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Review Article: J. L. Rees The pathogenesis and surgical treatment of tears of the rotator cuff J Bone Joint Surg Br 2008; 90-B: 827-832 [Abstract] [Full text] [PDF]

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The pathogenesis and surgical treatment of tears of the rotator cuff

Nicola Maffulli, Umile Giuseppe Longo, Vincenzo Denaro   (15 September 2008)

The pathogenesis and surgical treatment of tears of the rotator cuff 15 September 2008
Nicola Maffulli, Professor of Trauma and Orthopaedic Surgery Keele University School of Medicine, Stoke on Trent, England, Umile Giuseppe Longo, Vincenzo Denaro Send letter to journal: Re: The pathogenesis and surgical treatment of tears of the rotator cuff n.maffulli{at}keele.ac.uk Nicola Maffulli, et al.	Sir, We read this paper with interest. It may have been submitted before the publication of our investigations, nevertheless, we would like to call your attention to the fact that we have performed several studies on the aetiology, histopathology and management of rotator cuff tendinopathy. For example, new evidence is now available on the decision on single- versus double-row technique for repair of rotator cuff tears.1 We recruited 60 patients in a randomised controlled clinical trial2 to compare the clinical and structural outcome of arthroscopic repair in patients with large and massive rotator cuff tears in whom the repair was effected using single- or double-row arthroscopic technique. In our hands, single- and double-row technique provide comparable clinical outcomes at two years. Our study showed that there were no advantages in using a double-row suture anchor technique to restore the anatomical footprint. The mechanical advantages evidenced in cadaver studies do not translate into superior clinical performance when compared with the more traditional, technically less demanding, and economically more advantageous technique of single-row suture anchor repair. In another study,3 we investigated supraspinatus tendon samples obtained from patients undergoing arthroscopic repair of a rotator cuff tear to examine the distribution of tendinopathic changes associated with this condition. At arthroscopy, a full thickness supraspinatus tendon biopsy was harvested close to the tear edge. We found more frequent tendon changes on the articular side of the rotator cuff. In another study4 to evaluate the histopathological features of macroscopic intact tendon portion of patients with rotator cuff tears, we demonstrated that the supraspinatus tendons of patients undergoing arthroscopic repair for a rupture show profound histopathological changes, while the tendons of elderly patients with no known tendon abnormalities have, as a group, little histological evidence of pathological change. Moreover, tendon changes are not only localised at the site of rupture, but also in the macroscopic intact tendon portion. Relatively few studies have tried to quantify the histopathological findings of tendinopathy, which are currently described in a subjective, or at best semiquantitative, fashion.5-9 This may result in uncertainty about the histopathological findings of tendinopathy, and has produced a lack of diagnostic uniformity among surgical pathologists. Ideally, the pathological diagnoses in different studies should follow an accepted classification scheme, thus allowing comparison of data. We are aware of two scoring systems that can be used for the classification of the histopathological findings of tendinopathy: the Movin score9 and its validated modifications,4,7,8 and the Bonar score.10 We compared the reliability of these two scores.11 Both have a high correlation and assess similar characteristics and variables of tendon pathology. In conclusion, we agree that several aspects of rotator cuff pathology, aetiopathogenesis and management are still unclear. We are also trying to shed some light on, and inject some science into, this topic. N. Maffulli, Professor of Trauma and Orthopaedic Surgery, U. Giuseppe Longo, V. Denaro, Keele University School of Medicine, Stoke on Trent, England. 1. Reardon DJ, Maffulli N. Clinical evidence shows no difference between single- and double-row repair for rotator cuff tears. Arthroscopy 2007;23:670-3. 2. Franceschi F, Ruzzini L, Longo UG, et al. Equivalent clinical results of arthroscopic single-row and double-row suture anchor repair for rotator cuff tears: a randomized controlled trial. Am J Sports Med 2007;35:1254-60. 3. Longo UG, Franceschi F, Ruzzini L, et al. Light microscopic histology of supraspinatus tendon ruptures. Knee Surg Sports Traumatol Arthrosc 2007;15:1390-4. 4. Longo UG, Franceschi F, Ruzzini L, et al. Histopathology of the supraspinatus tendon in rotator cuff tears. Am J Sports Med 2008;36:533-8. 5. Aström M, Rausing A. Chronic Achilles tendinopathy. A survey of surgical and histopathologic findings. Clin Orthop 1995;316:151-64. 6. Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M. Histopathology of common tendinopathies. Update and implications for clinical management. Sports Med 1999;27:393-408. 7. Maffulli N, Barrass V, Ewen SW. Light microscopic histology of achilles tendon ruptures. A comparison with unruptured tendons. Am J Sports Med 2000;28:857-63. 8. Maffulli N, Testa V, Capasso G, et al. Similar histopathological picture in males with Achilles and patellar tendinopathy. Med Sci Sports Exerc 2004; 36:1470-5. 9. Movin T, Gad A, Reinholt FP, Rolf C. Tendon pathology in long-standing achillodynia. Biopsy findings in 40 patients. Acta Orthop Scand 1997;68:170-5. 10. Cook JL, Feller JA, Bonar SF, Khan KM. Abnormal tenocyte morphology is more prevalent than collagen disruption in asymptomatic athletes' patellar tendons. J Orthop Res 2004;22:334-8. 11. Maffulli N, Longo UG, Franceschi F, Rabitti C, Denaro V. Movin and Bonar scores assess the same characteristics of tendon histology. Clin Orthop 2008;466:1605-11.