measures
ts
Zumstein JSES Rotator cuff Double-row 35 (17 12 mths •Subjective No Difference
(2016) tear repair per Shoulder
group) Value
LR-PRP versus •Simple
control Shoulder Test
•Constant
Carr (2015) AJSM Chronic cuff Arthroscopic 60 (30 24 mths •Oxford No difference
tendinopathy acromioplasty per Shoulder
group) Score Tendon
LR-PRP versus cellularity
control •Analysis of DECREASED
tendon in PRP group
biopsy
Verhaegen JSES Chronic Arthroscopic 40 (20 12 mths •Simple No difference
(2016) calcific needling/ per Shoulder Test
tendinitis debridement group) •QuickDASH
•Constant
LR-PRP versus
control

LR-PRP = leukocyte-rich PRP LP-PRP = leukocyte-poor PRP

 Recent RCTs RTC Repair + PRP
Study Journal Disease Treatment No. of Follow- Outcome Findings
(year) patient up Measures
s
D'Ambrosi Musculoske Full Single row 40 (20 per 6 mths •DASH Short term
(2016) let Surg. thickness repair group) •Constant reduction in
cuff tears LHB tenotomy •VAS pain with PRP
•US at 6
LR-PRP vs months
control

Flury AJSM Supraspina Double row 120 (60 24 mths •Constant No difference
(2016) tus tear repair per group) •OSS
•ASES
LP-PRP at •Disabilities
footprint versus of Arm
ropivacaine in •Shoulder
SA space and Hand
Holtby Orthop J Partial or Majority single 82 (41 per 6 mths •VAS Short term
(2016) Sports Med full rotator row repair group) •ShortWORC reduction in
cuff tears •ASES pain with PRP
<3 cm PRP vs control •Constant
•ROM

LR-PRP = leukocyte-rich PRP LP-PRP = leukocyte-poor PRP

 PRP Summary
•  Considerable heterogeneity of the content,
quality, and quantity of growth factors used
•  Leukocyte rich vs poor vs unknown
•  Routine use of PRP at time of RCR is not
warranted based on current available evidence
 Evidence for use of PRP
Level I Evidence

•  Lateral Epicondylitis Yes

•  RTC Repair No
•  Patellar Tendinopathy Yes
•  Achilles Tendinopathy No
•  Acute Injury No
•  Intra-operatively No
•  Chondral Defects No
•  OA symptoms Yes
•  Muscle regeneration ?
 Insertion Site Preparation

•  Methods to improve
local environment
ü Bed abrasion-Crimson Vail
ü Microfracture

•  Think Biology!
Marrow Stimulation

MS 78%
Control 55%

AJSM, 2013

MS > Control

Arthroscopy, 2013

MS > Control
Taniguchi et al, JSES 2013 Slide Courtesy of Brian Cole
 Stem Cell Therapy

•  Only 3 clinical studies have been published

•  Mesenchymal stem cell (MSCs) therapy may
improve healing by:
•  Secreting growth factors
•  Providing cellularity
•  Local paracrine activity

•  MSCs may be isolated from:

•  bone marrow
•  adipose tissue
•  Matched Case-Control Study
•  45 patients BMAC + RCR
•  45 matched control RCR
•  MSCs drawn from ASIS and placed at tendon interface
•  87% healing (BM-MSC) vs. 44 % (Non BM-MSC)
•  10 years follow-up
•  Control group 4x as likely to have “poor outcome”
 JSES 2013

•  Best results with

•  RTC Repair-re-tensioning
•  ADSC injection

•  Fatty degeneration
 Stem Cell Summary

•  Clinical evidence to support the use of stem

cells to augment RTC repair is promising
•  More RCTs will be necessary to verify
Hernigou’s findings
Where should stem cells be
harvested?

Proximal Humerus Iliac Crest

•  125 patients with tear
75 w/o cuff tear
•  Marrow aspirated Tear= 214 ±128
from greater tuber-
No tear= 564 ±216
osity of humerus
•  Patients with tear had
significantly lower
levels of MSCs
RTC Scaffolds
 RTC Scaffolds
•  Types
ü Allograft
ü Xenograft (Bovine)
ü Synthetic

•  Uses
ü Augment repair
ü Extend cuff

•  Questions
ü Expensive
ü Do they work?
Scaffold Augmentation

N=10
80% intact

N=18
83% intact

N=10
90% intact

Slide Courtesy of Brian Cole

•  LOE III
•  152 patients with massive RCT

•  Control Re-tear 41%

•  Collagen Patch Re-tear 51%
•  Polypropylene Re-tear 17%
 Scaffolds Summary

•  May be useful in worst case scenario

•  Routine use may be questioned due to
ü Cost
ü Lack of consistent literature
ü Unclear biologic benefit
 Summary

•  Give biology the same attention as you give

implant and repair techniques
•  Think about the local biological environment
and optimize it when possible
•  This may lead to improved healing rates and
clinical outcomes
Thank you
 DOUBLE ROW VERSUS SINGLE ROW ROTATOR CUFF REPAIR

Ian K.Y. Lo, MD, FRCSC

University of Calgary
Calgary, AB, CANADA

Technique of Arthroscopic Rotator Cuff Repair

• Both single row and double row techniques continue to evolve

• Makes comparisons of double row versus single row a moving target
• Results of both single row and double row repairs continue to improve with
improved
o Understanding of tear patterns, releases advances
o Surgical expertise improves
o Technology advances
• Current trends
o Single row
 Evolution of single row, double loaded simple stitch
reconstructions  single row, triple loaded, loading sharing
stitch reconstructions (e.g. rip-stop stitches), +/- medial
footprint anchor placement
o Double row
 Evolution of classic medial anchor/mattress stitch, lateral
anchors/simple stitch reconstructions  medial
anchor/mattress stitch, lateral anchor/spanning suture (e.g.
“suture bridge,trans-osseous equivalent) medial
anchor/tape suture, lateral anchor/spanning tape  medial
anchor/rip stop stitch/tape suture, lateral anchor/spanning
tape
• Evolution of technique (esp with double row)
o Increases complexity of repair
o Increases OR time
o Increases suture/anchor load
o Increases cost
• However, failure of rotator cuff repair (clinical or anatomic)  revision
rotator cuff repair   cost

Goals Of Rotator Cuff Repair

1. Restore Anatomy
2. Biomechanically secure construct
3. Long-term durability (i.e. healing)
4. Restore Function
5. ?Enhance healing
PRIMARY GOAL IS FOR TENDON HEALING (BY WHATEVER MEANS) SINCE TENDON HEALING
FOLLOWING REPAIR IS ASSOCIATED WITH

• Improved active motion

• Improved strength
• Improved patient self-assessed function

THE EVIDENCE

Biomechanical Studies

• There are numerous studies which have evaluated the biomechanics of single
row versus double row rotator cuff repairs
• Multiple construct variability (e.g. suture weaves, anchor
number/configurations) makes direct comparisons difficult
• Multiple studies (but not all) have demonstrated double row superiority over
single row techniques in:
o Initial fixation strength and stiffness
o Gap formation
o Contact area
o Contact pressure
• These studies have been extensively reviewed by Pedowitz RA. Single versus
double row rotator cuff repair: Does it really matter. AANA Specialty Day, San
Francisco, CA, pp 81-87, Feb 11, 2012.
o Biomechanical studies lowest level of evidence
o His conclusion double row has better biomechanical properties and
footprint coverage
• Homann et al. Single – versus Double-row repair for full-thickness rotator
cuff tears using suture anchors. A systematic review and meta-analysis of
basic biomechanical studies. Eur J Orthop Surg Trauma, Dec 2017.
o Latest meta-analysis and review
o 8 studies- significant heterogeneity
o Double row
– significantly greater load to failure
- lower gap formation

Prospective Randomized Trials

• Since 2007, multiple prospective randomized trials have been published

comparing single and double row repair (Level I and Level II)
• In addition to some differences in inclusion criteria, different surgical
techniques (both single and double row) have been utilized making direct
comparisons difficult
Study Year Patients Technique utilized Outcome
Single Row Double Row Clinical Anatomic
Franceschi 2007 52 Mattress Med mattress, lat simple NSD DR trend better
Grasso 2009 72 Simple Med mattress, lat simple NSD NA
Burks 2009 40 Simple Med mattress, lat simple NSD NSD
Aydin 2010 68 Simple Suture bridge NSD NA
Gartsman 2011 83 Simple Suture bridge NA DR better
Koh 2011 62 Simple Med mattress, lat simple NSD NSD
Lapner 2012 90 Mattress Med mattress, lat simple NSD NSD (trend better for small tear/DR)
Carbonel 2012 160 Simple Med mattress, lat simple DR better, esp tears > 3 cm NSD
Ma 2012 53 Simple Med mattress, lat simple NSD/DR better strength tears > 3 cm NSD

• While the majority have demonstrated no significant difference using

standard shoulder outcome measurement tools (e.g. Constant, ASES, etc.)
there is a general trend toward superior anatomic outcomes with double row
rotator cuff repair and to a lesser extent clinical outcome.
• No study has demonstrated superiority of single row over double row

Meta-Analysis And Structured Literature Reviews

• With the addition of multiple prospective cohort and prospective

randomized trials recently several meta-analysis and structured literature
reviews have been published

Study Studies Total Clinical Outcome Anatomic Outcome

Included Patients
Nho et al 2009 5 547 NSD DR trend better healing
Duquin et al 2010 23 1252 N/A DR significantly lower retear rate
NSD, DR better for tears > 3
Saridakis et al 2010 6 388 DR improved structural healing
cm
Wall et al. 2011 5 308 NSD N/A
Prasathaporn et al
5 308 DR better ext rotation DR better healing
2011
DR trend toward lower retear
DeHaan et al 2012 7 446 NSD
rate
Sheibani-Rad et al.
5 349 NSD N/A
2013
 Chen et al. 2013 6 476 NSD DR significantly higher intact rate
Xu et al. 2014 9 651 DR higher ASES DR lower reatear rate
Millett et al. 2014 7 567 NSD DR lower retear rate
Hein et al, 2015 32 2048 N/A DR & SB lower retear rate
Spiegl et al, 2016 8 MA 1075 No clinical difference Trend with double row

Marcarenhas et al. Is double-row rotator cuff repair clinically superior to single row
rotator cuff repair: a systematic review of overlapping meta-analyses. Arthro, 2014.
• 8 meta-analysis included (4 Level I, 4 Level I/II)
• 6 no difference in clinical outcome, 2 favor DR with tears > 3 cms
• 2 favor double row for healing of all tears, 3 more for tears > 3 cms
• Conclusion: DR provides superior clinical healing to SR

In summary double row rotator cuff repair when compared to single row rotator
cuff repair is associated with
o Improved structural healing and a lower retear rate
o Maybe better in tears > 3 cms
o No or small clinical superiority

But Is it Cost Effective?

Controversial Data – 2 major studies

Genuario et al. The cost-effectiveness of single row compared with double row
arthroscopic rotator cuff repair. JBJS Am, 2012.
• 2 cohorts: Tears < 3 cms, > 3 cms
• Probabilities of retear, symptoms, health utilities derived from literature
• Incremental cost effectiveness ratio massive for DR-RCR > $460,200-
571,500
• Conclusion: DR not cost effective for any size of rotator cuff tear

Huang et al. Double-row arthroscopic rotator cuff repair is more cost effective than
single row rotator cuff repair. JBJS Am , 2017.
• Health care cost, probabilities and utility derived from literature
• Efficacy data obtained from previous RCT comparing DR to SR
• Canadian study in public system.
• DR more costly than SR (only $2,134.41 vs $1,654,76)
• DR more effective than SR (4.073 vs 4.055 QALY)
• ICER $26,666.75 per QALY ~ may be lower for larger tears (> 3 cms)
• Conclusion: based on willingness to pay threshold of $50,000 per QALY DR
more cost effective than SR
Can I Accelerate Rehab With DR-RCR?

Few studies
Can superior fixation allow quicker rehab?

Franceschi et al. Double-row repair lowers the retear risk after accelerated
rehabilitation. AJSM 2016.
• 58 patients SR or DR (age 50-70 y.o.; No massive tears)
• Risk factors: calcific tendinopathy, adhesive capsulitis, labral tear requiring
repair, single tendon supraspinatus tear, PASTA)
• Rehab: Sling X 4 weeks, passive ER + early closed chained passive overhead
ROM exercises (i.e. table slides); Overhead stretching/pulleys at 6 weeks
• MRA: Retear rate DR lower than SR (8% vs 24%)
• NSD in clinical outcome (UCLA), ROM, Stiffness
• Conclusions: in select patients at high risk for stiffness and necessitating
accelerated rehab DR repair leads to lower retear rate

Conclusions

• Still controversial, evolving information

• If all other factors considered equal (e.g. tear size, patient age). Double row
rotator cuff repair is associated with:
o Better biomechanics (> Level V)
o Small trend better clinical outcome (? larger tears)(Level I/II)
o Better anatomic outcome (Level I/II)
• Downsides
o Cost
o Time
o Complexity
o Type II failures
• Both acceptable for clinical use
• Not all or one suitable for all tears
• Tailor the repair type/technique to patient, tear, rehab and own personal
skill set

References

Aydin N, Kacaoglu B, Guven O. Single-row versus double-row arthroscopic rotator

cuff repair in small- to medium-sized tears. J Shoulder Elbow Surg 2010;19:722-725.

Barber A, Herbert MA, Schroeder A et al. Biomechanical advantages of triple-loaded

suture anchors compared with double-row rotator cuff repairs. Arthroscopy
2010;26(3):316-323.
Barber A, Drew OR. A biomechanical comparison of tendon-bone interface motion
and cyclic loading between single-row, triple-loaded cuff repairs and double row
suture-tape repairs using biocomposite anchors. Arthroscopy 2012;28(():1197-
1205.

Burks RT, Crim J, Brown N et al. A prospective randomized clinical trial comparing
arthroscopic single- and double-row rotator cuff repair: Magnetic resonance
imaging and early clinical evaluation. Am J Sports Med 2009;37;674-82.

Carbonel I, Martinez AA, Calvo A et al. Single-row versus double-row arthroscopic

repair in the treatment of rotator cuff tears: a prospective randomized clinical study.
Int Orthop 2012;36:1877-1883.

Charousset C, Grimberg J, Duranthon LD et al. Can a double-row anchorage

technique improve tendon healing in arthroscopic rotator cuff repair? A prospective
nonrandomized, comparative study of double-row and single-row anchorage
techniques with computed tomographic arthrography tendon healing assessment.
Am J Sports Med 1997;35 (8):1247-1253.

Chen MD, Xu W, Dong Q et al. Outcomes of single-row versus double-row

arthroscopic rotator cuff repair: A systematic review and meta-analysis of the
current evidence. J Shoulder Elbow Surg 2013:29(8):1437-1449.

Dehaan AM, Axelrad TW, Kaye E. Does double row rotator cuff repair improve
functional outcome of patients compared with single row technique. A systematic
review. Am J Sports Med 2012;40:1176-1185.

Dines JS, Bedi A, ElAttrache NS, et al. Single-row versus double-row rotator cuff
repair: techniques and outcomes. J Am Acad Orthop Surgeons 2010;18(2):83-93.

Duquin TR, Buyea C, Bisson LJ. Which method of rotator cuff repair leads to highest
rate of structural healing: A systematic review. Am J Sports Med [Link]-841.

Franceschi F, Ruzzini L, Longo UG et al. Equivalent results of arthroscopic single-row

and double-row suture anchor repair for rotator cuff tears: A randomized controlled
trial. Am J Sports Med 2007;35:1254-60.

Gazielly DF, Gleyze P, Montagnon C. Function and anatomical results after rotator
cuff reapri. Clin Orthop Rel Res 194;304:43-53.

Grasso A, Milano G, Salvatore M, et al. Single-row versus double-row arthroscopic

rotator cuff repair: a prospective randomized clinical study. Arthroscopy 2009;25:4-
12.
Harryman DT 2nd, Mack LA, Wang KY, et al. Repairs of the rotator cuff: correlation of
functional results with integrity of the cuff. J Bone Joint Surg Am 1991;73(7):982-
989.

Hein J, Reilly JM, Chae J, et al. Retear rates after arthroscopic single-row, double-row
and suture bridge rotator cuff repair at a minimum of 1 year of imaging follow-up: A
systematic review. Arthroscopy 2015; epub.

Koh KH, Kang KC, Lim TK et al. Prospective randomized clinical trial of single-
versus double-row suture anchor repair in 2- to 4- cm rotator cuff tears: clinical and
magnetic resonance imaging results. Arthroscopy 2011;27(4):453-462.

Lapner PL, Sabri E, Rakhra K et al. A multicenter randomized controlled trial

comparing single-row with double-row fixation in arthroscopic rotator cuff repair. J
Bone Joint Surg Am 2012;94:1249-57.

Ma HL, Chiang ER, Wu HT et al. Outcome and imaging of arthroscopic single-row and
double-row rotator cuff repair: A prospective randomized trial. Arthroscopy
2012;28(1):16-24.

Millett PJ, Warth RJ, Dornan GJ et al. Clinical and structural outcomes after
arthroscopic single-row versus double-row rotator cuff repair: A systematic review
and meta-anslysi fo the level I randomized clinical trials. J Shoulder Elbow Surg
2014;23:586-597.

Nho SJ, Slabaugh MA, Seroyer ST et al. Does the literature support double-row
suture anchor fixation for arthroscopic rotator cuff repair? A systematic review
comparing double-row and single-row suture anchor configuration. Arthroscopy
2009;25:1319-28.

Papalia R, Franceschi F, Del Buono A et al. Double row repair: is it worth the hassle?
Sports Med Arthrosc 2011;19(4):342-7.

Prasathaporn N, Kuptniratsaikul S, Kongrukgreatiyos. Single-row repair versus

double-row repair of full-thickness rotator cuff tears. Arthroscopy 2011;27(7)978-
985.

Reardon DJ, Maffulli N. Evidence shows no difference between single- and double-
row repair for rotator cuff tears. Arthroscopy 2007;:23(6):670-3.

Saridakis P, Jones G. Outcomes of single-row and double-row arthroscopic rotator

cuff repair: a systematic review. J Bone Joint Surg Am, 2010;92:732-42.
Sheibani-Rad S, Giveans R, Arnoczky SP, Bed A. Single-row versus double-row
rotator cuff repair: A meta-analysis of the randomized clinical trials. Arthroscopy
2013:29(2):343-348.

Thomazeau H, Boukobza E, Morcet N, et al. Prediction of rotator cuff repair results

of magnetic resonance imaging. Clin Orthop Rel Res 1997;344:275-283.

Trappey GJ, Gartsman GM. A systematic review of the clinical outcomes single row
versus double row rotator cuff repairs. J Shoulder Elbow Surg 2011;20:S14-S19.

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.

Wall LB, Keener JD, Brophy RH. Clinical outcomes of double-row versus single-row
rotator cuff repairs. Arthroscopy 2009;25:1312-8.
 Subscapularis Tears –
Why We Can Miss These – How to Diagnose and Fix

AOSSM/AANA Specialty Day

Morial Convention Center
New Orleans, Louisiana
March 10, 2018

Jeffrey S. Abrams, M.D.

Princeton, New Jersey

Introduction:
Rotator cuff tears involving the subscapularis are not uncommon. Tears can be isolated
single tendon tears or be in combination with the rotator interval and supraspinatus
(anterosuperior tear). Because radiologists and surgeons are accustomed to looking at
tears posterior to the biceps on coronal views; subscapularis tears can be missed. MRI
and CT scan transverse cuts can illustrate the detached subscapularis and in certain cases
a displaced long head of the biceps tendon.
Anterior capsular ligaments including the medial reflection pulley can “hide” the
subscapularis insertion during arthroscopy. Physicians who perform a careful
preoperative and intraoperative exam will be best prepared to repair the subscapularis
tear.
Medial sagittal cuts may identify muscular changes including atrophy and fatty
infiltration. Although prognosis of strength return may be compromised, the tenodesis
effect of an intact cuff is beneficial to maintaining the humerus glenoid relationship.

I. Preoperative testing
Passive external rotation is increased if complete tendon tear
Weakness internal rotation (i.e., lift-off, belly-press, bear hug signs)
Imaging: MRI

MRI of subscapularis tear Right shoulder internal rotation

weakness as elbow collapses to side
Subscapularis Tears – Why We Can Miss These – How to Diagnose and Fix Jeffrey S. Abrams, M.D.
March 10, 2018 Page 2

II. What should we do with the coracoid?

The coracoid provides an interesting restraint to medial retraction. The pulley and
coracohumeral ligaments can limit medial retraction to the glenoid articular margin.
Coracoids can be decompressed with a shaver, removing soft tissue along its lateral
margin, allowing a clear interval along the bursal aspect of the tendon. A small
coracoidplasty can be applied in selected cases. Preoperative imaging may be helpful to
discover osteophytes or reduced intervals between the coracoid and lesser tuberosity. On
occasion, a coracoid decompression can be used in patients with pain in the absence of
tears.

Cautery debridement of coracoid to maximize interval prior to repair.

What should we do about the biceps?

The unstable biceps can be problematic. It may appear normal on an MRI or CT study,
since most of it can remain in the groove, with the upper portion subluxation with
humerus rotation. When the tendon rests out of the groove, tenodesis is the best decision.
In very young individuals with a mobile clicking tendon, a medial pulley repair can be
considered. Most, however, have a more predictable outcome with tenodesis.
A tenotomy is performed with a tag suture on the tendon. This allows a displaced tendon
to be retracted away from the subscapularis footprint. I can incorporate the tenodesis
into the same suture anchor that addresses the upper border of the subscapularis repair;
particularly if the suture anchor has three available sutures.
III. Common Releases and Mobilization
 MGHL – upper release to visualize the subscapularis
 Bursal interval release
• Coracoid
• Brachioradialis and short head to the biceps
• Musculocutaneous nerve
 Traction sutures during release

Traction stitch in tendon edge to assist suture passage and releases.

Subscapularis Tears – Why We Can Miss These – How to Diagnose and Fix Jeffrey S. Abrams, M.D.
March 10, 2018 Page 3

IV. Integrity and utilization of the comma sign:

A band of connective tissue that normally attaches to the upper lateral border to the
subscapularis and extends to the medial biceps pulley. It is made up of the SGHL,
coracohumeral ligament and pulley. Surgical reduction can assist the reduction of a
retracted supraspinatus.

Anchor placed along medial footprint, and sutures will

incorporate subscapularis and comma extension.

V. Cannula placement:
Create a window in the rotator interval capsule; a large working cannula can be inserted.
Access to the coracoid, subscapularis tendon and lesser tuberosity can be approached
from this location. The cannula can be partially backed out to allow bursal access and
avoid soft tissue capture during suture passes and knot-tying. This window allows the
scope to remain in the posterior articular viewing portal, and both the articular and bursal
tendon can be mobilized and accessed. Advance the scope and rotate the light cord to
maximize the field of vision.

Cannula should allow both bursal and articular access to tendon.

Subscapularis Tears – Why We Can Miss These – How to Diagnose and Fix Jeffrey S. Abrams, M.D.
March 10, 2018 Page 4

VI. Anchor placement:

The most common configuration used today for the subscapularis is a multistitched
single-row repair. Lateral rows can violate the bicipital groove which makes this
different that the supraspinatus decisions. The complex repair can be approached in
different ways. The inferior muscular portion can be initially fixed with an anteroinferior
anchor, especially in cases where the joint capsule is being repaired with the same
fixation. The upper-third subscapularis repair is performed with an anchor along the
superior footprint, adjacent to the articular margin to minimize tension. This important
landmark for the subscapularis requires secure repair.

Suture passing and retrieving

 Transtendon suture retrieval of lateral border
 Antegrade suture passing from a superior portal

 Fixation
Mattress sutures
Simple sutures

A mattress suture is placed to create the correct tension

in the upper border of the tendon.

Combo repair
Repair inspection and augmentation
Rotate humerus to avoid unintended adhesions to neighboring tissue

Should an anterior interval release be a common technique for the complex tear?
“Medial tissue attached to the coracoid can be divided and released, visualizing from a
lateral portal.” Rotator interval capsule can be resected. Preservation of the comma
sign is helpful in patients with combined supraspinatus and subscapularis tears.

Postoperative restriction:
Passive external rotation to 0°
Active internal rotation exercises for 8 to 10 weeks
Delay behind-the-back movements (extension, internal rotation) for more than 8
weeks
Subscapularis Tears – Why We Can Miss These – How to Diagnose and Fix Jeffrey S. Abrams, M.D.
March 10, 2018 Page 5

VII. Techniques:
Subscapularis Window
• The articular view approach is best performed on partial-thickness tears, superior
border full-thickness tears, and minimally-retracted tears.
• A window is created through the interval, allowing the surgeon to visualize both the
articular aspect of the tendon and the bursal side if the scope is pushed through the
window.
• Do not divide the comma sign tissue in moderately retracted tears. Work medially
and laterally to this bridging tissue.
• Clear the coracoid process and decompress in selected cases.

Subscapularis Mobilization
• Pull traction suture through a separate skin portal or puncture wound.
• Open rotator interval window and visualize coracoid process.
• Place shaver on bursal and articular side of subscapularis to improve mobility.
• 360° subscapularis release: Cut articular capsule to visualize and mobilize. Cut
interval capsule, release bursal and coracoid adhesions.
• May need to switch scope to lateral or anterior portal to mobilize from inferior arch
of coracoid. Stay close to bone and do not shave medial to arch. It is better to
deliver tendon laterally with traction stitch.
• Coracoidplasty in selected cases. Increase tendon clearance.

Lesser tuberosity footprint preparation

Elevate biceps and pulley; if displaced, place biceps marker suture and tenotomize
adjacent to superior labrum.

If normal, leave alone.

Internally rotate humerus and abrade soft tissue attachment with arthroscope in
posterior portal; advance anteriorly towards the interval, viewing laterally. If
difficult to visualize, may switch to 70° scope.
Subscapularis Tears – Why We Can Miss These – How to Diagnose and Fix Jeffrey S. Abrams, M.D.
March 10, 2018 Page 6

Suture anchors insertion into lesser tuberosity

Begin inferiorly and work inferior to superior
Single anchor per cm tear
May consider double-row, but lateral margin of tuberosity is soft.

Suture pass options

If retracted, place traction on superior tendon margin or “comma sign” to stabilize
the tendon.
Suture hook and shuttle: Work hook from bursal to articular surface.
Piercing instrument retrieves sutures. May be easiest and quickest.
Antegrade push through tendon articular to bursal side.

Suture hook passes monofilament suture on shuttle.

Advance and tie after sutures in place – beginning inferiorly.

Subscapularis Tears – Why We Can Miss These – How to Diagnose and Fix Jeffrey S. Abrams, M.D.
March 10, 2018 Page 7

Bursal approach to subscapularis

• Full-thickness tears that extend across the interval and have medial or inferior
retraction can be approached from the subacromial and subcoracoid space.
• After articular releases, the scope is placed in the anterolateral portal. Debridement
along the inferior border of the coracoid allows for improved visualization.
• A clear plastic cannula can be placed in the anterior portal and withdrawn to
penetrate the deltoid, but not the interval tissues. This provides an excellent view of
the footprint and soft tissue restraining the long head of the biceps.
• This same portal allows visualization of the anterior margin of the supraspinatus tear
as well.

Bursal technique for repair

1. Debride footprint
2. Externally rotate humerus and create a medial puncture to optimize angle of suture
anchor introduction.
3. A single- or double-row repair can be accomplished.
4. If a lateral anchor is placed, the biceps groove often has softer subchondral density.
Large anchors may be needed.
5. Reinforcement of the comma connective tissue with a lateral anchor after biceps
tenotomy or tenodesis may be a good option to provide additional strength to the
repair.
6. Sutures through the subscapularis are tied prior to repairing the supraspinatus and
infraspinatus repairs. This will relieve some of the tension, reduce the size of the
“hole,” and reduce risk of suture enlargement.

Bursal view of footprint coverage – repair Subscapularis tendon repair

supraspinatus or posterior tear extension
Subscapularis Tears – Why We Can Miss These – How to Diagnose and Fix Jeffrey S. Abrams, M.D.
March 10, 2018 Page 8

Postoperative

Ultrasling for 5-6 weeks

External rotate to 0° for 4-5 weeks.

After 5 weeks:
Supine passive flexion
External rotate to 20°
Scapular shrugs
Grip strength

After 8-10 weeks:

Increase external rotation to 45°
Internally rotate behind back to waist

After 10-12 weeks:

Gentle strength to cuff – internal and external rotation
Scapular strength

4-6 months:
Return to sports and physical activity
Subscapularis Tears – Why We Can Miss These – How to Diagnose and Fix Jeffrey S. Abrams, M.D.
March 10, 2018 Page 9

References:

1. Abrams JS. Repair of large anterosuperior cuff tears. In: Abrams JS, Bell RH eds. Arthroscopic
Rotator Cuff Surgery: A Practical Approach to Management. New York: Springer; 2008:228-
45.
2. Abrams JS, Song FS. Subscapularis Injury. In: Miller MD, Thompson SR (eds). DeLee &
Drez’s Orthopaedic Sports Medicine: Principles and Practice. Elsevier Saunders. Philadelphia
PA. 2015:602-611.
3. Bennett WF. Arthroscopic repair of isolated subscapularis tears: A prospective cohort with 2- to
4-year follow-up. Arthroscopy 2003;19:131-43.
4. Bennett WF. Arthroscopic repair of anterosuperior (supraspinatus/subscapularis) rotator cuff
tears: A prospective cohort with 2- to 4-year follow-up classification of biceps subluxation
instability. Arthroscopy 2003;19(1):21-23.
5. Burkart SS, Brady PC. Arthroscopic subscapularis repair: Surgical tips and pearls A to Z.
Technical note. Arthroscopy 2006;22(9):1014-27.
6. Burkhart SS, Tehrany AM. Arthroscopic subscapularis repair: Technique and preliminary
results. Arthroscopy 2002;18:454-63.
7. Dakurai G, Ozaki J, Tomita Y, et al. Incomplete tears of the subscapularis tendon associated with
tears of the supraspinatus tendon: Cadaveric and clinical studies. J Shoulder Elbow Surg
1998;7:510-515.
8. Deutsch A, Altchek DW, Veltri DM, et al. Traumatic tears of the subscapularis tendon. Clinical
diagnosis, magnetic resonance imaging findings, and operative treatment. Am J Sports Med
1997;25:13-22.
9. Edwards TB, Walch G, Sirveaux F, Molé D, Nové Josserand L, et al. Repair of tears of the
subscapularis. JBJS 2005;87(A):725-30.
10. Gerber C, Hersche O, Farron A. Isolated rupture of the subscapularis tendon. Results of
operative repair. J Bone Joint Surg Am 1996;78:1015-23.
11. Gerber C, Krushell RJ. Isolated rupture of the tendon of the subscapularis muscle. Clinical
features in 16 cases. J Bone Joint Surg Br 1991;73:389-94.
12. Krenz PC, Remiger A, Engselect C, et al. Isolated and combined tears of the subscapularis
tendon. Am J Sports Med 2005;33(12):1831-7.
13. Lafosse L, Jost B, Reiland Y, Audebert S, Toussaint B, Gobezie R. Structural integrity and
clinical outcomes after arthroscopic repair of isolated subscapularis tears. JBJS
2007;89A(6):1184-93.
14. Lo IK, Burkhart SS. The comma sign: An arthroscopic guide to the torn subscapularis tendon.
Arthroscopy 2003;19:334-7.
15. Richards DP, Burkhart SS, Lo IK. Subscapularis tears: Arthroscopic repair techniques. Orthop
Clin N Am 2003;34:485-98.
16. Richards DP, Burkhart SS, Tehrany AM, Wirth MA. The subscapularis footprint: An anatomic
description of its insertion site. Arthroscopy 2007;23(3):251-4.
17. Sakurai G, Ozaki J, Tomita Y, et al. Incomplete tears of the subscapularis tendon associated with
tears of the supraspinatus tendon: Cadaveric and clinical studies. J Shoulder Elbow Surg
1998;7:510-5.
18. Ticker JB, Warner JJP. Single-tendon tears of the rotator cuff: Evaluation and treatment of
subscapularis tears and principles of treatment for supraspinatus tears. Orthop Clin N Am
1997;28:99-116.
19. Warner JJP, Higgins L, Parsons IM, Dowdy P. Diagnosis and treatment of anterosuperior rotator
cuff tears. J Shoulder Elbow Surg 2001;10:37-46.
 2/19/18

Disclosure
Stephen S. Burkhart is a consultant for, and receives
Technique Spotlight inventor’s royalties from Arthrex, Inc. (Naples, FL). He also
Superior Capsular Reconstruction: receives book royalties from Wolters-Kluwer (Philadelphia,
Why and How I Do It PA).

Stephen S. Burkhart, M.D.,

San Antonio, Texas

The Goal: Background

Joint Preservation
• Mihata has reported good
clinical success with SCR as
a joint preservation option
using fascia lata as an
autograft

Indications:
Background Who Should Get SCR?

• More recently dermal allograft • Active patients with:

has been proposed as a graft – Irreparable tear of SS/IS
source – Minimal or no GH arthritis
– Reduced operative time – Functional deltoid/trapezius
– Reduced donor site morbidity
– Intact or repairable subscap
– History of use for cuff augmentation
• Active patients with failed cuff repair and
deficient capsule

1
 2/19/18

Clinical Results:
SSB Personal Series Results at 1 Year (n=51)
(as of 12/10/17)

Pre-Op Post-Op
• 115 patients, 3 years FF 137 165 (∆ FF = 28)
• 2 failures requiring revision surgery
– 1 revision to rTSR (fell at 10 months post-op) ASES 49.2 87.9 (∆ ASES = 38.7)
– 1 revision to SCR #2 (fell at 4 weeks post-op)

Results at 1 Year (n=51)

Pre-Op Post-Op
VAS 4.86 0.70 (∆ VAS = 4.16)
What About the MRIs?
SANE 38.2 85.7 (∆ SANE = 47.5)
(SSV)

1 Year Post-op MRIs SCR Tips

• 40 patients
– 33 patients’ grafts were fully healed (82.5%)
– 4 patients’ grafts were partially healed (10%)
– 3 patients’ grafts did not heal (7.5%)
• 92.5% of grafts were fully or partially healed at 1 year
post-op SCR

2
 2/19/18

Anteromedial Anchor Should Be

Anterior to Biceps Root

• At junction of coracoid base and coracoid neck

• To prevent anterosuperior escape
For Large Graft (> 30 mm AP),
Use 3 Medial Anchors on Superior Glenoid
• Prevents bowstringing of medial part of graft
• Maintains solid contact between graft and superior
glenoid

Improve Visualization of Superior Glenoid

With Posterior Interval Slide and
Supraspinatus Traction Suture

• Even if mobility of tendon is not improved, the

exposure of superior glenoid is improved for medial
fixation of dermal allograft
• Retrieve SS traction suture through Neviaser portal
to pull tendon up and out of the way

Technical Tip

• Cut rubber cannula lengthwise if graft is >

35 mm
– Avoid capture of graft within cannula
– Remove cannula from around sutures, and
shuttle graft without cannula
– Another option: place 8.25 mm twist-in plastic
cannula through split rubber cannula
(cannula-within-a-cannu la) after FiberTapes
have been retrieved

3
 2/19/18

SCR Utilizing Glenoid Fixation Self-Cinching Knotless Anchors

with Self-Cinching Knotless Technique

• If bone quality is good

Shape of Glenoid Determines

Which Anchor to Use

• Knotless 3.9 mm anchors mid & anterior

• Knotless 3.0 mm anchor posterior

Case Example
• 56 year old man
• Left shoulder
• Irreparable SS/IS
• Very large defect (42 mm x 45 mm) Glenoid Preparation
• Knotless fixation on glenoid

4
 2/19/18

Posterior Anchor Insertion

• Narrow posterior glenoid
• 3.0 mm knotless anchor
• Posterolateral working portal

Anterior Anchor Insertion

• Anterosuperior working portal

• Junction of coracoid base and coracoid neck
• 3.9 mm knotless anchor
• This is the best quality bone in superior glenoid

Middle Anchor
• Neviaser portal
• 3.9 mm knotless anchor
• Be careful of angle of drill: do not penetrate glenoid articular
surface

5
 2/19/18

Medial Row Humerus

• If > 30 mm AP defect, use 3 anchors for medial row

Retrieve Tapes/Sutures
of Humeral Anchors
through Split Rubber Cannula

Insert 8.25 mm Plastic Cannula

Through Split Rubber Cannula

• Tapes will be outside

plastic cannula
• Eliminates risk of
crossing glenoid sutures
between humeral sutures

6
 2/19/18

Retrieve 2/3 of Glenoid Sutures:

Working Suture Plus
Looped End of Shuttling Suture

• Create laxity of all 3 sutures with suture retriever,

then tension straight limb of shuttling suture to pull it
away from other sutures
• Retrieve the 2 “lax” sutures

Running the Lines

• To detect any crossing or fouling of sutures

• Do this with tape retriever or with zipline pusher

Threading the
Splice in the Anchor
• Pass working suture through looped end
of shuttling suture, then pull on straight
end of shuttling suture

7
 2/19/18

Transporting and Securing

the Graft to Glenoid

Watch for Fouling

of Knotless Mattress

• Friction and bunching of suture where it passes through dermal

allograft
• Solution: pull on mattress loop at top of graft to eliminate
bunching

Securing the Graft to Humerus

• Medial double pulley/double mattress

• Lateral fixation with linked double row construct

8
 2/19/18

Suture to Soft Tissue Anteriorly

(Comma) and Posteriorly (IS)

Final Result

New Study:
SCR Reverses Profound Pseudoparalysis
in Patients with Irreparable RCTs and
Minimal or No GH Arthritis
- S. Burkhart, R. Hartzler (Submitted to Arthroscopy)

Can SCR Reverse • Profound pseudoparalysis ≤ 45° active elevation (shoulder shrug only)
Pseudoparalysis? • Pre-op SSV = 36; post-op SSV = 91
• 9/10 reversed pseudoparalysis (avg pre-op FE = 27°; avg post-op FE = 159°)
• MRI at 1 year post-op:
– 7/10 grafts fully healed
– 3/10 grafts partially healed
• 1 failure; C5 radiculopathy requiring surgery 4 months post-SCR

9
 2/19/18

Clinical Exam Profound Pseudoparalysis Series:

1 Year Post-op MRI
• 7/10 fully
healed
• 3/10 partially
healed

T1 Coronal T2 Coronal
Pre-op Post-op

History
• 72 year old rancher
• Two failed rotator cuff repairs, left shoulder
• Constant pain
• Pseudoparalysis
• Was advised to have rTSR by 2 different orthopedic surgeons

1 Year Post-Op SCR

• Patient rates his shoulder as 97% normal
• Active elevation 160°
• Excellent ER strength

10
 2/19/18

SCR:
An Effective Biologic Alternative to Thank You!
Reverse Arthroplasty

• Provides a stable fulcrum

• Optimizes force couples
• Achieves joint preservation

11
Figure 1A
Muscle degenera-on

mild

Severe
Figure 1B
Tendon degenera-on

mild

Severe
Figure 1C
Tendon retrac-on

mild

Severe
Figure 2
Rotator cuff tears: 452 shoulders
Evaluate severity of supraspinatus degenera-on using preopera-ve MRI

“Severe” degenera-on “Severe” degenera-on

in none or one category in two or three categories

ARCR: 259 shoulders SCR: 193 shoulders

Arthroscopic finding Arthroscopic finding

All Reducible tear Reducible tear Irreducible tear

ARCR alone: SCR + ARCR: SCR alone:

259 shoulders 37 shoulders 156 shoulders
Loss of follow-up:
3 shoulders
SCR + ARCR:
34 shoulders
Figure 3A
Figure 3B
Figure 3C
Figure 4

A B

C D
Figure 5

A B
TABLE 1 Change in cuff integrity until 1 year after surgery

　 ARCR + SCR 　 ARCR

　 3 months 6 months 1 year 　 3 months 6 months 1 year
Sugaya classification
Type I 27 (79%) 30 (88%) 33 (97%) 42 (46%) 60 (66%) 68 (75%)
Type II 7 (21%) 4 (12%) 1 (3%) 38 (42%) 20 (22%) 12(13%)
Type III 0 0 0 6 (7%) 6 (7%) 7 (8%)
Type IV 0 0 0 2 (2%) 1 (1%) 0
Type V 0 0 0 　 3 (3%) 4 (4%) 4 (4%)
TABLE 2 Comparison of shoulder ranges of motion and functional outcomes between ARCR with and
without SCR

　 ARCR + SCR ARCR P (ARCR + SCR vs ARCR)

ASES score
Preoperative 46 ± 23 41 ± 14 0.27
Postoperative 92 ± 9 91 ± 8 0.28
P (Preoperative vs Postoperative) < 0.0001 < 0.0001

JOA score
Preoperative 60 ± 13 58 ± 11 0.66
Postoperative 94 ± 6 96 ± 6 0.12
P (Preoperative vs Postoperative) < 0.0001 < 0.0001

Active elevation
Preoperative 129 ± 39° 133 ± 45° 0.66
Postoperative 163 ± 16° 169 ± 19° 0.08
P (Preoperative vs Postoperative) < 0.0001 < 0.0001

Active external rotation

Preoperative 38 ± 14° 42 ± 20° 0.26
Postoperative 48 ± 15° 50 ± 18° 0.75
P (Preoperative vs Postoperative) 0.0002 0.006

Active internal rotation

Preoperative L4 L2 0.01
Postoperative L1 T11 < 0.0001
P (Preoperative vs Postoperative) < 0.0001 < 0.0001 　
ASES, American Shoulder and Elbow Surgeons
TABLE 3 Comparison of shoulder ranges of motion and functional outcomes between healed and re-tear cases

　 Healed cases 　 Re-tear cases 　

P (Healed ARCR + SCR vs Re-tear ARCR) P (Healed ARCR vs Re-tear ARCR)
　 ARCR + SCR ARCR 　 ARCR + SCR ARCR 　
ASES score
Preoperative 46 ± 23 41 ± 14 - 38 ± 14 0.52 0.59
Postoperative 92 ± 9 92 ± 4 - 60 ± 10 < 0.0001 < 0.0001
P (Preoperative vs Postoperative) < 0.0001 < 0.0001 0.04

JOA score
Preoperative 60 ± 13 59 ± 11 - 49 ± 9 0.13 0.08
Postoperative 94 ± 6 97 ± 3 - 80 ± 15 0.0002 < 0.0001
P (Preoperative vs Postoperative) < 0.0001 < 0.0001 0.004

Active elevation
Preoperative 129 ± 39° 135 ± 44° - 90 ± 62° 0.08 0.06
Postoperative 163 ± 16° 171 ± 9° - 120 ± 70° 0.003 < 0.0001
P (Preoperative vs Postoperative) < 0.0001 < 0.0001 0.29

Active external rotation

Preoperative 38 ± 14° 43 ± 20° - 33 ± 10° 0.44 0.30
Postoperative 48 ± 15° 50 ± 17° - 38 ± 22° 0.19 0.16
P (Preoperative vs Postoperative) 0.0002 0.002 0.7

Active internal rotation

Preoperative L4 L2 - L3 0.40 0.32
Postoperative L1 T11 - T12 0.43 0.61
P (Preoperative vs Postoperative) < 0.0001 < 0.0001 　 　 0.07 　 　 　
ASES, American Shoulder and Elbow Surgeons
 TABLE 4 Severity of rotator cuff tear
　 ARCR + SCR 　 ARCR 　 P (ARCR + SCR vs ARCR)
Tear size in anterior-posterior direction (cm) 2.2 (2-4) 2.5 (1.5-5) 0.10

Torn tendons (shoulders) 0.45

2 tendons: supraspinatus and infraspinatus 29 82
3 tendons: supraspinatus and infraspinatus,
5 9
subscapularis

Acromiohumeral distance (mm)

Before surgery 6.4 (2.0-11.4) 7.4 (4.3-11.5) 0.06
At 1 year after surgery 9.6 (6.8-13.7) 10.1 (6.3-15.3) 0.23

Goutallier classification
Supraspinatus 2.8 (2-4) 2.1 (1-4) < 0.0001
Infraspinatus 0.6 (0-3) 0.4 (0-2) 0.16
Teres minor 0.1 (0-1) 0.1 (0-2) 0.07
Subscapularis 0.4 (0-4) 0.3 (0-3) 0.24

*Tear size, acromiohumeral distance, and Goutallier classification are expressed as means (ranges).
 TABLE 5 Concomitant pathologies and surgeries
　 ARCR + SCR (n=34) 　 ARCR (n=91) 　 P (ARCR + SCR vs ARCR)
Subscapularis, n (%) 0.45
Intact or partial tear (no treatment) 29 (85%) 82 (90%)
Repair for complete tear 5 (15%) 9 (10%)

Biceps, n (%) 0.26

Intact (no treatment) 17 (50%) 58 (64%)
Partial tear (no treatment) 12 (35%) 24 (26%)
Complete tear (no treatment) 2 (6%) 7 (8%)
Tenodesis for dislocated biceps 2 (6%) 2 (2%)
Tenotomy for dislocated biceps 1 (3%) 0

Acromioplasty, n (%) 34 (100%) 　 91 (100%)