Articular surface partial-thickness rotator cuff tears

Partial-thickness rotator cuff tears: a review of current literature on evaluation and management

Rotator cuff disease is a common cause of shoulder pain for which partial-thickness rotator cuff tears occupy a significant proportion. Such tears are often difficult to diagnose and manage in the general clinic setting. A review of the available literature from well-known databases was performed in this study to provide a concise overview of partial-thickness rotator cuff tears to aid physicians in their understanding and management.

Long-Term Follow-Up of Inpatients with Rotator Cuff Tear Who Received Integrative Korean Medicine Treatment: A Retrospective Analysis and Questionnaire Survey

CONTEXT

Rotator cuff tear is one of the most common causes of shoulder pain and has become a prominent disease most frequently treated by surgery.

OBJECTIVES

To investigate the long-term therapeutic effect of integrative Korean medicine (KM) as a conservative treatment in treating rotator cuff tears.

DESIGN

A multicenter observational study.

SETTINGS

The settings involve four regional network KM hospitals.

PATIENTS

The study participants are 288 patients aged 19-70 with rotator cuff tear identified by radiologist based on magnetic resonance imaging who received integrative KM treatment for the chief complaint of shoulder pain between 1 January 2015 and 31 March 2020.

INTERVENTION

None.

MAIN OUTCOMES

The primary outcome was the pain score in the affected shoulder, measured by the numeric rating scale (NRS). The secondary outcomes were Shoulder Pain and Disability Index (SPADI), 5-Level Quality of life: EuroQol 5-Dimension (EQ-5D-5L), Patient Global Impression of Change (PGIC), and range of motion (ROM) scores.

RESULTS

Eligible patients for MCID achievement analysis for minimally clinical important change were 167, and 109 completed the follow-up survey. The mean NRS pain score in the affected shoulder was 5.80 ± 1.27 at admission, 3.50 ± 1.32 at discharge, and 3.83 ± 2.04 at follow-up.The mean SPADI score was 51.48 ± 20.18 at admission, 37.76 ± 19.23 at discharge, and 24.26 ± 21.80 at follow-up. The improvement at discharge (P-value < 0.001) and follow-up (P-value < 0.001) compared to those at admission was statistically significant. The results also presented a significant improvement in ROM for all motions at discharge after treatment (P-value < 0.001). The number of patients who achieved minimal clinically important difference in NRS was 116 (69.5%) at discharge and 71 (65.1%) at follow-up, and in SPADI was 82 (50.9%) at discharge and 77 (70.6%) at follow-up.

CONCLUSION

The results of this study suggested that integrative KM treatment can help improve pain, functional impairment, QoL, and ROM in patients with a rotator cuff tear TRIAL REGISTRATION: NCT04566939.

Effects of Arthroscopic Atelocollagen Insertion in High-Grade Partial Articular Supraspinatus Tendon Avulsion Lesions: A Retrospective Cohort Study With Propensity Score Matching

Background

This study sought to evaluate the effect of atelocollagen insertion into the bone-tendon interface of the repaired tendon after arthroscopic rotator cuff repair for high-grade partial articular supraspinatus tendon avulsion (PASTA) lesions.

Purpose

To compare clinical and radiological outcomes of atelocollagen-inserted rotator cuff repair and atelocollagen-noninserted rotator cuff repair in the high-grade PASTA lesions.

Study Design

Cohort study; Level of evidence, 3.

Methods

The data from 301 consecutive patients who underwent arthroscopic rotator cuff repair of PASTA lesions between January 2017 and June 2020 were retrospectively reviewed. Patients with minimum 2-year follow-up data were included and divided into 2 groups: those treated with transtendon suture-bridge repair without additional augmentation (group 1) and those with atelocollagen-inserted transtendon suture-bridge repair (group 2). Patients in group 2 were matched 1:1 to patients in group 1 using propensity score matching (n = 68 per group); and pain visual analog scale, American Shoulder and Elbow Surgeons, University of California, Los Angeles, Korean Shoulder Scoring System, Simple Shoulder Test, and range of motion scores were compared between these groups. Also, repaired tendon integrity and thickness were compared immediately, 6 months, and 1 year after surgery on magnetic resonance imaging (MRI) using the vertical distance from the midpoint footprint of the greater tuberosity.

Results

In most comparisons, there were no significant differences in outcome measures and range of motion between groups. However, less residual discomfort at the final follow-up was also documented in group 2 (P = .043). Also, the difference in forward flexion was 3.7° at 1 year and 5.4° at final follow-up, and the difference in abduction was 2.2° at final follow-up, which were all significantly greater in the experimental group. Group 2 showed significant greater tendon thickness of the repaired tendon immediately, 6 months, and 1 year after surgery on MRI (P≤ .001).

Conclusion

Addition of atelocollagen did not improve outcome scores. However, there was slightly greater flexion and abduction at final follow-up. Also, there was less residual discomfort at final follow-up.

Similar outcomes between transtendon repair and tear completion repair techniques for partial articular-sided supraspinatus tendon avulsion lesions: a systematic review and meta-analysis

PURPOSE

This study aimed to review studies comparing transtendon repair (TTR) with tear completion repair (TCR) techniques for partial articular-sided supraspinatus tendon avulsion (PASTA) lesions according to postoperative patient-reported outcomes and complications.

METHODS

Databases, including PubMed, Embase, Scopus, and Cochrane, were searched for studies published between 2008 and 2022 that directly compared the postoperative patient-reported outcomes and complications of the TTR and TCR techniques for PASTA lesions. Odds ratios (ORs) were calculated for dichotomous outcomes, while mean differences (MDs) were calculated for continuous outcomes.

RESULTS

A total of seven studies (497 shoulders) were analysed. No statistically significant differences in the postoperative clinical outcomes at the final follow-up were observed between the TTR and TCR techniques for PASTA lesions. The overall retear rates of the TTR and TCR techniques were 7.7% and 11.6%, respectively (corresponding healing rates were 92.3% and 88.4%), whereas the overall occurrence rates of adhesive capsulitis were 4.7% and 3.3%, respectively. Furthermore, no significant difference was observed in postoperative range of motion (forward flexion, MD = - 1.22, 95% confidence interval (95%CI) - 5.28 to 3.34, n.s.; external rotation, MD = - 1.39, 95% CI - 3.19 to 0.42, n.s.), overall retear rate (OR 0.72, 95% CI 0.29-1.08, n.s.), and occurrence rate of adhesive capsulitis (OR 1.11, 95% CI 0.35-3.52, n.s.) between the two techniques.

CONCLUSION

Both techniques improve clinical outcomes while having a low complication rate and a high rate of healing. No significant difference in clinical outcomes was observed between the two techniques.

LEVEL OF EVIDENCE

III.

The Spectrum of Shoulder Pathologies on Magnetic Resonance Imaging: A Pictorial Review

Patients present to the orthopedic outpatient department with complaints of shoulder pain on movement or restriction of movement in the shoulder joint and are referred for magnetic resonance imaging (MRI) of the shoulder joint. Almost all the patients have similar complaints but may have a wide range of pathology affecting the joint and causing pain. Rotator cuff tears or tendinopathy are the most common causes of shoulder pain. Ultrasound (USG) and MRI are the most commonly used imaging modalities for assessing rotator cuff pathologies. There is a wide range of pathologies affecting the shoulder joint, other than rotator cuff tendinopathies or tears, for which USG is less sensitive and specific in detecting accurate pathology. MRI is the choice of imaging for shoulder joint pathologies. We present a pictorial review discussing and depicting MRI features of a wide list of pathologies of the shoulder joint complex that should be kept in mind when the patient presents with shoulder pain.

All-Inside Arthroscopic Partial Articular-Sided Supraspinatus Tendon Avulsion (PASTA) Repair Without Bunching of the Bursal Side of the Tendon

PASTA (partial articular-sided supraspinatus tendon avulsion) lesions are supraspinatus tendon tears involved the articular surface. PASTA lesions are commonly repaired using trans-tendon repair or tendon takedown and repair. Systematic reviews have shown that both techniques can improve shoulder function similarly. The advantages of trans-tendon repair are the preservation of the intact tendon and superior biomechanical strength. However, there is a risk that the tendon will become overtensioned and that the technique will create tendon bunching on the bursal side, resulting in imbalanced tendon tension. This Technical Note describes an all-inside arthroscopic trans-tendon repair technique of PASTA lesion without bunching the tendon's bursal side.

Delamination in rotator cuff tears: Explanation of etiology through anatomical dissection

The prognostic significance of delaminated rotator cuff tears remains controversial. However, as the surgical goal is to maximize the contact area between layers, the macroscopic appearance of partial delaminated rotator cuff tears is essential. The aim of this anatomical study was to investigate the morphology of delaminated rotator cuff tears. We hypothesized that delamination zones at the intersection of the supraspinatus and infraspinatus tendon fibers are the origin of articular-side degenerative rotator cuff tears. Forty anatomical specimens were evaluated in this study. The supraspinatus and infraspinatus muscles were dissected, the origins were meticulously worked out and followed to their insertions at the humeral head. Fiber exchanges, overlays and delamination zones between the supraspinatus and infraspinatus muscles were photographically documented and measured. Delamination of rotator cuff tears can be classified into articular-side and bursal-side tears. The articular-layer consists of capsuloligamentous tissue, which included the rotator-cable/rotator-crescent complex, the joint capsule and a small part of the supraspinatus tendon. The bursal-side layer represents the tendinous tissue, which consists of the parallel, tendinous parts of the supraspinatus and infraspinatus muscles. Delamination of rotator cuff tears can be classified into articular-side and bursal-side tears. Present model of degenerative tears might explain the high prevalence of articular-side tears, which expand into the rotator-cable/rotator-crescent complex. It may be important for surgeons to incorporate these anatomical findings and considerations into the surgical planning.

No Difference in Outcome Between Articular-Sided and Bursal-Sided Tears: Comparative Study With Minimum 2-Year Follow-Up of Arthroscopic Repairs in 104 Patients in a Single-Surgeon Series

PURPOSE

To evaluate and compare the functional outcomes after arthroscopic repair of bursal-sided versus articular-sided partial-thickness rotator cuff tears.

METHODS

We conducted a retrospective analysis of patients who had undergone arthroscopic tear completion and subsequent repair of symptomatic partial-thickness rotator cuff tears in a single institution from 2010 to 2015. Range of motion (ROM) (forward flexion and abduction), the pain score as measured on the Numeric Pain Rating Scale, and outcome scores (Constant-Murley score, University of California, Los Angeles shoulder score, and Oxford Shoulder Score) were calculated preoperatively and at 1 year and 2 years postoperatively. The delta difference was calculated for each outcome parameter at the respective follow-up points as the difference from the preoperative baseline score.

RESULTS

A total of 104 patients were included. All tears involved the supraspinatus tendon and did not exceed 2 cm. Of the patients, 65 had an articular-sided tear (AST) whereas 39 had a bursal-sided tear (BST). The mean age of the patients was 53.4 years in the AST group and 55.8 years in the BST group. The AST and BST groups did not differ preoperatively in terms of age, sex, and the measured outcome parameters. Postoperatively, the patients in both groups achieved statistically significant improvement in pain relief and functional outcomes at 2 years. No statistically significant difference was observed between the 2 groups in terms of the delta-difference outcomes in ROM in forward flexion (P = .781) or abduction (P = .348), pain score (P = .187), Constant-Murley score (P = .186), University of California, Los Angeles shoulder score (P = .911), and Oxford Shoulder Score (P = .186) at 2 years.

CONCLUSIONS

Partial-thickness rotator cuff tears treated with arthroscopic tear completion and subsequent repair achieved good outcomes in terms of ROM, functional outcomes, and pain relief at 2 years. There was no difference in outcomes regardless of whether the location of the tear was articular sided or bursal sided.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Arthroscopic Repair of a PASTA of the Shoulder Using a Bursal Split

PASTA (partial articular supraspinatus tendon avulsion) lesions are a subset of partial rotator cuff tears that are commonly treated by surgeons. Multiple surgical techniques exist for managing these lesions, including debridement, transtendinous repair, and completion of the tear and repair. Each of these techniques provides its own set of advantages and disadvantages, and currently there is no consensus on which method provides the best clinical outcomes or ease of procedure. Here, we present our repair technique for PASTA lesions, which involves a bursal split that takes the advantages of previous techniques by allowing improved visualization of the footprint and suture passing while avoiding the takedown any of Sharpey's fibers.

Clinical Outcome of Transtendon Repair of Partial Articular Supraspinatus Tendon Avulsion Tear

Partial articular supraspinatus tendon avulsion (PASTA) tears are common. However, there is no consensus on the optimal surgical technique for the management of grade 3 tears (>50%). The authors report a retrospective consecutive case series of 64 patients with grade 3 PASTA lesions. The patients were treated by 2 surgeons from 2 centers with the same transtendon repair technique and implant system. The preoperative Oxford Shoulder Score (OSS) was compared with the postoperative OSS at final follow-up (mean, 28 months). Significant improvement in mean OSS occurred from 19.2 (SD, 7.5) preoperatively to 39.8 (SD, 7.8) postoperatively (P=.0001), and patient satisfaction rates were high (88%). The authors believe that transtendon repair of PASTA lesions of 50% or more is beneficial. High-quality randomized controlled trials are required to compare the benefit of repair vs debridement alone. [Orthopedics. 2020;43(6):e533-e537.].

MR Imaging of the Rotator Cuff

The cause of rotator cuff tears is multifactorial with both intrinsic and extrinsic contributing factors. Understanding the normal MR anatomy of the rotator cuff and using an appropriate search pattern can help readers identify common pathologic conditions. Accurate designation using classification systems for tear thickness, size, and degree of retraction and muscle fatty infiltration and atrophy are important in guiding surgical management. Knowledge of common disease locations for the rotator cuff tendons can help focus reader searches and increase sensitivity.

Partial-Thickness Rotator Cuff Tear by Itself Does Not Cause Shoulder Pain or Muscle Weakness in Baseball Players

BACKGROUND

Partial-thickness rotator cuff tears are common shoulder injuries in baseball players. For some tears, the symptoms can be relieved through physical therapy or debridement without rotator cuff repair.

PURPOSE

To assess whether partial-thickness rotator cuff tear by itself causes shoulder pain and muscle weakness in baseball players.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

We studied 87 university baseball players (age, 19.5 ± 0.8 years; baseball career, 11.5 ± 1.6 years). All data were obtained during a full-participation annual medical check in 1 team. Rotator cuff tendons were examined ultrasonographically and allocated to 4 groups: (1) no tear, (2) supraspinatus tendon tear, (3) infraspinatus tendon tear, and (4) both supraspinatus and infraspinatus tendon tears. Current shoulder pain and shoulder muscle strength (dominant/nondominant) in abduction, external rotation, and internal rotation were compared by using chi-square and t tests. All players could play baseball with or without shoulder pain in this study.

RESULTS

Of the 87 players, 41 (47%) had articular-sided partial-thickness rotator cuff tears diagnosed on ultrasonography; the remaining 46 athletes were tear-free. Of the 41 affected patients, 19 had tears in the supraspinatus, 13 in the infraspinatus, and 9 in both the supraspinatus and infraspinatus tendons. Tear depth (mean ± SD) was 4.6 ± 2.3 mm in the supraspinatus and 6.2 ± 3.6 mm in the infraspinatus. Neither the rate of shoulder pain nor muscle strength differed significantly among the 4 groups (P = .96 and P = .15-.70, respectively).

CONCLUSION

Articular-sided partial-thickness rotator cuff tear-by itself-did not cause shoulder pain and muscle weakness in university baseball players. Most so-called articular-sided partial-thickness rotator cuff tears may not be pathologic tendon tears.

Arthroscopic treatment for intratendinous rotator cuff tear results in satisfactory clinical outcomes and structural integrity

PURPOSE

This study aimed to evaluate the clinical outcomes and structural integrity of arthroscopic repair of intratendinous rotator cuff tear.

METHODS

Patients who were diagnosed with an intratendinous tear but in whom conservative treatment failed were selected and underwent arthroscopic repair. Between 2008 and 2014, a total of 30 patients (6 men, 24 women; mean age, 59 ± 3.7 years) met the inclusion criteria and were followed up. The mean follow-up period was 26.3 ± 0.7 months. The results were evaluated using the University of California at Los Angeles (UCLA) score, the Society of the American Shoulder and Elbow Surgeons rating scale (ASES) questionnaire, and the visual analog scale (VAS) and range of motion (ROM) were measured preoperatively and at final follow-up. Magnetic resonance imaging (MRI) was performed preoperatively and at 6.7 ± 0.2 months postoperatively. Postoperative MRI was performed on 27 out of 30 patients and analysed using the Sugaya classification.

RESULTS

Corresponding to the preoperative MRI findings, arthroscopic findings of intratendinous tears were observed in all 30 patients. The mean active forward elevation ROM was 137.3° ± 15.4° before surgery and 168.8° ± 15.2° at the final follow-up. The internal and external rotations at abduction were 31.7° ± 5.1° and 63.0° ± 11.6° before surgery, respectively, and 60.5° ± 8.0° and 75.2° ± 10.8° after surgery, respectively. The UCLA score improved from of 20.1 ± 7.4 points preoperative to 28.4 ± 5.5 points at the final follow-up. The ASES score improved from 55.7 ± 15.3 points preoperative to 82.6 ± 9.7 points postoperatively. The VAS for pain score decreased from 6.4 ± 1.2 points preoperative to 1.6 ± 0.9 points postoperative. Satisfactory outcomes (excellent/good) in terms of UCLA and ASES scores were observed in 29 of 30 patients. Based on Sugaya classification, grades I, II, and III structural integrities were observed in 9, 14, and 4 patients, respectively.

CONCLUSIONS

Successful clinical outcomes and structural integrity can be achieved with arthroscopic repair of intratendinous rotator cuff tears involving more than half thickness (> 50%). Therefore, arthroscopic repair is a practical next treatment option for patients with intratendinous rotator cuff tears in whom conservative treatment fails.

LEVEL OF EVIDENCE

IV.

Short-term Outcomes of Arthroscopic Debridement and Selected Acromioplasty of Bursal- vs Articular-Sided Partial-Thickness Rotator Cuff Tears of Less Than 50

Background:

While it is believed that good results can be achieved by arthroscopic debridement of partial-thickness tears (PTTs) of <50% tendon thickness, few studies have directly compared the treatment of articular- versus bursal-sided PTTs of <50%.

Purpose:

To compare the postoperative outcomes of patients with articular- versus bursal-sided PTTs of <50% tendon thickness that were treated with arthroscopic debridement and selective acromioplasty (for type II or III acromions).

Study Design:

Cohort study; Level of evidence, 3.

Methods:

An analysis was performed with data from 76 consecutive patients diagnosed with a PTT <50% tendon width (Ellman grade II) who had undergone arthroscopic debridement and selective acromioplasty (for type II or III acromions). Outcome measures included the short version of the Western Ontario Rotator Cuff index, the American Shoulder and Elbow Surgeons score, and the relative Constant-Murley score, as well as strength of the affected shoulder. A statistical paired t test (preoperative vs 2 years postoperative) and an independent t test were utilized to compare outcomes between patients with bursal- and articular-sided tears.

Results:

Between 2001 and 2010, there were 40 (53%) articular- and 36 (47%) bursal-sided tears treated with debridement and selective acromioplasty. The mean patient age was 55 years (range, 36-77 years) for the bursal group and 56 years (range, 33-81 years) for the articular group. The mean follow-up was 24 months (range, 22-26 months). Both groups showed significant improvement in the short version of the Western Ontario Rotator Cuff index, American Shoulder and Elbow Surgeons score, and relative Constant-Murley score 2 years after surgery (P < .0001) as well as in strength (P < .0001 for bursal tears, P = .006 for articular tears). There was no statistically significant difference between groups in any of the postoperative outcome measures at 2 years.

Conclusion:

The results of this study demonstrate that good outcomes can be achieved with arthroscopic debridement and selective acromioplasty among patients with articular- or bursal-sided PTT of <50% tendon thickness. No difference was observed between groups at 2-year follow-up.

Radiologic and clinical evaluation of a bioabsorbable collagen implant to treat partial-thickness tears: a prospective multicenter study

BACKGROUND

Treatment of partial-thickness cuff tears remains controversial. Although conservative therapy may treat symptoms, these defects do not spontaneously heal and conversion to a full-thickness lesion with subsequent repair may alter the tendon footprint. The ability to induce new tissue formation and limit tear progression in intermediate- and high-grade partial-thickness tears without surgical repair may represent a significant advancement in the treatment paradigm for these lesions.

METHODS

We prospectively enrolled 33 patients with chronic, degenerative, intermediate-grade (n = 12) or high-grade (n = 21) partial-thickness tears (11 articular, 10 bursal, 4 intrasubstance, and 8 hybrid) of the supraspinatus tendon in a multicenter study. Following arthroscopic subacromial decompression without repair, a bioinductive implant was attached over the bursal surface of the tendon. Clinical outcomes were assessed using American Shoulder and Elbow Surgeons and Constant-Murley scores preoperatively and at 3 and 12 months postoperatively. Magnetic resonance imaging was performed to assess postoperative tendon healing and thickness at the original tear site.

RESULTS

At 1-year follow-up, clinical scores improved significantly (P <.0001) and the mean tendon thickness increased by 2.0 mm (P <.0001). Magnetic resonance imaging evidence of complete healing was found in 8 patients and a considerable reduction in defect size was shown in 23, whereas 1 lesion remained stable. In 1 noncompliant patient with a high-grade articular lesion, progression to a full-thickness tear occurred while shoveling snow 1 month after surgery. No serious adverse events related to the implant were reported.

CONCLUSIONS

Arthroscopic implantation of a bioinductive collagen scaffold is a safe and effective treatment for intermediate- to high-grade partial-thickness rotator cuff tears of the supraspinatus tendon.

Treatment of Partial Thickness Rotator Cuff Tears in Overhead Athletes

PURPOSE OF REVIEW

To review the etiology, classification, presentation, evaluation, treatment strategy, and outcomes in overhead athletes with partial thickness rotator cuff tears.

RECENT FINDINGS

Despite advances in surgical repair techniques, return to play following surgical repair of partial rotator cuff tears remains modest at best. Overhead athletes may be particularly prone to rotator cuff pathology due to the supraphysiological strains within the tendon during the throwing motion, as well as mechanical stress with contact between the undersurface of the rotator cuff and the glenoid. The true prevalence of partial tears may be underestimated given the high incidence of asymptomatic tears. Both dynamic ultrasound and enhanced contrast MRI have improved our understanding of this pathology. For most overhead athletes, nonoperative management is the most common course. Despite advances in imaging, diagnosis, and surgical techniques, our ability to return these patients to their elite level is modest at best when nonoperative management fails and surgical treatment is performed. If a surgical route is needed, debridement alone is the most frequent procedure given concerns of over constraint and poor return to play with surgical repair of the partial thickness rotator cuff tear.

Structural Evolution of Nonoperatively Treated High-Grade Partial-Thickness Tears of the Supraspinatus Tendon

BACKGROUND

High-grade partial-thickness rotator cuff tears (hPTRCTs) are frequently encountered in the shoulder. However, little information is available on the prevalence or timing of tear progression. Purpose/Hypothesis: The purpose was to prospectively evaluate the structural progression of hPTRCTs with a minimum follow-up of 1 year using magnetic resonance imaging (MRI). The hypothesis was that a substantial portion of hPTRCT patients would experience tear progression or evolution to a full-thickness rotator cuff tear.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between May 2010 and December 2015, 362 patients were diagnosed with hPTRCT (tear involvement >50% of the mediolateral length of the footprint) of the supraspinatus and were treated nonoperatively. Among these patients, 81 underwent follow-up MRI at least 1 year after initial presentation, and these patients were included in the final analysis. Initial and follow-up MRIs were used to determine whether tears had improved, had not changed, or had progressed. A change in tear involvement of >20% was defined as a significant change. Patients were categorized as follows: (1) a decrease in tear involvement of >20% (improved), (2) an increase or decrease of ≤20% (no change), or (3) an increase in tear involvement of >20% (progressed). Demographic data and morphologic data were analyzed to identify variables related to tear progression. Among them, severity of tendinosis was graded using MRIs: grade 1 (mild tendinosis), mild focal increase in tendon signal; grade 2 (moderate tendinosis), moderate focal increase in tendon signal; and grade 3 (marked tendinosis), marked generalized increase in tendon signal.

RESULTS

At initial diagnosis, 23 were articular-side (28%) and 58 were bursal-side (72%) hPTRCTs. The study cohort was composed of 51 women and 30 men, and the mean patient age was 62.3 years (range, 41-77 years). Follow-up MRI was performed at a mean 19.9 ± 10.9 months (range, 12-52 months). A significant change in tear involvement was observed at follow-up. In 13 patients (16%, 2 articular-side and 11 bursal-side tears), tears were classified as progressed (the progressed group); in 48 patients (59%), tears exhibited no change (the unchanged group); and in 20 patients (25%, 9 articular-side and 11 bursal-side tears), tears were improved (the improved group). Univariate analysis showed initial tendinosis grade was significantly different in the 3 groups (grade 1, 2, and 3: 5, 4, and 4 in progressed; 36, 11, and 1 in unchanged; 10, 8, and 2 in improved group, respectively, P = .007).

CONCLUSION

Although progression of hPTRCT in the long term is uncertain, after 1-year follow-up with MRI, tears progressed in 16% of the tears in this study. Furthermore, some tears were healed or reduced in size, which indicates that decisions to undertake surgical repair at time of presentation may be excessive.

Relationship between the critical shoulder angle and the development of rotator cuff lesions: a retrospective epidemiological study

Objective

To perform a retrospective epidemiological study of radiographs in order to evaluate the relationship between the anatomy of the scapula and the development of rotator cuff injuries (RCIs).

Methods

This study retrospectively evaluated the relation of the critical shoulder angle (CSA) and RCIs from January 2011 to November 2013; patients were examined in the Orthopedics and Traumatology Department of a university hospital. The CSA was measured by radiographic standardization of two groups: a control group of 34 asymptomatic shoulders and a study group of 44 shoulders with complete RCIs.

Results

The mean age in the control group was 59.97 years (45–84) and the mean age in the group with RCIs was 59.75 years (45–84). Regarding the CSA, the control group had a mean angle of 33.59° (±3.37) and the group with RCIs had a mean angle of 39.75° (±5.35; p < 0.007).

Conclusion

There is an association between CSA and RCIs.

Arthroscopic Debridement of the Thrower's Shoulder: Less Is More

The thrower's shoulder has long been a topic of debate among shoulder specialists. The tremendous forces produced during the throwing motion coupled with the compilation of the pathology encountered in the thrower's shoulder have generated a complex treatment algorithm. Simplifying management options has been challenging and recommendations continue to evolve. Treatment of injuries to the thrower's shoulder most commonly involves addressing partial articular-sided rotator cuff tears. These can be isolated or more commonly associated with tearing of the posterior superior labrum. The understanding of the dramatic difference between the surgical treatment of shoulder injuries in overhead athletes and nonoverhead athletes is paramount to positive outcomes after surgery.

Evidence of healing of partial-thickness rotator cuff tears following arthroscopic augmentation with a collagen implant: a 2-year MRI follow-up

BACKGROUND

partial-thickness rotator cuff tears frequently enlarge due to increased local strain and often progress to full-thickness tears. Studies suggest the addition of new tendinous tissue to injured cuff tendons would significantly decrease peak strain, possibly protecting against tear progression. The aim of this study was to assess the ability of a highly-porous collagen implant to induce new tissue formation and limit tear progression when placed on the bursal surface of partial-thickness cuff tears.

METHODS

following arthroscopic subacromial decompression, the implant was attached to the bursal surface of the supraspinatus tendon in a prospective series of 13 consecutive patients with intermediate - (3-6 mm) to high-grade (>6 mm) partial - thickness cuff tears (5 articular, 3 bursal, 5 intra-substance). Tendon thickness, defect size, and tendon quality were evaluated using magnetic resonance imaging (MRI) preoperatively and at 3, 6, 12, and 24 months postoperatively. Clinical outcomes were assessed using the Constant and American Shoulder and Elbow Society scores at the same preoperative and follow-up times. All 13 patients completed all follow-up exams (mean length of follow-up 27.0 months, range 23.3-32.0); no patients were lost to follow-up.

RESULTS

the implant induced significant new tissue formation in all patients by 3 months (mean increase in tendon thickness 2.2 ± 0.26 mm). This tissue matured over time and became radiologically indistinguishable from the underlying tendon. The partial-thickness cuff tears showed consistent filling of the defects, with complete healing in 7 patients at 12 months, and a progressive improvement in tendon quality in the remaining patients. No tear progression was observed by MRI in any of the patients at 24 months. All clinical scores improved significantly over time. At 24 months, 12 of 13 patients (92%) had satisfactory or better results.

CONCLUSIONS

the results of this clinical study demonstrated the ability of a highly-porous collagen implant to induce new tendon-like tissue formation and create an environment conductive to the healing of partial-thickness cuff tears.

I.S.Mu.L.T - Rotator Cuff Tears Guidelines

Despite the high level achieved in the field of shoulder surgery, a global consensus on rotator cuff tears management is lacking. This work is divided into two main sessions: in the first, we set questions about hot topics involved in the rotator cuff tears, from the etiopathogenesis to the surgical treatment. In the second, we answered these questions by mentioning Evidence Based Medicine. The aim of the present work is to provide easily accessible guidelines: they could be considered as recommendations for a good clinical practice developed through a process of systematic review of the literature and expert opinion, in order to improve the quality of care and rationalize the use of resources.

Double arthroscopic transtendon repair of partial-thickness articular surface tears of the rotator cuff: a surgical technique

This study describes a technique of simultaneous arthroscopy and bursoscopy for transtendon repair of a partial-thickness articular surface rotator cuff tear. All procedures are under simultaneous visualisation from both the glenohumeral joint and the subacromial space to reduce the risk of intraoperative complications.

Partial rotator cuff injury in athletes: bursal or articular?

A painful shoulder is a very common complaint among athletes, especially in the case of those in sports involving throwing. Partial lesions of the rotator cuff may be very painful and cause significant functional limitation to athletes’ sports practice. The incidence of partial lesions of the cuff is variable (13–37%). It is difficult to make the clinical and radiological diagnosis, and this condition should be borne in mind in the cases of all athletes who present symptoms of rotator cuff syndrome, including in patients who are diagnosed only with tendinopathy.

Objective

To evaluate the epidemiological behavior of partial lesions of the rotator cuff in both amateur and professional athletes in different types of sports.

Methods

We evaluated 720 medical files on athletes attended at the shoulder service of the Discipline of Sports Medicine at the Sports Traumatology Center, Federal University of São Paulo. The majority of them were men (65%). Among all the patients, 83 of them were diagnosed with partial lesions of the rotator cuff, by means of ultrasonography or magnetic resonance, or in some cases using both. We applied the binomial test to compare the proportions found.

Result

It was observed that intra-articular lesions predominated (67.6%) and that these occurred more frequently in athletes in sports involving throwing (66%). Bursal lesions occurred in 32.4% of the athletes, predominantly in those who did muscle building (75%).

Conclusion

Intra-articular lesions are more frequent than bursal lesions and they occur predominantly in athletes in sports involving throwing, while bursal lesions were more prevalent in athletes who did muscle building.

Change in the Pathologic Supraspinatus: A Three-Dimensional Model of Fiber Bundle Architecture within Anterior and Posterior Regions

Supraspinatus tendon tears are common and lead to changes in the muscle architecture. To date, these changes have not been investigated for the distinct regions and parts of the pathologic supraspinatus. The purpose of this study was to create a novel three-dimensional (3D) model of the muscle architecture throughout the supraspinatus and to compare the architecture between muscle regions and parts in relation to tear severity. Twelve cadaveric specimens with varying degrees of tendon tears were used. Three-dimensional coordinates of fiber bundles were collected in situ using serial dissection and digitization. Data were reconstructed and modeled in 3D using Maya. Fiber bundle length (FBL) and pennation angle (PA) were computed and analyzed. FBL was significantly shorter in specimens with large retracted tears compared to smaller tears, with the deeper fibers being significantly shorter than other parts in the anterior region. PA was significantly greater in specimens with large retracted tears, with the superficial fibers often demonstrating the largest PA. The posterior region was absent in two specimens with extensive tears. Architectural changes associated with tendon tears affect the regions and varying depths of supraspinatus differently. The results provide important insights on residual function of the pathologic muscle, and the 3D model includes detailed data that can be used in future modeling studies.

Long-term functional evaluation of videoarthroscopic treatment of partial injuries of the rotator cuff

Objective

To compare the functional results from high and low-grade isolated partial lesions of the supraspinatus tendon of bursal and articular types, after arthroscopic treatment.

Methods

Sixty-four patients with isolated partial lesions of the supraspinatus tendon were evaluated. The mean length of follow-up was 76 months (range: 29–193). The mean age was 59 years (range: 36–82). The dominant side was affected in 44 patients (68.8%). There were 35 bursal lesions (54.7%) and 29 articular lesions (45.3%). We used the Ellman classification and characterized the lesions as low or high-grade according to whether they affected less than or more than 50% of the tendon thickness, respectively. Debridement was performed in 15 patients (23.5%), repair without completing the lesion in 11 (17%) and repair after completing the lesion in 38 (59.5%). The functional assessments on the patients were done using the Constant & Murley and UCLA scores.

Results

The mean Constant & Murley score among the patients with bursal lesions was 82.64 ± 6.98 (range: 59.3–99) and among those with articular lesions, 83.57 ± 7.58 (range: 66–95), while the mean UCLA score in the bursal lesions was 33.37 ± 2.85 (range: 21–35) and in the articular lesions, 32.83 ± 2.95 (range: 22–35).

Conclusion

Videoarthroscopic treatment of partial lesions of the rotator cuff presents good or excellent results when the low-grade lesions are debrided and the high-grade lesions are completed and repaired. These results are maintained over the long term, with a high satisfaction rate and few complications.

Partial supraspinatus tears are associated with tendon lengthening

PURPOSE

Tendon tear may result in muscular retraction with the loss of contractile amplitude and strength of the rotator cuff muscles. Currently, neither a validated method of measuring supraspinatus tendon length nor normal values are known. It was therefore the purpose of this study to measure the normal length of the supraspinatus tendon and to determine whether partial tears are associated with changes in tendon length.

METHODS

MR examinations of 49 asymptomatic volunteers and 37 patients with arthroscopically proven, isolated partial tears of the supraspinatus tendon were compared. The ratio of the extramuscular tendon length to the distance between the footprint and the glenoid surface was calculated (TL/FG ratio). Tendon length measurements were taken by two independent readers at the bursal and articular surfaces at the anterior, the central and the posterior parts of the tendon.

RESULTS

TL/FG ratios at the bursal surface of tendons with partial tears were significantly higher than those in the control group [anterior: 0.78 ± 0.20 vs. 0.66 ± 0.15 (p < 0.05); central: 0.61 ± 0.13 vs. 0.52 ± 0.10 (p < 0.05); posterior: 0.57 ± 0.15 vs. 0.52 ± 0.10 (p < 0.05)]. At the articular surface, differences were significant only anteriorly [0.60 ± 0.13, vs. 0.54 ± 0.10 (p < 0.05)]. A cut-off TL/FG ratio of 0.63 for measurements at the bursal surface in the center of the tendon achieved a sensitivity of 46 % and a specificity of 92 % for the identification of partial cuff tearing.

CONCLUSION

A reproducible method for measurement of extramuscular supraspinatus tendon length is described. Partial tearing of the supraspinatus tendon is associated with significant tendon lengthening, suggesting failure in continuity, and this is most reliably measured on the bursal surface.

LEVEL OF EVIDENCE

III.

Intratendinous rotator cuff tears: prevalence and clinical and radiological outcomes of arthroscopically confirmed intratendinous tears at midterm follow-up

BACKGROUND

Intratendinous tears of the rotator cuff are rare, and little has been written about them.

PURPOSE

To investigate the prevalence and clinical and radiological outcomes of arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Included in the study were 33 patients (16 male, 17 female; mean age, 53.4 years) with arthroscopically confirmed intratendinous tears treated with transtendon suture bridge repair from March 2006 to July 2012. A history of trauma was found in 10 cases (30.3%). The dominant arm was involved in 26 cases (78.8%). The mean follow-up duration was 56 months. Preoperatively, a thorough physical examination was performed; at final follow-up, shoulder range of motion (ROM) in forward flexion, abduction, external rotation (ER) at the side, and internal rotation (IR) at the back was noted, and clinical outcomes (American Shoulder and Elbow Surgeons [ASES] score; University of California, Los Angeles [UCLA] score; visual analog scale [VAS] for pain; and Simple Shoulder Test [SST]) were recorded and compared with the preoperative data. Postoperative magnetic resonance imaging (MRI) was performed at 6 months to investigate rotator cuff healing status and repair integrity.

RESULTS

The prevalence of arthroscopically confirmed intratendinous tears was 4.7% among all arthroscopically treated partial-thickness rotator cuff tears. Impingement signs were positive in most of the patients (positive Hawkins-Kennedy test result in 78.8%, positive Neer sign in 66.7%, and either positive Hawkins-Kennedy test result or Neer sign in 84.8%). At final follow-up, mean ASES, UCLA, VAS, and SST scores improved significantly from a preoperative mean of 51.4, 18.9, 6.0, and 5.4, respectively, to a postoperative mean of 90.6, 32.9, 1.4, and 10.8, respectively (P < .001). According to the UCLA rating scale, outcomes were excellent in 17, good in 13, and fair in 3 cases. Shoulder ROM in forward flexion, abduction, ER at the side, and IR at the back improved from a preoperative mean of 135°, 129°, 25°, and L2, respectively, to a postoperative mean of 161°, 160°, 29°, and T10, respectively (P < .001 for all except ER). As per the Sugaya classification, on postoperative MRI, type I healing status was found in 10 (30.3%), type II in 18 (54.5%), and type III in 2 (6.1%) cases. None of the patients showed any evidence of retears.

CONCLUSION

Transtendon suture bridge repair yielded satisfactory clinical and radiological outcomes in patients with intratendinous rotator cuff tears.

A Novel Arthroscopic Inside-Out Repair Technique for PASTA Lesions

There is no current consensus in the literature on the optimal technique for surgical treatment of partial articular-sided supraspinatus tendon avulsion (PASTA) lesions, although most techniques described to date require takedown of the partially torn tendon or passage of an anchor through the already damaged tendon. We describe a novel inside-out repair technique for partial articular surface supraspinatus tears that does not require further disruption of the partially torn tendon by passage of an anchor.

Low accuracy of interpretation of rotator cuff MRI in patients with osteoarthritis

BACKGROUND

Magnetic resonance imaging (MRI) is considered to be a valuable tool for the diagnosis of rotator cuff tears in patients with severe glenohumeral osteoarthritis who are indicated for total shoulder arthroplasty (TSA). We determined the sensitivity, specificity, and positive predictive value of MRI in diagnosing rotator cuff tears in such patients.

METHODS

MRI reports of 100 patients who had completed a shoulder MRI prior to TSA were reviewed to determine the radiologists' interpretation of the MRI including the diagnosis, presence of a full-thickness cuff tear, and the presence of atrophy and/or fatty infiltration within the rotator cuff muscle bellies. Operative reports were used as a gold standard to determine whether a full-thickness rotator cuff tear was present.

RESULTS

Preoperative MRI reports noted 33 of the 100 patients as having a full-thickness rotator cuff tear, 17 of which had multiple tendon tears. 2 of the 33 patients with full tears on MRI were found to have full-thickness tears at surgery. The sensitivity, specificity, and positive predictive value for MRI detection of full-thickness tears were 100%, 68%, and 6% respectively, with a false-positive rate of 32% and an accuracy of 69%.

INTERPRETATION

The study suggests that although MRI is highly sensitive, it has a low positive predictive value and moderately low specificity and accuracy in detecting full-thickness rotator cuff tears in patients with severe glenohumeral osteoarthritis.

Partial articular-sided rotator cuff tears: in situ repair versus tear completion prior to repair

Uncertainty exists over the ideal surgical treatment method for partial articular-sided rotator cuff tears, with options ranging from debridement to in situ repair to tear completion prior to repair. The purpose of this study was to determine whether in situ repair was a viable biomechanical treatment option compared with tear completion prior to repair of partial articular-sided rotator cuff tears. Fourteen fresh-frozen cadaveric shoulders were dissected. Partial articular-sided tears were created and repaired using in situ repair or tear completion prior to the repair. Strain and displacement were measured at 45°, 60°, and 90° of glenohumeral abduction. Testing was performed with a load of 100 N applied for 30 cycles. Data from the biomechanical testing displayed 4 conditions that showed improved characteristics of in situ repair over completion and repair: bursal-sided strain anteriorly at 45°, bursal-sided strain anteriorly at 90°, bursal-sided displacement anteriorly at 45°, and bursal-sided displacement anteriorly at 90°. The data indicate that in situ repair is a viable biomechanical treatment option compared with tear completion prior to repair of partial articular-sided rotator cuff tears. When clinically appropriate, the in situ repair may offer some biomechanical advantages, with lower strain and displacement observed on the bursal side compared with tear completion prior to repair.

Articular-sided rotator cuff tears: which is the best repair? A three-year prospective randomised controlled trial

PURPOSE

To compare two groups of patients who underwent two different arthroscopic procedures for repair of articular-sided partial-thickness rotator cuff tears (PTRCTs).

MATERIALS

This is a comparative prospective study of two methods for repair of partial cuff tears: Thirty-two patients underwent arthroscopic rotator cuff repair with a transtendon technique (group 1); 28 underwent arthroscopic full-thickness conversion and repair of the lesion (group 2). ROM measures, clinical findings, MRI features (tendon healing and re-tear), Constant-Murley and ASES scores were assessed pre- and postoperatively and compared. Patients were also asked about return to sport and level of activity.

RESULTS

At the last appointment, patients of both the groups were significantly improved for clinical findings, ROM measures, imaging features, Constant-Murley and ASES scores than at baseline, without any significant inter-group difference. In group 1, 15 of 20 patients (75 %) who practiced recreational sport activities had returned to sport at the same level as before the onset of symptoms, without any discomfort. In group 2, 12 of 18 patients (67 %) had returned to the same level of sport activity they practiced before symptoms. At the last follow up, MRI showed rotator cuff healing in 31 patients of Group 1 and 27 patients of Group 2 (p = 0.83).

CONCLUSIONS

The two procedures are safe, effective, and comparable.

Rotator cuff tears in overhead athletes

The rotator cuff is under significant stress during overhead athletics, which can predictably lead to a certain spectrum of rotator cuff injuries in this population. Although the cause is often multifactorial; tensile overload, outlet impingement, and internal impingement are common causes of cuff pathologic conditions in this group. Identification of symptomatic rotator cuff disease can be challenging in the overhead athlete because abnormalities of the rotator cuff are common in asymptomatic throwers and rotator cuff pathologic conditions often occur in conjunction with other injuries. Although nonoperative options should be exhausted, surgical treatment is typically necessary for any rotator cuff tear for which conservative treatment fails. Tear thickness has been classically used to determine the surgical approach, with tears involving less than 50% of the tendon thickness treated with debridement and more substantial tears treated with formal repair. However, some authors and some noted surgeons with experience in managing this patient population have more recently advocated a higher threshold of tendon involvement before considering formal repair. Multiple repair options have been described, but few reports have focused specifically on the outcomes of rotator cuff surgery in overhead athletes. The limited available data do lead, however, to a few reasonable conclusions. Surgical results typically correlate with tear severity. Partial-thickness tears treated with arthroscopic debridement and management of concomitant pathologic conditions seem to have fairly good outcomes in the literature, with most athletes able to return to activity at their preinjury level. Full-thickness tears, however, have fared much more poorly in the overhead athlete, with largely dismal outcomes after surgical repair. What is abundantly clear is that further refinement of surgical options is necessary to improve patient outcomes after rotator cuff repair in this particularly challenging patient population and to allow more consistent return to sports. Identification of symptomatic rotator cuff disease can be challenging in the overhead athlete because abnormalities of the rotator cuff are common in asymptomatic throwers and rotator cuff pathologic conditions often occur in conjunction with other injuries. Although nonoperative options should be exhausted, surgical treatment is typically necessary for any rotator cuff tear for which conservative treatment fails. Tear thickness has been classically used to determine the surgical approach, with tears involving less than 50% of the tendon thickness treated with debridement and more substantial tears treated with formal repair. However, some authors and some noted surgeons with experience in managing this patient population have more recently advocated a higher threshold of tendon involvement before considering formal repair. Multiple repair options have been described, but few reports have focused specifically on the outcomes of rotator cuff surgery in overhead athletes. The limited available data do lead, however, to a few reasonable conclusions. Surgical results typically correlate with tear severity. Partial-thickness tears treated with arthroscopic debridement and management of concomitant pathologic conditions seem to have fairly good outcomes in the literature, with most athletes able to return to activity at their preinjury level. Full-thickness tears, however, have fared much more poorly in the overhead athlete, with largely dismal outcomes after surgical repair. What is abundantly clear is that further refinement of surgical options is necessary to improve patient outcomes after rotator cuff repair in this particularly challenging patient population and to allow more consistent return to sports.

Partial-thickness articular surface rotator cuff tears in patients over the age of 35: Etiology and intra-articular associations

Purpose:

Partial-thickness articular-sided rotator cuff tears have a multifactorial etiology and are associated with degeneration of the tendon. They are often described as an injury of the young athlete, although they are also found in the older population. The aim of this study was to investigate the frequency and associations of partial-thickness articular-sided tears in patients over the age of 35 years.

Design:

Retrospective

Materials and Methods:

A retrospective study of all arthroscopic procedures for rotator cuff pathology in patients over the age of 35 years over a 2-year period by a single surgeon was performed. The included patients were divided into two groups based on the arthroscopic findings: those with a partial-thickness articular-sided rotator cuff tear and those with pure tendinopathy. The groups were then compared to identify the associated pathology with the rotator cuff lesions. 2×2 contingency table analysis and unpaired Student's t-test were used for statistical analysis.

Results:

One hundred patients were included in the study of whom 62 had a partial articular-sided tear. Those with a partial articular-sided tear were older (P=0.0001), were more commonly associated with a documented injury (P=0.03), and more commonly had biceps degeneration (P=0.001) and synovitis (P=0.02) within the joint.

Conclusion:

Partial-thickness articular-sided tears are a common occurrence in patients requiring arthroscopic surgery for rotator cuff pathology over the age of 35 years. This probably reflects an injury in an already degenerate cuff. This would support the theory of intrinsic degeneration of the tendon in this age group and probably represent a different etiology to those seen in the young athletes.

Level of Evidence:

Level 3

A comparison of outcomes after arthroscopic repair of partial versus small or medium-sized full-thickness rotator cuff tears

BACKGROUND

Little is known about the outcomes after repair of partial-thickness rotator cuff tears. The aim of this study was to assess the outcome after repair of partial-thickness rotator cuff tears compared with full-thickness tears. Our hypothesis was that repair of partial-thickness tears leads to more shoulder stiffness but fewer retears compared with repair of full-thickness tears.

METHODS

A group of 105 consecutive patients who had a full-thickness tear measuring <3 cm2 was compared with a group of sixty-four patients who had a partial-thickness tear. All tears were repaired with use of a knotless single-row arthroscopic repair. The American Shoulder and Elbow Surgeons (ASES) score and standardized patient and examiner-determined outcomes were obtained preoperatively and at six, twelve, and twenty-four weeks and at two years after surgery. Rotator cuff integrity was determined by ultrasound examination at six months and two years after surgery.

RESULTS

Examiner-determined postoperative stiffness at six weeks was common in both groups (50% of those with a partial-thickness tear and 47% of those with a full-thickness tear) but was decreased compared with preoperative findings in both groups to 21% and 19%, respectively, at three months and to 15% and 14% at six months. The ultrasound-determined retear rate was small (5% in the partial-thickness group and 10% in the full-thickness group) at six months, but increased to 10% and 20%, respectively, at twenty-four months. The ASES score, patient-determined overall shoulder function, and all pain scores were superior to preoperative scores at six months (p < 0.001) and at twenty-four months (p < 0.001) in both groups.

CONCLUSIONS

Arthroscopic repair of partial-thickness and small and medium-sized full-thickness rotator cuff tears was associated with excellent medium-term clinical outcomes with low retear rates. The data did not support our hypothesis: the differences in retear rate and postoperative shoulder stiffness rate found between the two groups did not reach significance.

The clinical results of arthroscopic transtendinous repair of grade III partial articular-sided supraspinatus tendon tears

PURPOSE

The purpose of this study was to evaluate the clinical results of arthroscopic transtendinous repair of deep partial articular-sided rotator cuff tears.

METHODS

We retrospectively evaluated the results of 53 patients who underwent arthroscopic transtendinous repair for Ellman grade III articular-sided rotator cuff tears (>50% of the thickness of the rotator cuff). The intact bursal side of the cuff was not detached, and all associated pathology was treated. Fifty patients available for follow-up were evaluated with the American Shoulder and Elbow Surgeons (ASES) questionnaire.

RESULTS

American Shoulder and Elbow Surgeons scores improved from a mean of 48.0 to 89.4 (+41.4) (P < .0001). Pain scores on a visual analog scale improved from 5.7 to 1.0 (P < .0001). Ninety-eight percent of patients were satisfied with the results of surgery. Results for the 50 patients available for follow-up were excellent in 32 (64%), good in 6 (12%), fair in 6 (12%), and poor in 6 (12%). Articular-sided rotator cuff tears rarely occurred in isolation but were typically found in association with coexisting pathology suggestive of the tears' etiology. Most common were impingement lesions, seen in 94% of patients, and instability lesions such as labral tears, seen in 30% of patients. Associated procedures included acromioplasty in 47, distal clavicle resection in 29, treatment of biceps pathology in 7, and instability repair in 15. One patient sustained a postoperative pulmonary embolism, which represented the only complication. Tears varied in size from 50% to 90% of the thickness of the cuff insertion. Significant differences were identified in the results of Workers' Compensation patients. Preoperative magnetic resonance imaging and magnetic resonance arthrography were accurate in identifying a partial-thickness rotator cuff tear in less than 40% of cases.

CONCLUSIONS

Arthroscopic transtendinous repair of partial articular-sided rotator cuff tears is a safe and effective treatment that allows identification of commonly associated pathology and reliable improvement in pain and function.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

The "50% rule" in arthroscopic and orthopaedic surgery

The "50% rule" is used commonly to guide treatment of partial tears of tendons and ligaments. The purpose of this study was to examine the history and validity of the 50% rule in arthroscopic and orthopaedic surgery. A PubMed search yielded 1,039 articles that were reviewed to identify the origins of the 50% rule for hand flexor tendon lacerations, partial anterior cruciate ligament tears, partial-thickness rotator cuff tears, and partial injuries of the long head of the biceps tendon. The rule appears to have evolved from the hand literature toward somewhat arbitrary application for other orthopaedic conditions. Little scientific information is available to support the 50% rule for these disparate entities. In our Level V opinion, the 50% rule allows surgeons to use subjective discretion in the management of prevalent orthopaedic conditions but there is very little scientific support for this ubiquitous decision-making criterion.

Trans-tendon arthroscopic repair for partial-thickness articular side tears of the rotator cuff

PURPOSE

The purpose of this study was to describe a modified trans-tendon method of repairing partial articular surface lesions, which restored the footprint of the rotator cuff anatomically.

METHODS

The 24 consecutive patients with modified trans-tendon method which allowed a wider pressurized contact area by use of additional knotless anchor were included in this study. All patients were evaluated with ASES score and visual analog scale (VAS) preoperatively, postoperative 3 and 12 months. The strength was measured using Isobex digital strength analyzer preoperatively and postoperative 12 months.

RESULTS

The ASES scores significantly improved from preoperative 38 ± 13 to 63 ± 5 at 3 months, and 89 ± 5 at 12 months postoperatively. The VAS scores also significantly improved from preoperative 6.6 ± 1.1 to 2 ± 0.7 at 3 months, 0.6 ± 0.7 at 12 months. The strengths significantly increased postoperatively, and there were no significant differences between affected and unaffected shoulders at 12 months postoperatively (P > 0.05). The 22 of 24 patients were either satisfied or very satisfied with postoperative result at 12 months postoperatively.

CONCLUSION

This arthroscopic-modified trans-tendon suture bridge technique for partial-thickness articular side tears of the rotator cuff has shown excellent functional results and very high satisfaction rate of patient during the 12-month follow-up period.

LEVEL OF EVIDENCE

Evidence therapeutic study, Level IV.

Clinical and magnetic resonance imaging results of arthroscopic full-layer repair of bursal-side partial-thickness rotator cuff tears

BACKGROUND

Partial rotator cuff tears are being diagnosed more often because of high-resolution magnetic resonance imaging (MRI). Articular-side partial tears are much more common than bursal-side tears, and all-inside or PASTA repairs that preserve the bursal tissue have gained popularity. In contrast, there have been few reports about preserving the articular tissue during bursal tear repair.

PURPOSE

To report clinical and radiological results of bursal-side partial-thickness rotator cuff tear (PTRCT) repair with preservation of as much of the intact articular-side tendon as possible.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From May 2006 to March 2008, 109 patients with PTRCT underwent arthroscopic repair. Among them, 38 consecutive patients who received a full-layer repair on the bursal side for greater than 50% thickness PTRCT were retrospectively evaluated. All repairs were performed with a technique that preserved intact articular fibers. To assess the outcome, pain visual analog scale (PVAS), American Shoulder and Elbow Surgeon (ASES) score, and Constant score were evaluated at final follow-up. Postoperative MRI at least 6 months after surgery was evaluated for repair integrity.

RESULTS

All 38 patients (21 men and 17 women) were available for final follow-up. The mean age at surgery was 50.8 years (range, 30-58 years), and the mean follow-up time was 26.9 months (range, 24-41 months). There were 21 right shoulders and 17 left shoulders, for which the mean time from the onset of symptoms to surgery was 47.0 months (±83.3 months). The PVAS improved from 5.2 (±2.5) to 1.6 (±1.5), and mean ASES and Constant scores improved from 53.1 (±20.4) and 59.9 (±15.3) to 87.2 (±9.4) and 83.2 (±12.0), respectively. Postoperative MRI was available in 33 patients at a mean 8.2 months after surgery. Twenty-nine shoulders (87.9%) had an intact repaired tendon, while 3 patients had shown partial-thickness delaminated retears, and 1 patient demonstrated a full-thickness retear on postoperative MRI.

CONCLUSION

For bursal-side PTRCT, clinical outcomes and tendon healing showed good results at a minimum 2 years after surgery, with minimal damage to intact articular tendon fibers on postoperative MRIs.

Multimedia article. The arthroscopic management of partial-thickness rotator cuff tears: a systematic review of the literature

PURPOSE

There is currently limited information available in the orthopaedic surgery literature regarding the appropriate management of symptomatic partial-thickness rotator cuff tears.

METHODS

A systematic search was performed in PubMed, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and the Cochrane Central Register of Controlled Trials of all published literature pertaining to the arthroscopic management of partial-thickness rotator cuff tears. Inclusion criteria were all studies that reported clinical outcomes after arthroscopic treatment of both articular-sided and bursal-sided lesions using a validated outcome scoring system and a minimum of 12 months of follow-up. Data abstracted from the selected studies included tear type and location (articular v bursal sided), treatment approach, postoperative rehabilitation protocol, outcome scores, patient satisfaction, and postoperative imaging results.

RESULTS

Sixteen studies met the inclusion criteria and were included for the final analysis. Seven of the studies treated partial-thickness rotator cuff tears with debridement with or without an associated subacromial decompression, 3 performed a takedown and repair, 5 used a transtendon repair technique, and 1 used a transosseous repair method. Among the 16 studies reviewed, excellent postoperative outcomes were reported in 28.7% to 93% of patients treated. In all 12 studies with available preoperative baseline data, treatment resulted in significant improvement in shoulder symptoms and function. For high-grade lesions, the data support arthroscopic takedown and repair, transtendon repairs, and transosseous repairs, with all 3 techniques providing a high percentage of excellent results. Debridement of partial-thickness tears of less than 50% of the tendon's thickness with or without a concomitant acromioplasty also results in good to excellent surgical outcomes; however, a 6.5% to 34.6% incidence of progression to full-thickness tears is present.

CONCLUSIONS

This systematic review of 16 clinical studies showed that significant variation is present in the results obtained after the arthroscopic management of partial-thickness rotator cuff tears. What can be supported by the available data is that tears that involve less than 50% of the tendon can be treated with good results by debridement of the tendon with or without a formal acromioplasty, although subsequent tear progression may occur. When the tear is greater than 50%, surgical intervention focusing on repair has been successful. There is no evidence to suggest a differential in outcome for tear completion and repair versus transtendon repair of these lesions because both methods have been shown to result in favorable outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Força do manguito rotador em indivíduos com síndrome do impacto comparado ao lado assintomático

OBJETIVO: Avaliar a força muscular de rotação interna, externa e elevação dos ombros sintomáticos comparado aos assintomáticos, associando a força muscular à função da articulação. MÉTODOS: Quarenta e oito indivíduos com diagnóstico de SIO unilateral foram avaliados quanto a força muscular isométrica do ombro sintomático e assintomático (utilizando um dinamômetro isométrico manual), além de serem avaliados quanto a função utilizando a escala de Constant-Murley. Os indivíduos foram distribuídos em 2 grupos: grupo 1 = 35 a 49 anos; grupo 2 = 50 a 65 anos. RESULTADOS: Foi encontrada redução da força de rotação interna, externa e elevação no ombro sintomático, comparado ao lado assintomáticos (p< 0,0001), mas não foi observada redução da força de rotação medial nos sujeitos do grupo 1. Também observamos que a força muscular é diretamente proporcional a função do ombro, onde indivíduos com pouca força do manguito rotador apresentam menor função. CONCLUSÃO: A SIO causa diminuição da força muscular de rotação interna, externa e elevação comparado ao lado assintomático, além de causar diminuição da função do ombro. A redução da função é proporcional a diminuição da força muscular do manguito rotador. Nível de Evidência III, Estudo analítico.

Results of surgical management of symptomatic shoulders with partial thickness tears of the rotator cuff

INTRODUCTION

The optimal management of partial thickness tears of the rotator cuff (PTRCT) is still controversial.

SOURCE OF DATA

A literature search, on PubMed, Cochrane and Google Scholar databases, identified 273 relevant abstracts of articles published in peer-reviewed journals. Twenty-three clinical studies reporting the outcomes of surgically treated patients affected by PTRCTs were selected.

AREAS OF AGREEMENT

The different repair approaches results in variable functional outcomes. The Coleman Methodology Score (CMS) used to asses the quality of the studies showed great heterogeneity in study design, the sample, pre- and post-operative diagnostic assessments and the score used to evaluate outcomes. The mean CMS value was 67.95 (ranging from 30 to 82).

AREAS OF CONTROVERSY

The heterogeneity of the treatment options and of the outcome assessment methods makes it difficult to compare the results of the different studies.

GROWING POINTS

There is a need to use standardized pre- and post-operative assessment methods and functional outcome scores. To improve the diagnosis and to choose the best treatment, it may be useful to measure the thickness of the rotator cuff to ascertain whether the size correlates with outcome.

CONCLUSION

There is a lack of scientifically based guidelines, probably a result of the relatively low levels of evidence of the studies. There is a need for adequately powered randomized clinical trials, using standard diagnostic assessment, common and validated scoring system comparing reported outcomes and duration of follow-up greater than 2 years.

Mattress suture-bridge technique for bursal-side partial-thickness rotator cuff tears

The standard procedure used to repair partial-thickness tears involves initial progression of the lesion to a full-thickness tear prior to tendon repair. However, the option for a bursal-side partial-thickness rotator cuff tear includes the preservation of as much of the remaining intact fibers as possible. Instead of inserting suture anchors in the medial row, as in the conventional suture-bridge technique, two mattress sutures are inserted into the rotator cuff. Full-thickness access is achieved using a percutaneous spinal needle and medial mattress sutures to preserve the articular bone attachment of the remnant fibers and to compress the repaired tendon on the footprint. Our method can help preserve the remnant rotator cuff tendon without tissue damage and can restore the normal rotator cuff footprint.

Transtendon arthroscopic repair of partial-thickness, articular surface tears of the supraspinatus: results at 2 years

Partial-thickness articular tears of the supraspinatus represent a not uncommon event in shoulder pathology, but their treatment remains controversial. We believe that these lesions must be treated with surgical repair: we hereby describe our technique of transtendon arthroscopic repair. We have treated 33 patients with an average age of 53.3 years (range 34-69). The average follow-up was 33 months (range 26-45). The post-operative Constant score values have shown a total increase of 48.2 points (from preoperative 44.4 points to post-operative 91.6 points). In the MRI follow-up assessment no cases of retears have occurred. The use of this technique enables the reconstitution of the tendon with complete reconstruction of its footprint without damaging its intact part. We believe that this can allow a better recovery.