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Review Article about Arthroscopic Transosseous Rotator Cuff Repair, published in the April 2023 edition of Journal of the American Academy of Orthopaedic Surgeons (JAAOS).

This paper discusses that per-implant cyst formation was not observed (0%) in the transosseous repair group with Tensor Surgical's TransOs Tunneler, while they were observed in 16.7% of the suture anchor group.

Clinical and Structural Outcome 20 Years After Repair of Massive Rotator Cuff Tears.

Arthroscopic Transosseous Rotator Cuff repair for the treatment of full-thickness Rotator Cuff tears provided good clinical results 12 to 18 years after surgery. Cuff integrity on follow-up MRI scans had a positive effect on the clinical outcome.
 

Clinical and radiological results of arthroscopic rotator cuff repair were evaluated using two different techniques: single-row anchor fixation versus transosseous hardware-free suture repair. Patients operated with the transosseous technique had significantly less pain, especially from the 15th postoperative day. 

Conclusion: 

No significant differences were found between the two arthroscopic repair techniques in terms of functional and radiological results. However, postoperative pain decreased more quickly

after the transosseous procedure, which therefore emerges as a possible improvement in the surgical repair of the Rotator Cuff. 

In the context of shifting health care models and the pressures to minimize costs, Dr. Uma Srikumaran's findings have important implications for the economics of rotator cuff repair. Considering the cost of a single anchor (ranging from $300 to $600), and the need for multiple anchors (often at least 4) to achieve an optimal repair, suture anchor based repairs contribute significantly to the overall cost of care. Srikumaran and his team revealed that the transosseous approach can reduce implant costs by 30% to 80% depending on tear size.

Brett Sanders, MD reviews his experience developing value-based transosseous techniques and technologies for Rotator Cuff Repair and Biceps Tenodesis.

This study clarified that the sequential vascular pattern inside the repaired Rotator Cuff depends on the suture technique used. Bone tunnels through the footprint may contribute to biologic healing by increasing blood flow in the repaired Rotator Cuff.

The transosseous tunnel rotator cuf repair technique creates significantly more contact and greater overall pressure distribution over a defined footprint when compared with suture anchor techniques. Stronger and faster rotator cuff healing may be expected when beneficial pressure distributions exist between the repaired rotator cuff and its insertion footprint. 

These approaches for soft tissue repair offer surgical options which respect biology, offer a biomechanically sound repair, create “two for one fixation points” with circumferential tendon compression, and synergies well with existing technology. As clinician’s incentives are increasingly aligned for value based treatments, these techniques can be employed to maximize clinical outcome, while minimizing cost in the value based care era of medicine.

In this study, the authors found no difference between the TO and TOE groups. Their results suggest that TO and TOE rotator cuff repair techniques result in no differences in patient-reported outcomes, shoulder ROM, and structural integrity in a matched cohort study that was adequately powered to detect the minimal clinically important difference for the ASES score. Operative time did not differ between techniques. The primary mode of failure for TOE repairs with suture anchors was Type 2 tendon tears that occur at the muscle-tendon junction with the residual tendon attached to the greater tuberosity, which can make revision surgery difficult and more costly. In contrast, the primary mode of failure after TransOs repair was Type 1 tear, in which the tendon re-tears from the greater tuberosity, which leaves more tendon and bone available for repair and simplifies revision.

Arthroscopic Transosseous Rotator Cuff repair techniques have been found to offer several potential advantages over suture anchor based repair, including broad footprint coverage with no foreign body at the footprint area, lower risk of rotator cuff failure at the musculotendinous junction (type 2 failure), lower risk of type III Sugaya magnetic resonance imaging readings (insufficient thickness after repair), improved blood flow at the bone-tendon interface, and decreased pain with similar functional outcomes. 

The authors describe a reproducible, step-by-step arthroscopic technique for anchorless transosseous rotator cuff repair using an X-box configuration. The technique uses 2 bone tunnels and 4 high-strength sutures and is suitable for medium to large tears of the supra- and infraspinatus that would alternatively need a double-row repair with 4 anchors. Biomechanically, results appear to be similar as for anchored transosseous equivalent techniques. Enhanced biological healing and lower material costs are the possible benefits of this appealing arthroscopic approach that mimics the previous gold standard. 

Straight bone tunnels in ATRCR surgery should be created at an angle of 60to the horizontal axis of the humerus or 30to the humeral shaft to ensure the safety of the axillary nerve while at the same time ensuring adequate thickness of the overlying bone roof. The anterior tunnel close to the bicipital groove should be created cautiously at 55to the horizontal axis or 35to the humeral shaft. The findings of this study will help the surgeon choose the best angle for placing tunnels during ATRCR surgery to avoid axillary nerve injuries as well as suture cut-through.

There is a significant difference in maximal pull-through strength favoring broad braided suturetape  over suture. 

Conclusions: Broad Suture Tape for Transosseous repair provides almost twice the bone pull-through strength and is slightly correlated to volumetric bone mineral density. 

The strength of the fixation of a Rotator Cuff repair can be increased by placing the transosseous sutures at least ten millimeters distal to the tip of the greater tuberosity and by tying them over a bone bridge that is at least ten millimeters wide. 

Transosseous suture repair compared with suture anchor repair demonstrated superior tendon fixation with reduced motion at the tendon-to-tuberosity interface.

The technique described in this article builds on previous arthroscopic transosseous technical knowledge to yield a cost-effective and efficient clinical method to perform biceps tenodesis in the suprapectoral location without the cost and complications of an implant. In addition, this technique provides 4 methods of tenodesis in series, which serves to decrease the risk of mechanical failure and leverages the robust method of suture cerclage for capture of the biceps.