Commentary & Perspective

Commentary & Perspective on
"Arthroscopic Repair of Full-Thickness Tears of the Supraspinatus: Does the Tendon Really Heal?"
by Pascal Boileau, MD, et al.

Commentary & Perspective by
Christian Gerber, MD*,
University of Zürich, Zürich, Switzerland

Despite satisfactory clinical outcome, there is current evidence that arthroscopic repair of full-thickness tears of the supraspinatus tendon only inconsistently leads to healing of the repaired tendon¹. As failure of healing has been associated with inferior clinical results^2,3, a definitive answer to this issue is important because this technique is often performed on patients who are young and putting high functional demands on the shoulder.

In the June issue of The Journal, Boileau et al. used excellent methodology in their study of the structural and clinical results of arthroscopic repair of the supraspinatus tendon: sixty-five patients with a full-thickness supraspinatus tear were treated by a single surgeon with a single arthroscopic technique and were evaluated clinically at a minimum of two years after surgery and with computed tomography-arthrography or magnetic resonance imaging at least six months after surgery.

The authors classified the tears on the anteroposterior view with respect to retraction, which is difficult because the stump of the tendon is more or less medial on almost every scan: Even considering that this type of measurement might overestimate the loss of tendon substance and retraction, they report to have treated 97% very small (stage I) or small (stage II) tears. In the sagittal plane, the tears were small in 49% and showed minimal extension in 42%, leaving only 9% with extension leading to partial lesions of the subscapularis and infraspinatus.

The technique utilized by the authors has some features that deserve mention:

• The "tension-band" technique leads to an indirect but most likely very wide and large contact of the undersurface of the tendon with the abraded greater tuberosity. A very lateral anchor placement was used.
• A biceps tenodesis or tenotomy was performed almost routinely; this has become the standard of care for rotator cuff repairs in Europe.
• Resorbable and elastic suture material and resorbable anchors were used, in contrast to the materials used in many North American studies⁴.
• The patients were treated with an abduction brace for six weeks postoperatively.

The clinical results reported are excellent but not surprising. Even after failure of healing, clinical results tend to be rated very favorably by the patients, especially if they were elderly or not very active^1,5. The structural outcome, in contrast, is surprisingly good and appears to be approximately at the level of successful open repair, although the healing rate of such relatively small tears is difficult to find in the literature and the comparison with the literature quoted in the Discussion is somewhat questionable as the tears in the quoted series were usually bigger. The present study did not have an open control group, which would have settled the question of superiority of one method over the other, and it can be hoped that this may follow in a later manuscript.

The results of this study impart several important messages:

• The results are better, specifically with respect to strength, if the tendon has healed.
• The age of the patient appears to be a valuable marker, with patients over sixty-five years of age showing healing in less than 50% of the operated shoulders, which raises the question of whether these patients would be better treated by débridement.
• The sagittal tear size is more predictive than that measured on the frontal view. This may not be surprising because imaging in the sagittal plane more easily allows measurement of the magnitude of true disinsertion of the tendon from the bone.
• If the subscapularis and infraspinatus tendons are partially torn, healing of the supraspinatus becomes less likely.

The present investigation answers some questions: it proves that small to midsize tears can heal after the performance of elegant, minimally invasive surgical techniques and can result in excellent clinical outcome in the majority of patients if operative treatment and aftercare follow a well-defined pattern. Similar to most other excellent studies, this investigation questions certain dogmas that are almost universally accepted: Are inelastic sutures with very good tendon-grasping techniques⁶ really beneficial? Are nonabsorbable sutures necessary? Should repairs more systematically be protected with the use of abduction splints? Up to what patient age should repair be preferred to simple débridement with very easy rehabilitation?

The investigation is not a randomized trial. It does not have a control group. It only addresses small, single-tendon tears. Nonetheless, it accomplishes a very important mission: After reports of very poor healing rates in massive tears, we now have a study which, based on excellent imaging methodology, unequivocally documents that arthroscopic repair does allow excellent clinical outcome and healing of tendon repairs. Furthermore, through the use of an unusual operative repair technique and postoperative regimen, the study refutes some former dogma and thus deserves our full attention.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

1. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. J Bone Joint Surg Am. 2004;86:219-24.
2. Harryman DT 2nd, Mack LA, Wang KY, Jackins SE, Richardson ML, Matsen FA. Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff. J Bone Joint Surg Am. 1991;73:982-9.
3. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. 2000;82:505-15.
4. Gerber C, Schneeberger AG, Beck M, Schlegel U. Mechanical strength of repairs of the rotator cuff. J Bone Joint Surg Br. 1994;76:371-80.
5. Bishop J, Lo I, Klepps S, Bird J, Gladstone JN, Flatow EL. Cuff integrity following arthroscopic versus open rotator cuff repair: a prospective study. Read at the Annual Meeting of the American Academy of Orthopaedic Surgeons; 2004 Mar 12; San Francisco, CA.
6. Gerber C, Schneeberger AG, Beck M, Schlegel U. Mechanical strength of repairs of the rotator cuff. J Bone Joint Surg Br. 1994;76:371-80.

Copyright © 2005 by the The Journal of Bone and Joint Surgery, Inc.