Transtendon technique versus repair after completion of the tear for articular-sided partial rotator cuff tear - a meta-analysis

doi:10.21203/rs.3.rs-1605506/v1

Download PDF

Research Article

Transtendon technique versus repair after completion of the tear for articular-sided partial rotator cuff tear - a meta-analysis

https://doi.org/10.21203/rs.3.rs-1605506/v1

This work is licensed under a CC BY 4.0 License

Journal Publication

published 22 May, 2023

Read the published version in Journal of Orthopaedic Surgery and Research →

You are reading this latest preprint version

Background

Partial-thickness rotator cuff tears (PT-RCTs) are a common cause of shoulder pain and disability. Arthroscopic repair is an effective treatment for articular-sided PT-RCTs, and transtendon repair and repair after completion of the tear have been widely used to treat such lesions. However, controversy continues with the best management. The present study was designed to compare the clinical outcomes and tendon integrity following arthroscopic repair of articular PT-RCTs using transtendon repair or repair after completion of the tear.

Methods

We performed a systematic electronic database search on Cochrane Central Register of Controlled Trials, PubMed and Embase to identify articles equating articular-sided PT-RCTs repair. The randomised controlled clinical trials that met our criteria were evaluated for quality of methodology. The results obtained were further analysed and correlated to present the benefits and drawbacks comparing the two surgical procedures.

Result

According to our inclusion and exclusion criteria, six articles were included in the present study. A total of 501 patients were analyzed as part of this study. The results indicated that both the surgical treatments provided excellent functional improvements and tendon integrity. However, no significant differences for the visual analogue scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, constant score, range of motion, postoperative adhesive capsulitis, tendon integrity and patient satisfaction were found between the two cohorts (p > 0.05).

Conclusions

The study demonstrated technical characteristics of both repair techniques, contributing to make a decision under different clinical circumstance. Compared to transtendon technique, repair after completion of the tear has the advantage of simple operation and the removal of possible bursal degeneration tissue, and could be a convenient choice to degenerated articular-sided PT-RCTs.

Partial rotator cuff tears (PT-RCTs) are a common cause of shoulder pain and disability and can be classified as bursal side, articular side, or intratendinous in accordance with the injury site.²² Ellman developed a system based on the location and depth of the tear to effectively classify, diagnose, and treat PT-RCTs.⁷ Most authors recommend repair of PT-RCTs involving>50% of the tendon thickness (Ellman grade III), whereas PT-RCTs involving < 25% (Ellman grade I) are treated conservatively rather than surgically. However, the current evidence does not provide guidance as to the best arthroscopic treatment plan for symptomatic PT-RCTs.²⁶

Generally, surgical alternatives for treating symptomatic articular-sided PT-RCTs include arthroscopic repair following full-thickness conversion and various in situ repairs.¹⁶ Some surgeons prefer conversion from PT-RCTs into full thickness tears with remnant debridement, acquiring a better view and repaired the remnant rotator cuff tissue using a familiar repair technique. This tear completion repair technique is reported to be satisfactory with good visualization, strain characteristics, and healing rates.^{16, 20} However, the tear completion repair technique sacrifices the intact bursal-sided rotator cuff tendon and causes some complications due to damaged integrity of the tendon.¹⁷ Therefore, some surgeons prefer the transtendon repair technique which restores the rotator cuff footprint while leaving the bursal side intact. Cadaveric biomechanical study reported that transtendon repair improve biological and biomechanical repair properties with less gap formation than the tear completion repair technique.¹⁰ Nevertheless, some authors have raised concerns about the potential damage to the intact tendon during suture anchor insertion and overtension after the repair.²⁰ At the same time, this procedure is relatively complex with poor visualization for surgeons. Currently, tear completion repair and the in situ transtendon procedure are the two commonly adopted methods. However, the optimal surgery method in the treatment of articular-sided PT-RCTs remains controversial.

The purpose of this study was to compare functional outcomes and tendon integrity for patients with an articular-sided PT-RCTs who undergone arthroscopic transtendon repair or tear completion repair. We hypothesized that arthroscopic repair of articular-sided PT-RCTs would provide satisfactory functional improvements and tendon integrity regardless of the two repair technique.

Search strategy

We carried out a meta-analysis of the literature with the search terms “partial”, “articular” and “rotator cuff tear”. A complete search of the literature in the following databases was performed: MEDLINE (PubMed) (1950 to June 2021), Embase (Ovid) (1974 to June 2021) and Cochrane (1996 to June 2021). Our inclusion criteria included outcome-based studies of isolated partial articular-sided rotator cuff tears (＞50% of the thickness of the tendon) which compared arthroscopic transtendon repair and tear completion repair by using clinical or functional scoring systems. Exclusion criteria included studies that involved cadaver or animal studies, biomechanical studies, literature reviews, letters to editors, expert opinion articles, case reports or technique notes which did not contain clinical outcome-based data.

Quality assessment

The coleman methodology score (CMS) was applied to determine the quality of the involved studies according to our previous study.¹⁹ The CMS consists of 15 items in its checklist and is scaled from 0 to100 points. A score from 85 to 100 is considered excellent, 70-84 as good, 55-69 as fair and below 55 as poor. An overall score of 100 suggests that the study avoids chance, bias and confounding variables. The quality assessment by CMS was carried out by two independent reviewers. In addition, all the results were confirmed by the senior author.

Outcome measures

The identified studies were measured and analysed for the following outcomes: visual analogue scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, constant score, range of motion, postoperative adhesive capsulitis, tendon integrity and patient satisfaction. Two reviewers evaluated the literature separately, and any discrepancies were reevaluated and resolved by consensus.

Statistical analysis

A formal meta-analysis was conducted only for clinical outcome data from comparative studies using Stata 12.0 (Stata Corp LP, College Station, TX, USA). Results for continuous or categorical outcomes were reported as a mean difference or an odds ratio, respectively, with 95% confidence intervals.

Literature search

A total of 1295 studies were selected after an intensive database search on PubMed (n = 576), Embase (n = 570) and Cochrane (n = 149). Of these 1295 articles, 472 repetitive articles were excluded and 171 articles were excluded due to study type. In addion, 635 articles were excluded after title/abstracts review and 11 articles excluded after full text review. Six articles that met our inclusion and exclusion criteria were subsequently included after a full-text review (Fig. 1). Four were prospective comparative study and two were retrospective comparative study (Table 1).

Table 1

Characteristics of the included studies.
Author	Study, LoE	Participants	Intervention	Outcomes
Shin, et al²⁵	Prospective comparative study, II	48 patients who underwent arthroscopic repair of articular-sided PT-RCTs between March 2006 and July 2008 were included.	24 transtendon repair 24 repair after completion of the tear	VAS score; ASES score; Constant score; Range of Motion; Patient satisfaction; MRI features
Franceschi, et al⁸	Prospective comparative study, II	60 patients who underwent arthroscopic repair of articular-sided PT-RCTs from 2007 to 2009.	32 transtendon repair 28 repair after completion of the tear	ASES score; Constant score; Range of Motion; MRI features
Kim, et al¹⁷	Prospective comparative study, II	92 cases between January 2008 and March 2011 with articular-sided PT-RCTs exceeding 50% of tendon thickness.	47 in Situ Repair 45 Tear Completion Repair	VAS score; ASES score; Constant score; MRI features
Castagna, et al²	Prospective comparative study, II	74 patients between 2006 and 2009 underwent an arthroscopic rotator cuff repair of articular-sided PT-RCTs.	37 transtendon repair 37 repair after completion of the tear	VAS score; Constant score;
Liu, et al²⁰	Retrospective comparative study, II	68 patients between December 2014 and June 2015 underwent rotator cuff repair.	30 transtendon repair 38 repair after completion of the tear	VAS score; ASES score;
Castricini R, et al⁵	Retrospective comparative study, II	151 patients (153 shoulders) who underwent rotator cuff repair between January 2003 to December 2014.	59 transtendon repair 94 repair after completion of the tear	Constant score; simple shoulder test (SST); Tendon integrity (Ultrasound); Patient satisfaction

Surgical outcome score

Patients were clinically assessed both preoperatively and postoperatively on a number of outcome-based scores that included the VAS score, ASES score, constant score, range of motion, postoperative adhesive capsulitis, tendon integrity and patient satisfaction. The VAS score was evaluated in two studies. A standard mean difference of 0.36 (-0.76 to 1.48) was found. No significant difference was observed regarding the VAS score between the two cohorts (P = 0.525) (Fig. 2).

ASES score was examined in three studies. A standard mean difference of 0.26 was found. No significant difference was observed between the two cohorts for the ASES score (P = 0.515) (Fig. 3).

The constant score was evaluated in 3 of the 6 studies. A standard mean difference of -0.21 was determined, implying that no significant difference was found between the two cohorts (P = 0.463) (Fig. 4).

The range of motion was evaluated in 2 of the 6 studies. In terms of forward flexion, a standard mean difference of -0.203 was determined (P = 0.615) while the standard mean difference of external rotation was − 0.254 (P = 0.190). This suggestted that no significant difference was found between the two cohorts (P>0.05) (Fig. 5). Two of six studies selected had evaluated postoperative stiffness. An odds ratio of 1.13 (0.32 to 3.959) was calculated with a P value of 0.854, implying no significant difference in postoperative adhesive capsulitis between the two groups (Fig. 6).

Four of six studies selected had evaluated tendon integrity. An odds ratio of 0.944 (0.374 to 2.384) was calculated with a P value of 0.903, implying no significant difference in tendon integrity between the two groups (Fig. 7). Two studies evaluated the patients satisfaction outcome. An odds ratio of 0.714 (0.222 to 2.303) was found with a P value of 0.573, thereby indicating that no significant difference in patients’ satisfaction between the two groups (Fig. 8).

The main finding of our study is that both procedures lead to improvements in clinical outcome with a low complication rate and a high rate of healing. No signifcant difference in clinical outcome was demonstrated between these two procedures for articular-sided partial rotator cuff tear repair.

Articular PT-RCTs with a thickness of greater than 50% can be repaired by tear completion repair and the in situ transtendon procedure. Tear completion repair is a relatively straightforward method for restoration of the tendon footprint with satisfactory clinical outcomes and high levels of patient satisfaction. Some authors advocated tear completion repair because it allowed better access to the tendon footprint and tended to be more convenient to secure tendon fixation.⁶ Furthermore, after the removal of degenerative tissue, it could obtain an advantageous healing microenvironment that is akin to an acute full-thickness tear.^{1, 15} Gereli et al found the completion repair technique exhibited increased healing characteristics compared with the in situ technique in spite of the concerns of detaching the intact tendon.⁹ The reason for this finding might be the refreshing effect of debridement at the chronic degenerated tendon that could improve the healing response.⁹ Although this technique achieved good clinical outcomes, it cannot to anatomically repair the lesion and restore native length–tension match after surgery.^{8, 13} Therefore, some authors raised its concerns of biological and mechanical flaws, which could reduce tendon integrity potential and result in functional disabilities overtime.

In contrast, the transtendon repair made it possible to better restore the rotator cuff footprint anatomically and maintain the tendon integrity as preserving the bursal-side rotator cuff tendon.¹ Cadaveric study has demonstrated that transtendon repair technique creates smaller gap formation and higher ultimate tensile loads than tear completion repair technique.^{10, 23} Meanwhile, some studies have found that transtendon repair is an effective treatment for articular PT-RCTs with significantly improved functional scores and pain relief.^{3, 8, 24, 25} Despite complete integrity, slower shoulder functional improvements during the recovery period and higher occurrence rate of postoperative shoulder stiffness after transtendon repair have been reported. ^{11, 14, 21} Jordan R W et al reviewed the incidence of post-operative stiffness of articular PT-RCTs using transtendon repair or tear completion repair.¹⁴ The included case series demonstranted a higher rate of stiffness in the transtendon repair group (range 0 to 18% compared to 0 to 2.8% after completion and repair). Furthermore, the shoulder discomfort after the transtendon repair technique might was caused by unbalance the tension of the remaining torn cuff because of a retracted articular rotator cuff layer and overtightening the bursal portion of the cuff.^{4, 12, 25} This altered tensioning on both sides of rotator cuff tendons may be the cause of the shoulder stiffness. Although various modifications of transtendon repair techniques have been introduced to avoid overconstraining the joint and tendon overstrain, improved arthroscopic instruments and transtendon repair techniques are needed to reduce risks of postoperative morbidity.²⁵ On the other hand, the remaining cuff tissue has already showed histopathological degeneration and would be a painful nidus causing early postoperative pain.^{9, 27} Yamakado, Kotaro has taken biopsy specimens of the residual tendon in 30 consecutive patients with articular-side PT-RCTs.²⁷ Samples were histopathologically examined and graded by use of a modified semiquantitative scale. The study showed that degenerative changes were evident in 28 of 30 cases (93%) and over 90% of the macroscopically intact residual tendon showed moderate histopathologic degeneration. But no difference was found between the 2 repair techniques with respect to VAS score in the present study. Further studies are required to determine the effect of remaining cuff tissue on early postoperative recovery and long-term clinical outcome. These findings together suggest that the biomechanical advantage of preserving the tendon integrity with transtendon repair does not provide better functional results and healing rates compared with tear completion repair.

The limitations of this study include a relatively small number of studies. Despite the small sample size, we included only level- II studies. Hence, these studies represent high-level evidence on a large number of patients. The preliminary results presented in this study would help to clarify technical characteristics of both repair techniques. In addition, the heterogeneity of imaging modality may represent a weakness of the study. There is a lack of standardized evaluation method for accurate assessment of tendon thickness. According to previous report, ultrasound and MRI have good and similar diagnostic accuracy for detection of rotator cuff tears, and they has been widely performed to evaluate the rotator cuff integrity.¹⁸

Arthroscopic repair of partial-thickness articular sided rotator cuff tears provided satisfactory functional improvements and tendon integrity regardless of the transtendon repair and repair after completion of the tear. Due to the simple operation and the removal of possible bursal degeneration tissue, the procedure of repair after completion of the tear is proposed in the case of obviously degeneration of rotator cuff.

Conflict of interest

The authors have no conflicts of interest relevant to this article.

Acknowledgements

This work was supported by National Natural Science Foundation of China (No. 81972125 and 81301578), Shanghai Sailing Program (21YF1404100) and Natural Science Foundation of Shanghai Committee of Science and Technology (21ZR1446000).

Brockmeier SF, Dodson CC, Gamradt SC, Coleman SH, Altchek DW. Arthroscopic intratendinous repair of the delaminated partial-thickness rotator cuff tear in overhead athletes. Arthroscopy. 2008;24(8):961–965.
Castagna A, Borroni M, Garofalo R, Delle Rose G, Cesari E, Padua R, Conti M, Gumina S. Deep partial rotator cuff tear: transtendon repair or tear completion and repair? A randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2015;23(2):460–463.
Castagna A, Borroni M, Garofalo R, Delle Rose G, Cesari E, Padua R, Conti M, Gumina S. Deep partial rotator cuff tear: transtendon repair or tear completion and repair? A randomized clinical trial. Knee Surg Sport Tr A (3.097). 2015;23(2):460–463.
Castagna A, Delle Rose G, Conti M, Snyder SJ, Borroni M, Garofalo R. Predictive Factors of Subtle Residual Shoulder Symptoms After Transtendinous Arthroscopic Cuff Repair A Clinical Study. Am J Sport Med (4.517). 2009;37(1):103–108.
Castricini R, La Camera F, De Gori M, Orlando N, De Benedetto M, Galasso O, Gasparini G. Functional outcomes and repair integrity after arthroscopic repair of partial articular supraspinatus tendon avulsion. Arch Orthop Traum Su (1.496). 2019;139(3):369–375.
Deutsch A. Arthroscopic repair of partial-thickness tears of the rotator cuff. J Shoulder Elbow Surg. 2007;16(2):193–201.
Ellman H. Diagnosis and treatment of incomplete rotator cuff tears. Clin Orthop Relat R (3.127). 1990(254):64–74.
Franceschi F, Papalia R, Del Buono A, Vasta S, Costa V, Maffulli N, Denaro V. Articular-sided rotator cuff tears: which is the best repair? A three-year prospective randomised controlled trial. Int Orthop (2.387). 2013;37(8):1487–1493.
Gereli A, Kocaoglu B, Ulku TK, Silay S, Kilinc E, Uslu S, Nalbantoglu U. Completion repair exhibits increased healing characteristics compared with in situ repair of partial thickness bursal rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. 2018;26(8):2498–2504.
Gonzalez-Lomas G, Kippe MA, Brown GD, Gardner TR, Ding A, Levine WN, Ahmad CS. In situ transtendon repair outperforms tear completion and repair for partial articular-sided supraspinatus tendon tears. J Shoulder Elbow Surg. 2008;17(5):722–728.
Huberty DP, Schoolfield JD, Brady PC, Vadala AP, Arrigoni P, Burkhart SS. Incidence and Treatment of Postoperative Stiffness Following Arthroscopic Rotator Cuff Repair. Arthroscopy. 2009;25(8):880–890.
Huberty DP, Schoolfield JD, Brady PC, Vadala AP, Arrigoni P, Burkhart SS. Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2009;25(8):880–890.
Ji J-H, Shafi M, Jeong J-J, Lee YS, McFarland EG, Kim T-K, Chung J-Y. Transtendon arthroscopic repair of high grade partial-thickness articular surface tears of the rotator cuff with biceps tendon augmentation: technical note and preliminary results. Arch Orthop Traum Su (1.496). 2012;132(3):335–342.
Jordan RW, Bentick K, Saithna A. Transtendinous repair of partial articular sided supraspinatus tears is associated with higher rates of stiffness and significantly inferior early functional scores than tear completion and repair: A systematic review. Orthopaedics & Traumatology: Surgery & Research. 2018;104(6):829–837.
Kamath G, Galatz LM, Keener JD, Teefey S, Middleton W, Yamaguchi K. Tendon Integrity and Functional Outcome After Arthroscopic Repair of High-Grade Partial-Thickness Supraspinatus Tears. J Bone Joint Surg Am. 2009;91A(5):1055–1062.
Katthagen JC, Bucci G, Moatshe G, Tahal DS, Millett PJ. Improved outcomes with arthroscopic repair of partial-thickness rotator cuff tears: a systematic review. Knee Surg Sport Tr A (3.097). 2018;26(1):113–124.
Kim Y-S, Lee H-J, Bae S-H, Jin H, Song HS. Outcome comparison between in situ repair versus tear completion repair for partial thickness rotator cuff tears. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2015;31(11):2191–2198.
Lenza M, Buchbinder R, Takwoingi Y, Johnston RV, Hanchard NC, Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database of Systematic Reviews. 2013(9).
Li M, Shaikh AB, Sun J, Shang P, Shang X. Effectiveness of biceps tenodesis versus SLAP repair for surgical treatment of isolated SLAP lesions: A systemic review and meta-analysis. Journal of orthopaedic translation. 2019;16:23–32.
Liu CT, Ge Ha, Hu R, Huang JB, Cheng YC, Wang M, Wu P, Cheng B. Arthroscopic knotless single-row repair preserving full footprint versus tear completion repair for partial articular-sided rotator cuff tear. J Orthop Surg-Hong K (0.542). 2018;26(2):2309499018770897.
Lo IKY, Burkhart SS. Transtendon arthroscopic repair of partial-thickness, articular surface tears of the rotator cuff. Arthroscopy. 2004;20(2):214–220.
Matava MJ, Purcell DB, Rudzki JR. Partial-thickness rotator cuff tears. Am J Sports Med. 2005;33(9):1405–1417.
Mazzocca AD, Rincon LM, O'Connor RW, Obopilwe E, Andersen M, Geaney L, Arciero RA. Intra-articular partial-thickness rotator cuff tears. Am J Sport Med (4.517). 2008;36(1):110–116.
Ono Y, Woodmass JM, Bois AJ, Boorman RS, Thornton GM, Lo IKY. Arthroscopic Repair of Articular Surface Partial-Thickness Rotator Cuff Tears: Transtendon Technique versus Repair after Completion of the Tear-A Meta-Analysis. Adv Orthop. 2016;2016:7468054–7468054.
Shin S-J. A comparison of 2 repair techniques for partial-thickness articular-sided rotator cuff tears. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2012;28(1):25–33.
Strauss EJ, Salata MJ, Kercher J, Barker JU, McGill K, Bach BR, Jr., Romeo AA, Verma NN. The Arthroscopic Management of Partial-Thickness Rotator Cuff Tears: A Systematic Review of the Literature. Arthroscopy. 2011;27(4):568–580.
Yamakado K. Histopathology of Residual Tendon in High-Grade Articular-Sided Partial-Thickness Rotator Cuff Tears (PASTA Lesions). Arthroscopy. 2012;28(4):474–480.

No competing interests reported.

Download PDF

Journal Publication

published 22 May, 2023

Read the published version in Journal of Orthopaedic Surgery and Research →

Editorial decision: Major revision
02 Feb, 2023
Reviews received at journal
18 Jan, 2023
Reviewers agreed at journal
16 Jan, 2023
Reviewers agreed at journal
22 Sep, 2022
Reviewers agreed at journal
05 May, 2022
Reviewers invited by journal
29 Apr, 2022
Editor assigned by journal
29 Apr, 2022
Submission checks completed at journal
28 Apr, 2022
First submitted to journal
28 Apr, 2022

You are reading this latest preprint version

Transtendon technique versus repair after completion of the tear for articular-sided partial rotator cuff tear - a meta-analysis

Status:

Journal Publication

Version 1

Abstract

Background

Methods

Result

Conclusions

Figures

Introduction

Materials And Methods

Results

Surgical outcome score

Discussion

Conclusions

Declarations

References

Additional Declarations

Status:

Journal Publication

Version 1