Three-Dimensional Analysis of the Repair Site Area of Suture Anchors and Transosseous Bone Tunnels
Abstract & Commentary
Synopsis: The repair technique of rotator cuff tears with the greatest 3-dimensional area of the repair site may provide better potential for healing.
Source: Apreleva M, et al. Arthroscopy. 2002;18:519-526.
Structural failure occurs in roughly 13-67% of either open or arthroscopic rotator cuff repairs, making it the most frequent complication. Since the introduction of arthroscopic rotator cuff repairs, a number of novel instruments and techniques have been developed. The most effective method of repair remains controversial. The literature regarding the 2 most common methods of tendon-to-bone fixation (transosseous sutures and suture anchor) is inconsistent. The purpose of this study was to determine the 3-dimensional anatomy of the supraspinatus (SS) tendon insertion and compare the area of intact SS with the repair site areas of the repaired SS tendon after 2 transosseous suture and 2 suture-anchor repairs.
Ten fresh-frozen cadaveric shoulders were included in the study from 3 male and 7 female cadaver specimens. The SS tendon was isolated from the subscapularis anteriorly and the infraspinatus posteriorly. A 2 cm longitudinal, full-thickness, SS tear was created from the anterior border of the SS tendon. The artificially created SS tendon tear was then reconstructed with 1 of 4 techniques: transosseous simple suture (TOS), transosseous mattress suture (TOM), suture-anchor simple suture (SAS), and suture-anchor mattress suture (SAM).
The intact tendon insertion and the repaired tendon insertions underwent 3-D digitization of the anatomic structures and repair-site areas. A Microscribe3DX digitizer (Immersion Corp, San Jose, Calif) manually obtained 60-120 points on the outline of the tendon-to-bone interface 3 times for each specimen. For the repaired specimens, sutures attaching the SS tendon and humeral head were carefully removed and the tear was extended posteriorly until the entire tendon was mobilized. The original SS insertion site was identified and digitized. Humeral head geometry and surface topography were also obtained with a high-resolution 3-D laser scanner (Digibot II-HD; Digibotics, Inc, Austin, Tex) of 3 representative humeri. A special registration system superimposed the data from the tendon insertion onto the geometry of the humeral head, and calculations of the insertion-site and repair-site areas permitted computer modeling and animation of each specimen (IPA software, Immersive Design, Acton, Mass).
There was a strong correlation between the SS tendon width and humeral head size (Pearson r = 0.77; P < 0.015) but a poor correlation between SS tendon width and the area of original SS insertion (Pearson r = 0.23; P < 0.55). None of the repairs were able to restore the area of original SS insertion, which was significantly greater than all repairs (P < 0.05). The TOS repair-site area was roughly 15% smaller than the intact SS tendon, but was 20% larger than repairs with the other 3 techniques (P < 0.05), each of which covered about 67% of the intact SS insertion.
Apreleva and colleagues were able to develop a novel method to quantify and visualize the 3-D insertion sites of the SS tendon and to compare it to the repair site areas of 4 common repair techniques for rotator cuff repair. The transosseous simple repair may be the most effective method for osseous incorporation and healing of tendon to bone, and ultimately greatest strength of repair.
Comment by Brian J. Cole, MD, MBA
There are a number of variables that contribute to a successful tendon repair including muscle-tendon integrity, intact neurovascular system, density of humeral head, suture or knot failure, and tendon-to-bone fixation. Presently, there are no studies that have directly compared the structural integrity of the transosseus bone tunnel and the suture anchor repair techniques.
Apreleva et al have developed an interesting method of computer modeling and visualization to determine the repair site area of rotator cuff tendon repair. This is the first study to provide a 3-D quantitative description of the rotator cuff tendon insertion onto the humeral head for intact and repaired SS tendons and may provide greater insight into tendon repair. Apreleva et al report that the TOS technique provides the greatest contact area between the tendon-to-bone interface; therefore, TOS may have the greatest ultimate strength of all 4 methods. All repairs spanned the width of the original insertion, but they differed in the lateral positioning over the greater tuberosity. Apreleva et al suggest that a more lateral placement of suture anchors may increase the repair site area. An in-vivo follow-up study that compares the effect of lateral distance of tendon-to-bone fixation to the surface area may help to elucidate any inherent benefits of the transosseous bone tunnels. Additionally, an animal model may prove to be beneficial in determining the long-term biology of different repair techniques.
Dr. Cole, Assistant Professor, Orthopaedic Surgery, Rush Presbyterian Medical Center, Midwest Orthopaedics, Chicago, is Associate Editor of Sports Medicine Reports. Author Acknowledgments: The reviewer would like to acknowledge Shane J. Nho, MS, for his assistance in preparation of this report.
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