Arthroscopic Posterosuperior Rotator Cuff Repair for Full-Thickness Tears
- Matthew P. Noyes, MD
- Patrick J. Denard, MD
- Stephen S. Burkhart, MA, MD
- Patrick J. Denard, MD
Abstract
This chapter provides a thorough review of the advancements in tear recognition that have facilitated the improved techniques which have resulted in anatomic repair and better outcomes following rotator cuff repair. The indications and descriptions for multiple techniques are discussed in detail.
Keywords: double row, full thickness tear, knotless repair, load-sparing rip stop, posterosuperior rotator cuff
Introduction
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Advancements in shoulder arthroscopy have allowed for better tear pattern recognition of the posterosuperior rotator cuff, which allows for anatomic repair and restoration of external rotation strength.
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The subscapularis generates the largest amount of force of any rotator cuff muscle and is generally believed to be the most important single rotator cuff muscle.
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The choice of knotted or knotless repair techniques is based on tissue quality.
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Massive rotator cuff tears are a subset of rotator cuff tears that remain a problematic condition to treat because the force couples are no longer balanced, resulting in an unstable fulcrum of motion and painful dysfunction.
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The Diamondback repair is an enhanced suture bridging repair construct that provides twice as many linked diagonal compression sutures with three times the number of intersection points.
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The load-sharing rip-stop construct is the authors’ preferred method for massive rotator cuff repair with poor tissue quality in which a double-row repair is not possible because of limited mobility.
Tear Pattern Recognition
One of the major advancements of arthroscopy has been the ability to more thoroughly evaluate rotator cuff tears compared to a traditional open approach. This has led to recognition of four major types of rotator cuff tears: (1) crescent tears, (2) U-shaped tears, (3) L-shaped tears, and (4) massive contracted tears. Recognition of these distinct tear patterns is crucial because the tear pattern dictates the repair pattern. Anatomic reconstruction of the posterosuperior footprint is important to restore external rotation strength and balance force couples, and repairing tears according to their tear pattern can lead to excellent results ( ).
Crescent-shaped tears are the simplest of all tears. These tears have good medial-to-lateral mobility and can be repaired directly to bone with minimal tension. Essentially, all crescent-shaped tears are repaired with a double-row construct.
In contrast, U-shaped rotator cuff tears extend much farther medially. The apex of the tear is usually adjacent to the glenoid rim medially. These tears demonstrate significant mobility in the anterior-to-posterior direction and should be initially repaired in a side-to-side fashion using margin convergence sutures. Failure in recognizing this tear pattern will result in overwhelming tensile stresses if an attempt is made to repair a lateral bone bed. However, sequential medial to lateral suturing of the anterior and posterior leaflets causes the free margin of the rotator cuff to converge toward the bone bed on the humerus. The free margin of the tear is then directly repaired to bone in a tension-free manner. This technique both allows repair of possible irreparable tears and minimizes strain on the repair site ( ).
L-shaped and reverse L-shaped tears have a leaflet that is more mobile than the other leaflet. In these cases, side-to-side suturing along the longitudinal split is required followed by repair to the greater tuberosity bone bed. The use of traction stitches is useful in assisting reduction and repair of these more complex tear patterns.
Massive contracted tears have limited mobility in both the anteroposterior and medial-lateral planes. These tears typically require advanced mobilization techniques such as interval slides to achieve repair. Based on their limited mobility and frequent tendon loss, these are often best addressed with a single-row or load-sharing rip-stop (LSRS) repair.
Importance of the Subscapularis
Although this chapter focuses on posterosuperior tears, one must not neglect the subscapularis tendon. The subscapularis generates the largest amount of force of any rotator cuff muscle and is generally believed to be the most important single rotator cuff muscle because it is the only anterior muscle that can balance the posterior forces of the rotator cuff. In addition, the anterior attachment of the rotator cable extends to the upper subscapularis insertion. Therefore repair of the upper subscapularis decreases the stress on the adjacent repair of the supraspinatus, thereby protecting the supraspinatus repair. After the subscapularis has been repaired, the comma sign is very useful in locating the anterolateral corner of the supraspinatus tendon, to which it remains attached. For these reasons, we strongly recommend repairing all subscapularis tears before proceeding with arthroscopic repair of the supraspinatus and infraspinatus tendons.
Surgical Technique: Setup and Preparation
In shoulder arthroscopy, angles and soft tissue and bone preparation play integral parts in anatomic rotator cuff repair.
Angle
The angle of visualization is influenced by the position of the patient, the angle of the arthroscope, and the position of the portal the surgeon is viewing through. We perform rotator cuff repairs in the lateral decubitus position. The arm is held in 20 to 30 degrees of abduction combined with 20 degrees of forward flexion with 5 to 10 lb of lateral weight suspended from a standard arthroscopic boom. We palpate the “soft spot” created by the glenoid medially and humeral head laterally and insert the arthroscope below the equator of the glenohumeral joint at about 7 o’clock. We have found that the often-used posterior portal tends to move too superior as soft tissue swelling increases and provides a poor angle of approach to the subacromial space. Therefore we avoid this by placing our skin incision more inferiorly. We also use 30- and 70-degree scopes interchangeably during the case.
Bone-Bed Preparation
A complete bursectomy is essential in all rotator cuff repair cases for two reasons. First, it is essential to see the entire rotator cuff margin to recognize the tear pattern. This includes removing all bursal leaders that attach to the internal deltoid fascia. We routinely release the internal deltoid fascia to achieve greater freedom for the instruments to move. Second, it removes the pain-generating cytokines that reside in the inflamed bursa in the subacromial space. With bone preparation, it is useful to remove all soft tissues from the greater tuberosity with an electrocautery device and then lightly use a high-speed bur to create a uniformly bleeding bone bed to facilitate healing.
Repair Techniques for Full-Thickness Tears
We strongly believe in restoration of anatomy. Therefore we perform a suture-bridging double-row repair whenever possible. However, the repair must respect the tear mobility and tendon length. A variety of suture-bridging techniques are available. As described further later, we base the choice of knotted and knotless techniques on tissue quality.
Suture-Bridging Double-Row Repair
The original double-row repair was described as two independent rows of anchors. The technique has progressed to linking of the medial and lateral row anchors, which has improved biomechanical properties and decreased retear rates ( Fig. 7A.1 ) ( )
The tear is initially visualized through a posterior subacromial viewing portal with a 30-degree arthroscope. A 70-degree arthroscope is also often helpful, particularly for lateral row placement. Additionally, the scope may be placed in the lateral viewing portal as necessary to better visualize the posteromedial aspect of the footprint. The medial anchors are placed through separate percutaneous portals. This allows the proper angle of approach and aids in suture management. A threaded double-loaded anchor (5.5-mm BioComposite Corkscrew FT; Arthrex, Naples, FL) is placed anteromedially adjacent to the articular margin and approximately 5 mm posterior the bicipital groove. A second anchor is placed posteromedially.
Medial mattress sutures are then passed with a self-retrieving antegrade suture passer. The mattress sutures should be evenly spaced to prevent suture cut-out. We have a simple way of restoring the normal length–tendon relationship, even in tendon loss, to achieve anatomic repair with normal biomechanics. In the setting of a mobile tear, an anatomic and properly tensioned double-row repair can be obtained if the surgeon passes the medial-row sutures 2 to 3 mm lateral to musculotendinous junction. This always restores proper length–tendon relationship. In the case of tendon loss in which only a single-row repair is possible, anchors are placed slightly lateral to the articular margin. In such cases of single-row repair, the sutures are placed more lateral, 6 to 7 mm from the musculotendinous junction. This allows the musculotendinous junction to be within 2 mm of the articular margin, preventing overtensioning and reducing the probability of retear.
Traditionally, only one suture pair from each anchor is used for the SutureBridge, but the use of the second suture pair may add fixation in poor quality tendons. The mattress sutures are tied with a static six-throw surgeon’s knot using a double-diameter knot pusher (Surgeon’s Sixth Finger; Arthrex). After each pair is tied, the suture limbs are preserved by retrieving them out the same portal used for anchor insertion. The lateral row is then established by crisscrossing the medial row suture limbs. One limb from each medial row anchor is retrieved out the lateral cannula and the combined suture limbs are secured with two 4.75- or 5.5-mm BioComposite SwiveLock C anchors (Arthrex). The sutures are tensioned through the cannula before inserting the anchor to determine the appropriate location of the lateral anchors. The lateral anchors are placed on the metaphyseal cortex lateral to the “corner” of the greater tuberosity. One anchor is placed anteriorly and another posteriorly. The sutures are cut flush with the anchor for a low-profile knotless lateral repair.
Knotless Double-Row Rotator Cuff Repair
In the setting of good-quality tissue, we use a knotless technique ( 
). The steps in the repair are essentially the same as previously described. Medial threaded anchors (BioComposite SwiveLock C; Arthrex) preloaded with a 2-mm suture tape (FiberTape; Arthrex) are placed adjacent to the articular margin.
- Video 7A.1
SpeedBridge™ with medial double pulley.
One of two techniques is then used for suture passage depending on the desired construct. The medial anchors have #2 safety sutures in the anchor eyelet that may be incorporated into the repair. We often use these to create a broad double-mattress suture between the two anchors using a double-pulley technique. The suture tape and safety sutures from one anchor are retrieved out the lateral working portal. The free end of a FiberLink suture (Arthrex) is loaded onto an antegrade suture passer and passed through the rotator cuff. The sutures from the anchor are then passed through the opposite end of the FiberLink, which is a closed loop. The free end of the FiberLink is then retrieved out the portal used for anchor placement and used to shuttle the sutures through the rotator cuff. These steps are repeated for the other anchor.
Next one #2 suture from each anchor is retrieved out the lateral portal. A six-throw surgeon’s knot is tied over an instrument and limbs are cut. Pulling the opposite limbs of the #2 sutures delivers the knot into the subacromial space so that it rests over one of the anchors. The remaining two #2 suture limbs are then retrieved and tied with a static knot (a sliding knot cannot be used since the previous knot prevents sliding) over the opposite anchor. This medial double-mattress creates a medial seal between the rotator cuff and the glenohumeral joint.
Before lateral fixation, the tendon repair is assessed for dog ears. The same FiberLink used for shuttling can be used to create cinch loops at the anterior and posterior margins of the tear to reduce dog ears and reinforce the rotator cable attachments. Finally, the suture tape limbs (and dog-ear sutures if placed) are crisscrossed and secured laterally with two knotless anchors as previously described ( Figs. 7A.2 and 7A.3 ).
If tissue quality is excellent, a completely knotless technique can be used. In this setting, the medial #2 safety sutures are removed and the suture tapes alone are passed through the rotator cuff in the standard fashion. Because the limbs of these tapes come prewedged into a single limb at the end of the suture, a shuttling technique is not required in this case.
Massive Tears
Massive rotator cuff tears are a subset of rotator cuff tears that remain a problematic condition to treat. With a significant tear, the force couples are no longer balanced, resulting in an unstable fulcrum of motion and painful dysfunction. However, not all tears will result in an unstable fulcrum. This is because many tears occur in the avascular crescent region of the posterior rotator cuff (e.g., supraspinatus tendon and anterior half of the infraspinatus tendon). Enclosed within the arc of the rotator cable is the classical crescent region of the rotator cuff, which is the area where the majority of tears begin. When a tear begins in this region, the muscle exerts its force on the humeral head through the rotator cable in much the same way that a suspension bridge exerts its force through a distributed load from its cable to its columns. Because of this preserved function, most tears that are contained within the rotator cable region still have a stable fulcrum, allowing for preserved motion and minimal strength deficits. Conversely, tears that extended through the rotator cable attachments usually result in an unstable fulcrum, with loss of strength and the possible development of pseudoparalysis ( ).
Interval Slides and Other Advanced Mobilization Techniques
Although partial rotator cuff repairs have been shown to work very well with regard to improving pain and function in the short term, a complete anatomic rotator cuff repair is desirable, particularly in younger patients. In two separate studies, showed that an anatomic repair of a massive rotator cuff tear is possible even in the setting of pseudoparalysis and results in restoration of the cable region with resultant improvement in function in 90% of cases or greater. It is critical to exhaust all efforts to mobilize the rotator cuff in the medial to lateral and anterior to posterior planes based on the tear pattern. Most massive rotator cuff tears may be reparable without releases after properly evaluating for the natural mobility. One of the keys in repairing massive tears is to first address and repair the subscapularis tendon, which is torn in the majority of massive rotator cuff tears. We also perform a limited subacromial decompression that preserves the coracoacromial arch. The other major key to success is to excavate the tendon and bursal leaders. This requires visualization of the scapular spine and clearing of the posterolateral gutter. While viewing through the lateral portal using a combination of motorized shaver and cautery placed through the posterior portal, the scapular spine is exposed. Bouncing the shaver off the scapular spine to enter the space ensures protection of the underlying rotator cuff. The scapular spine is a keel-shaped structure that delineates the interval between the supraspinatus and the infraspinatus tendons. Work can then be carried laterally to safely remove bursal leaders or false cuff that inserts on the deltoid.
The need for interval slides is based on the mobility of the rotator cuff tendon margins. When a tear has been determined to be irreparable despite standard releases, interval slides should be considered to improve mobility. The decision is based on a number of factors, including patient age, symptoms, tissue quality, and initial tear mobility. This is particularly relevant in patients with greater than 50% fatty atrophy on magnetic resonance imaging ( ).
Two slides are relevant to repairs of the posterior rotator cuff: the anterior interval slide in continuity and the posterior interval slide. The anterior interval slide is a release of the anterior leading edge of the supraspinatus tendon from the rotator interval. Our preferred method (anterior interval slide in continuity) is to use an electrocautery to release the coracohumeral ligament from the base of the coracoid while preserving the comma tissue ( ). This preserves the tissue adjacent to the anterior leading edge of the subscapularis. The anterior interval slide typically provides an additional 1 cm of excursion, and we use this in nearly all massive tears. The release is typically done while viewing with a 70-degree arthroscope through a posterior portal and working through an anterosuperolateral portal.
In contrast, the posterior slide is a release of the posterior edge of the supraspinatus from the infraspinatus. Our experience has been that the posterior interval slide provides more mobility than the anterior interval slide, with up to 4 cm of increased excursion noted after performing the slide. The posterior interval slide is performed while viewing through a lateral portal with a 30-degree arthroscope or from a posterior portal while viewing with a 70-degree arthroscope. Traction stitches are placed in the supraspinatus and infraspinatus tendons. A spinal needle is used to identify the correct angle approach in line with the posterior interval and toward the scapular spine. An arthroscopic scissor is then introduced and begins the posterior interval slide along the lateral margin of the rotator cuff directing the tendon incision toward the base of the scapular spine. The release is continued toward the scapular spine until the perineural fat pad lateral to the spine is encountered. This identifies the proximity of the suprascapular nerve. With an isolated posterior interval slide only, the mobility of the infraspinatus tendon is usually sufficiently improved to permit for repair to bone. After repair of the tendon to bone, the separation between the supraspinatus and infraspinatus is closed with margin convergence sutures, which reduces strain, thereby protecting the tendon–bone repair interface during critical phases of healing.
Diamondback Repair
The repair pattern must be adapted to the tear pattern. As such, in the setting of a large uncovered footprint from anterior to posterior, additional lateral or medial anchors may be placed as needed. One adaptation is the Diamondback repair. This repair was developed by the senior author (SSB) as an enhanced suture bridging repair construct that provides twice as many linked diagonal compression sutures with three times the number of intersection points.
Two medial double-loaded anchors (5.5-mm BioComposite Corkscrew FT; Arthrex) are placed just lateral to the articular margin in the fashion described previously for the knotted suture-bridging technique. All eight suture limbs are passed in a mattress fashion 2 to 3 mm lateral to the musculotendinous junction. The four central limbs are used in a double-pulley technique to create broad double-mattress sutures. The first two suture limbs are cut short, but the tails of the second pair are preserved. Mattress sutures are tied with the anterior-most two limbs and repeated posteriorly. A total of 3 BioComposite SwiveLock C anchors are placed laterally accepting two suture limbs for each SwiveLock in a crisscross fashion creating a diamondback pattern of repair. Biomechanical testing of the diamondback configuration demonstrated the highest initial footprint contact area and lowest decrease in contact pressure over time when compared with single- and double-row repairs ( )
Load-Sharing Rip-Stop Technique for Massive Rotator Cuff Repair
A Load-Sharing Rip-Stop technique (LSRS) technique was developed by the authors that combines the advantages of a wide rip-stop suture tape and load-sharing properties of a double-row repair ( ). demonstrated that a rip-stop suture with a double-loaded anchor had load to failure equivalent to a modified Mason-Allen stitch. This construct is particularly useful for cases in which there is limited medial tendon that precludes a standard double-row repair.
While viewing through a posterior portal, a FiberTape suture is passed through the rotator cuff as an inverted mattress stitch placed 3 mm lateral to the musculotendinous junction. If the tear has a large anterior-to-posterior dimension, then a second FiberTape may be placed in similar fashion. The limbs are retrieved out of an accessory portal. These rip-stop suture tapes must not be tensioned and repaired to bone until after the sutures from the medial anchors have been passed circumferentially around them.
Next, two double-loaded 5.5-mm anchors are placed anteromedially and posteromedially along the articular margin. Beginning posteriorly, the sutures are passed from the medial anchors as simple stiches that penetrate the rotator cuff medial to the rip-stop suture. After the medial sutures are passed, the FiberTape rip-stop sutures are retrieved from an accessory portal and secured laterally with two knotless suture anchors, making sure they encircle the sutures from the medial anchors.
Finally, simple sutures from the medial anchors are retrieved, and static knots are tied. It is important to delay knot tying until after the rip-stop stitch is secured laterally. This is done for two reasons. First, it is important to have a firm, taut rip stop. Second, the FiberTape serves to unload the medial sutures because the rip-stop construct is secured laterally to an anchor.
were the first to report a biomechanical study of an LSRS construct for repair of tissue-deficient rotator cuff tears. The mean load to failure for LSRS was nearly twice that for a single-row repair construct. The LSRS construct is the authors’ preferred method for massive rotator cuff repair with poor tissue quality in which a double-row repair is not possible because of limited mobility.
Outcomes
- Brian C. Lau, MD
- Alan L. Zhang, MD
- C. Benjamin, MA, MD
- Alan L. Zhang, MD
Abstract
The diagnosis and surgical management of posterior rotator cuff tears have evolved over the past several decades. Improved imaging protocols, in particular magnetic resonance imaging (MRI), has enhanced our characterization of size and tear pattern ( ). Improved techniques have expanded surgical treatment to include open, mini-open, and all arthroscopic. Efforts to study and determine outcomes have also seen the development of new tools to assess repairs including ultrasonography, MRI, and patient-reported outcome measures ( ). To critically assess the literature and determine optimal treatments, a thorough understanding of outcomes measurements must first be achieved. Despite the increase in surgical repairs, there is evidence that conservative treatment with physiotherapy alone may have comparable outcomes compared with open or mini-open repairs for rotator cuff tears smaller than 3 cm. All-arthroscopic repair has become the mainstay of treatment and has demonstrated comparable outcomes compared with mini-open and open repairs. Large and massive tears have greater failure rates and high retear rates, up to 94%. Fatty infiltration and muscle atrophy are predictors of poor outcomes and are irreversible. Preliminary studies demonstrate that repair techniques such as single-row and double-row techniques demonstrate comparable results. Early rehabilitation and delayed rehabilitation demonstrate similar functional outcomes and risk of retear. Currently, the use of plasma-rich platelets has not been shown to be cost effective, and their clinical benefit is uncertain
Keywords: functional, outcomes, patient-reported outcomes, posterior cuff, retear
Introduction
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The diagnosis and surgical management of posterior rotator cuff tears have evolved over the past several decades. Improved imaging protocols, in particular magnetic resonance imaging (MRI), have enhanced our characterization of size and tear pattern ( ).
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Improved techniques have expanded surgical treatment to include open, mini-open, and all-arthroscopic techniques.
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Efforts to study and determine outcomes have also seen the development of new tools to assess repairs including ultrasonography, MRI, and patient-reported outcome measures (PROMs) ( ).
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To critically assess the literature and determine optimal treatments, a thorough understanding of outcomes measurements must first be achieved.
Patient-Reported Outcomes
A study by reviewed 156 studies that evaluated rotator repair outcomes and found significant variability exists in outcomes reporting. The type of validated PROMs usage ranged greatly between 16% and 61%. Constant-Murley (Constant) score was the most frequently used in 61% of studies, the American Shoulder and Elbow Surgeons (ASES) score was the second most used at 59%, the University of California Los Angeles (UCLA) shoulder rating scale was the third most used at 35%, and the Simple Shoulder Test (SST) was the fourth most used at 28%. The Constant score was developed in 1986 and is a summative scale that provides a global score based on weighted measures of physical impairments in range of motion (ROM) and strength along with patient reported pain and activity limitation ( ). The distinguishing part of the Constant score from other PROMs is that 65% of the final score is based on an objective component scored by a health professional. The Constant score also allows for age- and sex-related changes in the musculoskeletal system by converting the absolute score to a relative score to adjust for age and sex ( ). The UCLA shoulder rating scale was developed in 1981 and is also a combination of physical examination findings (active forward elevation and strength) and subjective patient-reported measures (pain, satisfaction, and function) with a higher score indicating better function ( ). The distinguishing part of the UCLA score is that it preferentially weighs the subjective component ( ). Similarly, the ASES contains a physician and patient-rated component; however, only the patient-reported subjective pain visual analog scale and 10 functional questions are typically used to tabulate the reported ASES score ( ). The total score is evenly weighted between 50% pain and 50% function ( ). The SST relies solely on patient-subjective data and is composed of 12 yes-or-no questions ( ). Several studies appeared in fewer than 4% to 10% of all studies, including the Penn Shoulder Score, L’Insalata/Shoulder Rating Questionnaire, Shoulder Pain and Disability Index, Rotator Cuff-Quality of Life, EuroQol-5D, Shoulder Activity Scale, Marx Activity Scale, Korean Shoulder Score, and Rowe score, making it difficult to assess their utility ( ) ( Table 7B.1 ).
| Patient-Reported Measure | Percentage Used in Literature ∗ | Defining Characteristic |
|---|---|---|
| Constant-Murley (Constant) | 61 | Score combined patient subjective and physician objective with 65% based on Physician Objective component |
| American Shoulder and Elbow Surgeons (ASES) | 59 | Combination of patient subjective and physician objective but only patient-subjective data are used in generating the score with 50% based on pain and function |
| University of California Los Angeles (UCLA) Shoulder Rating | 35 | Score combines patient subjective and physician objective with 57% based on Patient Subjective component |
| Simple Shoulder Test | 28 | Patient-subjective component only with 12 yes/no questions |
Imaging Assessment
Tendon integrity and retear rates were evaluated with MRI in 38% and ultrasonography in 31% of studies ( ). The accuracy of these measures has been assessed in preoperative characterization of rotator cuff tears. In preoperative preimaging, MRI and ultrasonography have been shown to have similar sensitivity in rotator cuff diagnosis (90.4% and 92%, respectively) ( ). Postoperatively, however, the characterization of the rotator cuff and accuracy of detecting a tear become more difficult because of surgical changes and placement of hardware. determined a 91% sensitivity but a 25% specificity of a musculoskeletal radiologist diagnosing a recurrent rotator cuff after repair with MRI and cautioned at the high false-positive rate. Recent literature evaluated the interobserver agreement among seven fellowship-trained orthopaedic shoulder surgeons on MRI and determined that recurrent full-thickness tears had moderate agreement of 80%, but characterization of partial tears, rotator cuff footprint coverage, biceps tendon tear, bone marrow edema, and cyst formation had poor reliability ( ). Given the high costs of MRI, ultrasonography has been increasingly used for postoperative evaluation of rotator cuff repairs ( Fig. 7B.1 ). A recent prospective, multicenter study identified that ultrasonography had an 85% concordance with MRI for detecting a recurrent rotator cuff tear ( ).
Length of Follow-up
Length of follow-up is another consideration when evaluating outcome studies in rotator cuff repairs. Short-term refers to follow-up of 2 years and long-term follow-up at 10 or more years. Short-term follow-up allows assessment of time to return to function and early pain relief. Long-term follow-up allows assessment of the durability of repairs.
Outcomes for Conservative versus Operative Treatment
Conservative treatment including physiotherapy is a mainstay of early care for rotator cuff tears. However, there has been a trend toward surgical rotator cuff repair with a rise of the incidence of rotator cuff repairs over the past decade by 238% ( ). Both treatments have possible side effects, including risks associated with surgery such as infection and postoperative stiffness for surgical repairs versus progression of tears with physiotherapy alone. There have been several recent cohort and randomized studies directly comparing the two treatment options that support an initial trial of physical therapy.
The MOON Shoulder Group evaluated 452 patients in a prospective cohort study and treated patients with atraumatic full-thickness rotator cuff tears with a directed physical therapy program. At follow-up visits, patients who were not satisfied with their responses to physical therapy were allowed to convert to surgical treatment. Patients elected to convert to surgical fixation less than 25% of the time, and most did so within the first 6 to 12 weeks of treatment ( ).
randomized 103 patients with rotator cuffs smaller than 3 cm into primary repair (open or mini-open) or physiotherapy alone and found that patients who underwent primary repair had statistically significant improved results in ASES and Constant scores compared with physiotherapy alone. However, this was at or near the minimally clinically significant important difference. The study also found that in 37% of patients treated with physiotherapy alone, there was progression of tear size that was associated with inferior outcomes. In the physiotherapy treatment group, nearly a quarter of patients converted to the repair group with the majority choosing to convert within the first year. In the patients who underwent secondary repair, there were no significant differences in ASES or Constant scores at 5 years. The authors suggest that a primary trial of physiotherapy is supported in most patients with small to medium tears ( ).
randomized 56 patients with degenerative tears to a physiotherapy-only group and a surgical repair with mini-open technique group and found no difference in Constant scores. There was; however, a difference in pain and disability in favor of surgical treatment. Of note, at 1 year postoperatively, 73.7% of surgically repaired patients demonstrated retear of the rotator cuff. In a subgroup analysis, patients who had a retear after surgical repair did not have any significant difference with the physiotherapy group only ( ).
Bottom Line
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Conservative treatment is an effective initial option for rotator cuff tears.
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Patients who fail conservative treatment tend to convert to operative treatment early in physical therapy treatment.
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Delayed operative fixation after initial trial of conservative management has similar outcomes to initial operative fixation.
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Older patients with degenerative tears have improved pain and disability with surgical repair despite high retear rates.
Outcomes for Rotator Cuff Repair Based on Tear Thickness
Full-Thickness Tears
Full-thickness tears include involvement of all fibers in a superior-to-inferior direction, from the bursal side to the articular side. Repair techniques of full-thickness tears have been extensively studied and have demonstrated good to excellent PROMs, quality of life, and tendon integrity regardless of whether open, mini-open, or all arthroscopic techniques have been used.
Outcomes after open repair of full-thickness rotator cuffs identified that 88% of patients had good to excellent Constant scores and that all patients who were gainfully employed before surgery returned to employment after surgery ( ). In a randomized study comparing open repairs with mini-open repairs, there was improved early quality of life in the mini-open group up to 3 months postoperatively; however, in subsequent follow-ups, there was no difference in ROM or PROMs ( ).
Fixation Configuration
All arthroscopic repairs also have demonstrated good to excellent functional outcome whether using a suture-bridge or double-row technique ( ). evaluated 52 consecutive rotator cuff tears; at 2 years, the study identified significant improvement in Constant, ASES, and UCLA scores. compared single-row, double-row, and combined double-row and suture-bridge repairs in full-thickness rotator cuff tears and found retear rates of 10.8%, 26.1%, and 4.7%, respectively. They suggested that the combination of double-row with suture-bridge techniques may be beneficial. A randomized study of 86 patients with full-thickness all-arthroscopic repair identified similar ASES and quality of life indices with or without acromioplasty; however, 9% (4 of 45) patients without acromioplasty required reoperation versus none in the acromioplasty group ( ). Regarding the durability of an arthroscopic repair, a recent study of 59 patients with 1-year and 10-year follow-up after full-thickness arthroscopic repair demonstrated that improvements in ASES scores and ROM over that time period were retained ( ).
Bottom Line
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Full-thickness tears have good to excellent short- and long-term outcomes after surgical repair.
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A combination of double-row with suture-bridge techniques may be beneficial.
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Concurrent acromioplasty may help prevent reoperation but does not affect ROM or PROMs.
Partial-Thickness Tears
Partial-thickness tears can be divided into articular- or bursal-sided tears. There are two main approaches to repair of partial-thickness tears, including debridement and transtendon repair, to prevent progression or conversion to full-thickness tear followed by more traditional repair. Proponents of transtendon repair suggest that the maintenance of the intact rotator cuff tissues may strengthen the repair, but some authors suggest that transtendon repair may lead to stiffness ( ). It is common practice to use 50% thickness as an indicator of supporting one particular management approach over another ( ).
A recent study by evaluated articular-sided partial tears at 2 years from arthroscopic debridement and transtendon repair and found average improvement of 31.7 on the ASES and 17.9 on the UCLA score with 92.5% of patients reporting satisfaction with results. Despite concerns for increased stiffness, only 5 patients developed postoperative adhesive capsulitis, and all responded well to physical therapy.
A number of studies that directly compared transtendon repair with completion of tears with repair have found no significant difference in functional outcomes. prospectively compared arthroscopic transtendon repair with arthroscopic full-thickness conversion and repair and found no differences in functional outcome, return to sports, and retear rates. also prospectively randomized patients into one of the two repair groups and concluded satisfactory functional improvement and pain resolution with no significant difference between groups. These studies also found no significant difference in postoperative stiffness between treatment groups.
Several studies comparing partial-thickness tears based on the 50% thickness criteria also found no significant difference between treatment groups. A prospectively randomized study between transtendon repair and conversion to full-thickness and repair in partial rotator cuff tears greater than 50% thickness concluded there was no difference in functional improvements, PROMs, or pain relief ( ) ( Fig. 7B.2 ). In an evaluation between articular- and bursal-sided tears exceeding 50% thickness, there was no significant difference in PROMs. There was, however, an increase in retear rate in the conversion and repair group for bursal-sided tears but no difference in articular-sided tears ( ). Other studies comparing articular- and bursal-sided tears identified similar improvement in PROMs and functional outcomes with greater trend toward retears in bursal-sided tears compared with articular-sided tears in the conversion of tear and repair ( ).
Bottom Line
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There are two techniques for partial cuff tears: (1) transtendon repair and (2) completion of tear and then repair.
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PROMs, rate of stiffness, and return to sport are similar between repair techniques.
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In partial bursal tears that exceed 50%, there may be an increase in retear rate with completion of the tear and then repair.
Outcomes Based on Tear Size
Tear size is measured in the anteroposterior dimension and has been evaluated as a possible predictor of outcome. Small is defined as smaller than 1 cm, medium as less than 3 cm, large as less than 5 cm, and massive as larger than 5 cm.
Outcomes for small to medium-sized tears repaired all-arthroscopically with and without acromioplasty demonstrated excellent ROM and average ASES and Constant scores ( ). Although studies suggest that there may not be a difference between small and medium tears, several studies show that large and massive tears have lower healing rates and higher retear rates after rotator cuff repair. Failure rates after arthroscopic repair of large or massive rotator cuff tears have been reported to range from 34% to 94% depending on various series ( ). There is also a high retear rate as demonstrated in a recent systematic review of massive rotator cuff tears by of 18 studies and pooled data that demonstrated a 79% retear rate. through the rotator cuff registry of all-arthroscopic repairs found that predictors of rotator cuff defect at 5 years postoperatively were larger size of preoperative tear (odds ratio [OR], 1.72), and multiple tendon involvement (OR 5.56). Poor tendon healing is also associated with poorer outcomes ( ).
Interestingly, despite poor healing and high retear rates of large and massive tears, functional outcomes and return to daily activities have been generally good after repairs and not correlated to postoperative radiographic defects ( ). followed 59 patients (3 small tears, 31 medium tears, 12 large tears, and 13 massive tears) who underwent mini-open or all-arthroscopic repair and found that good to excellent UCLA, visual analog scale pain score, and ROM in 95% of cases. A possible explanation is that despite residual rotator cuff tendon defect or recurrent defect, there is enhancement in overall tendon integrity, resulting in functional improvement but not to the degree of smaller tears that have complete healing and tendon integrity at follow-up.
Bottom Line
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Small and medium tears have excellent functional outcomes and healing rates with low retear rates.
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Large and massive tears have poor healing and high retear rates.
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Large and massive tears may still have good functional and patient-reported outcomes and still benefit from repair.
Outcomes Based on Fatty Infiltration and Muscle Atrophy
As rotator cuff tears become larger than 5 cm (massive), there is an association with muscle fatty infiltration and atrophy. Two components that may lead to development of these changes appear to be unloading of the muscle–tendon unit and denervation of the muscle. Clinically, these changes have been found to be irreversible and correlated with poor functional outcomes following repair ( ).
Fatty infiltration, as described by , uses degree of fat (grade 0 to 4) as seen on CT within a muscle: grade 0 no fat; grade 1 thin streaks of fat; grade 2, less fat than muscle; grade 3, equal amounts fat and muscle; and grade 4, more fat than muscle and has been validated on T1-weighted MRI by several groups ( ). Muscle atrophy is described based on a scale proposed by and is described as none, mild, moderate, or severe based on the oblique sagittal MRI.
Outcomes after rotator cuff repair with preoperative fatty infiltration and muscle atrophy have a strong correlation with worse outcomes on ASES, Constant, and strength ( ). Furthermore, atrophy and fatty infiltration progressed despite repair, and in cases with retear, the progression was found to be worse ( ). in a series of 220 shoulders determined that there was a greater likelihood for retear at 3 years if the degree of fatty infiltration was 2 or greater. The study also found that fatty infiltration of the infraspinatus and subscapularis muscle had an influence on the supraspinatus tendon outcome.
The role of fatty infiltration and atrophy of the teres minor without tear but with tears of the supraspinatus and infraspinatus has demonstrated similar outcomes with SST and ASES scores ( ). Moreover, there was no significant change in fatty infiltration of the teres minor muscle after repair ( ) ( Fig. 7B.3 ).
