A Load-Sharing Rip-Stop Fixation Construct for Arthroscopic Rotator Cuff Repair  Patrick J. Denard, M.D., Stephen S. Burkhart, M.D.  Arthroscopy Techniques  Volume 1, Issue 1, Pages e37-e42 (September 2012) DOI: 10.1016/j.eats.2011.12.005 Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 1 Anchor-based rip-stop rotator cuff repair for rotator cuff tear that has loss of significant portion of lateral tendon (left shoulder, lateral-to-medial view). (A) In this rotator cuff tear with lateral tendon loss, there is limited space to achieve fixation in the remaining medial tendon. (B) A suture tape rip-stop has been placed as an inverted mattress stitch in the rotator cuff. (C) Two medial anchors are placed approximately 5 mm lateral to the articular margin. (D) The sutures from these anchors are passed medial to the suture tape rip-stop stitch (arrows). (E) Before sutures from the medial anchors are tied, the suture tape rip-stop stitch is secured to bone with 2 lateral knotless anchors. (F) Tying the suture limbs from the medial anchors completes the repair. It should be noted that tying the medial suture limbs must be delayed until after the rip-stop suture has been secured. Arthroscopy Techniques 2012 1, e37-e42DOI: (10.1016/j.eats.2011.12.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 2 Dual rip-stop rotator cuff repair (left shoulder, lateral-to-medial view). Two rips-stops are typically used if there is a 2-tendon tear. (A) In this rotator cuff tear with lateral tendon loss, there is limited space to achieve fixation in the medial tendon. (B) Two suture tape rip-stop sutures are placed 3 mm lateral to the musculotendinous junction as inverted mattress stitches. (C) Two medial anchors are placed in the greater tuberosity bone bed, approximately 5 mm lateral to the articular margin. (D) Suture limbs from the medial anchors are passed medial to the rip-stop stitches (arrows). (E) The suture tape rip-stop sutures are secured laterally with 2 knotless anchors (arrows). During this step, it is important to retrieve the rip-stop sutures so that they surround the lateral suture limbs from the medial anchors. (F) The repair is completed by tying the suture limbs from the medial anchors. Arthroscopy Techniques 2012 1, e37-e42DOI: (10.1016/j.eats.2011.12.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 3 Modified Mason-Allen stitch. Although this stitch pattern has a high load to failure, it has poor loop security under load. (A) A modified Mason-Allen stitch based off an anchor has been woven through the rotator cuff. (B) Under a medial tensile load (arrow), the complex weave cinches on itself, resulting in loss of loop security and thus medial displacement of the rotator cuff. (F, force from rotator cuff.) Arthroscopy Techniques 2012 1, e37-e42DOI: (10.1016/j.eats.2011.12.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions

Figure 4 Rip-stop stitch. This stitch pattern increases pullout and maximizes loop security by using only simple loops of suture. (A) A mattress stitch is placed from anterior to posterior through the rotator cuff perpendicular to the rotator cuff fibers. Then, a simple stitch from a suture anchor is passed medial to the rip-stop stitch. This technique can be performed as illustrated or with both sutures based off the anchor (i.e., with 1 of the sutures from the anchor passed as a rip-stop mattress stitch and the other anchor suture passed as a simple stitch medial to the rip-stop). (B) Under a tensile load (arrow), the rip-stop stitch resists cutout of the simple stitch. (F, force from rotator cuff.) Arthroscopy Techniques 2012 1, e37-e42DOI: (10.1016/j.eats.2011.12.005) Copyright © 2012 Arthroscopy Association of North America Terms and Conditions