High-Grade Articular, Bursal, and Intratendinous Partial-Thickness Rotator Cuff Tears: A Retrospective Study Comparing Functional Outcomes After Completion and Repair

The rotator cuff was assessed from the articular and bursal sides. For articular PTRCTs, a tagging suture was used to identify the lesion from the bursal side. Bursal-sided tears were probed to assess thinning of the tendon and determine tear grade. If preoperative MRI findings suggested an intratendinous tear, a probe was used to confirm thinning of the tendon. An arthroscopic shaver was then carefully used to débride the capsule on either side of the tendon at the location of the suspected tear. The shaver inevitably penetrated the capsule and entered the tear, where any degenerative tissue was further débrided (Figure 4).

Tear depth and percentage for all tear locations were determined with the aid of a calibrated arthroscopic probe with a 3-mm bent arm after débridement of degenerative tissue was complete (Figure 5).

Removal of frayed tendon before depth determination is a method recommended in the literature.² The operative indication for completion and repair was a tear exceeding 50% tendon thickness, satisfying Ellman’s grade 3 criteria. All PTRCTs in this study were then converted to full-thickness tears.

After the PTRCT was completed to full thickness, the rotator cuff footprint on the greater tuberosity was débrided to bleeding cortical bone. Depending on tear length, 1 or 2 Bio-Corkscrew absorbable suture anchors (Arthrex) with 2 No. 2 FiberWire sutures (Arthrex) were then placed in the tuberosity 3 to 5 mm lateral to the articular margin. An arthroscopic suture passer was used to move the 2 sutures through the rotator cuff, such that one was placed in the horizontal mattress and the other was placed in a simple fashion deep to the horizontal mattress. The sutures were then tied with a modified Roeder knot.

A standardized postoperative protocol was used for all patients starting within the first week after surgery. Passive range of motion (ROM) was performed for the first 6 weeks after surgery and was advanced to include active ROM from 6 to 8 weeks after surgery. Strengthening was initiated 8 weeks after surgery.

Statistical Analysis

Power analysis demonstrated that a sample size of 20 in each group was adequate for detecting a medium to large effect size with 80% power. Wilcoxon signed rank test was used to compare the preoperative and postoperative scores for each outcome measure, and analysis of variance (ANOVA) was used to compare the amount of improvement for each of the 3 PTRCT subtypes. Paired t test was used to compare preoperative and postoperative ROM values, and unpaired t tests were used to determine the impact of corticosteroid injections and preoperative PT. For statistical analysis, patients were divided into 2 groups (yes, no) regarding injections and 2 groups (yes, no) regarding PT. Last, multiple linear regression analyses were performed for each outcome measure to determine the impact of potential confounders. Covariates included symptom duration, etiology, age, injection, PT, tear location, percentage of tendon torn (medial-lateral), and tear length (anterior-posterior). P < .05 was considered significant.

Results

Patient Sample and Demographics

Sixty-seven patients underwent arthroscopic repair of a PTRCT—22 grade 3A, 23 grade 3B, and 22 grade 3C. In each of the 3 groups, 20 patients returned for end-of-healing evaluation. Thus, the study population consisted of 60 patients (60 shoulders). The 7 patients who did not return for end-of-healing evaluation or who could not be contacted were excluded from the study.

Table 1 summarizes the key patient demographics. Of the 60 patients, 35 were men and 25 were women.

Mean age at time of surgery was 47.43 years (range, 29-66 years). There were no throwing athletes in the study population. The dominant shoulder was involved in 32 (53%) of the 60 cases. Mean (SD) time from symptom onset to surgery was 14.23 (10.08) months. There was little variance among the articular, bursal, and intratendinous means with respect to age (50.4, 45.15, and 46.75 years, respectively) and time from symptom onset to surgery (13.4, 13.55, and 15.75 months, respectively). Mechanism of injury was traumatic (eg, motor vehicle crash, pulling, pushing, fall) in 32 cases and insidious in 28 cases. Forty patients (66.67%) had received at least 1 injection before surgery; mean time from injection to surgery was 4.36 months. Of the 46 patients (76.67%) who underwent a preoperative PT regimen, 32 (69.57%) completed 6 to 8 weeks of PT, and the other 14 completed either a 4-week program or a program lasting longer than 8 weeks. Mean time from completion of PT to surgery was 4.16 months.

Range of Motion

The sample as a whole exhibited statistically significant improvement in active ROM (Table 2).

Mean forward flexion improved from 138° to 157° (P < .0001), mean external rotation improved from 67° to 71° (P = .0119), mean abduction improved from 135° to 157° (P < .0001), and mean internal rotation improved from the 12th to the 7th thoracic vertebra (P < .0003). There was significant improvement in all planes of motion in each tear location group, exception for the bursal and intratendinous groups in external rotation, which exhibited mean increases of only 3.5° (P = .3142) and 1° (P = .6347), respectively.