Operative Findings
Operative findings included mean tear thickness of 74% for the sample as a whole and mean anterior-to-posterior tear length of 10.7 mm overall. There was very little variance among the articular, bursal, and intratendinous means with respect to percentage of tear thickness (78.3%, 75.0%, and 68.8%, respectively) and anterior-to-posterior tear thickness (11.5 mm, 11.4 mm, and 9.1 mm, respectively). Each of the 6 tears (3 bursal, 2 articular, 1 intratendinous) that were longer than 15 mm required 2 anchors. Fifty-nine repairs (98%) involved subacromial decompression, 38 (63%) involved acromioclavicular resection, 18 (30%) involved débridement of the superior labrum anterior-to-posterior (SLAP), and 12 (20%) involved biceps tenodesis/tenotomy.
Outcome Measures
In the study population as a whole, and in all 3 tear subtypes, postoperative improvement in VAS, ASES, and Constant scores was statistically significant (Table 3).
Multiple linear regression analyses showed that etiology, symptom duration, and steroid injection were the primary predictors of each outcome. After the other variables were adjusted for, injection (vs noninjection) seemed to be associated with more improvement in ASES (P = .0061), VAS (P = .020), and Constant (P = .067) scores. Insidious (vs traumatic) etiology was significantly associated with more improvement in ASES scores (P = .033) and VAS scores (P = .014) but not Constant scores (P = .50). Longer time from symptom onset to surgery was associated with less improvement, though the coefficient was not statistically significant in any of the models at P = .05. The other possible covariates had no significant impact on outcomes.
Complications
There were no intraoperative or postoperative complications, and there were no incidents of recurrent rotator cuff tear or postoperative stiffness.
Discussion
We investigated the effectiveness of arthroscopic completion and repair of Ellman grade 3 PTRCTs by comparing the functional outcomes for each subtype. Although several studies have analyzed results of PTRCT repair, they all either omitted intratendinous tears or were not grade-specific. In a systematic review, Strauss and colleagues13 discussed 4 PTRCT outcome studies4,6,14,15 in which only articular- and bursal-sided tears were addressed. Of these studies, only 1 (Kamath and colleagues6) focused on grade 3 lesions, and the number of bursal tears was insufficient for comparison with the articular tear group. Cordasco and colleagues4 limited their study to grade 1 and 2 tears but did not include intratendinous lesions.
In other research, Itoi and Tabata16 distinguished among the 3 subtypes but did not measure grade. As we did in our study, Deutsch5 focused on grade 3 lesions and used the completion-and-repair method, but he did not include intratendinous tears. Porat and colleagues17 reviewed grade 3 completion-and-repair results but did not compare them by subtype. Last, Uchiyama and colleagues18 reported strong outcomes for intratendinous tears but did not measure grade and used various surgical methods.
These studies have made important contributions to the ongoing PTRCT discussion, but debate about appropriate operative management persists. To limit the influence of external variables and provide the most exhaustive evidence regarding current PTRCT treatment algorithms, we designed the present study to consider outcomes with all 3 Ellman subtypes, only grade 3 lesions of the supraspinatus, only 1 surgical method, and consistent techniques of only 1 fellowship-trained shoulder surgeon.
Results of this chart review confirmed the findings of other grade 3 PTRCT repair studies. For instance, Koh and colleagues15 reported excellent results of 38 grade 3B PTRCTs completed to full thickness and repaired. Specifically, their mean ASES and Constant scores improved 34.1 and 23.7 points, respectively. These results are similar to our ASES and Constant score improvements—38.9 and 24.7 points for the group as a whole and 36 and 25.1 points for the grade 3B cohort. In addition, our ASES scores are nearly identical to the preoperative (46.1) and postoperative (82.1) ASES scores found by Kamath and colleagues.6 Although the mean ASES and VAS score improvements reported by Deutsch5 (51 and 5.7 points, respectively) were slightly better than ours, these results are still comparable and support completion and repair.
Although results of the study by Cordasco and colleagues4 support differing surgical treatments of grade 2 tears based on location, the present findings support the established 50% algorithm for all 3 high-grade PTRCTs. The completion-and-repair method not only produced significant improvements for each PTRCT subtype, but, importantly, there was no significant difference among those outcomes. Unlike previous results for grade 2 tears, the present results confirmed the established algorithm for grade 3 tears.
Our multiple linear regression analyses suggested that etiology, longer duration of symptoms, and steroid injections each had a strong impact on outcomes. The literature on these preoperative factors is often conflicting, and our results continue the trend. For instance, in a study of acute rotator cuff tears, Petersen and Murphy19 studied acute rotator cuff tears and also found tear size had no significant effect on functional outcomes. However, contrary to our findings, they did not find symptom duration to be a significant predictor of results. Also contrary to our findings, Oh and colleagues20 found age and tear size to be significant influences on outcomes for full-thickness tears. The strong correlation of preoperative steroid injection and better outcomes is novel and warrants further investigation.
In this study, we investigated the effectiveness of the completion-and-repair method in treating Ellman grade 3 PTRCTs. Although our findings validate this surgical technique, we acknowledge alternative approaches to high-grade PTRCTs. For instance, the transtendon method, which does not convert PTRCTs to full thickness, has also shown good clinical outcomes.21-23 In fact, the preoperative and postoperative VAS measures used in our study are nearly identical to those used in an Ellman grade 3A transtendon repair study.1 However, we agree with Porat and colleagues17 that the remaining, intact cuff material of PTRCTs is degenerative and may result in poor fixation, increased pain, or retear. In addition, nonoperative treatment typically is attempted before surgery, though little evidence is reported for success specifically in high-grade PTRCTs. One study found that 91% of PTRCT patients were still satisfied 4 years after nonoperative treatment, but it was noted that many of the tears were low-grade.24 To continue an evidence-based discussion on the more effective treatment, we invite advocates of alternative approaches to conduct a similar study on all 3 Ellman grade 3 subtypes.