Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.

Commentary & Perspective

Commentary & Perspective on
"Tendon Integrity and Functional Outcome After Arthroscopic Repair of High-Grade Partial-Thickness Supraspinatus Tears"
by Ganesh Kamath, MD, et al.

Commentary & Perspective by
William N. Levine, MD*,
Columbia University Medical Center, New York, NY

Posted May 2009

The management of partial-thickness rotator cuff tears remains controversial. Surgical options include débridement alone, transtendinous in situ repair, or conversion to a full-thickness tear followed by either single or double-row repair1-9. The exact incidence of partial-thickness rotator cuff tears in the general population is unknown. In a recent cadaveric study, Fukuda found that partial-thickness tears occurred with a prevalence of 13%, with articular-sided tears occurring more commonly than bursal-sided tears (27% compared with 18%, respectively)10. Débridement of high-grade partial-thickness tears is not recommended, however, because several clinical cohort studies have demonstrated progression to full-thickness tears following this procedure6,11.

In their paper, Kamath and colleagues report a high success rate both clinically and radiographically in a cohort of patients treated with arthroscopic repair of a high-grade partial-thickness rotator cuff defect. Because there remains little consensus on the optimal treatment for this problem, this paper is particularly timely.

The authors report their findings for forty-two shoulders (forty-one patients) that underwent arthroscopic conversion of a high-grade (>50%) partial-thickness tear to a full-thickness tear with subsequent repair. Clinical follow-up is reported at a minimum follow-up period of twenty-five months and, more importantly, all shoulders underwent postoperative surveillance imaging with dynamic ultrasound at a minimum of six months postoperatively. Ultrasound demonstrated that thirty-seven (88%) of forty-two rotator cuff repairs were healed at the time of the minimum six-month follow-up. Ninety-three percent of the patients in the study were satisfied with the outcome.

A recent biomechanical study demonstrated that in situ repair is biomechanically stronger than conversion to a full-thickness tear and subsequent repair12. The authors in the current study used a myriad of treatment options (single-row repair, double-row repair, side-to-side repair). With the numbers available, they could not perform discrete analysis to determine superiority of one technique over the other. A prospective study comparing in-situ repair with take-down and repair of the full-thickness defect would perhaps better address this controversy.

Regardless of technique, however, the authors' post-repair surveillance is what separates this study from many other recently reported clinical studies on repair of partial-thickness rotator cuff tears. With their validated instrument (ultrasound) and their dedication to understanding the natural history of rotator cuff disease13-15, the authors have set a standard for research on rotator cuff repair.

Finally, it is important to note that not all partial-thickness rotator cuff tears are similar—one must differentiate between the degenerative partial-thickness tear that may be sustained by the older patient and the intralaminar tear that may be sustained by the younger overhead athlete. The average age of the patients in the current series is fifty-three years, signifying that this group represents more of the degenerative-type tears and, therefore, that the results of this study should not be extrapolated to recommend the same treatment (conversion to full-thickness tear and repair) for overhead athletes. Repair of a full-thickness tear in an overhead athlete may lead to early failure due to the unique demands that are placed on these shoulders.

*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

References

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