Diagnosis and Management of Partial Thickness Rotator Cuff Tears

A Comprehensive Review

Kevin D. Plancher, MD, MPH; Jaya Shanmugam, MD; Karen Briggs, MPH; Stephanie C. Petterson, MPT, PhD

Disclosures

J Am Acad Orthop Surg. 2021;29(24):1031-1043. 

In This Article

Surgical Treatment

Surgical intervention should be considered when patients have failed 3 to 6 months of conservative management and in younger patients with acute, traumatic injury and is often directed by patient age, activity level, arm dominance, tear thickness, and location. Biomechanical studies support tear thickness as a major determinant for surgical decisions with tears >50% of tendon thickness yielding increased strain on the remaining portion of the intact tendon.[1] Professional athletes and especially overhead throwers may require alternative treatment in a different timeline.

Surgical options include arthroscopic débridement with or without subacromial decompression and acromioplasty, tear completion and repair (ie, conversion repair), and partial repair using various repair techniques. The American Academy of Orthopaedic Surgeons Management of Rotator Cuff Injuries Clinical Practice Guidelines report strong evidence for the use of either conversion repair or transtendinous (TT)/in situ repair for high-grade (eg, tear involvement >50% mediolateral footprint) PRCTs.[25]

Arthroscopic Débridement

Arthroscopic débridement without subacromial decompression and acromioplasty has been shown to be effective in tears <50% of tendon thickness.[30] A full-radius shaver is used to remove the frayed edges to achieve a healthy rim to promote healing. Reynolds et al[31] evaluated return to sport in 82 professional baseball pitchers who underwent arthroscopic débridement of small PRCTs. Sixty-six percent returned to competitive pitching at the professional level, and 55% returned to the same or higher level of competition. These data suggest arthroscopic débridement with or without acromioplasty is a viable option to return athletes with both bursal-sided and articular-sided tears to sport. Although early studies demonstrated added benefit of subacromial decompression, more recent studies do not suggest superior outcomes.[32]

Jaeger et al[33] published a 20-year follow-up in 22 patients with PRCTs who underwent arthroscopic débridement and acromioplasty. Two patients (9%) had revision surgery at 20 years, and 91% were satisfied. Similar findings were reported by Ranebo et al[30] in 45 patients with PRCTs (44 articular-sided and one bursal-sided) undergoing débridement and acromioplasty without RC repair at a 22-year follow-up. Seven percent (3/45) had radiological evidence of cuff tear arthropathy. The authors concluded that most PRCTs remained unchanged with good functional scores at the final follow-up.

Tear location also plays a crucial role. Cordasco et al[34] reported a notable failure rate (38%) in Ellman type 2B (<50% thickness bursal-sided) compared with articular-sided tears (failure rate 5%) treated with arthroscopic débridement and acromioplasty, suggesting that bursal-sided PRCTs involving <50% tendon thickness treated with débridement and acromioplasty have poorer outcomes.

Arthroscopic Repairs

Tear progression is the primary concern when patients present with asymptomatic PRCTs. Repair techniques include in situ repair with TT all-inside, or transosseous techniques and conversion repairs.

In Situ Repairs

In situ repairs preserve the intact tendon and repair the delaminated medial tendon. Although the remaining intact tendon is preserved, repair techniques are technically challenging. TT repair is the most commonly used in situ repair technique (Figure 10).

Figure 10.

Image showing the transtendinous knotless repair technique. Copyright book. Permission for reproduction pending.

Ranalletta et al[35] reported excellent outcomes in 80 patients (age 51 ± 5.4 years) with articular-sided PRCTs (Ellman grade 3A, >50% thickness) and TT repair. Improvements in function and pain were evident at 62-month follow-up with 92.5% being satisfied. Five patients developed adhesive capsulitis resolved with rehabilitation. Rossi et al[36] presented a 10.4-year follow-up in 62 patients with PRCTs (53% bursal-sided and 47% articular-sided). Eighty-seven percent of athletes returned to their preoperative sport and 80% returned to the same level with no notable differences between articular-sided and bursal-sided tears.

Good clinical outcomes have also been reported with TT repair in intratendinous PRCTs.[37] Park et al[37] reported clinical and radiographic outcomes in 33 patients (age 53.4 ± 9.1 years) with arthroscopically confirmed intratendinous PRCTs who underwent TT suture-bridge repair. At 4.6-year follow-up, 6.1% (N = 2) demonstrated Sugaya type III healing (ie, <50% normal tendon thickness without discontinuity). Notable improvement was seen in functional outcomes and shoulder ROM with 91% demonstrating good/excellent outcomes. Similarly, Xiao and Cui[38] reported good/excellent shoulder function and ROM in 33 patients who underwent bursal side débridement and single-row repair for intratendinous PRCT. Eighteen and a half percent of patients with an MRI follow-up of 15.2 months postoperatively demonstrated Sugaya type III healing.

Conversion Repair

Conversion repair involves incising the portion of the RC from the bursal side or articular side that is morphologically intact. The tendon edges are débrided, and the footprint is prepared in a routine fashion. The FTT is then repaired using the surgeon's preferred technique. Conversion repair allows for the removal of degenerative tissue and better access to the RC footprint for repair. Although good outcomes have been reported with in situ repairs for intrasubstance and articular-sided tears, our preferred method of treatment is conversion repair. Good functional outcomes and retear rates between 9.5% and 35.3% have been reported in the literature.[1]

Conversion Repair Versus in Situ Repair for PRCTs

Aydin et al[39] reported clinical outcomes of conversion repair in 29 patients (age 55.2 ± 7.6 years) with high-grade, bursal-sided tears. Constant score improved from 38.9 preoperatively to 89.2 and 87.8 at 2 years and 5 years postoperatively, respectively. Chung et al[40] analyzed outcomes among 34 consecutive patients with high-grade PRCTs (17 articular-sided, 16 bursal-sided, and one combined, age 57.9 ± 7.2 years) treated with conversion repair. Failure rate was 35.3% (12 patients); failures were attributed to higher tendinosis grade. All functional scores improved markedly at minimum 2-year follow-up.

Katthagen et al[1] conducted a systematic review comparing conversion and in situ repair. Six studies (277 patients) analyzed outcomes of conversion repair at 33.7-month follow-up. Retear rate among 146 patients with MRI scans was 15.1%. Complication rate was 4.5% including adhesive capsulitis, scapular bursitis and subcoracoid and subacromial impingement. Higher retear rates were found in bursal-sided compared with articular-sided tears (9.5% and 21.5%, respectively). Outcomes of in situ repair were reported in six studies (236 patients). Retear rate was 12.5% in 152 patients, and complication rate was 4.7% (eg, adhesive capsulitis, bursal-side anchor pullout) among 106 patients at 40.1 months. No difference in outcomes were reported between conversion and in situ repair for PRCTs involving >50% of tendon thickness. Castricini et al[41] compared outcomes of 94 patients with conversion repair and 59 patients with TT repair for PASTA (partial articular supraspinatus tendon avulsion) lesions. No notable difference in Constant and SST scores or satisfaction rates were reported between groups. The retear rate was 13.5% and 13.9% in the conversion repair and TT groups, respectively.

Similarly, Kim et al[42] investigated outcomes in patients with intratendinous tears who underwent bursal débridement plus either single-row repair or in situ suture-bridge repair, arthroscopic débridement and TT repair, or conversion repair with a single-row, double-row, suture-bridge, or side-to-side repair technique. At 2-year follow-up, similar functional outcomes, ROM, and retear rates were reported regardless of repair technique. Three patients (10.7%) demonstrated PRCT retear on MRI or ultrasonography (two articular-sided and one bursal-sided). Kanatli et al[43] compared arthroscopic repair in articular-sided, bursal-sided, and intratendinous tears. Articular-sided tears underwent conversion repair with double-row repair, and bursal-sided and intratendinous tears were treated with repair using a lateral tension band technique. Notable improvements in functional outcomes and ROM were achieved in all patients regardless of tear type and repair technique.

Although there may be a biomechanical advantage of in situ techniques, clinical outcomes do not demonstrate superiority over conversion repair for articular-sided, bursal-sided, or intratendinous tears. Figure 11 proposes a suggested treatment algorithm with a summary of relevant studies in Table 2.

Figure 11.

Flowchart showing an algorithm for treating partial thickness rotator cuff tears.

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