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Rotator cuff tear patterns dictate repair technique
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Rotator cuff tears represent a significant source of shoulder disability and socioeconomic burden. Outcomes after rotator cuff repair have improved significantly in recent years. Understanding and recognizing common tear patterns is helpful to achieve a low-tension repair and to improve outcomes.
Traditionally, tear patterns have been classified using 1-D or 2-D systems that measure the largest size of the tear. More recently, a 3-D system that defines the common tear patterns and includes tendon delamination is useful technically for arthroscopic and open repairs and is thought to help improve good clinical outcomes.
Typical tear patterns include crescent-shaped, L-shaped, U-shaped and massive rotator cuff tears. There are also atypical complex tear patterns and tongue type tears. To achieve a tension-free tendon-to-bone repair, a variety of surgical techniques such as intra-articular and extra-articular releases, side-to-side margin convergence sutures, and interval slide techniques can be applied and combined. These techniques allow for approximation of the tear edges to the footprint and reduction of tension at the repair site.
Classification systems
Davidson and Burkhart introduced a geometric classification system, linking tear patterns to treatment strategies and prognosis (see Table). The four most common tear patterns are crescent, L-shaped, U-shaped and massive tears. We have also noted some less common and atypical complex tear patterns which include tongue type tears and intra-substance mid-tendon tears. Recommended treatment methods differ for the common tear patterns based on biomechanical and functional principles.
Adequate tendon quality is crucial for maintenance of integrity of the repair regardless of the repair technique. Tissue quality is directly related to suture-holding capability and its potential for tendon-to-bone healing. The degree of muscle atrophy and fatty infiltration can be estimated preoperatively using CT and the Goutallier classification of fatty infiltration, or MRI and the Thomazeau classification of muscle atrophy.
It has been advocated for many years to avoid rotator cuff repair in patients with higher degree fatty infiltration due to unfavorable results. However, Burkhart and colleagues reported significant functional improvement after arthroscopic rotator cuff repair in 86.4% of 22 patients preoperatively graded as 3 or 4 fatty degeneration according to the Goutallier classification. Therefore, the decision on reparability should not only be based on preoperative imaging, but also be individualized according to particular factors of the patient, such as activity level, comorbidities, expectations and intraoperative assessment of tendon quality.
Assessment of rotator cuff tears
Using high-resolution MRI, preoperative determination of the 3-D tear pattern has become an option and can help counsel the patient about preoperative expectations. However, intraoperative arthroscopic assessment still remains the standard for surgical decision-making on the repair strategy.
Arthroscopic view from the posterolateral portal onto a crescent shaped tear in a right shoulder is shown.
Arthroscopic view from the posterolateral portal onto the four anchor knotless interconnected double-row rotator cuff repair of the crescent shaped tear in a right shoulder is shown.
Arthroscopic view from the posterolateral portal onto a six anchor knotless interconnected double-row rotator cuff repair for a larger crescent shaped tear in a right shoulder is shown.
Arthroscopic view from the posterolateral portal onto a L-shaped tear in a right shoulder is shown.
Images: Petri M, Millett PJ
We prefer to perform surgery in the beach chair position with a pneumatic arm holder. Standard posterior and anterosuperior portals are established and diagnostic arthroscopy is performed. Visualization and assessment of rotator cuff tear patterns is usually best performed via the lateral portal. We prefer to use two lateral portals so we can adequately visualize the tear and note any delaminations. Debridement of scar tissue and lysis of adhesions is then mostly performed via the anterosuperior and posterior portal. The mediolateral and anteroposterior mobility of the cuff is then assessed using a grasper. Once the tear pattern is determined, the repair technique is chosen accordingly.
Crescent shaped tears
These are the most common rotator cuff tears, accounting for about 40% of full thickness tears. They occur by direct detachment of the tendon from the footprint (Figure 1) and provide good mediolateral mobility, allowing for mostly tension-free direct repair of the tendon back to the bone. Good to excellent outcomes can usually be expected with this tear pattern.
The question of whether single- or double-row repairs are preferable has been a matter of debate for several years. Cadaveric studies suggest linked double-row repairs provide the best biomechanical results for most full thickness tears. However, even though double-row repairs apparently result in improved structural outcomes, clinical outcomes are not significantly different between single- and double-row repairs, although there may be a lower re-tear risk. Single-row repair is indicated in most partial thickness or small full thickness tears. Single-row repair also can be used for massive, immobile tears. Double-row repair may be performed in most cases. We prefer a self-reinforcing, knotless bridging double-row technique using suture tapes because of favorable biomechanical properties and clinical outcomes (Figures 2 and 3).
U-shaped tears
U-shaped tears are less common than crescent shaped tears and extend more medially (Figure 4). U-shaped tears provide less mediolateral mobility. If they are pulled toward the footprint too aggressively, then the risk of mid-substance tendon failure increases. The margin convergence technique using side-to-side sutures approaches the crest of the tear to the footprint and thereby reduces the risk of tensile overload.
This technique uses the advantage of the good antero-posterior mobility of the cuff in U-shaped tears. Eventually, the U-shaped tear is converted into a crescent shaped tear (Figures 5 and 6), allowing for low tension repair of the tendon onto the bone.
Arthroscopic view from the posterolateral portal onto the debridement of a L-shaped tear in a right shoulder is shown.
Arthroscopic view from the posterolateral portal onto the repaired L-shaped tear in a right shoulder repair, including the margin convergence sutures and four anchor knotless interconnected double-row rotator cuff repair, is shown.
Arthroscopic view from the posterolateral portal onto a U-shaped tear in a right shoulder is shown.
Arthroscopic view from the posterolateral portal onto the placement of the first margin convergence suture for a U-shaped tear in a right shoulder is shown.
L-shaped and reverse L-shaped tears
L-shaped and reverse L-shaped tear patterns account for approximately 30% of rotator cuff tears. One free margin of the tear has a greater mobility than the other (Figures 7 and 8). They can also be conceptualized as crescent shaped tears with an additional longitudinal split through either the anterior interval between the subscapularis and supraspinatus (L-shaped tear) or between the supraspinatus and infraspinatus (reverse L-shaped tear). When tearing occurs through both intervals, we have termed this a tongue type tear.
The key with L-shaped and reverse L-shaped tears is that the tendon repair occurs in a posteromedial to anterolateral direction for an L-shaped tear and an anteromedial to posterolateral direction for a reverse L-shaped tear, as opposed to a direct medial to lateral direction which would overtension the repair. A temporary reduction stitch at the anterolateral corner for L-shaped tears, or posterolateral corner for reverse L-shaped tears, respectively, can facilitate anatomic repair. Sometimes this corner can be secured with a suture anchor, and the tear will be converted into a crescent tear.
Side-to-side margin convergence sutures are typically placed to close the longitudinal split. These margin convergence sutures help to decrease stress on the tendon-bone-interface and reduce the tear to a crescent shaped tear, which can then be directly repaired onto the footprint using the standard technique (Figure 9).
Massive, contracted and immobile tears
This kind of tear was reported to occur in about 10% of rotator cuff tears (Figure 10). These tears are usually both poorly mobile in the anteroposterior and mediolateral direction and often show lateral tendon substance loss.
Arthroscopic view from the posterolateral portal onto the placement of the second margin convergence suture for a U-shaped tear in a right shoulder is shown.
Arthroscopic view from the anterolateral portal onto a massive rotator cuff tear in a right shoulder is shown.
Arthroscopic view from the anterolateral portal onto the mobilization of a massive rotator cuff tear in a right shoulder is shown.
Arthroscopic view from the posterolateral portal onto the eight anchor knotless interconnected double-row repair of a massive rotator cuff tear in a right shoulder is shown.
It is important to avoid confusion about the terminology “massive” and “irreparable.” Many tears deemed irreparable have become reparable with advanced intra-articular and extra-articular release techniques (Figures 11 and 12). Furthermore, interval slides, partial repairs or graft-augmented repairs can be performed to make a retracted tear reparable. However, overly extensive releases should be avoided to maintain sufficient blood supply and to avoid tensile overload of the remaining tendon.
Complex tear patterns
In some instances, a complex tear pattern may be encountered that does not fit the standard aforementioned pattern types. In such instances, the principles of rotator cuff repair should be used which include achieving a low-tension repair with good tendon grasping and good approximation of the tendon to bone. By removing damaged tissue performing adequate releases, understanding the anatomy of rotator cuff muscle tendon units, recognizing and closing delaminations, preparing the bone of the tuberosity for healing and then achieving a low-tension repair with good surface area for healing, a successful outcome should be expected.
Results of arthroscopic rotator cuff repair have significantly improved during the past years owing to considerable improvements in surgical technique and materials. Many tears deemed technically irreparable in the past are now reparable when the appropriate indication and surgical techniques are applied. Recognition of rotator cuff tear patterns is crucial as the tear pattern dictates the repair technique and allows an anatomic, low-tension repair, resulting in better healing and better outcomes for our patients.
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- For more information:
- Peter J. Millett, MD, MSc, can be reached at The Steadman Clinic, 181 West Meadow Dr., Vail, CO 81657; email: drmillett@thesteadmanclinic.com.
- Maximilian Petri, MD, can be reached at Unfallchirurgische Klinik, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625 Hannover, Germany; email: petri.maximilian@mh-hannover.de.
Disclosures: Petri reports his previous position at the Steadman Philippon Research Institute (SPRI) was supported by Arthrex and SPRI receives support from Arthrex, Smith & Nephew, Siemens Medical Solutions, Ossur Americas and Opedix. Millett reports he receives consultant payments from Arthrex and Myos, receives royalties from Arthrex, and has stock options with GameReady and VuMedi.