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PURPOSE: The aim of the present study is to provide a comprehensive review on the surgical outcomes following arthroscopic treatments of partial-thickness rotator cuff tears (PT-RCTs) and to compare the postoperative American Shoulder and Elbow Surgeons (ASES) score following in situ transtendon repair and tear completion, followed by repair. METHODS: Medline, EMBASE, Scopus, CINAHL and CENTRAL bibliographic databases were searched. Papers including patients with PT-RCTs of any grade who underwent treatment using debridement, in situ transtendon repair, tear completion and repair or bioinductive collagen implants were reviewed. Primary PT-RCTs were the sole indication for surgery. Primary postoperative outcomes assessed included the ASES score, the Absolute Constant-Murley score, the Simple Shoulder Test, the Visual Analogue Scale, the University of California-Los Angeles Shoulder Scale, the Western Ontario Rotator Cuff Score, range of motion, complications and revisions. A meta-analysis of comparative studies compared the postoperative ASES score between patients treated with in situ transtendon repair versus tear completion repair. RESULTS: Twenty-eight studies were included. The ASES score was reported by four comparative studies with contrasting results. The heterogeneity was high (I2 = 86%), and effect sizes ranged from -0.49 in favour of the tear completion and repair technique to an effect size of +1.07 favouring in situ transtendon repair. The overall effect size of 0.02 suggests an equivalence between the two techniques in terms of the ASES score. Two studies with a total sample size of 111 patients reported on debridement, and four studies with a total sample size of 155 patients reported on bioinductive collagen implants. CONCLUSION: Debridement alone is suitable for Ellman grades I-II PT-RCTs. In situ transtendon and tear completion repair techniques yield similar postoperative outcomes. Bioinductive collagen implants hold promise but lack long-term efficacy data. High-quality comparative studies are needed to determine the best treatment for PT-RCTs. LEVEL OF EVIDENCE: Level IV.

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Platelet-rich plasma injections have been shown to have many useful applications in various musculoskeletal pathologies. Research on the use of PRP for intrasubstance partial-thickness rotator cuff tears is lacking, although these tears have unique properties that may increase the efficacy of platelet-rich plasma injections. Patients with MRI-confirmed high-grade intrasubstance partial-thickness rotator cuff tears, that had failed traditional non-operative treatment, were offered either surgical repair (Group 1) or a single ultrasound-guided platelet-rich plasma injection into the tear site (Group 2). Patients were followed at 2 weeks, 6 weeks, 3 months, and a minimum of 2 years post-injection with ASES scores. A total of 25 patients received platelet-rich plasma injections, compared to 20 patients who had rotator cuff repair for intrasubstance tears in the last 3 years. The mean pre-injection ASES score for the platelet-rich plasma group was 53.2 and this improved to 92.9 at a minimum 2-year follow-up. The average convalescence period following platelet-rich plasma injection was 3.3 months. The average post-operative convalescence period for arthroscopic rotator cuff repair was 4.6 months. Both surgical repair and platelet-rich plasma injection into the tear site are equally effective in the treatment of high-grade intrasubstance partial-thickness rotator cuff tears, while platelet-rich plasma provides significantly shorter recovery time.

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BACKGROUND: The aim of this study is to examine the effect of preoperative conservative treatment on the success of high-grade bursal/articular-sided partial rotator cuff repair. METHODS: Patients who had undergone shoulder arthroscopy in institution for Ellman Stage 3 bursal-side or articular-side partial tears between January 2008 and April 2018 were investigated retrospectively. This study assessed 201 patients diagnosed with isolated partial rotator cuff tears with a history of failed conservative management and persistent shoulder pain who underwent arthroscopic surgery. The demographic data of patients and pre- and postoperative The American Shoulder and Elbow Surgeons Shoulder Scores (ASES) that were recorded in the archive were evaluated. RESULTS: While 55 of the patients with Ellman grade 3 bursal-sided partial tears received preoperative conservative management for at least 6 months (Group 1), 62 of them could not tolerate conservative management and early arthroscopic repair was performed (Group 2). On the other hand, 42 of the patients with Ellman grade 3 articular-sided tears received preoperative conservative management (Group 3), 42 of them could not tolerate preoperative conservative management (Group 4). The mean ASES score improvement was 52.33 ± 8.55 for Group 1, 54.68 ± 11.29 for Group 2, 48.4 ± 7.77 for Group 3 and 49.33 ± 10.05 for Group 4. A statistically significant difference was found between the groups with one-way ANOVA test (p = 0.05). With the Tukey test, this difference was seen to be caused by Group 2. CONCLUSION: Although there are many factors affecting its success, conservative management should be the first option in the treatment of partial rotator cuff tears. However, we think that it should not be insisted especially in patients with bursal-sided tears (> 50% of the tendon thickness) that cannot tolerate conservative management due to severe pain since the results of early arthroscopic repair of bursal-sided tears were found to be better. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.

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BACKGROUND: Reverse total shoulder replacement (TSR) in elderly patients with primary osteoarthritis (OA) and rotator cuff pathology is increasingly being performed. The purpose of our study was to determine the medium-term results of anatomic TSR for OA in patients with established preoperative partial-thickness rotator cuff tears on magnetic resonance imaging (MRI) scans. METHODS: We reviewed a cohort of patients who had undergone anatomic TSR for OA with a preoperative MRI diagnosis of partial-thickness rotator cuff tear. Patients were assessed with preoperative and post operative Oxford Shoulder Scores, evaluation of their range-of-movement and clinical rotator cuff assessment. Anteroposterior and axillary radiographs were used to assess for any proximal humeral migration (using the Torchia classification) and any evidence of loosening. The Lazarus score was used to grade glenoid radiolucencies. RESULTS: The study comprised 36 patients (14 men and 22 women) who underwent TSR and had partial-thickness rotator cuff tears on MRI; preoperatively, all showed mild to moderate fatty infiltration. The mean age of the patients was 79.2 years (range, 75-88 years); the mean follow-up period was 5.8 years (range, 5-9 years). Significant improvements in pain and range of movement were reported in all cases. At the final follow-up, the mean Oxford Shoulder Score was 42 points (range, 32-46 points), with a minimum improvement of 14 points (P = .001). External rotation (20° vs. 40°, P = .001), forward flexion (80° vs. 140°, P = .015), abduction (45° vs. 90°, P = .015), and internal rotation also improved. Lucencies were observed in 8 glenoids, with 6 showing grade 1 Lazarus changes, 2 showing grade 2, and none showing grade 3. There were no cases of implant loosening. Clinically, 4 patients had rotator cuff weakness but only 2 showed evidence of proximal migration. One patient remained satisfied, whereas the other patient, with moderate-grade proximal migration according to the Torchia classification, underwent revision for rotator cuff failure; one further patient underwent washout and DAIR (débridement, antibiotics, and implant retention) for infection. DISCUSSION: There is a paucity of literature on whether a preoperative partial-thickness rotator cuff tear has an adverse effect on the outcome of TSR. Our results show that the presence of a partial cuff tear on preoperative MRI does not significantly affect function after anatomic TSR in the medium term. With anatomic TSR having less morbidity for patients and allowing greater potential options for revision, we believe that the use of reverse shoulder arthroplasty in this cohort of patients, with partial rotator cuff tears, may not be necessary and we advocate consideration of anatomic TSR in this patient group.

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INTRODUCTION: The purpose of study is to describe outcome of the knotless-in-situ suture-bridge repair technique, combining concept of articular-preservation, medial-row knotless, and full-layer repair on the high-grade bursal-side rotator cuff tear (PBS-RCT). METHODS: The repair-technique, on 27 shoulders with PBS-RCT, were retrospectively evaluated. Range of Motion (RoM), visual analog scale (VAS), American Shoulder and Elbow Surgeon (ASES) score were evaluated. Minimal 6-months Post-operative MRI were evaluated for repair-integrity. RESULT: RoM evaluation, VAS, and ASES Score were improved significantly (P < 0.01). Post-operative MRI showed intact repaired tendon in 25-patients (96.2%). CONCLUSION: Arthroscopic knotless-in-situ suture-bridge repair technique in PBS- RCT showed good functional-outcome and repair-integrity at minimum 2-years after surgery.

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BACKGROUND: The purpose of this prospective study was to compare the clinical and structural findings following the arthroscopic repair of partial-thickness (exceeding 50%) articular-sided rotator cuff tears using either a single-row or a double-row suture bridge fixation. MATERIALS AND METHODS: Fifty patients were included in this study. The patients were randomly placed into two groups: 25 underwent the single-row (Group I) and 25 a double-row suture bridge fixation (Group II). The clinical outcomes were assessed using ASES and Constant shoulder scores, both preoperatively and at the end of follow-up. The pain level was evaluated using the visual analogue scale (VAS), preoperatively, at 6 months and at the end of follow-up. All patients underwent preoperative MRI to identify the rotator cuff tear, and postoperatively at 12 months to evaluate tendon integrity. RESULTS: The average follow-up was 32.5 months. The mean ASES scores increased from 35.9 to 96.7 in Group I and from 35.3 to 93.4 in Group II; the mean Constant shoulder scores increased from 55.6 to 97.8 in Group I and from 57.5 to 97.3 in Group II. There were no significant differences between the two groups. The average preoperative pain level decreased from 7.4 to 3 at 6 months and to 0.4 at the end of the Group I; and from 7.6 to 3 at 6 months and 0.8 in Group II. There was no significant difference between the two groups. At 12 months, the MRI assessments showed two retears in Group I (8%) and one retear in Group II (4%). CONCLUSION: Arthroscopic repair of partial-thickness articular rotator cuff tears that exceed 50% of tendon thickness with a single-row transtendon repair or double-row suture bridge provides functional improvement and pain relief regardless of the repair technique used. There were no differences in clinical results between both techniques. LEVEL OF EVIDENCE: Level II; prospective comparative study.

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PURPOSE: The purpose of this study was to investigate the relationship between the superior capsule tear patterns and synovitis with subacromial pathologies, such as bursal-sided rotator cuff tear and subacromial impingement syndrome. METHODS: Fifty patients who underwent arthroscopic treatment for isolated bursal-sided tear were included in the study. Fifty more patients who underwent arthroscopic treatment for isolated Superior Labrum Anterior Posterior (SLAP) 2 lesion without pathology in the rotator cuff were included in the control group. Firstly, superior capsule tear and common synovitis on the rotator cable were assessed during glenohumeral joint examination. Coracoacromial Ligament (CAL) degeneration grading was performed according to the Royal Berkshire Hospital classification. Bursal-sided partial tear grading was done using Ellman classification. Whether or not there was a relationship between synovitis, classic capsule tear, plus reverse flap capsule tear, and partial bursal-sided tear existence. RESULTS: There were 21 patients with reverse flap capsule tear in the study group and 3 patients in the control group. In addition, there were 13 patients with synovitis in the study group and 4 in the control group. Compared to the control group, there was also a significant positive correlation in the presence of both synovitis and reverse flap capsule tear with the presence of bursal-sided tear in the study group (p = 0.000). There was, however, no significant difference between the presence of classical capsule tear and the presence of bursal-sided tear (p = 0.485). CONCLUSION: This study shows that the presence of reverse flap capsule tear and synovitis was associated with partial bursal-sided tears. Therefore, if the reverse flap capsule tear or synovitis is detected in the superior capsule, the rotator cuff should be evaluated in more detail during subacromial bursoscopy in order not to miss a bursal-sided partial cuff tear.

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BACKGROUND: Partial-thickness rotator cuff tears (PTRCTs) are one of the leading causes of shoulder dysfunction. Successful results have been reported with different treatment techniques, but the long-term consequences of these procedures are not yet clearly known. The purposes of this study were to evaluate and compare the mid- and long-term clinical outcomes of arthroscopically repaired bursal-side PTRCTs after conversion to full-thickness tears and identify the possible effects of age, gender, and hand dominance on clinical outcomes. METHODS: Twenty-nine patients who had undergone arthroscopic repair of a significant bursal-side PTRCT were functionally evaluated. The repair was made after conversion to a full-thickness tear. The average patient age was 55.2 years (range 35-69 years, SD ±7.6 years). Clinical outcomes were evaluated at 2 and 5 years after surgery. Constant Shoulder Score (CSS) and Visual Analogue Scale for Pain (VAS pain) were used as outcome measures. RESULTS: The average CSS improved from 38.9 preoperatively to 89.2 and 87.8 at 2 and 5 years after surgery, respectively (p < 0.001). The average VAS pain score decreased from 7.90 preoperatively to 1.17 and 1.31 at 2 and 5 years after surgery, respectively (p < 0.001). A significant improvement was detected in patient functional outcomes and VAS pain scores at 2 and 5 years after surgery compared with the preoperative period. The patients who underwent surgery from their non-dominant extremity showed a significantly higher CSS increase relative to those who underwent surgery on the dominant extremity (p = 0.022). CONCLUSIONS: Arthroscopic repair of high-grade bursal-side PTRCTs after conversion to full-thickness tears is a reliable surgical technique with good functional outcomes and pain relief both at mid- and long-term follow-ups. Surgery on the non-dominant side may be related to better functional outcomes.

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BACKGROUND: At present, there is no widely accepted classification system for partial-thickness rotator cuff tears, and as a result, optimal treatment remains controversial. PURPOSE: To examine the interobserver reliability and accuracy of classifying partial rotator cuff tears using the Snyder classification system. We hypothesized that the Snyder classification would be reproducible with high reliability and accuracy. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Twenty-seven orthopaedic surgeons reviewed 10 video-recorded shoulder arthroscopies. Each surgeon was provided with a description of the Snyder classification system for partial-thickness rotator cuff tears and was then instructed to use this system to describe each tear. Interrater kappa statistics and percentage agreement between observers were calculated to measure the level of agreement. Surgeon experience as well as fellowship training was evaluated to determine possible correlations. RESULTS: A kappa coefficient of 0.512 indicated moderate reliability between surgeons using the Snyder classification to describe partial-thickness rotator cuff tears. The mean correct score was 80%, which indicated "very good" agreement. There was no correlation between the number of shoulder arthroscopies performed per year and fellowship training and the number of correct scores. CONCLUSION: The Snyder classification system is reproducible and can be used in future research studies in analyzing the treatment options of partial rotator cuff tears.

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BACKGROUND: The purpose of this study was to investigate the role of coracoacromial ligament degeneration and specific anatomic parameters in the etiology of partial-thickness rotator cuff tears. MATERIALS AND METHODS: This study retrospectively assessed 96 patients (mean age, 50.1 years [17-76]; 34 men, 62 women) diagnosed with bursal-side and articular-side rotator cuff tears with a history of failed conservative treatment and persistent shoulder pain who underwent arthroscopic surgery. Video records of the surgery were used to evaluate the type of cuff tear, grade of coracoacromial ligament degeneration, and associated pathologic changes; preoperative magnetic resonance images were used to measure acromioglenoid angle, supraspinatus glenoid angle, and subacromial distance. RESULTS: Most of the patients with articular-side tears demonstrated grade 0 and grade 1 coracoacromial ligament degeneration, whereas patients with bursal-side tears had grade 1 and grade 2. There was a significant positive correlation between the grade of coracoacromial ligament degeneration and bursal-side partial rotator cuff tears, whereas no correlation was observed with articular-side tears. There was no significant difference between bursal-side and articular-side partial cuff tears regarding acromioglenoid angle, supraspinatus glenoid angle, and subacromial distance. CONCLUSIONS: Grade 1 and grade 2 coracoacromial ligament degeneration is a strong predictive factor for impingement syndrome in the etiology of bursal-side partial cuff tears and can guide the surgeon to consider ligament release and débridement or acromioplasty in these patients.

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