Rotator cuff delamination had greater tendon retraction, higher fatty muscle infiltration
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Published results showed delaminated rotator cuff tears had significantly greater tendon retraction and a higher amount of fatty muscle infiltration of the supraspinatus and infraspinatus.
Philipp R. Heuberer, MD, and colleagues retrospectively compared MRI scans of patients who underwent arthroscopic rotator cuff repair from 2013 to 2015 to intraoperative findings and categorized the prevalence of tendon delamination, tendon retraction and fatty muscle infiltration according to different rotator cuff tear patterns. Researchers used the global retraction index, a description individually assessing tendon retraction in MRI scans of all visible layers, to compare the amount of tendon retraction of delaminated and non-delaminated rotator cuff tears.
Among 349 shoulders, results showed 66.2% of patients had tendon delamination. Researchers found rotator cuff delamination in 84.6% of posterosuperior rotator cuff tears. Researchers also noted a significantly higher global retraction index and higher fatty muscle infiltration of the supraspinatus and infraspinatus among delaminated rotator cuff tears. To detect rotator cuff delamination, MRI had an accuracy of 57.3%, a positive predictive value of 100% and a negative predictive value of 44.2%, according to results.
“This study reveals [that] if delamination cannot be detected on MRI, it is not said that it can be encountered during arthroscopy. If it is already seen on MRI, it is a certain sign of a chronic long-standing rotator cuff tear with a higher grade of fatty muscle infiltration,” Heuberer told Healio. “If only one tendon layer is present on MRI together with a high grade of muscle atrophy, a massive cuff tear with tendon substance defect is highly probable.”
When delamination is present on MRI, Heuberer said surgeons should perform a double-layer reconstruction, as a single-layer reconstruction has been found to have a higher failure rate. He added an examination of muscle atrophy and fatty infiltration is important when delamination is not visible to determine the repair strategy.
“Especially for the patient, it is important to know already before surgery the probability of repairability, retear rate and rehabilitation phase,” Heuberer said. “A one-size-fits-all approach is no longer sustainable. Nowadays, medical knowledge allows for a custom-made surgical and rehabilitation strategy for every patient already before surgery. Assessing tendon delamination is one piece of the puzzle.”
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These authors evaluated the presence of intraoperative rotator cuff delamination and correlated those findings with the ability of preoperative MRI at accurately detecting this prior to surgery. The authors also attempted to assess the level of retraction and fatty infiltration in delaminated tears vs. non-delaminated tears.
The authors reported that 66% of the 349 shoulders in this study had some level of delamination between the articular and bursal-sided layer of the rotator cuff. The authors stress that delamination may be under diagnosed when viewing from the posterior portal only and stress the importance of a lateral viewing portal to assess for delamination.
Tears of the posterior-superior cuff had the highest tendency to demonstrate delamination. Interestingly, tears with delamination had higher degrees of both retraction and fatty infiltration compared with non-delaminated tears in this series.
A concerning finding was the poor correlation with preoperative MRI, as it was only moderately accurate in detecting tear delamination. This study indicates that tear delamination may be more common than we may anticipate, and in these cases of delamination, a higher degree of tendon retraction may be encountered.
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Rotator cuff tendon delamination negatively affects healing and can be often hard to see on MRI. The imaging-based article by Jakob E. Schanda, MD, PhD, and colleagues corroborates this notion by demonstrating that MRI had only moderate accuracy (57%) to detect rotator cuff delamination. The authors also reported that rotator cuff delamination was associated with greater tear retraction and a higher amount of fatty muscle infiltration of the supraspinatus and infraspinatus. In other words, delaminated tears are essentially a marker of greater rotator cuff disease severity. While the pathogenesis of rotator cuff delamination has not been fully elucidated, it is clear that repair of the double-layered rotator cuff should be the goal to optimize healing potential and minimize retear risk. Viewing from a lateral portal early on in the case is important to promptly identify the presence of tendon delamination and plan the rest of the case accordingly. Future high-quality research comparing the effect of different delaminated rotator cuff repair techniques (eg, separate-layer repair vs. “en masse” repair) on tendon healing and patient-reported outcomes would be of value to better characterize the optimal treatment algorithm for these patients.
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