TECHNIQUE
Double-Row, Transosseous-Equivalent Suture-Bridge Repair
for Supraspinatus Tears: Power Up the Healing
Chris R. Mellano, MD, Kirk A. Campbell, MD,
Anthony A Romeo, MD, and Brian J. Cole, MD, MBA
Abstract: Arthroscopic rotator cuff repair is one of the most com-
monly performed surgeries in orthopedics. The primary goal of this
procedure is to reduce shoulder pain and restore its function so that
patients may return to some of their preinjury activities. Arthroscopic
double-row transosseous-equivalent or suture-bridge repair techniques
have become increasingly popular over the last decade. This repair
technique, which uses 2 rows of suture anchors to recreate a bio-
mechanically favorable healing environment at the anatomic footprint
of the rotator cuff, produces a strong fixation construct with improved
tendon-to-bone contact and compression over the anatomic footprint.
The addition of this technique to one’s armamentarium has the
potential to lead to improved patient outcomes after rotator cuff repair.
In this review, we will detail some of the technical pearls on how to
perform a double-row transosseous-equivalent repair and power up the
healing of rotator cuff tears involving the supraspinatus.
Key Words: rotator cuff tear, double-row repair, transosseous equiv-
alent, suture bridge, double-row TOE
(Tech Should Elb Surg 2016;17: 49–57)
T he main goals of rotator cuff repair surgery are to reduce
pain and to restore shoulder function. These goals are
typically achieved by carrying out a repair that has some of the
following characteristics: restoration of the rotator cuff ana-
tomic footprint, high initial fixation strength, minimum gap
formation with cyclic loading, and broad tendon-to-bone
contact to promote biological healing of the rotator cuff to the
bone.1–4 Traditionally, rotator cuff surgery was performed
through an open approach and it was repaired in a transosseous
manner. However, with continued improvements in surgical
instrumentation and techniques, these repairs have transitioned
from open, to mini open, to now all-arthroscopic procedures.
Although the underlying goals of surgery have remained
the same, the transition to an all-arthroscopic procedure led to
a move away from the transosseous repair to the adaption of
simpler repair configurations, such as a single-row repair.
Unfortunately, the high-failure rates that were found to range
from 5% to 94% led to a search for improved arthroscopic
repair techniques.1,5–10 Further advances in instrumentation
and technique then led to double-row rotator cuff repair and
then in an attempt to recreate the favorable biomechanical
characteristics of the original transosseous repair, there has
been a recent move toward the double-row transosseous-
From the Department of Orthopaedic Surgery, Rush University Medical
Center, Chicago, IL.
B.J.C. receives support from Arthrex, Carticept, Regentis, Zimmer,
Medipost, National Institutes of Health, DJ Orthopaedics, Athletico,
Ossur, Smith & Nephew, and Tornier. A.A.R. receives support from
Arthrex, DJO Surgical, Smith & Nephew, and Ossur. The other authors
declare no conflict of interest.
Reprints: Kirk A. Campbell, MD, Midwest Orthopedics at Rush University
Medical Center, 1611 W. Harrison Suite 300, Chicago, IL 60610
(e-mail: kirk.anthony@gmail.com).
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Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016
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equivalent (TOE) or suture-bridge repair techniques.1–4,11 This
construct uses 2 rows of suture anchors to recreate the favor-
able biomechanics, especially the improved tendon-to-bone
contact and compression over the anatomic footprint, found in
the original open transosseous rotator cuff repairs.1,4,12
The double-row TOE/suture-bridge rotator cuff repair has
been shown to lead to several biomechanical advantages over
the standard single-row repair. These include improved foot-
print coverage, greater load to failure, increased contact pres-
sure at the tendon footprint, decreased motion at the tendon-
bone footprint interface, and increased resistance to rotational
forces, which should all theoretically lead to improved tendon
healing to bone.1–4,12–14 However, these excellent bio-
mechanical characteristics do not always translate into clinical
improvements in the rotator cuff healing rate or functional
outcomes in the literature.9,15,16 Controversy still exists as to
whether single-row or double-row rotator cuff repairs lead to
better outcomes.9,15,16 Recent clinical trials have shown that
double-row repairs lead to improved postoperative strength
and decreased retear rate when compared with single-row
repairs.17,18 Furthermore, a recent systematic review of over-
lapping meta-analyses of the highest quality studies available
showed that double-row rotator cuff repair resulted in superior
structural healing when compared with single-row repair.9
The short-term clinical and structural integrity outcomes
of double-row TOE repair have compared favorably with those
reported for double-row repair of rotator cuff tears.10,12,15,19,20
A small randomized controlled trial of double-row TOE versus
single-row rotator cuff repair techniques for full-thickness
supraspinatus tears used ultrasound evaluation to show that
double-row TOE repair resulted in a 93% healing rate versus
PHOTO 1. Portal locations. Right shoulder beach-chair position.
Portals include: (A) Standard posterior portal. (B) Anterior rotator
interval portal created during the glenohumeral joint diagnostic
arthroscopy. (C) Lateral viewing portal typically created 2 finger
breadths lateral to the lateral acromial edge and in-line with the
posterior aspect of the distal clavicle. (D) Anterolateral working
portal, this portal location is optimized with a spinal needle to
provide unimpeded access to the cuff tear and anticipated
anchor insertion sites without crowding the lateral viewing
portal. A 6 mm cannula is placed through this portal.
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Mellano et al Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016

FIGURE 1. A, Right shoulder view from posterior. A tear of the supraspinatus is present. While visualizing through the lateral portal the
surgeon should localize the anterolateral working portal with a spinal needle. This portal should allow unimpeded access to the cuff tear
and eventual anchor locations. Care should be taken to avoid crowding the anterolateral working portal with the lateral viewing portal.
Next, the surgeon must introduce a grasping device through the anterolateral working portal to assess the tendon quality and tear
pattern. (Note that the separation between the supraspinatus and infraspinatus is depicted for illustration purpose only and does not
represent the arthroscopic appearance of the supraspinatus and infraspinatus in vivo.). B, Supraspinatus tear viewed from the lateral
portal.

75% for single-row repair.13 However, when the 3 most
common arthroscopic techniques (single row, double row, and
double-row TOE repairs) for repairing supraspinatus tears
were compared, it was found that all 3 techniques resulted in
clinical and statistically significant improvements in subjective
and objective outcomes at a minimum 2-year follow-up.
Interestingly, they noted a decrease in the rate of retears based
on the technique used: 22% for single row, 18% for double
row, and 11% for double-row TOE; however, this was not
statistically significant.15
Although larger randomized controlled trials are needed
to determine the long-term outcomes of double-row TOE, the
biomechanical and early short-term clinical results have been
very promising. This technique is an advance in rotator cuff
surgery and will help to facilitate the achievement of the main
goals of rotator cuff surgery: pain reduction and restoration of
shoulder functionality.
SURGICAL TECHNIQUE
Step 1: Prepare the Subacromial Space
A thorough bursectomy must be accomplished to create a
space to work. Please see the article on how to perform a
subacromial bursectomy, with or without an acromioplasty, for
more detailed description of how to prepare the subacromial
space.
Step 2: Establish Proper Portal Positioning.
In addition to the standard posterior viewing portal,
anterior rotator interval portal, and lateral viewing portal, an

FIGURE 2. A, Insertion of the medial-row posterior anchor. After the supraspinatus footprint on the greater tuberosity is decorticated
with a burr, the posterior-medial anchor is typically placed first. A tap is used first to create a hole typically 2 mm lateral to the articular
surface and aimed slightly medial to create an appropriate “dead-man’s” angle. This particular anchor (SwivelLock; Arthrex) is loaded
with a 2 mm broad suture (FiberTape; Arthrex). Depending on the necessary trajectory, this anchor can either be placed into the hole
through the anterolateral working portal (as shown here) or through a percutaneous incision. B, The posterior anchor of the medial row
after insertion.

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Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016
FIGURE 3. Retrograde suture shuttling of the medial-row posterior
anchor sutures. While visualizing through the lateral portal, a
curved suture-passing device (Spectrum; Linvatec) is placed
through the posterior portal and used to pass a #1 PDS suture
through the supraspinatus tendon just lateral to the MTJ medial to
the posterior portion of the tear. A suture retriever is inserted in the
anterolateral working portal and retrieves the #1 PDS suture
through the tear. The #1 PDS is tied around both suture tails. The
#1 PDS is then pulled back through the posterior portal to pass the
2 suture tails through the tendon together. Alternatively, each of
the suture tails could be passed independently through 2 different
locations in the tendon requiring 2 passes.
FIGURE 4. Retrograde suture shuttling of the medial-row posterior
anchor sutures. While visualizing through the lateral portal, a
curved suture-passing device (Spectrum; Linvatec) is placed
through the posterior portal and used to pass a #1 PDS suture
through the supraspinatus tendon just lateral to the MTJ medial to
the posterior portion of the tear. A suture retriever is inserted in the
anterolateral working portal and retrieves the #1 PDS suture
through the tear. The #1 PDS is tied around both suture tails. The
#1 PDS is then pulled back through the posterior portal to pass the
2 suture tails through the tendon together. Alternatively, each of
the suture tails could be passed independently through 2 different
locations in the tendon requiring 2 passes.
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DR TOE Repair
FIGURE 5. Insertion of the medial-row anterior anchor. While
both tails of the medial-row posterior anchor are “parked” out of
the posterior portal the process is repeated for the medial-row
anterior anchor. The tap is used to create a hole 2 mm off the
articular surface in a dead-man’s trajectory. The anchor
(SwivelLock; Arthrex) loaded with a broad 2 mm suture
(FiberTape; Arthrex) is inserted, either through the anterolateral
working portal (as shown here) or through a percutaneous
incision.
FIGURE 6. Retrograde suture shuttling of the medial-row
anterior anchor sutures. While visualizing through the lateral
portal, the curved suture-passing device (Spectrum; Linvatec) is
used through the anterior portal (as shown here) or through the
posterior portal based on ease of access. The suture passer
penetrates the tendon just lateral to the MTJ in the anterior
aspect of the tear and passes a #1 PDS suture. A suture retriever is
inserted in the anterolateral working portal and retrieves the #1
PDS suture through the tear. The #1 PDS is tied around both
suture tails of the anterior anchor. The #1 PDS is then pulled back
through the anterior portal to pass the 2 suture tails through the
tendon together (alternatively each tail can be passed
independently through 2 different locations in the tendon
requiring 2 passes). The 2 suture tails from the medial-row
anterior anchor are “parked” out of the anterior portal (as shown)
or the posterior portal based on surgeon preference.
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Mellano et al Techniques in Shoulder & Elbow Surgery
FIGURE 7. Retrograde suture shuttling of the medial-row
anterior anchor sutures. While visualizing through the lateral
portal, the curved suture-passing device (Spectrum; Linvatec) is
used through the anterior portal (as shown here) or through the
posterior portal based on ease of access. The suture passer
penetrates the tendon just lateral to the MTJ in the anterior
aspect of the tear and passes a #1 PDS suture. A suture retriever is
inserted in the anterolateral working portal and retrieves the #1
PDS suture through the tear. The #1 PDS is tied around both
suture tails of the anterior anchor. The #1 PDS is then pulled back
through the anterior portal to pass the 2 suture tails through the
tendon together (alternatively each tail can be passed
independently through 2 different locations in the tendon
requiring 2 passes). The 2 suture tails from the medial-row
anterior anchor are “parked” out of the anterior portal (as shown)
or the posterior portal based on surgeon preference.
FIGURE 8. Lateral-row posterior anchor. While the sutures from
the medial anchor are “parked” out of the posterior and anterior
cannula the lateral-row anchor insertion sites are planned. The
ideal position of the lateral-row posterior anchor can be
evaluated by performing a “lateral-row trial reduction.” This is
performed by using a grasper through the anterolateral working
portal to pull the medial-row sutures over to the lateral aspect of
the greater tuberosity and determining which posterior anchor
location gives the best footprint restoration. If a potential “dog-
ear” is noticed posteriorly during the trial reduction then the
surgeon can consider incorporating a cinch-stitch into the lateral
row (see below). When using the tap to create a hole for the
lateral-row posterior anchor be careful to avoid skiving off the
cortex.
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FIGURE 9. Insertion of the lateral-row posterior anchor. Using a
suture retriever a single suture limb is retrieved from both medial-
row anchors (posterior and anterior). These 2 limbs are inserted
into the lateral-row anchor (SwivelLock; Arthrex) outside of the
anterolateral working portal. Next, the anchor, now loaded with
the 2 suture limbs from the medial-row anchors, is inserted into
the lateral-row hole created by the tap. Before final seating of the
lateral anchor posterior anchor, the surgeon should remove all of
the slack from the sutures to create a rigid fixation construct. Pay
attention to the proprioception of the anchor seating as abrupt
“giving-way” may mean the anchor has skived out the cortex.
Once the posterior anchor is appropriately seated the suture
cutter is used directly on top of the anchor.
FIGURE 10. Insertion of the lateral-row posterior anchor. Using a
suture retriever a single suture limb is retrieved from both medial-
row anchors (posterior and anterior). These 2 limbs are inserted
into the lateral-row anchor (SwivelLock; Arthrex) outside of the
anterolateral working portal. Next, the anchor, now loaded with
the 2 suture limbs from the medial-row anchors, is inserted into
the lateral-row hole created by the tap. Before final seating of the
lateral anchor posterior anchor, the surgeon should remove all of
the slack from the sutures to create a rigid fixation construct. Pay
attention to the proprioception of the anchor seating as abrupt
“giving-way” may mean the anchor has skived out the cortex.
Once the posterior anchor is appropriately seated the suture
cutter is used directly on top of the anchor.
Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016
FIGURE 11. Lateral-row anterior anchor. The ideal position of the
lateral-row anterior anchor can also be evaluated by performing a
“lateral-row trial reduction.” Using a grasper through the
anterolateral working portal, pull the remaining 2 medial-row
sutures over to the lateral aspect of the greater tuberosity and
determining which location anterior to anchor insertion site gives
the best footprint restoration. If a potential “dog-ear” is noticed
anteriorly during the trial reduction then the surgeon can
consider incorporating a cinch-stitch into the lateral row (see
below). When using the tap to create a hole for the lateral anchor
anterior the surgeon must be careful to avoid skiving off the
anterior cortex, which is more likely than the posterior anchor.
FIGURE 12. Insertion of the lateral-row anterior anchor. A suture
retriever is used to retrieve both remaining medial-row sutures.
These 2 limbs are inserted into the lateral-row anterior anchor
(SwivelLock; Arthrex) outside of the anterolateral working portal.
Next, the anchor, now loaded with the 2 suture limbs from the
medial-row anchors, is inserted into the lateral-row anterior hole
created by the tap. Before final seating of the lateral-row anterior
anchor, the surgeon should remove all of the slack from the 2
sutures to create a rigid fixation construct. Again, pay attention
to the proprioception of the anchor seating as abrupt “giving-
way” may mean the anchor has skived out the cortex. Once the
anterior anchor is appropriately seated the suture cutter is used in
a similar manner.
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DR TOE Repair
FIGURE 13. Insertion of the lateral-row anterior anchor. A suture
retriever is used to retrieve both remaining medial-row sutures.
These 2 limbs are inserted into the lateral-row anterior anchor
(SwivelLock; Arthrex) outside of the anterolateral working portal.
Next, the anchor, now loaded with the 2 suture limbs from the
medial-row anchors, is inserted into the lateral-row anterior hole
created by the tap. Before final seating of the lateral-row anterior
anchor, the surgeon should remove all of the slack from the 2
sutures to create a rigid fixation construct. Again, pay attention
to the proprioception of the anchor seating as abrupt “giving-
way” may mean the anchor has skived out the cortex. Once the
anterior anchor is appropriately seated the suture cutter is used in
a similar manner.
anterolateral working portal is used for instrument access to
the cuff tear (Photo 1).
Step 3: Evaluate the Cuff Tear and Plan the
Repair Construct
A grasping device can be used to evaluate the tendon to
assess the tendon quality and mobility. This is a necessary step
to understand the tear pattern and plan the repair configuration,
including how many anchors, where to put the anchors, where
to pass the sutures through the tendon, and what sequence to
fix the sutures (Fig. 1).
Step 4: Prepare the Anatomic Footprint
The footprint of the torn supraspinatus tendon can be
prepared with a high-speed burr. Gentle decortication of the
footprint is thought to access mesenchymal stem cells within
the cancellous bone. This step is performed to improve tendon
healing to bone.
Step 5: Insert Medial-Row Posterior Anchor
For suture management purposes, it is easier to work from
posterior to anterior beginning with the medial-row posterior
anchor (Fig. 2).
Step 6: Pass the Medial-Row Posterior Anchor
Sutures Through the Tendon
This step can be performed with a variety of suture-
passing devices in either an antegrade or retrograde direction.
A retrograde suture-passing device is 1 option (Figs. 3, 4).
Step 7: Insert Medial-Row Anterior Anchor
This step is performed in a similar manner to insertion of
the medial-row posterior anchor (Fig. 5).
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Mellano et al Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016

FIGURE 14. A and B, Final appearance of a double-row, transosseous-equivalent, suture-bridge, knotless fixation construct. Some
surgeons may prefer to secure the medial-row fixation by tying knots (not pictured) after passing the sutures from the 2 medial anchors.
After tying the knots of your choice, such as alternating half hitches, the sutures would then be passed and used for the lateral-row
fixation and steps 9 to 12 would then be completed.

Step 8: Pass the Medial-Row Anterior Anchor
Sutures Through the Tendon
This step is performed similar to the posterior anchor
suture passage using a curved suture-passing retrograde device.
This can be performed through either the posterior or anterior
portal (Figs. 6, 7).
Step 9: Perform a Trial Reduction of the Lateral
Row
This step will allow the surgeon to understand where best
to place the lateral-row anchors and identify any potential dog-
ears (Fig. 8).
Step 10: Insert the Lateral-Row Posterior Anchor
Take 1 suture from each of the medial-row anchors and
incorporate into the lateral-row posterior anchor (Figs. 9, 10).
Cinch-Stitch Step 2: Create the Cinch-Stitch
The free suture has been passed through the tendon and
now the 2 free tails are pulled through the loop end to create a
cinch-stitch, or luggage-tag, configuration (Figs. 16, 17).
Cinch-Stitch Step 3: Incorporate the Cinch-Stitch
Into a Single Lateral-Row Anchor
Unlike the double-row suture-bridge configuration, the
cinch-stitch is only incorporated into a single lateral anchor
that is closest in location to the cinch-stitch (Figs. 18, 19).
Cinch-Stitch Step 4: Tighten the Cinch-Stitch
Before Final Insertion of Lateral-Row Anchor
Similar to removing slack from the double-row suture-
bridge configuration before lateral-row fixation, to avoid slack
in the cinch-stitch, it is necessary to “take up the slack” in the

Step 11: Lateral-Row Anterior Anchor

With the remaining 2 limbs of the medial anchor, the
surgeon can perform another “trial reduction” of the sutures to
locate the optimal position of the lateral-row anterior anchor.
Be careful of skiving with the tap near the anterior cortex
(Fig. 11).

Step 12: Insert Lateral-Row Anterior Anchor

Take the 2 remaining sutures from each of the medial-row
anchors and incorporate into the lateral-row anterior anchor
(Figs. 12, 13).

Step 13: Assess Final Repair Integrity

The arm can be manually rotated to assess for repair
integrity (Figs. 14A, B).
Cinch-Stitch Step 1: Identify Dog-Ears and Pass
Free Suture Through Tendon
Before performing the lateral-row repair, a “trial reduc-
tion” can demonstrate dog-ears in the repair configuration. A
cinch-stitch (luggage-tag suture configuration) can be incor-
porated into the lateral row to help reduce dog-ears. A cinch-
stitch requires the use of a free suture and a suture passer
(Fig. 15).
FIGURE 15. Pass cinch-stitch with retrograde suture passer.
Before performing the lateral-row fixation, a “trial reduction” may
demonstrate a possible dog-ear either anterior or posterior. To
avoid leaving a dog-ear the surgeon can incorporate a cinch-
stitch (luggage-tag suture configuration) into the lateral row. A
curved retrograde suture-passer device is passed through either
the posterior or anterior portal depending on the location of the
dog-ear. The suture passer passes a #1 PDS suture through the
tendon behind the dog-ear. A suture retriever then retrieves the
#1 PDS suture out of the anterolateral working portal. A free
suture (Fiberwire, Naples, FL) is doubled in half and the #1 PDS is
tied over both halves of the suture (see inset figure).

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Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016
FIGURE 16. Create the cinch-stitch (luggage tag) suture
configuration. Once the #1 PDS is tied around both halves of the
free suture then the #1 PDS is pulled back through the portal
bringing the 2 tail ends of the suture through the tendon behind
the dog-ear. The loop end of the suture is not pulled through the
tendon. Next, the 2 tail ends, which have now passed through
the tendon, are pulled back through the loop end to create the
cinch-stitch configuration. This step can be performed using a
suture retriever in 2 different ways, either outside the cannula
(inset figure) or arthroscopically (main figure). The suture
retriever is passed through the loop, then retrieves the 2 tail ends
out of the loop. Once the 2 tail ends are passed through the loop
the 2 tails are pulled to reduce and tighten the cinch-stitch to the
tendon.
cinch-stitch sutures before final lateral-row anchor seating. Once
the final repair construct is created, its integrity can be assessed
with gentle range of motion (cinch-stitch Figs. 20A, B).
FIGURE 17. Create the cinch-stitch (luggage tag) suture
configuration. Once the #1 PDS is tied around both halves of the
free suture then the #1 PDS is pulled back through the portal
bringing the 2 tail ends of the suture through the tendon behind
the dog-ear. The loop end of the suture is not pulled through the
tendon. Next, the 2 tail ends, which have now passed through the
tendon, are pulled back through the loop end to create the cinch-
stitch configuration. This step can be performed using a suture
retriever in 2 different ways, either outside the cannula or
arthroscopically. The suture retriever is passed through the loop,
then retrieves the 2 tail ends out of the loop. Once the 2 tail ends
are passed through the loop the 2 tails are pulled to reduce and
tighten the cinch-stitch to the tendon.
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DR TOE Repair
FIGURE 18. Incorporation of the cinch-stitch into the lateral row.
Both limbs of the cinch-stitch are incorporated into the same
lateral-row anchor. If the cinch-stitch is posterior (as shown here),
both limbs will be incorporated into the lateral-row posterior
anchor along with 1 limb from either medial anchor for a total of
4 suture limbs in the lateral-row posterior anchor. If the cinch-
stitch is anterior then the same process would be performed for
the lateral-row anterior anchor.
TECHNICAL PEARLS
(1) Have a clear understanding of rotator cuff footprint
anatomy and common tear patterns.21–23
(2) Do not skimp on exposure. Maximize visualization by
performing a thorough bursectomy ( ± acromioplasty when
indicated) before rotator cuff repair. If planning a double-
row repair then perform a bursectomy in the location of the
anticipated lateral-row anchor sites as well.
(3) Optimize your portal locations. Triangulate with a spinal
needle first. Do not crowd your lateral visual portal and
anterolateral working portal.
FIGURE 19. Incorporation of the cinch-stitch into the lateral row.
Both limbs of the cinch-stitch are incorporated into the same
lateral-row anchor. If the cinch-stitch is posterior (as shown here),
both limbs will be incorporated into the lateral-row posterior
anchor along with 1 limb from either medial anchor for a total of
4 suture limbs in the lateral-row posterior anchor. If the cinch-
stitch is anterior then the same process would be performed for
the lateral-row anterior anchor.
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Mellano et al Techniques in Shoulder & Elbow Surgery
FIGURE 20. A and B, Final appearance of double-row, transosseous-equivalent, suture-bridge with posterior cinch-stitch (blue)
incorporated into the lateral-row posterior anchor.
(4) Take time to evaluate the tendon quality and understand
the tear pattern as crescent, L-shaped, reverse L-shaped,
complex, or type II (musculotendinous junction) by
performing a “trial reduction” with the use of a grasping
device. Not all tears, especially L-shaped tears, are
properly repaired by pulling the tendon directly medial to
lateral. You must understand how the tendon is supposed
to reduce to avoid creating a high-tension, nonanatomic
repair with high likelihood of failure. Plan the locations to
pass each suture through the tendon based on the
reduction vectors need to properly reduce the tear.
(5) Do not ignore or miss a tear that extends into the
infraspinatus as this will lead to predictably poor clinical
outcomes. If the tear extends into the infraspinatus, in
general, this should be repaired first.
(6) Be comfortable with a variety of suture-passing devices.
Antegrade suture-passing devices such as the Scorpion
(Arthrex, Naples, FL) may be easy to use in large tears
but in small tears antegrade suture passers may be more
difficult to maneuver and cause frustration. Retrograde
passers such as the Spectrum (Linvatec, Largo, FL) or
Penetrator (Arthrex) may work best in small spaces.
(7) Anticipate “dog-ears” in the DR TOE repair construct.
This can be done by performing a “double-row trial
reduction” of the medial sutures over the cuff with the use
of a grasper before inserting lateral anchors. Consider
incorporating a cinch-stitch into the lateral-row anchors
to properly reduce the dog-ears.
(8) When placing the lateral-row anchors avoid skiving
through the cortex, especially anterior. This can be
avoided by understanding the osseous anatomy and
paying attention to the proprioceptive feedback during
anchor insertion. If you feel a sudden give during
insertion of the lateral-row anterior anchor, you must
evaluate closely for the anchor skiving out the anterior
cortex.
(9) If the tear of the supraspinatus extends anterior into the
rotator interval then priority should be given to repair the
anterior aspect of the supraspinatus, which includes the
rotator cable. The anterior rotator cable, which runs
through the anterior aspect of the supraspinatus and
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 Volume 17, Number 2, June 2016
rotator interval, must be reduced and fixed properly to
create the optimal mechanical repair construct. Avoid
“overreducing” the posterior aspect of the tear first which
may tether the tendon excursion anteriorly and lead to an
inadequate reduction of the anterior rotator cable or create
a repair under high tension. Consider reducing and fixing
the anterior rotator cable first before fixation of the
posterior half of the tear.
(10) Understand that a double-row TOE repair can be
successfully performed with different anchors, sutures,
or suture-passing devices than depicted in this article.
Adherence to the principles, and not necessarily the
specific implants, described here will assure the greatest
possibility for successful double-row TOE repair.
REFERENCES
1. Park MC, Elattrache NS, Ahmad CS, et al. “Transosseous-equivalent”
rotator cuff repair technique. Arthroscopy. 2006;22:1360.e1–1360.e5.
2. Park MC, ElAttrache NS, Tibone JE, et al. Part I: Footprint contact
characteristics for a transosseous-equivalent rotator cuff repair tech-
nique compared with a double-row repair technique. J Shoulder Elbow
Surg. 2007;16:461–468.
3. Park MC, Tibone JE, ElAttrache NS, et al. Part II: Biomechanical
assessment for a footprint-restoring transosseous-equivalent rotator
cuff repair technique compared with a double-row repair technique.
J Shoulder Elbow Surg. 2007;16:469–476.
4. Cole BJ, ElAttrache NS, Anbari A. Arthroscopic rotator cuff repairs:
an anatomic and biomechanical rationale for different suture-anchor
repair configurations. Arthroscopy. 2007;23:662–669.
5. Galatz LM, Ball CM, Teefey SA, et al. The outcome and repair
integrity of completely arthroscopically repaired large and massive
rotator cuff tears. J Bone Joint Surg Am. 2004;86-A:219–224.
6. Boileau P, Brassart N, Watkinson DJ, et al. Arthroscopic repair of full-
thickness tears of the supraspinatus: does the tendon really heal?
J Bone Joint Surg Am. 2005;87:1229–1240.
7. Bishop J, Klepps S, Lo IK, et al. Cuff integrity after arthroscopic
versus open rotator cuff repair: a prospective study. J Shoulder Elbow
Surg. 2006;15:290–299.
Techniques in Shoulder & Elbow Surgery  Volume 17, Number 2, June 2016
8. Baker CL, Liu SH. Comparison of open and arthroscopically assisted
rotator cuff repairs. Am J Sports Med. 1995;23:99–104.
9. Mascarenhas R, Chalmers PN, Sayegh ET, et al. Is double-row rotator cuff
repair clinically superior to single-row rotator cuff repair: a systematic
review of overlapping meta-analyses. Arthroscopy. 2014;30:1156–1165.
10. Lafosse L, Brozska R, Toussaint B, et al. The outcome and structural
integrity of arthroscopic rotator cuff repair with use of the double-row
suture anchor technique. J Bone Joint Surg Am. 2007;89:1533–1541.
11. Frank JB, ElAttrache NS, Dines JS, et al. Repair site integrity after
arthroscopic transosseous-equivalent suture-bridge rotator cuff repair.
Am J Sports Med. 2008;36:1496–1503.
12. Neyton L, Godeneche A, Nove-Josserand L, et al. Arthroscopic suture-
bridge repair for small to medium size supraspinatus tear: healing rate
and retear pattern. Arthroscopy. 2013;29:10–17.
13. Gartsman GM, Drake G, Edwards TB, et al. Ultrasound evaluation of
arthroscopic full-thickness supraspinatus rotator cuff repair: single-row
versus double-row suture bridge (transosseous equivalent) fixation.
Results of a prospective, randomized study. J Shoulder Elbow Surg.
2013;22:1480–1487.
14. Behrens SB, Bruce B, Zonno AJ, et al. Initial fixation strength of
transosseous-equivalent suture bridge rotator cuff repair is comparable
with transosseous repair. Am J Sports Med. 2012;40:133–140.
15. McCormick F, Gupta A, Bruce B, et al. Single-row, double-row, and
transosseous equivalent techniques for isolated supraspinatus tendon
tears with minimal atrophy: a retrospective comparative outcome and
radiographic analysis at minimum 2-year followup. Int J Shoulder
Surg. 2014;8:15–20.
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Copyright r 2016 Wolters Kluwer Health, Inc. All rights reserved.
DR TOE Repair
16. Millett PJ, Warth RJ, Dornan GJ, et al. Clinical and structural out-
comes after arthroscopic single-row versus double-row rotator cuff
repair: a systematic review and meta-analysis of level I randomized
clinical trials. J Shoulder Elbow Surg. 2014;23:586–597.
17. Ma HL, Chiang ER, Wu HT, et al. Clinical outcome and imaging of
arthroscopic single-row and double-row rotator cuff repair: a pro-
spective randomized trial. Arthroscopy. 2012;28:16–24.
18. 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. 2007;35:1247–1253.
19. Toussaint B, Schnaser E, Bosley J, et al. Early structural and functional
outcomes for arthroscopic double-row transosseous-equivalent rotator
cuff repair. Am J Sports Med. 2011;39:1217–1225.
20. Kim KC, Shin HD, Lee WY, et al. Repair integrity and functional
outcome after arthroscopic rotator cuff repair: double-row versus
suture-bridge technique. Am J Sports Med. 2012;40:294–299.
21. Ruotolo C, Fow JE, Nottage WM. The supraspinatus footprint: an
anatomic study of the supraspinatus insertion. Arthroscopy. 2004;20:
246–249.
22. Curtis AS, Burbank KM, Tierney JJ, et al. The insertional footprint of
the rotator cuff: an anatomic study. Arthroscopy. 2006;22:609 e1.
23. Millett PJ, Warth RJ. Posterosuperior rotator cuff tears: classification,
pattern recognition, and treatment. J Am Acad Orthop Surg. 2014;
22:521–534.
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