Large to Massive rotator cuff tears are defined as injuries involving two or more tendons without fatty infiltration or >3 cm. With the development of arthroscopy, arthroscopic repair technologies, including single row repair, double row repair and suture bridge repair, are gradually matured for large to massive rotator cuff tear. Snyder, et al. reported the surgical technique of arthroscopic tendon insertion migration and single row suture anchor repair combined with bare foot printing area drilling, and the follow-up results of postoperative shoulder joint function were good. Large to Massive rotator cuff tears are defined as injuries involving two or more tendons without fatty infiltration or >3 cm. With the development of arthroscopy, arthroscopic repair technologies, including single row repair, double row repair and suture bridge repair, are gradually matured for large to massive rotator cuff tear. Snyder, et al. reported the surgical technique of arthroscopic tendon insertion migration and single row suture anchor repair combined with bare foot printing area drilling, and the follow-up results of postoperative shoulder joint function were good.

To research the clinical outcome of arthroscopic single row suture anchor fixation accompanied with greater tuberosity bone marrow stimulate technique to treat large to massive rotator cuff tear.

(1) General information:From January 2011 to April 2016, a total of 24 patients (7 males and 17 females) of large to massive rotator cuff tears were treated using this technique, including 1 case of acute injury and 23 cases of dated injuries. Their ages ranged from 48 to 76 years. There were 9 cases in the left shoulder and 15 cases in the right. The preoperative VAS score was (6.3±1.9) points, UCLA score was (10.1±4.5) points, and ASES score was (27.9±17.8) points. Preoperative oblique sagittal MRI demonstrated that the supraspinatus and infraspinatus insertions were involved in all the patients. Oblique coronal MRI revealed that all the contracture of rotator cuff tears were within 2 degrees. Horizontal MRI suggested that the subscapular tendon was not involved. All 24 patients had crescentic tear under arthroscopy. (2) Surgical methods:After successful anesthesia, the patient was placed in lateral position with the affected arm on the upper side. Glenohumeral joint was examined from the posterior approach, and the anterior approach was made in the rotator cuff space from outside-in to explore glenoid labrum and long head tendon of biceps brachii with probe hook. For patients of over 60 years old with long head tendon of biceps brachii lesion (18 cases) , it was transected at the insertion of supraglenoid tubercle with plasm knife. After the angle of traction and abduction was changed to 45o, the arthroscope entered into the subacromial space through posterior approach. The lateral approach was made with the outside-in technique, through which the subacromial bursa was cleaned and the coracoacromial ligament was released with planer. For patients with type 3 acromion, the subacromial decompression was performed with grinding head. For patients of below 60 years old with long head tendon of biceps brachii lesion (6 cases) , the cortical bone at the middle of intertubercular sulcus was polished with grinding head to screw in a 3.5 mm Twinfix suture anchor (Smith & Nephew) . The tail thread was inserted into the thread in the reverse direction to pass through the corresponding tissue of long head tendon and knot for fixation, and then the long head tendon was transected with plasm knife. Through the lateral approach, the tearing morphology was determined with grasper. After the footprint area of greater tuberosity was cleaned with planer and plasma knife, the cortical bone was polished with grinding head. The cortical bone zone should be maintain within 5 mm of lateral margin of humeral head cartilage. The anterolateral superior approach was made close to the anterolateral angle of acromion with outside-in technique. Through this approach, a hole was drilled at the site of posterior edge of tearing and cortical bone zone of humeral head cartilage to implant a 5.0 mm Twinfix suture anchor (Smith & Nephew) . The arthroscope was turned for observation from the lateral approach. Through posterior approach the two free ends of two tail lines were passed through the posterior torn rotator cuff tissue respectively using suture hook (Smith & Nephew) with shuttle thread, and the distance of two threads on the rotator cuff was approximately 1 cm apart. With the repeat of above procedures, the lateral cartilage edge of middle and anterior torn areas was separately implanted into a 5.0 mm Twinfix suture anchor, and the tail threads were passed through the corresponding torn rotator cuff of middle and anterior areas. After a 50 mm×72 mm working sheath (Smith & Nephew) was placed through the lateral approach from the posterior approach, the tail threads were pulled into the working sheath in one-to-one correspondence, and the SMC knot and two half knots were tied to complete rotator cuff repair. The suture site was checked for reliable repair. In the exposed footprint area of greater tuberosity, 2 to 3 holes were drilled from anterior to posterior for bone marrow exudation. All the incisions were sutured and covered with dressings, and the affected limb was suspended in the position of external rotation and 20° of abduction. (3) Postoeprative rehabilitation:The affected limb was immobilized in abductive brace for 6 weeks after operaion. Within 6 weeks, progressive passive external rotation, forward flexion and abduction training were performed 1 time per day. As the brace was removed after 6 weeks, the passive range of motion was further increased within the allowable range of pain. The training of active range of motion was initiated 12 weeks later, and the strength training started after 16 weeks. (4) Evaluation index and statistical treatment:SPSS 17.0 software was used to conduct one way ANOVA and Wilcoxon rank sum test for the analysis of VAS score, UCLA score and ASES score, and the measurement data was expressed±s. A P value <0.05 was considered as statistical difference. The situation of soft tissue coverage on the footprint area of greater tuberosity was observed on the superior glenoid notch of coronal MRI.

(1) Pain:The preoperative and postoperative 12 months follow-up VAS scores were (6.3±1.9) points and (0.4±0.1) points, respectively (P<0.05) , and the shoulder pain was significantly improved in all patients. (2) Range of motion:The passive lifting angles of all shoulder joints were normal at 12 months after the operation. The passive external rotation in 5 cases decreased to 90% of the healthy side, and the internal rotation in 4 cases reduced by 2 vertebral height. The active lifting strength of shoulder joint in 23 cases were equivalent to that of unaffected side, and 1 case suffered from lower active lifting strength. (3) Complications:No infection was found in this study, and no suture anchor displacement or removal occurred in the final follow-up of MRI. There were 5 cases of shoulder joint stiffness at 3 months during follow up. Through strict rehabilitation exercise, the shoulder joint function improved and the range of motion in the final follow up was good. (4) Relationship between preoperative fatty infiltration and re-tear:The MRI examination of 12 months after rotator cuff repair demonstrated that 18 patients with preoperative global fatty degeneration index (GFDI) ≤ 1 had complete healing, 4 patients of preoperative GFDI between 1 to 1.5 had complete healing, 1 patient of preoperative GFDI between 1.5 to 2 had rotator cuff re-tear and 1 patient of preoperative GFDI > 2 had rotator cuff re-tear. (5) Functional evaluation:The preoperative and postoperative 12 months UCLA scores were (10.1±4.5) points and (30.4±4.2) points, respectively (P<0.05) , and the ASES scores were (27.9±17.8) points and (77.6±17.5) points respectively (P<0.05) . The postoperative shoulder joint function of 24 patients was significantly improved compared to that before operation. (6) Imaging assessment:The shoulder joint MRI examinations of postoperative 3rd day, 3rd month and 12th month were conducted to observe the healing of rotator cuff tendon and the soft tissue coverage of footprint area. During the follow ups of postoperative 12 month, the MRI examinations revealed that 22 patients had complete rotator cuff insertion and 2 patients had re-tear of less than 1 cm on sagittal position. The soft tissue coverage of footprint area in the 3rd and 12th months had improvements compared to that on the postoperative 3rd day in all patients. The mean coverage rates of postoperative 3rd day, 3rd months and 12th months were 34.3%, 89.1% and 88.7% respectively.

We believe that for large to massive rotator cuff tear, arthroscopic single row suture anchor fixation accompanied with greater tuberosity bone marrow stimulating technique can provide reliable repair, remarkably reduce pain, restore shoulder function and promote soft tissue coverage of footprint area.