Dr.Rob Hartzler: Welcome to the Arthroscopy Association's Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.
Dr.Rob Hartzler: Greetings. I'm Dr. Rob Hartzler from TSAOG Orthopaedics in San Antonio. Today on the podcast, we have the honor of hearing from Dr. Patrick Denard with Southern Oregon Orthopedics. In addition to being a very busy private practice shoulder surgeon and researcher, Dr. Denard is a faculty member at Oregon Health and Science University and is the director of shoulder and sports medicine at Providence Medford. Dr. Denard, welcome to the podcast.
Dr. Denard: Yeah, thanks for having me, Rob. It's great to be here.
Dr.Rob Hartzler: Today, we're going to be discussing your article from the March 2018 issue of the Journal entitled, "Triple-Loaded Suture Anchors Versus a Knotless Rip Stop Construct in a Single-Row Rotator Cuff Repair Model."
Dr.Rob Hartzler: Patrick, describe the knotless rip stop construct for us and tell us what's the difference between that and the load-sharing rip stop construct that you described with Steve Burkhart in 2012.
Dr. Denard: Yeah, sure. The knotless rip stop is really an alternative to a single-row repair. I'm a big believer in double-row rotator cuff repair. I think the studies clearly show that there's better healing when we can get a double-row repair, particularly with larger tears. There's evidence over 1 cm, particularly over 3 cm, there's really good evidence that there's greater healing. But the problem is that's not always possible to achieve. In those situations where you can only do a single-row repair, you want to think about what the best construct is, because we know that failure in rotator cuff repair occurs at the suture tendon interface. We want to maximize our fixation as best as we can.
Dr. Denard: So, as you said, we described the load sharing rip stop repair several years ago and the load share rip stop repair is great because it has really good strength, but the problem with the load sharing rip stop repair is that it requires more anchors and it's technically challenging for many people to perform. In that repair, you typically put two anchors medially and you do one to two anchors laterally and you place an inverted mattress suture and then place sutures from your medial anchors medial to the rip stop. As you can already tell, I'm describing this and it's getting quite complicated.
Dr. Denard: What we wanted to do was to look for an alternative to a single-row repair and particularly compare that to a triple-loaded anchor where people with a triple-loaded anchor typically place three simple sutures and with the knotless rip stop repair, we had the same number of passes, three passes through the tendon, but what we do is we take the suture tape, in this case it's a 2 mm tape and we pass that in a mattress fashion and then we take a suture that has a loop on the end, a number two suture, to create a cinch suture around that tape, so we pass medial to the tape to create a cinch suture, and then we have three limbs coming out and we take that out to an anchor in a knotless fashion.
Dr. Denard: As opposed to the traditional triple-load single-row repair where you're performing three passes and tying knots, you still have three passes through the tendon but you're not tying knots and you're coming out to a knotless anchor instead of placing the anchor first.
Dr.Rob Hartzler: So what did you find out when testing the knotless rip stop construct versus triple-loaded anchors in the lab?
Dr. Denard: In the lab, we found that it was equivalent to single-row repair in terms of the strength, just in terms of load to failure. In this study, we really only examined load to failure and displacement. So essentially we found that it was equivalent in terms of the biomechanics.
Dr. Denard: You might say why would I consider that type of repair, and I think there's a couple of reasons. Number one is if you can have a repair that is just as good biomechanically but faster, I think that's an advantage. In this case, a knotless rip stop is a much simpler technique I think than passing three sutures individually and tying knots. That takes more time. Although I was trained by somebody who's a great knot-tier, what I've seen ... in my experience over time and seeing the evidence, I've really come to believe that knotless technology really is more reproducible and I was resistant to that idea to begin with, but as I've come to really look at the data and see these studies about how people don't tie knots in a reproducible fashion, and seeing my own knots in practice, I really decided that a knotless fixation has a more secure loop, so that's the advantage here is you get that advantage of knotless technology.
Dr. Denard: If you can get all the tension out and get your tendon down to that anchor, it should be a more reproducible technique than tying a loop and relying on your knots every time.
Dr.Rob Hartzler: Do you have any indication in your practice now for a SCOI style single-row repair with a triple-loaded anchor?
Dr. Denard: Not for me. I mean, for me, if I'm going to ... Well, I wouldn't say never. I would say, “rarely.” For me, if I have a tear with limited tendon mobility or a short tendon stump, my go-to currently is a knotless rip stop repair. I think knots are nice when you need to deal with delaminated tissue. You can have cases where you need to pull over tendons in different directions to address longitudinal tears or, like I said delaminated tears, and in that case it can be advantageous to take multiple passes through the tissue. But for a standard massive contracted tear that you can get over the tuberosity, I think a knotless rip stop is as good or better than two anchors with a triple-loaded type of single-row construct.
Dr.Rob Hartzler: Any indication for you for the load sharing rip stop as opposed to a knotless rip stop?
Dr. Denard: Yeah, that one I can't give you an exact answer to yet. We're studying that currently. We went through a period in my patients where I did load-sharing rip stops on everybody who could not ... who did not have tendon mobility sufficient to obtain a double-row repair, so these were people who could only have a single-row repair because of large tears. I compared that to a year following where I did a single-row repair, and in that series, it was double-loaded anchors only where we tied simple sutures and when we compared those two, we found that clearly there was a difference in healing. The load-sharing rip stop was much higher. That study is hopefully going to be in press in Arthroscopy, but there's no difference in functional outcome at two years as you would expect.
Dr. Denard: Then we had a third arm where the third year we converted to a knotless rip stop repair and we're currently in the process of analyzing those, comparing how the knotless rip stop repair compares to the load-sharing rip stop. But currently right now, because there's ... I haven't yet seen a difference in functional outcome, even though I know a load-sharing rip stop repair is stronger, knotless rip stop has been my go-to from an efficiency standpoint and a cost standpoint, because we're increasingly being faced with an environment where we're having to use less anchors in a cost efficient manner and that's, for those reasons, that's what I've been using it for.
Dr. Denard: The only other point that I've thought about is the fact that sometimes with these anchors, we're really occupying a lot of the footprint, and even though they're cannulated and vented, you wonder about if you're putting too many anchors in, are you really providing an environment for the tendon to heal in?
Dr.Rob Hartzler: I think we're going to be hearing more in the future about superior capsular reconstruction in these types of settings and the repairable rotator cuff in the revision setting or in a short tendon. Are you currently using that in your practice?
Dr. Denard: Yeah, I do a lot of superior capsular reconstruction for patients who have irreparable rotator cuff tears and I've used it more and more for people who have a repairable tear but have significant atrophy, so if I have an individual who is less than 60 years of age, as a general guideline, and they have a repairable rotator cuff tear, but if they have grade three atrophy of their supraspinatus and their infraspinatus, even if I can pull that tendon over, I know that that tendon has a poor chance of healing and I'll consider doing a superior capsular reconstruction and then repairing the rotator cuff over the top of that.
Dr. Denard: You might ask why I do that in patients only less than 60, and my answer to that is I'm really trying to put a value kind of analysis on this. I don't have data yet to say exactly when that's going to work, but I know it's obviously a lot more time and a lot more cost to do a superior capsular reconstruction, so for older patients, I'll typically accept if I can repair the tear and if they get partial healing, they likely have less functional demand and I'm less worried about them going on to the potential for arthroplasty as a backup. I reserve that for patients less than 60 at this time.
Dr.Rob Hartzler: So many choices right now in rotator cuff repair! It's really difficult to decide what to do in a lot of these cases.
Dr. Denard: It is. It is. That's the fun of it and the reason why we need to keep researching, right, and trying to figure out what the best constructs are. That's why I currently am trying to do it in a systematic way and I've changed my technique for a defined period and trying to follow those patients and see how they do and explore the differences. It's also hard with the instruments we have to really detect differences, and that's the other thing. We have all these functional outcomes scores that really look at pain primarily and it's no wonder we don't really find a difference because we're not really assessing strength in a lot of these patients.
Dr.Rob Hartzler: All right. Any other closing thoughts?
Dr. Denard: I would say if you are not convinced by the knotless technology, I would go check out two articles. I would go check out Bryan Hanypsiak’s article from AJSM several years ago, which was one of the first articles that really tuned me in to this idea of how poor of a job we do, and then a second article we recently published in OJSM looking at the same, it was the same ... it was a different type of series looking at surgeons in Europe who did knotted constructs versus knotless constructs and the differences are really compelling. We don't do as good of a job as we like to think that we do at tying knots.
Dr.Rob Hartzler: Thank you, Dr. Denard, for your time today.
Dr. Denard: Thanks for having me.
Dr.Rob Hartzler: This article from the March 2018 issue of the Journal entitled "Triple-Loaded Suture Anchors Versus a Knotless Rip Stop Construct in a Single-Row Rotator Cuff Repair Model" can be found on the Arthroscopy Journal's website at arthroscopyjournal.org.