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Editorial Commentary: Restoration of Rotator Cuff Footprint Anatomy Is All That Matters, No Matter How We Get There
Editorial Commentary: Restoration of Rotator Cuff Footprint Anatomy Is All That Matters, No Matter How We Get There Darius Moezzi, M.D., Associate Editor
Abstract: Delamination of rotator cuff tears presents a challenge to shoulder arthroscopists. Tear pattern recognition and an understanding of anatomy as it relates to the superior capsule guide treatment strategies. The key to management of a delaminated rotator cuff tear is to recognize differential retraction of respective layers. Successful outcomes of surgical management require conscientious and deliberate restoration of the attachment points of the cable. The goal is to produce an anatomic repair.
See related article on page 3150
N
akamizo and Horie,1 in their article “Comparison of En Masse Versus Dual-Layer Suture Bridge Procedures for Delaminated Rotator Cuff Tears,” sought to compare the functional and radiographic outcomes of these 2 techniques. It is known that a failure to address rotator cuff delamination during repair may be a reason for lower healing rates after repair. Although this article focuses on 2 methods of repair, an equally and perhaps more important tenet of the study is the need for rotator cuff tear pattern recognition, as well as an understanding of footprint anatomy. The importance of tear pattern recognition cannot be overemphasized because delamination has been shown to be a negative prognostic indicator of rotator cuff repair outcomes.2,3 The incidence of posterior delamination is extremely high, and most of these lesions are missed if one is viewing solely from a posterior vantage point.4 If delamination is not specifically sought after from a more lateral portal, it is likely missed. Patterns of delamination can then guide the surgical repair strategy. The hope of an anatomic cuff repair, which also includes restoration of the layered structure, could re-establish native tendon morphology and thus potentially decrease retear rates.
The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2018 by the Arthroscopy Association of North America 0749-8063/181061/$36.00 https://doi.org/10.1016/j.arthro.2018.08.023
Nonanatomic repair has been postulated to be at least 1 factor leading to unfavorable outcomes after cuff repair. The rotator cuff cable courses from the junction of the upper border of the subscapularis and anterior supraspinatus to the anterior border of the infraspinatus. It is continuous with and, in fact, a thickening of the superior capsule that, by a suspension-bridge phenomenon, preserves shoulder function even in the setting of partial tears. It is paramount to recognize that the cable may delaminate from the cuff and to not mistake it for a retracted articular layer of cuff that could erroneously be repaired to the lateral footprint in a nonanatomic fashion. Although there remains debate as to whether the superior capsule is the “essential lesion” in rotator cuff tear anatomy,5 the importance of the relation of the superior capsule to glenohumeral function and its relation to the rotator cable cannot be overemphasized. Adams et al.6 have opined that their successful results of rotator cuff repair are due, in part, to recognition of tear anatomy and that, in their hands, delaminated tears are repaired as 2 separate lamina, with the deep or capsular layer being repaired more medially than the superficial or tendinous lamina. They additionally assume that the deep layer is the articular capsule. A similar study from the Republic of Korea compared the results of delaminated rotator cuff repair using a suture bridge technique with an all-layer repair or bursal layereonly repair.7 Patients with a reducible articular layer underwent a similar layer-by-layer repair to that in this study. When the articular layer could not
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 12 (December), 2018: pp 3157-3158
3157
3158
EDITORIAL COMMENTARY
be repaired in a tension-free manner, a more superficial repair was performed to prevent undue tension on the deeper layer. There were no differences in outcomes between the 2 techniques. There was no attempt to perform selective releases between the respective layers. Kim et al.8 compared “en masse” versus separate double-layer repair in a randomized fashion in 82 patients. Outcome measures including Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons, and Constant scores, as well as retear rates, were similar between groups, although lower pain scores were seen in patients with a layered repair. Nakamizo and Horie1 are commended for pointing out the limitation of the small patient sample that results in an underpowered study, as well as the small differences in SST and University of California, Los Angeles scores. I also like the fact that all included patients had postoperative magnetic resonance imaging scans at 12 months that were read by an unblinded radiologist. The difference in SST score did not meet the threshold for the minimal clinically important difference, and this value has not yet been established for the University of California, Los Angeles score. Time and again, I see studies that have statistically significant findings, and authors can often project these as pertinent conclusions of a given study. I cannot stress enough the importance of our reviewers and readers always questioning and assessing the clinical impact of any study, whether in this journal or elsewhere. It is noteworthy that 78 of the 98 cases involved tears that were medium rather than large to massive, and cases that underwent augmentation or had incomplete footprint coverage were excluded; thus, there is some selectivity regarding tear size. The deeper, articular layer was unlikely to be repaired under tension. Smaller tears were likely to have less medial retraction than tears measuring over 3 cm. Immobilization differed slightly between the groups, with the patients with smaller tears immobilized for 2 weeks less. Range of motion was slightly higher in the dual-layer group, yet it is unknown how tear size and timing differences with immobilization impacted this result. Separate reduction and fixation of the articular layer may be advantageous in large or massive tears. I have found that in the cases of larger posterosuperior tears,
layered, anatomic repair of the posterior cable and infraspinatus reliably restores the posterior force couple component, which becomes even more important in partial repairs that can result from acute-on-chronic injuries, whereby the anterior chronic supraspinatus component cannot be reliably mobilized and repaired. I would argue that the results are still good within both groups because of the authors’ recognition of tear pattern. But it is clear from this and other studies that recognizing the differential retraction of the respective layers, combined with a conscious and deliberate attempt to restore the attachment points of the cable to produce an anatomic repair, can lead to a successful outcome.
References 1. Nakamizo H, Horie R. Comparison of en masse versus duallayer suture bridge procedures for delaminated rotator cuff tears. Arthroscopy 2018;34:3150-3156. 2. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of fullthickness tears of the supraspinatus: Does the tendon really heal? J Bone Joint Surg Am 2005;87:1229-1240. 3. Flurin PH, Landreau P, Gregory T, et al. [Arthroscopic repair of full- thickness cuff tears: A multicentric retrospective study of 576 cases with anatomical assessment]. Rev Chir Orthop Reparatrice Appar Mot 2005;91:31-42 (S8) [in French]. 4. Han Y, Shin JH, Seok CW, Lee CH, Kim SH. Is posterior delamination in arthroscopic rotator cuff repair hidden to the posterior viewing portal? Arthroscopy 2013;29: 1740-1747. 5. Verma NN, Lubowitz JH, Brand JC, Provencher MT, Rossi MJ. Could disruption of the shoulder superior capsule be the “essential lesion” of rotator cuff disease? Possibly, but questions remain.. Arthroscopy 2016;32:2421-2423. 6. Adams CR, DeMartino AM, Rego G, Denard PJ, Burkhart SS. The rotator cuff and the superior capsule: Why we need both. Arthroscopy 2016;32:2628-2637. 7. Kim SJ, Choi YR, Lee HH, Chun YM. Surgical results of delaminated rotator cuff repair using suture-bridge technique with all-layers or bursal layer-only repair. Am J Sports Med 2016;44:468-473. 8. Kim YS, Lee HJ, Jin HK, Kim SE, Lee JW. Conventional en masse repair versus separate double-layer double-row repair for the treatment of delaminated rotator cuff tears. Am J Sports Med 2016;44:1146-1152.
Abstract: Delamination of rotator cuff tears presents a challenge to shoulder arthroscopists. Tear pattern recognition and an understanding of anatomy as it relates to the superior capsule guide treatment strategies. The key to management of a delaminated rotator cuff tear is to recognize differential retraction of respective layers. Successful outcomes of surgical management require conscientious and deliberate restoration of the attachment points of the cable. The goal is to produce an anatomic repair.
See related article on page 3150
N
akamizo and Horie,1 in their article “Comparison of En Masse Versus Dual-Layer Suture Bridge Procedures for Delaminated Rotator Cuff Tears,” sought to compare the functional and radiographic outcomes of these 2 techniques. It is known that a failure to address rotator cuff delamination during repair may be a reason for lower healing rates after repair. Although this article focuses on 2 methods of repair, an equally and perhaps more important tenet of the study is the need for rotator cuff tear pattern recognition, as well as an understanding of footprint anatomy. The importance of tear pattern recognition cannot be overemphasized because delamination has been shown to be a negative prognostic indicator of rotator cuff repair outcomes.2,3 The incidence of posterior delamination is extremely high, and most of these lesions are missed if one is viewing solely from a posterior vantage point.4 If delamination is not specifically sought after from a more lateral portal, it is likely missed. Patterns of delamination can then guide the surgical repair strategy. The hope of an anatomic cuff repair, which also includes restoration of the layered structure, could re-establish native tendon morphology and thus potentially decrease retear rates.
The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2018 by the Arthroscopy Association of North America 0749-8063/181061/$36.00 https://doi.org/10.1016/j.arthro.2018.08.023
Nonanatomic repair has been postulated to be at least 1 factor leading to unfavorable outcomes after cuff repair. The rotator cuff cable courses from the junction of the upper border of the subscapularis and anterior supraspinatus to the anterior border of the infraspinatus. It is continuous with and, in fact, a thickening of the superior capsule that, by a suspension-bridge phenomenon, preserves shoulder function even in the setting of partial tears. It is paramount to recognize that the cable may delaminate from the cuff and to not mistake it for a retracted articular layer of cuff that could erroneously be repaired to the lateral footprint in a nonanatomic fashion. Although there remains debate as to whether the superior capsule is the “essential lesion” in rotator cuff tear anatomy,5 the importance of the relation of the superior capsule to glenohumeral function and its relation to the rotator cable cannot be overemphasized. Adams et al.6 have opined that their successful results of rotator cuff repair are due, in part, to recognition of tear anatomy and that, in their hands, delaminated tears are repaired as 2 separate lamina, with the deep or capsular layer being repaired more medially than the superficial or tendinous lamina. They additionally assume that the deep layer is the articular capsule. A similar study from the Republic of Korea compared the results of delaminated rotator cuff repair using a suture bridge technique with an all-layer repair or bursal layereonly repair.7 Patients with a reducible articular layer underwent a similar layer-by-layer repair to that in this study. When the articular layer could not
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 12 (December), 2018: pp 3157-3158
3157
3158
EDITORIAL COMMENTARY
be repaired in a tension-free manner, a more superficial repair was performed to prevent undue tension on the deeper layer. There were no differences in outcomes between the 2 techniques. There was no attempt to perform selective releases between the respective layers. Kim et al.8 compared “en masse” versus separate double-layer repair in a randomized fashion in 82 patients. Outcome measures including Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons, and Constant scores, as well as retear rates, were similar between groups, although lower pain scores were seen in patients with a layered repair. Nakamizo and Horie1 are commended for pointing out the limitation of the small patient sample that results in an underpowered study, as well as the small differences in SST and University of California, Los Angeles scores. I also like the fact that all included patients had postoperative magnetic resonance imaging scans at 12 months that were read by an unblinded radiologist. The difference in SST score did not meet the threshold for the minimal clinically important difference, and this value has not yet been established for the University of California, Los Angeles score. Time and again, I see studies that have statistically significant findings, and authors can often project these as pertinent conclusions of a given study. I cannot stress enough the importance of our reviewers and readers always questioning and assessing the clinical impact of any study, whether in this journal or elsewhere. It is noteworthy that 78 of the 98 cases involved tears that were medium rather than large to massive, and cases that underwent augmentation or had incomplete footprint coverage were excluded; thus, there is some selectivity regarding tear size. The deeper, articular layer was unlikely to be repaired under tension. Smaller tears were likely to have less medial retraction than tears measuring over 3 cm. Immobilization differed slightly between the groups, with the patients with smaller tears immobilized for 2 weeks less. Range of motion was slightly higher in the dual-layer group, yet it is unknown how tear size and timing differences with immobilization impacted this result. Separate reduction and fixation of the articular layer may be advantageous in large or massive tears. I have found that in the cases of larger posterosuperior tears,
layered, anatomic repair of the posterior cable and infraspinatus reliably restores the posterior force couple component, which becomes even more important in partial repairs that can result from acute-on-chronic injuries, whereby the anterior chronic supraspinatus component cannot be reliably mobilized and repaired. I would argue that the results are still good within both groups because of the authors’ recognition of tear pattern. But it is clear from this and other studies that recognizing the differential retraction of the respective layers, combined with a conscious and deliberate attempt to restore the attachment points of the cable to produce an anatomic repair, can lead to a successful outcome.
References 1. Nakamizo H, Horie R. Comparison of en masse versus duallayer suture bridge procedures for delaminated rotator cuff tears. Arthroscopy 2018;34:3150-3156. 2. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of fullthickness tears of the supraspinatus: Does the tendon really heal? J Bone Joint Surg Am 2005;87:1229-1240. 3. Flurin PH, Landreau P, Gregory T, et al. [Arthroscopic repair of full- thickness cuff tears: A multicentric retrospective study of 576 cases with anatomical assessment]. Rev Chir Orthop Reparatrice Appar Mot 2005;91:31-42 (S8) [in French]. 4. Han Y, Shin JH, Seok CW, Lee CH, Kim SH. Is posterior delamination in arthroscopic rotator cuff repair hidden to the posterior viewing portal? Arthroscopy 2013;29: 1740-1747. 5. Verma NN, Lubowitz JH, Brand JC, Provencher MT, Rossi MJ. Could disruption of the shoulder superior capsule be the “essential lesion” of rotator cuff disease? Possibly, but questions remain.. Arthroscopy 2016;32:2421-2423. 6. Adams CR, DeMartino AM, Rego G, Denard PJ, Burkhart SS. The rotator cuff and the superior capsule: Why we need both. Arthroscopy 2016;32:2628-2637. 7. Kim SJ, Choi YR, Lee HH, Chun YM. Surgical results of delaminated rotator cuff repair using suture-bridge technique with all-layers or bursal layer-only repair. Am J Sports Med 2016;44:468-473. 8. Kim YS, Lee HJ, Jin HK, Kim SE, Lee JW. Conventional en masse repair versus separate double-layer double-row repair for the treatment of delaminated rotator cuff tears. Am J Sports Med 2016;44:1146-1152.