Rotator cuff tear - the value of open transosseous repair for small to medium sized defects

At a 10-Year Follow-up, Tendon Repair Is Superior to Physiotherapy in the Treatment of Small and Medium-Sized Rotator Cuff Tears

These authors studied 103 patients with a rotator cuff tear not exceeding 3 cm who were randomly assigned to primary tendon repair or physiotherapy with optional secondary repair. Blinded follow-up was performed after 6 months and 1, 2, 5, and 10 years. Outcome measures included the Constant score and the self-report section of the American Shoulder and Surgeons Score.

Operative treatment was open or mini-open tendon repair. Following a diagnostic arthroscopy of the glenohumeral joint, the tear was exposed through a deltoid-splitting approach, and an anterior acromioplasty was performed. Tendons were mobilized and repaired by transosseous sutures. Tenodesis of the long head of the biceps was performed in patients with a partial tear of the tendon. Postoperatively, the arm was immobilized in a sling, and passive range-of-motion exercises were started and were continued for 6 weeks. Active range-of-motion exercises were started 6 weeks after the surgical procedure and were supplemented by strengthening exercises after 12 weeks.

Ninety-one of 103 patients attended the last follow-up. After 10 years, the results were better for primary tendon repair, by 9.6 points on the Constant score (p = 0.002), 15.7 points on the American Shoulder and Elbow Surgeons score (p <0.001), 1.8 cm on a 10-cm visual analog scale for pain (p < 0.001), 19.6 for pain-free abduction (p = 0.007), and 14.3 for pain-free flexion (p = 0.01). Fourteen patients had crossed over from physiotherapy to secondary surgery and had an outcome on the Constant score that was 10.0 points inferior compared with that of the primary tendon repair group (p = 0.03).

In 47 patients treated by primary repair, tendon integrity was assessed by MRI after 1 year and by sonography after 5 and 10 years. Full or partial-thickness retears were found in 10 (21%) after 1 year, 13 (28%) after 5 years, and 16 (34%) after 10 years. Five of the retears after 10 years were classified as partial-thickness only. A comparison of the Constant score after 10 years between the 16 patients with a retear at the last follow-up (76.9 points) and the 31 patients with an intact repair (82.9 points) showed a better result for intact repairs, with a between-group difference of 6.0 points (95% CI, 0.2 to 11.8 points; p = 0.04). 

Comment: It is not known if the results with arthroscopic repairs using suture anchors are equivalent to these with open transosseous repair.

It is of interest that these structural and functional outcomes for small to medium sized tears repaired with open transosseous repairs are virtually identical to those presented by the late Douglas Harryman 28 years ago using a similar surgical technique:

Repairs of the Rotator Cuff: Correlation of Functional Results with Integrity of the Cuff.

These authors evaluated the results of 105 operative repairs of tears of the rotator cuff of the shoulder in eighty-nine patients at an average of five years postoperatively. They correlated the functional result with the integrity of the cuff, as determined by ultrasonography.

The size of the rotator cuff defect as seen at surgery (operative type) and as seen at followup by sonography (followup type) was classified as follows:

Type 0 - intact cuff

Type lA - thinning or a partial-thickness defect of the supraspinatus tendon. 

Type lB - a full-thickness defect of the supraspinatus tendon

Type 2 - a full thickness defect involving the supraspinatus and infraspinatus tendons'

Type 3 - a full-thickness defect involving the supraspinatus ,infraspinatus ,and subscapularis tendons.

The tear size seen at surgery was related to age at the time of repair

Eighty per cent of the repairs of a tear involving only the supraspinatus tendon were intact at the time of the most recent follow-up, while more than 50 per cent of the repairs of a tear involving more than the supraspinatus tendon had a recurrent defect. 

Older patients and patients in whom a larger tear had been repaired had a greater prevalence of recurrent defects. 

At the time of the most recent follow-up, most of the patients were more comfortable and were satisfied with the result of the repair, even when they had sonographic evidence of a recurrent defect.

The shoulders in which the repaired cuff was intact at the time of follow-up had better function during activities of daily living and a better range of active flexion (129 +/- 20 degrees compared with 71 +/- 41 degrees) compared with the shoulders that had a large recurrent defect. Similar correlations were noted for the range of active external and internal rotation and for strength of flexion, abduction, and internal rotation. 

In the shoulders in which the cuff was not intact, the degree of functional loss was related to the size of the recurrent defect.

The function of the patients who had an intact cuff after repair of a large tear was as good as that of the patients who had an intact cuff after repair of a small tear.

Comment: This study is of interest because of the detailed correlations examined among patient age, tear size, repair integrity at five years and function at five years after surgery.

It is also of interest that this study was published in 1991, bringing up the question "are current methods of cuff repair yielding results that are equal to or superior to those achieved over 25 years ago?"

For further information on our management of cuff tears, see this PDF on rotator cuff surgery.


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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Rotator Cuff 10 - Surgery for rotator cuff tears - repair

The decision to repair a rotator cuff tear requires consideration of a number of factors.

Is the tear acute and the result of a definite injury? In such a case, surgery deserves strong consideration in that repair is often most successful if performed soon after the tear occurs (say within a few weeks on months).

If the tear is chronic (long standing), are the symptoms related to weakness, to stiffness, or to catching and grinding? Has the shoulder had a good attempt at non-operative management to resolve these symptoms? (there is no rush for surgery when the tear is chronic).

Is it likely that the tear is reparable?

Is the patient prepared to avoid active use of the shoulder of the shoulder for three or so months while the tendon repair heals and remodels? Note that any active use of the arm with the elbow away from the side puts a load on the repair and many challenge its successful healing.

Should the repair be done with a mini open approach or using arthroscopic techniques? Here it is important to recall that the goal of repair is the secure reattachment of the torn tendon back to the bone from which it became separated, not the size of the skin incision. Here's the skin incision I use.

It almost always heals with a barely visible scar, even when appearance is very important, as in this man (can you see the scar?)

The surgeon should use the method that in that surgeon's hands yields the most secure repair. My personal preference now and for the last 40 years is for a mini-open approach that does not in any way compromise the deltoid muscle and that enables complete mobilization and secure repair of the tendon - to a groove in bone if necessary. Doing it securely the first time is the key for us. I also avoid shaving the acromion in that in my view there is no evidence that this improves the results on one hand and in that it adds unnecessarily to the procedure on the other.


So, in my hands the priorities in treating disorders of the rotator cuff are:
(1) to preserve the deltoid – our mini-open surgical approach is conducted through the superior ‘deltoid-on’ approach (which I will describe in more detail later).

(2) to assure smoothness of the humeroscapular motion interface – thus the upper aspect of the humerus and cuff must present a smooth convexity to articulate with the concave undersurface of the coracoacromial arch. All hypertrophic bursa and excrescences of the tuberosities are removed leaving a smooth proximal humeral convexity.

Sutures are placed so that the knots do not lie on the superior aspect of the cuff or tuberosity. "Top knots" (such as those shown below) are avoided. 

 (3) to maintain the normal mobility of the glenohumeral joint – thus limiting scar must be resolved and the cuff tendons must be released from the glenoid and coracoid if necessary before reattachment. 

(4) to assure an even distribution of tension on the cuff insertion spreading the load among multiple sutures – thus differential tightness at the area of cuff repair is avoided.

(5) to assure that if cuff tendon reattachment is performed, that it is sufficiently robust to heal and to allow early motion after surgery – thus multiple sutures securing the tendon edge into a bony trough are preferred. The trough excludes joint fluid from the repair site and allows for the possibility of some slip of the tendon while maintaining tendon to bone contact.

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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).