Anatomical and Interpositional Bursa Preservation Showed Similar Improved Tendon to Bone Healing Compared With the Bursa Removal in a Rat Rotator Cuff Tear Model

Published:December 07, 2022DOI:


      To compare the effects of anatomical preservation (AP) and interpositional preservation (IP) of subacromial bursa tissue on tendon-to-bone healing in a rat model of rotator cuff tear.


      In this study, 48 male Sprague–Dawley rats (average weight 283 g) underwent bilateral supraspinatus tendons severed by sharp incision and repaired immediately. The subacromial bursa tissues were completely removed in 16 rats, who served as the control (CON) group. The other 32 rats were randomly divided into 2 groups AP and IP between tendon and bone. Eight rats of each group were sacrificed for bilateral shoulders at 3 and 9 weeks after the operation, including 5 rats for biomechanical tests and 3 for histologic analysis.


      No significant differences in terms of biomechanical properties were observed among the groups 3 weeks after surgery. At 9 weeks, the maximum load and stiffness of the AP (32.95 ± 6.33 N, P = .029; 12.49 ± 3.17 N/mm, P < .001; respectively) and IP (33.58 ± 8.47 N, P = .015; 11.63 ± 2.84 N/mm, P = .010, respectively) groups were significantly superior to that of the CON group (26.59 ± 4.47 N; 8.42 ± 2.33 N/mm, respectively). More organized collagen and more mature tendon insertion were observed in AP and IP groups at the interface at 9 weeks, which means better tendon-to-bone healing compared with the CON group.


      The subacromial bursa plays a positive role in tendon-bone healing. Either anatomical preservation or interpositional preservation between tendon and bone can similarly facilitate the process of healing.

      Clinical Relevance

      Considering the additional surgical time and surgical manipulation, preserving the subacromial bursa at the anatomical position seems to be a better way to promote rotator cuff healing.
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        • Xu J.
        • Su W.
        • Chen J.
        • et al.
        The effect of antiosteoporosis therapy with risedronate on rotator cuff healing in an osteoporotic rat model.
        Am J Sports Med. 2021; 49: 2074-2084
        • Tashjian R.Z.
        • Hollins A.M.
        • Kim H.M.
        • et al.
        Factors affecting healing rates after arthroscopic double-row rotator cuff repair.
        Am J Sports Med. 2010; 38: 2435-2442
        • Wu X.L.
        • Briggs L.
        • Murrell G.A.
        Intraoperative determinants of rotator cuff repair integrity: An analysis of 500 consecutive repairs.
        Am J Sports Med. 2012; 40: 2771-2776
        • Lapner P.
        • Henry P.
        • Athwal G.S.
        • et al.
        Treatment of rotator cuff tears: A systematic review and meta-analysis.
        J Shoulder Elbow Surg. 2022; 31: e120-e129
        • Dyrna F.
        • Zakko P.
        • Pauzenberger L.
        • McCarthy M.B.
        • Mazzocca A.D.
        • Dyment N.A.
        Human subacromial bursal cells display superior engraftment versus bone marrow stromal cells in murine tendon repair.
        Am J Sports Med. 2018; 46: 3511-3520
        • Greenberg D.L.
        Evaluation and treatment of shoulder pain.
        Med Clin North Am. 2014; 98: 487-504
        • Chillemi C.
        • Petrozza V.
        • Franceschini V.
        • et al.
        The role of tendon and subacromial bursa in rotator cuff tear pain: A clinical and histopathological study.
        Knee Surg Sports Traumatol Arthrosc. 2016; 24: 3779-3786
        • Wolff A.B.
        • Magit D.P.
        • Miller S.R.
        • Wyman J.
        • Sethi P.M.
        Arthroscopic fixation of bursal-sided rotator cuff tears.
        Arthroscopy. 2006; 22 (1247:e1241-1244)
        • Safi E.
        • Ficklscherer A.
        • Bondarava M.
        • et al.
        Migration of mesenchymal stem cells of bursal tissue after rotator cuff repair in rats.
        Joints. 2018; 6: 4-9
        • Nourissat G.
        • Diop A.
        • Maurel N.
        • et al.
        Mesenchymal stem cell therapy regenerates the native bone–tendon junction after surgical repair in a degenerative rat model.
        PLoS One. 2010; 5e12248
        • Poldoja E.
        • Rahu M.
        • Kask K.
        • Weyers I.
        • Kolts I.
        Blood supply of the subacromial bursa and rotator cuff tendons on the bursal side.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 2041-2046
        • Ficklscherer A.
        • Zhang A.Z.
        • Beer T.
        • et al.
        The effect of autologous Achilles bursal tissue implants in tendon-to-bone healing of rotator cuff tears in rats.
        J Shoulder Elbow Surg. 2020; 29: 1892-1900
        • Sun Y.
        • Kwak J.M.
        • Kholinne E.
        • Koh K.H.
        • Tan J.
        • Jeon I.H.
        Subacromial bursal preservation can enhance rotator cuff tendon regeneration: A comparative rat supraspinatus tendon defect model study.
        J Shoulder Elbow Surg. 2021; 30: 401-407
        • Van Gulick L.
        • Saby C.
        • Morjani H.
        • Beljebbar A.
        Age-related changes in molecular organization of type I collagen in tendon as probed by polarized SHG and Raman microspectroscopy.
        Sci Rep. 2019; 9: 7280
        • Liao H.
        • Yu H.P.
        • Song W.
        • et al.
        Amorphous calcium phosphate nanoparticles using adenosine triphosphate as an organic phosphorus source for promoting tendon-bone healing.
        J Nanobiotechnol. 2021; 19: 270
        • Sun Y.
        • Kwak J.M.
        • Zhou Y.
        • et al.
        Suprascapular nerve injury affects rotator cuff healing: A paired controlled study in a rat model.
        J Orthop Translat. 2021; 27: 153-160
        • Sun Y.
        • Kwak J.M.
        • Kholinne E.
        • Tan J.
        • Koh K.H.
        • Jeon I.H.
        Nonabsorbable suture knot on the tendon affects rotator cuff healing: A comparative study of the knots on tendon and bone in a rat model of rotator cuff tear.
        Am J Sports Med. 2019; 47: 2809-2815
        • Xu J.
        • Ye Z.
        • Chen C.
        • et al.
        Abaloparatide improves rotator cuff healing via anabolic effects on bone remodeling in a chronic rotator cuff tear model of rat with osteoporosis: A comparison with denosumab.
        Am J Sports Med. 2022; 50: 1550-1563
        • Xu J.
        • Li Y.
        • Ye Z.
        • et al.
        Biceps augmentation outperforms tear completion repair or in situ repair for bursal-sided partial-thickness rotator cuff tears in a rabbit model.
        Am J Sports Med. 2022; 50: 195-207
        • Cavinatto L.
        • Malavolta E.A.
        • Pereira C.A.M.
        • et al.
        Early versus late repair of rotator cuff tears in rats.
        J Shoulder Elbow Surg. 2018; 27: 606-613
        • Ficklscherer A.
        • Loitsch T.
        • Serr M.
        • et al.
        Does footprint preparation influence tendon-to-bone healing after rotator cuff repair in an animal model?.
        Arthroscopy. 2014; 30: 188-194
        • Kabuto Y.
        • Morihara T.
        • Sukenari T.
        • et al.
        Stimulation of rotator cuff repair by sustained release of bone morphogenetic protein-7 using a gelatin hydrogel sheet.
        Tissue Eng Part A. 2015; 21: 2025-2033
        • Chillemi C.
        • Petrozza V.
        • Garro L.
        • et al.
        Rotator cuff re-tear or non-healing: Histopathological aspects and predictive factors.
        Knee Surg Sports Traumatol Arthrosc. 2011; 19: 1588-1596
        • Iwata Y.
        • Morihara T.
        • Tachiiri H.
        • et al.
        Behavior of host and graft cells in the early remodeling process of rotator cuff defects in a transgenic animal model.
        J Shoulder Elbow Surg. 2008; 17: 101S-107S
        • Morikawa D.
        • Johnson J.
        • Kia C.
        • et al.
        Examining the potency of subacromial bursal cells as a potential augment for rotator cuff healing: An in vitro study.
        Arthroscopy. 2019; 35: 2978-2988
        • Aydin A.
        • Duruksu G.
        • Erman G.
        • et al.
        Neurogenic differentiation capacity of subacromial bursal tissue-derived stem cells.
        J Orthop Res. 2014; 32: 151-158
        • Steinert A.F.
        • Kunz M.
        • Prager P.
        • et al.
        Characterization of bursa subacromialis–derived mesenchymal stem cells.
        Stem Cell Res Ther. 2015; 6: 114
        • Song N.
        • Armstrong A.D.
        • Li F.
        • Ouyang H.
        • Niyibizi C.
        Multipotent mesenchymal stem cells from human subacromial bursa: Potential for cell based tendon tissue engineering.
        Tissue Eng Part A. 2014; 20: 239-249
        • Pancholi N.
        • Gregory J.J.
        Biologic augmentation of arthroscopic rotator cuff repair using minced autologous subacromial bursa.
        Arthrosc Tech. 2020; 9: e1519-e1524
        • Plate J.F.
        • Brown P.J.
        • Walters J.
        • et al.
        Advanced age diminishes tendon-to-bone healing in a rat model of rotator cuff repair.
        Am J Sports Med. 2014; 42: 859-868
        • Angeline M.E.
        • Ma R.
        • Pascual-Garrido C.
        • et al.
        Effect of diet-induced vitamin D deficiency on rotator cuff healing in a rat model.
        Am J Sports Med. 2014; 42: 27-34
        • Yang J.
        • Wang S.
        • Liu L.
        • Shao Y.
        • Wang J.
        The analgesic effect and safety of preoperative versus postoperative administration of celecoxib in patients who under-went arthroscopic rotator cuff repair: A randomized, controlled study.
        Inflammopharmacology. 2022; 30: 185-191
        • Goldstein K.
        • Jones C.
        • Kay J.
        • Shin J.
        • de Sa D.
        Tranexamic acid administration in arthroscopic surgery is a safe adjunct to decrease postoperative pain and swelling: A systematic review and meta-analysis.
        Arthroscopy. 2022; 38: 1366-1377:e1369
        • Klatte-Schulz F.
        • Thiele K.
        • Scheibel M.
        • Duda G.
        • Wildemann B.J.C.
        Subacromial bursa: A neglected tissue is gaining more and more attention in clinical and experimental research.
        Cells. 2022; 11: 663