Coracoclavicular and acromioclavicular ligament reconstruction with a double-bundle semitendinosus autograft and cortical buttons for chronic acromioclavicular joint dislocations: clinical and imaging outcomes.

BACKGROUND: There are few clinical and radiographic studies of coracoclavicular (CC) ligament reconstruction in chronic acromioclavicular (AC) joint dislocation. Additionally, reported AC joint reduction rates vary. HYPOTHESIS: Arthroscopically assisted double-bundle semitendinosus tendon autografts with CC and AC ligament reconstruction for AC joint reconstruction provide AC joint stability and improved function at the final visit. METHODS: In this retrospective study of prospectively collected data, 21 patients surgically treated for chronic AC joint dislocation (Rockwood III-V) were assessed clinically and radiographically preoperatively, and at day 1, 3 months, 12 months, and at a final visit (>24 months) postoperatively. Clinical assessments included Constant and American Shoulder and Elbow Surgeons scores. The CC vertical distance (CCD) on the affected and unaffected sides [CCD ratio (%)] on the anterosuperior view were measured. AC joint vertical reduction loss was defined as an increase in the CCD ratio of >25%. Horizontal AC joint instability was evaluated on axillary views. Pearsons' correlation coefficients were generated to examine the relationships among postoperative clinical scores, CCD ratio, interval from injury to surgery, and age at the time of surgery. RESULTS: Twenty-one shoulders in 21 patients (mean age, 40.0 years at the time of surgery; 16 men, 5 women) were evaluated with a mean 31.7-month follow-up period. The mean Constant scores, American Shoulder and Elbow Surgeons scores, and CCD ratios significantly improved from preoperatively to the final visit (57.4 ± 10.1, 49.1 ± 12.1, 101.6 ± 64.1 preoperatively; 89.6 ± 5.3, 96.5 ± 4.2, 9.9 ± 34.5 at the final visit, respectively [P < .001 for all]). Vertical AC and horizontal AC joint instability were observed in 4 shoulders (19.0%) and in 1 shoulder (4.8%), respectively. However, there was no significant correlation between the increase in CCD and clinical scores at the final visit (Constant score; r = 0.179, P = .438: American Shoulder and Elbow Surgeons score; r = -0.260, P = .256) or the interval from injury to surgery (r = 0.099, P = .669) or age at the time of surgery (r = 0.019, P = .935). No clinical complications were associated with clinical symptoms. CONCLUSIONS: Patients who underwent the index procedure achieved significant improvement in shoulder function without complications related clinical symptom after a mean follow-up interval of 31.7 months. In contrast, the rates of total ACJ instability in the vertical and horizontal planes were unsatisfactory but compatible with those in previous studies.

Long-term outcomes and duration of outdoor ambulation following primary total knee arthroplasty in patients with rheumatoid arthritis.

BACKGROUND: The medical treatment of rheumatoid arthritis (RA) has made remarkable progress with the introduction of methotrexate and biological agents. However, there have been few reports of long-term results of total knee arthroplasty (TKA) for RA since the introduction of these drugs. Ambulation is an important form of exercise for maintaining health. We investigated the long-term outcomes and the ability to walk outdoors following TKA in patients with RA. METHODS: We retrospectively reviewed 142 patients with RA (201 knees) who had undergone primary TKA. The mean follow-up was 10.6 years. RESULTS: Markers of RA disease activity all improved significantly postoperatively. Mean Japanese Orthopedic Association scores improved from 49.3 points before surgery to 81.8 at follow-up. The mean maximum flexion angle improved from 107.8° to 112.9°. The causes of TKA revision comprised 2 mechanical loosening, 1 late infection, and 1 fracture of the femoral condyle. The survival rate of TKA was 96.6% at 15 years. Fifty-five patients were not able to walk outdoors. The rate of inability to ambulate outdoors was 38.3 per 1000 person-years. The survival rate of ability to ambulate outdoors were 48.8% at 15 years. Preoperative advanced age, low body weight, steroid use and non-use of biologics were identified as risk factors for inability to ambulate outdoors. CONCLUSIONS: Although the cumulative survival rate of TKA implants was as good as 96.6% in 15 years, the cumulative rate of ability to ambulate outdoors was only 48.8%. The reason for the inability to walk outdoors was thought to be mainly due to deterioration of RA, comorbidity or muscular weakness associated with aging, rather than knee dysfunction.

Bone healing potential of fascia lata autografts to the humeral head footprint in rotator cuff reconstruction based on magnetic resonance imaging and histologic evaluations.

BACKGROUND: The purpose of the study was to evaluate the bone healing potential of fascia lata autograft (FLA) by magnetic resonance imaging (MRI) and histologic analysis. METHODS: The study included 69 patients assessed by MRI after an FLA patch procedure. Three of the 69 patients underwent a revision procedure after the primary FLA procedure; 1 underwent a second-look arthroscopy and 2 underwent reverse shoulder arthroplasties (RSAs). In the 2 RSA patients, we histologically evaluated greater tuberosities with the repaired graft. Moreover, as a control, we harvested the greater tuberosity with the cuff tendon at the time of RSA for failed open reduction-internal fixation of 4-part proximal humeral fracture. Based on MRI, retear cases were divided into type 1 (the graft did not remain on the greater tuberosity) and type 2 (the graft remained on the greater tuberosity). Histologic sections were evaluated to examine fascia-bone or rotator cuff-bone interfaces. RESULTS: There were 35 intact repairs: 7 type 1 and 27 type 2 shoulders (type 1 vs. type 2, P < .001). Second-look arthroscopic findings confirmed that the graft was securely attached to the greater tuberosity. Histologic analysis of greater tuberosities in RSA patients showed solid continuity of the graft to the bone, with cells with nuclei in the collagen matrix oriented in parallel. The FLA to bone junction consisted of the FLA, fibrocartilage, and bone, which is similar to the normal cuff tendon to bone junction. CONCLUSIONS: These results indicate that a fresh cellular FLA has good to excellent bone healing potential.

Ankle Structures of Professional Soccer (Football) Players With Proximal Diaphyseal Stress Fractures of the Fifth Metatarsal.

Despite a high incidence of proximal diaphyseal stress fractures of the fifth metatarsal (zone 3) in soccer (football) players, studies that examine risk factors of the fractures in professional soccer players are scarce; in particular, ankle structures have not yet been investigated. This study was designed to investigate ankle structures of professional soccer players with proximal diaphyseal stress fractures of the fifth metatarsal. We reviewed the ankle radiographs of 100 professional soccer players (stress fractures n = 15; controls n = 85) and measured the medial malleolar slip angle (MMSA), the ratio of the medial malleolar length to the width of the talar dome (MML:TD ratio), the ratio of the lateral malleolar length to the width of the TD (LML:TD ratio), and the ratio of the MML to the LML (MML:LML ratio). The MMSA (p < .01: 28.7° ± 5.8° versus 23.0° ± 4.9°) in the stress fractures was significantly wider and the MML:TD ratio (p = .08: 0.49 ± 0.08 versus 0.52 ± 0.07) had a trend to be smaller compared with the values of the controls. Logistic regression analysis revealed that a wider malleolar slip angle became a factor associated with stress fractures in professional soccer players (p < .01: odds ratio 1.27, 95% confidence interval 1.110 to 1.463). Receiver operating characteristic curve with MMSA for the stress fractures was depicted with an area under the curve of 0.778, and the suitable cut-off point was set at MMSA >27° with a positive likelihood ratio of 3.67 (95% confidence interval 2.173 to 6.188). Our study results show that a wide MMSA was associated with proximal diaphyseal stress fractures of the fifth metatarsal in professional soccer players.

Minimum Infliximab Dosage for Keeping Serum Infliximab Levels Greater than 1 µg/mL among Patients with Rheumatoid Arthritis.

Infliximab shows drastic efficacy for controlling inflammation in rheumatoid arthritis (RA), though the ideal dose of infliximab to keep suppressing inflammation has not yet been identified. Recently, it has been evidenced that the minimum trough serum infliximab levels required for suppressing inflammation are greater than 1 µg/mL. This cross-sectional study was designed to identify the minimum dosage of infliximab for maintaining serum infliximab levels greater than 1 µg/mL. Thirty seven RA patients were enrolled in this study and they were divided into two groups (high-infliximab vs. low-infliximab) in reference to Remi-check Q®, a kit for examining serum infliximab levels above/below 1 µg/mL by LC. Infliximab dosage (p=0.06) and dosage interval (p=0.05) had trends to have differences between groups. A formula calculated by infliximab dosage divided by dosage interval and body weight (mg/weeks/kg) was shown to have significantly higher levels among high-infliximab group (p=0.04). Based on whether serum infliximab levels above/below 1 µg/mL and values led by the equation, infliximab dosage/infliximab interval/body weight (mg/weeks/kg), a receiver operating characteristic curve (ROC) was depicted with area under the ROC curve 0.750 and the cut-off point for the serum infliximab levels greater than 1 µg/mL was identified as infliximab dosage/infliximab interval/body weight ≧0.750 with the sensitivity 0.393 and the specificity 1.000. In conclusion, we identified that the minimum infliximab dosage to maintain serum infliximab levels greater than 1 µg/mL was infliximab dose/dosage interval/body weight (mg/weeks/kg)≥0.750.

Arthroscopic surgery of irreparable large or massive rotator cuff tears with low-grade fatty degeneration of the infraspinatus: patch autograft procedure versus partial repair procedure.

PURPOSE: This study aimed to compare the arthroscopic patch graft procedure and partial repair for irreparable large or massive rotator cuff tears (RCTs) in shoulders with low-grade fatty degeneration of the infraspinatus (stage 1 or 2 according to Goutallier et al.) in terms of the functional and structural outcomes. METHODS: This study included 24 patients who underwent the patch graft procedure (group A) and 24 patients who underwent partial repair (group B) for irreparable large or massive RCTs. Clinical outcomes were evaluated at a mean of 35.5 months postoperatively in group A and 35.7 months in group B. RESULTS: The clinical findings were significantly improved at the final follow-up in both groups (P < .001). A significant difference was found between groups A and B in terms of postoperative Constant and American Shoulder and Elbow Surgeons scores (P = .001 and P = .021, respectively). There was a significant difference in the retear rate for the infraspinatus tendon (ISP) between the 2 groups (2 patients [8.3%] in group A v 10 patients [41.7%] in group B, P = .015). At the final follow-up, there was a significant difference in the affected side-versus-unaffected side muscle strength ratios for abduction and external rotation between group A and group B (P < .001 for both). Shoulders with retears of the ISP showed significantly inferior clinical outcomes compared with those without retears (P < .001). CONCLUSIONS: In arthroscopic surgery for irreparable large or massive RCTs with low-grade fatty degeneration of the infraspinatus, the patch graft procedure showed an 8.3% retear rate for the repaired ISP with both improved clinical scores and recovery of muscle strength, whereas the partial repair had a retear rate of 41.7% (P = .015). LEVEL OF EVIDENCE: Level Ш, retrospective comparative study.

Irreparable Large to Massive Rotator Cuff Tears With Low-Grade Fatty Degeneration of the Infraspinatus Tendon: Minimum 7-Year Follow-up of Fascia Autograft Patch Procedure and Partial Repair.

BACKGROUND: In shoulders with irreparable massive rotator cuff tears (RCTs) with high-grade fatty degeneration (Goutallier stage 3 or 4) of the supraspinatus tendon and low-grade fatty degeneration (Goutallier stage 1 or 2) of the infraspinatus tendon (ISP), arthroscopic patch grafting (PG) has been reported as superior to partial repair (PR) regarding the ISP retear rate at short-term to midterm follow-up. However, the longer term outcomes are unclear. PURPOSE: To compare clinical and structural outcomes in the PG and PR groups at a minimum of 7 years postoperatively. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: We evaluated 24 patients in the PG group and 24 patients in the PR group. We primarily used the Constant score for clinical outcomes and performed magnetic resonance imaging for structural outcomes in the PG and PR groups. The risk factors for a retear of the ISP were identified by univariate and multivariate (forward stepwise selection method) logistic regression analyses. We primarily compared values at midterm follow-up (<4 years) with values at the final follow-up (minimum 7 years) for each patient. RESULTS: The mean midterm and final follow-up times for the PG group were 41.0 and 95.1 months, respectively, compared with 35.7 and 99.3 months, respectively, for the PR group. We found significant differences for the midterm and final follow-up Constant total scores in the PG and PR groups (midterm follow-up: 79.1 vs 69.9, respectively [P = .001]; final follow-up: 76.0 vs 65.3, respectively [P = .006]) and in the Constant strength scores (midterm follow-up: 14.6 vs 8.5, respectively [P < .001]; final follow-up: 13.1 vs 8.3, respectively [P = .001]). Treatment group (PR) was a significant predictor of an ISP retear in the logistic regression analysis (odds ratio, 3.545; P = .043). CONCLUSION: Patients with low-grade massive RCTs treated with PG or PR improved significantly in terms of clinical outcomes at the midterm and final follow-up time points. However, Constant scores were significantly better in the PG group at the final follow-up.

Clinical and Radiographic Outcomes After Arthroscopic Lamina-Specific Double-Row Repair of Large Delaminated Rotator Cuff Tears in Active Patients.

BACKGROUND: The presence of delamination and a larger rotator cuff tear (RCT) size have been associated with poorer outcomes in rotator cuff repair. Therefore, we developed a new surgical procedure, arthroscopic lamina-specific double-row fixation (ALSDR), for the repair of large delaminated RCTs. PURPOSE: To investigate the clinical outcomes, magnetic resonance imaging findings, and satisfaction with several variables after ALSDR for large delaminated RCTs. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: A total of 30 active patients (mean age, 59.1 years) undergoing ALSDR were assessed by a numeric rating scale (NRS; 0-10) for pain, surgery, work, and exercise as well as American Shoulder and Elbow Surgeons (ASES), Constant, and Simple Shoulder Test (SST) scores at a mean of 65.9 months postoperatively. Rotator cuff integrity was determined by magnetic resonance imaging. The Spearman correlation coefficient (ρ) was used to determine the correlation between clinical and NRS scores. RESULTS: Five patients (16.7%) had a retear. Each of the postoperative functional and NRS scores except the NRS work score was significantly better in the healed shoulders than in the shoulders with a retear (P < .001). The NRS pain score showed a significant negative correlation with ASES, Constant, and SST scores (ρ = -0.775, -0.668, and -0.742, respectively; P < .001 for all). The NRS surgery score had a positive correlation with Constant and SST scores (ρ = 0.393 [P = .032] and ρ = 0.456 [P = .011], respectively). The NRS work score had a positive correlation with ASES, Constant, and SST scores (ρ = 0.382 [P = .037], ρ = 0.386 [P = .035], and ρ = 0.414 [P = .023], respectively). The NRS exercise score had a positive correlation with ASES, Constant, and SST scores (ρ = 0.567 [P = .001], ρ = 0.511 [P = .004], and ρ = 0.639 [P < .001], respectively). CONCLUSION: Our results showed that there was a significant correlation between clinical and NRS scores. The results indicate that ALSDR can provide a high degree of functionality and can be a useful alternative treatment for active patients with large delaminated RCTs.

Surgical Management with Self-Locking Pins and Circumferential Wiring for Treating Comminuted Patella Fractures Achieved Seiza-Style Sitting.

Surgical fixation of comminuted patella fractures is technically challenging. Despite the fact that tension band wiring or screw fixation are the most common surgical procedures, these surgical techniques have crucial limitations for laterally scattered fragments. We demonstrate two cases with comminuted patella fractures undergoing surgical fixation with self-locking pin and circumferential wiring, confirming the rigid fixation achieving deep knee flexion. After midline longitudinal skin incision, 2.0 mm stainless pins (AiMedic MMT, Tokyo, Japan) were inserted radially to penetrate each fragment and 1.2 mm stainless wire was circumferentially looped and self-locked in the holes on the pins, which satisfied rigid fixation. Any restrictions in range of motion and weight bearing were required postoperatively and 3- to 6-month postoperative cares achieved seiza-style sitting with deep knee flexion.

Serial Radiographs Showing Progression of a Patellar Stress Fracture and Beneficial Surgical Technique for a Displaced Patellar Stress Fracture.

Stress fractures of the patella occurring in athletes are quite rare and only 23 cases have been introduced in English literatures. Stress fractures of the patella are classified into two types: transverse and longitudinal. They are mostly seen in the distal one-third of the patella on a plain lateral radiograph. We present here a 16-year-old female basketball player with a stress fracture of the patella. Her serial radiographs demonstrated progression of the fracture including a lytic cortex lesion, known as the gray cortex sign for early stage stress fractures, in the distal one-third of the patella on plain lateral radiographs. In addition, we introduce a surgical technique using non-absorbable suture ligatures (No.2 Ethibond) for a displaced transverse stress fracture of the patella when the extensor mechanism is intact. The ligatures are passed through into the patella using suture passers and simply tied down over the top of the patella. In our case, it led to neither hardware-related nor circumferential loop-related irritation postoperatively.

Shoelace capsular and external rotators closure techniques in posterior (southern) approach to hip joint.

The possible increased risk of dislocation with a posterior approach for femoral hemiarthroplasty is attributed to disruption of the posterior soft-tissue structures, including the posterior capsular ligament structure and short external rotators of the hip. In this surgical technical note, we demonstrate the surgical technique for shoelace suturing of the external rotators and the capsule with use of ULTRATAPE. After prosthesis stem insertion, shoelace suturing using ULTRATAPE was performed between the great trochanter and the external rotators for preventing the external rotators from tearing. Also, ULTRATAPE was sewed alternately on the split capsule like shoe lacing, and it was laced up from proximal to distal in line with the split as shoelaces tied down. The shoelace suturing technique using ULTRATAPE after a posterior approach to the hip joint, possibly lowers risks of tearing hip capsular ligament and external rotators and stabilizes the posterior wall.

Infliximab equivalently suppresses oxidative stress compared to tocilizumab among well-controlled patients with rheumatoid arthritis.

AIM: This study was designed to investigate which biological agent, infliximab or tocilizumab, would more intensively keep suppressing oxidative stress among well-controlled patients as C-reactive protein (CRP) levels normalized in rheumatoid arthritis (RA). In addition, it was intended to clarify indicative factors of oxidative stress among well-controlled patients with RA. METHODS: We recruited 61 well-controlled (CRP < 0.3 mg/dL within normal ranges) patients with RA using biological agents (infliximab n = 33; tocilizumab n = 28), active RA patients with CRP > 1.0 mg/dL (n = 10) and healthy subjects (n = 10) and examined the fraction of oxidized albumin (oxidized-albumin [%]) as a marker of oxidative stress in addition to inflammatory measures and disease activity scores such as CRP, erythrocyte sedimentation rate (ESR), matrix metalloproteinase 3 (MMP-3), serum amyloid A (SAA), Clinical Disease Activity Index, Simplified Disease Activity Index, visual analog scale (VAS), Disease Activity Index of 28 joints (DAS28)-CRP, DAS28-ESR and renal function (creatinine clearance [CCr]). RESULTS: Oxidized-albumin (%) was significantly elevated among active RA patients (33.83 ± 5.31%) as compared with healthy subjects (23.00 ± 2.56%). Although oxidized-albumin (%) among well-controlled RA patients also increased, there was no difference with oxidized-albumin (%) between infliximab and tocilizumab groups (26.40 ± 5.44% in infliximab; 26.62 ± 4.53% in tocilizumab). In Pearson's correlation, oxidized-albumin (%) had significant correlations with CRP, MMP-3, ESR, SAA, age, CCr, VAS, DAS28-CRP and DAS28-ESR. With those variables, multiple stepwise forward regression analysis was conducted and revealed that CCr, DAS28-ESR and CRP are the statistically significant explanatory variables on oxidized-albumin (%) among well-controlled RA patients. CONCLUSIONS: We demonstrated that there was no difference with infliximab and tocilizumab on oxidative stress and we clarified that CCr, DAS28-ESR and CRP become indicative factors of oxidative stress among well-controlled RA patients.

Anatomic Coracoclavicular Ligament Reconstruction for the Treatment of Acute Acromioclavicular Joint Dislocation: Minimum 10-Year Follow-up.

BACKGROUND: The long-term clinical and radiographic outcomes following coracoclavicular (CC) ligament reconstruction for the operative treatment of acute acromioclavicular (AC) joint dislocation remain uncertain. The purpose of the present study was to determine the long-term clinical and radiographic outcomes of CC ligament reconstruction and to identify risk factors for unfavorable outcomes. METHODS: We reviewed 20 cases of AC joint dislocation in 19 patients (18 male and 1 female; mean age, 32.3 years) that were treated with single-bundle reconstruction. The mean duration of follow-up was 12.7 years. We measured the CC vertical distance (CCD) on the anteroposterior view and compared the affected and unaffected sides (CCD ratio). We divided the patients into those with a CCD ratio of <25% (Group 1) and those with a CCD ratio of ≥25% (Group 2). We radiographically investigated the clavicular tunnel anteroposterior (CTAP) angle, clavicular tunnel ratio, and coracoid tunnel orientation on the basis of the entry and exit points at the base of the coracoid. For the coracoid tunnel orientation, we compared center-center orientation and noncenter-center orientation. RESULTS: Group 1 comprised 17 cases (85%), and Group 2 comprised 3 cases (15%). At the time of the latest follow-up, Group 1 had a significantly higher mean Constant score than Group 2 (98.2 compared with 90.7; p = 0.038). Of the 3 radiographic parameters, only the CTAP angle was significantly different between the 2 groups (p < 0.0001). Two (67%) of the 3 cases in Group 2 were associated with posterior AC joint displacement. CONCLUSIONS: CC ligament reconstruction for the treatment of acute AC joint dislocation resulted in successful long-term clinical and radiographic outcomes. It is important to decrease the CTAP angle and to ensure proper anatomic placement of the clavicular and coracoid tunnels at the time of surgery. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Effect of Fatty degeneration of the infraspinatus on the efficacy of arthroscopic patch autograft procedure for large to massive rotator cuff tears.

BACKGROUND: In a 2013 study involving 24 patients whose shoulders had large or massive rotator cuff tears (RCTs) and low-grade fatty degeneration of the infraspinatus (Goutallier stage 1 or 2), we reported significantly improved clinical results after an arthroscopic fascia lata autograft patch procedure, with a 79.2% rate of intact repairs. Based on that study, we began applying the fascia lata autograft patch procedure to shoulders with stage 3 or 4 degeneration of the supraspinatus and stage 3 or 4 degeneration of the infraspinatus. PURPOSE: To investigate the effects of the fascia lata autograft patch procedure on massive RCTs in shoulders with high-grade degeneration of the infraspinatus by comparing the clinical outcomes and structural features with those in shoulders with low-grade degeneration of the infraspinatus. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A case series of 45 consecutive patients with large to massive RCTs with high-grade fatty degeneration of the supraspinatus and either low-grade (group L; n=26 [the same patients as in our previous study plus 2 additional patients]) or high-grade (group H; n=19) fatty degeneration of the infraspinatus were treated with the fascia lata autograft patch procedure. Clinical (Constant and American Shoulder and Elbow Surgeons [ASES]) scores, structural outcomes on MRI, and muscle strength were assessed at a minimum 2-year follow-up and compared between the 2 groups. RESULTS: Patients in group L had a higher frequency of intact repairs than did those in group H (73.1% vs 10.6%; P<.001), as assessed by MRI. Clinical scores, range of motion, and muscle strength ratios were improved after surgery in both groups. However, at the final follow-up, the mean Constant (78.4 in group L vs 63.9 in group H; P<.0001) and ASES (91.3 in group L vs 73.6 in group H; P<.001) scores were significantly higher in group L than in group H. Moreover, there were significant between-group differences in the mean muscle strength ratio of the affected to healthy sides for both abduction (0.68 in group L vs 0.54 in group H) and external rotation (0.67 in group L vs 0.50 in group H) for abduction at the final follow-up (P<.0001 for both). CONCLUSION: The arthroscopic fascia lata autograft patch procedure was not as beneficial for massive RCTs with high-grade fatty degeneration of the supraspinatus and infraspinatus as other treatment options that produce similar functional results.

Arthroscopic lamina-specific double-row fixation for large delaminated rotator cuff tears.

Delamination is a commonly observed finding at the time of rotator cuff repair, but few studies have described the surgical techniques used for delaminated rotator cuff tears (RCTs) or their clinical outcomes. We developed a technique using a combination of a double row and an additional row, which we call lamina-specific double-row fixation, for large delaminated RCTs. The lamina-specific double-row technique is performed using an additional row (lamina-specific lateral row) of suture anchors placed between the typical medial and lateral rows of suture anchors. The technique is performed as follows: (1) medial-row sutures are passed through the inferior (articular-side) and superior (bursal-side) layers in a mattress fashion; (2) lamina-specific lateral-row simple sutures are passed through the inferior layer; and (3) lateral-row simple sutures are passed through the superior layer. We believe that this technique offers the following advantages: (1) creation of a larger area of contact between the inferior layer and the footprint, (2) higher initial fixation strength of the articular-side components of the repaired rotator cuff tendon, and (3) an adaptation between the superficial and inferior layers. This technique represents an alternative option in the operative treatment of large delaminated RCTs.