INTRODUCTION
Large-to-massive rotator cuff tears pose significant treatment challenges, as structural failure after repair remains common despite advancements in arthroscopic surgical techniques. Over the past two decades, rotator cuff repair strategies have evolved from single-row fixation to double-row and suture-bridge constructs, aiming to restore the native tendon footprint and enhance tendon-bone healing. These approaches seek to increase the contact area and compression between the tendon and the greater tuberosity footprint while ensuring stable fixation during the biological healing process [1,2].
However, large or massive tears often involve tendon retraction, compromised tissue quality, and increased mechanical loading across the repair site, all of which may contribute to higher rates of postoperative structural failure. To address these challenges, several modified repair constructs have been developed, combining improved footprint coverage with enhanced fixation stability. The double-pulley triple-row (DPTR) technique is one such modification, integrating a medial double-pulley configuration with a triple-row repair construct for managing large rotator cuff tears [1,3]. The double-pulley mechanism allows controlled approximation of the tendon to the prepared footprint, while the triple-row configuration increases the number of fixation points across the repair interface.
Previous biomechanical studies have suggested that modified triple-row constructs increase footprint contact area and compression compared to conventional double-row repairs, potentially providing a mechanical environment favorable for tendon healing [4,5]. Although this construct is conceptually intended to facilitate balanced tensioning and broader footprint coverage, its biomechanical and clinical advantages remain to be validated. Therefore, the present Technical Note focuses on describing the surgical steps and technical considerations of the double double-pulley triple-row (DDPTR) technique rather than documenting improved clinical outcomes [2-5].
TECHNIQUE
As this manuscript is a technical note describing a surgical technique, it does not involve new patient recruitment or identifiable patient data. Therefore, it was deemed exempt from institutional review board approval. Written informed consent was obtained from the patients for the use of intraoperative images for publication.
Indications and Exclusions
DDPTR may be considered for symptomatic, reparable full-thickness posterosuperior tears meeting large-to-massive criteria (including tears >5 cm measured intraoperatively) after failure of nonoperative management [1]. Exclusion criteria include irreparable tears (inability to mobilize to the footprint without unacceptable tension), advanced cuff tear arthropathy, active infection, and inability to comply with rehabilitation. The key indications, contraindications, technical advantages, limitations, and pearls and pitfalls of the DDPTR technique are summarized in Table 1.
Assessments of Bone and Tendon Quality
“Good bone quality” was identified through preoperative risk evaluation for osteoporosis/osteopenia. Anchor pull-out strength correlates with bone mineral density, making low bone quality a practical contraindication to anchor-dense constructs [6]. “Poor tendon quality” was assessed by preoperative imaging and intraoperative suture-holding capacity (friability, delamination, and cut-through with passage/tensioning).
Positioning and Portal Placement
In DDPTR, the patient is positioned in lateral decubitus. A posterior viewing portal and lateral working portal are established, with an anterior working portal. An accessory anterosuperior portal may be added for the anteromedial anchor (AMA) if required [1]. An accessory anterosuperior portal is used to manage sutures from medial anchors. Cannulas are recommended for suture management. Portal roles may switch during the procedure (Fig. 1A).
Diagnostic Arthroscopy and Tendon Mobilization
Diagnostic arthroscopy is performed through the posterior portal to evaluate the glenohumeral joint, including the cartilage, biceps tendon, labrum, and rotator cuff, to determine tear size, pattern, and tissue quality [1,3]. Tendon mobility is assessed using an arthroscopic probe. The arthroscope is then advanced into the subacromial space, where bursectomy improves visualization of the rotator cuff, footprint, and acromion undersurface. Tendon mobilization, including capsular release and lysis of adhesions, may be performed to allow reduction of the cuff to the prepared footprint (Fig. 1). Adequate mobilization is confirmed with an arthroscopic grasper to ensure reduction with acceptable tension before repair (Fig. 1).
Subacromial Decompression
Subacromial decompression is performed for impingement or to create working space for the DDPTR technique. Operating from the lateral or anterolateral portal while viewing from the posterior or lateral portal, a burr resects osteophytes and part of the coracoacromial ligament (Fig. 1) to increase subacromial space for anchor placement and suture management. Care must be taken to avoid excessive resection and protect the deltoid origin.
Footprint Medialization and Medial Row Anchors Placement
Through the lateral portal with posterior viewing, the rotator cuff footprint is debrided to expose bleeding bone, and microfracture may be performed. In retracted tears, limited footprint medialization may facilitate tendon reduction. Three medial-row double-loaded suture anchors are inserted just lateral to the articular cartilage margin (Fig. 2). The posteromedial (PMA1) and central medial anchors (CMA2) are placed via the anterior portal, while the anteromedial anchor (AMA3) may require an accessory anterosuperior portal. Sutures are passed through the tendon in a mattress fashion 5–10 mm from the edge. The central anchor (CMA2) serves as the shared anchor for the anterior and posterior double-pulley systems (Fig. 2).
Medial-Row Anchor Placement and Suture Passage
Three double-loaded medial-row anchors are inserted adjacent to the articular margin: a posteromedial anchor (PMA), a central medial anchor (CMA), and an AMA. The PMA and CMA are typically placed via the anterior portal, while the AMA may require an accessory anterosuperior portal for optimal trajectory. Sutures are passed through the tendon in a mattress configuration approximately 5–10 mm from the tendon edge, targeting the region of maximal tissue thickness to optimize suture-holding capacity. The CMA functions as the shared anchor between the two pulley systems, with one suture pair allocated to the posterior pulley and the other to the anterior pulley. This configuration enables balanced load distribution across the medial row while maintaining controlled suture management (Fig. 2).
Middle-Row Reduction Anchor
Prior to tying the medial pulley constructs, a knotless middle-row anchor is inserted at the mid-lateral aspect of the footprint. This anchor is used to reduce the leading edge of the tendon, prevent dog-ear formation, and decrease tension across the medial repair. Controlled reduction at this stage facilitates improved footprint contact and optimizes the biomechanical environment before final fixation.
Construction of the Double Double-Pulley Systems
The DDPTR construct is formed through two independent double-pulley systems that share the CMA.
Posterior pulley system
One suture limb from the PMA is paired with a corresponding limb from the CMA. These limbs are tied extracorporeally, and the knot is advanced onto the tendon bridge between the two anchors using the anchor eyelets as pulleys, consistent with the double-pulley principle. The remaining limbs are subsequently tied to complete the mattress configuration, achieving controlled medial compression (Fig. 2, Supplementary Video 1).
Anterior pulley system
The same sequence is repeated between the AMA and the CMA to construct the anterior pulley. Tensioning is performed incrementally and alternated between the anterior and posterior pulley systems to avoid excessive localized stress and to maintain balanced compression across the medial footprint (Fig. 2, Supplementary Video 2).
Lateral-Row Completion
Two lateral knotless anchors are placed distal/lateral to the footprint edge to complete a suture-bridge. One free limb from PMA and one from CMA (posterior-designated) are secured posteriorly. One free limb from AMA and one from CMA (anterior-designated) are secured anteriorly. The construct is inspected dynamically, confirming coverage and absence of excessive medial constriction (Fig. 2, Supplementary Video 3).
Rehabilitation
Postoperative rehabilitation is designed to protect the repair while facilitating gradual functional recovery. The shoulder is immobilized in an abduction sling for 4–6 weeks, with early passive range-of-motion exercises initiated during this period. Active-assisted motion is typically introduced at 6-8 weeks, followed by progressive strengthening beginning at 12–16 weeks. Return to strenuous activities is generally permitted after approximately 6 months, depending on clinical and functional recovery [3].
DISCUSSION
This Technical Note introduces the DDPTR technique, a modified arthroscopic rotator cuff repair strategy designed to address the challenges of large-to-massive tears, including tendon retraction, poor tissue quality, and increased mechanical stress. Despite advances from single-row to double-row and suture-bridge constructs, structural failure remains common in this subset, necessitating techniques that allow controlled reduction and improved load distribution [1,2].
The DDPTR technique integrates two independent double-pulley systems sharing a CMA within a triple-row construct. This configuration enables stepwise tendon reduction and coordinated tensioning between anterior and posterior segments. Unlike conventional techniques that apply force in a single vector, this approach allows more balanced load distribution across the medial footprint, potentially improving tendon apposition and footprint coverage.
Biomechanical studies suggest that triple-row constructs can increase footprint contact area and pressure compared with standard double-row repairs [4,5]. However, these findings should be interpreted cautiously. Increased contact pressure does not necessarily translate into improved structural strength or clinical outcomes. For instance, constructs with additional medial anchors have demonstrated higher contact forces without significant improvements in cyclic displacement or load-to-failure [5]. Therefore, the advantages of the DDPTR technique remain conceptual and require validation.
A key technical feature of this technique is the use of a middle-row knotless anchor to achieve preliminary tendon reduction before medial knot tying. This may reduce tension at the medial row and help prevent excessive compression, which has been associated with compromised vascularity and tendon strangulation in suture-bridge constructs [5]. Incremental and alternating tensioning of the anterior and posterior pulley systems further supports balanced force distribution.
These potential benefits must be weighed against limitations. The DDPTR technique requires increased implant utilization, with six anchors compared to conventional constructs, which may impact cost and surgical efficiency. In addition, suture management is more complex, and operative time may increase, particularly during the learning phase. Patient selection is critical. Anchor fixation strength is closely related to bone mineral density, and poor bone quality may increase the risk of anchor failure or suture cut-through [6,7]. Similarly, severely degenerated tendon tissue may limit the effectiveness of any repair construct. Careful intraoperative assessment is therefore essential.
This study is limited by its descriptive nature, as no biomechanical or clinical outcome data are presented. Future studies are required to evaluate the mechanical performance, healing characteristics, and clinical outcomes associated with this technique. Thus, the DDPTR technique provides a structured approach for controlled tendon reduction and enhanced medial fixation in large-to-massive rotator cuff tears. While it offers potential mechanical advantages, these remain theoretical, and further biomechanical and clinical validation is necessary.
The DDPTR technique represents a structured modification of arthroscopic rotator cuff repair, enabling controlled tendon reduction and broad medial footprint compression in large-to-massive tears. While it offers potential mechanical and procedural advantages, these remain conceptual. Further biomechanical and clinical studies are required to validate its effectiveness and define its clinical role.
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