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Editorial Commentary: Is Arthroscopic In Situ Repair Effective for Long-Term Functional Recovery and Pain Relief in Symptomatic Partial Rotator Cuff Tears?

      Abstract

      Currently, although most evidence suggests that surgery is effective in treating symptomatic partial-thickness rotator cuff tears in patients with failure of nonoperative management and with a tear of more than 50% of the tendon thickness, there is little consensus on the best method of repair. Some surgeons would advocate completing the tear and repairing it, whereas others would advocate performing in situ repair. In our opinion, it is important to also consider treating the long head of the biceps tendon, which is frequently a source of pain at the time of or after surgery.
      Partial-thickness rotator cuff tears (PT-RCTs) are common. Nonoperative treatment such as physical therapy, anti-inflammatory medication, and modification of activities is recommended as first-line treatment. Failure of nonoperative management and a PT-RCT of more than 50% of the tendon thickness are accepted as indications for surgical repair. In the study “Long-Term Outcomes After Arthroscopic In Situ Repair of Partial Rotator Cuff Tears,” Rossi, Bertona, Tanoira, Bongiovanni, Maignon, and Ranalletta
      • Rossi L.A.
      • Atala N.A.
      • Bertona A.
      • et al.
      Long-term outcomes after in situ arthroscopic repair of partial rotator cuff tears.
      studied the outcomes of rotator cuff repair using an in situ repair technique. They presented long-term results with a special focus on return-to-sport and complication rates.
      The outcomes of 62 patients with a mean age of 52.4 years who had undergone isolated arthroscopic in situ repairs for PT-RCTs were reported.
      • Rossi L.A.
      • Atala N.A.
      • Bertona A.
      • et al.
      Long-term outcomes after in situ arthroscopic repair of partial rotator cuff tears.
      The results were quite convincing after a mean follow-up period of 10.4 years (minimum, 8 years), showing significant improvements in the American Shoulder and Elbow Surgeons (ASES) score and the visual analog scale score for pain. Furthermore, of the 30 patients who participated in sports (21 recreational athletes and 9 competitive athletes), 26 (87%) were able to return to sports and 24 (80%) returned to the same level as before injury. The authors detected no differences between articular- and bursal-sided tears when comparing functional outcomes or return to sports. Postoperative adhesive capsulitis developed in 3 patients, which resolved under physical therapy. According to the authors, no revision surgical procedures were required in their follow-up interval.
      The best treatment for high-grade symptomatic PT-RCTs continues to be debated. The present options include completion of the tear and repair in a traditional fashion
      • Deutsch A.
      Arthroscopic repair of partial-thickness tears of the rotator cuff.
      • Kim K.C.
      • Shin H.D.
      • Cha S.M.
      • Park J.Y.
      Repair integrity and functional outcome after arthroscopic conversion to a full-thickness rotator cuff tear: Articular- versus bursal-side partial tears.
      or in situ repair,
      • Katthagen J.C.
      • Bucci G.
      • Moatshe G.
      • Tahal D.S.
      • Millett P.J.
      Improved outcomes with arthroscopic repair of partial-thickness rotator cuff tears: A systematic review.
      • Vap A.R.
      • Mannava S.
      • Katthagen J.C.
      • et al.
      Five-year outcomes after arthroscopic repair of partial-thickness supraspinatus tears.
      as was reported in this study.
      • Rossi L.A.
      • Atala N.A.
      • Bertona A.
      • et al.
      Long-term outcomes after in situ arthroscopic repair of partial rotator cuff tears.
      Some surgeons are not advocating bio-augmentation for these types of tears.
      • Bokor D.J.
      • Sonnabend D.
      • Deady L.
      • et al.
      Evidence of healing of partial-thickness rotator cuff tears following arthroscopic augmentation with a collagen implant: A 2-year MRI follow-up.
      As summarized in a recent systematic review by our group, both techniques provide effective improvement of functional outcomes and pain relief without significant differences in outcomes when compared directly.
      • Katthagen J.C.
      • Bucci G.
      • Moatshe G.
      • Tahal D.S.
      • Millett P.J.
      Improved outcomes with arthroscopic repair of partial-thickness rotator cuff tears: A systematic review.
      Moreover, similar complication rates (e.g., stiffness) and retear rates have been reported, with no differences for articular- or bursal-sided repairs.
      • Katthagen J.C.
      • Bucci G.
      • Moatshe G.
      • Tahal D.S.
      • Millett P.J.
      Improved outcomes with arthroscopic repair of partial-thickness rotator cuff tears: A systematic review.
      • Franceschi F.
      • Papalia R.
      • Del Buono A.
      • et al.
      Articular-sided rotator cuff tears: Which is the best repair? A three-year prospective randomised controlled trial.
      • 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.
      Controversy still exists because in situ repairs perform better biomechanically at time zero, are better at preserving the tendon length, and restore the native footprint more anatomically
      • Franceschi F.
      • Papalia R.
      • Del Buono A.
      • et al.
      Articular-sided rotator cuff tears: Which is the best repair? A three-year prospective randomised controlled trial.
      • Brockmeier S.F.
      • Dodson C.C.
      • Gamradt S.C.
      • Coleman S.H.
      • Altchek D.W.
      Arthroscopic intratendinous repair of the delaminated partial-thickness rotator cuff tear in overhead athletes.
      • Gonzalez-Lomas G.
      • Kippe M.A.
      • Brown G.D.
      • et al.
      In situ transtendon repair outperforms tear completion and repair for partial articular-sided supraspinatus tendon tears.
      • Lo I.K.
      • Burkhart S.S.
      Transtendon arthroscopic repair of partial-thickness, articular surface tears of the rotator cuff.
      whereas completion with repair of the tear removes all diseased tissue, offers a lower morbidity rate and earlier recovery, and in many instances is technically less challenging. We applaud Rossi et al.
      • Rossi L.A.
      • Atala N.A.
      • Bertona A.
      • et al.
      Long-term outcomes after in situ arthroscopic repair of partial rotator cuff tears.
      for generating data over this long period and for sharing the excellent results of the in situ repair technique. One of the strengths of this study, besides presenting long-term outcome results, is that patients underwent no concomitant procedures; so, it can be assumed that the postoperative improvement in patient satisfaction and outcome scores was related only to the PT-RCT in situ repair itself. However, it is possible that this effect was caused solely by the debridement and subsequent rehabilitation.
      In our experience, biceps disease exists quite frequently in association with PT-RCTs. We have concerns that an isolated PT-RCT in situ repair without additional treatment of the long head of the biceps (LHB) with tenodesis or tenotomy will result in inferior outcome scores. This is because of concomitant disease of the LHB that is present at the time of the PT-RCT or acquired disease of the LHB that occurs after the PT-RCT repair owing to stenosis or entrapment of the LHB at the superior aspect of the bicipital groove.
      • Braun S.
      • Horan M.P.
      • Elser F.
      • Millett P.J.
      Lesions of the biceps pulley.
      Although Rossi et al.
      • Rossi L.A.
      • Atala N.A.
      • Bertona A.
      • et al.
      Long-term outcomes after in situ arthroscopic repair of partial rotator cuff tears.
      showed a final ASES score of 85, we have shown in a past study that PT-RCT in situ repair with treatment of the LHB tendon yielded better ASES scores, with a mean score of 97 at a mean follow-up of 6 years.
      • Vap A.R.
      • Mannava S.
      • Katthagen J.C.
      • et al.
      Five-year outcomes after arthroscopic repair of partial-thickness supraspinatus tears.
      LHB pathology is often seen concomitantly with PT-RCT because they are adjacent to one another anatomically and because they have similar mechanisms of injury with repetitive overhead motion. Therefore, we believe it is important to treat the LHB to achieve better results. For example, Walch et al.
      • Walch G.
      • Nove-Josserand L.
      • Boileau P.
      • Levigne C.
      Subluxations and dislocations of the tendon of the long head of the biceps.
      and Braun et al.
      • Braun S.
      • Horan M.P.
      • Elser F.
      • Millett P.J.
      Lesions of the biceps pulley.
      from our group showed that subluxation and dislocation of the LHB tendon are highly associated with (partial) tearing of the supraspinatus tendon (lateral pulley system) in symptomatic patients. This is in line with the results of Wu et al.,
      • Wu P.T.
      • Jou I.M.
      • Yang C.C.
      • et al.
      The severity of the long head biceps tendinopathy in patients with chronic rotator cuff tears: Macroscopic versus microscopic results.
      who found degenerative macroscopic and microscopic changes of the LHB tendon even in PT-RCTs, which suggests that this might be addressed during surgical PT-RCT treatment. We believe that the integrity of the pulley system is irreversibly destroyed, especially when articular-sided PT-RCTs are present, and this cannot be restored by an isolated PT-RCT in situ repair alone. Moreover, repair of the lateral pulley frequently entraps the LHB, resulting in a painful LHB if it is not treated at the time of the repair of the partial cuff tear.
      In our hands, we have documented excellent clinical and cosmetic results in patients treated with subpectoral biceps tenodesis for isolated biceps reflection pulley tears or for tenosynovitis of the LHB tendon,
      • Tahal D.S.
      • Katthagen J.C.
      • Vap A.R.
      • Horan M.P.
      • Millett P.J.
      Subpectoral biceps tenodesis for tenosynovitis of the long head of the biceps in active patients younger than 45 years old.
      • Vap A.R.
      • Katthagen J.C.
      • Tahal D.S.
      • et al.
      Isolated biceps reflection pulley tears treated with subpectoral biceps tenodesis: Minimum 2-year outcomes.
      as well as by a combination procedure that included in situ PT-RCT repair and subpectoral biceps tenodesis.
      • Vap A.R.
      • Mannava S.
      • Katthagen J.C.
      • et al.
      Five-year outcomes after arthroscopic repair of partial-thickness supraspinatus tears.
      However, these more invasive surgical techniques can also result in inherent limitations and complications.
      Again, we applaud Rossi et al.
      • Rossi L.A.
      • Atala N.A.
      • Bertona A.
      • et al.
      Long-term outcomes after in situ arthroscopic repair of partial rotator cuff tears.
      for highlighting this tendon-preserving approach with its convincing long-term functional outcomes and high rate of return to sports. Their results are consistent with the hypothesis that in situ repair successfully relieves pain and restores function in symptomatic PT-RCTs over a period of at least 8 years. An evidence-based gold-standard treatment for patients with symptomatic PT-RCTs, however, remains to be determined.

      Supplementary Data

      References

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