A patient with a severe rotator cuff injury required surgical treatment. Before the surgery, the doctor issued a list of spare materials for the surgery, including seven or eight anchors to repair the rotator cuff and fix the tendon, and the anchors alone cost 60,000 to 70,000 dollars. The patient wondered, “Do I have to use anchors for rotator cuff repair? This is the evolution of the rotator cuff repair method. In the past, the classic method of rotator cuff repair was arthrotomy: a bone tunnel was made in the greater tuberosity of the humeral head, sutures were threaded through the bone tunnel, and the sutures were used to pull the ruptured and retracted rotator cuff back into the greater tuberosity of the humeral head. At this time, no anchor staples were used (of course, the anchor staples were not very reliable in terms of material quality and design), and only sutures were used to reposition and fix the rotator cuff. This method of repair is called a through-the-bone suture repair. During this period, 20-30 years ago, rotator cuff repair underwent a change from incisional to arthroscopic surgery. At that time, the procedure was called arthroscopically assisted surgery, which meant that some minimally invasive procedures were performed using arthroscopic techniques, but ultimately the procedure was done through a mini-open incision. This was the time when the arthroscopic technique was maturing. As for the rotator cuff repair method, the first trial will be with a wire anchor nail, and if the surgery cannot be completed with a wire anchor nail, eventually the repair will be done with a bone piercing suture. In the last 20 years, because of the development and maturation of arthroscopic rotator cuff repair instruments and the maturation of arthroscopic surgical techniques, rotator cuff repair has moved beyond the mini-open stage to a fully arthroscopic repair. Currently, the standard arthroscopic rotator cuff repair is to use a wire anchor staple: a wire anchor staple is placed in the greater tuberosity of the humerus, then the wire from the anchor staple is passed through the torn rotator cuff, and finally the rotator cuff is pulled back to the greater tuberosity of the humerus for fixation. Figure 2. Single-row repair of rotator cuff with wire anchors The method of rotator cuff repair with wire anchors is also changing. The earlier repair was called a single-row repair, in which the rotator cuff was pulled back with a single row of anchors. Although the rotator cuff was pulled back to the humeral head, the contact area with the humeral head was not very large, which was far less than that of the past joint incision repair with bone penetrating sutures, and eventually the healing of the rotator cuff was compromised. In recent years, a new technique of repairing the rotator cuff with wire anchor staples has emerged, called the bone-piercing technique. Generally, 2 rows of anchors are used: first, the inner row of anchors is used to pass through the rotator cuff medially as much as possible to reset the rotator cuff; then the outer row of anchors is used to press down the sutures from the inner row of anchors along with the rotator cuff, which can fully increase the contact area between the rotator cuff and the greater tuberosity of the humerus, and the effect is similar to that of the osteotomy suture repair in the past, so it is called the osteotomy-like technique. In terms of the biomechanics of the rotator cuff and the clinical outcome of the repair, the bone-through technique has significant advantages over the single-row anchor nail repair technique. The above patient had a larger number of anchors in preparation for the bone-like double-row rotator cuff repair. Because of the wire anchors, conventional rotator cuff repair can be accomplished arthroscopically with a minimally invasive arthroscopic technique. However, there are certain problems associated with the use of anchor nails to repair the rotator cuff. One of the biggest problems is that if the patient has osteoporosis, the anchor nail can easily pull out of the bone and cause the repair to fail. Most rotator cuff injuries occur in middle-aged and elderly patients who already have generalized osteoporosis and a corresponding decrease in bone density locally in the shoulder joint. In addition, some studies have shown that after a complete rotator cuff rupture, if not repaired in time, there is an increase in localized osteoporosis in the shoulder joint, called disuse bone atrophy. This condition is predominant in domestic patients, who prefer to delay surgical treatment. The decrease in the original bone density of the shoulder, combined with the wasting bone atrophy, makes it more difficult to repair the rotator cuff. For osteoporosis of the shoulder joint, the surgeon will use some methods to circumvent it. For example, when implanting anchor nails, they choose areas with high bone density, use larger anchor nails, and use specially designed anchors with high extraction resistance. However, in severe osteoporosis, none of these methods may be able to prevent the anchor nail from being pulled out. Because repair with wire anchors is not reliable in patients with osteoporosis of the shoulder, some scholars have reverted to the method of repair with through-bone sutures. Of course, instead of the previous arthrotomy, the current osteotomy repair is done arthroscopically. Arthroscopic suture-through-bone repair is more complex and time-consuming than wire-anchored repair. A skilled sports medicine or arthroscopic surgeon who can perform an arthroscopic osteotomy-like repair with wire anchors in less than 90 minutes will typically take 2 hours to complete a true osteotomy suture repair under arthroscopy. For patients without significant osteoporosis, a conventional wire-anchored nail-like through-bone repair procedure is recommended. This procedure saves surgical time despite the tens of thousands of dollars in material costs. Because shoulder arthroscopy is performed under general anesthesia and with blood pressure lowered to a low limit (to reduce intraoperative surgical field bleeding), an additional half hour of operative time is an additional half hour of risk of cerebral ischemia. However, in patients with significant osteoporosis, where rigid anchor repair would certainly result in surgical failure, there is value in using a more complex procedure – arthroscopic bone penetration repair. In some patients, there is extreme osteoporosis, which is not reliable even with osteotomy suture repair: because the shoulder bone is very loose, the sutures will cut through the loose bone and displace it. This is where a special through-the-bone repair technique, known as Fix-to-suture Base repair, is needed. This technique was designed by Jinzhong Zhao: the suture is still tied to the greater tuberosity of the humerus, but instead of being tied to the greater tuberosity or the lateral tuberosity, it is tied to a reliable suture base on the distal side, thus avoiding the suture cutting through the loose bone. Figure 4. Fix-to-Suture Base Repair Technique for the Rotator Cuff The Fix-to-Suture Base repair technique was used in the early stages to treat patients who had failed rotator cuff repair due to severe osteoporosis, and is now used as a preferred measure to aggressively treat rotator cuff injuries in patients with osteoporosis. First, the degree of osteoporosis and the presence of localized cavities (bone cysts) in the rotator cuff should be understood preoperatively by X-rays, CT and MRI; intraoperatively, the density of the bone at the site of the intended nail placement should be investigated with a puncture cone, and the Fix-to-Suture Base technique should be used once the bone is found to be too soft. So, do I have to use an anchor nail for rotator cuff repair? The answer is: in the absence of severe shoulder osteoporosis, anchor nailing is preferable to save operative time; in the presence of severe shoulder osteoporosis, anchor nailing is contraindicated and arthroscopic bone penetration repair or even Fix-to-Suture Base repair technique is required.