Editorial Commentary: Tension of the Repair During Rotator Cuff Surgery Appears to Matter More Than Medial-Lateral Footprint Coverage.

The ideal rotator cuff repair construct has low tension, maximizes footprint coverage, is biomechanically strong, and optimizes tendon-to-bone healing. However, these principles are not always feasible, especially with larger tear patterns and poor tendon quality, factors that are also associated with higher retear rates. There is a constant effort with often opposing priorities to achieve a tension-free rotator cuff repair while also achieving maximal footprint coverage. This is not always possible, and there are few data to guide surgeons on which factor-tension-free repair or footprint coverage-should be prioritized. Recent studies have reported that achieving a tension-free repair with incomplete medial-to-lateral footprint coverage leads to similar functional and radiographic outcomes to complete footprint coverage using a transosseous-equivalent repair with bone marrow stimulation. Many factors affect rotator cuff tendon-to-bone healing, most notably tear size and retraction, tendon quality/preoperative fatty infiltration, repair construct, patient age, and medical comorbidities. In terms of these factors, achieving a tension-free repair and achieving maximal footprint coverage are some of the only factors we can control during surgery. However, although we may be able to pull the torn tendon edge all the way over to the lateral aspect of the footprint during our reduction maneuver, we know that fixing the tendon in this location creates a significant risk of a type 2 retear due to high tension. In the end, achieving a tension-free repair is probably the most important factor during rotator cuff repair-even if it comes at the cost of a smaller amount of medial-to-lateral footprint coverage.