Abstract
Rotator cuff tears (RCTs) are common injuries, and treatments for irreparable massive RCTs are still controversial. Among the various treatment options for irreparable massive RCTs, rotator cuff reconstruction is considered a reasonable approach, yet there is no consensus on the optimal reconstruction technique. In this article, we introduce a suture anchor onlay technique for rotator cuff reconstruction. In our technique, the peroneus longus tendon is harvested and prepared as an autograft, and on the lateral side, a suture anchor is implanted to fix the autograft on the greater tuberosity surface. The key steps of our technique are performing anchor implantation to ensure that the autografts are fixed tightly on the greater tuberosity surface, knotting the sutures from the medial-row anchors that we pre-implanted at the midsubstance of the autograft to provide additional fixation, and finally, achieving “onlay” fixation of the autografts. Our technique can effectively reduce surgical time, simplify the reconstruction procedure, and has good clinical application value.
Technique Video
Rotator cuff tears (RCTs) are common upper-extremity injuries, with massive RCTs being a type of injury characterized by large, full-thickness tears involving 2 or more tendons, representing up to 40% of all cases.1 Currently, double-row suture-bridge techniques are considered a reliable surgical approach for rotator cuff repair.2 However, owing to the aforementioned characteristics, massive RCTs are often deemed “irreparable”; thus, many methods including superior capsular reconstruction, patch bridging grafts, and muscle advancement have been proposed as alternative strategies to manage these irreparable massive rotator cuff tears (IMRCTs).3,4 Although various options exist, the optimal approach remains controversial because each method has its own limitations.5 Superior capsular reconstruction, for example, has been shown to alleviate pain and improve range of motion, but it cannot restore full shoulder function, particularly in patients with significant muscle atrophy or fatty infiltration.6 For IMRCTs, the ideal methods should directly suture or bridge the torn edges of the rotator cuff. Currently, the peroneus longus tendon (PLT) is widely used in ligament reconstruction surgery, showing comparable biomechanical strength and biocompatibility to hamstring tendon autograft.7 Studies have performed reconstruction surgical procedures for IMRCTs using PLT autografts.8,9
In this article, we introduce a suture anchor onlay technique that uses PLT autografts for graft augmentation in IMRCT reconstruction. In our technique, the grafts are suspended on the rotator cuff tendons for a medial connection, while suture anchors are used on the lateral side to achieve the graft’s onlay fixation on the lateral humeral surface.
Surgical Technique
The patient is placed in the lateral decubitus position with the operative shoulder positioned for arthroscopic access (Video 1). After standard draping and disinfection, a lateral posterior portal is established as the observation portal and an anterior portal is established as the operation portal, allowing instrumentation to explore the glenohumeral joint. Preoperative imaging (computed tomography and magnetic resonance imaging) reveal superior migration of the humeral head, indicating a massive RCT (Fig 1). Next, the lateral portal is constructed to release the rotator cuff, and the arthroscopic camera is used to evaluate the extent of pathology. An IMRCT with the absence of the long head of the biceps tendon is identified (Fig 2A). A suture retriever is used to assess tendon tension, and the supraspinatus tendon exhibits significant retraction and high tension, confirming its irreparability. In contrast, the infraspinatus tendon exhibits relatively lower tension, suggesting the potential for partial repair (Fig 2B and C).
Fig 1.
Preoperative imaging of right shoulder. (A) Three-dimensional computed tomography reconstruction shows superior migration of the humeral head. (B) Coronal magnetic resonance imaging shows a massive rotator cuff tear with tendon retraction. The black arrow indicates the humeral head, and the green arrow indicates the retracted rotator cuff.
Fig 2.
Arthroscopic exploration of irreparable massive rotator cuff tear in right shoulder (patient in lateral decubitus position, viewed from lateral posterior observation portal and lateral operation portal). (A) A full-thickness tear is observed, with the absence of the long head of the biceps tendon. (B) On probing with a suture retriever, the supraspinatus is significantly retracted and irreducible. (C) On probing with a suture retriever, the posterior edge of the infraspinatus is partially repairable. The black arrow indicates the supraspinatus; green arrow, infraspinatus; white arrow, suture retriever; orange arrow, glenoid; and purple arrows, humeral head.
Step 1: Preparation of Autografts
A small longitudinal incision approximately 1.5 cm in length is made over the lateral aspect of the lower leg on the operative side, approximately 2 to 3 cm proximal to the lateral malleolus. The PLT is exposed, and a tendon stripper is used to harvest two-thirds of the proximal PLT. During harvesting, care is taken to protect the sural nerve and small saphenous vein. The harvested tendon is then divided into 2 equal segments, each measuring approximately 7 cm in length. Different-colored ultrahigh-molecular-weight polyethylene sutures were used to augment the grafts, making the 2 grafts identifiable via the arthroscopic camera. The grafts should be kept moist in a saline solution–soaked gauze until used in the reconstruction (Fig 3).
Fig 3.
Peroneus longus tendon (right) harvesting and preparation. (A) Through a small longitudinal incision on the lateral side of the lower leg, the peroneus longus tendon is exposed and the proximal two-thirds of the tendon is harvested. (B) Two autografts are prepared, with each graft measuring 7 cm in length. Both ends are sutured with ultrahigh-molecular-weight polyethylene sutures in different colors (to ensure the 2 grafts are identifiable via the arthroscopic camera).
Step 2: Partial Repair of Infraspinatus Tendon
Under arthroscopic surveillance, we construct the lateral anchor portal adjacent to the lateral edge of the acromion. Through the lateral anchor portal, an anchor (HEALIX PEEK [polyether ether ketone] Anchor with ORTHOCORD; DePuy Mitek, Raynham, MA) is implanted on the posterior side of the footprint area, near the cartilage edge (Fig 4A). Then, we construct the posterior portal. Through this portal, a suture hook loaded with a polydioxanone suture (PDS) is used in combination with a penetrating grasper to suture the posterior edge of the infraspinatus, achieving partial repair of the infraspinatus (Fig 4B and C).
Fig 4.
Partial repair at posterior edge of infraspinatus (right) (viewed from lateral posterior observation portal, posterior operation portal, and acromial anchor portal). (A) Through the lateral anchor portal, an anchor is implanted in the posterior footprint area. (B, C) The infraspinatus is sutured using a suture hook with a traction suture and penetrating grasper, both introduced through the posterior operation portal. The red arrow indicates the suture anchor; purple arrows, humeral head; green arrow, infraspinatus; and blue arrow, penetrating grasper.
Step 3: Passage of Autografts Into Joint
A suture hook loaded with a PDS is used to pass suture through the midportion of the supraspinatus, and the PDS is retrieved through the anterior portal (Fig 5A and B). Similarly, another suture hook loaded with PDS is used to pass through the anterior edge of the infraspinatus tendon, and the suture is retrieved through the lateral portal (Fig 5C and D). The PDS are left in place, passing through each tendon. The PDS’ intra-articular positions are shown in Figure 5E, and the externalized ends of the sutures are shown in Figure 6.
Fig 5.
Pre-placement of traction sutures through anterior and posterior sides of rotator cuff (right) (viewed from lateral posterior observation portal, posterior suture portal, and lateral operation portal). (A, B) The supraspinatus tendon is sutured using a suture hook loaded with polydioxanone suture (PDS), and the PDS are pulled out through the anterior portal. (C, D) The infraspinatus tendon is sutured using a suture hook loaded with PDS, and the sutures are pulled out through the lateral portal. (E) Intra-articular positions of the 2 PDS. The red arrows indicate the suture hook; black arrow, supraspinatus tendon; green arrows, infraspinatus tendon; and blue arrow, PDS.
Fig 6.
Location of shoulder arthroscopic portals in right shoulder. The green arrow indicates the anterior portal. The orange arrow indicates the posterior portal. The white arrow indicates the lateral posterior portal. The blue arrow indicates the lateral anchor portal. The black arrow indicates the lateral portal. The blue triangle indicates the lateral distal accessory portal. The black dashed line indicates the clavicle and the edge of the acromion.
Through the lateral anchor portal, a medial-row anchor (Fastlock PK; Star Sports Medicine, Beijing, China) is implanted at the midportion of the footprint area; one suture tail of the anchor is retrieved through the posterior portal, and the other is retrieved through the anterior portal. With the help of the previously placed PDS, the first autograft is pulled into the subacromial space through the lateral portal, and placed through the infraspinatus (Fig 7A-C). Similarly, the second autograft is pulled in and placed through the supraspinatus (Fig 7D-F).
Fig 7.
Passage of 2 autografts into joint (right) (viewed from lateral posterior portal). (A, B) Through the lateral portal, the posterior infraspinatus autograft is passed into the joint using the traction sutures. (C) A medial-row anchor is pre-implanted at the lateral cartilage edge of the central footprint area. (D, E) Through the anterior portal, the anterior supraspinatus autograft is passed into the joint similarly. (F) Another medial-row anchor is pre-implanted at the lateral cartilage edge of the anterior footprint area. With the assistance of a suture retriever, the 2 suture tails from each anchor are placed on either side of the corresponding autograft. The green arrow indicates the anterior edge of the infraspinatus tendon; white arrows, the posterior infraspinatus autograft; blue arrows, the greater tuberosity footprint area; orange arrows, the medial-row suture anchor that fixes the posterior infraspinatus autograft; black arrow, the supraspinatus tendon; yellow arrows, the anterior supraspinatus autograft; and purple arrow, the medial-row suture anchor that fixes the anterior supraspinatus augmented autograft.
Step 4: Onlay Fixation of Graft Using Anchors via Arthroscopy
Another medial-row anchor (CanFix PEEK Anchor; Canwell Medical, Zhejiang, China) is implanted at the anterior part of the footprint area. A suture retriever is used to place the grafts between the 2 suture tails of their corresponding anchors. Then, a lateral distal portal is constructed. Through this portal, a lateral-row anchor (4.75-mm Biocomposite SwiveLock; Arthrex, Naples, FL) is implanted at the greater tuberosity footprint area to fix all 8 sutures from the 2 autografts (Fig 8A and B). Next, the sutures from the 2 medial-row anchors are knotted correspondingly to fix the midsubstance of the 2 autografts (Fig 8C and D). Then, the sutures from the most posterior anchor, which is used to partially repair the infraspinatus, are knotted. Another lateral-row anchor (4.75-mm Biocomposite SwiveLock) is implanted on the posterolateral side of the humeral greater tuberosity footprint area and used to fix 3 of the 4 sutures from the most posterior anchor (Fig 8E). The remaining fourth suture is tied to the sutures that fix the infraspinatus autograft (Fig 8F).
Fig 8.
Fixation of autograft tendons using suture anchor onlay technique (right) (viewed from posterior lateral observation portal). (A, B) A total of 8 sutures from the 2 autografts are fixed on the lateral side of the greater tuberosity footprint area by implanting a lateral-row anchor. (C, D) The sutures from the 2 medial-row anchors are knotted correspondingly to fix the midsubstance of the autografts. (E) Three sutures from the most posterior anchor that partially repair the posterior infraspinatus tendon are fixed at the greater tuberosity footprint area by another lateral-row anchor. (F) The fourth suture is tied to the sutures used to fix the infraspinatus autograft. (G) The proximal part of the reconstructed autograft is fixed. (H) The distal part of the reconstructed autograft is fixed, and the infraspinatus is partially repaired. The red arrow and the black arrow indicate the total of 8 sutures from the 2 autografts. The orange arrow indicates the lateral-row anchor. The yellow arrows indicate the supraspinatus autograft. The white arrows indicate the infraspinatus autograft. The blue arrows indicate the repaired edge of the infraspinatus tendon.
Discussion
In this article, we describe a suture anchor onlay technique for IMRCT reconstruction. Currently, there is no consensus on the optimal treatment for IMRCTs.3 In our technique, the grafts are placed through the torn supraspinatus and infraspinatus tendons on the medial side and fixed on the surface of the greater tuberosity by anchors. In this way, both the anatomy and the function of the rotator cuff are re-established, which achieves “dynamic” reconstruction. Furthermore, anchors make the tension of the reconstructed tissue “adjustable” during the surgical procedure and help achieve a more precise reduction of the humeral head. Recently, the PLT has been more and more favored because of its unique advantages such as smaller incisions both at the donor site and for the surgical portal, which is used to pass the graft into the joint.10,11 Studies have shown that PLT autograft exhibits biomechanical properties comparable to those of fascia lata.12 Recently, Tang and Zhao9 reported a technique called “rooting rotator cuff reconstruction,” in which the PLT is suspended through the torn rotator cuff medially and is fixed in bone tunnels on the lateral side. The use of graft fixation on the lateral side in their technique is similar to cruciate ligament reconstruction, which represents “inlay” fixation. However, their technique includes drilling a total of 4 bone tunnels in the greater tuberosity; this would increase the risk of fracture caused by severe osteoporosis and large bone tunnels. By contrast, our onlay technique opts to fix the autografts using anchors, which would significantly reduce the loss of bone.
Previous studies have reported an onlay technique for posterior cruciate ligament reconstruction, and it was found that the onlay technique showed comparable biomechanical results to the other techniques examined.13,14 Therefore, we think the onlay technique is a feasible method for IMRCT reconstruction because it can simplify the surgical procedure, reduce the operative time, and lower the risk of fractures caused by drilling. In this case, postoperative imaging confirmed satisfactory anatomic restoration of the rotator cuff (Fig 9). The pearls and pitfalls of this technique are listed in Table 1, and the advantages and disadvantages are listed in Table 2. In conclusion, although the long-term outcomes of the operation require further observation, our technique has good application value in IMRCT reconstruction.
Fig 9.
Postoperative imaging of right shoulder. (A) Postoperative 3-dimensional computed tomography reconstruction shows that the humeral head (black arrow) returned to its normal anatomic position. (B) Postoperative magnetic resonance imaging shows the reconstructed autograft (yellow arrow) and the supraspinatus tendon (green arrow) with good tension.
Table 1.
Pearls and Pitfalls of Suture Anchor Onlay Technique
| Pearls |
| When preparing the autograft, it is advisable to braid one end of the tendon into a fusiform shape; this will help the autograft pass through the torn tendon more smoothly. |
| If the autograft encounters excessive resistance while passing through the torn tendon, a hemostat can be used to slightly enlarge the entry point of the tendon. |
| If excessive resistance is encountered while pulling the autograft, both autografts can be introduced through the lateral portal. However, the anterior autograft should be pulled out through the anterior portal, and the posterior autograft should be pulled out through the posterior portal, which aims to avoid excessive bending effects. |
| When fixing the autografts, fixing the sutures of the lateral-row anchors first, followed by knotting the sutures of the medial-row anchor, is recommended. This allows for better graft tension adjustment. |
| Constructing the lateral distal accessory portal is necessary because it allows appropriate tension when fixing the distal end of the autograft. Moreover, it does not interfere with knot tying and helps avoid suture entanglement. |
| Pitfalls |
| It is necessary to test the tension and displacement of the torn rotator cuff tendons and to estimate the needed lengths of the autografts to avoid grafts that are either too long or too short. |
| In patients with osteoporosis, after the lateral-row anchor is implanted, it is recommended to keep the inserter rod in place and apply slight inward pressure. The rod should only be removed after the sutures have been knotted, which helps reduce the risk of complications during removal. |
Table 2.
Advantages and Disadvantages of Suture Anchor Onlay Technique
| Advantages |
| The suture onlay technique for lateral fixation has a low learning curve, and the procedures are convenient (similar to traditional rotator cuff repair). |
| Compared with fascia lata, the donor-site incision for the PLT and the portal incision for graft introduction are smaller. In addition, there is no need to expand the incision during the operation. |
| The autograft is passed through the rotator cuff tendons, yielding better biomechanical results and achieving dynamic reconstruction. |
| Via lateral-row anchor fixation, the tension of the autograft and torn tendons is adjustable, helping achieve more precise reduction of the humeral head. |
| For different types of IMRCTs, the supraspinatus or infraspinatus can be augmented separately or together. In addition, this technique is applicable to irreparable tears of the subscapularis tendon. |
| Disadvantages |
| Complications can occur at the donor site of the PLT. |
| Autografts cannot achieve complete anatomic coverage of the rotator cuff, and the long-term outcomes require further observation. |
IMRCT, irreparable massive rotator cuff tear; PLT, peroneus longus tendon.
Acknowledgments
Disclosures
All authors (Y.L., W.Y., F.W., Y.P., C.M., H.W., W.H.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgments
The authors acknowledge support from the National Natural Science Foundation of China Youth Program (ID: 82002318) and the Hubei Provincial Natural Science Foundation General Program (ID: 2024AFB705).
Footnotes
Y.L. and W.Y. contributed equally to this work and are co-first authors.
Supplementary Data
Suture anchor onlay technique for arthroscopic irreparable massive rotator cuff tear (IMRCT) reconstruction. The patient was a 71-year-old woman who presented with right shoulder pain and restricted mobility for several months. The preliminary diagnosis suggested a massive rotator cuff tear. A tear in the upper one-third of the subscapularis tendon was identified through the posterior observation portal, and the tear was then repaired with a single-anchor technique through the anterior operation portal. Through the lateral posterior observation portal and the lateral operation portal, an irreparable massive rotator cuff tear with a missing long head of the biceps tendon was identified. The tension of the torn tendon was tested to estimate the required length of the tendon graft. The peroneus longus tendon on the same side was harvested and prepared into two 7-cm tendon grafts to serve as autografts for the subsequent procedures. Through the lateral posterior observation portal, a lateral anchor portal was constructed along the lateral edge of the acromion. A double-row anchor was placed at the posterior aspect of the footprint area, near the cartilage edge. Then, through the posterior operation portal, a suture hook loaded with polydioxanone (PDS) suture was used to suture the residual tendon tissue at the posterior edge of the infraspinatus, which could partially repair the infraspinatus. Through the posterior operation portal, a suture hook loaded with a traction PDS suture was used to suture the residual tendon tissue at the midportion of the supraspinatus and the anterior edge of the infraspinatus. One traction suture was placed for each tendon; the traction suture in the supraspinatus was pulled out through the anterior portal, and the other traction suture was pulled out through the lateral portal. Through the lateral anchor portal, a double-row anchor was placed at the midportion of the rotator cuff footprint area, near the cartilage edge. Then, the 2 suture tails of the anchor were respectively pulled out through the posterior and anterior portals. The first autograft was passed into the subacromial space and placed through the infraspinatus. Through the anterior portal, the second autograft was passed into the subacromial space and placed through the supraspinatus. A double-row anchor was placed at the anterior part of the rotator cuff footprint area, near the cartilage edge. A suture retriever was used to place the 2 grafts through their corresponding anchor sutures. Through the lateral distal portal, a total of 8 sutures from the 2 autografts were placed on the lateral side of the humeral greater tuberosity footprint area using a lateral-row anchor. Then, through the lateral portal, the sutures from the medial-row anchors were knotted to fix the midsubstance of the autografts. Next, we knotted the sutures from the most posterior anchor, which was used to partially repair the infraspinatus, and we used another lateral-row anchor to fix the 4 sutures from the medial anchors on the posterolateral side of the humeral greater tuberosity footprint area. Finally, the sutures from the posterior autograft and those used to partially repair the infraspinatus were knotted again. Another arthroscopic examination was performed, and the operation was finished. After surgery, magnetic resonance imaging showed that the reconstructed grafts and the residual rotator cuff maintained good tension and the humeral head was restored to its normal anatomic position.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Suture anchor onlay technique for arthroscopic irreparable massive rotator cuff tear (IMRCT) reconstruction. The patient was a 71-year-old woman who presented with right shoulder pain and restricted mobility for several months. The preliminary diagnosis suggested a massive rotator cuff tear. A tear in the upper one-third of the subscapularis tendon was identified through the posterior observation portal, and the tear was then repaired with a single-anchor technique through the anterior operation portal. Through the lateral posterior observation portal and the lateral operation portal, an irreparable massive rotator cuff tear with a missing long head of the biceps tendon was identified. The tension of the torn tendon was tested to estimate the required length of the tendon graft. The peroneus longus tendon on the same side was harvested and prepared into two 7-cm tendon grafts to serve as autografts for the subsequent procedures. Through the lateral posterior observation portal, a lateral anchor portal was constructed along the lateral edge of the acromion. A double-row anchor was placed at the posterior aspect of the footprint area, near the cartilage edge. Then, through the posterior operation portal, a suture hook loaded with polydioxanone (PDS) suture was used to suture the residual tendon tissue at the posterior edge of the infraspinatus, which could partially repair the infraspinatus. Through the posterior operation portal, a suture hook loaded with a traction PDS suture was used to suture the residual tendon tissue at the midportion of the supraspinatus and the anterior edge of the infraspinatus. One traction suture was placed for each tendon; the traction suture in the supraspinatus was pulled out through the anterior portal, and the other traction suture was pulled out through the lateral portal. Through the lateral anchor portal, a double-row anchor was placed at the midportion of the rotator cuff footprint area, near the cartilage edge. Then, the 2 suture tails of the anchor were respectively pulled out through the posterior and anterior portals. The first autograft was passed into the subacromial space and placed through the infraspinatus. Through the anterior portal, the second autograft was passed into the subacromial space and placed through the supraspinatus. A double-row anchor was placed at the anterior part of the rotator cuff footprint area, near the cartilage edge. A suture retriever was used to place the 2 grafts through their corresponding anchor sutures. Through the lateral distal portal, a total of 8 sutures from the 2 autografts were placed on the lateral side of the humeral greater tuberosity footprint area using a lateral-row anchor. Then, through the lateral portal, the sutures from the medial-row anchors were knotted to fix the midsubstance of the autografts. Next, we knotted the sutures from the most posterior anchor, which was used to partially repair the infraspinatus, and we used another lateral-row anchor to fix the 4 sutures from the medial anchors on the posterolateral side of the humeral greater tuberosity footprint area. Finally, the sutures from the posterior autograft and those used to partially repair the infraspinatus were knotted again. Another arthroscopic examination was performed, and the operation was finished. After surgery, magnetic resonance imaging showed that the reconstructed grafts and the residual rotator cuff maintained good tension and the humeral head was restored to its normal anatomic position.