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A Biomechanical Comparison of 2 Technical Variations of Double-Row Rotator Cuff Fixation

The Importance of Medial Row Knots

Benjamin T. Busfield, MD^,*, Ronald E. Glousman, MD, Michelle H. McGarry, MS, James E. Tibone, MD and Thay Q. Lee, PhD

From the Kerlan-Jobe Orthopedic Clinic, Los Angeles, California, and the Orthopaedic Biomechanics Laboratory, VA Long Beach Healthcare System, Long Beach, California, and the University of California, Irvine, California

^* Address correspondence to Benjamin T. Busfield, MD, AOS Medical Center, 1505 Wilson Terrace, Suite 200, Glendale, CA 91206 (e-mail: bbusfield{at}yahoo.com).

Background: Previous studies have shown comparable biomechanical properties of double-row fixation versus double-row fixation with a knotless lateral row. SutureBridge is a construct that secures the cuff with medial row mattress suture anchors and knotless lateral row fixation of the medial suture ends. Recent completely knotless constructs may lead to lesser clinical outcomes if the construct properties are compromised from lack of suture knots.

Hypothesis: A completely knotless construct without medial row knots will compromise the biomechanical properties in both cyclic and failure-testing parameters.

Study Design: Controlled laboratory study.

Methods: Six matched pairs of cadaveric shoulders were randomized to 2 groups of double row fixation with SutureBridge: group 1 with medial row knots, and group 2 without medial row knots. The specimens were placed in a materials test system at 30° of abduction. Cyclic testing to 180 N at 1 mm/sec for 30 cycles was performed, followed by tensile testing to failure at 1 mm/sec.

Results: Data included cyclic and failure data from the materials test system and gap data using a video digitizing system. All data from paired specimens were compared using paired Student t tests. Group 1 had a statistically significant difference (P < .05) for gap formation for the 1st (3.47 vs 5.05 mm) and 30th cycle (4.22 vs 8.10 mm) and at yield load (5.2 vs 9.1 mm). In addition, there was a greater energy absorbed (2805 vs 1648 N-mm), yield load (233 vs 183.1 N), and ultimate load (352.9 vs 253.9 N) for group 1. The mode of failure for the majority (4/6) of group 2 was lateral row failure, whereas all group 1 specimens failed at the clamp.

Conclusion: Although lateral row knotless fixation has been shown not to sacrifice structural integrity of this construct, the addition of a knotless medial row compromises the construct leading to greater gapping and failure at lower loads.

Clinical Relevance: This may raise concerns regarding recently marketed completely knotless double row constructs.

Key Words: double row • rotator cuff • knotless fixation