Hi, this is Paul Sethi. I'm remotely reporting on partial thickness rotator cuff tears, the Anna Advanced Arthroscopy course. I want to thank the chairman for inviting me to be part of this course, and I hope that by next year's time, we're going to all be in person. As I said, the topic is going to be on partial thickness rotator cuff tears. This is a challenging topic, and although it can seem simple when we manage them, at least at a first glance, there are many opinions, there are many controversies, and as in with many orthopedic situations, there's very little good data to help support or help us drive the direction of treatment of partial thickness cuff tears. They can come on the articular side, which are pretty easy to understand, at least and visualize. They can come on the bursal side, where I think the most compelling evidence on treatment exists, and they can be intratendinous, which I think leads to a huge amount of challenge. This discussion has been present since at least the early 1980s on how to manage each of these three slightly different pathological tears. Well, look, it's very easy to look at this left image and see a partial thickness undersurface tear, and similarly, on the right side, a partial thickness bursal tear. In this case, there's a blue shoot striker going through them. I think that understanding those two ideologies is pretty straightforward, and what we do on them, we can get into some good guidelines on. The intratendinous ones, however, are challenging. How do you decide whom to repair and whom not to repair? Well, look, the bursal side of tears, most of us are going to agree that anything more than 15% or 20% we're going to want to repair, and there's data from Weber that says you shouldn't. But what about partial thickness articular tears? There's a 50% rule. This 50% rule was originally described by Dr. Novisor, and it was his, in Washington, D.C., it was his idea or his thought process. Well, Mazzocca and his team went and looked at this, and they put it into the lab. As it turns out, there's actually a lot of science behind the 50% rule. As you sequentially section or cut rotator cuff, the strain, the strain on the tendon actually substantially increases when you get to about a 50% partial tear. Strain is bad. Strain is lengthening relative to the original length of the tear, and tenocytes don't like strain. Once you get beyond 50%, partial thickness tearing, the strain increases. There is some science and some thought process behind repairing the 50%, and that's what I'm going to stick with. The natural history of these partial tears has been looked at for a long time and more recently by the group at Washington University, but they're going to slowly, slowly increase, particularly on the articular side. There is a rare chance that it's going to actually be able to heal on itself. Really, this goes consistent. This is consistent with what happens with most rotator cuff tears that depending upon the location, they're probably going to increase over time. What are the treatment options? Well, how do I decide what I'm going to do? Option one is just a simple debridement and a decompression with or without treatment to the biceps. I'd be remiss if I don't bring up the biceps. An isolated decompression debridement is a probably uncommon operation in my personal practice because I think most of these patients can be rehabilitated. I really want to caution you and look for alternate sources of pain in isolated decompressions. I think you can be at a big risk for an unhappy patient. Now, while it works sometimes, it's something I want to proceed with caution, but this is going to be an older patient. It's got wear and tear, degenerative changes to the rotator cuff. They may or may not have acrominal changes. For me personally, at the time of arthroscopy, I want to look at the CA ligament. If the CA ligament is substantially eroded or frayed, that might be a good reason. This is the right kind of patient, non-dominant arm. Again, I'm staying with under 50% of tendon involvement. Debridement alone. When am I going to do a debridement alone and not consider doing acromioplasty? Now we're going to look at younger athletic patients, people with some micro instability, internal impingement that we see in baseball players. I think a debridement may be a role there. If you can treat the lesion, a slap tear, be clear. I'm not saying fix slap tears here. The right answer may be tenodesis or debridement, but if you can identify an alternate source and an alternate generator of pain. Now, when I get into younger patients, particularly throwing athletes, I want to think about greater tendon involvement. I don't want to take this down too quickly. I want to avoid overtightening, which is one of the major complications of repairing the rotator cuff in situ. My operative treatments on articular side of tears. Now, when I look at articular side of tears, I can debride alone. I can repair in situ. I can complete and repair. More importantly, I want to treat the associated pathology, whether it's the capsule, the biceps, or what I identify are cartilage lesion. So, completion in line with repair. If you're high grade, just hanging on by a thread, this is basically a full thickness tear. I think the dye doesn't leak through, so perhaps it gets called partial thickness, but really, this is going to be straightforward. I'm going to remove, I'm going to detach, I'm going to debride a little bit, and I'm going to repair this. And I think this is a great operation. It's typically a slightly older patient. And then from a technical standpoint, do you split it in line with the fibers or do you lift it up? And to me, that's going to be decided by the anterior to posterior width of the tear. So, if it's a short segment tear that I have to get through, then I'll cut it in line. If it's a longer segment, centimeter and a half, then I'm going to lift it up and turn it into a larger tear that I put a few anchors into. This is really borne out in literature to be a worthwhile experience for patients, completion and takedown. What about an in-situ repair? Certainly, we can talk about how to do that arthroscopically, and I will show a video of it. I think this is where you have at least 50%. I don't want to start using in-situ repairs for 30% tears because you're really going to over-operate and over-tighten patients. I like to do this when I have delamination. I like it in the dominant arm. In some of my athletic patients, I want to leave that good, healthy, versatile attachment with sharpest fibers going in and try and sort of rely on that versatile fiber intact to protect my articular side. It's a long debate whether you do this in-situ versus complete. I'm giving the talk, so I'm supposed to give you an answer, but I don't know. In general, in older patients, I'm going to complete the tear. In my younger patients, I'm going to try and do an in-situ repair. I think that just has to do with healing capacity and the degeneration and the changes in the tendon morphology. You can do this in a lot of ways. I tend to do my rotator cuffs and beach chairs. Certainly, lateral is acceptable. I think you can place your portals. Again, these are standard portals, a standard posterior viewing portal, a posterior lateral portal, a mid-lateral workhorse portal. I'm going to view from where the X is. I'm going to view from posterior lateral. I think that's an important thing to talk about with all rotator cuff surgery. Technically, how will I do this? Well, look, if I'm addressing a bursal-sided tear, I'm going to go ahead and try and do a bursal-sided fix. I can use a number of different commercially available items, pass this through with an anti-grade or a retrograde passer, get sutures through. I want to get enough good tendon. I want to have prepared the bone underneath. I don't decorticate bone, excoriate it, but I get it annoyed enough so that it's going to accept healing and I'm going to drop it out into a lateral anchor. This is a great, simple operation. I think you can rehab these bursal tears a little bit faster because the articular margin will see load first. You can use a ripstop. You can condition an additional anterior-posterior suture. You can use a single regular anchor. I always use triple-loaded anchors. I don't use double-loaded because I think you can get more fixation. There's a lot of ways. And this is a tear that just tends to do really well. For me, I will specifically decompress these tears with a subacroma decompression. And I know that will be a topic of debate. Now, what about moving on to an in situ repair? Well, here you can see a partial thickness tear. The articular surface has got about 50% left untreated. And what I'm going to first do is really prepare and debride. So I want to get that bone as ready as possible. And then I'm going to start to pass my sutures through the anterior aspect of the cable, not really in the middle aspect of the cable. Here we are continuing along in a similar vein. I'm going to insert an anchor behind the biceps tendon. In this case, yes, Paul Sethi, that left the biceps behind and started a course chairman. And I'll go ahead and I'll place a hole right on the medial anchor, right on the medial margin. And again, I don't want to start to take the center of the cable, but I'm going to drop an anchor in here. You can use this anchor. You can use a soft tissue anchor. There's all sorts of devices, but these are trans-tendon. I'll come up and I'll find these anchors on the top after I pass two anchors, one anteriorly and one posteriorly. And I'm going to try and link them together. And when I link these two anchors together, I can then create a compressive bridge across medially. And I'll shimmy these down. And once they start to get shimmy down, I'll shimmy down the next set. And there are a few different companies. And if you wanted to use anchors with regular sutures and tie them together, I absolutely think that's just as reasonable. These knotless devices happen to be my preference. And now I've got this double bar that I'll pull on the limbs. I'll look inside. This is a great view. You look inside as you're going to pull that reduction, boom, it sucks it over and that footprint gets pulled back down to where it belongs. And I think that's sort of very attractive to me where I can get an anatomic reduction of that rotator cuff without over-tensioning the cable. And I'm really pulling pretty hard on this right now, as you can see the shoulder shaking. Not uncommon to see a little bit of synovitis on the undersurface of these partial thickness tears. Now I go back above and I'm going to take the limbs of the anchor that I just placed in. And I'm going to put these out to an additional lateral anchor just to secure with a larger anchor this fixation and have some compression across the footprint in its entirety. And this is, so now you've seen how I'm going to deal with a bursal sided tear. This is how I'm going to manage most of my articular sided tears. And again, you have your preference on anchors. And again, these should move pretty darn quickly. You can see that this is a nice look. It's a nice compression that I got across there spread apart by a good centimeter. So I'm not getting it too tight. Some of the steps really getting into it. You can look at how the knotless mechanism works and you can add additional sutures into it. If you find that you did this case and your anchors or your sutures are not spread wide enough across your footprint, you can put a free independent suture in. So I've got the two blue sutures that came out of the anchors, but they've added an independent inverted mattress there as well. I've left some items uncertain. Partial tears in athletes. What do you do? Who do you fix? Will this be the end of a baseball thrower's career? And I think that, look, you have to be very, very careful in repairing any kind of athlete. Partial tears in athletes have traditionally done poorly. My mentor, Jim Tobony, wrote about this where he did an open resection and repair with acromioplasty and had poor return back to sports. I think the treatment is just typically debridement, brisectomy, maybe a ligament release. If you have more pathology, if you have subluxation, if you have labral tears, you have worse results. And look, if you have acute traumatic brisectomy, maybe you can get away with it. To complete or not, this is a long debate. This is an article I wrote with Gus Mazzocan. Going back to our orthopedic in-training exam, we remember that there's four zones of transition where you go down to eventually sharpies fibers. We know that with rotator cuff repair, we don't get a four-zone transition without any biological enhancement. We're just getting a fibrocartilage attachment. It's hard to take down good sharpies fibers and replace it with fibrocartilage, but that may be a way in the future and looking at nanofibers and better ways to enhance the insertion, get us more excited about this. Intersubstance tears, what to do? Gosh, you get into that case, the patient's painful and pathologic. Do you split it open? Do you make a cut and have it open up all the way for you? Do you do a methylene blue injection? Maybe this is one where putting a patch, a commercially available patch is a good idea. I think the data is completely lacking on this, and this is really a hard one to figure out. Importantly, just make sure you realize what your pain generator is. This is a picture of an arthroscopic patch inserted. Michael Bryan's recently published good results with this, but is this voodoo? Is it just from the stimulation of the cuff? Do these patches really do anything? We really have to wait and see, but the intratendonus may be the example for this. The theory behind this, if you have impingement, you're going to decompress it. If you have tendon degeneration, I'll probably resect it. If you have altered kinematics, meaning a torn cuff, I'm going to stabilize it, and you're not sure, I joke around and say multiple codes. My take-home points are sneak in the bursa first to see that your tear doesn't go through to your reversal side. Be careful with MRAs. MRAs are arthrograms. When you're looking at labral pathology, overestimate your tear. Avoid stiffness. Being very careful with an in situ repair to avoid stiffness, I think, is a key element. Don't overoperate. Beware, a lot of partial thickness rotator cuff tears, I think, are related specifically to adhesive capsulitis. I think if you treat their capsulitis and get their range of motion better, you may be able to avoid an operation. When you do operate, these are patients that require early motion because of the risk of stiffness, once again, and don't forget to treat the biceps and the other associated pathology. You practice these partial thickness cuff tears, and you think you got it, and you think you listened to the lecture, and you understand it, and you feel a lot like this athlete here who's prepared for this kick for six months, and she's ready to take that pencil. Sometimes you just feel like that. Just get you. Thank you very much for listening to this talk, and I appreciate the opportunity to participate in this course.

partial thickness rotator cuff tears

challenges and controversies

treatment decisions

management strategies

50% rule