Rotator cuff repair - should the tear edges be trimmed?

Este artículo es originalmente publicado en:
http://shoulderarthritis.blogspot.mx/2014/12/rotator-cuff-repair-should-tear-edges.html

Sunday, December 7, 2014

Rotator cuff repair - should the tear edges be trimmed?

Is resection of the tendon edge necessary to enhance the healing process? An evaluation of the homeostasis of apoptotic and inflammatory processes in the distal 1 cm of a torn supraspinatus tendon: part I.


Is resection of the tendon edge necessary to enhance the healing process? An evaluation of the expression of collagen type I, IL-1β, IFN-γ, IL-4, and IL-13 in the distal 1 cm of a torn supraspinatus tendon: part II

In these two articles the authors examine in nine patients the concept that resection of the distal 1 cm of a torn rotator cuff tendon would enhance its healing properties. 

They hypothesized that the expression of proapoptotic and antiapoptotic molecules and cytokines is dependent on the distance from the torn supraspinatus tendon edge and this expression may influence its potential for healing.

They found that in moving from the distal to the proximal parts of the tendon edge, the expression of proapoptotic caspases 9, 8 and 3; Bax; and TNF-α significantly decreased and the the expression of antiapoptotic Bcl-2 and IL-10 expression was increased. 

They also found that expression of type I collagen, pro-proliferative IL-4, and IL-13 significantly increased and that of pro-inflammatory IL-1β and anti-proliferative IFN-γ decreased from the distal to the proximal parts of the tendon edge.

On these bases they suggest that resection of 10 mm from the edge of the torn supraspinatus tendon may enhance the healing process.

However, they point out that the number of patients that could be included in this study was limited because of the increased risk of tension in the repaired tendon when its distal centimeter was resected. 

Comment: This is interesting work. Basically the authors found that the tendon edge is less metabolically enabled that the tendon a bit more proximal. What we don't know is how these metabolic characteristics are changed by the repair process - it is possible that surgery changes the environment from what became evident from these biopsies taken before the repair was carried out. At rotator cuff repair surgery, avoiding excessive tension is a priority - thus there is a concern that resection of 10 mm of tendon will increase the tension.  Finally, there is the question of whether the majority of the healing activity takes place from the tendon edge or from the bone to which it is repaired.

To optimize the mechanical environment at the repair site, we create a trough in bleeding bone at the tuberosity into which the tendon edge is inserted tongue and groove style.