Review Question - QID 219955

The patient has a partial thickness articular-sided supraspinatus tear (PASTA lesion) that involves >50% of the thickness of the tendon. Given that this represents a high-grade partial-thickness tear that has not responded to 9 months of conservative management, arthroscopic surgical intervention with tear completion and rotator cuff repair is a reasonable next step in the treatment algorithm for this patient (answer choice 4).

Rotator cuff tears are a very common source of shoulder pain and decreased motion that can occur due to both traumatic injuries in young patients, as well as degenerative disease in the elderly patient. Partial-thickness tears are typically graded according to the Ellman classification (Illustration A) that subdivides these into low, intermediate, and high-grade tears based on the percentage of the tendon thickness that is disrupted and whether the tears occur on the bursal, articular, or interstitial aspects of the tendon. In general, partial articular-sided tears involving >50% of the tendon (i.e., grade III tears) can be treated with tear completion and repair when conservative management fails, while lower grade articular-sided tears may be treated with arthroscopic debridement alone.

Gallinet et al. performed a prospective, randomized single-blind study to assess the benefits of distal clavicle resection during rotator cuff repair. The authors included 200 patients and found that at 1 year postoperatively, all the clinical outcome measures studied were worse in the cohort that included a distal clavicle resection. They concluded with the recommendation that a routine distal clavicle resection should not be provided in the setting of arthroscopic rotator cuff repair.

Oh et al. published a prospective randomized comparative study assessing whether arthroscopic distal clavicle resection (DCR) is necessary for patients with radiological acromioclavicular joint (ACJ) arthritis and rotator cuff tears. The authors included 78 patients with rotator cuff tears in addition to radiological and asymptomatic ACJ arthritis and found that preventive arthroscopic DCR in patients with rotator cuff tears and concomitant asymptomatic radiological ACJ arthritis did not result in better clinical or structural outcomes, and did lead to symptomatic ACJ instability in some patients. They concluded that preventive arthroscopic DCR is not recommended in patients with radiological but asymptomatic ACJ arthritis.

Figure A is a Grashey AP radiograph of a right shoulder showing minimal degenerative change other than at the AC joint. Figures B-D are coronal and axial T2-weighted and sagittal T1-weighted MRI images, respectively, of a right shoulder with a high grade partial-thickness articular-sided supraspinatus tear involving 7mm of the tendon's thickness without evidence of appreciable fatty infiltration. Illustration A depicts the Ellman classification system for grading partial-thickness rotator cuff tears.

Incorrect Answers:
Answer 1: Though the patient does have some degenerative changes of the AC joint on the presented radiograph and nondescript pain over the joint clinically, she has a negative provocative cross-body adduction exam and a high-grade partial thickness articular-sided rotator cuff tear that is more likely the cause of her persistent pain. An isolated arthroscopic distal clavicle excision would not address this adequately.
Answer 2: The patient has exhausted 9 months of appropriate conservative management; thus, it would be appropriate to offer her a surgical treatment option to return her to her higher baseline level of activity.
Answer 3: Though an isolated debridement can be considered for low- and intermediate-grade partial thickness tears, high-grade lesions that remain symptomatic are more appropriately treated with either a trans-tendinous repair or tear completion with repair.
Answer 5: Though a trans-tendinous repair can be performed, a distal clavicle excision is not indicated in this patient.