Orthopaedic Crossfire® Tackles Arthroscopic Cuff Repair

Dr. Bell:  “Arthroscopic approaches allow us to look at and treat additional pathology. Chondral lesions, biceps lesions, AC [acromioclavicular] joint problems, and of course, articular side partial thickness tears, which we would not visualize if it were mainly bursal lesions. Mobilization…very selective releases…you can do these open, but arthroscopically you can do them even in a more selective, less traumatic fashion. Paralabral capsulotomies…much as we do for adhesive capsulitis. Anterior interval releases for the leading edge of the supraspinatus, and then posterior interval releases (in this case of a supraspinatus lesion which is retracted anteriorly and medially).”

“So the question is, ‘Does the arthroscopic approach affect rehab?’ This isn’t an evidence based Level 1 study, but I looked at a large group of patients—open and arthroscopic—and we looked at the total number of visits, average cost per visit, total cost of rehab, and compared those to subsets. We found that the arthroscopic group had significantly fewer visits, were discharged over a month sooner, and their average total charge was less than the open repairs. That still doesn’t save you a great deal of money, but it did lessen the time in rehab.”

“What about OR charges? We compared ‘time in’ to ‘time out’ for an arthroscopic and an open group of patients…the open group was about an hour and a half; arthroscopic was about an hour. The 30% decrease against what your OR charges are, that can translate into reasonable savings.”

“As for the case we’re discussing today, it was an active older gentleman with significant functional limitations who wanted to get back to playing tennis. I can almost guarantee you he’d have intra-articular pathology, with a biceps lesion. I would debride and perform a concomitant decompression to open up his subacromial space. I’d do a paralabral release if need be…if the cuff was retracted, anterior and posterior interval releases. A Mumford, possibly, if symptoms dictated and not relying on a radiographic picture. And then the repair itself would be a double row repair. In an active individual like this, two anchors medially, two to three anchors laterally; we’d pass all the medial sutures through in a mattress fashion…tie those first, creating a medial row and coupling those laterally to recreate the footprint, realizing a stable construct that we could get going fairly quickly.”

 “Re-tear rates are improving as we obtain better materials; better anchors with better pullouts, enhanced suture materials…our suture passing devices are improving…double row reconstructions…less early postop issues with adhesive capsulitis. Cost issues will improve as we lessen the time in surgery. Biologics are going to enhance this a great deal in terms of platelet rich plasma. There is no question in my mind that arthroscopic rotator cuff repair is the way to go.”  

Dr. Brems:  “I’m taking the tack that in a specific case, open repair would offer the better option. Consider a 60-year-old male executive who is an avid tennis player. He’s had two years of minor symptoms while playing tennis, several injections of steroids over the last 12 months, physical therapy, sleep interruption, many oral anti-inflammatories, and the MRI scan which showed supra- and intra-spinatous tears, 2 cm retraction, and mild muscle atrophy. Some cuff tears can be treated arthroscopically, but not all cuff tears should be treated arthroscopically.”

“In this tear, why is open the better option? Considerations: patient’s age and physical demands; tear size and configuration; tissue quality; fat replacement of the muscle can be suggestive of size and chronicity of tear; quality of the bone to which it has to be reattached; delamination issues, which are commonly seen in large cuff tears.”

“Except in acute tears—which we rarely see—‘retraction’ is an orthopedic myth. In chronic tears—which we see commonly—the tendon is gone…it’s not just pulled back and retracted where you can pull it back and sew it. The bony footprint is often osteopenic and anchor failure is not uncommon. So now we recommend the double row technique, but some studies showed as recently as 2008 the double row technique suggests there’s now hypovascularity imparted by the newer suture techniques, and may damage the repaired tissue. The open technique can permit large bone tunnels and transosseous fixation with lower risk of fixation failure.”

“In an arthroscopic situation, when people have gone back in and looked at it in revision situations you’ll get a spot welding where the anchors may be. Whereas an open technique along a large bony trough using a transosseous suture technique in a horizontal mattress fashion obtains a seam…considerably more durable in tension than the spot welding may be.”

“There are three major differences between open and arthroscopic techniques…two are permanent and one is temporary…one is very significant. With one difference, arthroscopic wins: the length and permanency of the scar. Another difference: there is no doubt that arthroscopic surgery is less painful, but pain can be a good thing…and perhaps some of the failure rates in arthroscopic surgery are because patients without pain think they are healing and they feel better before they really are better. Difference three: in this case, open is the clear and convincing winner—definitely better outcomes, especially when considering cuff integrity. Many arthroscopists will acknowledge that cuff integrity fails, but because the pain has not returned they consider it a good outcome.”

“What is not different? Patients do not heal faster…they don’t return to work sooner, they don’t return to sports quicker; they should not resume strengthening any sooner because the rate limiting step is the time it takes a tissue to heal to the bone. And some argue that the healing is more robust with the open technique because of the better blood supply in the bone trough.”

“In an ultrasound follow-up of 127 patients in 2009—Dr. David Altchek from New York—found that the progression from a single tendon tear to a multiple tendon tear increased the likelihood of re-tear by at least nine times. If we look at Dr. Brian Cole, 47 shoulders, two year follow-up, all arthroscopic repairs, 22% re-tear rate in two years. Dr. Leesa Galatz looked at 18 patients with single and two tendon tears, ultrasound analysis, where 94% failed in a two year follow-up.”

“Open repairs do stand the test of time. Dr. Joseph Iannotti looked at 40 patients and had 88% good/excellent outcomes; Dr. Francis Cuomo looked at 30 patients and had 100% good/excellent outcomes…and on and on.”

“So this man’s large, 2 cm tear should be treated open.”

Moderator Thornhill:  “Rob, do you ever do open repairs?”

Dr. Bell:   “Absolutely. And John and I don’t disagree as is often the case in a situation like this. Certain cuff tears I will address open…not infrequently a combined subscapularis/ supraspinatus that I need to work on lateralizing, I do open. But the majority I fix arthroscopically. I think the data—even though John nicely demonstrated this—the reports on the efficacy of the open repairs in the last group was based not upon the confirmed integrity of the repair, but the outcomes, and I think the outcomes now are very similar between the two groups.”

Moderator Thornhill: “So what is the learning curve? Who should be able to do this and what should be our level of training?

Dr. Brems:  “I appreciate the question because we had a discussion in our residency program last week about this issue. I wonder…at how many training programs are the residents even being exposed to open techniques anymore? Are we soon going to be graduating residents who’ve never even seen an open rotator cuff repair? As we’ve tried to show today, there are situations, and I think—from my heart—the case that I’ve just showed I would do that open. There are tears that are smaller and less complex—if there’s an acute tear which can and should be treated arthroscopically—my point is that we should not always do it, and not be considered inadequate if we don’t. The issue is when to do what.”

Moderator Thornhill: “Rob, I had the pleasure of going to Columbia, sort of the birthplace of acromioplasty, and Dr. Bill Levine gave a talk suggesting that we’re doing too many acromioplasties. In the case that you talked about today you did a rotator cuff repair, you did a Mumford procedure, you did several other things. Do you think we’re overdoing these?”

Dr. Bell:  “No. It’s a good question and I put that up there as an option that would be part of it. If I look statistically at the Mumford, for instance, it’s probably less than ten…I do fewer Mumfords now arthroscopically than I did open. I do decompression acromioplasty still in the majority of chronic tears. If I have a younger individual under the age of 40, which is infrequent in an acute tear, I would not do a decompression. But I see very little morbidity associated with doing a decompression in the face of a chronic lesion. In fact, I think it enhances the outcome.”

Dr. Brems:  “I would argue the opposite. With open repairs—Dr. Evan Flatow taught me this—when I do an open repair for large cuff tears, I will do an acromioplasty, but when I take the coracoacromial (CA) ligament off the acromion I keep it intact with the deltoid undersurface and clearly reconstruct the CA arch when I close the deltoid. In larger tears it becomes incumbent to maintain that arch because of the potential problems down the line. If the cuff fails again you want the arch intact to try to minimize superior escape that might occur.”

Dr. Bell:  “I agree with that and Evan and I had this conversation ten years ago when he first started talking about CA ligament reconstructions and I said, ‘I don’t know why you have to reconstruct them, just don’t resect them!’ And so my acromioplasty is peeling it back, not resecting it and when we come back—God forbid I’d ever have to re-scope a shoulder—I can see that the CA ligament attachment is back to the decompressed acromion.”

Moderator Thornhill:  “I thought I had it. I went from single row to double row, and so to increase the footprint, look to see if there’s fat in the muscle…and then I heard that they all fall apart anyway. So tell me, do I do double row, give as big of a footprint as I can and be very judicious about rehab?”

Dr. Bell: “There probably is not a significant difference in the outcomes on double versus single. Early, biomechanically there is. One thing we’re not doing is releasing these cuffs the way we used to do open so I would do single row in the majority of cases.”

Dr. Brems:  “As would I…single row in the majority of cases.”

Moderator Thornhill:   “Gentlemen, thank you.”

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