as another patient-specific variable; again, the emphasis should not necessarily be which repair to do but when to do a particular type of repair. Finally, it should be emphasized that the remnant tendon length alone, even if 10 mm, in the face of either insufficient tissue mobility or quality, would not necessarily predict sufficient tendon healing.
Treatment Outcomes of Single- Versus Double-Row Repair for Larger Than Medium-Sized Rotator Cuff Tears: Letter to the Editor
Maxwell C. Park, MD Woodland Hills, California, USA
DOI: 10.1177/0363546514526546
Dear Editor: I read with much interest the timely study published by Kim et al2 titled ‘‘Treatment Outcomes of Single- Versus Double-Row Repair for Larger Than Medium-Sized Rotator Cuff Tears: The Effect of Preoperative Remnant Tendon Length’’ in the October 2013 issue. While there has been much emphasis on single-row versus double-row repair,1,5 another question that deserves equal attention should involve considering not so much which repair to perform but when to perform each one. In other words, what are the indications to perform one or the other? This study by Kim et al,2 by quantifying ‘‘remnant tendon length,’’ helps toward better answering this question, although the statistical power of their study is limited. One concern that is raised comes from Figure 5. The legend reads, ‘‘An appropriate length of the captured tendon that covers the footprint is 8 mm.’’ Further, the figure itself depicts 8 mm as the threshold remnant tendon length. Also, within the Discussion, the authors state, ‘‘Park et al[4] have reported that 8 mm of the medial-lateral dimension is appropriate for maximizing the potential footprint contact area in the DR repair with 4 footprint-flanking 6.5-mm suture anchors.’’2 However, based on the authors’ study design, stratification was based on a 10-mm threshold. Although their Conclusion section correctly states that a 10-mm remnant tendon length is the relevant cut-off dimension, in the context of Figure 5 and the Discussion, there could be confusion with the discrepancy between reporting 8- versus 10-mm thresholds. The original description of the transosseous-equivalent repair emphasized the following: ‘‘It is critical that the suture passes through the tendon are as medial as possible, ideally 10 to 12 mm medial to the lateral edge of the rotator cuff tear; otherwise, the amount of lateral tendon available for compression will not be maximized.’’3 In their Discussion, the authors misrepresent ‘‘8 mm’’ as being the medial-lateral dimension ‘‘appropriate for maximizing the potential footprint contact.’’ To clarify, the 8-mm dimension strictly refers to the pressure-sensitive film dimension placed on the bony footprint and not the dimension for medial suture-passing through the tendon.4 Ultimately, each repair should be individualized, and the tear characteristics dictate the type of repair that can be achieved. The authors should be commended for bringing forth this concept by quantifying remnant tendon length
Address correspondence to Maxwell C. Park, MD (e-mail: [email protected]). The author declared that he has no conflicts of interest in the authorship and publication of this contribution.
REFERENCES 1. Gartsman GM, Drake G, Edwards TB, et al. Ultrasound evaluation of arthroscopic full-thickness supraspinatus rotator cuff repair: singlerow versus double-row suture bridge (transosseous equivalent) fixation. Results of a prospective, randomized study. J Shoulder Elbow Surg. 2013;22:1480-1487. 2. Kim YK, Moon SH, Cho SH. Treatment outcomes of single- versus double-row repair for larger than medium-sized rotator cuff tears: the effect of preoperative remnant tendon length. Am J Sports Med. 2013;41:2270-2277. 3. Park MC, ElAttrache NS, Ahmad CS, Tibone JE. ‘‘Transosseousequivalent’’ rotator cuff repair technique. Arthroscopy. 2006;22:1360.e1-1360.e5. 4. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ. Part I: footprint contact characteristics for an arthroscopic transosseousequivalent rotator cuff repair technique. J Shoulder Elbow Surg. 2007;16:461-468. 5. Xu C, Zhao J, Li D. Meta-analysis comparing single-row and doublerow repair techniques in the arthroscopic treatment of rotator cuff tears. J Shoulder Elbow Surg. 2014;23:182-188.
Treatment Outcomes of Single- Versus Double-Row Repair for Larger Than Medium-Sized Rotator Cuff Tears: Response DOI: 10.1177/0363546514526548
Authors’ Response: We appreciate your interest in our study and your critical comments. First of all, we would like to offer our sincere apologies for our misinterpretation of your study4 when citing it. In your study, you described that an
The American Journal of Sports Medicine, Vol. 42, No. 4 Ó 2014 The Author(s)
NP22
Vol. 42, No. 4, 2014
‘‘8-mm medial-lateral dimension was chosen to maximize the potential footprint contact area within the constraints of 4 footprint-flanking 6.5-mm suture anchors necessary for double-row repair,’’4(p462) so the pressure-sensitive film was shaped to conform to 8 mm for the medial to lateral dimension. We interpreted this wrongly and stated that 8 mm was the appropriate dimension for maximizing the potential footprint contact area in the double-row repair. In your study, you commented that there is an obligatory loss of surface area when suture anchors are placed flanking the footprint, so 8 mm was the mediallateral dimension of the pressure-sensitive film for maximizing the potential footprint contact area. We thought wrongly that this measurement was the minimum coverage dimension when performing double-row or suture-bridge repair, and it could support that 10 mm is an appropriate threshold for remnant tendon length considering the dimension from the musculotendinous junction to the medial suture. This is the reason why we cited ‘‘8 mm’’ for the medial-lateral dimension of the pressure-sensitive film in our Discussion section. In this process, there was a misinterpretation of your study. Accordingly, we apologize for our misinterpretation again. In our article,2 the suggestion of a 10-mm threshold for remnant tendon length was not based on a precise biomechanical study. It was determined by the authors’ clinical experience. However, when we set up the threshold, we considered the fact that some authors have mentioned that the proper length of a captured tendon is 10 to 15 mm.1,3 We therefore came to think of 10 mm as the minimum threshold. The purpose of our study was to compare single-row and suture-bridge repair based on 10 mm as a minimum threshold, and our study, based on this threshold, showed significant clinical differences between the 2 techniques. As you mentioned, we agree with your opinion that there could be confusion between 8 and 10 mm. Figure 5 shows an example when the remnant tendon length is 10 mm at a minimum. In this case, considering the dimension from the musculotendinous junction to the medial suture for avoiding pull-out tears, the captured tendon length should be necessarily 8 mm at a minimum. However, we think that the description of this figure is not adequate, so it could cause some confusion. We feel sorry about that.
Letter to the Editor
NP23
In other words, in Figure 5, a minimum 10-mm remnant tendon length is appropriate for suture-bridge repair, and the captured tendon length should be 8 mm at this time. Also, what we tried to say here was that in this condition, we can get better clinical results by performing suturebridge repair than single-row repair. As you mentioned in closing, it is correct that the decision for each repair should be individualized. Also, several factors like tear shape, size, tendon quality, and mobility should be considered when selecting the repair technique. We totally agree with your opinion and declared such a comment in our Discussion section. Finally, we emphasize that our study intended to suggest remnant tendon length as a meaningful considering factor in the decision for a repair technique. Young Kyu Kim, MD Sung Hoon Moon, MD Seung Hyun Cho, MD Incheon, South Korea
Address correspondence to Sung Hoon Moon, MD (e-mail: [email protected]). The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
REFERENCES 1. Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained? Am J Sports Med. 2011;39(10):2108-2116. 2. Kim YK, Moon SH, Cho SH. Treatment outcomes of single- versus double-row repair for larger than medium-sized rotator cuff tears: the effect of preoperative remnant tendon length. Am J Sports Med. 2013;41:2270-2277. 3. Millett PJ, Mazzocca A, Guanche CA. Mattress double anchor footprint repair: a novel, arthroscopic rotator cuff repair technique. Arthroscopy. 2004;20(8):875-879. 4. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ. Part I: footprint contact characteristics for an arthroscopic transosseous-equivalent rotator cuff repair technique. J Shoulder Elbow Surg. 2007;16:461-468.
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav
Treatment Outcomes of Single- Versus Double-Row Repair for Larger Than Medium-Sized Rotator Cuff Tears: Letter to the Editor
Maxwell C. Park, MD Woodland Hills, California, USA
DOI: 10.1177/0363546514526546
Dear Editor: I read with much interest the timely study published by Kim et al2 titled ‘‘Treatment Outcomes of Single- Versus Double-Row Repair for Larger Than Medium-Sized Rotator Cuff Tears: The Effect of Preoperative Remnant Tendon Length’’ in the October 2013 issue. While there has been much emphasis on single-row versus double-row repair,1,5 another question that deserves equal attention should involve considering not so much which repair to perform but when to perform each one. In other words, what are the indications to perform one or the other? This study by Kim et al,2 by quantifying ‘‘remnant tendon length,’’ helps toward better answering this question, although the statistical power of their study is limited. One concern that is raised comes from Figure 5. The legend reads, ‘‘An appropriate length of the captured tendon that covers the footprint is 8 mm.’’ Further, the figure itself depicts 8 mm as the threshold remnant tendon length. Also, within the Discussion, the authors state, ‘‘Park et al[4] have reported that 8 mm of the medial-lateral dimension is appropriate for maximizing the potential footprint contact area in the DR repair with 4 footprint-flanking 6.5-mm suture anchors.’’2 However, based on the authors’ study design, stratification was based on a 10-mm threshold. Although their Conclusion section correctly states that a 10-mm remnant tendon length is the relevant cut-off dimension, in the context of Figure 5 and the Discussion, there could be confusion with the discrepancy between reporting 8- versus 10-mm thresholds. The original description of the transosseous-equivalent repair emphasized the following: ‘‘It is critical that the suture passes through the tendon are as medial as possible, ideally 10 to 12 mm medial to the lateral edge of the rotator cuff tear; otherwise, the amount of lateral tendon available for compression will not be maximized.’’3 In their Discussion, the authors misrepresent ‘‘8 mm’’ as being the medial-lateral dimension ‘‘appropriate for maximizing the potential footprint contact.’’ To clarify, the 8-mm dimension strictly refers to the pressure-sensitive film dimension placed on the bony footprint and not the dimension for medial suture-passing through the tendon.4 Ultimately, each repair should be individualized, and the tear characteristics dictate the type of repair that can be achieved. The authors should be commended for bringing forth this concept by quantifying remnant tendon length
Address correspondence to Maxwell C. Park, MD (e-mail: [email protected]). The author declared that he has no conflicts of interest in the authorship and publication of this contribution.
REFERENCES 1. Gartsman GM, Drake G, Edwards TB, et al. Ultrasound evaluation of arthroscopic full-thickness supraspinatus rotator cuff repair: singlerow versus double-row suture bridge (transosseous equivalent) fixation. Results of a prospective, randomized study. J Shoulder Elbow Surg. 2013;22:1480-1487. 2. Kim YK, Moon SH, Cho SH. Treatment outcomes of single- versus double-row repair for larger than medium-sized rotator cuff tears: the effect of preoperative remnant tendon length. Am J Sports Med. 2013;41:2270-2277. 3. Park MC, ElAttrache NS, Ahmad CS, Tibone JE. ‘‘Transosseousequivalent’’ rotator cuff repair technique. Arthroscopy. 2006;22:1360.e1-1360.e5. 4. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ. Part I: footprint contact characteristics for an arthroscopic transosseousequivalent rotator cuff repair technique. J Shoulder Elbow Surg. 2007;16:461-468. 5. Xu C, Zhao J, Li D. Meta-analysis comparing single-row and doublerow repair techniques in the arthroscopic treatment of rotator cuff tears. J Shoulder Elbow Surg. 2014;23:182-188.
Treatment Outcomes of Single- Versus Double-Row Repair for Larger Than Medium-Sized Rotator Cuff Tears: Response DOI: 10.1177/0363546514526548
Authors’ Response: We appreciate your interest in our study and your critical comments. First of all, we would like to offer our sincere apologies for our misinterpretation of your study4 when citing it. In your study, you described that an
The American Journal of Sports Medicine, Vol. 42, No. 4 Ó 2014 The Author(s)
NP22
Vol. 42, No. 4, 2014
‘‘8-mm medial-lateral dimension was chosen to maximize the potential footprint contact area within the constraints of 4 footprint-flanking 6.5-mm suture anchors necessary for double-row repair,’’4(p462) so the pressure-sensitive film was shaped to conform to 8 mm for the medial to lateral dimension. We interpreted this wrongly and stated that 8 mm was the appropriate dimension for maximizing the potential footprint contact area in the double-row repair. In your study, you commented that there is an obligatory loss of surface area when suture anchors are placed flanking the footprint, so 8 mm was the mediallateral dimension of the pressure-sensitive film for maximizing the potential footprint contact area. We thought wrongly that this measurement was the minimum coverage dimension when performing double-row or suture-bridge repair, and it could support that 10 mm is an appropriate threshold for remnant tendon length considering the dimension from the musculotendinous junction to the medial suture. This is the reason why we cited ‘‘8 mm’’ for the medial-lateral dimension of the pressure-sensitive film in our Discussion section. In this process, there was a misinterpretation of your study. Accordingly, we apologize for our misinterpretation again. In our article,2 the suggestion of a 10-mm threshold for remnant tendon length was not based on a precise biomechanical study. It was determined by the authors’ clinical experience. However, when we set up the threshold, we considered the fact that some authors have mentioned that the proper length of a captured tendon is 10 to 15 mm.1,3 We therefore came to think of 10 mm as the minimum threshold. The purpose of our study was to compare single-row and suture-bridge repair based on 10 mm as a minimum threshold, and our study, based on this threshold, showed significant clinical differences between the 2 techniques. As you mentioned, we agree with your opinion that there could be confusion between 8 and 10 mm. Figure 5 shows an example when the remnant tendon length is 10 mm at a minimum. In this case, considering the dimension from the musculotendinous junction to the medial suture for avoiding pull-out tears, the captured tendon length should be necessarily 8 mm at a minimum. However, we think that the description of this figure is not adequate, so it could cause some confusion. We feel sorry about that.
Letter to the Editor
NP23
In other words, in Figure 5, a minimum 10-mm remnant tendon length is appropriate for suture-bridge repair, and the captured tendon length should be 8 mm at this time. Also, what we tried to say here was that in this condition, we can get better clinical results by performing suturebridge repair than single-row repair. As you mentioned in closing, it is correct that the decision for each repair should be individualized. Also, several factors like tear shape, size, tendon quality, and mobility should be considered when selecting the repair technique. We totally agree with your opinion and declared such a comment in our Discussion section. Finally, we emphasize that our study intended to suggest remnant tendon length as a meaningful considering factor in the decision for a repair technique. Young Kyu Kim, MD Sung Hoon Moon, MD Seung Hyun Cho, MD Incheon, South Korea
Address correspondence to Sung Hoon Moon, MD (e-mail: [email protected]). The authors declared that they have no conflicts of interest in the authorship and publication of this contribution.
REFERENCES 1. Cho NS, Lee BG, Rhee YG. Arthroscopic rotator cuff repair using a suture bridge technique: is the repair integrity actually maintained? Am J Sports Med. 2011;39(10):2108-2116. 2. Kim YK, Moon SH, Cho SH. Treatment outcomes of single- versus double-row repair for larger than medium-sized rotator cuff tears: the effect of preoperative remnant tendon length. Am J Sports Med. 2013;41:2270-2277. 3. Millett PJ, Mazzocca A, Guanche CA. Mattress double anchor footprint repair: a novel, arthroscopic rotator cuff repair technique. Arthroscopy. 2004;20(8):875-879. 4. Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ. Part I: footprint contact characteristics for an arthroscopic transosseous-equivalent rotator cuff repair technique. J Shoulder Elbow Surg. 2007;16:461-468.
For reprints and permission queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav
