Arthroscopic treatment of partial tears of the lateral rotator cuff bursa
OBJECTIVE: To investigate the surgical method and clinical results of arthroscopic treatment of lateral partial rotator cuff bursa tears. METHODS: Arthroscopic surgery was performed on 57 patients with lateral partial tears of the rotator cuff bursa from 2002 to 2007, of which 49 cases were followed up for more than 2 years. There were 34 male cases and 15 female cases, with an average age of 49.7 years. There were 15 cases of left shoulder and 34 cases of right shoulder, involving the dominant side in 41 cases. According to the Ellman classification criteria, there were 7 cases of degree I, 6 cases of degree II, and 36 cases of degree III. Preoperative orthogonal and supraspinatus radiographs were taken, 29 ultrasound examinations were performed, and 36 MRI or MRA examinations were performed. Patients with degrees I and II underwent subacromial decompression and rotator cuff debridement; patients with degrees III underwent subacromial decompression and rotator cuff repair. The rotator cuff repair was performed in 3 cases with direct discontinuity suture, 26 cases with rotator cuff stop reconstruction using suture anchor nailing, and 7 cases with combined discontinuity suture and suture anchor nailing techniques. The UCLA shoulder score criteria were used for evaluation at preoperative and final follow-up, respectively. RESULTS: The follow-up time ranged from 2 to 7 years with a mean of 48 months, and the mean UCLA scores before and after surgery were 16.5±2.4 versus 32.1±3.8. The mean pain score was 2.9±1.0 versus 8.4±1.7 (P=0.000), the mean functional score was 5.4±1.2 versus 9.1±1.4 (P=0.000), the mean active forward flexion score of the shoulder was 4.3±1.1 versus 4.9±0.2 (P=0.000), and the mean forward flexion muscle strength score was 4.0±0.4 versus 4.8±0.4 (P= 0.000), excellent in 16 cases, good in 31 cases, and poor in 2 cases. 47 patients expressed satisfaction with the surgical results. CONCLUSION: Arthroscopic surgery is an effective method for treating lateral partial tears of the rotator cuff bursa. The surgery is less invasive and recovery is fast.
Arthroscopic treatment of bursal-side partial-thickness rotator cuff tears
XIAO Jian CUI Guoqing WANG Jianquan.
Institute of sports medicine, the third hospital of Peking University, Beijing 100191, China
Abstract: Objective To study the surgical techniques and results of athroscopic treatment of bursal-side partial-thickness rotator cuff tears. Methods From June 2002 to December 2007, 57 patients with bursal-side partial-thickness rotator cuff tears underwent athroscopic treatment. 49 The patients had been reviewed at least two years after the operation with an average of 48 months(24-90). There were 34 males and 15 females, The average age was 50 years(25-71). Seven cases were classified as degree Ⅰ,6 as Ⅱ and 36 as Ⅲ according to Ellman classification.The AP and the The AP and the supraspinatus outlet projection of the X-rays were obtained before surgery. 29 patients had been received by sonography and 36 patients had undergone MR All the patients underwent subacromial bursectomy and acromioplasty, 13 cases underwent cuff debridement, 36 cases underwent cuff repair. Among them, 3 cases were treated by side to side suture of rotator cuff, 26 cases were treated by suture anchor, 7 cases were treated by side to side The UCLA scoring system was adopted before operation and at the final evaluation Results The average score was 32.1±3.8 postoperatively, and the mean pain score was 2.9±1.0 vs 8.4±1.7 (P=0.000) for pre- vs post-operation, the function score was 5.4±1.2 vs 9.1±1.4 (P=0.000 ), the mean forward flexion score was 4.3±1.1 vs 4.9±0.2 (P=0.000), the mean forward flexion strength was 4.0±0.4 vs 4.8±0.4 (P=0.000), The results were The results were 16 excellent, 31 good and 2 bad. 47 patients were satisfied with the operation. Conclusion Arthroscopy was shown to be an effective method for the The key to the operation lies in bleeding control, proper acromioplasty and correct suturing method. The key to the operation lies in bleeding control, proper acromioplasty and correct suturing method. this surgery has many advantages such as mini-invasion and rapid recovery.
Key words：Shoulder joint; Rotator cuff; Lacerations; Arthroscopy
Rotator cuff tears are a common cause of shoulder pain and dysfunction. For diagnostic and other reasons, partial rotator cuff tears have been less studied compared with total tears. In recent years, with the continuous development of shoulder arthroscopy techniques, partial rotator cuff tears have received increasing attention. We performed arthroscopic surgery on 57 patients with partial rotator cuff bursal side tears from June 2002 to December 2007, and 49 of them obtained follow-up, which are reported below.
1. Subjects and methods
1.1 General data
All 49 cases in this group were confirmed to have partial tears of the lateral bursa of the rotator cuff by arthroscopic examination. There were 34 male cases and 15 female cases. The age ranged from 25 to 71 years old, with an average of 49.7 years old. There were 15 cases of left shoulder and 34 cases of right shoulder. The duration of the disease ranged from 15 days to 20 years, with an average of 16.5 months. 21 cases had a history of trauma. All cases had shoulder pain, including 28 cases with nocturnal pain. Shoulder joint movement was limited in 16 cases.
The active anterior flexion and abduction angles of the affected shoulder are shown in Table 1. The anterior flexion and abduction muscle strength: grade 5 in 4 cases, grade 4 in 42 cases, grade 3 in 3 cases. 46 cases had positive Neer impingement sign, 46 cases had positive pressure pain at the anterior and lateral edges of the shoulder peak, 37 cases had positive pain arc sign from 60° to 120°, 38 cases had positive supraspinatus test (Jobe test), and 15 cases had popping sound in the subacromial space.
Table 1 Preoperative active forward flexion and abduction angles in 49 cases
Observed index 150° 121°~150° 91°~120° 46°~90° 30°~45° 30°
Anterior flexion(n=49) 32 6 4 6 1 0
Abduction(n=49) 35 3 2 6 2 1
Preoperative orthopantomogram and supraspinatus exit radiographs were taken. According to the Bigliani shoulder crest staging criteria, 32 cases were type II and 17 cases were type III. 29 cases were examined by ultrasound: 9 cases had no tear, 15 cases had partial rotator cuff tears, 1 case had an intra-tendon tear, and 4 cases had total tears. 36 cases were examined by MRI or MRA: 5 cases had no tear, 27 cases had partial tears on the bursal side, 1 case had a partial tear on the articular side, and 3 cases had total tears.
Preoperatively, 47 cases underwent conservative treatment for a minimum of 1 month, including rest, ice, physical therapy, oral anti-inflammatory and pain-relieving drugs and muscle strengthening exercises, with poor results. 1 case was treated with rest and oral anti-inflammatory and pain-relieving drugs for half a month, with poor results. 1 case was not treated conservatively before surgery.
1.2 Methods
General anesthesia was used in all 49 cases, and the semi-sitting position was adopted. The joint perfusion fluid was isotonic saline with 10g/L epinephrine 1~1.5mg per 3000ml. controlled hypotension was taken to control the systolic blood pressure at 95~100mmHg (1mmHg=0.133kPa). A routine posterior approach was performed to examine the glenohumeral joint, and an anterior approach was established to treat the combined injury and examine the articular side of the rotator cuff.
The subacromial space was accessed via a posterior approach mirror, and a lateral approach to the acromion was established. The subacromial space was first decompressed: the subacromial bursa was excised with a planing knife, anterior acromioplasty was performed with a grinding drill and radiofrequency, and the rostral shoulder ligament was cut. The shape of the rotator cuff tear and the degree of tendon retraction were observed from the posterior and lateral approaches, respectively. The tendon severed end was shaved with a planer to remove the granulation tissue. The depth and length of the tear were evaluated with a known graduated probing hook. The bone bed of the greater tuberosity was then prepared: a grinding drill was used to grind away the thin layer of bone cortex, and the length of the bone bed was the same as the length of the tendon tear.
The rotator cuff was cleaned with a planer in 7 patients with degree I and 6 patients with degree II. 36 patients with degree III underwent rotator cuff suturing, keeping the articular side of the tendon intact during suturing. In 7 cases, the tendon was first sutured with 1 to 3 stitches, after which the suture anchors were screwed into the bone bed and the sutures were passed through the tendon severed ends and fixed with knots; in 26 cases, the rotator cuff stops were reconstructed directly with anchors, using 1 to 3 anchors; in 3 cases, the severed ends were sutured with 1 to 2 stitches.
After surgery, the affected limb was suspended by a triangular scarf, and the drainage tube was removed after 1 d. Passive forward flexion exercises were started, and the angle was gradually increased, and active activities were started after 6 weeks, along with muscle strength training of the deltoid and rotator cuff. The progress and intensity of the rehabilitation training depended on the size of the tear and the tension of the repair.
1.3 Efficacy evaluation and analysis
The total score of UCLA was 35, including 10 points for pain, 10 points for function, 5 points for anterior flexion angle, 5 points for anterior flexion strength, and 5 points for patient satisfaction. 34-35 was considered excellent, 28-33 was considered good, 21-27 was considered acceptable, and 0-20 was considered poor.
A paired t-test was performed before and after surgery, and SPSS11.5 software was applied for statistical analysis.
2. Results
2.1 Intraoperative observations
All 49 cases were examined after anesthesia and had no glenohumeral instability. 49 cases were confirmed intraoperatively to have partial tears of the lateral bursa of the rotator cuff. According to the Ellman classification criteria, there were 7 cases of degree I, 6 cases of degree II, and 36 cases of degree III.
The combined injuries included 18 cases of superior labrum anterior and posterior (SLAP) grade I injuries, which were cleaned up. 2 cases of SLAP grade II injuries were cleaned up with a planer without sutures because the patients were over 60 years old. 21 cases of biceps longus tendon tenosynovitis and 4 cases of partial rupture of the biceps longus tendon, which were shaved with a planer. Two cases of partial rupture of the subscapularis tendon, less than 20%, were trimmed with a planer. 6 cases combined with a partial tear of the lateral aspect of the rotator cuff joint, the depth of which did not exceed 3 mm, were trimmed with a planer. 2 cases combined with a posterior superior glenoid labrum injury were trimmed with a planer.
2.2 Treatment results
The follow-up time ranged from 2 to 7 years, with an average of 48 months. Preoperative scores ranged from 8 to 20, (16.5±2.4); postoperative scores ranged from 15 to 35, (32.1±3.8). There were 16 excellent cases, 31 good cases, and 2 poor cases. The excellent rate was 95.9%. There were significant differences in all scores before and after surgery.
Twenty cases had no pain, 23 cases had occasional mild pain or discomfort, 4 cases had pain during strenuous exercise or special movements, 1 case had pain during daily activities, and 1 case still had pain at night. 31 cases had completely normal activities, 15 cases could work above shoulder level, 2 cases could do daily household work, and 1 case could do light household work.
Postoperative active forward flexion and abduction angles: 46 cases were greater than 150°, and 3 cases were between 90° and 120°.
Postoperative forward flexion and abduction muscle strength: grade 5 in 40 cases and grade 4 in 9 cases.
Table 2 Comparison of UCLA scores before and after surgery in 49 cases ( ±s) Score
Before and after surgery Total score Pain function Forward flexion angle Forward flexion muscle strength
Preoperatively 16.5±2.4 2.9±1.0 5.4±1.2 4.3±1.1 4.0±0.4
Postoperative 32.1±3.8 8.4±1.7 9.1±1.4 4.9±0.2 4.8±0.4
t-value – -20.001 -15.011 -4.122 -11.162
P value – 0.000 0.000 0.000 0.000 0.000
Forty-seven cases resumed daily life and sports and expressed satisfaction with the surgical results and were willing to undergo the same surgery if the healthy shoulder suffered from the same disease. 2 cases were not satisfied with the surgical results because they still felt pain in the shoulder.
3. Discussion
Ellman [4] classified partial rotator cuff tears into three categories, namely bursal lateral partial tears, intertendinous partial tears, and articular lateral partial tears. Each category is divided into three degrees according to the tear depth: degree I 3 mm, degree II 3-6 mm, and degree III 6 mm or more than 50% of the tendon thickness.
Partial rotator cuff tears are not uncommon. Although the literature reports variable incidence, it is significantly higher than that of total tears. Many authors report a significantly lower incidence of bursal lateral partial tears than articular lateral partial tears. The vast majority of tears are located in the supraspinatus tendon.
Although the causes of partial rotator cuff tears are multifactorial, Fukuda concluded that subacromial impingement is the main cause of partial bursal tears, unlike the occurrence of articular lateral partial tears.Fukuda’s study showed that patients with partial bursal tears had a significantly lower rate of shoulder trauma than articular lateral partial tears and a higher mean age than articular lateral partial tears.The Ko study found that bursal lateral partial tears had less tendon degeneration and more histological changes in the acromion compared to articular lateral partial tears.
The main symptoms of a partial rotator cuff bursal tear include pain and limitation of motion. The pain is located around the acromion and is worse with shoulder abduction and supination, and Fukuda suggests that partial bursal side tears tend to be more painful than full laminar tears. Some lateral bursal tears have diagnostic value because of the flap-like shape of the torn tissue, which can cause interlocking and subacromial gap popping.
Arthroscopic treatment of partial tears of the bursal side is divided into two categories: acromioplasty, rotator cuff cleaning and acromioplasty, and rotator cuff suturing. Lateral bursal tears are associated with subacromial impingement and require subacromial bursal resection. If the preoperative supraspinatus exit position x-ray shows a type II or type III shape of the acromion and intraoperative findings show signs of impingement wear on the subacromial surface, anterior acromioplasty should be performed.
For tears, whether to perform cleanup or suturing depends primarily on the depth and width of the tear and the quality of the remaining tendon, and the patient’s age and level of motion should be considered. For I degree tears, it is currently believed that a clean-up procedure can be performed with good results. For degree III tears, it is now generally accepted that cleanup and acromioplasty alone cannot promote tendon healing, and that partial tears may develop into full tears with time. Cordasco believes that the rotator cuff on the bursal side has more nerve fibers and vascular tissue than the articular side, and that postoperative pain is often not relieved if only acromioplasty is performed without suturing the rotator cuff. The treatment of grade II tears is still controversial. the biomechanical study by Yang et al. showed that when the tear depth exceeded 50%, there was a significant increase in the stress acting on the remaining normal tendon. this result did not support suturing of grade II tears. park et al. performed cleanup of grade II tears with good results. However, more authors take a different view on this, and they believe that a more aggressive approach should be taken to suture the tear.
There is also controversy regarding the method of suturing the tear. Some authors advocate that it should be sutured after transforming it into a total tear, which is simpler to perform. Other authors believe that the normal tendon tissue on the articular side should be preserved as much as possible, which will protect the repaired bursal side tendon and better reconstruct the rotator cuff stop footprint. For this reason, some unique repair techniques have been proposed. We also preserved the articular side tendon tissue when we sutured
The partial tear of the bursal side of the rotator cuff is usually located anterior to the supraspinatus tendon, so intraoperative examination focuses on the tendon tissue immediately posterior to the biceps tendon. Sometimes the tear is superficial or even covered by scar tissue and should be carefully examined using a probing hook. After a tear is found, the degenerative tissue between the severed ends should be thoroughly removed using a planer to facilitate determination of the size and depth of the tear.
We followed 47 cases for a mean of 40 months and the results were similar to previous reports in the literature. the UCLA score improved from 16.5 preoperatively to 32.1 postoperatively. Patients showed significant pain reduction and functional improvement of the affected limb. 47 cases expressed satisfaction with the surgical results and expressed willingness to undergo the same surgery if the healthy shoulder suffered from the same disease. We believe that for partial tears of the bursal side of degree I and II, they can be cleaned up, but for degree III tears, they should be aggressively sutured.
To achieve a satisfactory outcome, 2 aspects should be noted: (1) careful assessment of the supraspinatus exit position radiograph to avoid too much or too little resection of the acromion bone; (2) increasing the suture strength to promote tendon healing: end-to-end suture and anchor nailing techniques should be used when appropriate, the large tuberosity bone bed should be sufficiently fresh, and to increase the anchor nail’s resistance to extraction stress, the anchor nail should be screwed in at an angle of 45° to the plane of the rotator cuff tendon intraoperatively, and the tail of the nail should be moderately pulled after screwing in After screwing in, the anchor nail should be stretched moderately to test whether it can be pulled out.