Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
William N. Levine, MD*,
Columbia University Medical Center, New York, NY
Posted May 2009
The management of partial-thickness rotator cuff tears
remains controversial. Surgical options include débridement alone, transtendinous
in situ repair, or conversion to a full-thickness tear followed by either
single or double-row repair1-9. The exact incidence of partial-thickness
rotator cuff tears in the general population is unknown. In a recent cadaveric
study, Fukuda found that partial-thickness tears occurred with a prevalence of
13%, with articular-sided tears occurring more commonly than bursal-sided tears
(27% compared with 18%, respectively)10. Débridement of high-grade
partial-thickness tears is not recommended, however, because several clinical
cohort studies have demonstrated progression to full-thickness tears following
this procedure6,11.
In their paper, Kamath and colleagues report a high success
rate both clinically and radiographically in a cohort of patients treated with
arthroscopic repair of a high-grade partial-thickness rotator cuff defect.
Because there remains little consensus on the optimal treatment for this
problem, this paper is particularly timely.
The authors report their findings for forty-two shoulders (forty-one
patients) that underwent arthroscopic conversion of a high-grade (>50%)
partial-thickness tear to a full-thickness tear with subsequent repair.
Clinical follow-up is reported at a minimum follow-up period of twenty-five
months and, more importantly, all shoulders underwent postoperative
surveillance imaging with dynamic ultrasound at a minimum of six months postoperatively.
Ultrasound demonstrated that thirty-seven (88%) of forty-two rotator cuff
repairs were healed at the time of the minimum six-month follow-up.
Ninety-three percent of the patients in the study were satisfied with the
outcome.
A recent biomechanical study demonstrated that in situ
repair is biomechanically stronger than conversion to a full-thickness tear and
subsequent repair12. The authors in the current study used a myriad
of treatment options (single-row repair, double-row repair, side-to-side
repair). With the numbers available, they could not perform discrete analysis
to determine superiority of one technique over the other. A prospective study
comparing in-situ repair with take-down and repair of the full-thickness defect
would perhaps better address this controversy.
Regardless of technique, however, the authors' post-repair
surveillance is what separates this study from many other recently reported
clinical studies on repair of partial-thickness rotator cuff tears. With their
validated instrument (ultrasound) and their dedication to understanding the
natural history of rotator cuff disease13-15, the authors have set a
standard for research on rotator cuff repair.
Finally, it is important to note that not all partial-thickness
rotator cuff tears are similar—one must differentiate between the degenerative
partial-thickness tear that may be sustained by the older patient and the intralaminar
tear that may be sustained by the younger overhead athlete. The average age of
the patients in the current series is fifty-three years, signifying that this
group represents more of the degenerative-type tears and, therefore, that the
results of this study should not be extrapolated to recommend the same
treatment (conversion to full-thickness tear and repair) for overhead athletes.
Repair of a full-thickness tear in an overhead athlete may lead to early
failure due to the unique demands that are placed on these shoulders.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
References
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2. Porat S, Nottage WM, Fouse MN. Repair of partial thickness rotator cuff tears: a retrospective review with minimum two-year follow-up. J Shoulder Elbow Surg. 2008;17:729-31.
3. Brockmeier SF, Dodson CC, Gamradt SC, Coleman SH, Altchek DW. Arthroscopic intratendinous repair of the delaminated partial-thickness rotator cuff tear in overhead athletes. Arthroscopy. 2008;24:961-5.
4. Yoo JC, Ahn JH, Lee SH, Kim JH. Arthroscopic full-layer repair of bursal-side partial-thickness rotator cuff tears: a small-window technique. Arthroscopy. 2007;23:903.e1-4.
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