PARTIAL-THICKNESS ROTATOR CUFF TEARS

Partial-Thickness Rotator Cuff Tears

James C. Esch and Michael Yergler

Partial-thickness rotator cuff tears are a significant source of shoulder pain and have been the subject of multiple articles in the literature. Codman first described these tears in 1934. Arthroscopy, as well as advanced imaging techniques such as magnetic resonance imaging (MRI), have made us aware of the high and often unexpected incidence of articular and bursal side rotator cuff tears. The best treatment for significant partial-thickness tears is repair, usually with an associated arthroscopic subacromial decompression.

Partial-thickness bursal side rotator cuff tears are most often associated with an impingement-type syndrome. Articular side tears may be associated with underlying instability of the shoulder. A Bankart lesion or capsular laxity may be present. Partial-thickness rotator cuff tears may be associated with shoulder stiffness, especially loss of elevation and internal rotation. It is best if this can be treated prior to surgery. Articular side rotator cuff tears are often associated with SLAP tears (type II).

Indications

1. A bursal side, articular side, or intratendinous location is possible.

2. The tear thickness ranges from a few millimeters to a significant thickness exceeding 75% of the tendon.

3. Degenerative changes in the acromion are associated with bursal side tears. Arthroscopic subacromial decompression is part of the treatment plan.

4. Articular side tears are often not associated with acromial changes. Arthroscopic subacromial decompression may not be necessary for the articular side tear.

Contraindications

Stiffness may be associated with a partial thickness rotator cuff tear. Every effort should be made to correct this before a cuff repair is attempted.

Physical Examination

1. A prominent complaint is shoulder pain, especially night pain.

2. A painful arc of motion in the impingement range is commonly present.

3. Shoulder stiffness is often present. This may be a subtle loss of internal rotation with the arm at 90 degrees of elevation.

4. Pain with throwing or working overhead commonly occurs.

Diagnostic Tests

Radiography

1. Radiographs may show a type II or type III acromion on the arch view X-ray.

2. An MRI scan may show increased signal within the supraspinatus tendon.

3. An MRI arthrogram with gadolinium may delineate a partial-thickness rotator cuff tear on the articular side.

Diagnostic Arthroscopy

1. Diagnostic arthroscopy is the hallmark of making the diagnosis.

2. A systematic examination is performed from the posterior and anterior portal.

3. Specific attention is addressed to the rotator cuff and its insertion onto the humeral head (called the rotator cuff footprint).

4. Determine the tear thickness by inserting a probe or arthroscopic shaver blade into the tear.

5. A partial tear with retraction can be diagnosed by realizing that when a bare area of bone is seen, instead of articular cartilage, at the normal supraspinatus tendon insertion the rotator cuff is no longer attached to the humeral head.

6. Determine the extent and location of bursal side tears by subacromial bursoscopy.

Special Considerations

1. Partial rotator cuff tears are a significant source of shoulder pain.

2. Partial tears are more painful than complete rotator cuff tears.

3. Most of these tears will enlarge in size and progress to full-thickness rotator cuff tears within 2 years.

4. Treatment by subacromial decompression without repair often fails.

Special Instruments

1. Clear cannula

2. Smith & Nephew Elite System Cuff Sew hook with a 30-degree upward tilt

3. Smith & Nephew Elite System ArthroPierce suture passer

4. Panacryl sutures (or #1 PDS or #2 Ethibond)

5. Smith & Nephew 5.0 PeBA suture anchor

Anesthetic Options

1. General anesthesia

2. Scalene block

Patient and Equipment Position

1. Lateral decubitus position

2. Beach chair as alternate

Surgical Approach

Treatment of the Acromion

1. Arthroscopic subacromial decompression by smoothing the acromion from posterior to anterior is indicated for bursal side tears. Aggressive resection of the acromion and coracoacromial ligament is not necessary.

2. Articular side tears may not require arthroscopic subacromial decompression. The authors do not perform a subacromial decompression for articular side tears if the subacromial bursoscopy is normal.

3. A subacromial decompression is not done if there is no fraying of the acromial attachment of the coracoacromial ligament.

Types of Repair

The following types of repairs are performed:

1. Side-to-side bursal repair

2. Bursal side repair with suture anchor

3. Articular side tear converted to complete rotator cuff tear

4. Articular side transtendon repair

Side-to-Side Bursal Side Repair

1. Repair the tear using a lateral portal for arthroscopic viewing. The anterior and posterior portals are operating portals for the tools.

2. Knot tying is easier when the posterior portal is an 8- to 9-mm clear cannula.

3. This technique is effective for tears involving 25 to 75% of the cuff thickness.

4. Authors’ preferred technique:

a. View with the arthroscope in the lateral portal.

b. From the 8.5-mm posterior portal cannula, pass the suture from posterior to anterior in one pass using a Smith & Nephew Elite Sys tem Cuff Sew hook with a 30-degree upward tilt. This pass needs to obtain solid purchase in the cuff posterior to the tear in a superior to inferior direction. The cuff sew is then advanced across the tear and up through the cuff anterior to the tear in an inferior-to-superior direction. The author’s suture preference is long lasting absorbable suture (Panacryl). Other options are absorbable (#1 PDS) or braided nonabsorbable (#2 Ethibond) suture.

c. From the anterior portal use a suture manipulator to grasp and stabilize the suture on the cuff sew that has been passed through the rotator cuff. Once the suture is firmly gasped, withdraw the cuff sew out the posterior portal. The suture is withdrawn out the anterior portal.

d. The suture out the anterior portal is then moved over the top of the cuff tear to the posterior portal. This is accomplished by passing the suture manipulator from the posterior portal over the top of the tear. Loop the suture where it exits the cuff and pull it out the posterior portal.

e. Tie a knot. Use a sliding suture knot down the posterior cannula. Follow this sliding knot with three half hitches alternating the post with each half hitch.

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