Outcomes After Limited or Extensive Bursectomy

During Rotator Cuff Repair: Randomized Controlled

Trial
Ji-Hoon Nam, M.D., Sanghyun Park, M.D., Hwa-Ryeong Lee, D.P.T., and
Sae Hoon Kim, M.D., Ph.D.

Purpose: To evaluate the effects of extensive bursectomy (EB) and limited bursectomy (LB) during arthroscopic rotator
cuff repair. Methods: In the EB group (n ¼ 39), subacromial bursae were thoroughly removed from anterior to posterior
and lateral to medial. In the LB group (n ¼ 39), bursectomy was minimized to allow torn cuff visualization and tendon
repair. Visual analog scale pain scores, passive forward flexion, external rotation at the side (ER), and internal rotation at
the back were measured at 5 weeks and 3, 6, and 12 months after surgery. At each time point, bursal thickness was
measured and repair integrity was assessed by sonography or magnetic resonance imaging. Results: The analysis
included 36 patients in the LB group and 35 in the EB group. Group visual analog scale pain scores were not significantly
different at any time (P > .05 for all). Forward flexion and internal rotation at the back showed no intergroup difference
during follow-up. However, ER was significantly better in the LB group at 6 months and 1 year postoperatively (31  15
vs 22  16 [P ¼ .020] and 40  19 vs 27  20 [P ¼ .009], respectively). Integrity failures were not significantly
different at 5 weeks and at 3, 6, and 12 months (P > .05 for all). Marked bursal thickening (>2 mm) was more frequently
observed in the EB group (18 of 32 in the LB group and 27 of 32 in the EB group) at 6 months (P ¼ .014).
Conclusions: EB during arthroscopic rotator cuff repair appears to have no benefit in terms of reducing pain. More
adhesions in the subacromial space after EB may result in slower motion recovery, especially in terms of ER. The extent of
bursectomy did not affect tendon integrity. However, marked bursal thickening was more frequently observed in the EB
group. Level of Evidence: Level I, randomized controlled study.

T he subacromial bursa (SAB), which is the largest

bursa in the human body,1,2 is located under the
coracoacromial arch and deltoid muscle. The inferior
aspect of the SAB contacts the greater tuberosity of the
humerus and rotator cuff muscles. The main function of
the SAB is to reduce friction between the rotator cuff
From the Department of Orthopedic Surgery, Seoul National University
College of Medicine, Seoul National University Hospital, Seoul, Republic of
Korea.
This study was funded by the Grant-Aid-Program of Seoul National
University Hospital (No. 06 2015 1370; $10,000; original source: Jeil Phar-
maceutical, Seoul, Republic of Korea). The authors report that they have no
conflicts of interest in the authorship and publication of this article. Full
ICMJE author disclosure forms are available for this article online, as
supplementary material.
Received January 1, 2018; accepted June 26, 2018.
Address correspondence to Sae Hoon Kim, M.D., Ph.D., Department of
Orthopaedic Surgery, Seoul National University Hospital, 101 Daehak-ro,
Jongno-gu, Seoul 110-744, Republic of Korea. E-mail: drjacobkim@gmail.
com
Ó 2018 by the Arthroscopy Association of North America
0749-8063/171560/$36.00
https://doi.org/10.1016/j.arthro.2018.06.056
tendon and muscle and the coracoacromial arch during
shoulder movement, and thus, the SAB contributes to
lubrication of the shoulder joint.1,3,4 For this reason, the
SAB is considered one of the most important tissues
associated with discomfort and restriction of shoulder
movement.2,5-7
During arthroscopic rotator cuff repair, subacromial
bursectomy is required for visualization. Furthermore,
some authors are of the opinion that the SAB may be
pathologic tissue and that its removal is likely to reduce
symptoms and enhance outcomes,8,9 and this point of
view is supported by previous reports that inflamma-
tory proliferation of the SAB present in a rotator cuff
tear is related to the degree of pain.8,10 In addition, the
SAB is known to have a significantly richer supply of
free nerve fibers than other tissues, and nociceptive
information relayed by these fibers may be responsible
for pain generation.11,12 Furthermore, bursal specimens
from patients with subacromial bursitis or rotator cuff
disease have shown increases in cytokines, including
interleukin (IL) 1, IL-6, tumor necrosis factor, cyclo-
oxygenase (COX) 1, COX-2, matrix metalloproteases

Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol -, No - (Month), 2018: pp 1-8 1
2 J-H. NAM ET AL.
(MMPs), and substance P.9,12,13 Therefore, subacromial
bursectomy is considered important for reducing
inflammation in rotator cuff disease.9
Other authors have emphasized the biological role of
bursal tissue and recommended avoiding unnecessary
SAB removal.14 In a histologic study, vascularized
connective tissue covering rotator cuff tears and
proliferating cells in fragmented tendons were found to
exhibit more features of repair than of degeneration or
necrosis, and thus, it was suggested that the SAB may
play an important role in tendon reconstitution and
remodeling.14 Furthermore, growth factors and cyto-
kines, such as basic fibroblast growth factor, trans-
forming growth factor b, and vascular endothelial
growth factor, have been detected in SAB tissues.15,16
The purpose of this prospective randomized study was
to evaluate the effects of extensive bursectomy (EB)
and limited bursectomy (LB) during arthroscopic
rotator cuff repair. The hypothesis was that clinical
outcomes, primarily visual analog scale (VAS) pain
scores, would be different in the EB and LB groups.
Methods
Inclusion and Exclusion Criteria
This prospective, randomized controlled study (Korea
Centers for Disease Control & Prevention, registry No.
KCT0002860, http://nih.go.kr/NIH_NEW/intro.html)
was performed after we obtained approval from our
institutional review board (Seoul National University
Hospital Institutional Review Board No. H-1305-610-
492). Written informed consent was obtained from all
participating patients. The study was double blinded,
that is, patients and the single evaluator were unaware
of group assignments.
Sample size analysis was performed before the study
using previously reported VAS pain scores (the primary
study outcome). These previous reports showed that
the VAS pain scores of patients after rotator cuff repair
are normally distributed and exhibit a standard devia-
tion of 2.17 For a mean VAS score difference of 1.5
between groups,18 29 subjects were needed per group
to reject the null hypothesis (power, 0.8; type I error,
.05). Thus, on the basis of a predicted dropout rate of
25%, 78 patients were required.
Patients were enrolled prospectively from April 2015
to April 2016. The following inclusion criteria were
applied: (1) a full-thickness rotator cuff tear was pre-
sent, as verified by preoperative magnetic resonance
imaging (MRI) and confirmed at surgery, and (2)
complete repair was possible arthroscopically. The
exclusion criteria applied were previous ipsilateral
shoulder surgery, incomplete repair, rheumatoid
arthritis, parkinsonism, Alzheimer disease, refusal to
participate, and the need for an additional procedure
such as acromioplasty or SLAP repair.
Surgical Technique and Group Allocation
All surgical procedures were performed by a single
surgeon (S.H.K.). Surgery was performed with patients
under general anesthesia with no additional nerve
block. All patients underwent all-arthroscopic repair of
a full-thickness rotator cuff tear by the single-row repair
technique in the lateral decubitus position.
Initially, an arthroscope was introduced into the gle-
nohumeral joint through a standard posterior viewing
portal, and intra-articular pathology was examined
carefully, particularly biceps status. To address biceps
pathology, biceps tendon debridement was performed
for tears of less than 50% of the tendon width. Biceps
tenotomy or subpectoral tenodesis was performed in
patients with tears greater than 50% of the tendon
width. After completion of the intra-articular proced-
ures, the arthroscope was moved to the subacromial
space. Acromioplasty was not performed in any case
included in this study.
Patients were randomly allocated (by permuted-block
randomization) to either the EB group (n ¼ 39) or LB
group (n ¼ 39). In the EB group, the SAB was thor-
oughly removed with a shaver from anterior to poste-
rior and lateral to medial. Viewing and working portals
were switched to enable complete bursa removal. Bursa
on the medial side of the rotator cuff tendon and
muscle and in the anterior and posterior gutter area
was completely removed in all patients. In the LB
group, bursectomy was minimized to enable torn cuff
visualization and tendon repair.
Rotator cuff repair was performed in a standardized
manner in all study subjects. In each case, the greater
tuberosity was prepared using a motorized burr to
cause surface bleeding. Anchors were inserted at the
lateral footprint margin through an accessory portal
created by a small stab incision. A triple-loaded all-
suture anchor, Y-Knot RC (ConMed Linvatec, Largo,
FL), was used in all cases. Loaded sutures were passed
through the tendon at 0.5 to 1 cm medial to its edge
using a flexible suture passer (Expressew; DePuy
Mitek, Raynham, MA). All knots were tied securely
using a self-locking, sliding knot. The number of an-
chors used depended on tear size: usually 1 for small
tears, 2 or 3 for medium to large tears, and 4 or more
for massive tears.
Rehabilitation
The same rehabilitation protocol was used in the 2
groups. Immobilization was maintained with a sling
and abduction pad for 5 weeks in all patients. After
weaning from brace use, patients were instructed on
how to conduct passive assisted stretching exercises and
active exercises (forward elevation, external rotation,
and internal rotation before active exercises). Return to
sports was not allowed until approximately 5 months
after surgery.
 EXTENSIVE VERSUS LIMITED BURSECTOMY 3

Outcome Evaluation primary outcome at each of these time points. Passive

In accordance with our clinic’s protocol, all data (at
baseline and at 5 weeks and 3, 6, and 12 months after
surgery) were prospectively collected by a clinical
researcher (H-R.L.) unaware of study details and group
assignments (Fig 1). The VAS pain score was the
ranges of motion (ROMs)dforward flexion (FF),
external rotation at the side (ER), and internal rotation
at the back (IR)dwere also evaluated as secondary
outcomes at 3, 6, and 12 months after surgery. Three
patients in the LB group and 4 patients in the EB group

Fig 1. Study flow diagram.

(MRI, magnetic resonance
imaging; ROM, range of
motion; Sono, sonography;
VAS, visual analog scale.)
4 J-H. NAM ET AL.
were lost to follow-up; thus, 36 patients in the LB group
and 35 in the EB group were included in the clinical
outcome analysis.
Pain was assessed by patients using a 10-cm-long VAS
pain ruler. Patients located an indicator on the front of
the ruler with facial expressions and were not able to
see the VAS scores on the other side.19 Possible VAS
scores ranged from 0 to 10, where 10 indicated greatest
pain.
Passive ROM was measured using a goniometer with
the spine in a straight position. Passive FF was
measured in degrees between the arm and thorax in
the scapular plane. Passive ER was measured in degrees
between the thorax and forearm, with the patient’s arm
in an adducted position and the elbow flexed to 90 .
Passive IR was measured using the vertebral level
reached by the thumb tip. The vertebral levels were
numbered serially as follows: 12 for the 12th thoracic
vertebra, 13 for the first lumbar vertebra, 17 for the
fifth lumbar vertebra, and 18 for any level below the
sacral region.20
Routine postoperative sonography was performed at
5 weeks, 3 months, and 6 months and MRI was per-
formed at approximately 1 year after surgery. During
image analysis, bursal thickness was measured and
repair integrity was assessed. Bursal thickness was
measured in 1 location in the middle of the repaired
tendon area, usually above the supraspinatus tendon.
Marked bursal thickening was defined as a measured
bursal thickness of greater than 2 mm either by so-
nography or by MRI (Fig 2).21-23 Image evaluation was
conducted by a musculoskeletal radiologist blinded to
patient information and not otherwise involved in the
study.
Statistical Analysis
Statistical analysis was performed using IBM SPSS
Statistics software (version 21.0; IBM, Armonk, NY).
Group demographic data were compared using the
Student t test and the c-square test. The paired t test
and the Student t test were used to perform intragroup
and intergroup comparisons of outcome variables at
different times. Statistical significance was accepted for
P < .05.
Results
Three patients in the LB group and 4 patients in the
EB group were lost to follow-up, and these patients
Fig 2. Bursal thickness was
measured during assess-
ment of rotator cuff repair
integrity. Sonography (A)
and magnetic resonance
imaging (B) of right shoul-
der. (C) Magnetic reso-
nance imaging of left
shoulder in another patient.
 EXTENSIVE VERSUS LIMITED BURSECTOMY 5

Table 1. Patient Demographic Characteristics and Surgical Data

Variable Limited Bursectomy (n ¼ 36) Extensive Bursectomy (n ¼ 35) P Value

Age, yr 59.7  6.1 60.7  5.4 .484
Sex 17 M and 19 F 20 M and 15 F .403
Laterality 25 right and 11 left 26 right and 9 left .650
Diabetes 3 4 .710
No. of involved tendons S in 9, SþI in 21, and SþIþSubS in 6 S in 3, SþI in 24, and SþIþSubS in 8 .176
No. of anchors/patient 1.9  0.7 2.0  0.7 .379
Biceps procedure None in 14, tenotomy in 3, and subpectoral None in 10, tenotomy in 1, and subpectoral .327
tenodesis in 19 tenodesis in 24
NOTE. Data are presented as mean  standard deviation or absolute number.
F, female; M, male; S, tears confined to 1 tendon (supraspinatus); SþI, supraspinatus tears with some degree of infraspinatus involvement;
SþIþSubS, tears involving 3 tendons (supraspinatus, infraspinatus, and part of subscapularis).

were excluded from the analysis. Finally, 71 patients
were included in the analysis (36 in the LB group and
35 in the EB group) (Fig 1).
Demographic characteristics and surgical data are
shown in Table 1. Biceps procedures were performed in
47 cases (tenotomy in 4 and subpectoral anchor
tenodesis in 43). Tear size was categorized according to
the number of tendons involved; tears confined to 1
tendon (supraspinatus) were observed in 12 cases,
supraspinatus tears with some degree of infraspinatus
involvement were found in 45 cases, and tears
involving 3 tendons (supraspinatus, infraspinatus, and
part of the subscapularis) were observed in 14 cases
(Table 1).
Preoperative VAS pain scores were similar in the 2
study groups, and no significant difference was
observed during follow-up (Table 2). Regarding post-
operative passive ROMs, mean FF was similar in the 2
groups throughout follow-up. However, the LB group
showed significantly better ER at 6 months and 1 year
postoperatively and tended to show greater IR at
6 months postoperatively (Table 3). At final follow-up
(1 year postoperatively), Constant scores, Simple
Shoulder Test scores, and American Shoulder and
Elbow Surgeons scores failed to show any intergroup
differences (Table 4).
Sonography was performed at 5 weeks after surgery
in 69 cases, at 3 months in 66, and at 6 months in 64,
and MRI was performed at 1 year in 41 cases. At
5 weeks and at 3 and 6 months after surgery, integrity
failures evaluated by sonography were not significantly
different. Similarly, no significant intergroup difference
was evident by MRI at 1 year after surgery (Table 5).
Marked bursal thickening was more frequently
observed in the EB group at 6 months but not at 1 year
after surgery (Table 6).
Discussion
The findings of this study suggest EB during rotator
cuff repair may not reduce pain and could lead to
external rotation deficits for up to 1 year after surgery,
which may be due to the formation of adhesions in the
subacromial space. In terms of tendon integrity, no
difference was observed between the 2 study groups.
However, marked bursal thickening was more
frequently observed in the EB group, and this reached
statistical significance at 6 months postoperatively,
which was in accord with the ER limitation observed at
6 months. The minimal clinically important difference
for ER has been proposed to be 11 ,24 and in our study,
the intergroup difference observed at 1 year post-
operatively (13 ) was greater than this value. However,
at 6 months postoperatively, the difference was 9 . In
terms of bursal thickness, normally the SAB is rarely
thicker than 2 mm and greater thicknesses are regarded
as abnormal.21-23
The extent of bursectomy remains uncertain when
performing rotator cuff repair. Some clinicians have
claimed that the bursal tissue is inflamed in painful
rotator cuff tears and that it should be removed to
improve symptom relief,9 whereas others have claimed
that the bursal tissue provides a gliding surface between
the rotator cuff and the acromion and deltoid4 and that
removal of this tissue detrimentally affects repair
because it contains vasculature and growth factors.2
Furthermore, it has been claimed that after the crea-
tion of a bleeding milieu by thorough bursectomy,
fibrosis could occur and cause ROM limitation. The
results of our study concur with this hypothesis.
Biomolecular studies have indicated that various cy-
tokines play roles in inflammation of the SAB.9,13,25,26
In these studies, proinflammatory factors were
Table 2. Preoperative and Postoperative VAS Pain Scores
VAS Pain Score
Limited Extensive
Bursectomy (n ¼ 36) Bursectomy (n ¼ 35) P Value
Preoperative 4.8  2.5 4.4  1.9 .477
5 wk PO 2.7  1.6 2.7  2.0 .956
3 mo PO 3.5  2.2 4.0  2.2 .338
6 mo PO 2.2  1.6 2.3  1.6 .827
1 yr PO 1.6  1.8 1.0  1.5 .173
NOTE. Data are presented as mean  standard deviation.
PO, postoperative; VAS, visual analog scale.
6 J-H. NAM ET AL.

Table 3. Postoperative Serial ROM

Limited Bursectomy (n ¼ 36) Extensive Bursectomy (n ¼ 35) P Value

3 mo PO
Forward flexion,  111  25 110  28 .841
External rotation,  20  19 13  18 .156
Internal rotation (spine level reached) 14.5  3.0 14.4  2.8 .948
6 mo PO
Forward flexion,  139  25 128  26 .089
External rotation,  31  15 22  16 .020
Internal rotation (spine level reached) 11.4  2.6 12.6  3.0 .091
1 yr PO
Forward flexion,  154  17 152  17 .646
External rotation,  40  19 27  20 .009
Internal rotation (spine level reached) 9.4  2.4 10.0  2.9 .403
NOTE. Data are presented as mean  standard deviation.
PO, postoperative; ROM, range of motion.

targeted and IL-1b levels were found to be elevated in cuff repair.29 However, in this study we failed to detect
the bursal tissues of patients with rotator cuff disor- any difference between EB and LB in terms of rotator
ders.25,26 A correlation was reported between increased cuff healing.
IL-1b messenger RNA expression in bursae and pre- One should bear in mind that acromioplasty was not
operative ROM and Constant scores,25 and a relation performed in any case during our study, and recently,
was also reported between its expression and VAS pain suspicion was cast on the effect of acromioplasty.30,31 In
scores.26 Other cytokines, such as tumor necrosis factor, a previous study, bursectomy alone without acromio-
IL-1a, IL-6, MMP-1, MMP-9, COX-1, COX-2, and plasty was proposed to be effective in the treatment of
substance P, have also been reported to be increased in rotator cuff disease.8,32
the SAB in rotator cuff disorders.9,13 In line with these
findings, it was claimed in a previous study that simple Limitations
arthroscopic resection of the SAB appears to be as Regarding study limitations, first, LB and EB are
effective as subacromial decompression with acromio- subjective concepts and have no literature basis, and
plasty.27On the other hand, the SAB could provide a thus, the cutoff point used in this study may be debat-
smooth gliding surface between the coracoacromial able. As we verified previously, bursae in the LB group
arch and rotator cuff. Furthermore, the SAB may assist were saved as much as possible to visualize and repair
tendon healing by providing a healing milieu because torn rotator cuffs, whereas in the EB group, bursae
bursal tissue is rich in stem cells, growth factors, and were cleared to the anterior and posterior gutter areas
other biological factors.28,29 Tendons also contain stem and to the far medial part of the rotator cuff muscle and
cells, but their amounts and differentiation capacities from torn cuff areas. Second, rehabilitation is a concern
are considerably less than those in bursae. In addition, because controversy exists regarding the best time to
inflammatory cytokines expressed in bursal tissue could start passive ROM exercise after rotator cuff repair.33
aid tendon healing during the early reparative phase of Some authors have reported that early ROM exercise
does not affect healing rates as compared with delayed
rehabilitation and results in the early restoration of
Table 4. Functional Scores of Both Study Groups
ROM.34,35 Furthermore, it has been suggested recently
Limited Extensive
Bursectomy Bursectomy
(n ¼ 36) (n ¼ 35) P Value Table 5. Integrity of Rotator Cuff Tendons
Constant score
Cuff Integrity: Intact vs Defect, n
Preoperative 60.5  15.5 63.9  13.2 .326
Postoperative (1 yr) 76.6  9.4 77.1  10.1 .856 Limited Extensive
SST score Bursectomy Bursectomy P Value
Preoperative 4.4  2.8 4.9  2.7 .477 5 wk PO 35 vs 1 30 vs 3 .343
Postoperative (1 yr) 9.5  2.7 9.5  3.0 .962 3 mo PO 35 vs 1 27 vs 3 .323
ASES score 6 mo PO 32 vs 0 28 vs 4 .113
Preoperative 60.7  14.6 64.1  15.3 .349 1 yr PO 17 vs 3 18 vs 3 .948
Postoperative (1 yr) 87.8  12.2 91.1  11.3 .280 NOTE. Sonography was performed at 5 weeks, 3 months, and
NOTE. Data are presented as mean  standard deviation. 6 months and magnetic resonance imaging was performed at 1 year
ASES, American Shoulder and Elbow Surgeons; SST, Simple postoperatively.
Shoulder Test. PO, postoperative.
 EXTENSIVE VERSUS LIMITED BURSECTOMY
Table 6. Marked Bursal Thickening (>2 mm) in Both Groups
at Different Times After Surgery
Marked Bursal Thickening: Yes vs No, n
Limited Extensive
Bursectomy Bursectomy P Value
5 wk PO 21 vs 15 24 vs 9 .210
3 mo PO 25 vs 11 26 vs 4 .141
6 mo PO 18 vs 14 27 vs 5 .014
1 yr PO 15 vs 5 17 vs 4 .719
NOTE. Sonography was performed at 5 weeks, 3 months, and
6 months and magnetic resonance imaging was performed at 1 year
postoperatively.
PO, postoperative.
that delayed rehabilitation does not alter functional
outcomes or improve the tendon healing rates of large
tears.36-38 In our study an identical rehabilitation pro-
tocol was applied in all study subjects, that is, 5 weeks
of immobilization with no passive ROM exercise fol-
lowed by gradual rehabilitation, regardless of tear size.
Third, no imaging follow-up was performed in some
cases (mostly for financial reasons), although a suffi-
cient number were followed up to meet the sample size
requirements for the determination of primary out-
comes. In addition, at the last imaging follow-up visits,
MRI was used instead of sonography, which may have
influenced measured bursal thicknesses. However,
group comparisons made at each time point were per-
formed using findings obtained using the same
modalities.
Conclusions
EB during arthroscopic rotator cuff repair appears to
have no benefit in terms of reducing pain and may
retard motion recovery by promoting adhesion forma-
tion in the subacromial space. In terms of tendon
integrity, bursectomy extent did not affect the results.
However, marked bursal thickening was more
frequently observed in the EB group.
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