Double Pulley-Triple Row Technique for Arthroscopic Rotator Cuff Repair: A Technical Note
As this study is a technical note describing a novel surgical technique and does not involve any human participants, it was exempt from IRB review and informed consent requirements. Surgical Technique The procedure involves positioning the patient laterally and utilizing standard arthroscopic portals (anterior, posterior, anterolateral, posterolateral, and lateral). A 30° arthroscope, two 8-mm cannulas (PassPort, Arthrex), mini-Lasso (Arthrex), and suture shuttling device (Scorpion, Arthrex) were utilized. Additionally, a medial anchor (4.8 mm, Kinex Fix2Lock Healmax, OSTEONIC), a middle anchor (2.8 mm, Q-FIX, Smith & Nephew), a lateral anchor (5.5 mm, HEALICOIL Knotless REGENESORB, Smith & Nephew), radiofrequency (ArthroCare), a cannula (Smith & Nephew), 2 triple-loaded 5.5-mm screw-in suture anchors (Stryker), 1 double-loaded screw-in suture anchor (Stryker), and 2 5.5-mm knotless suture anchors (Arthrex) were used. Surgical Steps Diagnostic arthroscopy and subacromial decompression The procedure began with the patient in a lateral position. The posterior portal was used for visualization, and diagnostic arthroscopy was performed through the anterior portal. Subacromial decompression and clearance of adhesions from the anterior, posterior, and lateral gutters were carried out via a lateral portal. Acromioplasty was performed using a cutting block technique with a 5.5-mm arthroscopic burr. Anterolateral and posterolateral working portals were established approximately 3–4 cm from the acromion. Rotator cuff mobility was evaluated and adjusted. An anterior subacromial portal was created, followed by the placement of PassPort cannulas (Arthrex) in the anterior and lateral portals. Footprint medialization and medial row anchor placement Using an arthroscopic drill, tuberoplasty was performed to address uneven surface and spurs as well as to provide a vascular bed for graft uptake, preserving cortical bone integrity. Two triple-loaded 5.5-mm anchors (Kinex Fix2Lock Healmax; OSTEONIC) were precisely placed adjacent to the humeral articular margin and strategically positioned at the anterior and posterior edges of the tear . Microfracturing was performed around the intended footprint. The mini-lasso suture technique facilitated the passage of all anchor limbs through both the anterior and posterior margins of the medial healthy cuff tissue . Middle and lateral row anchor placement A lateral accessory portal was established adjacent to the outer edge of the acromion. A 5.5-mm screw loaded with a suture anchor (Healicoil Knotless Regenesorb, Smith & Nephew) was inserted just inside the greater tuberosity and aligned with the peak of the rotator cuff tear . The suture ends were threaded through the anterior and posterior cuff edges, and arthroscopic knots were tied to draw the cuff tissue towards the footprint . Double-Pulley Application The sutures in the medial row were secured using the double-pulley method. Each suture end from the medial anchors was pulled through the lateral portal and tied as a 6-throw surgeon knot outside the cannula . The knot was then moved over the top of the tendon. Static knots were applied to prevent movement, and the second knot was tied with moderate pressure using a knot pusher . Third Row and Completion of Construct A single strand and 1 suture limb from each anchor in the medial row were pulled through the lateral portal using a loop grasper. These strands were passed through the eyelet of a 5.5-mm PEEK SwiveLock anchor and inserted immediately behind the bicipital groove . Subsequently, the remaining sutures were retrieved and inserted to finalize the suture bridge formation . Postoperative Protocol and Follow-up Following surgery, patients were immobilized in an abduction sling for 6 weeks. Passive and active-assisted range of motion exercises began progressively. At 12 weeks, the range of motion was unrestricted, and strengthening exercises were initiated. At 18 weeks postoperatively, patients were permitted to resume all activities except heavy lifting and participation in contact sports. 

The procedure involves positioning the patient laterally and utilizing standard arthroscopic portals (anterior, posterior, anterolateral, posterolateral, and lateral). A 30° arthroscope, two 8-mm cannulas (PassPort, Arthrex), mini-Lasso (Arthrex), and suture shuttling device (Scorpion, Arthrex) were utilized. Additionally, a medial anchor (4.8 mm, Kinex Fix2Lock Healmax, OSTEONIC), a middle anchor (2.8 mm, Q-FIX, Smith & Nephew), a lateral anchor (5.5 mm, HEALICOIL Knotless REGENESORB, Smith & Nephew), radiofrequency (ArthroCare), a cannula (Smith & Nephew), 2 triple-loaded 5.5-mm screw-in suture anchors (Stryker), 1 double-loaded screw-in suture anchor (Stryker), and 2 5.5-mm knotless suture anchors (Arthrex) were used. 

Diagnostic arthroscopy and subacromial decompression The procedure began with the patient in a lateral position. The posterior portal was used for visualization, and diagnostic arthroscopy was performed through the anterior portal. Subacromial decompression and clearance of adhesions from the anterior, posterior, and lateral gutters were carried out via a lateral portal. Acromioplasty was performed using a cutting block technique with a 5.5-mm arthroscopic burr. Anterolateral and posterolateral working portals were established approximately 3–4 cm from the acromion. Rotator cuff mobility was evaluated and adjusted. An anterior subacromial portal was created, followed by the placement of PassPort cannulas (Arthrex) in the anterior and lateral portals. Footprint medialization and medial row anchor placement Using an arthroscopic drill, tuberoplasty was performed to address uneven surface and spurs as well as to provide a vascular bed for graft uptake, preserving cortical bone integrity. Two triple-loaded 5.5-mm anchors (Kinex Fix2Lock Healmax; OSTEONIC) were precisely placed adjacent to the humeral articular margin and strategically positioned at the anterior and posterior edges of the tear . Microfracturing was performed around the intended footprint. The mini-lasso suture technique facilitated the passage of all anchor limbs through both the anterior and posterior margins of the medial healthy cuff tissue . Middle and lateral row anchor placement A lateral accessory portal was established adjacent to the outer edge of the acromion. A 5.5-mm screw loaded with a suture anchor (Healicoil Knotless Regenesorb, Smith & Nephew) was inserted just inside the greater tuberosity and aligned with the peak of the rotator cuff tear . The suture ends were threaded through the anterior and posterior cuff edges, and arthroscopic knots were tied to draw the cuff tissue towards the footprint . 

The procedure began with the patient in a lateral position. The posterior portal was used for visualization, and diagnostic arthroscopy was performed through the anterior portal. Subacromial decompression and clearance of adhesions from the anterior, posterior, and lateral gutters were carried out via a lateral portal. Acromioplasty was performed using a cutting block technique with a 5.5-mm arthroscopic burr. Anterolateral and posterolateral working portals were established approximately 3–4 cm from the acromion. Rotator cuff mobility was evaluated and adjusted. An anterior subacromial portal was created, followed by the placement of PassPort cannulas (Arthrex) in the anterior and lateral portals. 

Using an arthroscopic drill, tuberoplasty was performed to address uneven surface and spurs as well as to provide a vascular bed for graft uptake, preserving cortical bone integrity. Two triple-loaded 5.5-mm anchors (Kinex Fix2Lock Healmax; OSTEONIC) were precisely placed adjacent to the humeral articular margin and strategically positioned at the anterior and posterior edges of the tear . Microfracturing was performed around the intended footprint. The mini-lasso suture technique facilitated the passage of all anchor limbs through both the anterior and posterior margins of the medial healthy cuff tissue . 

A lateral accessory portal was established adjacent to the outer edge of the acromion. A 5.5-mm screw loaded with a suture anchor (Healicoil Knotless Regenesorb, Smith & Nephew) was inserted just inside the greater tuberosity and aligned with the peak of the rotator cuff tear . The suture ends were threaded through the anterior and posterior cuff edges, and arthroscopic knots were tied to draw the cuff tissue towards the footprint . 

The sutures in the medial row were secured using the double-pulley method. Each suture end from the medial anchors was pulled through the lateral portal and tied as a 6-throw surgeon knot outside the cannula . The knot was then moved over the top of the tendon. Static knots were applied to prevent movement, and the second knot was tied with moderate pressure using a knot pusher . 

A single strand and 1 suture limb from each anchor in the medial row were pulled through the lateral portal using a loop grasper. These strands were passed through the eyelet of a 5.5-mm PEEK SwiveLock anchor and inserted immediately behind the bicipital groove . Subsequently, the remaining sutures were retrieved and inserted to finalize the suture bridge formation . 

Following surgery, patients were immobilized in an abduction sling for 6 weeks. Passive and active-assisted range of motion exercises began progressively. At 12 weeks, the range of motion was unrestricted, and strengthening exercises were initiated. At 18 weeks postoperatively, patients were permitted to resume all activities except heavy lifting and participation in contact sports. 

Large-to-massive rotator cuff tears demand better construct to reduce retear. Despite the superior biomechanical properties and broader footprint restoration, double-row repair has shown failure to reduce retears. In the arthroscopic transosseous equivalent technique, also referred to as the suture-bridge technique, following knotting of the medial row, the suture ends are crossed over the cuff tissue and secured to screws positioned 1 cm lateral to the lateral edge of the greater tuberosity. This configuration compresses the tissue between the screws and anatomical footprint, thereby preventing penetration and strangulation of the lateral cuff tissue by the knots, consequently preserving tendon vascularity. The MTJ has been identified as the primary failure point for both double-row and TOE repairs. Thus, it is essential to position the medial row sutures lateral to the MTJ and avoid overstretching of the medial row. To address these concerns, modifications have been made to the TOE technique, which involves completely knotless approaches. Wider surface sutures were loaded onto the medial row anchors and passed through the tendon without knot tying. These sutures are then crossed over or fixed to lateral row knotless anchors. This technique, being technically simpler and faster due to the absence of knots, mitigates the risk of tendon strangulation at the medial row and reduces the elevated suturetendon surface pressure that could compromise the healing process. Our technique employs a modified triple-row configuration featuring an additional anchor row situated between the customary medial and lateral rows of the suture bridge assembly. This supplementary row facilitates the anatomical alignment of cuff tissue within the footprint before securing the medial row anchor, thereby enhancing the footprint contact area and pressure distribution. Previous biomechanical investigations have underscored the efficacy of incorporating linked medial anchors in rotator cuff repair. Consequently, we adopted the principles of the double-pulley technique to secure the medial row of our construct, wherein the medial knot was drawn down over the cuff using the eyelets of 2 medial suture anchors as pulleys. Ultimately, this method culminates in the compression of a cuff tissue bridge against the bone bed, establishing a robust construct within the medial aspect of the footprint. The double pulley-triple row technique for arthroscopic rotator cuff repair introduces several significant advancements compared to existing methods, particularly the standard double-pulley and triple-row techniques. This technical approach includes a modified triple-row configuration that incorporates an additional anchor row between the medial and lateral rows of the suture bridge assembly. This modification enhances the anatomical alignment of the cuff tissue within the footprint before securing the medial row anchor, leading to a more substantial footprint contact area and improved pressure distribution. Unlike conventional techniques, this method mitigates the risk of medial tissue bunching, which is a common complication of suture bridge techniques. Integration of the double-pulley mechanism ensures robust medial fixation while preserving tendon vascularity by minimizing tissue strangulation and ensuring consistent contact pressure across the footprint. Additionally, this technique simplifies the repair process by passing the medial row suture limbs through a single point in the rotator cuff, reducing the need for multiple tissue bites and medial knots, which can compromise vascularity. These differences collectively enhance mechanical stability, promote better tissue healing, and reduce complications, such as secondary cuff failures and tendon necrosis, making this technique particularly beneficial for large-to-massive rotator cuff tears. The double pulley-triple row technique shows promise in improving clinical outcomes for arthroscopic rotator cuff repair, particularly in large-to-massive tears, by addressing some of the limitations found in single-row, double-row, and standard triple-row techniques. Unlike single-row repairs, which often fail to fully restore the anatomical footprint leading to high retear rates, the double pulley-triple row technique provides a significantly larger footprint contact area and more uniform pressure distribution, which are crucial for promoting tendon-to-bone healing and reducing retears. This method also outperforms double-row repairs by enhancing the medial fixation strength and maintaining the vascularity of the tendon, which are vital for preventing secondary cuff failures often observed near the MTJ owing to stress concentration and tissue strangulation. Compared with standard triple-row techniques, this novel approach introduces an additional anchor row between the medial and lateral rows, further optimizing anatomical alignment and minimizing the risk of medial tissue bunching, which can compromise repair integrity. Clinical studies have demonstrated that the biomechanical advantages of the double pulley-triple row technique translate into lower retear rates, improved functional outcomes, and greater patient satisfaction. For instance, patients undergoing this technique have shown better shoulder strength, range of motion, and overall shoulder function than those treated with conventional methods. The outcomes suggest (unpublished data) that the double pulley-triple row technique not only enhances the mechanical stability of the repair, but also supports better biological healing processes, making it a superior option for treating complex rotator cuff injuries. This double pulley-triple row repair technique combines the strengths of 2 established biomechanical methods. The double pulley aspect ensures robust medial fixation while preserving tendon vascularity, whereas the triple row sutures enhance the contact area and distribute compression pressure evenly across the footprint. This suture bridging not only distributes the load across fixation points but also prevents synovial fluid from interfering with tendon-to-bone healing. Our technique streamlines the process compared to traditional methods by passing the medial row suture limbs from both anchors through a single point in the rotator cuff, eliminating the need for multiple tissue bites and medial knots that can compromise vascularity. Although there is a theoretical risk of irritation from the 6-throw surgeon’s knot in the subacromial space, we have not encountered this issue . Additionally, while our technique may incur higher costs owing to the use of extra anchors, it is justified by its aim to restore the anatomical footprint of the rotator cuff. The double pulley-triple row technique for arthroscopic rotator cuff repair introduces several innovative modifications that improve upon existing methods. It features a modified triple-row configuration with an additional anchor row between the medial and lateral rows, enhancing anatomical alignment and uniform pressure distribution. This method for securing sutures further optimizes tendon vascularity and stability, creating a sealed environment conducive to tendon-to-bone healing. These advancements aim to improve mechanical stability, tissue healing, and reduce complications compared to current techniques. The double pulley-triple row technique for arthroscopic rotator cuff repair distributes pressure uniformly over a larger contact area, thus mitigating tissue strangulation and necrosis. This method enables tension-free repair and incorporates superior biomechanically validated elements. While these factors suggest potential advantages over previous methods, particularly in large-to-massive rotator cuff tears, further studies are required to definitively establish its superiority. This technique may be especially beneficial for tear patterns and sizes that are characterized by significant tissue loss or degeneration. 

