These authors reported the clinical outcomes of arthroscopic debridement vs. repair for Ellman grade II bursal-side partial thickness rotator cuff tears.
On the basis of preoperative findings and patient preference, 20 patients underwent debridement whereas 26 underwent arthroscopic repair.
All 46 patients were available throughout follow-up. At 2 years postoperatively, the VAS score had improved from 6.42 to 0.65 0.51 in the debridement group and from 6.26 to 0.75 in the repair group. The average VAS score was worse for the repair group at 6 months postoperatively.
The American Shoulder and Elbow Surgeons score, Constant score, and University of California–Los Angeles scores were worse for the repaired group at 6 months postoperatively.
At followup, there was no difference in the cuff integrity between the repaired and debrided groups.
Based on their results, the authors question the rationale for repair of these lesions.
Comment: While this is not a randomized clinical trial it does indicate that debridement can be an effective treatment for these partial thickness cuff tears. The inferior outcomes for the first 6 months after repair surgery serve to remind us that when a cuff defect is repaired, the cuff tension is shifted from the intact tendon to the repaired tendon. Pain and functional limitation associated with preferential loading of the repair subsides when the stress is relaxed, either by failure of the repair or by stretching of the repaired musculotendinous unit. See this related article , "Failure With Continuity in Rotator Cuff Repair "Healing" "(link). 13 patients had arthroscopic repair of small tears. At the time of the repair, tantalum markers were placed in the substance of the tendon. The markers of all repaired tendons retracted away from the suture anchors over the first year. The average retraction was 16.1 mm with a range of 5.7 to 23.2 mm. Tendon retraction correlated with patient age. As reported previously for open repairs, most of the retraction occurred during the early phases of recovery (i.e. 12 weeks).
The stress relaxation hypothesis is consistent with these observations:
Consider this diagram of a cuff tear where the orange part of the cuff has pulled away from the blue tuberosity leaving the red portions of the cuff intact.
The surgeon repairs the torn (orange) part of the cuff to the tuberosity, but in doing so, takes the normal tension off of the intact (red) portions of the cuff and causing the repaired portion to support the load applied by the cuff musculature.
Stress relaxation must occur so that the normal portions of the cuff are under physiologic load. This can happen by recurrence of the cuff defect, as diagrammed below (this may be the situation in older individuals with larger cuff defects)
or by 'failure in continuity' in which the torn (orange) and intact (red) portions of the cuff progressively return to their original position, but that new regenerative tissue (green) tissue forms as the edge of the torn tendon pulls away from the footprint (this may be the situation for younger patients with smaller defects).
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