Independent third row augmentation of massive rotator cuff repairs: surgical technique with radiological and patient outcomes.

Background: Primary repair of massive posterosuperior rotator cuff is challenging with a high rate of failure. This study details the technique and outcomes of a standard double-row cuff repair augmented with a synthetic ligament inserted in a separate adjacent location from the tendon-bone construct to off-load and de-tension the repair interface. Methods: Eleven patients with massive rotator cuff tears involving two or more tendons with >2.5 cm of retraction were prospectively enrolled. All patients underwent arthroscopically assisted mini-open double-row repair. This was augmented by a synthetic ligament passed medially through the supraspinatus and infraspinatus musculotendinous junctions before fixation distal to the second-row anchors. This represents a third row of repair that is remote from the double-row construct and aims to minimize repair tension. The primary outcome was repair integrity according to the Sugaya classification on postoperative magnetic resonance imaging. Secondary outcomes included the Constant score, EQ-5D 3L, and Oxford Shoulder Scores. Results: The mean patient age was 65 with 10 males. At a mean follow-up of 13 months, 8 (73%) of the repaired tendons were intact on magnetic resonance imaging. Of the 3 retears, one occurred at the musculotendinous junction. All outcome scores were significantly improved after surgery beyond the minimal clinically important difference. Conclusion: The insertion of an independent third row to off-load a standard rotator cuff repair construct resulted in favorable healing rates in patients with massive cuff tears. The technique is a simple, time-efficient method of de-tensioning the repair of massive rotator cuff tears.