Partial Thickness Tears

Clinical

 

Pain & Stiffness

- often more pain than FT tears

 

Bursal side tears more painful than articular

 

Articular side more common

 

May see in young patient overhead throwing

 

Examination

 

Painful arc

 

Impingement signs

 

No weakness

- function good

- cable system intact

 

Classification

 

Articular sided more common than bursal

 

Ellman

- A (articular)

- B (Bursal)

 

Grade 1    <  3mm

Grade 2    <  3-6 mm

Grade 3    <  6 mm footprint exposed

 

Incidence

 

Sher et al JBJS Am 1995

- 19 - 39 years - 4% PT , no FT

- > 60 years - 26% PT, 28% FT

 

NHx

 

Yamanaka et al Clin Orthop 1994

- 40 patients with articular sided PT

- a few heal 10%

- a few don't progress 10%

- 50% enlarge

- 30% become FT

 

MRI

 

Articular Sided

 

Shoulder MRI Footprint Exposure Supraspinatous Articular TearShoulder MRI Articular Supraspinatous Tear

 

Bursal Sided

 

Arthroscopy

 

Articular side

 

Minor

 

Rotator Cuff Small Partial Articular TearPartial Articular Supraspinatous Tear

 

Major

- see uncovering of footprint

- SS inserts laterally

- bare area lateral to cartilage

 

PASAT Arthroscopy 1PASTA Arthroscopy 2

 

Bursal Sided

 

Shoulder Scope Bursal Supraspinatous TearSupraspinatous Bursal Sided Tear

 

Management

 

Non Operative

 

Physio / HCLA

 

Operative

 

Indications

 

1.  Failure of non operative treatment (6-12 months)

2.  Symptomatic pain or weakness

3.  Repair if > 50% depth

 

Options

 

1.  Acromioplasty and debridement

2.  Conversion to FT and repair

3.  Repair without conversion to FT

 

1.  Acromioplasty + debridement

 

Indications

- < 50% tears

 

Shoulder Scope PASTA Debridement

 

Results

 

Park et al Orthopaedics 2003

- 37 patients PT < 50%

- 87% good results at 2 years

 

Weber Arthroscopy 1999

- 63 patients with grade 3A / 3B

- mini open repair v acromioplasty / debridement

- significantly improved results with repair

 

Cordasco et al Am J Sports Med 2002

- SAD and debridement

- 2A 5% failure rate

- 2B 38% failure rate

- recommend repair 2B PT

 

Conclusions

- bursal sided tears tend to do more poorly than articular sided

- repair > 50% especially in young patients

 

2.  Acromioplasty and repair

 

May be done open / arthroscopically / arthroscopically + mini open

 

Options

A. Convert to FT and repair

- arthroscopic or open

B. Transtendinous articular repair

- must be done arthroscopically

C.  Bursal repair

- can be done arthroscopically or open

 

A.  Convert to FT and repair

 

Kamath et al JBJS Am 2009

- 42 > 50% PT converted to FT arthroscopically

- 88% cuff intact on US

- 93% patient satisfaction

 

B.  Articular sided / transtendinous PASTA repair

 

Gonzalez J Shoulder Elbow Surg 2008

- biomechanical study of PT articular

- coversion to FT and double row repair v

- transtendinous repair of PT

- transtendinous repair higher ultimate strength and

- decreased gap formation

 

Ide et al Am J Sports Med 2005

- all arthroscopic transtendinous repair 3A PT

- 14 / 17 excellent, 2 good, 1 fair

 

C.  Bursal sided

- can repair top layer of tear only

 

Technique Transtendinous Arthroscopic PASTA Repair 

 

Advantage

- repair medial footprint

- don't injure intact tendon

- can range immediately

- in fact need to do so to avoid stiffness

 

Technique

 

Camera in glenohumeral joint

- anterior glenohumeral cannula for suture management

- 5mm anchor passed through SS transtendinous into footprint

- retrieve sutures through anterior GH portal

 

Shoulder Partial Articular Supraspinatous Tear PASTA

 

Must pass sutures from anchor through torn cuff

- aim to reapproximate to footprint

 

A.  Pass bird beak suture passers through cuff to retrieve sutures

 

B.  Pass 20G spinal needle and pass down 0 nylon, retrieve via anterior portal

- tie to thread, and pass suture back through tendon

- do so each time for each thread in horizontal mattress pattern

 

Shoulder PASTA Repair Needle Suture ShuttleShoulder PASTA Repair Sutures Shuttled

 

Camera into subacromial space

- lateral portal

- retrieve sutures and tie

- check repair again via GHJ

 

Shoulder PASTA Repair Sutures in Subacromial SpaceShoulder PASTA Repair Knots Tied Subacromial Space

 

Post op

- can range aggressively

- the repair is protected by the intact portion of the tendon

- prevents stiffness

 

Technique Open Articular PT Tears

 

Arthroscopy

- put spinal needle through torn portion

- pass suture through to mark tendon

 

Open approach over needle entry

- identify tear by suture

- convert to FT and repair

 

Technique Arthroscopic Bursal Sided Tear

 

Identify tear

- see partial uncovering footprint

- camera in subacromial space

- debride tear edges

- prepare footprint insertion

 

Insert anchor

- pass sutures through top layer of torn tendon

- tie down

 

Bursal Sided Supraspinatous TearBursal Sided Supraspinatous Tear Repair