Techniques of Cuff Repair

1.Arthroscopic Debridement with or without AcromioplastyArthroscopic debridement is generally performed in PTRCTs that involve < %50of the tendon thickness (Grades I and II) and may be combined with or withouta concomitant acromioplasty. While numerous reports have reported favorableresults9-1, it does appear that arthroscopic debridement alone or in combinationwith subacromial decompression does not prevent progression of a PTRCT to a fullthickness tear. In a report by Kartus et al. at a mean of -101month followup, %35 ofPTRCTs progressed to full thickness tears as evidenced by ultrasound. There was a significantly higher failure rate in bursal surface tears (%29) versus articular surfacetears (5)%3. This led the authors to conclude that formal repair may be considered inpatients with bursal surface tears involving <%50 of the tendon thickness. Reynoldset al. reported that %76of professional pitchers were able to return to throwingfollowing arthroscopic debridement. However, only %55 were able to return to thesame or higher level of play.2. Repair - Conversion repair: Conversion repair involves completing a PTRCT to a fullthickness rotator cuff tear followed by repair. This technique has major advantagesof completely removing any devitalized tissue and allowing the utilization of standardrotator cuff repair techniques. This technique has resulted in encouraging outcomeswith significant improvement in range of movement, strength, pain relief, and overallfunction12-10. Furthermore, anatomic outcomes utilizing imaging modalities havebeen favorable. Conversion repair has had successful clinical and anatomic outcomesand has the surgical advantage of using routine rotator cuff repair techniques15-10.However, the theoretical concerns of detaching the residual intact rotator cuff fromthe greater tuberosity have led surgeons to develop other repair techniques (e.g., insitu repair). - In Situ Repair: In situ repair techniques have the theoretical advantage ofpreservation of the existing anatomy by maintaining the intact lateral insertion of thecuff while reestablishing the medial delaminated portion. Although a number of in siturepair techniques have been described, the transtendon repair technique is themostcommonly reported technique and is generally performed on articular surface tears.The transtendon technique has demonstrated excellent clinical results with a > %90satisfaction rate (range 19-16.)%98–%91 Transtendon repair has generally showngood results in athletes, but with a wide range (%33 to %89) of athletes returningto their same level of sport or higher. Patients with poorer results and the inabilityto return to sport were generally associated with concomitant pathologies suchas shoulder instability, SLAP lesions, and bicep tendinopathies. However, it shouldbe noted that, even in patients with excellent outcomes by shoulder specific ratingscales, some symptoms might persist. While this residual pain can be multifactorial innature, some authors have attributed these symptoms to the effect of overtensioningor inappropriate tensioning of the remaining fibers of the rotator cuff to the greatertuberosity (i.e., bursal surface versus articular surface tension mismatch) This hasled to the development of a completely all-inside intra-articular technique, whichonly reduces the retracted articular fibers to the bone bed and may provide a moreanatomic repair. Although there appears to be a theoretical and biomechanicaladvantage of transtendon repair over conversion repair, comparative studies havenot been able to detect a significant clinical advantage.