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Editorial Commentary: The Partial Thickness Rotator Cuff Tear: Is Acromioplasty Without Repair Ever Indicated?

      Abstract

      I believe that arthroscopic repair is the treatment of choice for patients with partial thickness rotator cuff tears when nonoperative methods have been exhausted. Excluding overhead athletes and patients in whom long head biceps tendon pathology is the primary concern, I do not believe that a significant role exists for debridement with or without acromioplasty in the majority of patients with partial thickness tears. Regarding the repair technique, I prefer in situ repair for bursal-sided tears because the superior capsule is intact and completion of the tear with repair for articular-sided tears.
      For the purpose of this discussion regarding partial-thickness rotator cuff tears (PTRCTs), I am excluding patients with idiopathic adhesive capsulitis, those in whom long head biceps tendon pathology is the primary diagnosis and overhead athletes. Excluding patients with adhesive capsulitis and those with primary long head biceps tendon pathology is understandable. I have excluded overhead athletes from this discussion of patients with PTRCTs because in my view they represent a unique population of outliers. There is evidence to suggest that debridement of PTRCTs provides satisfactory outcomes in elite overhead throwers whereas repair of these lesions may compromise the adaptive changes that have developed during their career and limit their ability to return to sport at their prior level of performance.
      • Reynolds S.B.
      • Dugas J.R.
      • Cain E.L.
      • McMichael C.S.
      • Andrews J.R.
      Debridement of small partial-thickness rotator cuff tears in elite overhead throwers.
      Patients in the general population with PTRCTs often respond well to nonoperative measures. When surgery is indicated, many studies and recent systematic reviews have demonstrated satisfactory outcomes without significant differences between in situ repair and repair with completion of the tear.

      Katthagan JC, Bucci G, Moatshe G, Tahal DS, Millett PJ. Improved outcomes with arthroscopic repair of partial thickness rotator cuff tears: A systematic review [published online May 19, 2017]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-017-4564-0.

      • Strauss E.J.
      • Salata M.J.
      • Kercher J.
      • et al.
      Multimedia article. The arthroscopic management of partial-thickness rotator cuff tears: a systematic review of the literature.
      Vap, Mannava, Katthagen, Horan, Fritz, Pogorzelski, and Millet, in their study “Five Year Outcomes Following Arthroscopic Repair of Partial-Thickness Supraspinatus Tears,”
      • Vap A.R.
      • Mannava S.
      • Katthagen J.C.
      • et al.
      Five year outcomes following arthroscopic repair of partial-thickness supraspinatus tears.
      have reported on a series of patients with partial-thickness rotator cuff tears treated with either in situ repair or repair with completion of the tear. All 24 patients received an open subpectoral long head biceps tendon tenodesis (see Table 1 in Vap et al.
      • Vap A.R.
      • Mannava S.
      • Katthagen J.C.
      • et al.
      Five year outcomes following arthroscopic repair of partial-thickness supraspinatus tears.
      ). The authors' indication for tenotomy and subpectoral biceps tenodesis was fraying or tenosynovitis. They found excellent outcomes and a high return to activity at minimum 5-year follow-up. No patient required a revision surgery. Outcome scores correlated neither with patient age nor location of the tear; however, the number of bursal-sided tears was limited. It is difficult to know what portion of the postoperative improvement in patient satisfaction and outcomes scores was related to the rotator cuff repair and what portion was the result of the biceps tenodesis, particularly without postoperative imaging to document healing (or lack thereof) of the rotator cuff repair. The authors admit this potential confounder in their limitations section.
      There are 2 potential controversies within the topic of PTRCT management. The first potential controversy relates to whether debridement with or without acromioplasty alone is ever indicated in the standard middle-aged patient with a PTRCT. We should remember that in Neer's landmark article published in 1972 in which he described anterior acromioplasty, only 19 of 50 procedures performed over a 5-year period were for patients with PTRCTs.
      • Neer C.S.
      Anterior acromioplasty for the chronic impingement syndrome in the shoulder.
      Our group reported our experience over 15 years ago and concluded that acromioplasty provided satisfactory treatment for patients with PTRCTs <50% [Ellman grade I or II
      • Ellman H.
      Diagnosis and treatment of incomplete rotator cuff tears.
      ]. We were concerned regarding the inferior outcomes and higher failure rates after arthroscopic debridement and decompression of bursal-sided PTRCTs compared with articular-sided PTRCTs and concluded that the former might be better served with a repair.
      • Cordasco F.A.
      • Backer M.
      • Craig E.V.
      • Klein D.
      • Warren R.F.
      The partial-thickness rotator cuff tear: Is acromioplasty without repair sufficient?.
      It is important to remember the historical context during the decade or so before the time of that publication in 2002, in that the alternative to subacromial decompression was a more invasive mini-open rotator cuff repair. Given that the majority of middle-aged patients with grade I and II articular-sided PTRCTs do well with nonoperative treatment, I have rarely indicated these patients for isolated debridement with or without subacromial decompression in recent years. My personal experience with patients who have grade I or II bursal-sided PTRCTs is that nonoperative treatment is more likely to fail. Currently, I believe that when surgery is indicated in patients with either articular- or bursal-sided PTRCTs, arthroscopic repair should be the treatment of choice because the symptoms are more likely related to intrinsic rotator cuff pathology rather than extrinsic subacromial impingement syndrome.
      The second potential controversy regards the repair technique. Which technique is superior: in situ repair or completion of the tear with repair? The literature, including this paper by Vap et al., would suggest that differences are difficult to identify.

      Katthagan JC, Bucci G, Moatshe G, Tahal DS, Millett PJ. Improved outcomes with arthroscopic repair of partial thickness rotator cuff tears: A systematic review [published online May 19, 2017]. Knee Surg Sports Traumatol Arthrosc. doi:10.1007/s00167-017-4564-0.

      • Strauss E.J.
      • Salata M.J.
      • Kercher J.
      • et al.
      Multimedia article. The arthroscopic management of partial-thickness rotator cuff tears: a systematic review of the literature.
      • Vap A.R.
      • Mannava S.
      • Katthagen J.C.
      • et al.
      Five year outcomes following arthroscopic repair of partial-thickness supraspinatus tears.
      • Kim Y.S.
      • Lee H.J.
      • Bae S.H.
      • Jin H.
      • Song H.S.
      Outcome comparison between in situ repair versus tear completion repair for partial thickness rotator cuff tears.
      Should we choose the repair technique predicated on the type of PTRCT: bursal- or articular-sided? Grant described the so-called full-thickness supraspinatus tear with an intact superior glenohumeral capsule in 1993.
      • Grant Jr., L.B.
      Full-thickness supraspinatus tendon tears with intact superior glenohumeral capsule.
      As we know, in recent years, a role has been developed for superior capsular reconstruction.
      • Mihata T.
      • Lee T.Q.
      • Watanabe C.
      • et al.
      Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears.
      • Adams C.R.
      The rotator cuff and the superior capsule: Why we need both.
      I have generally favored an in situ repair for bursal-sided PTRCTs because the superior capsule is generally robust and intact when viewed from the intra-articular side of the rotator cuff tendons as Grant described over 2 decades ago. There are some data to suggest that completion of the tear in patients with bursal-sided PTRCTs may yield less successful outcomes.
      • Kim Y.S.
      • Lee H.J.
      • Bae S.H.
      • Jin H.
      • Song H.S.
      Outcome comparison between in situ repair versus tear completion repair for partial thickness rotator cuff tears.
      In contrast, when articular-sided tears are present (described by Codman
      • Codman E.A.
      The shoulder.
      as “Rim Rents”), I have generally proceeded with a completion of the tear and repair as I view these as largely degenerative and repairing in situ would be akin to “closing the stable door after the horse has bolted.”
      In summary, I rarely perform isolated debridement with or without anterior acromioplasty for patients with isolated PTRCTs, who are not overhead athletes and in whom the long head biceps tendon does not appear to be the primary source of symptoms. In general, I favor in situ repair for patients with bursal-sided PTRCTs because the superior capsule is intact and completion of the tear with repair for those with articular-sided PTRCTs.
      Vap et al. should be congratulated for providing us with a series of patients successfully managed with repair of PTRCTs at mid-term (5-year) follow-up.

      Supplementary Data

      References

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        • Andrews J.R.
        Debridement of small partial-thickness rotator cuff tears in elite overhead throwers.
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