Orthopedics: Arthroscopic vs. Open Rotator

ORTHOPEDICS: ARTHROSCOPIC vs. OPEN ROTATOR CUFF

ORTHOPEDICS: ARTHROSCOPIC vs. OPEN ROTAR CUFF

Arthroscopic vs. Open Rotator Cuff

Orthopedics: Arthroscopic vs. Open Rotator cuff repair

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Data was compiled to research Arthroscopic vs. open Rotator cuff repair. The findings suggest that regardless of the method utilized for repair there will more than likely be a need for maintenance repairs. Healing time is consistent between the two methods, and cost associated with both procedures is comparable. Researchers have indicated consistently through the research that there is a need for additional therapy of some sort after any procedure has been implemented. However, significant research does indicate that there is a higher level of skill associated with Arthroscopic procedures, this process has proven to be rather effective but intricate in nature; therefore calling for more experience than open rotator cuff procedures. Regardless of the technique utilized one thing remains consistent throughout the research; more often than non-additional repairs will have to be done, and method utilized should be due to the choice of the client in conjunction with the expertise of the surgeon.

Orthopedics: Arthroscopic vs. Open Rotator Cuff Repair

Damage to the rotator cuff that can be due to trauma, as from falling and injuring the shoulder; overuse in sports, particularly those that involve repetitive overhead motions; inflammation, as from tendonitis, bursitis, or arthritis of the shoulder; or degeneration, as from aging. The main symptom of rotator cuff disease is shoulder pain of gradual or sudden onset, typically located to the front and side of the shoulder and increasing when the shoulder is moved away from the body. A person with torn rotator cuff tendons may not be able to hold the arm up because of pain. With very severe tears, the arm falls because of weakness; this is called the positive drop sign. Diagnosis is made via observation and can be confirmed with X-rays showing bony injuries; an arthrogram in which contrast dye is injected into the shoulder joint to detect leakage out of the injured rotator cuff; or a magnetic resonance imaging (MRI) scan, which can provide more information than either an X-ray or an arthrogram. Treatment depends on severity (22).

Problems of the shoulder are common enough that they touch all of us. Chances are that if you have not personally suffered from a torn rotator cuff, you are aware of a spouse, family member, colleague or close friend who has. Shoulder injuries specifically, tom rotator cuffs -- can be caused by trauma or sports activities that involve repetitive overhead motion, such as golf, tennis, swimming and throwing. More commonly, individuals engaged in everyday activities like washing windows, gardening or lifting can experience shoulder injuries due to repetitive overhead arm movement. Each year, an estimated four million people in the United States seek medical attention for shoulder injuries. Nearly 300,000 will undergo surgical repair of the rotator cuff. The vast majority of these surgeries are performed by "open" or "mini-open" surgical techniques (23).

The reported rate of failure after arthroscopic rotator cuff repair has varied widely. The influence of the repair technique on the failure rates and functional outcomes after open or arthroscopic rotator cuff repair remains controversial (17).

Surgical options for rotator cuff disease that has failed to improve with conservative treatments include open or arthroscopic subacromial decompression (ASD) with or without rotator cuff repair (RCR). Arthroscopic approaches are being increasingly used because of purported advantages including earlier recovery, hypothesized to be due to preservation of the deltoid muscle with this approach; smaller scars; and the ability to access the glenohumeral joint to exclude other causes of shoulder pain. Researchers recently completed a Cochrane systematic review of randomised controlled trials to determine the effectiveness and safety of surgery for rotator cuff disease. Researchers identified six trials that had compared arthroscopic to open subacromial decompression and while it was not possible to draw firm conclusions due to their overall poor quality, none of the trials reported significant differences between trial arms in terms of comparative improvements in pain, function or participant evaluation of success, while four trials reported earlier recovery with arthroscopic decompression. There were also no differences between trial arms for adverse events including post-operative adhesive capsulitis (1).

The clinical outcomes of the surgical methods of rotator cuff repair (open, mini-open, and all-arthroscopic cuff repair) vary, as each method provides an array of advantages and disadvantages. Although the open surgical technique has long been considered the gold standard of rotator cuff repair, surgeons are becoming more adept at decreasing patient morbidity through decreased surgical trauma from an all-arthroscopic approach. In addition to a surgery-specific rotator cuff rehabilitation program, effective communication, and coordination of care by the physical therapist and surgeon are essential in optimal patient education and outcomes. In the ideal situation, a very well-educated therapist who has great communication with the treating surgeon can mobilize the shoulder early, re-establish scapulothoracic function safely and minimize the risk of stiffness and retear, while facilitating return to function, Treatment options can be individualized according to patient age, size and chronicity of tear, Surgical approach, and fixation method (21).

This is not a new notion. For years, orthopedic surgeons have sought a means to effectively perform arthroscopic surgery, a minimally invasive surgery technique, to repair torn rotator cuffs. Indeed, some surgeons around the country have seen success performing rotator cuff repairs arthroscopically, but it has been a difficult procedure to teach and perform and due to the limited visibility and complicated knot-tying involved, it has rarely yielded the same level of results as open surgery. Indeed, less than ten percent of rotator cuff repairs are currently performed through minimally invasive, totally arthroscopic surgery (23).

Researchers recommend that patients who have undergone an all-arthroscopic rotator cuff repair undergo an accelerated postoperative rehabilitation program. A rational approach to therapy involves early, safe motion to allow optimal tendon healing, yet maintenance of joint mobility with minimal stress. As the field of orthopedics and, particularly, rotator cuff repair continues to develop with new technologies, the patient, physical therapist, and doctor need to work together to ensure optimal outcomes and patient satisfaction (21).

The purpose of the research conducted by Lafosse was to evaluate the functional and anatomic results of arthroscopic rotator cuff repairs performed with the double-row suture anchor technique on the basis of computed tomography or magnetic resonance imaging arthrography in order to determine the postoperative integrity of the repairs. A prospective series of 105 consecutive shoulders undergoing arthroscopic double-row rotator cuff repair of the supraspinatus or a combination of the supraspinatus and infraspinatus were evaluated at a minimum of two years after surgery. The evaluation included a routine history and physical examination as well as determination of the preoperative and postoperative strength, pain, range of motion, and Constant scores. All shoulders had a preoperative and postoperative computed tomography arthrogram (103 shoulders) or magnetic resonance imaging arthrogram (two shoulders). There were thirty-six small rotator cuff tears, forty-seven large isolated supraspinatus or combined supraspinatus and infraspinatus tendon tears, and twenty-two massive rotator cuff tears. The mean Constant score (and standard deviation) was 43.2 +/- 15.1 points (range, 8 to preoperatively and 80.1 +/- 11.1 points (range 46 to postoperatively. Twelve of the 105 repairs failed. Intact rotator cuff repairs were associated with significantly increased strength and active range of motion (14).

Among many physicians it has been stated that there is not a significant difference between arthroscopic and open rotary cuff repair, however it is a matter of technique that often draws the line between the two styles of repair. Rotator cuff tears are the most common source of shoulder pain and disability. Only poor quality studies have compared mini-open to arthroscopic repair, leaving surgeons with inadequate evidence to support optimal, minimally-invasive repair (5).

Anatomic studies detailing rotator cuff tears in cadavers have noted a prevalence ranging from 17% to 72%. Traditional treatment of full thickness tears of the rotator cuff has consisted of open surgical repair . Reported satisfactory outcomes for open repair have ranged from 70% to 95%. Although the effectiveness of open rotator cuff repair is well established, significant pain and morbidity can be associated with the procedure. A significant limitation to rehabilitation after open repair is pain associated with reattachment of the deltoid to the acromion. More recently, reports have described the evolution of rotator cuff repair to help minimize deltoid trauma and expedite post-operative rehabilitation. Good results have been reported with arthroscopically-assisted "mini-open" repair, as well as completely arthroscopic techniques (6).

Rotator cuff repair has evolved from a classic open operative technique, which involved significant deltoid dissection and detachment, to a less invasive approach called the mini-open deltoid splitting approach. Long-term results were similar and rehabilitation was easier for patients who had the mini-open approach. Now more surgeons are repairing the rotator cuff with an all-arthroscopic technique, and this study compares Nottage's results with repairs done arthroscopically to the repairs they previously performed through the mini-open approach (10).

Investigators publish new data in the report 'Cost-effectiveness of open vs. arthroscopic rotator cuff repair. 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

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 may have contributed to this lack of improvement. For both groups, the overall improvement observed in pain and function is comparable to reports by other authors.

Research completed compared the clinical and quality of life related outcome of rotator cuff repair performed using either mini-open or an arthroscopic technique for rotator cuff tears of less than 3 cm. The records of 64 patients who underwent rotator cuff repair between September 2003 and September 2005 were evaluated. Thirty-two patients underwent a mini-open rotator cuff repair, and 32 patients underwent an arthroscopic rotator cuff repair. The mean follow-up period was 31 months in the mini-open group and 30.6 months in the arthroscopic group (p >0.05). The UCLA rating system, range of motion examination and the self-administered SF-36 used for postoperative evaluation showed a statistically significant improvement from the preoperative to the final score for both groups (p 0.05),the researchers concluded: This study suggests that there is no difference in terms of subjective and objective outcomes between the two surgical procedures studied if patients have rotator cuff tears of less than 3 cm (12).

Schroder et al. (7), state that from 1988 till 1997, 272 acromioplasties on 250 patients were performed. The researchers were able to follow up 238 patients. There were 111 men and 127 women with a mean age of 46 (17 to 77). 12 patients were lost to follow up, 2 died, 7 were untraceable due to moving abroad. Three patients were excluded one with a malignancy of the scapula, one with a shoulder instability after sustaining a shoulder injury in the postoperative period and one with a conversion confirmed by the psychiatrist. The mean follow up was 21/2 years (1 to 10 years). There were no differences in age and follow up between the patient groups. In 129 cases the right shoulder was involved, in 86 the left and in 23 patients both shoulders were treated. Of the 261 shoulders treated primary for a subacromial impingement 80 procedures were performed open and 181 arthroscopically. The difference in outcome between the results of the patients treated by open technique and the patients treated arthroscopically by experienced surgeons is significant (P < 0.05). Significant worse (P < 0.05) is the outcome of the first 10 arthroscopic procedures.

There were no significant differences between the patients with a supraspinatus tear and those with a subscapularis tear with regard to the relative or absolute Constant score, score for activities of daily living, amounts of functional flexion and abduction, and strength of abduction. However, preoperative external rotation was significantly greater in patients with a subscapularis tear than in patients with a supraspinatus tear (p < 0.017), and preoperative internal rotation was significantly less in patients with a subscapularis tear than in patients with a supraspinatus tear (p < 0.011). There was a trend toward patients with a subscapularis tear having more preoperative pain than those with a supraspinatus tear, but this was not significant (2).

The aim of this study was to determine the functional outcome and rate of re-tears following mini-open repair of symptomatic large and massive tears of the rotator cuff using a two-row technique. The 24 patients included in the study were assessed prospectively before and at a mean of 27 months (18 to 53) after surgery using the Constant and the Oxford Shoulder scores, researchers in the United Kingdom report. Ultrasound examination was carried out at follow-up to determine the integrity of the repair. Patient satisfaction was assessed using a simple questionnaire. The mean Constant score improved significantly from 36 before to 68 after operation (p < 0.0001) and the mean Oxford Shoulder score from 39 to 20 (p < 0.0001). Four of the 24 patients (17%) had a re-tear diagnosed by ultrasound. A total of 21 patients (87.5%) were satisfied with the outcome of their surgery. The repair remained intact in 20 patients. The researchers concluded: "However, the small number of re-tears (four patients) in the study did not allow sufficient analysis to show a difference in outcome in relation to the integrity of the repair (4).

There was no significant difference between the single-row and double-row groups within each study in terms of postoperative clinical outcomes. However, one study divided each of the groups into patients with small-to-medium tears (or=3 cm in length), and the authors noted that patients with large to massive tears who had double-row fixation performed better in terms of the American Shoulder and Elbow Surgeons scores and Constant scores in comparison with those who had single-row fixation. Two studies demonstrated a significant difference in terms of structural healing of the tendons after surgery, with the double-row method having superior results. There was an overlap in the confidence intervals between the single-row and double-row groups for all of the studies and the American Shoulder and Elbow Surgeons, Constant, and University of California at Los Angeles scoring systems utilized in the studies, indicating that there was no difference in these scores between single-row and double-row fixation. Potential biases included selection, performance, detection, and attrition biases; each study had at least one bias. Two studies had potentially inadequate power to detect differences between the two techniques. There appears to be a benefit of structural healing when an arthroscopic is performed with double-row fixation as opposed to single-row fixation. However, there is little evidence to support any functional differences between the two techniques, accept, possibly, for patients with large or massive tears (20).

Arthroscopic repair of rotator cuff tears can yield excellent results. This less invasive technique offers potential advantages over open surgery -- less surgical morbidity and perioperative pain, improved shoulder function, a more comprehensive evaluation of the joint, faster rehabilitation, and a better cosmetic result (9). The criticisms of the arthroscopic subacromial decompression given by Schroder et al. (7) have mainly revolved around the considerable learning curve. The researcher's results from surgeons not yet familiar with the procedure are discouraging due to the high failure rate. The arthroscopic method is a highly demanding procedure reserved for the experienced arthroscopic surgeon. Unlike most other arthroscopic procedures, the surgeon is working in a narrow space. The view is most often obstructed by a greater or lesser amount of fibrous tissue which is located in the subacromial bursa and which is part of the proliferative changes developed with the disease. The results strongly indicate the need for an intensive teaching course including cadaver studies.

In conclusion, the study evaluated by Pearsall et al. (6) reached the following outcome of patients undergoing an arthroscopically-assisted or completely arthroscopic technique for repair of a small or medium rotator cuff tear. Based upon the number available, they found no statistical difference in outcome between the two groups, indicating that either procedure is efficacious in the treatment of small and medium size rotator cuff tears. Researchers believe that Arthroscopic tendon-to-bone repairs are technically more difficult than open repairs because all surgical steps have to be performed through cannulae. This limits the selection of the instruments and the implants and may increase operative time. Most of the currently applied arthroscopic techniques of rotator cuff repair use a simple or a mattress stitch and suture fixation with bone anchors. The bone anchors typically use number-2 braided polyester sutures, which are weaker (8).

Current study results from the report, management of the failed rotator cuff surgery: causation and management, have been published. According to a study from the United States, "Rotator cuff repair is a common orthopedic procedure. Techniques have evolved from open procedures to an arthroscopic (assisted) procedure in many patients. Tendon healing is anticipated, but complications may occur. There is approximately 90% patient satisfaction with index surgery, but imaging studies reveal defect recurrence in approximately one-third of the larger tears. For patients who are limited by pain, revision surgery is considered. Newer techniques of stabilizing the damaged structures, combined with delay in rehabilitation, improved the number of successful surgeries. Revision surgery for pain relief is promising when causes of persistent pain have been identified. The researchers concluded that strength deficits may persist, particularly if permanent atrophy and fatty infiltration within the cuff muscles are demonstrated preoperatively (15).

The purpose of this research was to perform a comparative analysis of mini-open and arthroscopic rotator cuff repairs through the use of subjective and objective scoring tools. Researchers conducted a prospective comparative cohort study that evaluated 123 consecutive patients who underwent rotator cuff repairs (arthroscopic and 31 mini-open repair), scientists in London, and the United Kingdom report. Subjective and objective functional assessment was performed preoperatively and postoperatively at 3, 6, 12, 18 and 24 months using the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, the Oxford Shoulder Score (OSS) and the Constant-Murley score. Statistical analysis was performed on the datasets assessing the Pearson correlation coefficients and any significant differences present at each respective time point. At every time point the arthroscopic group scored better than the mini-open group, regardless of the assessment tool employed. The percentage recovery from the baseline measured at 1 year was similar with either treatment option. A significant difference was found between the arthroscopic and mini-open groups for the Constant-Murley, DASH and OSS scoring systems preoperatively (P < 0.05), reflecting a difference in tear severity. Arthroscopic rotator cuff repair is comparable with the mini-open technique with well correlated postoperative rates recovery, The researchers concluded: Subjective scoring provides an accurate and potentially easier method of postoperative assessment for long-term follow-up of rotator cuff repairs (16).

The aim of this study was to investigate the correlation of tendon integrity following open cuff repairs with functional and isokinetic strength measurements. Twenty-six shoulders of 25 patients were included in this study," scientists in Ankara, Turkey report. At the final follow-up, 14 repairs (53.8%) were intact and 12 repairs (46.2%) had failed on magnetic resonance imaging (MRI). Mean UCLA score at latest follow-up was 28.5 and mean Constant score was 80.3. Constant scores were found to be significantly low for the failed group. Age was found to be significantly related to failed repair. Fatty infiltration stage in the failed repair group was significantly high, and a strong positive correlation for both groups existed pre and postoperatively. When both groups were compared, the failed group was found to have significantly low measurements at extension and internal rotation. Despite high failure rates, functional results were satisfactory (13).