Marginal Convergence Repair Technique for Partial Articular‐Sided Rotator Cuff Tears

Abstract

Partial rotator cuff tears present a common clinical challenge, and optimal management remains debated. This technical note describes an arthroscopic margin convergence repair technique performed without the use of suture anchors for patients with partial‐thickness rotator cuff tears. The technique is applicable for partial‐thickness tears of varying configurations, including longitudinal, horizontal, and complex tear patterns. The procedure preserves the native tendon footprint and minimizes disruption of healthy tissue while restoring the rotator cuff's biomechanical continuity. With the patient in the beach‐chair position, standard posterior and anterosuperior portals are used to access both articular and bursal aspects of the tear. Suture passage is performed side‐to‐side using a nonlocking loop configuration to achieve tension‐free convergence. This approach avoids hardware complications, reduces cost, and allows accelerated rehabilitation by maintaining anatomic integrity. This technique is particularly suitable for high‐grade partial rotator cuff tears that fail conservative treatment.

Partial‐thickness rotator cuff tears (PTRCTs) are a frequent source of pain and disability in adults, affecting individuals across diverse activity levels, from athletes to those with sedentary lifestyles. ¹ , ² PTRCTs can be classified by their size (3 mm, 3‐6 mm, and >6 mm), by their location (articular, bursal, and intratendinous), or by their tendons involved (supraspinatus, infraspinatus, teres minor, and subscapularis). Consequently, management remains challenging, and the ideal approach to treatment continues to be debated. ³

Conservative management is typically the first‐line treatment, specifically for patients involving less than 50% of tendon thickness. However, surgical decision is driven by a variety of factors including age, tear configuration, tear thickness, tear location, and concomitant pathologies. ⁴

Currently, there are some surgical techniques used in the repair process of partial rotator cuff tears (PRCTs). Arthroscopic debridement alone or in combination with subacromial decompression is generally recommended for tears involving less than 50% of tendon thickness involvement. Although this approach has had favorable results, it does not prevent the progression to a full‐thickness tear. Another common strategy is conversion repair, which consists of completing a PTRCT to a full‐thickness rotator cuff tear. Although this technique has shown promising clinical outcomes, it raises concerns because of the detachment of healthy tissue and longer recovery time and rehab that is considered for a full‐thickness rotator cuff tear. In contrast, in situ repair using transtendon fixation preserves the remaining intact tendon while addressing the partial tear.

This technique has the advantage of preserving and maintaining the intact lateral insertion of the cuff while reestablishing the tearing side more medially. Although this technique does have excellent clinical results, some symptoms might persist. It was mentioned that the effect of overtensioning or inappropriate tensioning of the remaining fibers of the rotator cuff to the greater tuberosity could be the cause of these symptoms. ⁵ , ⁶

Application of collagen‐based scaffold for PRCT repair is another treatment option. The collagen‐based scaffold repair was studied by Dai et al. in which patients with PRCTs had highly porous collagen‐based bioreductive implants that were placed on the bursal side of PRCTs. The study showed improved functional outcomes and a significant increase in tendon thickness in a 20‐month follow‐up. Although early results have been promising, a lack of consistency is still observed.

Arthroscopic margin convergence technique consists of suturing side‐to‐side in the anteroposterior manner, shifting the free margin of the tendon, and ultimately decreasing the tension at the repair site. ⁷ Ghasemi et al. ⁸  introduced arthroscopic margin convergence technique without the use of suture anchors as a viable option for patients with rotator cuff tear. Preliminary research has shown encouraging results regarding motion preservation and anchor‐related complications; however, literature on anchorless margin convergence for partial‐thickness tears remains limited.

Although marginal convergence has been previously described, most reports focus on full‐thickness tears or anchor‐based constructs. In contrast, the current technique extends this concept to articular‐sided partial‐thickness tears and uses an anchorless construct to preserve native tendon anatomy while reducing partial repair‐site tension.

This technical note describes marginal convergence repair for PRCTs. This technique provides a biologically based repair without changing the anatomy of the rotator cuff footprint and preserving the intact part with the advantage of an accelerated rehabilitation program and faster recovery. This study was approved by the Institutional Review Board of Thomas Jefferson University.

SURGICAL TECHNIQUE

With the patient positioned in the beach‐chair position, standard sterile preparation and draping are performed. Two arthroscopic portals are established, 1 posterolateral and 1 anterosuperior, to allow optimal access to both the articular and bursal sides of the rotator cuff. The arthroscope is introduced through the posterior portal, and a thorough diagnostic evaluation of the glenohumeral joint is conducted to assess the extent of the PTRCTs (Figure 1). Once the tear is identified on the articular surface, a spinal needle is used to pass a polydioxanone suture (Arthrex, Naples, FL), effectively tagging the lesion for localization and facilitating later suture passage (Figure 2).

FIGURE 1.

Intra‐articular arthroscopic view of the left shoulder with the patient in the beach‐chair position, viewed through the posterior portal, showing an articular‐sided partial‐thickness rotator cuff tear with associated biceps tendon instability identified using a probe introduced through the anterolateral portal.

FIGURE 2.

Intra‐articular arthroscopic view of the left shoulder with the patient in the beach‐chair position, viewed through the posterior portal, showing the partial‐thickness rotator cuff tear with retraction of the long head of the biceps tendon. A probe is introduced through the anterolateral portal.

Associated intra‐articular lesions are addressed before rotator cuff repair through a standard posterior portal in the glenohumeral joint (Figure 3). The tear, once localized in the articular joint, is debrided and identified using a spinal needle. Soft tissue fraying is debrided using an arthroscopic shaver, followed by gentle bony preparation of the exposed footprint with a burr to achieve punctate bleeding and promote healing in the injured part of the footprint in an intra‐articular tear (Figure 4). In cases with difficult access to the tear site, we advance the shaver through the subacromial space and penetrate through the tendon.

FIGURE 3.

Intra‐articular arthroscopic view of the left shoulder with the patient in the beach‐chair position, viewed through the posterior portal, showing the rotator cuff tear after management of the biceps tendon with tenodesis. A probe is introduced through the anterolateral portal.

FIGURE 4.

Intra‐articular arthroscopic view of the left shoulder with the patient in the beach‐chair position, viewed through the posterior portal, showing minimal debridement of the rotator cuff tear footprint after localization of the lesion. The arthroscopic shaver is introduced through the anterolateral portal.

After visualization of the tear site and identification using a spinal needle, we transfer our attention of the subacromial space tear site. In a massive intra‐articular partial tear, 2 spinal needles are inserted percutaneously on either side of the partial tear to establish appropriate anchor points for suture passage.

Attention is then directed to the subacromial space, where a bursectomy is performed as needed to optimize visualization and working space and debridement, preparation, and punctuating bleeding of the subacromial partial tear.

In cases with subacromial or intra‐articular partial tear, including longitudinal, complex, or irregular tear patterns, a suture‐passing lasso (Arthrex) is introduced through the anterolateral portal and passed through the anterior margin of the partial tear, exiting at the posterior aspect of the defect (Figure 5). The loop wire inside the lasso is pulled out from the posterolateral subacromial space, and a FiberWire (Arthrex) is passed through the tendon (Figures 6 and 7). Once both suture limbs are positioned on either side of the tear, they are securely tied using a nonlocking Duncan loop knot under direct arthroscopic visualization from the subacromial space (Figures 8 and 9).

FIGURE 5.

Arthroscopic view of the subacromial space of the left shoulder with the patient in the beach‐chair position, viewed through the posterior portal, showing use of a 45° suture‐passing lasso passed acrossed the rotator cuff tear to shuttle the suture across both margins of the defect before FiberWire passage.

FIGURE 6.

Arthroscopic view of the subacromial space of the left shoulder with the patient in the beach‐chair position, viewed through the posterior portal, showing passage of 2 FiberWire sutures through the anterolateral and posterolateral margins of the rotator cuff tear prior to knot tying.

FIGURE 7.

Arthroscopic view of the subacromial space of the left shoulder with the patient in the beach‐chair position, viewed through the posterior portal, showing FiberWire sutures spanning the rotator cuff defect and retrieved through the posterolateral portal in preparation for knot fixation.

FIGURE 8.

Arthroscopic view of the subacromial space of the left shoulder with the patient in the beach‐chair position, viewed through the posterior portal, showing tensioning of the Duncan loop knot with a knot pusher to secure the FiberWire suture during marginal convergence repair.

FIGURE 9.

Final arthroscopic view of the subacromial space of the left shoulder with the patient in the beach‐chair position, viewed through the posterior portal, showing approximation of the rotator cuff tissue and closure of the articular‐sided partial‐thickness tear after anchorless marginal convergence repair.

In cases with bigger size partial‐thickness tear, 2 or 3 front to posterior longitudinal sutures are recommended to decrease the tension at the tear site and marginal convergence of the partial tear site.

After completion of the repair, the construct is meticulously assessed for stability, ensuring adequate tissue approximation without undue tension and shoulder range of motion (Figure 9). Once satisfactory fixation is achieved, the instruments are removed, portals are closed in the standard fashion, and a sterile dressing is applied. Postoperative rehabilitation is initiated per accelerated rehab shoulder protocol to optimize tendon healing and functional recovery. The complete arthroscopic technique is shown in the accompanying video (Video 1).

VIDEO 1.

Download video file ^{(2.1MB, mov)}

The tear is visualized from the intra‐articular side in the junction of the rotator cuff attachment to greater tuberosity and then tagged using a spinal needle. After localization of the tear, we do minimal debridement while protecting as much tissue as possible, just to promote healing at the tear footprint. We then switch our camera to the subacromial space where the spinal needle is located. You can see the rotator cuff subarticular surface. We then pass using a 90° lasso with a guidewire inserted, and using the spinal needle as reference, we pass the lasso from 1 side of the tear to the other side. We grab the guidewire, we shuttle a number 1 FiberWire (Arthrex, Naples, FL), and then, we do the same thing more laterally. We then suture both ties using a nonlocking Duncan suture from the lateral side portal. Video content can be viewed at https://doi.org/10.1002/atn2.70240.

Postoperative rehabilitation was conducted using a structured, criterion‐based rotator cuff protocol consistent with the American Society of Shoulder and Elbow Therapists consensus guidelines. ⁹ The shoulder was immobilized in a sling for the first 2 weeks after surgery. Protected passive range of motion was initiated between weeks 2 and 6, with progression guided by pain tolerance and tissue‐healing considerations. Active range of motion was gradually introduced after restoration of protected passive motion and adequate scapular control. Progressive strengthening exercises were initiated at approximately 12 weeks postoperatively once full passive motion and appropriate dynamic stability were achieved.

DISCUSSION

Although margin convergence is well‐documented in cases of complete rotator cuff tears, its efficacy in partial‐thickness tears remains limited. In our previous work, we reported the clinical outcomes of arthroscopic margin convergence repair without suture anchors in a combined cohort of both partial‐ and full‐thickness rotator cuff tears, which showed significant functional improvement. ⁸ The present study builds specifically on a technique for patients with partial‐thickness tears.

Our findings are comparable to existing techniques, including conversion and in situ repair, but differ by maintaining healthy tissue integrity and offering accelerated rehabilitation and faster recovery.

Preserving tendon integrity remains a crucial goal, as it contributes to successful postoperative recovery. Improvements in clinical outcomes may result from reduced tension across the rotator cuff tendon, because excessive tension increases retear risk. Park et al. and Takeda et al. revealed that higher tension correlates with greater postoperative failure rates, whereas Wolf et al. and Davidson and Rivenburgh reported improved outcomes when tension was minimized. ¹⁰ , ¹¹ , ¹² , ¹³ This aligns with the rotator cable suspension bridge concept supported by our prior work, which maintains tendon length, prevents medialization, and preserves shoulder motion. ⁸

The in situ repair technique preserves tendon anatomy, but symptoms may persist. Castagna et al. reported 41% of patients continued to experience discomfort during daily living activities. ⁴ Muench et al. discussed the biomechanical advantage of repair of small rotator cuff tears, showing a significant improvement in functional outcomes and risk of midterm glenohumeral osteoarthritis. ¹⁴

In articular‐based partial‐thickness tears, traditional transtendinous repair uses anchors to restore the medial footprint. During margin convergence, suturing the cuff inferiorly toward the footprint without anchors may enhance biological repair through fibrocartilage fixation, potentially explaining the improved functional outcomes observed.

Given the ongoing debate regarding optimal management, arthroscopic margin convergence with anchorless sutures represents a reliable, cost‐effective, and anatomically preserving option. The main advantages, disadvantages, pearls, and pitfalls are summarized in Tables 1 and 2 to guide reproducibility and minimize complications. Future research should emphasize long‐term outcomes and comparisons with other repair methods.

TABLE 1.

Advantages and Disadvantages of the Marginal Convergence Repair Technique for Partial Articular‐Sided Rotator Cuff Tears

Advantages	Disadvantages
Preserves the anatomic footprint and reduces tissue disruption	Requires advanced skill for anterior‐to‐posterior suture passage through the rotator cuff tendon
Effective for small and diffuse partial‐thickness supraspinatus and infraspinatus tears
Promotes healing through marginal convergence suture compression over a prepared bleeding bone bed
Avoids anchor‐ and hardware‐related complications
Minimizes risk of chondral surface injury
Performed in a standard arthroscopic setting without the need for expensive scaffolds
Allows for an accelerated rehabilitation program by preserving tendon attachment

TABLE 2.

Pearls and Pitfalls for Performing the Marginal Convergence Repair Technique

Pearls	Pitfalls
Debride the footprint and prepare bloody bone bed for advanced healing	Inadequate debridement could affect the healing
Debridement subacromial space for better exposure for passing the suture from anterior to posterior	Inadequate subacromial debridement affects the passing the suture
Ensure the placement of the needle in the middle of tearing to mark it and use it in subacromial space

We introduced margin convergence technique without an anchor for patients with PRCTs. We believe that this technique is low‐cost, simple, and efficacious to deal with such tears especially after failure of conservative treatment with the advantage of accelerated recovery.

DISCLOSURES

The authors (S.A.G., A.F., A.N., A.B., J.R., G.S.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.