Mid-term outcomes of arthroscopic single-row, tension-free repair for large and massive rotator cuff tears: A retrospective study of 35 cases

INTRODUCTION

The incidence of rotator cuff tears (RCTs) enhances with age and is a common cause of shoulder dysfunction in the elderly.^[1] Patients with symptomatic massive RCTs often report reduced shoulder strength, limited motion range, chronic pain, disturbed sleep, and difficulty performing daily activities independently.^[2] Management of massive RCTs poses a clinical challenge due to structural deterioration of the tendon, retraction, fatty infiltration, reduced tendon mobility, and the presence of adhesions.^[3]

Various treatment options are available, consisting of conservative measures, arthroscopic debridement, long head of biceps tenotomy or tenodesis, partial or complete tendon repair, biological or synthetic patch augmentation, superior capsular reconstruction, tendon transfers, and reverse total shoulder arthroplasty.^[4] Among these, arthroscopic rotator cuff repair (ARCR) is widely used and has been shown to provide pain relief and functional improvement.^[5] The primary surgical goal is to re-establish tendon integrity through a tension-free repair, promoting biological healing and restoring shoulder kinematics.^[6]

The biomechanics of the shoulder are significantly influenced by the integrity of the rotator cuff. The deltoid and supraspinatus muscles form the coronal force couple, whereas the subscapularis and infraspinatus comprise the axial force couple. These muscle groups act synergistically to center the humeral head inside the glenoid cavity during shoulder elevation, thus ensuring joint stability.^[7] A tear in the rotator cuff disrupts this balance, leading to superior migration of the humeral head and increasing the risk of subacromial impingement between the greater tuberosity and the acromion. As the tear size enlarges, the forces required for arm movement increase, contributing to further extension of the anterior or posterior tear. The absence of load-sharing by torn tendons places excessive tensile stress on the remaining fibers, accelerating tear propagation, especially when tendon quality is poor.^[4,8]

This study aims to analyze the mid-term clinical, functional, and radiological outcomes following arthroscopic single-row repair of large to massive RCTs. We hypothesize that a tension-free single-row construct can restore acromiohumeral distance (AHD), improve tendon integrity, and yield favorable functional results, even in elderly patients with degenerative tendon changes and muscle atrophy.

MATERIALS AND METHODS

Study design and setting

This was a retrospective monocentric cohort study with prospectively collected data conducted at a tertiary orthopedic center from July 2017 to January 2023. Ethical approval was obtained, and informed consent was secured from all participants. The study included 35 patients who underwent arthroscopic single-row repair for large to massive RCTs, with a minimum follow-up of 24 months. Flowchart 1 summarises the flow of events of the study.

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Flowchart 1:

Summarise the flow of events.

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Surgical technique

All procedures were evaluated by a single senior surgeon with patients in the beach-chair position (at an 80° incline) under general anesthesia and interscalene block. Intraoperative systolic blood pressure was maintained at 80– 100 mmHg to reduce bleeding. After diagnostic arthroscopy, the subacromial space was visualized using a posterolateral portal. Bursectomy and decompression were evaluated.

Tear size was calculated with the help of a calibrated probe. Adhesions were released, and the greater tuberosity was prepared with a motorized shaver to expose the cancellous bone bed [Figure 1]. The cuff edges were refreshed. Depending on the tear configuration, 2 or 3 suture anchors (double- or triple-loaded titanium, bioabsorbable, or polyether-ether-ketone) with non-absorbable sutures were used. The Duncan sliding knot technique was employed. When required, footprint medialization (up to 8 mm) [Figure 2] or margin convergence was performed to achieve a tension-free construct. Biceps tenotomy was performed in cases with evident [Figure 3]. Final repair was done with cuff tissue covering the tuberosity after tying the knots [Figure 4].

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Figure 1:

Cuff tear visualized from the lateral portal in beach chair position with cancellous bone preparation done and glenoid seen medially. Red arrow showing rotator cuff tear, Blue showing glenoid, and green showing footprint.

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Figure 2:

Medialized repair done to prevent any tension on the retracted cuff with up to 8 mm medialization, causing no difference in clinical outcomes. Blue arrow showing medialized footprint and green arrow showing original footprint.

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Figure 3:

Tenotomy of the long head of the biceps in a mushroom shape from the insertion at the supraglenoid tubercle to prevent the popeye sign. Blue arrow showing the tenotomized biceps and green arrow showing the subscapularis tendon.

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Figure 4:

Final repair using the single row technique with the cuff well seated on the tuberosity, on tying knots. Blue arrow showing rotator cuff and green arrow showing suture anchor.

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Outcome measures

Primary outcome variables included:

• Constant–Murley score

• UCLA shoulder score

• Simple shoulder test (SST)

• Visual analog scale (VAS) for pain

• Active forward flexion and external rotation

• Muscle strength (scale 0–25)

• AHD, measured through true AP radiographs [Figure 5a and b].

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Figure 5:

(a) Reduced acromiohumeral distance due to cuff tear and loss of biomechanics of the shoulder. (b) Restoration of acromiohumeral distance with cuff repair, as it causes a head depressor effect and maintains the biomechanics of the shoulder.

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RESULTS

DISCUSSION

This study demonstrates significant clinical and functional improvements following single-row ARCR in patients with large to massive RCTs. Post-operative gains were evident in constant and UCLA scores, SST, range of motion, muscle strength, and pain reduction. These findings support the hypothesis that single-row tension-free repair offers substantial benefits. Similar results were reported by Oh et al. and Denard et al., who advocated ARCR as the primary treatment for pseudoparalysis in non-arthritic shoulders.^[9,10] Melillo et al., Gerber et al., and Burkhart emphasized restoring force couples and functional independence, even in massive tears.^[11-13] Despite early re-tears, long-term functional improvements are well documented.^[14]

Biomechanically, the anterior deltoid helps counteract the superior migration of the humeral head in massive cuff tears by compressing it against the glenoid.^[15] In addition, suprascapular neuropathy due to traction injury may be reversed post-repair, contributing to recovery.^[16]

In this study, all patients underwent single-row repair using an average of 2.37 ± 0.49 anchors, including at least one triple-loaded anchor. As Jost et al., emphasized, the number of effective suture passes is more critical than the anchor count.^[17] Mazzocca et al., demonstrated comparable load-to-failure between single- and double-row techniques, both exceeding 250 N.^[18] Similarly, randomized trials by Nicholas et al., and Millet et al., reported excellent clinical outcomes irrespective of the repair method.^[19,20]

Subscapularis repair restores anterior-posterior balance, which is especially crucial in massive tears. Repairing its upper part, which forms the anterior rotator cable, offloads the supraspinatus and enhances overall repairability.^[13,21,22] In our series, 17 patients underwent arthroscopic subscapularis repair with marked functional improvement. Barth et al., noted that nearly 40% of such tears may be missed clinically, underscoring the value of arthroscopic evaluation over mini-open approaches.^[23]

When anatomical tension-free repair is unachievable due to chronicity, footprint medialization up to 12 mm is an accepted approach to maintain biomechanics without excessive tension.^[24] In this cohort, six patients underwent medialized repair (up to 8 mm) with excellent outcomes. These results support prior work by Goutallier et al., Taniguchi et al., and Malahias et al., emphasizing the importance of a tension-free construct.^[25-28] Chalmers^[29] and Burns and Snyder further noted that medialized single-row repairs may offer biomechanical advantages over high-tension double-row repairs.^[30]

Fatty infiltration remains a negative prognostic factor and is often irreversible if untreated.^[31,32] While its reversal post-repair is limited, functional recovery is still achievable in high-grade cases, as reported by Burkhart^[13] and Burkhart et al.^[33] In our study, re-tear patients had higher fatty infiltration scores (1.75 ± 0.96) than those with healed repairs (1.13 ± 1.09), though both groups maintained favorable postoperative scores.

Re-tear is a known concern in massive cuff repairs, with reported failure rates of 39–40%.^[2,34,35] Using the Sugaya classification on post-operative ultrasound, re-tears (grade 4) were noted in 4 of 35 patients (11%), a lower rate than commonly reported, possibly due to structured rehabilitation. Importantly, these patients still achieved satisfactory, constant, UCLA, and VAS scores [Table 3], aligning with findings that functional outcomes may improve despite structural failure.^[36,37]

In massive cuff tears, the long head of the biceps becomes functionally inactive during abduction and contributes little to stability.^[38] However, lesions are frequent and may lead to pain and dysfunction. Arthroscopic tenotomy, performed in 20 patients in our series, led to clinical improvement, consistent with findings from Walch et al., demonstrating its value, especially in elderly populations.^[39-41]

Restoration of the AHD is a key radiological indicator of repair success. In this study, AHD improved significantly from 5.26 ± 1.22 mm preoperatively to 8.54 ± 1.31 mm postoperatively. This correlates with better functional outcomes and restored force couples. Post-operative values below 4.1 mm are associated with poorer outcomes and higher failure risk.^[2,42] Goutallier et al. stated that complete, tension-free repairs promote better healing through improved osseous integration, even in large or massive tear cases.^[26,43] ARCR improves functional and clinical outcomes even in patients with comorbid disability, and better surgical planning and post-operative rehabilitation are crucial for good outcomes.^[44]

Elderly patients (n = 23, aged ≥65 years) demonstrated significant functional improvement, indicating that ARCR remains a viable first-line treatment even in this demographic.

This study’s strength lies in its homogeneous sample; all surgeries were evaluated by a single surgeon with the help of a standardized technique and evaluated with uniform clinical and radiological protocols. To our knowledge, this is among the few studies focusing exclusively on single-row repair for large and massive tears, while examining both structural integrity and functional recovery. Limitations include its retrospective design and the absence of serial ultrasound monitoring.

CONCLUSION

Single-row ARCR for large to massive tears resulted in good functional and clinical outcomes. Structural integration and tendon healing were confirmed on ultrasonography at a 2-year follow-up, with a low rate of re-tear. These findings support single-row repair as an effective and reliable treatment approach.