Arthroscopic modified Mason Allen technique for large U or L shaped rotator cuff tears

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1 DOI /s y SHOULDER Arthroscopic modified Mason Allen technique for large U or L shaped rotator cuff tears Sung Weon Jung 1 Dong Hee Kim 1 Seung Hoon Kang 1 Ji Heon Lee 1 Received: 28 July 2015 / Accepted: 22 January 2016 European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2016 Abstract Purpose While a conventional single- or double-row repair technique could be applied for repair of C-shaped tears, a different surgical strategy should be considered for repair of U- or L-shaped tears because they typically have complex patterns with anterior, posterior, or both mobile leaves. This study was performed to examine the outcomes of the modified Mason-Allen technique for footprint restoration in the treatment of large U- or L-shaped rotator cuff tears. Methods Thirty-two patients who underwent an arthroscopic modified Mason-Allen technique for large U- or L-shaped rotator cuff tears between January 2012 and December 2013 were included in this study. Margin convergence was first performed to reduce the tear gap and tension, and then, an arthroscopic Mason-Allen technique was performed to restore the rotator cuff footprint in a Sung-Weon Jung MD and Dong-Hee Kim MD contributed equally to this article as joint first authors. Electronic supplementary material The online version of this article (doi: /s y) contains supplementary material, which is available to authorized users. * Sung Weon Jung can1204@hanmail.net Dong Hee Kim dhkim1149@gmail.com Seung Hoon Kang slash508@gmail.com Ji Heon Lee kakioos@hanmail.net side-to-end repair fashion. All patients were evaluated preoperatively and for a minimum of 2 years of follow-up with a visual analog scale (VAS) for pain, Constant score, and ultrasonography. Results There was significant improvement in all VAS and Constant scores compared with the preoperative values (P < 0.001). Functional results by Constant scores included 9 cases that were classified as excellent, 11 cases as good, 8 cases as fair, and 2 cases as poor. Binary logistic regression analysis revealed that heavy work, pseudoparalysis, joint space narrowing, fatty degeneration of the SST and IST, and a positive tangent sign were found to significantly correlate with functional outcomes. Multivariable logistic regression analysis revealed that only fatty degeneration of the SST was a risk factor for fair/poor clinical outcomes. Complications occurred in 5 of the 32 patients (15.6 %), and the reoperation rate due to complications was 6.3 % (2 of 32 patients). Conclusions An arthroscopic modified Mason-Allen technique was sufficient to restore the footprint of the rotator cuff in our data. Overall satisfactory results were achieved in most patients, with the exception of those with severe fatty degeneration. An arthroscopic modified Mason-Allen technique could be an effective and reliable alternative for patients with large U- or L-shaped rotator cuff tears. Level of evidence Case Series, Therapeutic Level IV. Keywords Rotator cuff tear Large size Mason-Allen technique Margin convergence Shoulder Introduction 1 Department of Orthopedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, 50, Hapsung 2 Dong, Changwon si, Gyeongsangnam do, Korea While small-to-medium one-tendon tears present with a simple tear pattern, large-to-massive two-tendon tears

2 present with a complex tear pattern and are more likely to undergo structural deterioration [1, 3]. As large-sized rotator cuff tears have various tear patterns, the exact identification of the pattern is an important initial step and the surgical strategy is requisite for anatomic restoration of the footprint [7]. For crescent-shaped large tears, the identification of tear patterns and anatomic reduction can be easily performed. However, for U- or L-shaped large tears, the original tear pattern cannot be as easily distinguished and end-to-end repair can result in high tension at the repair site. A conventional single- or double-row repair technique can be applied for repair of crescent-shaped tears, but a different surgical strategy should be considered for repair of U- or L-shaped tears since they may exhibit complex patterns with anterior, posterior, or both leaves. An anatomic restoration of rotator cuff fibres could increase the potential for complete healing and proper function. Margin convergence is attempted as a first step in the repair of U- and L-shaped tears and is considered to be effective for reducing tear size and decreasing repair tension [4]. However, a recent anatomic study has revealed that repair of a U-shaped tear with a mobile posterior leaflet is more appropriate than a margin convergence repair [14]. Although advancements in repair technique have resulted in reduction of torn rotator cuffs, high re-tear rates in cases of large tears remain a problem, with failure rates ranging from 21 to 91 % [19]. Despite advances in surgical technique and operative equipment, successful repair of large-to-massive tears remains a challenge. It is important to note that double-row techniques are strong and have a better chance of healing due to the larger contact area. The optimal anchor suture configuration and subsequent integrity according to the tear shape have not yet been reported. And it is unclear whether the residual defect (lack of coverage) after surgery could influence on the functional outcome. The hypothesis of this study was that an arthroscopic Mason-Allen technique coupled with margin convergence in a side-to-end repair fashion (hereafter referred to the arthroscopic modified Mason- Allen technique, Fig. 1) allows excellent healing and good shoulder motion. This study was performed to examine the outcomes of a modified Mason-Allen technique for footprint restoration in the treatment of large U- or L-shaped rotator cuff tears. Materials and Methods Among 120 patients who underwent arthroscopic rotator cuff repair between 2012 and 2013, 32 patients had large-sized, full-thickness, U- or L-shaped tears and were included in our study. Tear size was classified according to the rating system proposed by DeOrio and Cofield in which a tear 3 5 cm in length was classified as a largesized tear. Tear size was intraoperatively measured using an arthroscopic probe. Patients with small, medium, or large C-shaped rotator cuff tears, massive (>5 cm) tears, advanced glenohumeral arthritis, revision surgery, conversion to open repair, and acromioclavicular arthritis that required distal clavicle resection were excluded from this study. All patients underwent arthroscopic rotator cuff repair, which was performed using the modified Mason-Allen technique, and all surgeries were performed by a single surgeon (S.W.J.). This study included 16 men and 16 women with a median age of 63 years (range years). The median symptom duration before surgery was 5 months (range 3 24 months). Patients were followed for a median of 30 months (range months) post-operatively. Examinations were performed 1 day before the operation and at 12 and 24 months after the operation by two orthopaedic surgeons (resident and attending). Pre- and post-operative subjective pain was measured with a visual analog scale (VAS). VAS score is one of the most commonly used tool to measure pain comprehensively, with 0 indicating no pain and 10 indicating extremely severe pain. Patients were asked to say current pain intensity. The Constant score was also used for clinical assessment, which is a widely used shoulder-specific scoring system that is composed of four parts: shoulder pain (0 15 points), activities of daily living (0 20 points), range of motion (0 40 points), and strength (0 25 points) [6]. With regard to pain, 15 points indicate no pain, 10 points indicate mild pain, 5 points indicate moderate pain, and 0 point indicates severe pain interfering with activities. Patients were asked to say pain intensity related with daily activity. With regard to activities of daily living, the ability to perform these activities was assigned 20 points. Range of motion was measured with a goniometer between the upper arm and the upper part of the thorax. Active shoulder motion, including forward flexion, abduction, internal rotation, and external rotation, was measured. Strength was assessed by use of the Isobex Dynamometer. The strength measurement was assessed in the scapular plane of abduction. It was measured by a minimum force of 1 kg. All calculations were then converted to pounds. Zero point was given for no ability to hold 1 pound, and 25 points were given for the ability to hold 25 pounds at 90 abduction. The number of points correlated with the number of pounds held by the patient. Standardized radiographs were performed preoperatively, including anteroposterior (AP) views, a Grashey view (30 internally angled AP view), supraspinatus outlet views, and a Rockwood view (30 caudally angled AP view). Preoperative magnetic resonance imaging (MRI) of the affected shoulder was performed, and fatty degeneration

3 Fig. 1 a When the apex of the torn cuff was located adjacent to the glenoid rim, these were considered to be U- or L-shaped tears. One or two margin convergences (side-to-side suture) were first performed to reduce the tear gap and tension. b After inserting the anchors, suture lines were re-passed over a transverse line to tighten the torn cuff. c This procedure was repeated while moving posteriorly until adequate suture lines had been made. d Instead of medial knot ties, three anterior suture lines were inserted into the anterior pilot hole maintaining constant tension with the push-in-type device and three posterior suture lines were inserted into the posterior pilot hole in the same manner and atrophy of the rotator cuff muscles were evaluated. Fatty degeneration was evaluated using the 5-stage grading system suggested by Goutallier et al. [8]. Hypotrophy of the supraspinatus muscle was assessed with the muscle occupation ratio of the supraspinatus fossa (Tangent sign). Residual defects (lack of coverage) on the footprint of the greater tuberosity were measured using an arthroscopic probe after modified Mason-Allen technique (Table 1). The integrity of the rotator cuff repair was determined by ultrasonographic evaluation, which all patients underwent at final follow-up. One specialized radiologist with over 10 years of experience, who did not have any information regarding the intraoperative findings, performed all followup ultrasonographic examinations. Rotator cuff integrities were classified into 3 categories: intact rotator cuff, partialthickness tear, and full-thickness tear according to Naqvi et al. [15]. Repeated measurements were taken with an interval of 2 3 months to minimize the potential for examiner bias. In case of disagreement of the two examiners interpretation, it was confirmed by another orthopaedic surgeon. Radiologic interpretations were confirmed with the assistance of a musculoskeletal radiologist.

4 Table 1 Summary of patient characteristics Cases Sex, n Men: 16, women: 16 Age (years) 69.3 ± 7.9 (range 51 79) Follow-up period (months) 30.2 (24 48) Preoperative symptom duration 5.5 (3 24) (months) DM (yes/no) 23:9 HT (yes/no) 25:7 Married (yes/no) 28:4 Heavy work (yes/no) 12:20 Trauma Hx (yes/no) 17:15 Pseudoparalysis (yes/no) 8:24 BMD 1.8 ± 0.4 (range 1.0 to 2.5) X-ray findings Subacromial spur (yes/no) 30:2 Joint space narrowing (yes/no) 6:26 MRI findings Goutalier stage SST I: 2, II: 24, III: 6 Goutalier stage IST I: 26, II: 6, III: 0 Goutalier stage SSC I: 32, II: 0, III: 0 Tangent sign (yes/no) 6:26 Residual defect (lack of coverage) 25:7 (yes/no) Post-operative examination Rotator cuff integrity by U/S 20:12 (yes/no) Operative technique After the patient was positioned in the lateral decubitus position, physical examination and manipulation were performed under general anaesthesia. The arthroscope was placed into the shoulder joint, and all inflamed tissue was debrided, with careful observation of the subscapularis tendon, the biceps, and other findings within the shoulder joint. A total of 15 shoulders with fraying, tearing, or instability of the biceps tendon in patients over age 50 were managed with biceps tenotomy. The arthroscope was inserted into the subacromial space through the posterior portal, and a thorough bursectomy was performed with a shaver and an electrocautery probe. Subacromial decompression was performed with a 5.0-mm burr to create a flat undersurface of the acromion. After debridement of the degenerated tendon edges, tear size, retraction, delamination, and initial pattern were evaluated via the posterolateral and direct lateral portal. When the apex of the torn rotator cuff was located adjacent to the glenoid rim, the tear was considered to be a U- or L-shaped tear. Mobility of the anteromedial or posteromedial leaf of the torn rotator cuffs was attempted using an Fig. 2 a After reassessment of torn cuff mobilization, one or two margin convergences (side-to-side suture) were first performed to reduce the tear gap and tension. b After making a transverse line, suture limbs were re-passed over the transverse line to tighten the torn cuff. c Instead of medial knot ties, three anterior suture lines were inserted into the anterior pilot hole while maintaining constant tension with the push-in-type device, and three posterior suture lines were inserted into the posterior in the same manner arthroscopic tendon grasper. The mobilization procedures included coracohumeral ligament release at the base of the coracoid, capsular release at the superior aspect of the labrum, and posterior release of scar tissue at the base of the scapular spine. Once the mobilization procedures were performed, the mobility of the rotator cuff was reassessed. After reassessment of torn rotator cuff mobilization, one or

5 two margin convergences (side-to-side suture) were performed to reduce the tear gap and tension with 2-0 ethibond (Ethicon, Johnson and Johnson, Belgium; Fig. 1a). The footprint was thoroughly debrided, and a small incision was made just lateral to the acromion in order to insert the suture anchors. This anchor portal was placed between the extension line of the anterior and posterior borders of the clavicle. A 5.0-mm Bio-Corkscrew suture anchor (Peekzip, Stryker, USA) was inserted at the junction of the articular cartilage and the footprint on the greater tuberosity. The suture limb was passed 8 12 mm from the rotator cuff margin with an antegrade suture passer (Scorpion, Stryker) or a retrograde suture passer (Banana Lasso, Arthrex). After making a transverse line, suture limbs were re-passed over the transverse line to tighten the torn rotator cuff as suggested by Rhee et al. (Fig. 1b) [17]. This procedure was repeated while moving posteriorly until adequate suture passes had been made. In total, six suture passes were made with two medial anchors (Fig. 1c). We believe that the modified Mason-Allen technique allows for superior fixation of the rotator cuff tissues by approximating a Mason-Allen configuration through the rotator cuff. Lateral pilot holes for the push-in-type device were created using a punch, 1 2 cm distal to the lateral edge of the footprint. Instead of medial knot ties, three anterior suture lines were inserted into the anterior pilot hole maintaining constant tension with the push-in-type device (Reelex, Stryker) and three posterior suture lines were inserted into the posterior pilot hole in the same manner (Fig. 1d). After the device was fully engaged in the pilot hole, the sutures were cut. Finally, the Mason-Allen technique coupled with margin convergence was performed to restore the rotator cuff footprint in a side-to-end repair fashion (Fig. 2). A total of 25 shoulders (78.1 %) had small-sized residual defects (1 1 cm 2 ) after surgery, and these were triangle-shaped lacks of coverage on the footprint. While margin convergence sutures were passed through half point of the anterior leaflet and half point of the posterior leaflet in U-shaped tear, more corner point of the posterior leaflet was passed to place its anatomic position in L-shaped tear (Fig. 3) [20]. After the surgery was completed, the glenohumeral joint and subacromial space were infiltrated with 10 ml of 0.5 % bupivacaine and 160 mg of triamcinolone acetonide. All patients were placed in a sling with abduction pillow in the operating room. All patients were treated with a standardized protocol of sling immobilization for the first 6 weeks after surgery. Immediate active motion was allowed at the elbow, wrist, and digits. They were instructed to wear their sling full-time even while sleeping, with the exception of changing clothes, and passive stretching exercises were not started to prevent re-tear. At 6 weeks from the date of surgery, patients stopped using the sling, and active and Fig. 3 a One margin convergence suture was passed through half point of the anterior leaflet and more corner point of the posterior leaflet to place its anatomic position. b Final arthroscopic finding of the modified Mason-Allen technique active-assisted exercise was begun. The return to full and unrestricted activities usually began at 3 months post-operatively. This study was approved by Institutional Review Board of Samsung medical centre (2014-SCMC ). Statistical analysis κ values were calculated for intraobserver reliabilities to assess levels of agreement, with κ values below 0.40 considered poor; between 0.41 and 0.59, fair; between 0.60 and 0.74, good; 0.75 or higher, excellent. The nonparametric Wilcoxon signed-rank test was used to assess differences between the pre- and post-operative means. Binary logistic regression analysis was used to evaluate correlations between fair/poor functional results and other variables such as sex, age, DM, HT, marital status, work load, trauma history, pseudoparalysis, BMD, subacromial spur, joint space narrowing, degree of fatty degeneration of SST, IST, and SSC (Goutalier stage), tangent sign, residual defects, and post-operative rotator cuff integrity on ultrasonography. All calculations were performed using IBM SPSS 21.0 software (IBM Corp, Armonk, NY, USA). P values < 0.05 were considered to be statistically significant. As no group comparisons were conducted, a sample size calculation was not necessary.

6 Table 2.Functional results by VAS and Constant scores Methods Preoperative scores Post-operative 1-year scores Final scores P value VAS 8 (2 10) 3 (2 5) 2 (0 5) n.s. Constant 31 (12 72) 79 (40 95) 79 (40 95) n.s. Pain 0 (0 10) 10 (10 15) 10 (10 15) n.s. Activities of daily living 6 (2 16) 18 (6 20) 18 (6 20) n.s. Range of motion Forward flexion 6 (2 10) 10 (4 10) 10 (4 10) n.s. Abduction 6 (2 10) 10 (4 10) 10 (4 10) n.s. Internal rotation 4 (0 8) 8 (4 10) 8 (4 10) n.s. External rotation 4 (2 10) 8 (4 10) 8 (4 10) n.s. Strength 5 (4 8) 15 (8 20) 15 (8 20) n.s. All data are expressed as median and range Results Of the 52 tears identified as large according to the classification of DeOrio and Cofield, there were 32 large U- or L- shaped tears, and the remaining 20 cases were C-shaped tears. Analyses of intraobserver reliability showed good-toexcellent agreement: Goutalier-Supraspinatus (κ = 0.77), Goutalier-Subscapularis (κ = 0.66), Goutalier-Infraspinatus (κ = 0.67), tangent sign (κ = 0.73), VAS score (κ = 0.73), Constant score, pain (κ = 0.75), Constant score, activity (κ = 0.65), Constant score, motion (κ = 0.73), and Constant score, strength (κ = 0.66). One variable postoperative rotator cuff integrity examined by ultrasonography showed fair reliability (κ = 0.48). There were two cases of partial-thickness tears interpreted as intact rotator cuff, and one case of full-thickness tears interpreted as partial-thickness tears. There was significant improvement in all VAS and Constant scores compared with the preoperative values (p < 0.001, Table 2). Functional results included 9 cases classified as excellent, 11 cases classified as good, 8 cases classified as fair, and 2 cases classified as poor according to the Constant scores. Binary logistic regression analysis was used to evaluate the correlations between fair-to-poor functional results (as expressed by the Constant score) and other variables. This analysis revealed that sex, age, DM, HT, BMD, marital status, trauma history, subacromial spurs, fatty degeneration of the SSC, residual defects, and post-operative rotator cuff integrity did not correlate with fair-to-poor results. Heavy work, pseudoparalysis, joint space narrowing, fatty degeneration of the SST and IST, and a positive tangent sign were found to significantly correlate with functional outcomes (Table 3). Multivariable logistic regression analysis revealed that only fatty degeneration of the SST was a risk factor for fair-to-poor clinical outcomes (Table 4). Repair integrities by Naqvi classification were identified as 20 cases with an intact rotator cuff, 10 cases with a partial-thickness tear, and 2 cases with a full-thickness tear (Table 5). Complications occurred in 5 of the 32 patients (15.6 %), and the reoperation rate due to complications was 6.3 % (2 of 32 patients). Two patients suffered from shoulder stiffness. Shoulder stiffness was defined as total active and passive forward flexion of <100 and total passive external rotation of <30 with the arm in 90 of abduction [1]. Shoulder stiffness had resolved with conservative treatment in each of these patients at the time of final follow-up. Follow-up U/S found that 7 patients had sustained partialthickness re-tears and 2 sustained full-thickness re-tears. As all patients except 2 had good-to-excellent clinical outcomes, further treatment was needed for these 2 patients. One patient who showed a full-thickness re-tear underwent revision surgery due to persistent shoulder pseudoparalysis (defined as the inability to forward elevate the arm >90 ). After open revision, the patient s symptoms fully resolved. One patient who had a large-sized rotator cuff tear with osteoarthritis exhibited progression of osteoarthritis after surgery. She ultimately underwent revision arthroplasty, because of painful limitation of motion. No incidences of nerve palsy or infection were recorded in our patients. Discussion The most important findings of the present study was that pain relief and clinical function can be generally achieved even though irrespective of the final state of the repaired tendon, better outcomes and increased shoulder abduction strength are observed after a healed repair. Large-to-massive rotator cuff tears remain a difficult condition to treat, and operative repair includes three options: open repair, mini-open repair, and arthroscopic repair. Some surgeons feel that arthroscopy is contraindicated in treating largeto-massive tears and favour an open approach, and factors

7 Table 3 Comparison by binary logistic regression analysis between the excellent/good group and the fair/poor group according to the Constant scores Variable Excellent/good group (n = 22) Fair/poor group (n = 10) P value Age (years) 64.9 ± 7.3 (range 54 75) 61.6 ± 9.0 (range 51 79) n.s. Sex, n Men: 12, Women: 10 Men: 4, Women: 6 n.s. DM (yes/no), n 18:4 5:5 n.s. HT (yes/no), n 20:2 5:5 n.s. BMD 1.8 ± 0.3 (range 1.0 to 2.2) 1.9 ± 0.5 (range 1.0 to 2.5) n.s. Married state (yes/no), n 19:3 9:1 n.s. Trauma Hx (yes/no), n 8:14 9:1 n.s. Heavy work (yes/no), n 2:4 15: Pseudoparalysis (yes/no), n 3:19 9: Subacromial spur (yes/no), n 20:2 10:0 n.s. Joint space narrowing (yes/no), n 0:22 6: Goutalier stage, SST I: 2, II: 20, III: 0, IV: 0 I: 0, II: 4, III: 6, IV: Goutalier stage, IST I: 22, II: 0, III: 0, IV: 0 I: 4, II: 6, III: 0, IV: Goutalier stage, SSC I: 22, II: 0, III: 0, IV: 0 I: 10, II: 0, III: 0, IV: 0 n.s. Tangent sign (yes/no), n 0:22 6: Residual defect (yes/no), n 15:7 10:0 n.s. Rotator cuff integrity (yes/no), n 16:4 4:8 n.s. Table 4 Risk factors for fair/poor clinical outcomes by multivariable logistic regression analysis Variable P value Exp(B) 95 % CI Heavy work n.s Pseudoparalysis n.s Joint space narrowing n.s Fatty degeneration SST Fatty degeneration IST n.s Tangent sign n.s Variables that had significant relationships on univariate analysis were included in the multivariate logistic regression analysis. Fatty degeneration of SST was statistically significant, P < 0.05 Exp(B), exponentiation of the B coefficient, which means odds ratio CI confidence interval such as difficulty in recognizing the tear pattern and obtaining adequate mobilization contribute to this opinion [11]. In cases of U- or L-shaped large tears, end-to-end repair can produce significant tension at the repair site due to the large and complex tear patterns. The goal of surgery is to effectively restore the coverage of the original footprint in order to maximize functional outcomes, and many suture techniques have been used, such as the single-row repair, dualrow repair, bridge-type repair, and the Mason-Allen suture technique [13]. The repair technique should be based on the tear pattern and tissue quality, and a tension-free suture line should take precedence over coverage of the entire footprint. Achieving adequate fixation near the attachment points of the rotator cuff should be a priority, and various repair techniques have been suggested that focus on reattaching Table 5 Repair integrity according to fatty degeneration of the rotator cuff Preoperative fatty degeneration Intact cuff a (n = 20) Partial-thickness tear (n = 10) Full-thickness tear (n = 2) Grade 1 (n = 15) Grade 2 (n = 16) Grade 3 (n = 1) Grade 4 (n = 0) Goutallier classification of fatty degeneration: Grade 0 (no fatty deposits), grade 1 (some fatty streaks), grade 2 (more muscle than fat), grade 3 (as much muscle as fat), and grade 4 (less muscle than fat) a Naqvi classification of the rotator cuff after repair

8 the torn rotator cuff edge to its original footprint. Studies have demonstrated widely varying results with respect to rotator cuff integrity after arthroscopic repair and clinical function. Lapner et al. [12] published a randomized trial comparing clinical and structural outcomes for double-row versus single-row repairs, and they were unable to identify a difference in clinical results between the two groups. While another study showed no difference between these two groups, they did identify a statistically significant benefit with respect to re-tear rates for larger tears. In contrast to a single-row repair, a double-row repair tends to fail at the musculotendinous junction instead of at the repair site. Modern, new type single-row repairs (i.e. modified Mason- Allen technique suggested by Scheibel and Habermeyer) or new type double-row repairs (i.e. modified Mason-Allen suture bridge technique by Rhee et al.) could be an alternative to avoid stress concentration at the repair site [17, 18]. Because the structural stability and re-tear rate of the dualrow fixation technique are superior to that of the single-row fixation technique, the former was used with achievement of satisfactory results in our study. The torn supraspinatus and infraspinatus tendons are typically pulled medially and posteriorly by their respective muscles and therefore need to be repaired by bringing these tendons laterally and anteriorly onto their native insertion sites. A margin convergence suture technique can be used for distributing force and minimizing tension. Burkhart et al. [5] reported good and excellent results in 95 % of arthroscopic rotator cuff repairs performed using a margin convergence technique regardless of tear size. They also reported that a delay from injury to diagnosis was not a contraindication, and patients with massive rotator cuff tears and pseudoparalysis still were candidates for arthroscopic repair. We also used a margin convergence suture technique, and we believed that it should be a first step to reduce the tear gap and repair tension for large U- or L-shaped tears. While margin convergence sutures were passed through half point of the anterior and the posterior leaflet in U-shaped tear, more corner point of the posterior leaflet was passed to place its anatomic position in L-shaped tear. The Mason-Allen technique has several advantages. It not only improves the contact pressure at the footprint, but also it diverges the concentrated stress at the repair site, which might prevent re-tear at the repair site. Baums et al. reported that the contact pressure of Mason-Allen stitches was greater than those of simple and horizontal mattress stitches in the biomechanical study and supported that Mason-Allen stitch improved the environment for healing of the repaired rotator cuff tendon [2]. Rotator cuff re-tear is the one of the most common complications of rotator cuff repair, and this is reported to be closely related to the tear size, degenerative changes (i.e. delamination, thinning, and atrophy), over-tensioning and early rehabilitation. Varying prognoses have been reported after arthroscopic rotator cuff repair with structural healing rates ranging from 20 to 93 % [7]. A multicentre study reported a significant decrease in abduction strength compared to the uninjured side in the re-tear group when compared to intact patients [10]. Although most patients may achieve successful clinical outcomes despite the presence of a re-tear, some have poor functional outcomes if tendon continuity is lost. There is a lower re-tear incidence in the treatment of the small-to-medium rotator cuff tears compared with large-to-massive tears with degeneration. Complete repair with over-tensioning might not have a benefit compared with partial repair for large-to-massive contracted tears. Early rehabilitation has also been evaluated with respect to risk of re-tear. Parsons et al. [16] reported that delayed rehabilitation after arthroscopic rotator cuff repair may be justified and that early restriction of ROM does not lead to long-term stiffness, even in patients who are clinically stiff in the early post-operative period. The immobilization period might be somewhat long in patients with large-tomassive tears, though post-operative stiffness had been resolved after regular exercise or physical therapy even in patients who are kept in an abduction brace for 6 8 weeks in our study. Post-operative stiffness has been shown to be one of the most common complications, but the functional implication of re-tear has been regarded as far more serious. The ideal post-operative outcomes after treatment of rotator cuff tears are full recovery of motion with complete healing. There is a general consensus that a secure repair of the rotator cuff is basically more important than partial repair. The partial repair with tension-free suture technique based on the tear pattern and tissue quality would be better over coverage of the entire footprint. Harryman et al. [9] identified recurrent rotator cuff defects using ultrasonography in patients who had undergone standard repair, and these findings were more common in larger rotator cuff tears. Large portion of patients (25 of 32, 78.1 %) did not have a complete coverage of the footprint of the great tuberosity in our study, and these small-sized residual defects after surgery were not correlated with functional results (n.s.). The limitations of this study should be taken into account. First, this was a retrospective study based on observations of outcomes in a case series of patients who underwent a specific surgery with a small number of patients over a relatively short follow-up period. Further studies that include a greater number of patients and a longer follow-up period are required to verify our findings. Second, all patients underwent ultrasonographic evaluations to check the integrity of repaired rotator cuff tendons.

9 One might argue that this diagnostic modality was likely to show fewer re-tears than MRI. Finally, wide confidence intervals in Table 4 showed that the binary logistic regression analysis was not a secure tool in small, not normally distributed populations. Although this statistical approach yielded relevant results, it might have the decreased statistical power. Conclusions An arthroscopic modified Mason-Allen technique was sufficient to restore the footprint of the rotator cuff in our data. Overall satisfactory results were achieved in most patients, with the exception of those with severe fatty degeneration. An arthroscopic modified Mason-Allen technique could be an effective and reliable alternative for patients with large U- or L-shaped rotator cuff tears. Acknowledgments This study was approved by the IRB committee of Samsung Medical Center. Compliance with ethical standards Conflict of interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. References 1. Arce G, Bak K, Bain G, Calvo E, Ejnisman B, Di Giacomo G et al (2013) Management of disorders of the rotator cuff: proceedings of the ISAKOS upper extremity committee consensus meeting. Arthroscopy 29: Baums MH, Spahn G, Steckel H, Fischer A, Schultz W, Klinger HM (2009) Comparative evaluation of the tendon bone interface contact pressure in different single- versus double-row suture anchor repair techniques. Knee Surg Sports Traumatol Arthrosc 17: Bedi A, Dines J, Warren RF, Dines DM (2010) Massive tears of the rotator cuff. J Bone Joint Surg Am 92: Burkhart SS, Athanasiou KA, Wirth MA (1996) Margin convergence: a method of reducing strain in massive rotator cuff tears. Arthroscopy 12: Burkhart SS, Danaceau SM, Pearce CE Jr (2001) Arthroscopic rotator cuff repair: analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair. Arthroscopy 17: Constant CR, Murley AH (1987) A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res 214: Curtis AS, Burbank KM, Tierney JJ, Scheller AD, Curran AR (2006) The insertional footprint of the rotator cuff: an anatomic study. Arthroscopy 22: Goutallier D, Postel JM, Gleyze P, Leguilloux P, Van Driessche S (2003) Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears. J Shoulder Elbow Surg 12: Harryman DT, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA (1991) Repairs of the rotator cuff: correlation of functional results with integrity of the cuff. J Bone Joint Surg Am 73: Iannotti JP, Deutsch A, Green A, Rudicel S, Christensen J, Marraffino S (2013) Time to failure after rotator cuff repair: a prospective imaging study. J Bone Joint Surg Am 95: Jones CK, Savoie FH III (2003) Arthroscopic repair of large and massive rotator cuff tears. Arthroscopy 19: Lapner PL, Sabri E, Rakhra K, McRae S, Leiter J, Bell K et al (2012) A multicenter randomized controlled trial comparing single-row with double-row fixation in arthroscopic rotator cuff repair. J Bone Joint Surg Am 94: Lee BG, Cho NS, Rhee YG (2012) Modified Mason-Allen suture bridge technique: a new suture bridge technique with improved tissue holding by the modified Mason-Allen stitch. Clin Orthop Surg 4: Mochizuki T, Sugaya H, Uomizu M, Maeda K, Matsuki K et al (2009) Humeral insertion of the supraspinatus and infraspinatus: new anatomical findings regarding the footprint of the rotator cuff surgical technique. J Bone Joint Surg Am 91: Naqvi GA, Jadaan M, Harrington P (2009) Accuracy of ultrasonography and magnetic resonance imaging for detection of full thickness rotator cuff tears. Int J Shoulder Surg 3: Parsons BO, Gruson KI, Chen DD, Harrison AK, Gladstone J, Flatow EL (2010) Does slower rehabilitation after arthroscopic rotator cuff repair lead to long-term stiffness. J Shoulder Elbow Surg 19: Rhee YG, Cho NS, Park CS (2012) Arthroscopic rotator cuff repair using modified Mason-Allen medial row stitch: knotless versus knot-tying suture bridge technique. Am J Sports Med 40: Scheibel MT, Habermeyer P (2003) A modified Mason-Allen technique for rotator cuff repair using suture anchors. Arthroscopy 19: Schmidt CC, Jarrett CD, Brown BT (2014) Management of rotator cuff tears. J Hand Surg Am 40: Thes A, Hardy P, Bak K (2015) Decision-making in massive rotator cuff tear. Knee Surg Sports Traumatol Arthrosc 23:

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