Is Arthroscopic Rotator Cuff Repair Superior?

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Chapter 100 Is Arthroscopic Rotator Cuff Repair Superior?

RICHARD M. HOLTBY, MBBS, FRCSC, SHASHANK. MISRA, MBBS, DNB

Tears of rotator cuff can be repaired by open or mini-open surgery, or arthroscopically. Codman first described open repair in 1911. Charles Neer is credited with describing the most commonly performed open technique in which acromioplasty with or without resection of the lateral end of clavicle is performed, a bone trough is made at the articular margin for reattachment of the cuff, and transosseous sutures are placed through bone tunnels. Complex sutures are possible because of the open exposure. The advent of a mini-open technique was largely in response to the most important shortcoming of open repair, the necessity for deltoid detachment. In the mini-open technique, the acromioplasty is done arthroscopically, and the cuff repaired through a smaller deltoid-splitting incision. Most recently, advances have allowed the passage of sutures arthroscopically and, therefore, an all arthroscopic rotator cuff repair procedure.

The advantages of minimally invasive surgery over more invasive techniques are generally recognized. With minimal soft-tissue violation, pain and tissue damage are minimized, reducing analgesic use and potentially allowing early discharge from hospital and return of function. The risk for stiffness, which is common after open surgery, may be minimized. In addition, it has been suggested that the use of the arthroscope, when repairing the rotator cuff, offers specific advantages. It not only spares the deltoid from potential detachment, it provides enhanced visualization of the tear and associated pathology. Tear geometry and edge mobility are better appreciated when observed arthroscopically. Intra-articular pathology of the biceps tendon, labrum, and articular cartilage, which could affect decision making, can be assessed. Concerns about arthroscopic repair include inadequate visualization because of bleeding, fluid extravasation, difficulty in passing sutures, suture failure, and a steep learning curve. Arguably, advances in technology and technique have addressed all but the last of these concerns. The cost of arthroscopic surgery in terms of time and equipment remains a concern. This chapter analyzes the evidence available to support decision making in rotator cuff repair surgery.

PREFERENCES—A MATTER OF CHOICE

No Level I or II full manuscript published reports of studies favor 1 type of repair over another. Mohtadi and Hollingshead ⁴⁶ compared open with mini-open repairs in a randomized, controlled trial and found no difference in disease-specific quality-of-life outcomes at 1 year (only available Level I evidence on rotator cuff repair). Most of the evidence in the literature is Level III with patients compared retrospectively. These articles often report a surgeon’s transition from an open to a less invasive technique. The open cases serve as a control group for the newer technique.¹^–⁵ Such studies are generally poorly controlled and subject to the multiple types of bias inherent in retrospective studies. Retrospective Level IV studies, where cohorts are studied after a particular surgery and analyzed without any comparator group, are most common and are ill-equipped to compare one technique over another.

A surgeon’s preferences are largely dictated by the training the surgeon has received. In agreement with elsewhere in surgery, there appears to be a general trend toward less invasive procedures. The patient choice, however, is clear. Sperling and colleagues ⁶ demonstrate an overwhelming 92% patient preference for arthroscopic shoulder surgery compared with open. Patients anticipated superior functional outcomes and less morbidity with arthroscopic surgery. Moreover, a significant number of patients would prefer to avoid surgery if the only option was an open procedure. In the consumer-driven society of today, patient preferences at least partially explain the trend from open to mini-open, and ultimately to arthroscopic cuff repair.

Assessment of the success of cuff repairs is problematic. Historically, success was measured using relatively crude, nonvalidated assessments of clinical parameters, sometimes assigning a score or groupings such as good or excellent. Modern studies more often use functional outcome measures in which the patients assess their symptoms and ability to function using validated, specially designed questionnaires. There has also been a move recently to look at success in terms of the integrity of the repair using imaging methods such as magnetic resonance imaging (MRI) or ultrasound. This difference in the way success is measured makes it difficult to compare studies and particularly to compare new and old repair techniques. In general, most authors have reported clinical improvement after all types of cuff repairs. Since Codman’s first description in 1911, many surgeons have reported good results with open repairs. Ellman,⁷ Hawkins,⁸ Cofield⁹, and others report in early articles 72% to 87% good to excellent results on the basis of improvement in pain, function, and strength (Level IV). More recently, Klepps,¹⁰ Mellado,¹¹ and Bishop and others¹² have shown 71% to 90% good functional results. Whereas Mellado and coworkers¹¹ used the UCLA score (and postoperative MRI studies), others have used American Shoulder and Elbow Surgeons (ASES) and Constant scores. Functional outcome scores of arthroscopic repairs are similar. Burkhart and coauthors,^13,¹⁴ Gartsman and coworkers,¹⁵ Youm and researchers,¹⁶ and Bishop and others¹² (ASES and Constant) have reported 80% to 93% satisfaction rates using UCLA and Constant scores (Level IV).

Studies of early arthroscopic repairs suggest greater re-tear rates than with open surgery. Improvements in implants and evolution of technique now are reported to produce intact cuffs as often as open repairs. Verma and coworkers ¹⁷ found a 25% re-tear rate after both mini-open and arthroscopic repairs at 2-year ultrasound follow-up (Level III). Boileau and coauthors¹⁸ report a 29% recurrence rate on computed tomography (CT). Fuchs⁴³, and Goutalier⁴⁴ found a 10% to 30% re-tear rate for small and medium tears with greater rates for massive tears. In the largest multicenter study published to date, Flurin et al.¹⁹ assessed 576 arthroscopically repaired cuffs with MRI or CT arthrogram. Seventy-five percent showed no dye leakage compared with a mean of 69% for all published series in the literature for open repairs (Level IV). The authors conclude that arthroscopic repairs yield intact cuffs as often as open repairs. Previously, Gerber and colleagues²⁰ had provided a useful reference point, reporting an MRI-proven recurrent defect in 40% of open repairs of massive tears in 32 shoulders compared with 22% for arthroscopic repairs in 49 shoulders, which included multiple tendon tears²¹ (Level III). Lafosse⁴¹ reports a 12% failure rate on 105 cuffs repaired arthroscopically; 70% of these tears were large or massive.

Verma and coworkers,¹⁷ Bishop and others¹² have found that good functional results are possible in the absence of a watertight repair. Irrespective of the technique used, however, there is evidence that intact repairs correlate with better functional results. In 1991, Harryman⁴⁵ suggested that clinical results after open repair correlate with cuff integrity based on ultrasound. Though he found significant satisfaction rates in terms of motion, strength, and pain relief even in the presence of recurrent defects, better results were seen with intact cuffs. Gerber and colleagues²⁰ found that patients who had a re-tear (on MRI) showed less improvement than those who had intact repairs.