Editorial Commentary: Superior Capsule Reconstruction Using Dermal Allograft in Posterosuperior Rotator Cuff Tears—Do Patients Benefit and Allografts Heal?

Irreparable rotator cuff tears are challenging to treat, especially in highly active and young patients. Superior capsule reconstruction is a joint-preserving, anatomic, and arthroscopic option that has shown promising mid-term results. Over time, this procedure has undergone evolution in terms of patient selection and technical aspects, such as graft choices and fixation methods. Initially, superior capsule reconstruction was used for isolated irreparable tears of the supraspinatus tendon; now, the indication has widened to technically irreparable massive posterosuperior rotator cuff tears. The trend in North America and Europe has been toward using human dermal allografts, as opposed to fascia lata autografts, to avoid donor-site morbidity and reduce surgery time. How these modifications affect clinical outcomes and whether dermal allografts heal remains unknown.     

Editorial Commentary: Side-to-side Rotator Cuff Repairs—Are Perfectly Placed Sutures Enough?

Arthroscopic side-to-side rotator cuff repair of large U-shaped tears should incorporate repair of the greater tuberosity. Recent research has found that pain at rest and with motion, range of motion, strength, and University of California–Los Angeles and Constant scores improved overall in patients with side-to-side repairs. Although the clinical results were quite good overall, rotator cuff healing was found to be significantly better, with 28% improvement confirmed by magnetic resonance imaging evidence of healing when the side-to-side repair was further repaired to the tuberosity.     

Editorial Commentary: Delaminated Rotator Cuff Tears—Does the Suture Pattern Matter?

The configuration of the suture placed in the rotator cuff tendon in the presence of a delaminated tear may be an important determinant of outcome. Delaminated rotator cuff tears are difficult to repair and probably occur more frequently than appreciated. The goal of anatomic reduction of the tendon to the footprint, attaching the deep tendon layer to the medial aspect of the footprint while approximating the superior tendon layer to the more lateral aspect of the footprint, may best result in complete healing.     

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: 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: Biologically-Enhanced Patch Augmentation: The Perfect Marriage of Mechanical Stability and Biology for Rotator Cuff Healing? Unfortunately,Not Yet

Recurrent rotator cuff tears are a frequent cause of shoulder disability. To repair a rotator cuff, the surgeon faces both mechanical and biological challenges. Patch use as a scaffold for rotator cuff repair is well-described, as is biological augmentation, with clinical indications and efficacy being the subjects of ongoing study. However, a clinical report of dermal allograft patch augmentation combined with attempts at supercharging the biology is novel. This technique would benefit from controlled, prospective studies, with tight inclusion criteria.     

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: Are We Ready to Apply Stem Cell Therapy in Rotator Cuff Tear Surgery?

For rotator cuff tear surgery, application of mesenchymal stem cells (MSCs) is a promising new option. Among various MSC sources, synovial tissue contains a high number of MSCs with high chondrogenic potential. Because chondrogenic formation is an important factor in enthesis healing in rotator cuff repair, synovial MSCs derived from the subacromial bursa are superior candidates for the augmentation of rotator cuff tear surgery.     

Editorial Commentary: Rotator Cuff Surgery Planning: Yet Another Reason for Orthopedic Surgeons to Learn to Use Ultrasound…

Several factors that affect the healing rate of shoulder rotator cuff tears have been elucidated, including tear size, degree of retraction, and degree of muscle atrophy. Identifying these factors preoperatively is critical for appropriate surgical planning and patient counseling. Ultrasound can be used to predict rotator cuff stiffness, which could result in a way to better plan for rotator cuff surgeries.     

Editorial Commentary: Optimizing Postoperative Care After Rotator Cuff Repair: What Do We Know and Understand?

Optimization of the management of rotator cuff tears is still needed. Preoperative patient selection, perioperative surgical techniques, and postoperative care are all important topics that are studied extensively. This commentary will examine the current situation and important fields of interest for future research. Postoperative pain management is scrutinized in relation to the level of abduction using an abduction brace.     

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: 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: Dermal Grafts for Irreparable Rotator Cuff Tears—“Bridge Over Troubled Waters”

The treatment of an irreparable rotator cuff tear is an enigma. There are so many treatment options, with different experts recommending different treatments. These include physical therapy, partial repairs, tendon transfers such as the latissimus dorsi and the lower trapezius, biceps tenotomy, tissue augmentation with allografts or autografts, balloon spacers, and finally a reverse prosthesis. It is an easy decision when the patient is physiologically old with many medical comorbidities and arthritis. It is much more difficult when the patient is younger with no arthritis. Many patients with a failed massive cuff repair do well with a supervised therapy program despite the absence of 2 tendons (the supraspinatus and infraspinatus). Nothing works well when the subscapularis and/or teres minor are irreparable. I will usually try a 3-month physical therapy program, and if this is not successful in improving pain and function, consider surgery. If I can do an adequate partial repair, where the residual defect is small enough that the humeral head does not button hole through the defect like a boutonniere deformity, that is my treatment of choice. I will only do grafts with Hamada stage 1 or 2, as stage 3 with a fixed humeral head against the acromion do not do well. I am intrigued by the balloon spacer and why the results are still adequate, even when there is no balloon present after about 1 year. I’m holding judgment on that until there are more published studies. A reverse prosthesis I use as a last resort.     

Editorial Commentary: Does the Morphology of the Acromion Explain All Rotator Cuff Tears?

Given the high prevalence of rotator cuff tears and their socioeconomic impact, surgeons and researchers have tried to understand their etiology and pathomechanism for almost hundred years. Articles about tendon degeneration with increasing age dominate the literature, and numerous factors contributing to tendon degeneration have been identified. One of them, the lateral extension of the acromion, as quantitated using the acromion index or the critical shoulder angle, has become very popular in the last few years. Other big tendons in the human body, such as the distal biceps tendon, the Achilles tendon, or the patellar tendon, are also subject to degenerative changes, but they normally do not lose their continuity without a relevant trauma. This raises 2 questions: What makes the rotator cuff different from the other tendons, and why are there not more rotator cuff tears related to a trauma? What we do know is that risk factors for rotator cuff tear include trauma, dominant arm, and age, whereas the effect of a large acromion is more ambiguous.     

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: Superior Capsular Reconstructions in Cases of Irreparable Rotator Cuff Tendons Only Partially Restore Anatomy,Yet Significantly Normalize Biomechanics–Without Resorting to Reverse Anatomy

The goal of shoulder superior capsular reconstruction and/or anterior cable reconstructions, at least in terms of biomechanics, is to primarily restore a fulcrum to assist with pain control and functional optimization, with the secondary hope of maintaining cartilage. Fully restoring glenohumeral joint loads with SCR cannot be expected in the setting of persistent tendon insufficiency. Biomechanical studies characterizing shoulder capsular reconstructions have demonstrated anatomic and functional restorations toward normalization when tested with standard biomechanical methods. Glenohumeral abduction, superior humeral head migration, deltoid forces, and glenohumeral contact pressure and area, can be optimized toward the normal intact condition, as measured by motion tracking and pressure mapping in real time, using dynamic actuators. Insofar as restoring normal native anatomy is considered a fundamental priority, with the idea that joint functional longevity is enhanced by preserving anatomy, as surgeons, we should not lose sight of reconstruction over replacement (such as nonanatomic reverse total shoulder arthroplasty) as a favored goal. Anatomy-based reconstructions such as superior capsule or anterior cable reconstruction, may prove over time to be the best primary treatment as knowledge and innovations (technical and medical) develop, with nonanatomic arthroplasty truly being a last resort (yet a clinically viable option when indicated).     

Editorial Commentary: “Rotator-Metrics”: Understanding Risk Factors for Rotator Cuff Repair Failure May Lead to Better Outcomes

Retear following rotator cuff repair is a significant risk and is associated with worse patient-reported outcomes. Tear size, fatty infiltration, age, and chronicity have all been reported as independent risk factors. Understanding risk factors for rotator cuff repair failure may allow surgeons to optimize outcomes by addressing certain tears, such as tears involving the anterior rotator cuff cable and subscapularis, more acutely and incorporating patch augmentation in tears that are at high risk for failure.     

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 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: 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].”