Editorial Commentary: Does a Medialized Repair Allow Single-Row to Outperform Double-Row Rotator Cuff Repair?

The optimal surgical technique for arthroscopic rotator cuff repair remains controversial, with advantages and disadvantages to each of the most commonly used methods. The pattern as well as number of suture anchors relative to the footprint has been one of the most common sources of debate, with proponents and arguments for both single- and double-row arrangements. Although double-row techniques have been shown to be biomechanically superior and to improve footprint coverage, evidence has been mixed as to whether they are clinically superior, especially in small- and medium-sized tears. Whereas historically, single-row repairs have aimed to restore pre-tear tendon tension, there recently has been interest in a medialized single-row technique to reduce repair tension. Advantages of this technique include a reduced number of anchors and thus a reduced cost, an efficient technique, and a potential reduction in tension, which could improve healing rates. Disadvantages of this technique include a reduced tendon-to-bone area of contact, which may lead to higher rates of incomplete healing.     

Editorial Commentary: Steroid Injections Prior to Arthroscopic Rotator Cuff Repair—Is It Time to Rethink a Conservative Treatment Paradigm?

The standard of care for most rotator cuff conditions over the past half century or longer has been a trial of nonoperative treatment including nonsteroidal anti-inflammatory agents, physiotherapy, and steroid injections prior to surgery. There is compelling basic science data to suggest a negative effect of corticosteroids on tissue quality. Chronicity of the tear is a risk factor for unsuccessful repair, but other factors including use of tobacco products, repair technique, and postoperative management all have an impact. Evidence either in favor of or against use of steroid injections as a treatment option is limited or weak at best. Given advances in rotator cuff repair techniques and successful long-term outcomes, treating surgeons should be mindful of how injections might affect surgical outcomes owing to either delayed surgical intervention or a direct effect on tissue quality.     

Editorial Commentary: Can We Do Better While Spending Less: How Many Shoulder Rotator Cuff Anchors Are Enough?

We have published that shoulder rotator cuff tear is a highly cost-effective procedure, and to continue to improve value, a goal is to contain cost while maintaining or improving outcome. To bend the cost curve, reduction in direct costs (number of suture anchors used) could be a goal, and because rotator cuff repair failures are as much biologic as they are mechanical, the effect of adding anchors to improve outcomes has an obvious limit.     

Editorial Commentary: Improving Strength and Clinical Outcomes After Rotator Cuff Repair—Role of Choosing Single- Versus Double-Row Repair

The controversy as to what is the best technique to repair a rotator cuff continues, with single–anchor row versus double-row techniques being highlighted. The literature has presented multiple studies with clinical outcomes being similar, even though double-row linked and transosseous-equivalent repairs have a higher success rate with postoperative imaging. Clinical outcome instruments weigh pain as a major criterion, but strength improvement favors an intact repair. Treatment of chronic rotator cuff tears often yields muscular changes that may compromise the strength-improvement portion of the outcome. Larger tears benefit from additional fixation, and tissue loss continues to require adjustments to the repair strategy. Attempting a repair that emphasizes footprint coverage may over-tension the cuff repair and risk shoulder stiffness and medial failure of the repair. By use of a 3-dimensional spherical attachment surface, a linked infraspinatus repair can be combined with an anteromedial supraspinatus repair to create a lower-tensioned secure repair. Additional grafting methods, including use of the biceps, may provide additional strength to the repair construct.     

Editorial Commentary: Is It Time to Abandon the Latissimus Dorsi Tendon Transfer as a Salvage Procedure for Patients With Large Irreparable Rotator Cuff Tears That Failed Primary Repair?

The management of large irreparable rotator cuff tears in the young and active patient population without arthritis presents a challenge for shoulder surgeons due to the limited number of treatment options available that provide predictable outcomes. Latissimus dorsi tendon transfer (LDTT) for the treatment of large, irreparable posterosuperior rotator cuff tears or as a salvage procedure for failed surgical (arthroscopic or open) repair was originally introduced in 1988. Multiple studies have reported both the short- and long-term outcomes after LDTT; however, the majority of these studies included patients without history of previous surgery or a mixed patient population. However, LDTT as a salvage procedure is not as predictable as a primary procedure in terms of pain relief and functional improvement. This is especially true in patients with severe fatty infiltration of the posterior cuff musculature and preoperative acromiohumeral distance <7 mm on static anteroposterior radiography. Conversely, we should not abandon the LDTT in young and active patients with large irreparable rotator cuff tear and intact or repairable subscapularis without arthritis as a primary procedure for treatment. There is plenty of clinical evidence that demonstrates good-to-excellent outcomes in this subset of patients. However, in the setting of one or multiple failed arthroscopic or open cuff repairs, limited range of motion, acromiohumeral distance <7 mm on static anteroposterior radiograph, and severe fatty infiltration of the posterior cuff musculature, I would caution against the use of LDTT as a salvage procedure due to the high failure rate and unreliable clinical results. Currently, there is no role in my own practice for LDTT as a salvage procedure in this patient population.     

Editorial Commentary: When Less Is More—The Benefits of Limiting Bursectomy in Arthroscopic Rotator Cuff Repair

Although the exact function of the subacromial bursa as it relates to rotator cuff repair is still debatable, most surgeons would agree that the more invasive the procedure, the more likely there will be scarring and/or adhesions, which can lead to decreased motion. So, when performing subacromial bursectomy during rotator cuff repair, “Observe due measure, moderation is best in all things [subacromial].”     

Editorial Commentary: All-Suture Anchor for Medial-Row Fixation in Rotator Cuff Repair—Ready for Prime Time?

We, orthopaedic surgeons, are always on the watch for suture anchor approaches that will enhance our potential for success with tendon-to-bone healing or at least make their use easier or more applicable in certain situations. It is always best to have some biomechanical testing to compare recently introduced suture anchors with established and more studied conventional anchors. Although this is a good start, unfortunately, secondary aspects of an anchor sometimes are only observed after use in a biological setting. An all-suture anchor certainly can be inserted with a smaller starting defect in the proximal humerus, which could help in different settings when trying to accomplish a rotator cuff repair. However, as in many biomechanical studies, we need to be cautious about how the findings apply to the actual clinical situation.     

Editorial Commentary: The Partial Thickness Rotator Cuff Tear: Is Acromioplasty Without Repair Ever Indicated?

I believe that arthroscopic repair is the treatment of choice for patients with partial thickness rotator cuff tears when nonoperative methods have been exhausted. Excluding overhead athletes and patients in whom long head biceps tendon pathology is the primary concern, I do not believe that a significant role exists for debridement with or without acromioplasty in the majority of patients with partial thickness tears. Regarding the repair technique, I prefer in situ repair for bursal-sided tears because the superior capsule is intact and completion of the tear with repair for articular-sided tears.     

Editorial Commentary: All-Suture Shoulder Glenoid Anchors: Can We Adequately Tension Them or Knot?

All-suture anchors require smaller drill holes (often under 2.0 mm) than comparable solid glenoid anchors (e.g., Gryphon: 2.5-mm drill). A smaller drill allows closer anchor approximation, but there is no indication that this improves repair biomechanics. In fact closely associated multiple fixation points are associated with glenoid fractures, and the same multiple fixation points can be achieved with double- or triple-loaded conventional anchors. All-suture anchors require deployment immediately adjacent to intact cortical bone. Without this, slack and pistoning of the suture ball anchor occur during cyclic loading and have been associated with bone cavitation, repair loosening, and gap formation. A mechanical tensioning mechanism more effectively removes the slack than hand tensioning by the surgeon. Drill length is another concern. All-suture anchor drills measure between 20 and 24 mm long. This length is commonly associated with far cortex penetration and places the suprascapular nerve and axillary nerve at increased risk of contact damage. Maximizing all-suture anchor performance is associated with mechanical deployment systems rather than hand traction applied by the surgeon. Finally, no current all-suture anchor is biodegradable, osteoconductive, or replaced by bone.     

Editorial Commentary: What's Hamada With Partial Rotator Cuff Repair?

Early repair of acute traumatic rotator cuff tears has been shown to restore functional range of motion, whether or not there is complete healing. The ability to predict those cuff tears that can achieve only a partial repair can help with preoperative patient counseling. The Hamada classification can be predictive in determining outcomes in the treatment of massive rotator cuff tears.     

Editorial Commentary: Platelet-Rich Plasma in the Treatment of Rotator Cuff Tears—From Hero to Zero?

As failure rates after arthroscopic rotator cuff remain high, platelet-rich plasma (PRP) has gained interest as a potential biological augmentation to enhance bone–tendon healing. Recent research shows that delayed PRP application fails to significantly improve clinical results or decrease retear rates but may result in less fatty-infiltration of the repaired rotator cuff muscles. In combination with a lower trend toward retear, this may hint that we should not bid farewell to PRP in rotator cuff repair just yet, and whether our current enthusiasm for emerging biological strategies in rotator cuff repair is justified remains subject to additional investigation.     

Editorial Commentary: The Top Cited Rotator Cuff Repair Articles: It’s All About Popular

The Thomson Institute for Scientific Information Web of Science database was used to rank the top 50 articles regarding rotator cuff repair by number of citations received. Although the number of citations is a useful benchmark, it must be taken as only one of many indices of the value of an article to the study of orthopaedics. The most cited articles are out of date, reflecting that a longer time in publication allows more time for citation, and most have low levels of evidence (Level IV, retrospective case series absent a control group).     

Editorial Commentary: Doc,Is It All in My Head? With Rotator Cuff Tears,It Partially Is!

Psychosocial factors including anxiety, depression, and poor mental health negatively influence the baseline clinical expression of rotator cuff tearing. The same factors may influence clinical outcomes after rotator cuff repair surgery. Counseling patients preoperatively about postoperative expectations of rotator cuff repair surgery has a substantial positive impact on postoperative functional outcomes. As surgeons, we need to take the time to not just be technicians but counsel our patients and consider the impact of distress, anxiety, and expectations on the success of our treatments for rotator cuff tears.     

Editorial Commentary: Is It Time to Take a Stand? When Arthroscopic Bankart Repair Is No Longer a Viable Option for Anterior Shoulder Instability

Recurrent anterior instability remains a challenging pathology to treat effectively. Arthroscopic Bankart repair, with its low invasiveness and complication rates, is readily the first, as well as most commonly, used procedure. However, some outcomes studies have reported an unacceptably high failure rate. As such, the ideal candidate for an arthroscopic repair has yet to be fully defined, mainly because of the multiple risk factors for failure after arthroscopic instability repair. Among those factors, recurrence of an instability event is clearly a risk factor for worse outcomes after arthroscopic instability repair. This may be due to an association between recurrent instability and an increase in glenoid bone loss, humeral bone loss, and more extensive labral tears, as well as more capsular, ligamentous, and rotator cuff injuries. Patients who present with 2 preoperative dislocations and a duration of instability symptoms of more than 6 months, as well as off-track Hill-Sachs lesions, may not be ideal candidates for arthroscopic instability repair. There is a “cost” to waiting on surgery after a first dislocation.     

Editorial Commentary: Is Arthroscopic Bankart Repair Using Suture Anchors on the Glenoid Appropriate Treatment for Traumatic Anterior Shoulder Instability?

Fracture of the anterior glenoid rim along the sites of suture anchor insertion is not rare after arthroscopic Bankart repair for traumatic anterior shoulder instability. In addition to the influence of the number, type, and size of the suture anchors, placing multiple anchors in a linear arrangement might impose excessive stress on the surrounding bone, leading to critical loss of osseous integrity and glenoid fracture. Although highly active young male collision or contact athletes are most at risk, such fractures sometimes occur after relatively minor trauma at a long interval after surgery, suggesting persistent impairment of bone quality. In patients with postoperative recurrence of instability, detailed examination using computed tomography is recommended.     

Editorial Commentary: Is Magnetic Resonance Imaging of the Shoulder Ever Appropriate in Evaluating Patients With Calcific Tendinopathy of the Rotator Cuff?

Calcific tendinopathy of the rotator cuff is a common pathology that often presents with clinical symptoms simulating a rotator cuff tear. The reported incidence of rotator cuff tear in the setting of calcific tendinopathy varies widely; however, the reported incidence of full-thickness rotator cuff tear on imaging in calcific tendinopathy is consistently low (<5%). In patients with symptomatic calcific tendinopathy, initial conservative management followed by minimally invasive treatments should be employed prior to performing shoulder magnetic resonance imaging to assess for a rotator cuff tear. A shoulder magnetic resonance imaging may be performed for preoperative planning prior to surgical removal of calcium deposits, but even in this patient population, the incidence of full-thickness rotator cuff tear is low.