Successful early mobilization of major cuff repair using a suture post Robert N. Atkinson, MBBS, MA, DCH, FRACS(Orth), Andrew S. Comley, MBBS, John Van Essen, MBBS, Peter J. Hallam, FRCS(Orth), Neil Ashwood, FRCS(Orth), and Quentin A. Fogg, BSc(Hons), Adelaide, South Australia Repair of massive rotator cuff tears in the elderly can be challenging because of degenerative, retracted, and contracted tendons producing an extensive defect. The quality of the tendon and particularly the bone of the proximal humerus is an inherent weakness in the repaired construct. We report a method that secures the rotator cuff to a fixation post placed in cortical bone at the surgical neck of the humerus, bypassing the weakest point. This is an evolution of techniques designed to fix to the greater tuberosity. We reviewed 32 repairs (16 men and 14 women; mean age, 68 years) with a minimum of 2 years’ follow-up (mean, 4.3 years). Constant scores improved from a mean of 27.9 preoperatively to 78.2 postoperatively. Pain scores improved from 8.2 to 1.9, with 87% of patients being satisfied with the results of surgery. This is a ro- bust construct that is easily learned and able to solve a technical problem. (J Shoulder Elbow Surg 2006;15: 183-187.) M assive tears have a diameter of greater than 5 cm and account for a third of rotator cuff injuries leading to pain and restricted function. 1,13 In the working age group, tears reduce function, and in the elderly age group, tears cause loss of independence. 9 Acute large or massive rotator cuff tears can result in a sudden loss of shoulder function with disabling pain and are often resistant to nonoperative treatment. 12 More commonly, massive tears can present in an acute-on-chronic fashion with a sudden exacerbation of symptoms in a shoulder that has exhibited preex- isting degeneration and tearing. 15 Open treatment of such tears with fixation of the tendon into a bone trough in the greater tuberosity by transosseous su- tures has been a standard approach with good results in more than 85% of patients. 4 In elderly patients, however, the cuff tissue is edematous, friable, and retracted. The hypertrophied greater tuberosity tends to be osteopenic, leading to an inherent weakness in most repair constructs. Multiple studies evaluating the in vitro strength of the tissues involved in rotator cuff repair have shown the bone-suture interface to be a significant weak link in the construct, with the bone failing at lower tensile loads than the suture. 3,10,12,21 Better methods of soft-tissue fixation to bone have been developed, including suture anchors, but even these have shown variable results. 20 Soft tissues can be fixed with sutures, staples, or screws. 17 Screws with spiked washers or metallic soft-tissue plates have been shown to have superior holding power. 8 In this study, at the time of surgery, all shoulders underwent arthroscopic acromioplasty and evaluation that estab- lished the size of the rotator cuff tear before proceed- ing to open surgery. This confirmed the completeness of the acromioplasty and arthroscopic assessment of the tear. We present the results for a technique that uses a screw (designed for hamstring anterior cruciate re- construction) inserted into the strong metaphyseal bone at the surgical neck of the humerus bypassing the osteoporotic and hypertrophic greater tuberosity. This method provides secure fixation of the rotator cuff, allowing early mobilization. MATERIALS AND METHODS Over a 3-year period, 32 shoulders in 30 patients underwent repair of massive rotator cuff tears via the fixa- tion post technique. The mean age of the patients at the time of surgery was 68 years (range, 47-89 years), and there were 14 women and 16 men. Of the patients, 17 were retired, and 5 of the remaining 13 individuals were still employed in manual jobs. Twenty-five repairs were per- formed in the dominant limb. All patients had a clinically significant rotator cuff tear (minimum diameter of 5 cm) that was noted arthroscopically and confirmed at open repair. Most patients presented after an acute exacerbation of a chronically painful shoulder with limited movement. All had received a minimum of 3 months’ nonoperative manage- ment. Three patients had an acute presentation after trauma to an otherwise normal shoulder proceeding to immediate From Modbury Public Hospital. Reprint requests: Robert N. Atkinson, MA, DCH, FRACS(Orth), 135 Hutt St, Adelaide, South Australia 5000 (E-mail: wattle135@ ozemail.com.au). Copyright © 2006 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2006/$32.00 doi:10.1016/j.jse.2005.06.005 183