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IAS 2014 
ARTHROSCOPIC TRANSOSSEOUS 
(No implant) ROTATOR CUFF REPAIR 
Dr. Raghuveer Reddy. K 
Sai Institute of Sports Injury & Arthroscopy 
Shoulder & Knee Specialty Centre, Hyderabad
I am Thankful to Dr. Sumant G. Krishnan 
for providing with Biomechanical work 
& Clinical outcome statistics of his 
study done in U.S.
History
Cycle of Rotator Cuff Repair 
Open 
Transosseous 
Mini-Open 
Transosseous 
Mini-Open 
with Anchors 
Arthroscopic 
Transosseous 
Arthroscopic 
with Anchors 
SR vs DR vs 
TOE
The Perfect RCR 
 Large Contact Area 
 High Initial Fixation Strength 
 Stable Construct 
 Biology 
 High Contact Pressure 
 Low Tension Repair
Cuff Healing - Stimulation 
Mechanical fixation Biological healing 
Suture strength 
Multiple sutures 
Suture configuration 
Suture anchors 
Transosseous Equivalent 
Transosseous Repair 
Prepare bone foot print 
? Acromioplasty?? 
• Collagen coated suture 
Growth Factors ( PRP) 
Stem Cells 
ECM Grafts 
Biologic Scaffolds 
Graft Jacket
Cyclic Testing 
Tunnel: Bone Failure 
Anchors: Tendon Failure 
Burkhart et al Arthroscopy 1997
Design Arthrotunneller
Arthroscopic Transosseous RCR 
HISTORICAL PERSPECTIVE 
 Fleega 2002 
 “Giant Needle” 
 Krishnan 2002 
 All-Arthroscopic 
Transosseous 
 Lu 2005 
 ACL Guide 
 Beauchamp 2007 
 Curved passers 
 Resch 2009 
 Curved hollow needle 
 Castagna 2012 
 Taylor Stitch 
 Kuroda 2013 
 Customized drill guide
ATRCR 
The Surgical Technique
ARTHROSCOPIC TRANSOSSEOUS 
(ANCHORLESS) ROTATOR CUFF REPAIR
ARTHROSCOPIC TRANSOSSEOUS 
(ANCHORLESS) ROTATOR CUFF REPAIR 
Surgical Technique – 
Any suture configuration possible 
 Simple (medial) 
 Mattress (ant/post) 
 Bridges
ARTHROSCOPIC TRANSOSSEOUS 
(ANCHORLESS) ROTATOR CUFF REPAIR 
Single Tunnel
ARTHROSCOPIC TRANSOSSEOUS 
(ANCHORLESS) ROTATOR CUFF REPAIR 
Two Tunnel
ATRCR 
The Science 
BIOMECHANICAL EVALUATION
Ideal Rotator Cuff Repair 
● High initial fixation strength 
● Minimal gap formation 
● Mechanical stability till tendon bone healing 
Gerber JBJS (Br) 1994 
Sugaya JBJS 2007
Arthroscopic Transosseous RCR 
REVISITING HISTORY 
● Burkhart et al. - Arthroscopy, 2000 
● Barber et al. - Arthroscopy, 2010 
● Jost et al. - JBJS, 2012 
“Increasing the number of sutures crossing the repair 
site increases the load to failure and decreases gap 
formation under cyclic loading”
ATRCR 
The Outcomes of 
Our Prospective Clinical Study & 
Sumant’s Randomized Study
My Experience 
PROSPECTIVE CLINICAL STUDY 
Material 2013 - 14 20 cases
Our Prospective Clinical Study 
 Primary 18, Revision 2 
 Posterior superior tears 14, Superior 6 tears 
 Single tunnel 11Pts. Simple Suture 
Two tunnel 9Pts. Mattress Suture 
 10 Cases evaluated. 6 - 12 months follow up 
 Functional evaluation (VAS, ASES) 
One pt. Had ASES < 70 
 MRI Evaluation – Sugaya criteria for cuff healing 
5 pts. Type I Three pts , Type II Two pts
MRI evaluation using Sugaya 
Criteria for Cuff Healing Arthroscopy 2005 
Type I: Sufficient thickness with homogeneously low intensity 
Type II: Sufficient thickness with partial high intensity 
Type III: Insufficient thickness without discontinuity 
Type IV: Presence of a minor discontinuity 
Type V: Presence of a major discontinuity
Case 1 Post op MRI 
Type I: Sufficient thickness with homogeneously low intensity 
Type II: Sufficient thickness with partial high intensity 
Type III: Insufficient thickness without discontinuity 
Type IV: Presence of a minor discontinuity 
Type V: Presence of a major discontinuity
Case 2 Post op MRI 
Type I: Sufficient thickness with homogeneously low intensity 
Type II: Sufficient thickness with partial high intensity 
Type III: Insufficient thickness without discontinuity 
Type IV: Presence of a minor discontinuity 
Type V: Presence of a major discontinuity
Case 3 Post op MRI 
Type I: Sufficient thickness with homogeneously low intensity 
Type II: Sufficient thickness with partial high intensity 
Type III: Insufficient thickness without discontinuity 
Type IV: Presence of a minor discontinuity 
Type V: Presence of a major discontinuity
Prospective Randomized Study - Sumant 
INCLUSION CRITERIA 
Posterosuperior rotator cuff tear amenable 
to GT footprint repair without tension (L , 
Crescent, reverse L) 
• No subscapularis tendon involvement 
• Grade I, II, III (Goutallier) FI 
• One single surgeon 
• Prospective Randomized allocation 
• MRI evaluation at 1 year postop from 3 
independent radiologists using Sugaya 
Criteria for cuff healing
TECHNIQUE AT SUTURE ANCHORS 
N cases 28 24 
Retear (NH) 4 (14%) 4 (16%) 
Grade I 10 (38%) 6 (26%) 
Grade II 13 (48%) 8 (34%) 
Grade III (PT) 1 (3%) 6 (26%) 
OVERALL 86% 84%
Type I healing Type III healing 
Type I: Sufficient thickness with homogeneously low intensity 
Type II: Sufficient thickness with partial high intensity 
Type III: Insufficient thickness without discontinuity 
Type IV: Presence of a minor discontinuity 
Type V: Presence of a major discontinuity
Arthroscopic Transosseous Repair Integrity 
Various Centers 
LOCATION STRUCTURAL INTEGRITY 
# OF CASES 
TO DATE 
Krishnan ASES 2010 82% (49/60) MRI 1350 
Mozes ISRAEL 2011 96% (48/50) U/S 98 
Brassart FRANCE 2011 86% (33/38) U/S 241 
Mikek SECEC 2011 95% (56/59) U/S 175 
OVERALL 86% (214/239) >2000
Double Row & TOE Repair Integrity 
Study Overall Integrity Type 
Sugaya JBJS 2007 83% ( 71 / 86 ) DR SA 
DeBeer JBJS 2007 83% ( 174 / 210 ) DR SA 
LaFosse JBJS 2007 89% (93 / 105 ) DR SA 
ElAttrache AJSM 2008 88% (22 /25) TOE/Suture bridge 
Gartsman ASES 2010 94% (44 / 47) TOE/Suture bridge 
Volgt AJSM 2010 71% ( 32 / 45) TOE/Suture bridge 
Boileau Nice 2010 72% (28 / 39) TOE/Suture bridge 
Sethi JSES 2010 83% (33 / 40) TOE/Suture bridge 
Toussaint AJSM 2011 86% (132 / 154) TOE/Suture bridge 
Rhee AJSM 2011 67% (58 / 87) TOE/Suture bridge 
Kim JBJS 2012 85% (62 / 73) TOE/Suture bridge 
OVERALL 82% (749 / 911)
Ideal Rotator Cuff Repair 
Transosseous repairs10,000+ cases worldwide 
Requirement Transosseous 
RCR 
Suture Anchor 
RCR 
Contact Area X X 
Initial Strength X X 
Contact Stability X X 
Gap Formation X X 
Mechanical Stability X X 
Biology X 
No Implants in Bone X
Arthroscopic Transosseous RCR 
WHAT ARE THE CONCERNS AND RISK? 
Bone Tunnel 
Placement 
Bone Quality 
Overtensioning 
Of repair 
Number of 
Tunnels
Arthroscopic Transosseous RCR 
REVISITING HISTORY 
 Tunnel Augmentation 
 Warner JP, Piza P 
 Warren Alpert Medical School 2012 
 Bone “Tunnel Protection” 
Courtesy: Warner JP
Arthroscopic Transosseous RCR 
ASSESS THE TEAR AND AVOID OVERTENSIONING 
Myotendinous Junction Retears 
Some cuffs cannot be pulled all the 
way out to cover the old footprint 
Shorter tendon = increased tension if pulled to normal length
Arthroscopic Transosseous RCR 
Tight Cuff Tears 
• Covers the footprint as much as possible and 
remaining with suture 
• Auto adjusts the tension – Spiral Binding 
• Less over tensioning when compared to DR/ TOE
Comparison 
ARTHROTUNNELER Vs ANCHORS 
Implant ARTHROTUNNELER 
No Implant 
ANCHORS 
Implant Present 
Small Tears 
Single tunnel 
Expensive Cheap 
Large Tears 
Two or three tunnel 
Cheap Expensive 
Technique Simple suture - Easy SR - Easy 
Mattress suture - Demanding DR - Demanding 
TOE - Easy 
Biology Bone marrow from tunnel - More Less in vented anchors 
Re tear Easy Re -operation Difficult
Arthroscopic Transosseous RCR 
CONCLUSIONS 
● Equivalent to Current Methods 
● Repair Integrity 
● Biomechanical Strength 
● Reliable/Reproducible Technique 
● Multiple Sutures 
● Bone Tunnel Augmentation 
● Assess the lesion 
● Anatomic repair and avoid over tensioning 
● More easy reoperation in case of Re-tear 
● Biology 
● Marrow elements from bone tunnels
IAS 2014 
ARTHROSCOPIC TRANSOSSEOUS 
(ANCHORLESS) ROTATOR CUFF REPAIR 
Dr. Raghuveer Reddy. K 
Sai Institute of Sports Injury & Arthroscopy 
Shoulder & Knee Specialty Centre, Hyderabad
06 Hrs
Recent Advances 
Rotator Cuff Repair 
OASIS 2014 
ARTHROSCOPIC TRANSOSSEOUS 
(ANCHORLESS) ROTATOR CUFF REPAIR 
Dr. Raghuveer Reddy. K 
Sai Institute of Sports Injury & Arthroscopy 
Shoulder & Knee Specialty Centre, Hyderabad
TOE Concerns 
Myotendinous Junction Retears 
Lill, et al. Arthroscopic Supraspinatus Tendon Repair with 
Suture Bridging Technique: Functional Outcome 
and MRI. - AJSM 2010 
Retear rate by MRI at 12 mos: 28.9% 
Cho, et al. Retear Patterns After Arthroscopic Cuff Repair: 
Single Row vs. Suture Bridge Technique. - AJSM 
2010 
27 cases of failed suture bridge technique 
74% failure at myotendinous junction 
Gerhardt et 
al. 
Arthroscopic Single-Row Modified Mason-Allen 
Repair vs. Double-Row SutureBridge 
Reconstruction for Supraspinatus Tendon Tears - 
AJSM Dec. 2012 
20 patients/5 retears 
80% retears at myotendinous junction
TOE Concerns 
Myotendinous Junction Retears 
Hayashida et al. Characteristic re-tear pattern after arthroscopic double-row 
repair. Arthroscopy, 2012 
15% retear rate at myotendinous junction 
Conclusion: 
“A new repair method, which achieves a wide 
footprint, a good initial fixation strength, and 
avoids re-tearing around the proximal suture 
anchors should be developed to obtain better 
cuff integrity and clinical results.”