"Strings" (Multiple Tendon Interposition Autografts) for Reconstruction of Presumably Irreparable Rotator Cuff Tears

Abstract

Irreparable rotator cuff tears are challenging to treat. Especially in younger patients without concomitant osteoarthritic changes, joint-preserving procedures are warranted. To date, no treatment guideline exists because none of the available techniques has shown superiority over the others, and long-term survivorship data are missing. The aim of the "Strings" is to provide an arthroscopic solution to anatomically reconstruct presumably irreparable rotator cuff tears by bridging the gap with multiple string-like tendon interposition autografts.

Fig 1

Positioning of the patient in the beach chair position with the affected arm, as well as the ipsilateral knee, prepared and draped.

Fig 2

Arthroscopic image viewing from the posterior portal of the right shoulder. The posterosuperior rotator cuff is completely detached from its footprint at the greater tuberosity (black arrows). The long head of the biceps tendon is partially torn (blue arrow).

Fig 3

Arthroscopic images viewing from the posterolateral portal of the right shoulder. (A) A tenotomy of the long head of the biceps tendon (LHBT) is performed to further improve visualization of the glenohumeral joint. (B) The extensive injury to the rotator cuff is confirmed, as is an irreparable massive tear including the supraspinatus tendon (blue arrow) and the infraspinatus tendon (orange arrow). Both tendons are retracted to the level of the glenoid. The subscapularis tendon is macroscopically intact (gray arrow). HH, Humeral head.

Fig 4

Arthroscopic images viewing from the lateral portal of the right shoulder. A surgical release of the rotator cuff is performed, and the reducibility of the tendons and the potential for achieving a tension-free repair to the native footprint at the humeral head (HH) is assessed. If possible for the infraspinatus tendon (ISP), a horizontal mattress stitch repair using a double-loaded suture anchor is accomplished (blue arrow). SSP, Supraspinatus tendon.

Fig 5

Preparation of the harvested autograft. (A) The tendon graft is divided into several Strings of approximately 5 cm each. (B) The Strings are armed with nonabsorbable no. 2 sutures in a running stitch technique at both ends (red arrows).

Fig 6

Arthroscopic view through the posterolateral portal in a right shoulder. Both suture strands from one side of the String are passed through the tendon stump of the supraspinatus tendon (SSP) using a retrograde suture-passing device in a reverse fashion.

Fig 7

The arthroscope is placed through the posterolateral (PL) portal of a right shoulder. After both suture strands are passed out of the anterolateral (AL) portal for proper suture management, a clamp is used to insert the String (orange arrows) into the joint through the working cannula (lateral portal).

Fig 8

Arthroscopic view through the posterolateral portal in a right shoulder. (A) Two Strings are separately attached medially to the remaining cuff using a mattress stitch (blue arrows). (B) A one-point fixation (orange arrow) is used laterally to attach both Strings to the anatomic footprint.

Fig 9

Final arthroscopic view through the posterolateral portal in a right shoulder. In addition to partial repair of the infraspinatus tendon (ISP), Strings (black stars) are used to bridge the gap between the irreparable supraspinatus tendon (SSP) and the humeral head (HH).

Fig 10

Schematic illustration of the use of Strings for reconstruction of an irreparable rotator cuff tear in various planes (A-D). Strings can be attached on top (C) or on the bottom (D) of the remaining tendon stump of the rotator cuff.