“trAnsosseous-equivAlent” rotAtor cuff repAir

tears remains challenging, because the high re-tear rate following rotator cuff repair is due to multiple factors. Aspects such as poor tendon biology, muscular fatty infiltration and retraction, and nonanatomical repairs ultimately lead to inferior repair biomechanics. Although many of these factors remain beyond the control of the surgeon, certain repair constructs have been shown to decrease suture interface stress and ultimate gap formation while increasing initial fixation strength. A repair that can recreate the tendon’s natural footprint, while providing sufficient bony contact and repair construct stiffness during the healing process, optimizes the biomechanical aspects of rotator cuff repair. For the purposes of this article, a double-row construct consists of 2 rows of suture anchors all placed within the supraspinatus footprint. The transosseous-equivalent repair is a variant of the double-row repair and consists of a medial row of suture anchors; however, the lateral row of fixation is accomplished through more laterally based sutures and anchors to compress the rotator cuff footprint. The use of either the double-row or, more recently, the “transosseous-equivalent” repair construct has been advocated, as both have demonstrated superior biomechanical properties and footprint restoration. These repairs allow for an even distribution of load and increased tendon-bone contact in the area of the tendon’s natural insertion.1-3 In addition, when assessed at time zero, double-row and transosseous-equivalent repairs have demonstrated less gap formation, less bone-tendon interface motion, and superior overall biomechanical tendon fixation properties compared with single-row techniques.4-7 Although the biomechanical advantages of these procedures are attractive, the double-row and transosseous-equivalent repair types require additional surgical expertise. It should be noted that superior long-term clinical results for these techniques remain to be seen. The following outlines 5 points on the surgical and technical aspects of performing an arthroscopic double-row or transosseous-equivalent rotator cuff repair. Identify candidates on the basis of tear size and pattern. Once the subacromial space is adequately prepared, the rotator cuff tear is visualized and assessed from the lateral portal. The rotator cuff edges are débrided and the overall medial-to-lateral and anterior-to-posterior mobility of the tear is assessed. The tear pattern is then classified, and it is determined whether the tear is amenable to double-row or transosseousequivalent repair techniques. Most U-shaped, L-shaped, and crescent tears (following side-to-side repair when necessary) whose lateral edge is reducible to the lateral edge of the tuberosity are amenable to double-row repair constructs.8 Various techniques may be utilized to completely liberate the borders of the tear, allowing for optimal tendon mobilization and reduction. Smaller tears may not require a double-row repair configuration simply because the strength of the single-row repair is more than adequate to resist in-vivo forces and cyclic load during the initial postoperative protection phase. Larger