Arthroscopic Transosseous Anchorless Rotator Cuff Repair Using the X-Box Technique

Abstract

We describe a reproducible, step-by-step arthroscopic technique for anchorless transosseous rotator cuff repair using an X-box configuration with the Arthrotunneler device. 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.

Fig 1

Patient in beach chair position, right shoulder. View of an Arthrotunneler device showing a suture inserter with a Fiberwire loop inside the deployed Nitinol loop. (AT, Arthrotunneler device; FW, Fiberwire loop inside Nitinol loop.)

Fig 2

Patient in beach chair position, right shoulder, flexible soft tissue extension, 2 working cannulas in anterosuperior and lateral portal. The assistant holds the arm in position A in full adduction. The arthroscope is in the lateral portal; a 2.9-mm trocar creates an anterior tunnel. (AS, arthroscope; TR, trocar.)

Fig 3

Identical setup as in Figure 2, but the assistant holds the arm in position B with 45° of abduction for the posterior tunnel. (TR, trocar; AS, arthroscope.)

Fig 4

Right shoulder, posterolateral viewing portal. (A) Medial tunnels adjacent to articular cartilage 1 to 2 cm apart. (B) The Arthrotunneler is introduced into the anterior tunnel, and the arch flush with the footprint. (C) The Arthrotunneler retrieves the Fiberwire shuttle loop. (AT, anterior tunnel; ATD, Arthrotunneler device; FW, Fiberwire loop; PT, posterior tunnel.)

Fig 5

Right shoulder, posterolateral viewing portal. (A) Both Fiberwire loops have been pulled through bone tunnels. (B) Clever hook catching the posterior Fiberwire loop. (C) Both shuttling loops have been pierced through the cuff anteriorly and posteriorly. (AFW, anterior Fiberwire loop; AM, articular margin; CH, Clever hook; PFW, posterior Fiberwire loop.)

Fig 6

(A) Right shoulder, lateral view. Diagram showing shuttle loops ready to pull 3 color-coded high-strength sutures through the posterior tunnel. Tunnels are about 2 cm apart. (BT, biceps tendon; ISP, infraspinatus; SSP, supraspinatus.) (B) Diagram showing suture management for the anterior shuttling maneuver.

Fig 7

Right shoulder, posterolateral viewing portal. (A) Posterior tunnel with cortical augmentation device and 3 different sutures (light blue, violet, tiger). (B) The anterior white suture is tied first. (C) The tiger suture of the X is tied last. (AC, anterior cuff; AS, anterior suture; CAD, cortical augmentation device; XS, X suture.)

Fig 8

(A) Right shoulder, lateral view. Diagram after shuttling of all 4 permanent sutures through the 2 tunnels. (BT, biceps tendon; ISP, infraspinatus; SSP, supraspinatus) (B) Diagram after knot tying, X-box is complete; all knots are flush on the bone of the greater tuberosity.

Fig 9

Coronal magnetic resonance imaging scan of patient 2 years postoperatively. Tunnel with a 15-mm bone bridge and recreation of the footprint are clearly appreciated. Sugaya type II tendon. (FP, footprint; RC, rotator cuff.)