Editorial Commentary: Success of Rotator Cuff Healing—Do We Need to Improve on the Strength Anymore?

I am excited to read the article by Noyes, Ladermann, and Deanard, “Functional Outcome and Healing of Large and Massive Rotator Cuff Tears Repaired With a Load-Sharing Rip-Stop Construct.” Theirs was a small sample of 21 patients with a minimal 2-year follow-up with good clinical outcome. The rip-stop suture they used acted as a load-sharing construct and also could resist tissue pullout and, we hope, enhance healing. Nevertheless, only 50% of the tears had completely healed at 6 months on ultrasonographic evaluation.

I read this article with interest as I reflected on my own learning and maturation as a shoulder surgeon. When I was a resident, Galatz et al. had reported a 94% failure rate of arthroscopic rotator cuff repairs. I still remember the presentation where doubters commented that the surgery had failed because of poor repair technique. That study was one of the first to radiographically assess healing instead of using only patient-reported outcomes or physician evaluations. The results of that study have since been confirmed with multiple objective evaluations of rotator cuff repairs. That study and others have prompted the field to look at why arthroscopic rotator cuff repairs of the large and massive rotator cuff tears have higher failure rates when compared with open repairs. This prompted a huge wave of interest in finding better ways of repairing arthroscopic rotator cuff tears. Single- and double-row biomechanical studies were performed almost simultaneously, and different groups published their data on single- versus double-row fixation in 3 prestigious sports medicine journals within a few months.^{,  ,}  I still remember the complexity of performing the traditional double-row repairs as a junior attending, which involves lots of suture passage and knot tying. Over the years, there have been many attempts to improve arthroscopic rotator cuff repair constructs, for example, the arthroscopic Mason-Allen stitches, the massive cuff stitch, arthroscopic transosseous repairs, and transosseous equivalent repairs. The field has witnessed tremendous improvement in techniques of arthroscopic repairs with stronger constructs, better suture materials, and tissue releases. In my own practice, the easier and more reliable instrumentation nowadays have enabled me to perform the repairs much more efficiently.

However, despite improvements in the biomechanical strength of the repair, our current success rates repairing large and massive rotator cuff tears remain poor. I find myself disappointing patients when they come in with the hope of a rotator cuff repair but turning them away when I see a massive rotator cuff tear with degenerative changes. In this report, 50% of the rotator cuff repairs have complete healing. Although we can say that ours is better than almost all Major League baseball players' batting averages, we are still in the lowest category of National Basketball League free-throw shooters. Imagine how a patient would feel when we tell her something like, “Mrs. Lee, about half of the time the repair that we'll perform on you works … only after 6 months of dedicated rehabilitation and recovery.” I commend Noyes et al. for showing that the load-sharing rip-stop technique has improved on our earlier reports. On the other hand, we all have visions of these retracted massive rotator cuff tears with poor tissue quality. Will our repair construct be able to overcome poor tissue healing capabilities?

I do think that as a field we have done a great job in succeeding to perform a really strong construct for arthroscopic rotator cuff repairs, and any failure is due to the poor healing of tissue, not lack of strength of the repair. Of most importance to us as shoulder surgeons is to recognize when the biology of healing of the rotator cuff tendons is insufficient and when we need to rely on biologics such as tissue augmentation or biologic modulation to improve healing of the degenerated tendon. We also need to recognize that some of these asymptomatic tears will deteriorate with time, and if they become symptomatic, we might have missed the window for successful surgical intervention. There are also tears that can remain asymptomatic for an extended period of time. The key is to recognize when to wait, when to operate, and when not to operate.

We live in an exciting time, and I do believe that we have improved significantly over the past decade and a half since the results of the study by Galatz et al. were published, but we still have some work to do.