Published 9/1/2008
Annie Hayashi

Repair without a tear?

New technique could change approach to partial rotator cuff tears

“If a patient has a partial tear of the rotator cuff, it makes more sense to me to repair it in situ than to complete the tear and start all over again. We have refined an arthroscopic, transtendon technique to repair partial thickness rotator cuff tears and are able to report excellent results,” said Timothy E. Foster, MD, senior author of “Arthroscopic transtendon repair of partial thickness articular side rotator cuff tears.”

“These are degenerative tears of the rotator cuff—not the type of tears seen in overhead throwing athletes,” he emphasized.

The study was presented by co-author Jason E. Simon, MD, at the annual meeting of the American Orthopaedic Society of Sports Medicine.

Moving beyond the “mini-open”
“The way we have treated partial rotator cuff tears—where the tendon is torn more than

50 percent—was to complete the tear and then do the repair,” explained Dr. Foster. “At that point, you would have a full rotator cuff tear that could be repaired arthroscopically or with a ‘mini-open’ procedure.

“With this new procedure, however, we can repair these partial tears without turning them into full tears,” he said. “The procedure is technically challenging and has a learning curve. If you are an experienced shoulder surgeon who is skilled with using an arthroscope, however, you can learn this technique pretty quickly.”

Dr. Foster indicated that after performing about 10 procedures, a shoulder surgeon should be “comfortable” using the technique.

Highlights of technique
“Patients with Ellman grade III tears were diagnosed by history, physical examination, and magnetic resonance (MR) arthrogram,” explained Dr. Simon. “A standard diagnostic arthroscopy was per­formed in a lateral decubitus position.

“Cuff involvement was calculated by measuring the extent of the medial footprint of the tear with a calibrated probe, evaluating the remaining lateral footprint, and determining if the footprint involvement was greater than 50 percent,” he said.

“We used a spinal needle to retrieve sutures through the rotator cable, which allowed for optimal placement,” Dr. Simon continued. “The glenohumeral space was evaluated at the completion of the repair to ensure that the medial footprint had been restored.”

Patients were evaluated postoperatively by Dr. Foster at weeks 1, 8, 12, 16, and 20, followed by a yearly evaluation. Dr. Simon reported an 85 percent excellent/good result according to the University of California, Los Angeles (UCLA) scale.

Increasing need for care
“As our population ages, especially the ‘baby boomers,’ orthopaedic surgeons will be seeing more people with partial tears due to primary tendon degeneration resulting from the aging process,” Dr. Foster said.

“Partial tears are thought to be two to three times more common than full tears. If you look at statistics, as patients enter their 60s, the healing potential of the rotator cuff significantly diminishes.

“We are discovering that age 63 is the magic number,” he continued. “On patients older than age 63, you can perform a perfect repair but the ability to heal has been greatly compromised.”

Changing the natural history of rotator cuff disease
“We can change the natural history of rotator cuff disease by using this procedure,” said Dr. Foster. “People initially have a partial tear, which progresses to a full thickness tear of the rotator cuff, usually over several years.

“If these patients are identified early enough, and if they have more than a 50 percent tear of the rotator cuff to be repaired, then you can prevent them from sustaining a full tear. That is significant, particularly in view of the numbers of patients who will need this procedure in the not-so-distant future.”

The authors had no disclosures or conflicts of interest related to this study. Other authors of this study are Lorenzo Silvestri, MD, and Jinsil K. Sung, MD. The authors are currently preparing a report for publication.

Annie Hayashi is the senior science writer for AAOS Now. She can be reached at hayashi@aaos.org