In situ repair of partial-thickness rotator cuff tears: a critical analysis review

Arthroscopic double row partial articular supraspinatus tendon avulsion bridge repair technique for shoulder: A transtendinous approach

Partial articular supraspinatus tendon avulsion (PASTA) lesions, a subset of partial rotator cuff tears, pose a surgical challenge, disrupting the integrity of the supraspinatus tendon. Transtendinous repair is the preferred choice in young individuals for limiting tear progression and preserving intact, high-quality cuff tissue, thus preventing tendon shortening, as compared to the tear completion and repair technique. Our approach leverages these advantages, specifically those indicated for Ellman's Grade 3 tears and cases where conservative treatments have failed. In our technique, we employ progressive dilation, anchor drill sleeve insertion to facilitate medial row anchor placement, followed by percutaneous spinal needles for suture shuttling, and finally locking sliding knots for compressive medial row repair, followed by lateral row fixation for additional stability. This method accelerates rehabilitation and restores optimal shoulder function.

Biomechanical effect of increased number of suture strands on rotator cuff repair in a bovine model

OBJECTIVE

This study aimed to investigate if there was a link between the biomechanical properties and the number of suture strands in repairing a rotator cuff (RC) tear in a bovine model using the transosseous technique.

METHODS

Fifty-four fresh tendons from bovine (mean age: 7.1 ± 0.5 months; range 6.5-7.5 months) and 1 humeral head from porcine (8.5 months) were used in this study. All the specimens had no apparent abnormalities. Using the transosseous structure, the RC tendon was detached from the greater tuberosity and randomly assigned to 3-strand, 4-strand, 5-strand, and 6-strand groups, with the glenohumeral abducted at 0° and 90°. Biomechanical tests were conducted to compare the groups' differences in the failure mode, pull-toextension load in the 1-, 2-, and 3-mm formations, and the maximum load. The analysis of variance test was performed to compare the results. Statistical significance was set at P < .05.

RESULTS

No significant difference was observed among the groups concerning the tendon characteristics (all P ≥ .05). At 90° shoulder abduction, a significant difference was detected in the load between 3- and 5-strand groups for 1-mm gap formation (P=.049). No statistical differences were noted in the load at the gap displacements in the 1-, 2-, and 3-mm formations at 0° and 90° shoulder abduction (all P > .05). The maximum failure load and extension in maximal tension increased with the number of sutures.

CONCLUSION

The maximum load and ultimate extension increase with the number of sutures at both positions. The number of sutures was not an influencing factor of gap formation. Regarding the tear size and tension of the RC, choosing the appropriate number of strands individually instead of excessively increasing the number of sutures is advocated for RC repair.

Functional and MRI Outcomes After In Situ Repair Versus Tear Completion Before Repair of Bursal-Side Partial-Thickness Rotator Cuff Tears

OBJECTIVE

The optimal repair method for bursal-side partial-thickness rotator cuff tears (PTRCTs) involving >50% of the thickness remains a controversial topic. The study was aimed to compare the functional and magnetic resonance imaging (MRI) outcomes after in situ repair or tear completion before repair of bursal-side PTRCTs.

METHODS

A retrospective clinical study was conducted involving 58 patients who underwent in situ repair or tear completion before repair of bursal-side PTRCTs between January 2019 and December 2020. These patients were divided into two groups: the in situ repair group and the tear completion before repair group. Functional assessment consisted of active range of motion (ROM), visual analog scale (VAS), American Shoulder and Elbow Surgeons (ASES) score, and Constant-Murley score. The percentages of patients in each group achieving the minimal clinical important difference (MCID) of the functional scores were determined. The healing status of the rotator cuff was assessed by postoperative MRI.

RESULTS

There were no statistically significant differences between the two groups in terms of demographic data. The mean follow-up period was 14.53 ± 2.64 months in the in situ repair group and 15.40 ± 2.66 months in the tear completion before repair group. At the final follow-up, the forward elevation, external rotation, and internal rotation improved significantly in both groups. The VAS, ASES score, and Constant-Murley score improved significantly in the in situ repair group (5.17 ± 2.00 points to 0.11 ± 0.41 points, p = 0.001; 44.04 ± 17.40 points to 95.47 ± 4.32 points, p = 0.001; 49.50 ± 14.38 points to 93.50 ± 3.49 points, p = 0.001) and in the tear completion before repair group (5.43 ± 3.32 points to 0.03 ± 0.18 points, p = 0.001; 41.50 ± 19.59 points to 95.94 ± 2.68 points, p = 0.001; 47.54 ± 17.13 points to 93.97 ± 2.61 points, p = 0.001). Postoperative MRI revealed that the re-tear rate was 7.1% (2/28) in the in situ repair group and 3.3% (1/30) in the tear completion before repair group. No significant differences were observed in terms of the functional scores, the percentages of patients achieving the MCID of the functional scores, and the re-tear rate between the two groups (p > 0.05).

CONCLUSIONS

Both in situ repair and tear completion before repair yielded satisfactory clinical outcomes for patients with bursal-side PTRCTs. No significant differences were observed in the functional and MRI outcomes between the two groups.

Transtendon Repair Under Switching-Scope Technique for Articular Partial-Thickness Rotator Cuff Tears

Partial-thickness rotator cuff tears are common diseases causing pain and disability. Among the different surgical methods, the transtendon repair technique is recommended due to its biomechanically superiority. However, this technique has a high learning curve and is time-consuming. In this Technical Note, we introduce a safer and more effective modified transtendon repair technique. Our switching-scope technique sets a switching stick into the glenohumeral joint through the posterior portal and is used as a guide for switching the arthroscope between the subacromial and articular spaces. This technique can reduce surgical time and overcome the disadvantage of vision limitation in articular-sided transtendon repair.

Repair of high-grade partial thickness supraspinatus tears after surgical completion of the tear have a lower retear rate when compared to full-thickness tear repair

PURPOSE

High-grade partial thickness rotator cuff tears (i.e., those involving at least 50% of the tendon thickness) are especially challenging to treat and various treatment strategies have been described. Prior studies have demonstrated equivalent outcomes between in situ tear fixation and tear completion repair techniques. However, it is unknown how repair of completed high-grade partial thickness tears to full tears compares to repair of full-thickness tears. The purpose of this study was to compare clinical outcome measures at least 1 year postoperatively between patients who had completion of a high-grade partial thickness supraspinatus tear to a full-thickness tear (PT) and those who had an isolated full-thickness supraspinatus tear (FT). The hypothesis of this study was equivalent retear rates as well as equivalent clinical and patient-reported outcomes between the two groups.

METHODS

A retrospective review of 100 patients who underwent isolated arthroscopic supraspinatus repair between 2013 and 2018 with a minimum of 1 year follow-up was performed. Patients were separated into two groups based on their treatment: 56 had completion of a partial thickness supraspinatus tear to full-thickness tear with repair (PT) and 44 had isolated full-thickness supraspinatus repairs (FT). The primary outcome was rotator cuff retear, which was defined as a supraspinatus retear requiring revision repair. Secondary outcomes were patient-reported outcome measures (PROs) including visual analog pain scale (VAS) and subjective shoulder value (SSV), range of motion (ROM) and strength in forward flexion (FF), external rotation (ER), and internal rotation (IR).

RESULTS

There was a significantly lower rate of retear between the PT versus FT groups (3.6% vs. 16.3%, p = 0.040). There were no significant differences between groups for all PROs, all ROM parameters, and all strength parameters (all n.s.).

DISCUSSION

The data from this study demonstrated that the PT group had a significantly lower retear rate at 1 year follow-up than the FT group, while PROs, ROM, and strength were similar between the two groups. Patients with PT supraspinatus tears can have excellent outcomes, equivalent to FT tears, after completion of the tear, and subsequent repair with low retear rates. These findings may aid the treating surgeon when choosing between in situ fixation of the PT supraspinatus tear or completion of the tear and subsequent repair, as it allows the treating surgeon to choose the procedure based on comfort and experience level.

LEVEL OF EVIDENCE

Level III.

Editorial Commentary: Arthroscopic Repair of Partial Thickness Rotator Cuff Tears: What Do We Know So Far and Where Should We Put the Focus of Our Future Research?

The available evidence shows that arthroscopic repair using either the transtendon in situ repair technique or the tear completion and subsequent repair technique are associated with favorable results in the short term. Likewise, the location of the lesions (articular or bursal) does not seem to significantly influence the clinical results, regardless of the technique used. Specifically with regard to the surgical technique of choice in the case of deciding to complete the tear and then repair it, it remains to be defined more clearly in future investigations whether it is better to repair with a single- or double-row technique, whether associated subacromial decompression has any advantage and what the results of this technique are in the subgroup of athletes, especially in competitive and overhead athletes in whom repair of rotator cuff tears has shown unfavorable outcomes mainly at the expense of a low return to the same level of sport.