ALL ARTHROSCOPIC VERSUS MINI OPEN ROTATOR CUFF REPAIR

Stephen C. Weber, M.D.

I. Cuff repair options:

 

A. Open repair. Good results reported by Ellman, Cofield, and numerous others. Anticipate about an 85% success rate.

 

1. Advantages:

a.      easy to do

b.      no special equipment required -

c.      allows direct visualization of cuff repair and acromioplasty

d.      Good long term follow-up. Several studies with >10 year follow-up show generally stable results with time.

 

2. Disadvantages:

a.      deltoid detachment required. This increased perioperative morbidity in all comparative studies reported (Baker and Liu, Weber)

b.      False positive studies (arthrogram 2%, MRI 10%) will lead to unnecessary open exploration

c.      Unrepairable tear will be opened. Although Rockwood showed good results with open debridement and acromioplasty, other authors have made patients worse, especially by causing anterosuperior instability, which is virtually untreatable.

d.      Significant intraarticular pathology will be missed except in very large tears:

1.      radiographically silent DID as discussed by ElIman

2.      Significant inferior surface partial cuff tears, which are

3.      not well handled by acromioplasty alone (Weber, others).

4.      rare SLAP lesions and instability will go unnoticed

e.      Grana, et. al. only author to show no difference between mini open and open repair. In his hands, arthroscopic evaluation never once changed treatment. This high degree of preoperative clinical accuracy is unlikely to be duplicated by many surgeons

 

B. Arthroscopic debridement. Good initial results reported by ElIman and Esch for full thickness tears. Early results of debridement of small to moderate size tears very equivalent to open repair.

 

1. Advantages:

a.      simple to do with modest arthroscopic skills

b.      low morbidity

c.      few complications

d.      avoids many of the problems of open repair noted above

2. Disadvantages:

a.      even early results sometimes unpredictable

b.      Some good long term results, but Ellman and others showed that results generally deteriorated with time

c.      Savoie, et. al. in his prospective, randomized study showed that repair clearly favored over debridement, with a significant percentage of debrided patients going on to cuff arthropathy.

 

C. Mini open repair. Multiple studies presented in the early 90’s of retrospective reviews of arthroscopic evaluation and acromioplasty followed by open repair through a deltoid splitting incision. Appeared to combine advantages of open repair (direct visualization of repair, palpation of acromioplasty, long -~ term success of repair) with arthroscopic visualization and decreased morbidity.

 

1. Advantages:

a.      easy to do with modest arthroscopic skills

b.      allows for arthroscopic correction of intraarticular pathology c. well established improvement in perioperative morbidity in two large studies with no increase in complication or compromise in outcome

c.      cost effective. Decrease in hospital time leads to significant decrease in cost

d.      easy to "bail out" to full open procedure if desired

e.      avoid opening patients with false positive studies

f.        avoid opening patients with unrepairable defects

g.      no truly long terms studies, but in theory should hold up as well as open repair.

 

2. Disadvantages:

a.      does require basic arthroscopic skills. Should complete acromioplasty in about 1/2 hour to avoid compromise of exposure with swelling

b.      if basic arthroscopic skills do not allow recognition of pathology, inserting arthroscope does not improve outcome and increases cost.

c.      not possible to do outpatient for all authors (30% in our 1993 AAOS study)

 

D. All arthroscopic repair. Intellectually attractive procedure which is perceived by virtually all patients and many surgeons to be superior to open procedures. Early retrospective series by Snyder, Wolf, Tippett, and others demonstrated that skilled surgeons could apply these new techniques with one to two year results comparable to prior series of open repair.

 

1. Advantages:

a.      patients like it "sell surgery"

b.      has all the advantages of mini open repair in terms of diagnosis and arthroscopic treatment of intraarticular pathology

c.      the assertion of improvement in perioperative morbidity born out in prospective, nonrandomized study (Weber, 1997 AAOS) d. can convert at any time to mini open if needed without compromise.

 

2. Disadvantages

a.      patients like it "sell surgery." Like other arthroscopic techniques, patient and surgeon perception of "minor surgery make it prone to abuse. Indications for repair remain the same.

b.      While some authors report no complication and no failures (Gartsman, JBJS) these outstanding results have not been -duplicated by others (Weber, Wolf). Expect worse results as these techniques are applied in the community

c.      Paulos in laboratory studies clearly showed cuff requires fixation for 12 weeks to heal. Three to six weeks of fixation not adequate if cuff closure surgeon’s goal. Christian Gerber’s meticulous work in the laboratory with sheep shows that efforts to improve strength of initial repair will be rewarded with more healed repairs. Mini open repair allows more options (sutures through tunnels, Masoneuve suture) to do this.

d.      Technique requires suture anchors, which don’t always stay in bone. Must see anchor go into bone, and test intra-operatively; not all currently espoused techniques allow this. Loose anchors will migrate, sometimes dangerously, and must be removed. Improved anchors have decreased, but not eliminated this problem.

e.      reports of improved outcome with all arthroscopic repair NOT
born out in comparative studies.

f.        temptation to accept marginal arthroscopic repair over adequate
open repair to be avoided.

g.      cost. Virtually all arthroscopic passers disposable now, and not
inexpensive (Arthrex passer only exception). Suture anchors not
cheap either, with "second generation" anchors even more
expensive, for reasons unclear. Hospital will mark these items up
300-400%. In my hospital, this leads to an increase in charges of
$2170 over mini open repair through bone tunnels. Direct billing
of surgeon for anchors, and disposable anchors will obviate some
of these problems.

 

II. Summary:

 

A.     Remember that most of us will be judged by outcome in the long run, not perioperative morbidity. Pick the procedure that in your hands offers the best outcome.

2. Current all arthroscopic techniques are too difficult for all but the surgeon dedicated to a real effort to gain the surgical skills to perform them successfully Mini open repair may be a more realistic goal for many surgeons
3. If you choose to master these complex arthroscopic skills, and the procedure in any way becomes marginal, remember that the difference in converting to a mini open repair is a three week moderate increase in perioperative morbidity. There is no current evidence that all arthroscopic repairs change outcome. Don’t hesitate to open to provide the patient a reasonable repair.
4. Always see anchor go into bone, and test pull-out under direct visualization. Techniques which do not allow this are unacceptable.
5. Strive for a repair that you can move early. Immobilization of arthroscopic repairs associated with stiffness in most early studies.
6. Cost still a problem. Managed care and informed patients will not let us double our surgical costs.
7. Further work needed. The goal of a simple, easily reproducible repair done arthroscopically remains elusive.