Arthroscopic Rotator Cuff Repair
Abstract & Commentary
Synopsis: Arthroscopic rotator cuff repair yields 95% good-to-excellent outcomes regardless of tear size.
Source: Burkhart SS, et al. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair. Arthroscopy. 2001;17(9):905-912.
Most rotator cuff tears can be broadly classified into 2 patterns: crescent-shaped tears and U-shaped tears. Crescent-shaped tears pull away from bone with minimal retraction, and these tears can be repaired to the tuberosity using simple sutures from laterally placed suture anchors. U-shaped tears often extend medial to the glenoid, and these tears are repaired by margin convergence. In this technique, the side-to-side component of the tear is first reduced to decrease the size of the tear and the tension at the lateral tendon-to-bone repair site. In 1998, Gartsman and colleagues1 and Tauro2 published an arthroscopic rotator cuff repair series but only included small and medium tears. In this study, Burkhart and associates report the outcome of arthroscopic rotator cuff repair and analyzed the results according to tear size and repair technique.
Sixty-two patients underwent arthroscopic rotator cuff repair between 1993 and 1997 by a single surgeon. Shoulder function was evaluated with a modified UCLA scoring system, and the only modification was the measurement of external rotation strength rather than forward elevation strength. The rotator cuff tear was characterized by recording the size of tear (small, < 1 cm; medium, 1-3 cm; large 3-5 cm; massive, > 5 cm), number of tendons, and classification by shape (crescent-shaped vs U-shaped). Prior to October 1995, the large and massive U-shaped tears were arthroscopically repaired with margin convergence alone, leaving the tendon edge to attach to the prepared bony bed on its own. Smaller, crescent shaped tears were repaired with a mini-open technique using trans-osseous tunnels. After October 1995, suture anchors were used to provide direct tendon-to-bone fixation and enable surgeons to arthroscopically repair both crescent shaped tears and the converged margin of U-shaped tears.
Fifty-six of 59 (95%) patients reported good-to-excellent results according to a modified UCLA scoring system at an average follow-up of 3.5 years. There were no statistical differences among tear size, number of tendons, and shape groups. Patients returned to full overhead function approximately 4 months postoperatively regardless of tear size.
Burkhart et al report that large and massive tears performed similarly to small and medium tears, in contrast to the open series3-5 in which larger tears had worse outcomes than smaller tears. Arthroscopic margin convergence repairs yielded results comparable to arthroscopic tendon-to-bone fixation and, therefore, supports the use of the margin convergence technique for large and massive rotator cuff tears.
Comment by Brian J. Cole, MD, MBA
It is thought that arthroscopic rotator cuff repair can provide the patient with greater benefits than open or mini-open repairs. Arthroscopy affords the ability to recognize tear configuration and to plan for anatomic repair. Burkhart et al have demonstrated that the margin convergence technique for larger U-shaped tears is just as effective as direct tendon-to-bone fixation for smaller crescent-shaped tears, and arthroscopic rotator cuff repair with margin convergence is superior to open repair of large and massive tears. The results seem to make a strong case that margin convergence and tendon repair to bone does, in fact, address the underlying pathology, and that this procedure is based on anatomic and biomechanical principles.
Dr. Cole, Assistant Professor, Orthopaedic Surgery, Rush Presbyterian Medical Center, Midwest Orthopaedics, Chicago, IL, is Associate Editor of Sports Medicine Reports.
Author Acknowledgments: The reviewer would like to acknowledge Shane Nho, MS, for his assistance in preparation of this report.
References
1. Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg. 1998;80A:832-840.
2. Tauro JC. Arthroscopic rotator cuff repair: Analysis of technique and results at 2- and 3-year follow-up. Arthroscopy. 1998;14:45-51.
3. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am. 1986;68A:1136-1144.
4. Iannotti JP, et al. Postoperative assessment of shoulder function: A prospective study of full-thickness rotator cuff tears. J Shoulder Elbow Surg. 1996;5:449-457.
5. Harryman DT, et al. Repairs of the rotator cuff: Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73A:982-989.
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