Orthopedics

Feature Article 

Outcomes Following Double-Row and Medial Double-Pulley Rotator Cuff Repair

Matthew P. Noyes, MD; Patrick J. Denard, MD

Abstract

Multiple arthroscopic double-row repair techniques have been developed to treat full-thickness rotator cuff tears. However, healing rates and functional outcomes vary among these repair methods. A suture tape and medial double-pulley (STDP) technique that incorporated 2-mm suture tape for a knotless double-row with a broad double-mattress suture medially was developed as an alternative method to other double-row repair techniques. This prospective study reviewed the functional outcomes and healing rates of full-thickness supraspinatus tendon tears repaired using an STDP technique. Of 33 consecutive patients who underwent arthroscopic rotator cuff repair with an STDP construct, 24 patients with a minimum of 1 year of follow-up were included in the study. Preoperative fatty atrophy was recorded. Ultrasound imaging was used to assess rotator cuff healing at a minimum of 6 months postoperatively. Range of motion and functional outcome scores were evaluated at final follow-up. Mean active forward elevation improved from 124° preoperatively to 160° postoperatively. Comparing preoperative and postoperative values, the American Shoulder and Elbow Surgeons score improved from 45.9 to 90.8, the Single Assessment Numeric Evaluation score improved from 34.6 to 87.1, and the visual analog scale score decreased from 5.3 to 1.3. Twenty-one of 24 patients (88%) were satisfied with their outcomes. Ultrasound evaluation demonstrated complete healing in 88% of the cohort. The STDP technique is a technically efficient method of obtaining medial fixation in a double-row repair and appears to demonstrate clinically acceptable results. Healing was observed in 88% of cases, and functional outcome showed a statistically significant improvement. [Orthopedics. 2021;44(1):e125–e130.]

Abstract

Multiple arthroscopic double-row repair techniques have been developed to treat full-thickness rotator cuff tears. However, healing rates and functional outcomes vary among these repair methods. A suture tape and medial double-pulley (STDP) technique that incorporated 2-mm suture tape for a knotless double-row with a broad double-mattress suture medially was developed as an alternative method to other double-row repair techniques. This prospective study reviewed the functional outcomes and healing rates of full-thickness supraspinatus tendon tears repaired using an STDP technique. Of 33 consecutive patients who underwent arthroscopic rotator cuff repair with an STDP construct, 24 patients with a minimum of 1 year of follow-up were included in the study. Preoperative fatty atrophy was recorded. Ultrasound imaging was used to assess rotator cuff healing at a minimum of 6 months postoperatively. Range of motion and functional outcome scores were evaluated at final follow-up. Mean active forward elevation improved from 124° preoperatively to 160° postoperatively. Comparing preoperative and postoperative values, the American Shoulder and Elbow Surgeons score improved from 45.9 to 90.8, the Single Assessment Numeric Evaluation score improved from 34.6 to 87.1, and the visual analog scale score decreased from 5.3 to 1.3. Twenty-one of 24 patients (88%) were satisfied with their outcomes. Ultrasound evaluation demonstrated complete healing in 88% of the cohort. The STDP technique is a technically efficient method of obtaining medial fixation in a double-row repair and appears to demonstrate clinically acceptable results. Healing was observed in 88% of cases, and functional outcome showed a statistically significant improvement. [Orthopedics. 2021;44(1):e125–e130.]

Double-row constructs were developed to improve fixation strength and anatomic footprint restoration compared with single-row repairs.1 These double-row constructs lead to improved healing compared with single-row repairs, particularly for tears 3 cm or larger.2 Multiple double-row arthroscopic rotator cuff repair techniques have been described in detail in recent years. Although intrinsic factors such as tendon quality and patient age are predetermined, double-row techniques may be modified to improve rotator cuff healing.

Arrigoni et al3 first described the double-pulley technique, which uses the eye-lets of two anchors as pulleys to create a broad-based, double-mattress suture that compresses the intervening tendon bridge against its bone bed. This technique allows stress to be distributed over a large surface area. Although originally described for a nonlinking double-row construct, the technique has multiple applications (eg, remplissage or PASTA repair) and subsequently has been incorporated into suture-bridging double-row repairs.

Recently, a modified suture-bridging repair has been described that incorporates a 2-mm suture tape and medial double pulley (STDP).4 This technique requires only 2 suture passes through the cuff to achieve knotless fixation of the suture tape, as well as a broad mattress suture medially that maximizes the cuff-to-bone compression along the medial row and provides medial row independence. The biomechanical advantage of this technique, combined with its simplicity, makes it an appealing approach. However, no clinical studies have examined the healing rate or functional outcome with this technique.

This study prospectively evaluated the functional outcomes and healing rates of full-thickness supraspinatus tendon tears arthroscopically repaired with an STDP technique. The hypothesis was that an STDP construct would demonstrate improved functional outcomes in patients undergoing arthroscopic rotator cuff repair.

Materials and Methods

A prospective analysis was performed of arthroscopic rotator cuff repair using an STDP technique for full-thickness supraspinatus tendon tears performed at a single institution between January 2015 and August 2015. Institutional review board approval was obtained prior to commencing the study. Inclusion criteria were a primary repair of a full-thickness supraspinatus tendon tear amenable to a double-row repair (sufficient tissue mobility to allow for 100% coverage of the greater tuberosity). All tears amenable to a double-row repair during the period were repaired with an STDP technique by the senior author (P.J.D.) regardless of size or tissue quality. Tears that involved extension into the infraspinatus or subscapularis also were included. Exclusion criteria were revision repairs and partial or single-row repairs due to limited tendon mobility. The minimum follow-up for inclusion in the study was 1 year. A total of 33 repairs met the study criteria during the study period. Nine patients were lost to follow-up, leaving 24 patients available for analysis.

Range of motion including forward flexion, external rotation at the side, and internal rotation to the nearest spinal level was recorded preoperatively and at 12 months postoperatively. Functional outcome was assessed using American Shoulder and Elbow Surgeons (ASES) scores5 and Single Assessment Numeric Evaluation (SANE) scores. Pre- and postoperative pain was graded from 0 to 10 on a visual analog scale (VAS).

Preoperative fatty atrophy of the rotator cuff was assessed using the Goutallier classification system.6 An ultrasound evaluation was performed by the senior author (P.J.D.) at a minimum of 6 months postoperatively to determine tendon healing. Tendon healing was assessed as complete or no healing.

Surgical Technique

The double-pulley technique originally was described by Lo and Burkhart.1 This technique has been modified to incorporate a 2-mm suture tape (FiberTape; Arthrex Inc) for double-row knotless fixation (Figure 1).2 Following bone bed preparation, an anteromedial bone socket was prepared adjacent to the articular margin. A SwiveLock C anchor (Arthrex Inc) was preloaded with FiberTape suture and placed through the same percutaneous portal used for punch insertion. A free FiberLink (Arthrex Inc) suture was used to shuttle the FiberTape and the FiberWire (Arthrex Inc) safety sutures through the rotator cuff.

Schematic illustration demonstrating a suture tape and double-pulley construct. (Reprinted with permission from Burkhart SS, Lo IK, Brady PC, Denard PJ. The Cowboy's Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Lippincott Williams and Wilkins; 2012.)

Figure 1:

Schematic illustration demonstrating a suture tape and double-pulley construct. (Reprinted with permission from Burkhart SS, Lo IK, Brady PC, Denard PJ. The Cowboy's Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Lippincott Williams and Wilkins; 2012.)

While viewing from a posterior portal, an antegrade suture passer was used to pass the closed end of a FiberLink through the anteromedial rotator cuff, 2 to 3 mm lateral to the musculotendinous junction. The FiberTape and FiberWire safety sutures from the anteromedial anchor then were retrieved from the lateral portal and passed through the looped end of the FiberLink. The 4 suture limbs then were shuttled through the rotator cuff by pulling the closed end of the FiberLink. This sequence was repeated for the posteromedial anchor sutures.

A double-pulley technique was used to tie the medial mattress stitches between the 2 medial anchors. A suture limb was retrieved from both the anteromedial anchor and posteromedial anchor. Extracorporeally, a surgeon's knot was tied over an instrument, and the knot security was checked by pulling on the sutures beneath the knot to ensure the knot did not slide. The suture limbs were cut above the knot, and the knot was delivered into the subacromial space and seated onto the rotator cuff by pulling on the opposite ends of the sutures that exit through percutaneous portals used for anchor placement. The opposite ends of the suture limbs were retrieved, and the double-mattress stitch was completed by tying a static knot in the subacromial space with a surgeon's Sixth Finger Knot Pusher (Arthrex Inc). The suture limbs from this knot were cut.

To complete the repair, the FiberTape limbs were crisscrossed and secured laterally with 2 additional SwiveLock anchors. A suture limb from the anteromedial anchor and a suture limb from the posteromedial anchor were retrieved from a lateral portal. While maintaining tension on the suture limbs, the lateral cannula was used to determine the appropriate position for an anterolateral anchor. A punch was inserted to create a bone socket, the FiberTape was threaded through the eyelet of a BioComposite SwiveLock C anchor, the anchor was inserted, and the sutures were cut flush with the anchor. The remaining FiberTape suture limbs were retrieved, and the steps then were repeated with a posterolateral anchor. The final repair not only was a transosseous equivalent repair, but also provided a medial seal from the joint via the medial double-mattress stitch (Figure 2).

Preoperative arthroscopic posterior subacromial view of the right shoulder demonstrating a full-thickness supraspinatus tendon tear (A) and postoperative view showing a speed tape double-pulley repair (B). The arrow points to the medial mattress suture that compresses along the articular surface to seal the joint. Abbreviation: RC, rotator cuff.

Figure 2:

Preoperative arthroscopic posterior subacromial view of the right shoulder demonstrating a full-thickness supraspinatus tendon tear (A) and postoperative view showing a speed tape double-pulley repair (B). The arrow points to the medial mattress suture that compresses along the articular surface to seal the joint. Abbreviation: RC, rotator cuff.

Concomitant procedures included 25 acromioplasties (100%), 21 arthroscopic biceps tenodeses (84%), 2 distal clavicle excisions (8%), 2 biceps tenotomies (8%), and 1 labral repair (4%). Postoperatively, patients underwent immobilization in a sling for 6 weeks with basic hand, wrist, and elbow exercises started immediately. After 6 weeks, the sling was discontinued and range of motion commenced. Strengthening was initiated at 3 months postoperatively.

Statistical Analysis

Continuous data were described by mean and standard deviation. A t test was used to analyze the difference in pre- and postoperative outcome scores for forward flexion and VAS, ASES, and SANE scores. All statistical analyses were conducted by a trained statistician. Two-tailed P<.05 was considered significant.

Results

The mean age of the cohort was 62.5 years at the time of surgery. Sixteen patients (67%) were men, and 15 patients (63%) had involvement of their dominant extremity. Sixteen patients (67%) had an associated subscapularis tear that required repair. The average tear size was 2.5×2.6 cm in the medial to lateral and anterior to posterior planes, respectively. Operative characteristics are summarized in Table 1.

Operative Characteristics of Arthroscopic Rotator Cuff Repair With the Suture Tape and Medial Double-Pulley Technique (N=24)

Table 1:

Operative Characteristics of Arthroscopic Rotator Cuff Repair With the Suture Tape and Medial Double-Pulley Technique (N=24)

The differences between pre- and postoperative forward elevation and ASES, SANE, and VAS pain scores were statistically significant. Active forward elevation improved from 124° preoperatively to 160° postoperatively (gain, 35°±48°; P=.005). There was no change in external rotation postoperatively. The mean VAS pain score improved from 5.3 preoperatively to 1.3 postoperatively (decrease, 4.0±2.1; P<.0001). The mean ASES score improved from 45.9 preoperatively to 90.8 postoperatively (gain, 46.4±19.1; P<.0001), and the mean SANE score improved from 34.6 preoperatively to 87.1 postoperatively (gain, 53.6±34.9; P<.0001). Objective measures and functional outcome scores are summarized in Table 2.

Operative Results of Suture Tape and Medial Double-Pulley Technique Repairs

Table 2:

Operative Results of Suture Tape and Medial Double-Pulley Technique Repairs

Ultrasound imaging at a minimum of 6 months after surgery revealed 21 patients (88%) had evidence of complete healing of the supraspinatus and infraspinatus tendon. Three patients had imaging that demonstrated residual defects or incomplete healing.

Subjectively, 22 patients (92%) reported being satisfied with the procedure, and 23 patients (96%) were able to return to their previous activity or work level. One patient had postoperative stiffness. The patient declined an arthroscopic capsular release at the 1-year follow-up as he was not reporting any pain and was satisfied. No secondary procedures were performed, and there were no instances of deep wound infection or implant failure in the cohort.

Discussion

This study examined the ability of an STDP construct for full-thickness supraspinatus tendon tears to improve functional outcomes. The data supported the study hypothesis that an STDP technique improves functional outcome in the setting of a posterosuperior rotator cuff tear amenable to a double-row repair. Outcomes in this study were favorable compared with other reports7,8 of arthroscopic double-row repairs. Range of motion and functional outcome scores increased, and pain scores decreased.

Double-row repair constructs have demonstrated improved healing rates in the literature as well. A recent summary of 8 meta-analysis studies by Spiegl et al9 demonstrated lower retear rates in double-row constructs compared with single-row constructs. In particular, superior results were noted in the setting of large to massive tears when the repair was amenable to a double-row technique.

Hein et al7 performed a systematic review of retear rates after single-row and linking double-row repairs. Double-row repairs had statistically significantly lower retear rates than single-row repairs for small, medium, and massive rotator cuff tears. Moreover, double-row repairs had a lower overall retear total. These results paralleled those of Sugaya et al,8 who reported a 5% retear rate in small and medium rotator cuff tears repaired with a double-row construct. Retears identified on magnetic resonance imaging had inferior functional outcomes and strength, supporting the idea that patients who go on to heal their rotator cuff tears have clinically better results.

Many novel techniques from knotted to knotless techniques have been described for suture-bridging double-row repairs. A study by Ide et al10 compared outcomes between arthroscopic knotless double-row and single-row repairs for anterosuperior rotator cuff tears. The failure rate was nearly double in the single-row group (32% [5 of 36]) compared with the knotless double-row group (14% [8 of 36]). Moreover, there was a lower incidence of positive lift off or belly press tests in the knotless group, as well as higher abduction strength scores. The authors concluded that knotless double-row techniques may be useful for improving subscapularis function, abduction strength, and tendon healing.

Vaishnav and Millett11 performed a biomechanical evaluation of a completely knotless double-row repair with 2 mm and demonstrated that ultimate load to failure was 539 N in the double-row knotless group compared with 511 N in the standard knot tying double-row group. In their series of 22 patients with a minimum 1-year follow-up, patients were allowed to start rehabilitation faster, which minimized convalescence, and patients returned to full unrestricted activity at 4 months postoperatively. However, tendon healing was not evaluated. Hug et al12 reported a healing rate of 77.3% in a prospective series of 22 patients with 22 supraspinatus tendon tears repaired with completely knotless fixation using the same 2-mm tape used in the current study. The current study's healing rate of 88% supports the use of 2-mm tape, and the higher healing rate compared with that of Hug et al12 may reflect the addition of medial knots.

Although avoiding knots medially has the advantage of decreased surgical time, completely knotless constructs have potential limitations. A cadaveric study was performed to compare footprint contact area and interface pressure on the greater tuberosity between knotless and knot-tying transosseous-equivalent repairs.13 The medial knotless repair produced a statistically significantly inferior footprint contact area and interface pressure compared with conventional medial knot-tying repair.

Similarly, Pauly et al14 reported on a biomechanical study comparing 4 different knotless double-row configurations with or without medial or lateral row reinforcement. The medial mattress stitch reinforcement construct demonstrated both significantly ultimate higher tensile strength than the other constructs and provided increased maximal force resistance at 3- and 5-mm gap formation compared with the completely knotless technique without reinforcement.

The STDP technique is a hybrid construct with two unique features that are different from other double-row techniques. First, a total of only 2 suture passes are required for the STDP technique, whereas other double-row suture bridge constructs typically use 4 suture passes. The STDP technique therefore leads to improved technical efficiency and easier suture management. A biomechanical study by Park et al15 compared standard suture bridge repair technique vs a medial pulley mattress technique and calculated a “technical efficiency ratio.” There were no significant differences between constructs in cyclical loading or load to failure. Less tendon cut-out was noted with the medial pulley construct. The medial pulley construct had a technical efficiency ratio of 2.0 vs 2.5 for the standard suture bridge construct. This implies that less suture passage, which is technically less demanding, does not necessarily sacrifice biomechanical strength of the repair. The technical efficiency ratio then could be used to assess technical difficulty of any construct and help provide some standardization when comparing other double-row constructs in the future.

Second, the broad mattress suture medially provides a seal of the joint, preventing synovial fluid from egressing through the tear site into the subacromial space. After the medial double-pulley mattress suture is tied, the suture ends are cut and not brought over for a lateral row. This provides medial independence between the 2 rows of anchors compared with standard suture bridging techniques. The addition of a 2-mm tape as opposed to no. 2 suture also provides increased contact surface area for compression of tendon to bone.

However, few publications describe a double-pulley technique that creates a broad mattress suture medially along the articular margin. Choi et al16 reported on their technique that was a modification of the original description and possessed the advantages of both the double pulley and suture bridge techniques by creating a linking construct, which maximized compression along the medial row. The final overall healing rate was 81% (33 of 41 patients), and no retears occurred in small tears. In the current study, the authors observed an 88% rate of complete healing, which is favorable compared with other studies, particularly given that the tears in the current patients were not limited to isolated supraspinatus tendon tears.

There were some limitations to this study and technique. The duration of follow-up was short at 1 year. However, the authors believe this follow-up is reasonable as the goal was to assess healing, and it has been demonstrated that 6 months is an adequate predictor of long-term healing.17 Several patients in the entire cohort were lost to follow-up at 1 year and were not included in the study. It is possible that these patients were doing well postoperatively and declined to return for a 1-year follow-up examination.

There was no comparative group of completely knotless repairs (no medial knots) or a group of repairs with no. 2 suture alone. Therefore, the authors could not determine in what cases a completely knotless repair was adequate clinically and could not prove the 2-mm tape improved healing compared with no. 2 suture alone. Future prospective evaluation is needed to compare these other constructs.

Concomitant procedures could influence patient satisfaction independent of rotator cuff healing, and these were not independently evaluated for their influence on outcome. In addition, all surgeries were performed by a single surgeon and the results may not be universally reproducible. Finally, ultrasound examinations were performed by a single observer, which could lead to inaccuracies or inject bias regarding whether the rotator cuff was healed.

Conclusion

The STDP technique is a technically efficient method of obtaining medial fixation in a double-row repair for full-thickness posterosuperior rotator cuff tears and appears to demonstrate clinically acceptable results. Healing was observed in 88% of cases, and functional outcome showed statistically significant improvements.

References

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  3. Arrigoni P, Brady PC, Burkhart SS. The double-pulley technique for double-row rotator cuff repair. Arthroscopy. 2007;23(6):675.e1–675.e4. doi:10.1016/j.arthro.2006.08.016 [CrossRef]. PMID:17560485
  4. Burkhart SS, Lo IK, Brady PC, Denard PJ. The Cowboy's Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Lippincott Williams and Wilkins; 2012.
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  6. Goutallier D, Postel JM, Bernageau J, et al. Fatty muscle degeneration in cuff ruptures. Pre and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994;304:78–83. PMID:8020238
  7. Hein J, Reilly JM, Chae J, Maerz T, Anderson K. Retear rates after arthroscopic single-row, double-row, and suture bridge rotator cuff repair at a minimum of 1 year of imaging follow-up: a systematic review. Arthroscopy. 2015;31(11):2274–2281. doi:10.1016/j.arthro.2015.06.004 [CrossRef]. PMID:26188783
  8. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair: a prospective outcome study. J Bone Joint Surg Am. 2007;89(5):953–960. doi:10.2106/00004623-200705000-00006 [CrossRef]. PMID:17473131
  9. Spiegl UJ, Euler SA, Millett PJ, Hepp P. Summary of meta-analyses dealing with single-row versus double-row repair techniques for rotator cuff tears. Open Orthop J. 2016;10(1):330–338. doi:10.2174/1874325001610010330 [CrossRef]. PMID:27708735
  10. Ide J, Karasugi T, Okamoto N, Taniwaki T, Oka K, Mizuta H. Functional and structural comparisons of the arthroscopic knotless double-row suture bridge and single-row repair for anterosuperior rotator cuff tears. J Shoulder Elbow Surg. 2015;24(10):1544–1554. doi:10.1016/j.jse.2015.03.015 [CrossRef]. PMID:25940379
  11. Vaishnav S, Millett PJ. Arthroscopic rotator cuff repair: scientific rationale, surgical technique, and early clinical and functional results of a knotless self-reinforcing double-row rotator cuff repair system. J Shoulder Elbow Surg. 2010;19(2)(suppl):83–90. doi:10.1016/j.jse.2009.12.012 [CrossRef] PMID:20188272
  12. Hug K, Gerhardt C, Haneveld H, Scheibel M. Arthroscopic knotless-anchor rotator cuff repair: a clinical and radiological evaluation. Knee Surg Sports Traumatol Arthrosc. 2015;23(9):2628–2634. doi:10.1007/s00167-014-3026-1 [CrossRef]. PMID:24792075
  13. Kim SJ, Kim SH, Moon HS, Chun YM. Footprint contact area and interface pressure comparison between the knotless and knot-tying transosseous-equivalent technique for rotator cuff repair. Arthroscopy. 2016;32(1):7–12. doi:10.1016/j.arthro.2015.07.004 [CrossRef]. PMID:26382638
  14. Pauly S, Fiebig D, Kieser B, Albrecht B, Schill A, Scheibel M. Biomechanical comparison of four double-row speed-bridging rotator cuff repair techniques with or without medial or lateral row enhancement. Knee Surg Sports Traumatol Arthrosc. 2011;19(12):2090–2097. doi:10.1007/s00167-011-1517-x [CrossRef]. PMID:21556828
  15. Park MC, Peterson A, Patton J, McGarry MH, Park CJ, Lee TQ. Biomechanical effects of a 2 suture-pass medial inter-implant mattress on transosseous-equivalent rotator cuff repair and considerations for a “technical efficiency ratio.”J Shoulder Elbow Surg. 2014;23(3):361–368. doi:10.1016/j.jse.2013.06.019 [CrossRef]. PMID:24035567
  16. Choi CH, Kim SK, Cho MR, et al. Functional outcomes and structural integrity after double-pulley suture bridge rotator cuff repair using serial ultrasonographic examination. J Shoulder Elbow Surg. 2012;21(12):1753–1763. doi:10.1016/j.jse.2011.12.012 [CrossRef]. PMID:22541867
  17. Kluger R, Bock P, Mittlböck M, Krampla W, Engel A. Long-term survivorship of rotator cuff repairs using ultrasound and magnetic resonance imaging analysis. Am J Sports Med. 2011;39(10):2071–2081. doi:10.1177/0363546511406395 [CrossRef]. PMID:21610262

Operative Characteristics of Arthroscopic Rotator Cuff Repair With the Suture Tape and Medial Double-Pulley Technique (N=24)

CharacteristicValue
Age, mean±SD, y62.5±9.9
Tear size, mean±SD, cm
  Mediolateral2.5±0.79
  Anteroposterior2.6±0.79
Interval slides, No.3 (12%)
Fatty degeneration of the supraspinatus, No.
  Goutallier grade 06
  Goutallier grade 19
  Goutallier grade 28
  Goutallier grade 31
  Goutallier grade 40
Fatty degeneration of the infraspinatus, No.
  Goutallier grade 010
  Goutallier grade 19
  Goutallier grade 24
  Goutallier grade 31
  Goutallier grade 40

Operative Results of Suture Tape and Medial Double-Pulley Technique Repairs

OutcomeMean±SDPCI

PreoperativePostoperative
Forward flexion124°±48°160°±17°.005103–168
External rotation55°±13°56°±17°1.0047–64
Internal rotation (SL)L4±2.0L2±2.9.0503.7–7.4
ASES score45.9±17.690.8±8.9<.000137.9–54.9
SANE score34.6±22.387.1±20.6<.000138.5–68.7
VAS pain score5.3±2.21.3±1.0<.00010.3–6.2
Authors

The authors are from Canton Orthopaedic Institute (MPN), Canton, Ohio; and Southern Oregon Orthopedics, Medford, and the Department of Orthopaedics & Rehabilitation, Oregon Health & Science University (PJD), Portland, Oregon.

Dr Noyes has no relevant financial relationships to disclose. Dr Denard is a paid consultant for and has received grants from Arthrex Inc.

This study was supported by a grant from Arthrex Inc for prospective data collection.

The authors thank Shannon Hiratzka, MPH, for assistance with the statistics for this project.

Correspondence should be addressed to: Patrick J. Denard, MD, Southern Oregon Orthopedics, 2780 E Barnett Rd, Ste 200, Medford, OR 97504 ( pjdenard@gmail.com).

Received: June 24, 2019
Accepted: November 17, 2019
Posted Online: October 01, 2020

10.3928/01477447-20200925-01

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