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Commentary and Perspective   |    
Tension Required to Repair Rotator Cuff Is Detrimental to Muscle FunctionCommentary on an article by Sandeep Mannava, MD, et al.: “Evaluation of in Vivo Rotator Cuff Muscle Function After Acute and Chronic Detachment of the Supraspinatus Tendon. An Experimental Study in an Animal Model”
Lawrence V. Gulotta, MD
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The author did not receive payments or services, either directly or indirectly (i.e., via his institution), from a third party in support of any aspect of this work. Neither the author nor his institution has had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, the author has not had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Sep 21;93(18):e110 1-2. doi: 10.2106/JBJS.K.00801
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Rotator cuff tears are one of the most frequent reasons for patients to visit an orthopaedic surgeon. Despite their prevalence, controversy still exists regarding the indications and timing of surgical repair. Recent clinical studies have shown that rotator cuff tears have very little capacity to heal without surgery1. Instead, tears become bigger over time; the tendons become retracted, degenerated, and scarred to surrounding structures; and the muscles undergo fibro-fatty infiltration and become stiff. All of these factors have negative implications for rotator cuff tendon-to-bone healing, and failure of tendon healing has been associated with poor clinical outcomes2.
The clinical literature on rotator cuff repair has largely focused on achieving anatomic healing. Therefore, little is known about how a retracted muscle-tendon unit functions following repair if healing does occur. Such is the topic of the article by Mannava et al. In this article, the authors used a rat model to show a significant decline in rotator cuff muscle function at the peak tensions required to repair acute tears (four weeks) and an even larger functional decline at the tensions required to repair chronic tears (twelve weeks). This led the authors to conclude that early repairs with less tension may improve postoperative muscle function and therefore outcomes.
This article represents an interesting and novel approach to maximizing rotator cuff repair outcomes. While the hypothesis and findings of this animal study are valid and interesting, the authors also point out that further investigation is required before definitive clinical recommendations can be made, and I concur.
The clinical importance of these findings is hard to quantify because few studies have correlated intraoperative repair tension with postoperative rotator cuff function. Davidson and Rivenburgh compared repair tensions with clinical outcomes and found that repairs that were performed with a high tension of >8 lb were associated with poor subjective and objective outcomes3. However, they did not evaluate tendon healing in their postoperative analysis. Therefore, it is unclear if these inferior results were due to inadequate muscle function or to incomplete tendon-to-bone healing, which is also adversely affected by high repair tensions4. Clarification of the clinical ramifications of a healed but dysfunctional rotator cuff would be useful moving forward.
Another clinical concern is how these findings evolve over time. In the study, the authors investigated one time point shortly after the application of tension. This is understandable given the limitations of in vivo muscle testing in an animal model. However, very few surgeons allow their patients to actively elevate the arm and contract the rotator cuff shortly after repair. Instead, the functional outcome of the rotator cuff repair is most applicable approximately six weeks following the application of tension, when most patients stop wearing a sling and begin to actively use the shoulder. Circumstantial evidence would suggest that the muscle would undergo little physiologic adaptation over this time. Studies have shown that rotator cuff muscle atrophy and fatty infiltration are irreversible following a single-stage repair5. As function follows structure, one would also assume that the decline in muscle function seen in this study is also irreversible. It will be interesting to see if this logic holds true with future studies.
While more work still needs to be done in this field, this study provides a previously under-recognized rationale for the expeditious repair of acute rotator cuff tears. It does not provide a rationale for the acute treatment of chronic tears. In other words, this study adds to the consensus that patients with a clearly defined traumatic event that results in shoulder pain and weakness with correlative imaging of a rotator cuff tear without degeneration are better served by immediate repair. This study does not attempt or profess to delineate the timing of surgery for patients who present with a chronic tear. Interpretation of this study should keep this in perspective.
Yamaguchi  K;  Ditsios  K;  Middleton  WD;  Hildebolt  CF;  Galatz  LM;  Teefey  SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am.  2006;88:1699-704.[CrossRef][PubMed]
 
Gerber  C;  Schneeberger  AG;  Hoppeler  H;  Meyer  DC. Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: a study in thirteen patients. J Shoulder Elbow Surg.  2007;16:691-6.[CrossRef][PubMed]
 
Davidson  PA;  Rivenburgh  DW. Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elbow Surg.  2000;9:502-6.[CrossRef][PubMed]
 
Gimbel  JA;  Van Kleunen  JP;  Lake  SP;  Williams  GR;  Soslowsky  LJ. The role of repair tension on tendon to bone healing in an animal model of chronic rotator cuff tears. J Biomech.  2007;40:561-8.[CrossRef][PubMed]
 
Gladstone  JN;  Bishop  JY;  Lo  IK;  Flatow  EL. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med.  2007;35:719-28.[CrossRef][PubMed]
 

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References

Yamaguchi  K;  Ditsios  K;  Middleton  WD;  Hildebolt  CF;  Galatz  LM;  Teefey  SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am.  2006;88:1699-704.[CrossRef][PubMed]
 
Gerber  C;  Schneeberger  AG;  Hoppeler  H;  Meyer  DC. Correlation of atrophy and fatty infiltration on strength and integrity of rotator cuff repairs: a study in thirteen patients. J Shoulder Elbow Surg.  2007;16:691-6.[CrossRef][PubMed]
 
Davidson  PA;  Rivenburgh  DW. Rotator cuff repair tension as a determinant of functional outcome. J Shoulder Elbow Surg.  2000;9:502-6.[CrossRef][PubMed]
 
Gimbel  JA;  Van Kleunen  JP;  Lake  SP;  Williams  GR;  Soslowsky  LJ. The role of repair tension on tendon to bone healing in an animal model of chronic rotator cuff tears. J Biomech.  2007;40:561-8.[CrossRef][PubMed]
 
Gladstone  JN;  Bishop  JY;  Lo  IK;  Flatow  EL. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome. Am J Sports Med.  2007;35:719-28.[CrossRef][PubMed]
 
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