Hi, this is Rob Hartzler with TSAÖ Hi, this is Rob Hartzler with TSAOG Orthopedics and Baylor College of Medicine presenting on double row rotator cuff repair. I do have relevant financial disclosures which are available on the ANA and AAOS websites. Iíll start with a case which I think illustrates a good patient for a linked double row rotator cuff repair. This was a 49-year-old woman with a traumatic injury to her shoulder who failed non-operative treatment. Radiographs showed a type 2 acromion, otherwise normal. MRI demonstrated a full thickness retracted anterior supraspinatus tear with acceptable muscle quality. On the diagnostic arthroscopy, we can see that this is a significant tear involving the anterior cable region and one in which we would like to maximize our chances of healing for this young patient. We'll go through the how, why, and when of linked double row rotator cuff repair. We will start with the how or the technical issues involved in performing these repairs. One of our foundational principles in repairing rotator cuffs is to maximize visualization in order to achieve technically sound repairs. In order to maximize visualization, I prefer the lateral position and certain ways of managing fluid, which we'll go over. For me, the chief reason for preferring lateral position is that the anesthesiologist will typically be much more comfortable in performing hypotensive anesthesia during the case. Limiting fluid extravasation from portals is one of the key ways to maintain pressure in the shoulder and therefore enhancing the visualization. While there's some role for adjuvant medications in managing the fluid during shoulder arthroscopy, our primary way to improve the visual field is to run the pump high enough to be able to see well, which for us is typically 50 to 60 millimeters of mercury. In the following slides, we'll go through these steps in performing link double row rotator cuff repair. Our philosophy is that the primary healing for rotator cuff repairs comes from the tuberosity side and so we're very meticulous about removing all of the soft tissue elements and getting to healthy bone by excoriating the bone surface with a shaver or a ring curette or burr running on reverse. In the subacromial space, it's very important to remove all of the soft tissue from the bony landmark so these are easily visualized, particularly exposing the C-joint and the scapular spine and doing a thorough enough bursectomy in order to see the musculotendinous junction of the parts of the rotator cuff which are torn. In this case, we performed an acromioplasty because there was evidence of extrinsic impingement on the rotator cuff at the supraspinatus outlet. Tear pattern assessment is critical to repairing these tears well and we will interrogate the entire margin of the tear to ensure that we understand the pattern and that a significant anterior or posterior reduction maneuver does not need to be performed. Our philosophy over the years has been that understanding the tear pattern leads to a correct repair pattern. For linked double row rotator cuff repair, we'll typically place one anchor per 1.5 to 2 cm of anterior to posterior tear length, so a smaller size rotator cuff tear such as this one typically would only need one medial row anchor. On the other hand, in the case under consideration in this talk is at least two centimeters and so we'll place two anchors for that tear, one at the anterior and one at the posterior part of the medial margin. It's critical to be able to see, again, the rotator cuff and the musculotendinous junction very well so that the sutures aren't passed too medial. These should remain a few millimeters lateral to the musculotendinous junction. This will help to ensure that we don't place the repair at risk for a Type II failure with a suture placed in the muscle or at the musculotendinous junction. Here we can see that we have excellent visualization of the soft tissues and with the anti-grade passage we've maintained that 2 to 3 millimeter margin laterally away from the musculotendinous junction with our suture placement. Visualization of lateral row fixation is critical. A 70-degree arthroscope can be very helpful for this. To be able to see down into the lateral gutter, we will make sure that prior to the final seating of this knotless anchor that we have excellent compression from the suture tails which have been tied medially and brought over to the lateral row. Here we see intraarticular and personal views of this linked double row suture bridging type of repair construct with medial mattresses and a medial double pulley tied and then those suture tails brought to lateral row knotless anchors. Next we'll discuss the rationale for performing linked double row rotator cuff repairs done in this fashion. The primary reason to perform link-double-row repairs is that these have been shown to be biomechanically superior and that they are a self-reinforcing type of repair, meaning that the harder that the repair is placed under tension, the more compressive force is placed because of the integrated nature of the two rows of anchors. Clearly, some experts still advocate for the routine use of single-row rotator cuff repair. There are sound arguments for performing single row rotator cuff repairs for some tear patterns and advocates of double row repair should be familiar with these. Single row rotator cuff repair constructs are cost saving and for these successful operations it is difficult to prove superiority of one over another. However, when considering the individual needs of each patient, for me the most important issue is in clinical outcomes so we should try to examine what we know about that. In our practice, traditional independent double row repair was found to be far superior to single row repairs. Our best arguments for the routine use of link-double-row cuff repairs can be found in this Level 5 article in the Arthroscopy Journal. Link-double-row repairs have higher healing rates, particularly in large and massive tears. Better healing should lead to better strength. And when comparing with single-row repairs, we don't have very many good studies which are powered appropriately for being able to detect these differences. In my practice, link-double-row repairs have allowed my large and massive cuff repair patients to achieve as good of outcomes as those with small and medium-sized tears. So when do I use link-double-row rotator cuff repair in my practice? For me, linked double row cuff repairs are done for all large and massive cuff repairs, the vast majority of medium-sized tears in patients in which I think rehab or compliance might be an issue and patients in which there is significant motor dysfunction where I'm prioritizing cuff healing. It may be that in the future we find that there's a benefit for linked double row repairs and allowing patients to return to activities faster. And at this time, we just have some hints of that ability in the literature. In conclusion, prioritize visualization in doing rotator cuff repairs and you'll be able to do much more technically sound repairs. Whether single or double row, good outcomes can be achieved if we perform repairs in this fashion. Prioritize link double row repairs when healing can be a challenge and when it matters most. And I would encourage you to consider link double row repairs to be used routinely in patients with larger tears greater than two to three centimeters and I think that in the future we'll be able to understand that this does lead to better outcomes particularly in restoring strength and is cost effective. Thank you very much for your time and attention today.

rotator cuff repair

double row technique

biomechanical superiority

anchor placement

shoulder injury