Diagnosis and Management of Partial Thickness Rotator Cuff Tears

A Comprehensive Review

Kevin D. Plancher, MD, MPH; Jaya Shanmugam, MD; Karen Briggs, MPH; Stephanie C. Petterson, MPT, PhD

Disclosures

J Am Acad Orthop Surg. 2021;29(24):1031-1043. 

In This Article

Biologic Augments and the New Frontier

Despite the ability to alleviate pain, restore function, and prevent tear progression, high failure rates of surgical repair are still reported within 1 year. Biologic augments, including platelet rich plasma (PRP), platelet rich fibrin, platelet-derived growth factor, anabolic growth factors, bone marrow aspirate concentrate, stem cells, and proteinase inhibitors, have become an attractive adjunct to current repair techniques to improve tendon healing.

Early animal models suggest augmentation with PRP increases failure strain with more linear collagen fibers at 21 days. However, studies have not demonstrated similar clinical benefit with the PRP and meta-analyses demonstrate mixed results.[45–47] Randelli et al[47] delivered PRP at the tendon–bone interface during repair of FTTs in a RCT. Notable improvement was seen at 3 months with PRP; however, there were no differences in outcomes at 6 months. In another RCT, Castricini et al[45] showed notable differences in Constant score with a PRP matrix. A more recent meta-analysis suggested that the addition of PRP to repair of PRCTs and FTTs decreases retear rate and improves healing and clinical outcomes.[46] The lack of PRP standardization compounded by the variety of repair techniques and tear types makes it difficult to achieve consensus on the use of PRP for PRCT repair.

Mesenchymal stem cells are another option to improve healing rates although clinical evidence is limited in PRCT repair. Hurd et al[48] compared an injection of uncultured, unmodified, autologous adipose-derived regenerative cells with a combination of methylprednisolone and bupivacaine injection in patients with symptomatic PRCTs who failed conservative management. The uncultured, unmodified, autologous adipose-derived regenerative cell group showed markedly higher ASES scores at weeks 24 and 52. More evidence is needed to support the clinical use of stem cells in PRCTs healing both with and without surgical repair.

Augmentation with biologic scaffolds has also gained popularity. Augments include synthetic, xenografts, autografts, or allografts patches. A recent meta-analysis of multiple graft types suggests that augmentation results in lower retear rate, with autograft augments achieving superior graft integrity although no difference in clinical outcome scores was evidenced.[49]

Mechanical properties and biologic incorporation of different graft types varies greatly. A bioinductive collagen patch has been shown to yield cellular incorporation, new tissue formation, maturation, implant resorption, and biocompatibility.[50] However, similar to other biologic adjuvants, there is limited evidence for use in PRCTs. Schlegel et al[51] used a bioinductive collagen patch in 33 patients with PRCTs (11 articular-sided, 10 bursal-sided, four intrasubstance, and eight hybrid tears). All patients underwent arthroscopic subacromial decompression without repair, and the patch was "stapled" on the bursal side. Notable improvement in clinical scores was reported at 1 year with MRI evidence of a markedly increased mean tendon thickness of 2 mm. MRI showed complete healing in eight patients (24%), reduction in defect size in 23 patients (70%), one tear remained stable (3%), and one patient had progression to FTT (3%). Long-term research is still needed to support the use of these biologic adjuvants and other patch augmentation alternatives in PRCTs.

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