Orthopedics Arthroscopic vs Open Rotator Research Paper

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According to recent research published in the Journal of Shoulder and Elbow Surgery, "Economic evaluation of surgical procedures is necessary in view of more expensive newer techniques emerging in an increasingly cost-conscious health care environment (18).

Rotator cuff tendon repair has been reported to yield excellent, durable clinical results that are superior to the natural history of the condition. Retears after a repair of one tendon occur with variable frequency. They are not synonymous with clinical failure, but they are associated with a poorer clinical outcome than are repairs followed by structural healing. Chronic tendon tears are usually associated with atrophy and fatty infiltration of the rotator cuff muscles. These changes reflect loss of contractile elements and may be responsible for changes in the physiological properties of the remaining musculotendinous units (7). Such changes can be assessed quantitatively with magnetic resonance imaging and correlated with age and gender-matched normal values, making it possible to study the changes in the musculotendinous units associated with a chronic tendon (2).

Schneeberger et al. (8) explained that Retears after rotator cuff repairs occur with a relatively high frequency, and it seems that intact repairs yield substantially better functional results than retears do. In previous in vitro and in vivo studies, the researchers assessed different open tendon-suturing and bone-anchoring techniques on sheep infraspinatus tendons. A modified Mason-Alien tendon stitch was found to be biologically compatible, and, combined with a bone augmentation membrane, it yielded the most favorable mechanical repair properties with high failure loads of about 350 N. For two stitches, with use of number-3 Ethibond sutures, and superior stiffness characteristics. Because of the improvement in arthroscopic tools, and considering the advantages of arthroscopic surgery, interest in arthroscopic repairs of the rotator cuff is growing rapidly. Most current arthroscopic techniques for rotator cuff repair use simple or mattress stitches fixed with bone anchors with use of number-1 or 2 suture materials. Simple or mattress stitches have, however, shown failure loads of only 184 and 269 N, respectively, with two stitches of number-3 suture material. With thinner suture materials, which are currently used in arthroscopic surgery, even lower holding strengths would be expected.

In 2003 researchers confirm that the minimally invasive "AutoCuff System" made its public debut earlier that year at the American Academy of Orthopedic Surgeons Annual meeting; developed by California-based Opus Medical, Inc. And a team of researchers and forward thinking orthopedic surgeons (including Dr. Hawkins), this new FDA-approved technology enables surgeons to perform rotator cuff repair without open surgery or knot-tying of any kind. The system itself is comprised of two instruments, the SmartStitch Suturing Device and the Magnum Knotless Fixation Implant. When used together, they eliminate the shortcomings of current shoulder repair devices. The SmartStitch Suturing Device delivers a unique "incline" mattress stitch directly into the tissue in a matter of seconds. The surgeon then loads and deploys the Magnum Implant, a device containing an internal mechanism that provides cinch able and reversible suture tension to achieve an excellent tissue-to-bone interface result without knots (23).

Arthroscopic repair of a rotator cuff tear with use of the double-row suture anchor technique results in a much lower rate of failure than has previously been reported in association with either open or arthroscopic repair methods. Patients with an intact rotator cuff repair have better pain relief than those with failed repair new findings from L. Lafosse and co-authors describe advances in surgical technologies (17).

The purpose of this researchers study was to systematically review the English-language literature to see if there is a difference between single-row and double-row fixation techniques in terms of clinical outcomes and radiographic healing. PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE were reviewed with the terms 'arthroscopic rotator cuff,' 'single row repair,' and 'double row repair.' The inclusion criteria were a level of evidence of III (or better), an in vivo human clinical study on arthroscopic rotator cuff repair, and direct comparison of single-row and double-row fixation. Excluded were technique reports, review articles, biomechanical studies, and studies with no direct comparison of arthroscopic rotator cuff repair techniques. On the basis of these criteria, ten articles were found, and a review of the full-text articles identified six articles for final review. Data regarding demographic characteristics, rotator cuff pathology, surgical techniques, biases, sample sizes, postoperative rehabilitation regimens, American Shoulder and Elbow Surgeons scores, University of California at Los Angeles scores, Constant scores, and the prevalence of recurrent defects noted on radiographic studies were extracted. Confidence intervals were then calculated for the American Shoulder and Elbow Surgeons, University of California at Los Angeles, and Constant scores (20).

A few low-quality case series have evaluated the outcomes of these two surgical interventions. A completely arthroscopic technique has been reported as effective across a spectrum of tears, specifically in small to medium, moderate to large, and large/massive tears. There is consensus across these studies that clinical improvements can be obtained in the majority of cases, although a recurrent defect was reported in large or massive tears. Similarly, other cases series report a high percentage of good/excellent results in patients treated with arthroscopically assisted mini-open repairs across a spectrum of tear sizes, specifically for both small/moderate to large tears (5).

Research was conducted on 30 consecutive patients, of whom 15 had an arthroscopic repair and 15 had an open procedure. Clinical effectiveness was assessed using Oxford and Constant shoulder scores. Costs were estimated from departmental and hospital financial data. At last follow-up, no difference Oxford and Constant shoulder scores was noted between the 2 methods of repair. There was no significant difference between the groups in the cost of time in the operating theater, inpatient time, and amount of postoperative analgesia, number of postoperative outpatient visits, physiotherapy costs, and time off work (18).

Comparisons of mini-open vs. all-arthroscopic rotator cuff repair. Two studies found similar disability and strength scores at follow-up; another study reported similar long-term disability, but faster return of motion in the arthroscopic group as compared to the mini-open procedure. In these studies, patients were not randomized, follow-up was retrospective, and in one study, patients received a mini-open procedure following "technical failure" of arthroscopic repair. Thus, these low-quality studies from different subpopulations may be biased since groups potentially differ in their prognostic balance. Further, comparison across previous studies is difficult due to variation in patient selection techniques, symptom duration, disability levels, and extent of pathology. To date, no randomized clinical trial has attempted to compare the results of an all-arthroscopic repair to an arthroscopically assisted mini-open repair. High-quality evidence is required to assist surgeons to determine whether the move towards less invasive procedures in cuff repair is appropriate (5).

The clinical and structural outcomes of patients with known rotator cuff defects will remain unchanged after a longer period of follow-up. Case series; Level of evidence, This study was performed in 15 patients (18 shoulders) from a previous study who had recurrent rotator cuff defects 3.2 years after repair. Each patient completed the American Shoulder and Elbow Surgeons Scoring Survey, the Simple Shoulder Test, the L'Insalata Scoring Survey, and a visual analog scale for pain. Eleven patients (13 shoulders) were clinically reexamined at an average of 7.9 years for range of motion and strength, with targeted ultrasound. At the 7.9-year follow-up the average scores were 95, 11 (Simple Shoulder Test), and 0 (visual analog for pain), which were not statistically significantly different from the scores at 3.2 years. There was no change in the average range of motion; however, there was a statistically significant reduction in forward flexion strength and external rotation strength, as measured by a dynamometer. The average external rotation strength decreased by a mean of 42% and the mean forward flexion strength decreased by a mean of 45% (p <.001). Furthermore, there was a statistically significant increase in the mean size of the defect, from 273 mm (2) to 467 mm (2) (p <.001) (11).

According to a study from the United States, although a number of reports have documented outcomes after open revision rotator cuff repair, there are few studies reporting results after arthroscopic revision. Arthroscopic repair of failed rotator cuff results in significant improvement in shoulder functional outcome and pain relief. The researchers concluded: Female patients and those who have undergone more than 1 ipsilateral shoulder surgery are at increased risk for poorer results (19).

The study evaluated by Pearsall et al. (6) reported on the functional outcome in similar patient groups undergoing arthroscopically-assisted or completely arthroscopic rotator cuff repair. With the numbers available, there was no statistical difference between the two groups for any independent variable. When data at the most recent follow-up was compared to pre-operatively for the whole group, there was a statistical improvement in 7 out of 9 clinical parameters. Although active internal rotation was improved compared to preoperatively, the improvement did not meet statistical significance. Finally SF-12 scores were essentially unchanged from pre-operatively. Since the SF-12 measures well being, in addition to physical parameters, several parameters not-related to the patients' shoulder…[continue]

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