Partical thickness cuff tears: to repair or not to repair?

A comparative study of arthroscopic debridement versus repair for Ellman grade II bursal-side partial-thickness rotator cuff tears

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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Rotator Cuff 14 - Partial thickness rotator cuff tears - cuff curettage

Here is the detailed description of a procedure (in the form of an operative note) that we've found successful for the management of partial thickness cuff tears that have not responded to a program of stretching. We refer to it as cuff curettage.

DIAGNOSIS:
Partial thickness cuff tear involving the deep surface of the anterior supraspinatus near the tuberosity and the bicipital groove - ICD9 CODE 726.1.

PROCEDURE:
Rotator cuff exploration, lysis of adhesions, resection of bursal tissue, curettage of partial thickness cuff tear – CPT CODE 23405.

INDICATIONS:
The patient has functionally significant pain on elevation of the shoulder. The symptoms have not responded to a program of stretching exercises even though the range of motion is now full. The shoulder continues to manifest a positive supraspinatus tendon sign, i.e., pain on active isometric elevation in the plane of the scapula at 90 degrees of elevation while the arm is in slight internal rotation.  There is minimal atrophy of the supraspinatus and a slight local depression in the tendon near its insertion.

Cuff imaging tests reveal thinning of the supraspinatus tendon due to a partial thickness deep surface tear near its anterior insertion without retraction of the tendon.

Knowing the alternatives as well as the risks of infection, neurovascular injury, excessive stiffness, pain, weakness, irreparability, re-rupture, and the need for revision surgery, the patient desires to proceed with rotator cuff surgery. The patient understands that this surgery will probably consist of curetting the cuff lesion so that its tenuous attachments are released, but could also possibly include a rotator cuff repair if the tear is essentially full thickness and if the cuff tendons are of sufficient quantity and quality, and possibly include a smooth and move without repair if a large irreparable cuff lesion is encountered. The patient recognizes the goal of this procedure is to release weakly attached tendon fibers and understands that it cannot be expected to completely restore normal comfort and function to the shoulder. And lastly, the patient understands his/her critical role in the post surgical rehabilitation.

FINDINGS:
Examination under anesthesia reveals a slightly diminished range of motion and a slight palpable thinning of the cuff near the supraspinatus insertion to the greater tuberosity.

Surgical findings include mild scarring in the humeroscapular motion interface as well as bursal thickening. There is a partial thickness, deep surface defect involving the anterior supraspinatus tendon. The other aspects of the cuff tendons are of good quality and the long head of the biceps and the subscapularis are intact. The undersurface of the coracoacromial arch is smooth.

OPERATION: 

Under satisfactory anesthesia the patient is placed in a low beach chair position. The entire forequarter is carefully prepped and draped in the usual sterile fashion with the arm free to be moved.

The shoulder is approached through a superior incision in the skin line crossing the anterior corner of the acromion

The ‘deltoid-on’ approach is used

The deltoid tendon of origin running between the anterior and lateral thirds of the deltoid is identified and split longitudinally, leaving half of the tendon on either side of the split; no deltoid is detached from the acromion. This split is carried down to the sub deltoid bursa, which is divided in line with the deltoid split. The total length of the deltoid split is limited to 4 cm from the acromion. 

The humeroscapular motion interface is mobilized by blunt finger dissection. A small self-retaining retractor is inserted into the split.   The humeroscapular motion interface is mobilized beneath the coracoid muscles until the axillary nerve can be palpated medially on the front of the subscapularis. The interface is dissected laterally until the axillary nerve can be palpated laterally as it exits the quadrilateral space.

The thickened subacromial/subdeltoid bursa is excised.

This dissection provides excellent exposure of the rotator cuff. The thinned area of the cuff can be identified by palpation, even though the bursal side of the tendon is intact.

A small 000 curette is inserted through the thinnest part of the cuff without making a cuff incision.

The curette is felt to scrape against the uncovered bone from where cuff has been torn. This area is curetted from the anterior to the posterior extent of the tendon detachment until secure cuff insertion is encountered at either end.

On withdrawing the curette only a small puncture in the cuff is present, so no closure of this defect is needed. If the defect had been through most of the cuff thickness so that the tendon insertion was severely weakened, the detachment would have been completed and a formal repair would have been carried out.

Full motion of the glenohumeral joint is assured by gentle manipulation. The acromion is palpated while the shoulder is put through a complete range of motion to verify the absence of any crepitance. The undersurface of the coracoacromial arch is palpated to assure its smoothness. If there is a prominence that encroaches on the cuff, it is smoothed with a pinecone burr without jeopardizing the integrity of the coracoacromial arch.

Formal "acromioplasty" is avoided to preserve the coracoacromial concavity as well as to minimize the risk of adhesions and of weakening the deltoid origin.

Hemostasis is seen to be excellent. The wound is thoroughly irrigated. The deltoid origin is intact at the conclusion of the case. The deltoid split is closed side-to-side-to-side with absorbable sutures.

A standard subcutaneous and subcuticular skin incision is carried out followed by the application of sterile tape closures and sterile dressings.



The patient is returned to Recovery Room in satisfactory condition, with the arm in continuous passive motion.

POSTOPERATIVE PLAN:

Our postoperative plan is for the 140 degrees of flexion/40 degrees of external rotation full motion active program, including stretches in forward flexion, external rotation, up the back, cross body, as well as internal rotation in abduction. There is no need for protection in that there has been no cuff repair and that the deltoid has only been split along its fibers. Forward elevation can also be assisted using a pulley. The ranges of motion are charted on a wall chart twice daily; the patient is discharged when the assisted range of motion goals are achieved.

Strengthening exercises will be started at six weeks after surgery when the shoulder is completely comfortable.

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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).

Rotator Cuff 12 - Partial thickness cuff tears - treatment

In the management of partial thickness cuff tears, the first line of treatment is stretching the shoulder to eliminate any tightness of internal rotation with the arm at the side

internal rotation of the arm in 90 degrees of abduction, the sleeper stretch

and cross body adduction

Often, as is the case with tennis elbow, progressive stretching exercises will eliminate the tightness and even out the distribution of force so that comfort and function are restored in the presence of a thinned tendon.

If symptoms are refractory to non-operative management, consideration can be given to a surgical release of the insecurely attached fibers at the margin of the tear – a procedure we refer to as cuff curettage (more on this later). This can be accomplished through a small deltoid split through which the location of the partial detachment can be confirmed by palpation of the thinned tendon. A small curette is inserted in the area of the detachment and used to release the weakly attached fibers around the periphery of the defect, leaving only the securely attached fibers to transmit the force of the muscle to bone. Since there is no deltoid detachment and no cuff repair, stretching and active use can be started immediately after surgery using the same exercises that were learned by the patient as a part of the non-operative program described in the previous paragraph.

In all cuff surgery, an important goal is to assure the smooth passage of the rotator cuff beneath the coracoacromial arch. Roughness can be detected at surgery by placing the fingers of one hand on the acromion while the arm is passively rotated throughout its range of motion.

The positions productive of crepitance are noted and, before wound closure, relief of this crepitance is verified. The source of subacromial crepitance is usually some combination of bursal hypertrophy, roughness on the upper surface of the cuff, and roughness around the humeral tuberosities. While it is our surgical routine to palpate the undersurface of the coracoacromial arch for sources of roughness, the acromion and the coracoacromial ligament are almost always smooth. While the presence of ‘spurs’ may be suggested on preoperative radiographs, these are usually only calcifications in the coracoacromial ligament and, as such, do not encroach on the free movement of the cuff beneath it.

Smoothness of the humeroscapular motion interface is assured by resecting any abnormal bursa or scar in this interface from the axillary nerve inferior-medially, between the subscapularis and the coracoid muscles, under the acromion, and down to the axillary nerve posterior inferiorly – a complete ‘nerve-to-nerve’ release.

Complete release of the external surface of the supraspinatus and infraspinatus can be verified by passing a smooth elevator between each tendon and the coracoacromial arch.

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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).