{"paper_id":"09016f07-c74b-4259-b657-9ce6c0c1fdb0","body_text":"Combined Autogenous Fascia Lata Graft Bridging with Biceps Transposition Versus Partial Repair for Massive Rotator Cuff Tears: A Retrospective Comparative Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Combined Autogenous Fascia Lata Graft Bridging with Biceps Transposition Versus Partial Repair for Massive Rotator Cuff Tears: A Retrospective Comparative Study Shaohua Zhang, Qingsong Zhang, Yushun Fang, Ming Tang, Yanan Li, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8464962/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background : Graft bridging (GB) and superior capsular reconstruction (SCR) are utilized to treat massive rotator cuff tears (MRCTs), however they all have reported mixed results. In this study, we explore to combine the GB and SCR in one surgery. The aim of this study was to compare the effectiveness of surgeries that combing GB and SCR (in which autogenous fascia lata is used as the graft for GB while the long head of the biceps tendon [LHBT] is transposed for SCR) with partial repair in the treatment of MRCTs. Methods : This retrospective comparative study evaluated two surgical treatments for MRCTs (> 5 cm, ≥ 2 tendons involved, Hamada grade 1–3): partial repair (the partial repair group) versus autogenous fascia lata graft bridging combined with LHBT transposition (the combined surgery group). Patients were enrolled between January 2016 and June 2023. The clinical outcomes included active range of motion (forward flexion, external rotation, internal rotation) and the American Shoulder and Elbow Surgeons (ASES) score and the Constant Murley Score (CMS) assessed before surgery and at the final follow-up (> 2 years). Radiographic assessments were used to determine the acromiohumeral interval(AHI) and graft integrity at before surgery and at the final follow-up. Results : The study enrolled 53 patients with MRCTs, of whom 24 underwent partial repair and 29 received autogenous fascia lata graft bridging with LHBT transposition. Both groups demonstrated significantly improved ASES and CMS scores at the final follow-up (> 2 years), with superior outcomes in the combined surgery group (ASES: 88.6 vs. 84.0, P = 0.014; CMS: 83.4 vs. 77.4, P < 0.001). While both groups showed comparable improvements in the range of motion (both P < 0.001), the combined surgery group exhibited significantly greater restoration of AHI (7.4 mm vs. 5.4 mm, P < 0.001). MRI assessment revealed significantly lower retear rates (6.9% vs. 37.5%, P = 0.015) in the combined surgery group. Conclusion : This study suggests that autogenous fascia lata graft bridging combined with biceps transposition is associated with better ASES and CMS scores, increased acromiohumeral distance, and lower retear rates compared with partial repair alone at two-year follow-up. massive rotator cuff tears graft bridging the long head of the biceps tendon transposition partial repair Figures Figure 1 Figure 2 Figure 3 Figure 4 Background Rotator cuff tears usually cause shoulder disability and pain, especially among the elderly[ 1 , 2 ]. Massive rotator cuff tears (MRCTs) are defined as defects measuring >5 cm[ 3 ] and may have two or more torn tendons [ 4 ] ;these account for approximately 20% of all rotator cuff tears and 80% of recurrent tears[ 5 , 6 ]. Although optimal outcomes can be achieved with complete anatomical repair and healing of the torn tendon, this approach is not universally applicable. Surgical repair can be limited by massive retracted tears with poor tissue quality[ 7 ], significant muscle atrophy, and fatty infiltration[ 8 ]. In these situations, the rotator cuff cannot be reattached to the footprint even after mobilizing and interval releasing procedures, or barely reached at high tension. Partial repairs that attempt to recreate the rotator cable to restore the function of the rotator cuff in a construct that resembles a suspension bridge have been proposed[ 9 , 10 ]. Studies have shown that partial repairs can lead to significant improvements in both shoulder function and pain relief[ 11 ], making them a viable treatment option for patients with massive tears. However, these repairs are associated with a high incidence of structural failure[ 12 ] and outcomes may deteriorate over time[ 13 , 14 ]. In an effort to enhance the healing rate, graft interposition has been introduced to manage MRCTs. In superior capsule reconstruction (SCR), the graft is interposed between the humeral head and the superior tubercle of the glenoid to restore a stable fulcrum and provide a static restraint against upward migration of the superior humeral head. In graft bridging (GB), the graft connects the greater tuberosity and the rotator cuff remnant, providing a dynamic anatomical reconstruction of the rotator cuff. Both procedures have demonstrated improved postoperative functional outcomes[ 15 – 19 ], despite some limitations. Normal shoulder mobility necessitates the coordinated functions of dynamic and static stabilizers [ 20 , 21 ]. These structures are connected histologically [ 22 ]. Rotator cuff tears disrupt both these stabilizers, as seen in superior capsular defects in MRCTs [ 23 ]. Thus, rotator cuff repair should ideally address both the rotator cuff and the superior capsule. However, few studies have combined these two techniques[ 24 ] and compared the outcome of the combination with that of partial repair. The aim of this study was to compare the effectiveness of combined GB and SCR surgery (in which an autogenous fascia lata is used as the graft for GB, while the long head of the biceps tendon [LHBT] is transposed for SCR) with that of partial repair, and we hypothesized that the combined surgery would result in superior healing rates and functional outcomes. Methods Patient selection Data on patients who had been treated for MRCTs were obtained from the medical records. The partial repair group included patients who had been treated between January 2016 and December 2017, while the combined surgery group comprised those who had undergone GB plus LHBT transposition between January 2018 and June 2023. This study was approved by the local ethics committee, and informed consent was obtained from all participants. The inclusion criteria were: (1) failure of nonoperative treatment to improve patient satisfaction after three months; (2) MRCTs: the dimension > 5 cm and two or more tendons fully torn, radiographic Hamada classification rotator cuff 1–3,the supraspinatus was not able to be pulled to cover the footprint after tendon liberation procedures (3) the infraspinatus and subscapularis tendon tears were partially or fully reparable (4) for the patients underwent GB plus LHBT:no excessive tendinitis or partial tears occurred in LHBT (partial tear involving less than 1/3 of the tendon width at the intra-articular region). The exclusion criteria were: (1) patients who were lost to follow-up within two years; (2) those who underwent revision surgery. Patient assessment The patients provided standard demographic and clinical history and were physically examined by the same surgeon before surgery and at the final follow-up (≥ 2 years). The active range of motion (AROM), including forward flexion, external rotation with the arm at the side, and internal rotation, was measured. Internal rotation was defined as the highest vertebral body that the patient could reach with the thumb on the affected side. The vertebral levels were numbered serially from below the sacrum (level 0) to the 7th thoracic vertebra (level 12)[ 25 ]. The American Shoulder and Elbow Surgeons (ASES) score and the Constant Murley Score (CMS) were assessed both before surgery and at the final follow-up. Radiography and magnetic resonance imaging The Hamada classification[ 26 ] and the acromiohumeral interval (AHI)[ 27 ] were determined based on an anterior-posterior radiograph of the glenohumeral joint. Magnetic resonance imaging (MRI) was employed to evaluate the tear size before surgery, with tear sizes based on the Patte Grades[ 28 ]. MRI examinations were also conducted at the final follow-up to determine the status of the graft, assessed according to the Sugaya grade[ 29 ]. Type I, II, and III grades represented healing of the repaired tendon, while types IV and V were regarded as retears. All radiographic and MRI assessments were performed by a single experienced shoulder surgeon using standardized criteria. Surgical technique The GB plus LHBT transposition procedure (the combined surgery group) The patients were placed in the lateral decubitus position under general anesthesia. Four routine arthroscopic portals (anterior, posterior, lateral, and posterolateral) were used for the procedure. A posterior portal was established for an initial assessment of the glenohumeral joint. The rotator cuff tear was evaluated, and the condition of the biceps tendon was confirmed from the articular side. The arthroscope was then withdrawn and redirected into the subacromial space, where subacromial decompression was performed in cases where impingement was observed. Decortication of the greater tuberosity was performed to provide a fresh bleeding bone bed for the repair. The biceps tendon was mobilized and transposed to the superior aspect of the humeral head. The subscapularis and infraspinatus tendons were repaired or partially repaired. The arthroscope was then transferred to the posterolateral portal to measure the tear. A grasper was introduced through the lateral portal, and the morphology of the tear and the degree of mobility were assessed while viewing from the posterolateral portal. A suitable rectangular fascia lata graft was harvested at the site of the greater trochanter, based on the size of the cuff tear. The anterior-posterior dimension of the graft was required to be 4 mm wider than the cuff deficit (W), while the medial-lateral dimension of the graft needed to be 6 mm wider than L1×2 (Fig. 1 ). A patch was fashioned by folding the fascia lata graft in half, and the free ends of the graft were sutured to prevent it unfurling. The suture placement sites on the patch were marked (4 located medially for the medial side of the cuff defect, 2 for fixation to the tissue from the coracohumeral ligament, rotator interval, 2 for posterior fixation to the infraspinatus tendon, and 2 for lateral fixation to the greater tuberosity). A road map was created to provide orientation by drawing the patch and the color-coded sutures (Fig. 1 ). Based on the map, 10 sutures were then passed through the patch at their respective sites (1 to 10), and short-tailed interference knots were tied over a switching stick for patch passage and eventual fixation[ 30 ]. The anterior side of the cuff defect was stitched using PDS-II sutures, which act as traction sutures. The anterior suture limbs of the patch were brought through the lateral portal via the traction sutures. This procedure was repeated for both the posterior and medial sides of the cuff defect. Two anchors were inserted at the articular margin, and the sutures of the anchors were passed through the patch at sites 11 and 12. The patch was routed into the joint by maintaining an even tension on the medial sutures, followed by flattening using anterior and posterior suture tensioning. The anterior, posterior, and medial sutures were then tied, securing the patch to the rotator cuff defect. The lateral suture limbs of the patch and the suture limbs from the two anchors at the articular margin were crisscrossed and secured laterally to two lateral knotless anchors using a double-row suture bridge technique (Fig. 2 ). Lastly, the wound was sutured after hemostasis. Partial repair procedure (partial repair group) The surgical approach and management of concomitant injuries were identical to those used for the patch group. After assessment of the supraspinatus defect and retraction, single-row repair was performed after adequate mobilization and interval release procedures (Fig. 3 ). The biceps tendon was left intact if it appeared in good condition, but a biceps tenotomy was performed if excessive tendonitis or partial tears were observed. The surgeries in both groups were conducted by the same surgical team led by ZQS. G, glenoid; H, humeral head; SSP, supraspinatus tendon; ISP, infraspinatus tendon; SSC, subscapularis tendon; LHBT: long head of the biceps tendon. G, glenoid; H, humeral head; SSP, supraspinatus tendon; ISP, infraspinatus tendon; LHBT: long head of the biceps tendon Postoperative protocol Postoperative protocol Both patient cohorts followed an identical standardized rehabilitation protocol. The arm was supported for six weeks at 60 ° of abduction and 15 ° of external rotation in a sling with a small abduction pillow. Elbow, wrist, and hand exercises, as well as scapula shrugs, were begun immediately after surgery. Passive- and active-assisted exercises were initiated after the immobilization period. The patients began to perform exercises to strengthen the rotator cuff and scapular stabilizers eight weeks after surgery. Full activity was allowed by six months after surgery, when patients had sufficient range of motion and muscle strength. Statistical analysis All statistical analyses were conducted using SPSS software version 23.0 (IBM Corp., Armonk, NY, USA). Continuous variables are expressed as mean ± standard deviation (SD), and categorical variables are reported as frequencies and percentages. Intragroup comparisons of preoperative and postoperative values, including the ASES score, CMS score, AROM, and AHI, were performed using paired t-tests. Intergroup comparisons of continuous variables were conducted using independent-samples t-tests. Categorical variables, such as smoking status, tear size classification, and the rotator cuff healing rate, were compared using Pearson’s chi-square or Fisher's exact tests. Non-parametric variables, including the fatty infiltration grade of the supraspinatus and Hamada classification, were analyzed using the Kruskal-Wallis test. P-values < 0.05 were considered statistically significant. Results Patient characteristics A total of 53 patients with MRCTs were enrolled. Of these, 24 were treated using partial repair (January 2016 and December 2017) and 29 with autogenous fascia lata graft bridging plus LHBT transposition (January 2018 to June 2023). The preoperative characteristics of the two groups are shown in Table 1 . There were no significant differences between the groups in terms of age, sex, symptom duration, follow-up duration, smoking, tear size, fatty degeneration of the supraspinatus, or Hamada grade (P>0.05). Table 1 Patient characteristics Variable Partial repair (n = 24) Bridging repair (n = 29) P Value (a = 0.05) Age, y 61.8±6.8 62.8±5.1 0.534 Sex (male/female,n) 0.942 male 13 16 female 11 13 Symptom duration, mo 20.6±7.6 17.7±10.1 0.247 Follow-up duration, mo 30.4±5.3 31.3±6.7 0.612 Smoking (n) 0.817 Yes 14 15 No 10 14 Tear size 0.669 Patte I 0 0 Patte II 11 15 Patte III 13 14 Fatty degeneration of supraspinatus 0.926 Goutallier I 2 2 Goutallier II 8 19 Goutallier III 4 7 Goutallier IV 0 1 Hamada grade 0.591 I 6 9 II 14 15 III 5 5 Clinical outcomes The clinical outcomes are summarized in Table 2 . No significant differences in the mean ASES and CMS scores were observed between the two groups before surgery(P>0.05). At the final follow-up, although the scores had improved significantly in both groups (P<0.001), the ASES score was significantly better in the combined surgery group than in the partial repair group (88.6 vs. 84.0, P = 0.014), as was the mean CMS score (83.4 vs. 77.4, P<0.001). The AROM values, including forward flexion, external rotation with the arm at the side, and internal rotation, were similar between the groups at baseline. Postoperatively, these measures had improved markedly (P <0.001); however, no significant difference was found between the two groups (P>0.05). Table 2 Clinical outcomes Variable Preoperative Final follow up P ASES Partial repair 46.8±6.4 84.0±7.2 <0.001 Bridging repair 45.9±6.0 88.6±5.0 <0.001 P 0.618 0.014 CMS Partial repair 43.3±5.5 77.4±6.3 <0.001 Bridging repair 42.7±5.7 83.4±4.2 <0.001 P 0.682 <0.001 FE Partial repair 105.2±20.6 161.9±8.0 <0.001 Bridging repair 103.1±20.0 165.8±7.1 <0.001 P 0.708 0.069 ER Partial repair 31.6±6.9 47.4±7.1 <0.001 Bridging repair 33.4±8.7 49.2±7.5 <0.001 P 0.408 0.370 IR Partial repair 4.3±1.4 6.7±1.3 <0.001 Briding repair 4.0±1.6 6.5±1.4 <0.001 P 0.603 0.546 ASES, active range of motion and American Shoulder and Elbow Surgeons; CMS, Constant-Murley score; FE, forward elevation; ER, external rotation with the arm at the side ;IR, internal rotation behind the back. For internal rotation at the back (IR), values were converted into contiguously numbered groups: below the sacrum to 0, sacrum to 1, L5-L1 to 2–6, T12-T7 to 7–12 Values are presented as mean±SD Radiological evaluation The radiological evaluation results are shown in Table 3 . In the partial repair group, the AHI was increased, although the increase did not reach statistical significance (5.1 mm vs. 5.4 mm, P = 0.297). However, in the combined surgery group, the AHI improved significantly from a preoperative mean of 4.7 mm to 7.4 mm at the final follow-up (P < 0.001). The retear rate was assessed by MRI at the final follow-up (Table 4 ). This showed that in the partial repair group, the rotator cuff was healed in 15 patients (62.5%), while 9 showed retear (37.5%). Of those with retear, 4 had partial retear and 5 had complete retear. In the combined surgery group(Fig. 4 ), 27 patients had a healed rotator cuff ( 93.1%), with only 2 patients showing retear (6.9%); of these 1 had a partial retear and 1 had a complete retear. The retear rate of repaired rotator cuff was thus significantly lower in the combined surgery group (6.9%) compared with the partial repair group (37.5%) (P = 0.015). Notably, there was no incidence of wound infection, nerve injury, or other major surgical complications in either group. Table 3 Radiologic Evaluation by X rays Variable Preoperative Final follow up P AHI,mm Partial repair 5.1±1.0 5.4±1.1 0.297 Bridging repair 4.7±1.3 7.4±1.3 <0.001 P 0.248 <0.001 AHI, the acromiohumeral interval Values are presented as mean±SD Table 4 Radiologic Evaluation by MRI Variable Healed retear p Partial repair (n = 24),n% 15(62.5%) 9(37.5%) 0.015 Bridging repair (n = 29),n% 27(93.1%) 2(6.9%) Values are presented as mean±SD Discussion This study evaluated the effectiveness of surgery involving both autogenous fascia lata graft bridging and LHBT transposition for repairing MRCTs, with a minimum follow-up of two years. Compared with the partial repair, the combined surgical approach was associated with more favorable short- to mid-term clinical and structural outcomes, including improved ASES scores, CMS scores, AHI, and rotator cuff healing rates. MRCTs present a significant challenge for orthopedic surgeons due to their complexity and the limited success of traditional repair methods. To date, numerous surgical strategies have been used to manage MRCTs, including debridement, partial repair,GB, SCR, reverse shoulder arthroplasty, and tendon transfer. Partial repair has long been regarded as a primary treatment option for MRCTs, particularly in cases where complete repair is not feasible due to tendon retraction and poor tissue quality. Many studies have reported on the outcomes of partial repair of MRCTs. A study comparing partial versus complete arthroscopic repair found that partial repair yielded outcomes comparable to complete repair, with significant improvements in functional scores, such as the University of California, Los Angeles (UCLA) shoulder scores[ 31 ]. A further study focused on the clinical outcomes of arthroscopic partial repair with medialization of the attachment site of the rotator cuff tendon, finding significant improvements in clinical outcomes, even in cases where complete healing was not achieved, highlighting the potential of partial repair as a viable treatment option[ 32 ]. However, the structural integrity of partial repairs is significantly compromised by the high-tension environment at the tendon-anchor interface, which contributes to high retear rates[ 33 ]. A systematic review of 170 shoulders reported 77 cases of retear, corresponding to a failure rate of close to 45%[ 34 ]. Similarly, in the present study, while the partial repair group showed significant postoperative functional improvement, the retear rate was high, at 37.5%. To address the challenge of the high-tension environment in healing after rotator cuff repair and improve the healing rates, graft interposition represents a viable treatment option. This approach involves three primary techniques[ 18 ]: augmentation, SCR, and GB. Augmentation entails the positioning of a graft over the repaired tendon to boost its biomechanical strength and stability. The SCR approach involves the use of a graft to reconnect the greater tuberosity with the superior glenoid. Introduced by Mihata et al. in 2013,[ 17 ] SCR has demonstrated its effectiveness in the restoration of glenohumeral stability and function in MRCT cases. This effectiveness results from its ability to counteract migration of the proximal humerus, ultimately optimizing the force couples around the shoulder indirectly[ 23 , 35 ]. Despite persistent defects in the rotator cuff tendon, SCR has demonstrated favorable short-term clinical outcomes. Previous studies have reported reduced pain and increased function following SCR using fascia lata [ 36 ] or dermal allografts [ 16 ] within two years of surgery. However, it is important to note that while SCR reconstructs a portion of the static stabilizers, it does not address the repair of cuff tears. These cuff are considered dynamic stabilizers and play a crucial role in shoulder strength and range of motion[ 37 ]. Howell et al.[ 38 ] reported that the rotator cuff contributes approximately 50% of the overall muscle strength of the shoulder in terms of abduction and flexion. A further study [ 39 ] observed that after a mean follow-up of 63.2 ± 5.9 months, there was no improvement in muscle strength following SCR using a fascia lata autograft. A biomechanical cadaveric study by Mihata et al.[ 23 ] revealed that the total rotational range of motion at 0°, 45°, and 90° of shoulder abduction following SCR was lower compared with the intact condition. So some authors advocate for GB due to its ability to anatomically repair the tendon-bone interface[ 40 ]. The graft is secured medially to the torn stump of the rotator cuff and laterally to the greater tuberosity. Compared to SCR, GB provides a closer approximation of the natural anatomy of the rotator cuff and musculotendinous unit, and an animal study have demonstrated the remarkable ability of fascia lata autografts to undergo remodeling into tissues that structurally resemble normal tendons[ 41 ]. This This approach may help restore the dynamic functionality of the rotator cuff and directly re-establish the force couples around the glenohumeral joint. Clinical studies have demonstrated the efficacy of GB[ 18 , 42 ]. A recent study by Modi et al. [ 40 ] reported promising medium-term outcomes using a human dermal allograft for the reconstruction of an irreparable MRCT. However, despite these encouraging results, several unanswered questions remain regarding the use of GB. For instance, although the repaired rotator cuff can also reduce the superior translation of the humeral head, its strength is less than that of the intact rotator cuff and after SCR[ 23 ]. Hence, the graft may be vulnerable to abrasion and tearing caused by subacromial impingement, primarily due to poor stability[ 43 ]. This vulnerability has led to a high incidence of retears following GB procedures[ 44 , 45 ]. To address the complex biomechanical deficits associated with massive rotator cuff tears, a combined approach incorporating both graft bridging (GB) and superior capsular reconstruction (SCR) may be considered. This combination aims to restore both static and dynamic stability of the shoulder joint, along with proper force balance.Accordingly, in the present study, a combined SCR and GB technique was employed to evaluate its clinical and structural outcomes in the treatment of MRCTs. Graft options for rotator cuff repair include autografts and allografts. Autologous options, such as the LHBT [ 46 ] and fascia lata, [ 18 ] offer advantages including cost-effectiveness and superior histocompatibility, compared to allografts [ 40 ] or synthetic materials [ 47 ]. These autografts can be utilized in most healthcare settings. In the present study, we chose the LHBT for SCR and the autogenous fascia lata for GB. The use of the LHBT autograft is a technically feasible, cost- and time-saving alternative for SCR. Although the LHBT is not as wide as the fascia lata or dermal grafts used in other SCR techniques, a previous cadaveric biomechanical study[ 48 ] showed that SCR using LHBT results in equivalent, or even greater, strength compared with SCR using a fascia lata autograft in terms of preventing migration of the superior humerus. As the proximal portion of the LHBT remains attached to the superior glenoid, preservation of its vascularization is likely. Consequently, the LHBT graft may exhibit superior healing potential compared to other graft options. Finally, the LHBT in SCR occupies a small part of the footprint with only an anchor, allowing sufficient space for the following GB operation. In the current study, the combined surgery group showed significantly better outcomes, with lower retear rates (6.9%) compared to the partial repair group (37.5%). It has been reported[ 15 , 49 ] that successful functional outcomes are contingent upon successful graft healing. The ASES and CMS scores were significantly higher in the combined surgery group than in the partial repair group at the two-year follow-up. We speculate that there are several possible reasons for this. First, successful healing of rotator cuff repairs depends upon a biologically favorable healing environment, and excessive tension at the repair site may adversely affect healing outcomes[ 50 ]. Despite the use of techniques such as anchor medialization, marginal convergence, and interval slides, partial repair inevitably results in increased tension at the bone-anchor interface. This elevated tension may partly explain the higher failure rate observed in our study[ 33 ]. In contrast, the bridging technique utilizes a graft to link the native tendon to the humeral footprint. This approach enables a more even distribution of forces across the tuberosity and rotator cuff edges, reducing localized stress and promoting healing. Numerous studies comparing the use of bridging techniques with partial repair for treating MRCTs have reported similar findings[ 10 , 18 , 51 ]. One study[ 18 ] compared the mini-open interposition procedure using a fascia lata autograft with an arthroscopic partial repair technique, showing that the graft group had better UCLA, ASES, and CMS scores, as well as lower retear rates (15% vs. 45.5%) at the two-year follow-up. Second, we performed autologous LHBT transfer together with GB, which may have further reduced the retear rate. A meta-analysis revealed that SCR using LHBT significantly reduced the retear rate and improved the ROM and AHI compared to conventional rotator cuff repair, highlighting its effectiveness in managing large to massive rotator cuff tears[ 52 ]. In a similar study[ 24 ], MRCTs were treated using autologous fascia lata bridging repair (GB) combined with synthetic artificial augmentation for SCR. The patients were divided into two groups, finding that the combined surgery group (bridging + SCR) had better mean AHI (7.0 mm vs. 5.9 mm ), mean improvement in AHI (3.3 mm vs. 2.0 mm), and autograft healing rate (92.3% vs. 54.2%) than the control group (bridging only) after a two-year follow-up. The retear rate of 7.7% reported by the authors is comparable to the 6.9% rate observed in this study, suggesting the potential benefits of SCR augmentation in reducing the failure of bridging repairs. The transposed LHBT may help share the initial tensile load and provide resistance against superior humeral head migration, which could contribute to improved graft protection.Our final follow-up data also demonstrated significantly improved AHI values in the combined surgery cohort compared to those who received partial repair (7.4 vs 5.4, p<0.001), indicating superior anatomical restoration of the glenohumeral joint. This outcome likely reflects two synergistic mechanisms: (1) a depressor effect induced by the transposition of the LHBT, and (2) the spacer effect of the fascia lata autograft, which maintained critical subacromial dimensions while permitting biological incorporation. Many investigations have reported the greater suitability of GB for treating rotator cuff tears with lower fatty degeneration (Goutallier stage 1 or 2 fatty degeneration)[ 45 , 53 , 54 ]. A study by Mori et al.[ 54 ] showed that in the high-grade fatty degeneration group (Goutallier stage 3 or 4 fatty degeneration of the infraspinatus), the retear rate reached 89.4%. In contrast, in our combined surgery group, 8 patients with high-grade fatty degeneration of the supraspinatus (7 patients belonged to Goutallier stage 3 and 1 patient belonged to stage 4) and only 2 of them(25%) experienced retear at ≥ 2 years. We postulate that SCR with LHBT transposition improved the stability of the shoulder and promoted healing of the graft and rotator cuff even in patients with high-grade fatty degeneration. These findings suggest that the combined technique may remain effective in a subset of patients with advanced fatty degeneration; however, this observation should be interpreted with caution and requires confirmation in larger studies. Limitations This study has several limitations. First, the applicability of the combined procedure depends on the integrity of the LHBT. In many patients with MRCTs, the LHBT may be ruptured or severely degenerated, rendering it unsuitable for transposition. In addition, anatomical variations or absence of the LHBT have been reported in rare cases[ 55 ]. Therefore, careful preoperative MRI evaluation and intraoperative assessment of the LHBT are essential for appropriate patient selection. Although McClatchy et al[ 56 ]. reported favorable clinical outcomes following biceps tendon transfer regardless of tendon condition, further studies are required to clarify the optimal indications for this procedure.Second, although the combined procedure was compared with partial repair in the present study, comparisons with isolated GB or SCR procedures were not performed. This limitation was mainly due to the limited sample size and study design. With the accumulation of larger cohorts in the future, well-designed comparative studies with multiple treatment arms will be necessary to further determine the independent and additive effects of GB and SCR Third, the two surgical strategies were performed in different time periods, which may introduce temporal and learning-curve-related bias,although all procedures were performed by the same senior surgeon using standardized protocols.Fourth, the relatively small sample size in each group limited the ability to perform a formal power analysis.Fifth, the follow-up duration was mid-term, and longer-term studies are necessary to evaluate the durability of the clinical and structural outcomes of this combined technique. Conclusions Both autogenous fascia lata graft bridging with LHBT transposition and partial repair were effective in the treatment of MRCTs at two-year follow-up. However, the combined surgical approach was associated with better ASES and CMS scores, increased acromiohumeral distance, and lower retear rates compared with partial repair alone. Therefore, this combined technique may represent a viable surgical option for selected patients with massive rotator cuff tears. Abbreviations AHI Acromiohumeral interval AROM Active range of motion ASES American Shoulder and Elbow Surgeons score CMS Constant Murley Score GB Graft bridging LHBT Long head of the biceps tendon MRCTs Massive rotator cuff tears SCR Superior capsular reconstruction UCLA University of California, Los Angeles shoulder scores Declarations Ethics approval and consent to participate：This study was approved by the Institutional Ethical Committee of wuhan Fourth Hospital (KY2021-064-01). Due to the retrospective nature of the study, the requirement for informed consent was waived by the Ethics Committee. All procedures involving human participants were conducted in accordance with the Declaration of Helsinki. Consent for publication：Not applicable Availability of data and materials:The datasets generated and analyzed during the current study are not publicly available due to restrictions imposed by the hospital Ethics Committee to protect patient privacy. De-identified data may be made available from the corresponding author upon reasonable request, subject to approval by the ethics committee. Competing Interests: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article. Funding: This study received no external funding. Authors' contributions: Shaohua zhang: Designed ; Wrote the original draft ; Conducted statistical analysis. Qingsong zhang: Supervised the project ; Revised the manuscript ; Performed all arthroscopic procedures. Yushun Fang: Collected data , Managed the database ; Revised the manuscript Ming Tang: Conducted statistical analysis Yanan Li: Collected data Jun Xiong: Collected data Zhujun Wang: Collected data Tao Li: Collected data All authors read and approved the final manuscript. Acknowledgements: The authors would like to thank all the staff involved in patient care and data collection. References Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. 2006;88(8):1699–704. Tashjian RZ. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clin Sports Med. 2012;31(4):589–604. Cofield RH. Subscapular muscle transposition for repair of chronic rotator cuff tears. Surg Gynecol Obstet. 1982;154(5):667–72. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82(4):505–15. Burkhart SS, Danaceau SM, Pearce CE. Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2001;17(9):905–12. Lo IK, Burkhart SS. Arthroscopic revision of failed rotator cuff repairs: technique and results. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2004;20(3):250–67. Tashjian RZ, Erickson GA, Robins RJ, Zhang Y, Burks RT, Greis PE. Influence of Preoperative Musculotendinous Junction Position on Rotator Cuff Healing After Double-Row Repair. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2017;33(6):1159–66. Yoo JC, Ahn JH, Yang JH, Koh KH, Choi SH, Yoon YC. Correlation of arthroscopic repairability of large to massive rotator cuff tears with preoperative magnetic resonance imaging scans. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2009;25(6):573–82. Burkhart SS, Nottage WM, Ogilvie-Harris DJ, Kohn HS, Pachelli A. Partial repair of irreparable rotator cuff tears. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 1994;10(4):363–70. Wong I, Sparavalo S, King JP, Coady CM. Bridging Allograft Reconstruction Is Superior to Maximal Repair for the Treatment of Chronic, Massive Rotator Cuff Tears: Results of a Prospective, Randomized Controlled Trial. Am J Sports Med. 2021;49(12):3173–83. 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Graft Healing Is More Important Than Graft Technique: Superior Capsular Reconstruction Versus Bridging Grafts-A Prospective Randomized Controlled Trial. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2022;38(12):3109–17. Burkhart SS, Pranckun JJ, Hartzler RU. Superior Capsular Reconstruction for the Operatively Irreparable Rotator Cuff Tear: Clinical Outcomes Are Maintained 2 Years After Surgery. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2020;36(2):373–80. Mihata T, Lee TQ, Watanabe C, Fukunishi K, Ohue M, Tsujimura T, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2013;29(3):459–70. Ribeiro FR, Nogueira MP, Costa BM, Tenor AC Jr., Costa MPD. Mini-Open Fascia Lata Interposition Graft Results In Superior 2-Year Clinical Outcomes When Compared to Arthroscopic Partial Repair for Irreparable Rotator Cuff Tear: A Single-Blind Randomized Controlled Trial. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2024;40(2):251–61. Awad MA, Sparavalo S, Ma J, King JP, Wong I. Interposition Graft Bridging Reconstruction of Irreparable Rotator Cuff Tears Using Acellular Dermal Matrix: Medium-Term Results. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2022;38(3):692–8. Abboud JA, Soslowsky LJ. Interplay of the static and dynamic restraints in glenohumeral instability. Clin Orthop Relat Res 2002(400):48–57. Labriola JE, Lee TQ, Debski RE, McMahon PJ. Stability and instability of the glenohumeral joint: the role of shoulder muscles. Journal of shoulder and elbow surgery 2005;14(1 Suppl S):32s-8s. Clark JM, Harryman DT 2. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am. 1992;74(5):713–25. Mihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med. 2012;40(10):2248–55. Gan K, Bi M, Zhou K, Xia C, Ding W, Ding S, et al. Bridging repair reinforced with artificial ligament as an internal brace for irreparable massive rotator cuff tears. J Shoulder Elbow Surg. 2024;33(6):e322–35. Kim JH, Lee HJ, Park TY, Lee JU, Kim YS. Preliminary outcomes of arthroscopic biceps rerouting for the treatment of large to massive rotator cuff tears. J Shoulder Elbow Surg. 2021;30(6):1384–92. Hamada K, Fukuda H, Mikasa M, Kobayashi Y. Roentgenographic findings in massive rotator cuff tears. A long-term observation. Clin Orthop Relat Res 1990(254):92–6. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am. 1986;68(8):1136–44. Patte D. Classification of rotator cuff lesions. Clin Orthop Relat Res 1990(254):81–6. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg Am. 2007;89(5):953–60. Matthewson G, Coady CM, Wong IH. Rotator Cuff Reconstruction Using Fascia Lata Patch Autograft for the Nonrepairable Rotator Cuff Tear. Arthrosc techniques. 2020;9(1):e123–30. Iagulli ND, Field LD, Hobgood ER, Ramsey JR, Savoie FH. 3rd. Comparison of partial versus complete arthroscopic repair of massive rotator cuff tears. Am J Sports Med. 2012;40(5):1022–6. Lee KW, Lee GS, Yang DS, Park SH, Chun YS, Choy WS. Clinical Outcome of Arthroscopic Partial Repair of Large to Massive Posterosuperior Rotator Cuff Tears: Medialization of the Attachment Site of the Rotator Cuff Tendon. Clin Orthop Surg. 2020;12(3):353–63. Park SG, Shim BJ, Seok HG. How Much Will High Tension Adversely Affect Rotator Cuff Repair Integrity? Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2019;35(11):2992–3000. Davies A, Singh P, Reilly P, Sabharwal S, Malhas A. Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis. J Orthop Surg Res. 2022;17(1):552. Mihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical Effects of Acromioplasty on Superior Capsule Reconstruction for Irreparable Supraspinatus Tendon Tears. Am J Sports Med. 2016;44(1):191–7. Alarcon JF, Uribe-Echevarria B, Clares C, Apablaza D, Vargas JC, Benavente S, et al. Superior Capsular Reconstruction With Autologous Fascia Lata Using a Single Lateral-Row Technique Is an Effective Option in Massive Irreparable Rotator Cuff Tears: Minimum 2-Year Follow-Up. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2021;37(9):2783–96. Goetti P, Denard PJ, Collin P, Ibrahim M, Hoffmeyer P, Lädermann A. Shoulder biomechanics in normal and selected pathological conditions. EFORT open reviews. 2020;5(8):508–18. Howell SM, Imobersteg AM, Seger DH, Marone PJ. Clarification of the role of the supraspinatus muscle in shoulder function. J Bone Joint Surg Am. 1986;68(3):398–404. Baek CH, Kim BT, Kim JG, Kim SJ. Mid-Term Outcome of Superior Capsular Reconstruction Using Fascia Lata Autograft (At Least 6 mm in Thickness) Results in High Retear Rate and No Improvement in Muscle Strength. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2024;40(7):1961–71. Modi A, Haque A, Deore V, Singh HP, Pandey R. Interposition GraftJacklografts for irreparable rotator cuff tears. bone joint J 2022;104–b(1):91–6. Liao Y, Zhou Z, Wang J, Li H, Zhou B. Fascia Lata Autografts Achieve Interface Healing With the Supraspinatus Muscle Histologically and Mechanically in a Rat Supraspinatus Tendon Reconstruction Model for Massive Irreparable Rotator Cuff Tears. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2024;40(11):2655–66. Lewington MR, Ferguson DP, Smith TD, Burks R, Coady C, Wong IH. Graft Utilization in the Bridging Reconstruction of Irreparable Rotator Cuff Tears: A Systematic Review. Am J Sports Med. 2017;45(13):3149–57. Bi M, Zhou K, Gan K, Ding W, Zhang T, Ding S et al. Combining fascia lata autograft bridging repair with artificial ligament internal brace reinforcement: a novel healing-improvement technique for irreparable massive rotator cuff tears. bone joint J 2021;103–b(10):1619–26. Ranebo MC, Björnsson Hallgren HC, Norlin R, Adolfsson LE. Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up. Journal of shoulder and elbow surgery 2018;27(9):1622-8. Rhee SM, Oh JH. Bridging Graft in Irreparable Massive Rotator Cuff Tears: Autogenic Biceps Graft versus Allogenic Dermal Patch Graft. Clin Orthop Surg. 2017;9(4):497–505. Chiang CH, Shaw L, Chih WH, Yeh ML, Ting HH, Lin CH, et al. Modified Superior Capsule Reconstruction Using the Long Head of the Biceps Tendon as Reinforcement to Rotator Cuff Repair Lowers Retear Rate in Large to Massive Reparable Rotator Cuff Tears. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2021;37(8):2420–31. Sandhu H, Hackett L, Tumpalan JF, Lam PH, Murrell GAC. Synthetic polytetrafluoroethylene patches for irreparable rotator cuff tears-how are they doing at 5 years? J Shoulder Elbow Surg. 2023;32(3):e106–16. El-Shaar R, Soin S, Nicandri G, Maloney M, Voloshin I. Superior Capsular Reconstruction With a Long Head of the Biceps Tendon Autograft: A Cadaveric Study. Orthop J sports Med. 2018;6(7):2325967118785365. Barth J, Olmos MI, Swan J, Barthelemy R, Delsol P, Boutsiadis A. Superior Capsular Reconstruction With the Long Head of the Biceps Autograft Prevents Infraspinatus Retear in Massive Posterosuperior Retracted Rotator Cuff Tears. Am J Sports Med. 2020;48(6):1430–8. Davidson PA, Rivenburgh DW. Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elbow Surg. 2000;9(6):502–6. Mori D, Funakoshi N, Yamashita F. 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. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2013;29(12):1911–21. Shin KH, Jang IT, Han SB. Outcomes of Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon in Large to Massive Rotator Cuff Tears: A Meta-Analysis and Systematic Review. J Clin Med 2024;13(4). Gupta AK, Hug K, Berkoff DJ, Boggess BR, Gavigan M, Malley PC, et al. Dermal tissue allograft for the repair of massive irreparable rotator cuff tears. Am J Sports Med. 2012;40(1):141–7. Mori D, Funakoshi N, Yamashita F, Wakabayashi T. Effect of Fatty degeneration of the infraspinatus on the efficacy of arthroscopic patch autograft procedure for large to massive rotator cuff tears. Am J Sports Med. 2015;43(5):1108–17. Dierickx C, Ceccarelli E, Conti M, Vanlommel J, Castagna A. Variations of the intra-articular portion of the long head of the biceps tendon: a classification of embryologically explained variations. J Shoulder Elbow Surg. 2009;18(4):556–65. McClatchy SG, Parsell DE, Hobgood ER, Field LD. Augmentation of Massive Rotator Cuff Repairs Using Biceps Transposition Without Tenotomy Improves Clinical and Patient-Reported Outcomes: The Biological Superior Capsular Reconstruction Technique. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2024;40(1):47–54. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Mar, 2026 Reviews received at journal 11 Feb, 2026 Reviews received at journal 06 Feb, 2026 Reviews received at journal 05 Feb, 2026 Reviewers agreed at journal 02 Feb, 2026 Reviewers agreed at journal 01 Feb, 2026 Reviewers agreed at journal 31 Jan, 2026 Reviewers agreed at journal 28 Jan, 2026 Reviewers invited by journal 28 Jan, 2026 Editor assigned by journal 06 Jan, 2026 Submission checks completed at journal 05 Jan, 2026 First submitted to journal 02 Jan, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-8464962\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":false,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":582327763,\"identity\":\"c815e3bb-0e6b-4851-832e-c6500c791c96\",\"order_by\":0,\"name\":\"Shaohua Zhang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Wuhan Fourth Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Shaohua\",\"middleName\":\"\",\"lastName\":\"Zhang\",\"suffix\":\"\"},{\"id\":582327764,\"identity\":\"d6d13942-f8bb-4c36-a0d1-992e24ec47a7\",\"order_by\":1,\"name\":\"Qingsong Zhang\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAsklEQVRIiWNgGAWjYDACCQaGAwwMNjz87A2kaUmTkew5QIIWIDhsY3DDgUgd8rN7Dx4uqDjPw3CDgfHDxxwitDDOOZdweMaZ2zyMsxuYJWduI0ILs0SOwWHetts8zDIH2Jh5idHCBtby7xwPm0QCkVp4wFoaDvDwEK1FQiIv4TDPsWQeCZ6DzcT5RX5G7uHPPDV29vbHmw9++EiMFqDTYAzGBqLUI2sZBaNgFIyCUYADAACP8jKLzuXV5QAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Wuhan Fourth Hospital\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Qingsong\",\"middleName\":\"\",\"lastName\":\"Zhang\",\"suffix\":\"\"},{\"id\":582327765,\"identity\":\"4c7c1b57-7f69-4693-b434-263144778a80\",\"order_by\":2,\"name\":\"Yushun Fang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Wuhan Fourth Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yushun\",\"middleName\":\"\",\"lastName\":\"Fang\",\"suffix\":\"\"},{\"id\":582327766,\"identity\":\"f7e8b2a4-227b-4689-a2a1-ca2716390565\",\"order_by\":3,\"name\":\"Ming Tang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Wuhan Fourth Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ming\",\"middleName\":\"\",\"lastName\":\"Tang\",\"suffix\":\"\"},{\"id\":582327767,\"identity\":\"80cb0bcc-5ce7-4ca9-965a-351c2a9c7262\",\"order_by\":4,\"name\":\"Yanan Li\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Wuhan Fourth Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Yanan\",\"middleName\":\"\",\"lastName\":\"Li\",\"suffix\":\"\"},{\"id\":582327768,\"identity\":\"12d942d2-1d69-4b51-ab5e-8ae1a3e2a6b9\",\"order_by\":5,\"name\":\"Jun Xiong\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Wuhan Fourth Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Jun\",\"middleName\":\"\",\"lastName\":\"Xiong\",\"suffix\":\"\"},{\"id\":582327769,\"identity\":\"30fe1fc1-a33a-440d-aa89-189d82bab6c7\",\"order_by\":6,\"name\":\"Zhujun Wang\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Wuhan Fourth Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Zhujun\",\"middleName\":\"\",\"lastName\":\"Wang\",\"suffix\":\"\"},{\"id\":582327770,\"identity\":\"a7d0076b-58d7-4d82-a37e-e0eb5d9f4191\",\"order_by\":7,\"name\":\"Tao Li\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Wuhan Fourth Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Tao\",\"middleName\":\"\",\"lastName\":\"Li\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2025-12-28 09:38:14\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-8464962/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-8464962/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":101499553,\"identity\":\"a6fbb3c8-2a65-4d79-b1b0-9b27adf58cae\",\"added_by\":\"auto\",\"created_at\":\"2026-01-30 13:12:02\",\"extension\":\"jpeg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":63696,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe design process of the patch. (A)Tear size:W, the anterior-to-posterior of defect; L1 and L2, the width from the cuff tendon stump to the estimated location for lateral and medial row anchor; (B) the length and width of fascia lata graft to be harvested ;(C) the folded long side of fascia lata graft (in half) ;(D) The marked suture placement sites on the patch (1-10): M, medial; L, lateral; A: anterior; P; posterior;11 and 12, the place pass though for the two medial row anchors.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage1.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8464962/v1/f9199fe47716409c0fae3409.jpeg\"},{\"id\":101499571,\"identity\":\"e315bc71-ff51-4181-85f3-29d7a2c29586\",\"added_by\":\"auto\",\"created_at\":\"2026-01-30 13:12:06\",\"extension\":\"jpeg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":197973,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eSchematic diagram of combined surgery. (A) Massive rotator cuff tears involving SSP, ISP and SSC; (B) The transposed LHBT posteriorly to the superior aspect of the humeral head and the repaired concomitant injuries of ISP and SSC; (C) The introduced graft into the subacromial shoulder space; (D) The sutured patch with the surrounding tendon tissue. The lateral side was fixed to the large tubercle via double-row suture bridge technique; (E-H) Correspond to the intraoperative operating;\\u003c/p\\u003e\\n\\u003cp\\u003eG, glenoid; H, humeral head; SSP, supraspinatus tendon; ISP, infraspinatus tendon; SSC, subscapularis tendon; LHBT: long head of the biceps tendon.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage2.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8464962/v1/f4c69e60f6e16af338446ba7.jpeg\"},{\"id\":101499899,\"identity\":\"bc2aa4d6-42b5-45ae-a70c-d07c7833dc28\",\"added_by\":\"auto\",\"created_at\":\"2026-01-30 13:13:21\",\"extension\":\"jpeg\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":131407,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eIntraoperative arthroscopic views demonstrating partial repair of a massive rotator cuff tear. (A) Massive rotator cuff tears involving SSP, ISP, and the LHBT was in good conditon (B) Final view of repaired native rotator cuff after partial repair. There is a residual defect at the footprint.\\u003c/p\\u003e\\n\\u003cp\\u003eG, glenoid; H, humeral head; SSP, supraspinatus tendon; ISP, infraspinatus tendon; LHBT: long head of the biceps tendon\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage3.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8464962/v1/f3cddc7fed5f1ad3aacc47a5.jpeg\"},{\"id\":101499358,\"identity\":\"2173b29c-3be7-4ce7-8d3e-b95e7ba129df\",\"added_by\":\"auto\",\"created_at\":\"2026-01-30 13:11:10\",\"extension\":\"jpeg\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":172097,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eThe healing process of the graft evaluated with MRI (A)Preoperative MRI showing a massive tear of the rotator cuff with supraspinatus tendon retraction, and the upward migration of humeral head. (B) Postoperative MRI at the second day showing the very thick graft and the. transposed LHBT, and the clearly downward migration of humeral head (C) Postoperative MRI at six months showing the thinned graft get compared with the second day after surgery. (D) Postoperative MRI at 42 months showing the further remolded graft, the LHBT cannot be identified, the location of humeral head is still better than that before surgery, but not better than the second day after surgery. The red and white arrows indicate the bridging fascia lata graft and transposed LHBT, respectively.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"floatimage4.jpeg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8464962/v1/5f9e8df8826e878da55f8f15.jpeg\"},{\"id\":101500088,\"identity\":\"5abc8f32-5aaf-4062-acd5-a10669014acc\",\"added_by\":\"auto\",\"created_at\":\"2026-01-30 13:14:09\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":1347454,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-8464962/v1/d5e3c10c-1513-4370-8262-43323d212216.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Combined Autogenous Fascia Lata Graft Bridging with Biceps Transposition Versus Partial Repair for Massive Rotator Cuff Tears: A Retrospective Comparative Study\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eRotator cuff tears usually cause shoulder disability and pain, especially among the elderly[\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e]. Massive rotator cuff tears (MRCTs) are defined as defects measuring \\u0026gt;5 cm[\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e] and may have two or more torn tendons [\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e] ;these account for approximately 20% of all rotator cuff tears and 80% of recurrent tears[\\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eAlthough optimal outcomes can be achieved with complete anatomical repair and healing of the torn tendon, this approach is not universally applicable. Surgical repair can be limited by massive retracted tears with poor tissue quality[\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e], significant muscle atrophy, and fatty infiltration[\\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e]. In these situations, the rotator cuff cannot be reattached to the footprint even after mobilizing and interval releasing procedures, or barely reached at high tension. Partial repairs that attempt to recreate the rotator cable to restore the function of the rotator cuff in a construct that resembles a suspension bridge have been proposed[\\u003cspan citationid=\\\"CR9\\\" class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e]. Studies have shown that partial repairs can lead to significant improvements in both shoulder function and pain relief[\\u003cspan citationid=\\\"CR11\\\" class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e], making them a viable treatment option for patients with massive tears. However, these repairs are associated with a high incidence of structural failure[\\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e] and outcomes may deteriorate over time[\\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eIn an effort to enhance the healing rate, graft interposition has been introduced to manage MRCTs. In superior capsule reconstruction (SCR), the graft is interposed between the humeral head and the superior tubercle of the glenoid to restore a stable fulcrum and provide a static restraint against upward migration of the superior humeral head. In graft bridging (GB), the graft connects the greater tuberosity and the rotator cuff remnant, providing a dynamic anatomical reconstruction of the rotator cuff. Both procedures have demonstrated improved postoperative functional outcomes[\\u003cspan additionalcitationids=\\\"CR16 CR17 CR18\\\" citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e\\u0026ndash;\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e], despite some limitations. Normal shoulder mobility necessitates the coordinated functions of dynamic and static stabilizers [\\u003cspan citationid=\\\"CR20\\\" class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR21\\\" class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e]. These structures are connected histologically [\\u003cspan citationid=\\\"CR22\\\" class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e]. Rotator cuff tears disrupt both these stabilizers, as seen in superior capsular defects in MRCTs [\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. Thus, rotator cuff repair should ideally address both the rotator cuff and the superior capsule. However, few studies have combined these two techniques[\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e] and compared the outcome of the combination with that of partial repair.\\u003c/p\\u003e \\u003cp\\u003eThe aim of this study was to compare the effectiveness of combined GB and SCR surgery (in which an autogenous fascia lata is used as the graft for GB, while the long head of the biceps tendon [LHBT] is transposed for SCR) with that of partial repair, and we hypothesized that the combined surgery would result in superior healing rates and functional outcomes.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePatient selection\\u003c/h2\\u003e \\u003cp\\u003eData on patients who had been treated for MRCTs were obtained from the medical records. The partial repair group included patients who had been treated between January 2016 and December 2017, while the combined surgery group comprised those who had undergone GB plus LHBT transposition between January 2018 and June 2023. This study was approved by the local ethics committee, and informed consent was obtained from all participants. The inclusion criteria were: (1) failure of nonoperative treatment to improve patient satisfaction after three months; (2) MRCTs: the dimension\\u0026thinsp;\\u0026gt;\\u0026thinsp;5 cm and two or more tendons fully torn, radiographic Hamada classification rotator cuff 1\\u0026ndash;3,the supraspinatus was not able to be pulled to cover the footprint after tendon liberation procedures (3) the infraspinatus and subscapularis tendon tears were partially or fully reparable (4) for the patients underwent GB plus LHBT:no excessive tendinitis or partial tears occurred in LHBT (partial tear involving less than 1/3 of the tendon width at the intra-articular region). The exclusion criteria were: (1) patients who were lost to follow-up within two years; (2) those who underwent revision surgery.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003ePatient assessment\\u003c/h3\\u003e\\n\\u003cp\\u003eThe patients provided standard demographic and clinical history and were physically examined by the same surgeon before surgery and at the final follow-up (\\u0026ge;\\u0026thinsp;2 years). The active range of motion (AROM), including forward flexion, external rotation with the arm at the side, and internal rotation, was measured. Internal rotation was defined as the highest vertebral body that the patient could reach with the thumb on the affected side. The vertebral levels were numbered serially from below the sacrum (level 0) to the 7th thoracic vertebra (level 12)[\\u003cspan citationid=\\\"CR25\\\" class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e]. The American Shoulder and Elbow Surgeons (ASES) score and the Constant Murley Score (CMS) were assessed both before surgery and at the final follow-up.\\u003c/p\\u003e\\n\\u003ch3\\u003eRadiography and magnetic resonance imaging\\u003c/h3\\u003e\\n\\u003cp\\u003eThe Hamada classification[\\u003cspan citationid=\\\"CR26\\\" class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e] and the acromiohumeral interval (AHI)[\\u003cspan citationid=\\\"CR27\\\" class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e] were determined based on an anterior-posterior radiograph of the glenohumeral joint. Magnetic resonance imaging (MRI) was employed to evaluate the tear size before surgery, with tear sizes based on the Patte Grades[\\u003cspan citationid=\\\"CR28\\\" class=\\\"CitationRef\\\"\\u003e28\\u003c/span\\u003e]. MRI examinations were also conducted at the final follow-up to determine the status of the graft, assessed according to the Sugaya grade[\\u003cspan citationid=\\\"CR29\\\" class=\\\"CitationRef\\\"\\u003e29\\u003c/span\\u003e]. Type I, II, and III grades represented healing of the repaired tendon, while types IV and V were regarded as retears. All radiographic and MRI assessments were performed by a single experienced shoulder surgeon using standardized criteria.\\u003c/p\\u003e\\n\\u003ch3\\u003eSurgical technique\\u003c/h3\\u003e\\n\\u003cp\\u003eThe GB plus LHBT transposition procedure (the combined surgery group)\\u003c/p\\u003e \\u003cp\\u003eThe patients were placed in the lateral decubitus position under general anesthesia. Four routine arthroscopic portals (anterior, posterior, lateral, and posterolateral) were used for the procedure. A posterior portal was established for an initial assessment of the glenohumeral joint. The rotator cuff tear was evaluated, and the condition of the biceps tendon was confirmed from the articular side. The arthroscope was then withdrawn and redirected into the subacromial space, where subacromial decompression was performed in cases where impingement was observed.\\u003c/p\\u003e \\u003cp\\u003eDecortication of the greater tuberosity was performed to provide a fresh bleeding bone bed for the repair. The biceps tendon was mobilized and transposed to the superior aspect of the humeral head. The subscapularis and infraspinatus tendons were repaired or partially repaired. The arthroscope was then transferred to the posterolateral portal to measure the tear. A grasper was introduced through the lateral portal, and the morphology of the tear and the degree of mobility were assessed while viewing from the posterolateral portal.\\u003c/p\\u003e \\u003cp\\u003eA suitable rectangular fascia lata graft was harvested at the site of the greater trochanter, based on the size of the cuff tear. The anterior-posterior dimension of the graft was required to be 4 mm wider than the cuff deficit (W), while the medial-lateral dimension of the graft needed to be 6 mm wider than L1\\u0026times;2 (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). A patch was fashioned by folding the fascia lata graft in half, and the free ends of the graft were sutured to prevent it unfurling. The suture placement sites on the patch were marked (4 located medially for the medial side of the cuff defect, 2 for fixation to the tissue from the coracohumeral ligament, rotator interval, 2 for posterior fixation to the infraspinatus tendon, and 2 for lateral fixation to the greater tuberosity). A road map was created to provide orientation by drawing the patch and the color-coded sutures (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e). Based on the map, 10 sutures were then passed through the patch at their respective sites (1 to 10), and short-tailed interference knots were tied over a switching stick for patch passage and eventual fixation[\\u003cspan citationid=\\\"CR30\\\" class=\\\"CitationRef\\\"\\u003e30\\u003c/span\\u003e].\\u003c/p\\u003e \\u003cp\\u003eThe anterior side of the cuff defect was stitched using PDS-II sutures, which act as traction sutures. The anterior suture limbs of the patch were brought through the lateral portal \\u003cem\\u003evia\\u003c/em\\u003e the traction sutures. This procedure was repeated for both the posterior and medial sides of the cuff defect. Two anchors were inserted at the articular margin, and the sutures of the anchors were passed through the patch at sites 11 and 12.\\u003c/p\\u003e \\u003cp\\u003eThe patch was routed into the joint by maintaining an even tension on the medial sutures, followed by flattening using anterior and posterior suture tensioning. The anterior, posterior, and medial sutures were then tied, securing the patch to the rotator cuff defect. The lateral suture limbs of the patch and the suture limbs from the two anchors at the articular margin were crisscrossed and secured laterally to two lateral knotless anchors using a double-row suture bridge technique (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). Lastly, the wound was sutured after hemostasis.\\u003c/p\\u003e \\u003cp\\u003ePartial repair procedure (partial repair group)\\u003c/p\\u003e \\u003cp\\u003eThe surgical approach and management of concomitant injuries were identical to those used for the patch group. After assessment of the supraspinatus defect and retraction, single-row repair was performed after adequate mobilization and interval release procedures (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). The biceps tendon was left intact if it appeared in good condition, but a biceps tenotomy was performed if excessive tendonitis or partial tears were observed.\\u003c/p\\u003e \\u003cp\\u003eThe surgeries in both groups were conducted by the same surgical team led by ZQS.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eG, glenoid; H, humeral head; SSP, supraspinatus tendon; ISP, infraspinatus tendon; SSC, subscapularis tendon; LHBT: long head of the biceps tendon.\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003cp\\u003eG, glenoid; H, humeral head; SSP, supraspinatus tendon; ISP, infraspinatus tendon; LHBT: long head of the biceps tendon\\u003c/p\\u003e\\n\\u003ch3\\u003ePostoperative protocol\\u003c/h3\\u003e\\n\\u003cdiv class=\\\"Heading\\\"\\u003ePostoperative protocol\\u003c/div\\u003e \\u003cp\\u003eBoth patient cohorts followed an identical standardized rehabilitation protocol. The arm was supported for six weeks at 60 \\u0026deg; of abduction and 15 \\u0026deg; of external rotation in a sling with a small abduction pillow. Elbow, wrist, and hand exercises, as well as scapula shrugs, were begun immediately after surgery. Passive- and active-assisted exercises were initiated after the immobilization period. The patients began to perform exercises to strengthen the rotator cuff and scapular stabilizers eight weeks after surgery. Full activity was allowed by six months after surgery, when patients had sufficient range of motion and muscle strength.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical analysis\\u003c/h2\\u003e \\u003cp\\u003eAll statistical analyses were conducted using SPSS software version 23.0 (IBM Corp., Armonk, NY, USA). Continuous variables are expressed as mean \\u0026plusmn; standard deviation (SD), and categorical variables are reported as frequencies and percentages. Intragroup comparisons of preoperative and postoperative values, including the ASES score, CMS score, AROM, and AHI, were performed using paired t-tests. Intergroup comparisons of continuous variables were conducted using independent-samples t-tests. Categorical variables, such as smoking status, tear size classification, and the rotator cuff healing rate, were compared using Pearson\\u0026rsquo;s chi-square or Fisher's exact tests. Non-parametric variables, including the fatty infiltration grade of the supraspinatus and Hamada classification, were analyzed using the Kruskal-Wallis test. P-values\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 were considered statistically significant.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cdiv id=\\\"Sec10\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003ePatient characteristics\\u003c/h2\\u003e \\u003cp\\u003eA total of 53 patients with MRCTs were enrolled. Of these, 24 were treated using partial repair (January 2016 and December 2017) and 29 with autogenous fascia lata graft bridging plus LHBT transposition (January 2018 to June 2023). The preoperative characteristics of the two groups are shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e. There were no significant differences between the groups in terms of age, sex, symptom duration, follow-up duration, smoking, tear size, fatty degeneration of the supraspinatus, or Hamada grade (P\\u0026gt;0.05).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003ePatient characteristics\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePartial repair\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;24)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eBridging repair\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;29)\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e Value (a\\u0026thinsp;=\\u0026thinsp;0.05)\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAge, y\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e61.8\\u0026plusmn;6.8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e62.8\\u0026plusmn;5.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.534\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSex (male/female,n)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.942\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003emale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e16\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003efemale\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSymptom duration, mo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e20.6\\u0026plusmn;7.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e17.7\\u0026plusmn;10.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.247\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFollow-up duration, mo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e30.4\\u0026plusmn;5.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e31.3\\u0026plusmn;6.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.612\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eSmoking (n)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.817\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eYes\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eNo\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e10\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eTear size\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.669\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatte I\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatte II\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e11\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePatte III\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e13\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFatty degeneration of supraspinatus\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.926\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGoutallier I\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGoutallier II\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e8\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e19\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGoutallier III\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eGoutallier IV\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eHamada grade\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.591\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eI\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eII\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e14\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e15\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIII\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec11\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eClinical outcomes\\u003c/h2\\u003e \\u003cp\\u003eThe clinical outcomes are summarized in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e.\\u003c/p\\u003e \\u003cp\\u003eNo significant differences in the mean ASES and CMS scores were observed between the two groups before surgery(P\\u0026gt;0.05). At the final follow-up, although the scores had improved significantly in both groups (P\\u0026lt;0.001), the ASES score was significantly better in the combined surgery group than in the partial repair group (88.6 vs. 84.0, P\\u0026thinsp;=\\u0026thinsp;0.014), as was the mean CMS score (83.4 vs. 77.4, P\\u0026lt;0.001).\\u003c/p\\u003e \\u003cp\\u003eThe AROM values, including forward flexion, external rotation with the arm at the side, and internal rotation, were similar between the groups at baseline. Postoperatively, these measures had improved markedly (P \\u0026lt;0.001); however, no significant difference was found between the two groups (P\\u0026gt;0.05).\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eClinical outcomes\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePreoperative\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFinal follow up\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eASES\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePartial repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e46.8\\u0026plusmn;6.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e84.0\\u0026plusmn;7.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBridging repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e45.9\\u0026plusmn;6.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e88.6\\u0026plusmn;5.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.618\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.014\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eCMS\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePartial repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e43.3\\u0026plusmn;5.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e77.4\\u0026plusmn;6.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBridging repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e42.7\\u0026plusmn;5.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e83.4\\u0026plusmn;4.2\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.682\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eFE\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePartial repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e105.2\\u0026plusmn;20.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e161.9\\u0026plusmn;8.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBridging repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e103.1\\u0026plusmn;20.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e165.8\\u0026plusmn;7.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.708\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.069\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eER\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePartial repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e31.6\\u0026plusmn;6.9\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e47.4\\u0026plusmn;7.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBridging repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e33.4\\u0026plusmn;8.7\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e49.2\\u0026plusmn;7.5\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.408\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.370\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eIR\\u003c/p\\u003e \\u003cp\\u003ePartial repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.3\\u0026plusmn;1.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6.7\\u0026plusmn;1.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBriding repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.0\\u0026plusmn;1.6\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e6.5\\u0026plusmn;1.4\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.603\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e0.546\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eASES, active range of motion and American Shoulder and Elbow Surgeons; CMS, Constant-Murley score; FE, forward elevation; ER, external rotation with the arm at the side ;IR, internal rotation behind the back.\\u003c/p\\u003e \\u003cp\\u003eFor internal rotation at the back (IR), values were converted into contiguously numbered groups: below the sacrum to 0, sacrum to 1, L5-L1 to 2\\u0026ndash;6, T12-T7 to 7\\u0026ndash;12\\u003c/p\\u003e \\u003cp\\u003eValues are presented as mean\\u0026plusmn;SD\\u003c/p\\u003e \\u003c/div\\u003e \\u003cdiv id=\\\"Sec12\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eRadiological evaluation\\u003c/h2\\u003e \\u003cp\\u003eThe radiological evaluation results are shown in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e. In the partial repair group, the AHI was increased, although the increase did not reach statistical significance (5.1 mm vs. 5.4 mm, P\\u0026thinsp;=\\u0026thinsp;0.297). However, in the combined surgery group, the AHI improved significantly from a preoperative mean of 4.7 mm to 7.4 mm at the final follow-up (P\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001).\\u003c/p\\u003e \\u003cp\\u003eThe retear rate was assessed by MRI at the final follow-up (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e). This showed that in the partial repair group, the rotator cuff was healed in 15 patients (62.5%), while 9 showed retear (37.5%). Of those with retear, 4 had partial retear and 5 had complete retear. In the combined surgery group(Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e), 27 patients had a healed rotator cuff ( 93.1%), with only 2 patients showing retear (6.9%); of these 1 had a partial retear and 1 had a complete retear. The retear rate of repaired rotator cuff was thus significantly lower in the combined surgery group (6.9%) compared with the partial repair group (37.5%) (P\\u0026thinsp;=\\u0026thinsp;0.015).\\u003c/p\\u003e \\u003cp\\u003eNotably, there was no incidence of wound infection, nerve injury, or other major surgical complications in either group.\\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eRadiologic Evaluation by X rays\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003ePreoperative\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eFinal follow up\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eAHI,mm\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePartial repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e5.1\\u0026plusmn;1.0\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e5.4\\u0026plusmn;1.1\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e0.297\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBridging repair\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e4.7\\u0026plusmn;1.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e7.4\\u0026plusmn;1.3\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e0.248\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e\\u0026lt;0.001\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003ctfoot\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eAHI, the acromiohumeral interval\\u003c/td\\u003e\\u003c/tr\\u003e \\u003ctr\\u003e\\u003ctd colspan=\\\"4\\\"\\u003eValues are presented as mean\\u0026plusmn;SD\\u003c/td\\u003e\\u003c/tr\\u003e \\u003c/tfoot\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003e \\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e \\u003ccaption language=\\\"En\\\"\\u003e \\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e \\u003cdiv class=\\\"CaptionContent\\\"\\u003e \\u003cp\\u003eRadiologic Evaluation by MRI\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/caption\\u003e \\u003ccolgroup cols=\\\"4\\\"\\u003e \\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e \\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e \\u003cthead\\u003e \\u003ctr\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eVariable\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003eHealed\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003eretear\\u003c/p\\u003e \\u003c/th\\u003e \\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cem\\u003ep\\u003c/em\\u003e\\u003c/p\\u003e \\u003c/th\\u003e \\u003c/tr\\u003e \\u003c/thead\\u003e \\u003ctbody\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003ePartial repair\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;24),n%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e15(62.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e9(37.5%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e \\u003cp\\u003e\\u003cb\\u003e0.015\\u003c/b\\u003e\\u003c/p\\u003e \\u003c/td\\u003e \\u003c/tr\\u003e \\u003ctr\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e \\u003cp\\u003eBridging repair\\u003c/p\\u003e \\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;29),n%\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e \\u003cp\\u003e27(93.1%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e \\u003cp\\u003e2(6.9%)\\u003c/p\\u003e \\u003c/td\\u003e \\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e \\u003c/tr\\u003e \\u003c/tbody\\u003e \\u003c/colgroup\\u003e \\u003c/table\\u003e\\u003c/div\\u003e \\u003c/p\\u003e \\u003cp\\u003eValues are presented as mean\\u0026plusmn;SD\\u003c/p\\u003e \\u003cp\\u003e \\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eThis study evaluated the effectiveness of surgery involving both autogenous fascia lata graft bridging and LHBT transposition for repairing MRCTs, with a minimum follow-up of two years. Compared with the partial repair, the combined surgical approach was associated with more favorable short- to mid-term clinical and structural outcomes, including improved ASES scores, CMS scores, AHI, and rotator cuff healing rates.\\u003c/p\\u003e \\u003cp\\u003eMRCTs present a significant challenge for orthopedic surgeons due to their complexity and the limited success of traditional repair methods. To date, numerous surgical strategies have been used to manage MRCTs, including debridement, partial repair,GB, SCR, reverse shoulder arthroplasty, and tendon transfer. Partial repair has long been regarded as a primary treatment option for MRCTs, particularly in cases where complete repair is not feasible due to tendon retraction and poor tissue quality. Many studies have reported on the outcomes of partial repair of MRCTs. A study comparing partial versus complete arthroscopic repair found that partial repair yielded outcomes comparable to complete repair, with significant improvements in functional scores, such as the University of California, Los Angeles (UCLA) shoulder scores[\\u003cspan citationid=\\\"CR31\\\" class=\\\"CitationRef\\\"\\u003e31\\u003c/span\\u003e]. A further study focused on the clinical outcomes of arthroscopic partial repair with medialization of the attachment site of the rotator cuff tendon, finding significant improvements in clinical outcomes, even in cases where complete healing was not achieved, highlighting the potential of partial repair as a viable treatment option[\\u003cspan citationid=\\\"CR32\\\" class=\\\"CitationRef\\\"\\u003e32\\u003c/span\\u003e]. However, the structural integrity of partial repairs is significantly compromised by the high-tension environment at the tendon-anchor interface, which contributes to high retear rates[\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e]. A systematic review of 170 shoulders reported 77 cases of retear, corresponding to a failure rate of close to 45%[\\u003cspan citationid=\\\"CR34\\\" class=\\\"CitationRef\\\"\\u003e34\\u003c/span\\u003e]. Similarly, in the present study, while the partial repair group showed significant postoperative functional improvement, the retear rate was high, at 37.5%.\\u003c/p\\u003e \\u003cp\\u003eTo address the challenge of the high-tension environment in healing after rotator cuff repair and improve the healing rates, graft interposition represents a viable treatment option. This approach involves three primary techniques[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e]: augmentation, SCR, and GB. Augmentation entails the positioning of a graft over the repaired tendon to boost its biomechanical strength and stability. The SCR approach involves the use of a graft to reconnect the greater tuberosity with the superior glenoid. Introduced by Mihata et al. in 2013,[\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e] SCR has demonstrated its effectiveness in the restoration of glenohumeral stability and function in MRCT cases. This effectiveness results from its ability to counteract migration of the proximal humerus, ultimately optimizing the force couples around the shoulder indirectly[\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR35\\\" class=\\\"CitationRef\\\"\\u003e35\\u003c/span\\u003e]. Despite persistent defects in the rotator cuff tendon, SCR has demonstrated favorable short-term clinical outcomes. Previous studies have reported reduced pain and increased function following SCR using fascia lata [\\u003cspan citationid=\\\"CR36\\\" class=\\\"CitationRef\\\"\\u003e36\\u003c/span\\u003e] or dermal allografts [\\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e] within two years of surgery. However, it is important to note that while SCR reconstructs a portion of the static stabilizers, it does not address the repair of cuff tears. These cuff are considered dynamic stabilizers and play a crucial role in shoulder strength and range of motion[\\u003cspan citationid=\\\"CR37\\\" class=\\\"CitationRef\\\"\\u003e37\\u003c/span\\u003e]. Howell et al.[\\u003cspan citationid=\\\"CR38\\\" class=\\\"CitationRef\\\"\\u003e38\\u003c/span\\u003e] reported that the rotator cuff contributes approximately 50% of the overall muscle strength of the shoulder in terms of abduction and flexion. A further study [\\u003cspan citationid=\\\"CR39\\\" class=\\\"CitationRef\\\"\\u003e39\\u003c/span\\u003e] observed that after a mean follow-up of 63.2\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;5.9 months, there was no improvement in muscle strength following SCR using a fascia lata autograft. A biomechanical cadaveric study by Mihata et al.[\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e] revealed that the total rotational range of motion at 0\\u0026deg;, 45\\u0026deg;, and 90\\u0026deg; of shoulder abduction following SCR was lower compared with the intact condition. So some authors advocate for GB due to its ability to anatomically repair the tendon-bone interface[\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e]. The graft is secured medially to the torn stump of the rotator cuff and laterally to the greater tuberosity. Compared to SCR, GB provides a closer approximation of the natural anatomy of the rotator cuff and musculotendinous unit, and an animal study have demonstrated the remarkable ability of fascia lata autografts to undergo remodeling into tissues that structurally resemble normal tendons[\\u003cspan citationid=\\\"CR41\\\" class=\\\"CitationRef\\\"\\u003e41\\u003c/span\\u003e]. This This approach may help restore the dynamic functionality of the rotator cuff and directly re-establish the force couples around the glenohumeral joint. Clinical studies have demonstrated the efficacy of GB[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR42\\\" class=\\\"CitationRef\\\"\\u003e42\\u003c/span\\u003e]. A recent study by Modi et al. [\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e] reported promising medium-term outcomes using a human dermal allograft for the reconstruction of an irreparable MRCT. However, despite these encouraging results, several unanswered questions remain regarding the use of GB. For instance, although the repaired rotator cuff can also reduce the superior translation of the humeral head, its strength is less than that of the intact rotator cuff and after SCR[\\u003cspan citationid=\\\"CR23\\\" class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e]. Hence, the graft may be vulnerable to abrasion and tearing caused by subacromial impingement, primarily due to poor stability[\\u003cspan citationid=\\\"CR43\\\" class=\\\"CitationRef\\\"\\u003e43\\u003c/span\\u003e]. This vulnerability has led to a high incidence of retears following GB procedures[\\u003cspan citationid=\\\"CR44\\\" class=\\\"CitationRef\\\"\\u003e44\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e]. To address the complex biomechanical deficits associated with massive rotator cuff tears, a combined approach incorporating both graft bridging (GB) and superior capsular reconstruction (SCR) may be considered. This combination aims to restore both static and dynamic stability of the shoulder joint, along with proper force balance.Accordingly, in the present study, a combined SCR and GB technique was employed to evaluate its clinical and structural outcomes in the treatment of MRCTs.\\u003c/p\\u003e \\u003cp\\u003eGraft options for rotator cuff repair include autografts and allografts. Autologous options, such as the LHBT [\\u003cspan citationid=\\\"CR46\\\" class=\\\"CitationRef\\\"\\u003e46\\u003c/span\\u003e] and fascia lata, [\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e] offer advantages including cost-effectiveness and superior histocompatibility, compared to allografts [\\u003cspan citationid=\\\"CR40\\\" class=\\\"CitationRef\\\"\\u003e40\\u003c/span\\u003e] or synthetic materials [\\u003cspan citationid=\\\"CR47\\\" class=\\\"CitationRef\\\"\\u003e47\\u003c/span\\u003e]. These autografts can be utilized in most healthcare settings. In the present study, we chose the LHBT for SCR and the autogenous fascia lata for GB. The use of the LHBT autograft is a technically feasible, cost- and time-saving alternative for SCR. Although the LHBT is not as wide as the fascia lata or dermal grafts used in other SCR techniques, a previous cadaveric biomechanical study[\\u003cspan citationid=\\\"CR48\\\" class=\\\"CitationRef\\\"\\u003e48\\u003c/span\\u003e] showed that SCR using LHBT results in equivalent, or even greater, strength compared with SCR using a fascia lata autograft in terms of preventing migration of the superior humerus. As the proximal portion of the LHBT remains attached to the superior glenoid, preservation of its vascularization is likely. Consequently, the LHBT graft may exhibit superior healing potential compared to other graft options. Finally, the LHBT in SCR occupies a small part of the footprint with only an anchor, allowing sufficient space for the following GB operation.\\u003c/p\\u003e \\u003cp\\u003eIn the current study, the combined surgery group showed significantly better outcomes, with lower retear rates (6.9%) compared to the partial repair group (37.5%). It has been reported[\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR49\\\" class=\\\"CitationRef\\\"\\u003e49\\u003c/span\\u003e] that successful functional outcomes are contingent upon successful graft healing. The ASES and CMS scores were significantly higher in the combined surgery group than in the partial repair group at the two-year follow-up. We speculate that there are several possible reasons for this. First, successful healing of rotator cuff repairs depends upon a biologically favorable healing environment, and excessive tension at the repair site may adversely affect healing outcomes[\\u003cspan citationid=\\\"CR50\\\" class=\\\"CitationRef\\\"\\u003e50\\u003c/span\\u003e]. Despite the use of techniques such as anchor medialization, marginal convergence, and interval slides, partial repair inevitably results in increased tension at the bone-anchor interface. This elevated tension may partly explain the higher failure rate observed in our study[\\u003cspan citationid=\\\"CR33\\\" class=\\\"CitationRef\\\"\\u003e33\\u003c/span\\u003e]. In contrast, the bridging technique utilizes a graft to link the native tendon to the humeral footprint. This approach enables a more even distribution of forces across the tuberosity and rotator cuff edges, reducing localized stress and promoting healing. Numerous studies comparing the use of bridging techniques with partial repair for treating MRCTs have reported similar findings[\\u003cspan citationid=\\\"CR10\\\" class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR51\\\" class=\\\"CitationRef\\\"\\u003e51\\u003c/span\\u003e]. One study[\\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e] compared the mini-open interposition procedure using a fascia lata autograft with an arthroscopic partial repair technique, showing that the graft group had better UCLA, ASES, and CMS scores, as well as lower retear rates (15% vs. 45.5%) at the two-year follow-up. Second, we performed autologous LHBT transfer together with GB, which may have further reduced the retear rate. A meta-analysis revealed that SCR using LHBT significantly reduced the retear rate and improved the ROM and AHI compared to conventional rotator cuff repair, highlighting its effectiveness in managing large to massive rotator cuff tears[\\u003cspan citationid=\\\"CR52\\\" class=\\\"CitationRef\\\"\\u003e52\\u003c/span\\u003e]. In a similar study[\\u003cspan citationid=\\\"CR24\\\" class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e], MRCTs were treated using autologous fascia lata bridging repair (GB) combined with synthetic artificial augmentation for SCR. The patients were divided into two groups, finding that the combined surgery group (bridging\\u0026thinsp;+\\u0026thinsp;SCR) had better mean AHI (7.0 mm vs. 5.9 mm ), mean improvement in AHI (3.3 mm vs. 2.0 mm), and autograft healing rate (92.3% vs. 54.2%) than the control group (bridging only) after a two-year follow-up. The retear rate of 7.7% reported by the authors is comparable to the 6.9% rate observed in this study, suggesting the potential benefits of SCR augmentation in reducing the failure of bridging repairs. The transposed LHBT may help share the initial tensile load and provide resistance against superior humeral head migration, which could contribute to improved graft protection.Our final follow-up data also demonstrated significantly improved AHI values in the combined surgery cohort compared to those who received partial repair (7.4 vs 5.4, p\\u0026lt;0.001), indicating superior anatomical restoration of the glenohumeral joint. This outcome likely reflects two synergistic mechanisms: (1) a depressor effect induced by the transposition of the LHBT, and (2) the spacer effect of the fascia lata autograft, which maintained critical subacromial dimensions while permitting biological incorporation.\\u003c/p\\u003e \\u003cp\\u003eMany investigations have reported the greater suitability of GB for treating rotator cuff tears with lower fatty degeneration (Goutallier stage 1 or 2 fatty degeneration)[\\u003cspan citationid=\\\"CR45\\\" class=\\\"CitationRef\\\"\\u003e45\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR53\\\" class=\\\"CitationRef\\\"\\u003e53\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e]. A study by Mori et al.[\\u003cspan citationid=\\\"CR54\\\" class=\\\"CitationRef\\\"\\u003e54\\u003c/span\\u003e] showed that in the high-grade fatty degeneration group (Goutallier stage 3 or 4 fatty degeneration of the infraspinatus), the retear rate reached 89.4%. In contrast, in our combined surgery group, 8 patients with high-grade fatty degeneration of the supraspinatus (7 patients belonged to Goutallier stage 3 and 1 patient belonged to stage 4) and only 2 of them(25%) experienced retear at \\u0026ge;\\u0026thinsp;2 years. We postulate that SCR with LHBT transposition improved the stability of the shoulder and promoted healing of the graft and rotator cuff even in patients with high-grade fatty degeneration. These findings suggest that the combined technique may remain effective in a subset of patients with advanced fatty degeneration; however, this observation should be interpreted with caution and requires confirmation in larger studies.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec14\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eLimitations\\u003c/h2\\u003e \\u003cp\\u003eThis study has several limitations. First, the applicability of the combined procedure depends on the integrity of the LHBT. In many patients with MRCTs, the LHBT may be ruptured or severely degenerated, rendering it unsuitable for transposition. In addition, anatomical variations or absence of the LHBT have been reported in rare cases[\\u003cspan citationid=\\\"CR55\\\" class=\\\"CitationRef\\\"\\u003e55\\u003c/span\\u003e]. Therefore, careful preoperative MRI evaluation and intraoperative assessment of the LHBT are essential for appropriate patient selection. Although McClatchy et al[\\u003cspan citationid=\\\"CR56\\\" class=\\\"CitationRef\\\"\\u003e56\\u003c/span\\u003e]. reported favorable clinical outcomes following biceps tendon transfer regardless of tendon condition, further studies are required to clarify the optimal indications for this procedure.Second, although the combined procedure was compared with partial repair in the present study, comparisons with isolated GB or SCR procedures were not performed. This limitation was mainly due to the limited sample size and study design. With the accumulation of larger cohorts in the future, well-designed comparative studies with multiple treatment arms will be necessary to further determine the independent and additive effects of GB and SCR Third, the two surgical strategies were performed in different time periods, which may introduce temporal and learning-curve-related bias,although all procedures were performed by the same senior surgeon using standardized protocols.Fourth, the relatively small sample size in each group limited the ability to perform a formal power analysis.Fifth, the follow-up duration was mid-term, and longer-term studies are necessary to evaluate the durability of the clinical and structural outcomes of this combined technique.\\u003c/p\\u003e \\u003c/div\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eBoth autogenous fascia lata graft bridging with LHBT transposition and partial repair were effective in the treatment of MRCTs at two-year follow-up. However, the combined surgical approach was associated with better ASES and CMS scores, increased acromiohumeral distance, and lower retear rates compared with partial repair alone. Therefore, this combined technique may represent a viable surgical option for selected patients with massive rotator cuff tears.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eAHI\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eAcromiohumeral interval\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eAROM\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eActive range of motion\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eASES\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eAmerican Shoulder and Elbow Surgeons score\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eCMS\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eConstant Murley Score\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eGB\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eGraft bridging\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eLHBT\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eLong head of the biceps tendon\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eMRCTs\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eMassive rotator cuff tears\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eSCR\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eSuperior capsular reconstruction\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e \\u003cdiv class=\\\"Term\\\"\\u003eUCLA\\u003c/div\\u003e \\u003cdiv class=\\\"Description\\\"\\u003e \\u003cp\\u003eUniversity of California, Los Angeles shoulder scores\\u003c/p\\u003e \\u003c/div\\u003e \\u003c/div\\u003e \\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003eEthics approval and consent to participate：This study was approved by the Institutional Ethical Committee of wuhan Fourth Hospital (KY2021-064-01). Due to the retrospective nature of the study, the requirement for informed consent was waived by the Ethics Committee. All procedures involving human participants were conducted in accordance with the Declaration of Helsinki.\\u003c/p\\u003e\\n\\u003cp\\u003eConsent for publication：Not applicable\\u003c/p\\u003e\\n\\u003cp\\u003eAvailability of data and materials:The datasets generated and analyzed during the current study are not publicly available due to restrictions imposed by the hospital Ethics Committee to protect patient privacy. De-identified data may be made available from the corresponding author upon reasonable request, subject to approval by the ethics committee.\\u003c/p\\u003e\\n\\u003cp\\u003eCompeting Interests: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.\\u003c/p\\u003e\\n\\u003cp\\u003eFunding: This study received no external funding.\\u003c/p\\u003e\\n\\u003cp\\u003eAuthors' contributions:\\u003c/p\\u003e\\n\\u003cp\\u003eShaohua zhang: Designed ; Wrote the original draft ; Conducted statistical analysis.\\u003c/p\\u003e\\n\\u003cp\\u003eQingsong zhang: Supervised the project ; Revised the manuscript ; Performed all arthroscopic procedures.\\u003c/p\\u003e\\n\\u003cp\\u003eYushun Fang: Collected data , Managed the database ; Revised the manuscript\\u003c/p\\u003e\\n\\u003cp\\u003eMing Tang: Conducted statistical analysis\\u003c/p\\u003e\\n\\u003cp\\u003eYanan Li: Collected data\\u003c/p\\u003e\\n\\u003cp\\u003eJun Xiong: Collected data\\u003c/p\\u003e\\n\\u003cp\\u003eZhujun Wang: Collected data\\u003c/p\\u003e\\n\\u003cp\\u003eTao Li: Collected data\\u003c/p\\u003e\\n\\u003cp\\u003eAll authors read and approved the final manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eAcknowledgements: The authors would like to thank all the staff involved in patient care and data collection.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003eYamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. 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Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2001;17(9):905\\u0026ndash;12.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLo IK, Burkhart SS. Arthroscopic revision of failed rotator cuff repairs: technique and results. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2004;20(3):250\\u0026ndash;67.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTashjian RZ, Erickson GA, Robins RJ, Zhang Y, Burks RT, Greis PE. Influence of Preoperative Musculotendinous Junction Position on Rotator Cuff Healing After Double-Row Repair. 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Arthroscopic Partial Repair of Irreparable Rotator Cuff Tears: Preoperative Factors Associated With Outcome Deterioration Over 2 Years. Am J Sports Med. 2015;43(8):1965\\u0026ndash;75.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMoriyama H, Gotoh M, Tanaka K, Mitsui Y, Nakamura H, Ozono H, et al. Midterm Functional and Structural Outcomes of Large/Massive Cuff Tears Treated by Arthroscopic Partial Repair. Orthop J sports Med. 2021;9(3):2325967120988795.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eOno Y, LeBlanc J, Bois AJ, Tsuchiya S, Thangarajah T, More KD, et al. Graft Healing Is More Important Than Graft Technique: Superior Capsular Reconstruction Versus Bridging Grafts-A Prospective Randomized Controlled Trial. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2022;38(12):3109\\u0026ndash;17.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBurkhart SS, Pranckun JJ, Hartzler RU. Superior Capsular Reconstruction for the Operatively Irreparable Rotator Cuff Tear: Clinical Outcomes Are Maintained 2 Years After Surgery. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2020;36(2):373\\u0026ndash;80.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMihata T, Lee TQ, Watanabe C, Fukunishi K, Ohue M, Tsujimura T, et al. Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. 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Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2022;38(3):692\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAbboud JA, Soslowsky LJ. Interplay of the static and dynamic restraints in glenohumeral instability. Clin Orthop Relat Res 2002(400):48\\u0026ndash;57.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLabriola JE, Lee TQ, Debski RE, McMahon PJ. Stability and instability of the glenohumeral joint: the role of shoulder muscles. \\u003cem\\u003eJournal of shoulder and elbow surgery\\u003c/em\\u003e 2005;14(1 Suppl S):32s-8s.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eClark JM, Harryman DT 2. Tendons, ligaments, and capsule of the rotator cuff. Gross and microscopic anatomy. J Bone Joint Surg Am. 1992;74(5):713\\u0026ndash;25.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMihata T, McGarry MH, Pirolo JM, Kinoshita M, Lee TQ. Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. Am J Sports Med. 2012;40(10):2248\\u0026ndash;55.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGan K, Bi M, Zhou K, Xia C, Ding W, Ding S, et al. Bridging repair reinforced with artificial ligament as an internal brace for irreparable massive rotator cuff tears. J Shoulder Elbow Surg. 2024;33(6):e322\\u0026ndash;35.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eKim JH, Lee HJ, Park TY, Lee JU, Kim YS. Preliminary outcomes of arthroscopic biceps rerouting for the treatment of large to massive rotator cuff tears. J Shoulder Elbow Surg. 2021;30(6):1384\\u0026ndash;92.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHamada K, Fukuda H, Mikasa M, Kobayashi Y. Roentgenographic findings in massive rotator cuff tears. A long-term observation. Clin Orthop Relat Res 1990(254):92\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEllman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am. 1986;68(8):1136\\u0026ndash;44.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePatte D. Classification of rotator cuff lesions. Clin Orthop Relat Res 1990(254):81\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional outcome after arthroscopic double-row rotator cuff repair. A prospective outcome study. J Bone Joint Surg Am. 2007;89(5):953\\u0026ndash;60.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMatthewson G, Coady CM, Wong IH. Rotator Cuff Reconstruction Using Fascia Lata Patch Autograft for the Nonrepairable Rotator Cuff Tear. Arthrosc techniques. 2020;9(1):e123\\u0026ndash;30.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eIagulli ND, Field LD, Hobgood ER, Ramsey JR, Savoie FH. 3rd. Comparison of partial versus complete arthroscopic repair of massive rotator cuff tears. Am J Sports Med. 2012;40(5):1022\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLee KW, Lee GS, Yang DS, Park SH, Chun YS, Choy WS. Clinical Outcome of Arthroscopic Partial Repair of Large to Massive Posterosuperior Rotator Cuff Tears: Medialization of the Attachment Site of the Rotator Cuff Tendon. Clin Orthop Surg. 2020;12(3):353\\u0026ndash;63.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePark SG, Shim BJ, Seok HG. How Much Will High Tension Adversely Affect Rotator Cuff Repair Integrity? Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2019;35(11):2992\\u0026ndash;3000.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDavies A, Singh P, Reilly P, Sabharwal S, Malhas A. Superior capsule reconstruction, partial cuff repair, graft interposition, arthroscopic debridement or balloon spacers for large and massive irreparable rotator cuff tears: a systematic review and meta-analysis. J Orthop Surg Res. 2022;17(1):552.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMihata T, McGarry MH, Kahn T, Goldberg I, Neo M, Lee TQ. Biomechanical Effects of Acromioplasty on Superior Capsule Reconstruction for Irreparable Supraspinatus Tendon Tears. Am J Sports Med. 2016;44(1):191\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAlarcon JF, Uribe-Echevarria B, Clares C, Apablaza D, Vargas JC, Benavente S, et al. Superior Capsular Reconstruction With Autologous Fascia Lata Using a Single Lateral-Row Technique Is an Effective Option in Massive Irreparable Rotator Cuff Tears: Minimum 2-Year Follow-Up. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2021;37(9):2783\\u0026ndash;96.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGoetti P, Denard PJ, Collin P, Ibrahim M, Hoffmeyer P, L\\u0026auml;dermann A. Shoulder biomechanics in normal and selected pathological conditions. EFORT open reviews. 2020;5(8):508\\u0026ndash;18.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHowell SM, Imobersteg AM, Seger DH, Marone PJ. Clarification of the role of the supraspinatus muscle in shoulder function. J Bone Joint Surg Am. 1986;68(3):398\\u0026ndash;404.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBaek CH, Kim BT, Kim JG, Kim SJ. Mid-Term Outcome of Superior Capsular Reconstruction Using Fascia Lata Autograft (At Least 6 mm in Thickness) Results in High Retear Rate and No Improvement in Muscle Strength. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2024;40(7):1961\\u0026ndash;71.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eModi A, Haque A, Deore V, Singh HP, Pandey R. Interposition GraftJacklografts for irreparable rotator cuff tears. bone joint J 2022;104\\u0026ndash;b(1):91\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLiao Y, Zhou Z, Wang J, Li H, Zhou B. Fascia Lata Autografts Achieve Interface Healing With the Supraspinatus Muscle Histologically and Mechanically in a Rat Supraspinatus Tendon Reconstruction Model for Massive Irreparable Rotator Cuff Tears. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2024;40(11):2655\\u0026ndash;66.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLewington MR, Ferguson DP, Smith TD, Burks R, Coady C, Wong IH. Graft Utilization in the Bridging Reconstruction of Irreparable Rotator Cuff Tears: A Systematic Review. Am J Sports Med. 2017;45(13):3149\\u0026ndash;57.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBi M, Zhou K, Gan K, Ding W, Zhang T, Ding S et al. Combining fascia lata autograft bridging repair with artificial ligament internal brace reinforcement: a novel healing-improvement technique for irreparable massive rotator cuff tears. bone joint J 2021;103\\u0026ndash;b(10):1619\\u0026ndash;26.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRanebo MC, Bj\\u0026ouml;rnsson Hallgren HC, Norlin R, Adolfsson LE. Long-term clinical and radiographic outcome of rotator cuff repair with a synthetic interposition graft: a consecutive case series with 17 to 20 years of follow-up. \\u003cem\\u003eJournal of shoulder and elbow surgery\\u003c/em\\u003e 2018;27(9):1622-8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRhee SM, Oh JH. Bridging Graft in Irreparable Massive Rotator Cuff Tears: Autogenic Biceps Graft versus Allogenic Dermal Patch Graft. Clin Orthop Surg. 2017;9(4):497\\u0026ndash;505.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eChiang CH, Shaw L, Chih WH, Yeh ML, Ting HH, Lin CH, et al. Modified Superior Capsule Reconstruction Using the Long Head of the Biceps Tendon as Reinforcement to Rotator Cuff Repair Lowers Retear Rate in Large to Massive Reparable Rotator Cuff Tears. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2021;37(8):2420\\u0026ndash;31.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSandhu H, Hackett L, Tumpalan JF, Lam PH, Murrell GAC. Synthetic polytetrafluoroethylene patches for irreparable rotator cuff tears-how are they doing at 5 years? J Shoulder Elbow Surg. 2023;32(3):e106\\u0026ndash;16.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eEl-Shaar R, Soin S, Nicandri G, Maloney M, Voloshin I. Superior Capsular Reconstruction With a Long Head of the Biceps Tendon Autograft: A Cadaveric Study. Orthop J sports Med. 2018;6(7):2325967118785365.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBarth J, Olmos MI, Swan J, Barthelemy R, Delsol P, Boutsiadis A. Superior Capsular Reconstruction With the Long Head of the Biceps Autograft Prevents Infraspinatus Retear in Massive Posterosuperior Retracted Rotator Cuff Tears. Am J Sports Med. 2020;48(6):1430\\u0026ndash;8.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDavidson PA, Rivenburgh DW. Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elbow Surg. 2000;9(6):502\\u0026ndash;6.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMori D, Funakoshi N, Yamashita F. 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. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2013;29(12):1911\\u0026ndash;21.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eShin KH, Jang IT, Han SB. Outcomes of Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon in Large to Massive Rotator Cuff Tears: A Meta-Analysis and Systematic Review. J Clin Med 2024;13(4).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eGupta AK, Hug K, Berkoff DJ, Boggess BR, Gavigan M, Malley PC, et al. Dermal tissue allograft for the repair of massive irreparable rotator cuff tears. Am J Sports Med. 2012;40(1):141\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMori D, Funakoshi N, Yamashita F, Wakabayashi T. Effect of Fatty degeneration of the infraspinatus on the efficacy of arthroscopic patch autograft procedure for large to massive rotator cuff tears. Am J Sports Med. 2015;43(5):1108\\u0026ndash;17.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDierickx C, Ceccarelli E, Conti M, Vanlommel J, Castagna A. Variations of the intra-articular portion of the long head of the biceps tendon: a classification of embryologically explained variations. J Shoulder Elbow Surg. 2009;18(4):556\\u0026ndash;65.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcClatchy SG, Parsell DE, Hobgood ER, Field LD. Augmentation of Massive Rotator Cuff Repairs Using Biceps Transposition Without Tenotomy Improves Clinical and Patient-Reported Outcomes: The Biological Superior Capsular Reconstruction Technique. Arthroscopy: J arthroscopic Relat Surg : official publication Arthrosc Association North Am Int Arthrosc Association. 2024;40(1):47\\u0026ndash;54.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":false,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-orthopaedic-surgery-and-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"josr\",\"sideBox\":\"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)\",\"snPcode\":\"13018\",\"submissionUrl\":\"https://submission.nature.com/new-submission/13018/3\",\"title\":\"Journal of Orthopaedic Surgery and Research\",\"twitterHandle\":\"@MSKmedBMC\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true},\"keywords\":\"massive rotator cuff tears, graft bridging, the long head of the biceps tendon, transposition, partial repair\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-8464962/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-8464962/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003e\\u003cstrong\\u003eBackground\\u003c/strong\\u003e: Graft bridging (GB) and superior capsular reconstruction (SCR) are utilized to treat massive rotator cuff tears (MRCTs), however they all have reported mixed results. In this study, we explore to combine the GB and SCR in one surgery. The aim of this study was to compare the effectiveness of surgeries that combing GB and SCR (in which autogenous fascia lata is used as the graft for GB while the long head of the biceps tendon [LHBT] is transposed for SCR) with partial repair in the treatment of MRCTs.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eMethods\\u003c/strong\\u003e: This retrospective comparative study evaluated two surgical treatments for MRCTs (\\u0026gt; 5 cm, ≥ 2 tendons involved, Hamada grade 1–3): partial repair (the partial repair group) versus autogenous fascia lata graft bridging combined with LHBT transposition (the combined surgery group). Patients were enrolled between January 2016 and June 2023. The clinical outcomes included active range of motion (forward flexion, external rotation, internal rotation) and the American Shoulder and Elbow Surgeons (ASES) score and the Constant Murley Score (CMS) assessed before surgery and at the final follow-up (\\u0026gt; 2 years). Radiographic assessments were used to determine the acromiohumeral interval(AHI) and graft integrity at before surgery and at the final follow-up.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eResults\\u003c/strong\\u003e: The study enrolled 53 patients with MRCTs, of whom 24 underwent partial repair and 29 received autogenous fascia lata graft bridging with LHBT transposition. Both groups demonstrated significantly improved ASES and CMS scores at the final follow-up (\\u0026gt; 2 years), with superior outcomes in the combined surgery group (ASES: 88.6 vs. 84.0, P = 0.014; CMS: 83.4 vs. 77.4, P \\u0026lt; 0.001). While both groups showed comparable improvements in the range of motion (both P \\u0026lt; 0.001), the combined surgery group exhibited significantly greater restoration of AHI (7.4 mm vs. 5.4 mm, P \\u0026lt; 0.001). MRI assessment revealed significantly lower retear rates (6.9% vs. 37.5%, P = 0.015) in the combined surgery group.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003eConclusion\\u003c/strong\\u003e: This study suggests that autogenous fascia lata graft bridging combined with biceps transposition is associated with better ASES and CMS scores, increased acromiohumeral distance, and lower retear rates compared with partial repair alone at two-year follow-up.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Combined Autogenous Fascia Lata Graft Bridging with Biceps Transposition Versus Partial Repair for Massive Rotator Cuff Tears: A Retrospective Comparative Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-01-30 13:08:05\",\"doi\":\"10.21203/rs.3.rs-8464962/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0},{\"type\":\"decision\",\"content\":\"Revision requested\",\"date\":\"2026-03-27T12:48:46+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-11T11:42:53+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-06T18:05:38+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"editorInvitedReview\",\"content\":\"\",\"date\":\"2026-02-05T20:10:35+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"189334183779608502571680106032308411974\",\"date\":\"2026-02-02T12:41:46+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"109976451304084857443597856568315905874\",\"date\":\"2026-02-01T09:25:42+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"88930702302170410911950314390623410094\",\"date\":\"2026-01-31T12:16:51+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewerAgreed\",\"content\":\"55478358404545489955673378795176805655\",\"date\":\"2026-01-28T19:22:43+00:00\",\"index\":\"hide\",\"fulltext\":\"\"},{\"type\":\"reviewersInvited\",\"content\":\"\",\"date\":\"2026-01-28T12:14:51+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"editorAssigned\",\"content\":\"\",\"date\":\"2026-01-06T07:14:37+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"checksComplete\",\"content\":\"\",\"date\":\"2026-01-06T03:33:02+00:00\",\"index\":\"\",\"fulltext\":\"\"},{\"type\":\"submitted\",\"content\":\"Journal of Orthopaedic Surgery and Research\",\"date\":\"2026-01-02T05:47:09+00:00\",\"index\":\"\",\"fulltext\":\"\"}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"journal-of-orthopaedic-surgery-and-research\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":false,\"externalIdentity\":\"josr\",\"sideBox\":\"Learn more about [Journal of Orthopaedic Surgery and Research](http://josr-online.biomedcentral.com)\",\"snPcode\":\"13018\",\"submissionUrl\":\"https://submission.nature.com/new-submission/13018/3\",\"title\":\"Journal of Orthopaedic Surgery and Research\",\"twitterHandle\":\"@MSKmedBMC\",\"acdcEnabled\":true,\"dfaEnabled\":true,\"editorialSystem\":\"em\",\"reportingPortfolio\":\"BMC/SO AJ\",\"inReviewEnabled\":true,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"3988c9c6-0d9b-4e6a-9219-8360de09288d\",\"owner\":[],\"postedDate\":\"January 30th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"under-review\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-23T19:08:10+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-01-30 13:08:05\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-8464962\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-8464962\",\"identity\":\"rs-8464962\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}