The Effect of Tendon Delamination on Rotator Cuff Healing

Abstract

Background: While patient age, tear size, and muscle fatty infiltration are factors known to affect the rate of tendon healing after rotator cuff repair, the effect of tendon delamination is less known. Purpose: To assess the effect of tendon delamination on rotator cuff healing after arthroscopic single-row (SR) repair. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients (N = 117) with chronic full-thickness rotator cuff tears underwent arthroscopic SR repair with the tension-band cuff repair. The mean ± SD age at the time of surgery was 60 ± 8 years. There were 25 small, 63 medium, and 29 large tears. Tendon delamination was assessed intraoperatively under arthroscopy with the arthroscope placed in the lateral portal. Patients were divided into 2 groups: those with nondelaminated (n = 80) and delaminated (n = 37) cuff tears. The 2 groups were comparable for age, sex, body mass index, preoperative pain, strength, and a Constant-Murley score. Repair integrity was evaluated with sonography (mean, 24 months after surgery; range, 6-62 months) and classified into 3 categories: type A, indicating complete, homogeneous, and thick coverage of the footprint; type B, partial coverage with a thin tendon; and type C, no coverage of the footprint. Results: The prevalence of tendon delamination observed under arthroscopy was 32% (37 of 117), which increased with tear size and retraction: from 15% in small tears to 32% in medium tears and 45% in large tears (P = .028). Postoperatively, 83 patients had complete coverage of footprint (type A = 71%) and the cuff was considered healed, whereas 26 had partial coverage or a thin tendon (type B = 22%) and 8 had no coverage (type C = 7%). Overall, the rate of complete healing was 78% in nondelaminated cuff tears and 57% in the case of tendon delamination (P = .029). In large retracted tears, the healing rate dropped from 81% in the absence of delamination to 39% when the tendons were delaminated (P = .027). Conclusion: Tendon delamination increases with tear size and retraction. Patients with chronic delaminated and retracted rotator cuff tears (stage 2 or 3) are at risk of failure after SR cuff repair, whereas patients with small delaminated rotator cuff tears (stage 1) involving only the supraspinatus can be treated with an SR cuff repair with a high chance of tendon healing. These results suggest that SR cuff repair may be insufficient to treat delaminated chronic cuff tears. To improve the anatomic outcomes of rotator cuff repairs, surgeons should consider treating delaminated tears with a double-row or double-layer repair.

Separate double-layer repair versus en masse repair for delaminated rotator cuff tears: a systematic review and meta-analysis

“…With further research on the anatomical structure of the footprint area of the rotator cuff, it was found that there are two different layers of tissue structure on the end of the footprint area of the rotator cuff and that the two layers of tissue structure have different tension. The rotator cuff tear often leads to a change in stratification, and each layer of structure has a different degree of retraction [12,17]. Therefore, to restore the original anatomical structure of the rotator cuff in the footprint area, arthroscopic DR is increasingly used in clinical practice.…”

Clinical Outcomes of Arthroscopic Repair for Large or Massive Rotator Cuff Tear with Delamination: Comparison of Three Suture-Bridge Technique

“…The rotator cuff has a structure comprising 5 histologically different layers, and delamination tends to develop between the 2nd and 3rd layers with different ber distributions [30,31]. Delamination is one of the risk factors for postoperative retear after rotator cuff repair and healing; thus, repair with special attention to the possible presence and state of delamination is considered important [3][4][5]. For the delamination repair, methods suturing the super cial and deep layers en bloc [32,33], individually suturing the super cial and deep layers, and suturing only super cial layer [8,14,34,35] have been reported.…”

“…The delamination of the rotator cuff has been described as a horizontal lesion between the super cial and deep layers [1,2]. Delamination is observed in 36-82% of rotator cuff tear cases [3][4][5][6][7][8][9] and its presence is considered a risk factor for postoperative retear after rotator cuff repair [4]. Double-row double layer xation was reported as a repair method of the stump of delaminated rotator cuff tears, but a high incidence of retear in large and massive rotator cuff tear cases has been known [2,10], and optimal xation method for rotator cuff stump with delamination has yet been under debate.…”

Complete Repair of Massive, Retracted, and “Non-Repairable” Tears of the Rotator Cuff: The Anatomic Vector Repair

“…5 Additionally, there is concern that rotator cuff tendon delamination worsens as tear size increases and that delamination is associated with greater risk of repair failure when a single-row technique is used. 6 Placement of this anterolateral anchor is an important final step in the repair of massive tears according to the anatomic vector repair technique.…”