Anchorless Arthroscopic Transosseous and Anchored Arthroscopic Transosseous Equivalent Rotator Cuff Repair Show No Differences in Structural Integrity or Patient-reported Outcomes in a Matched Cohort

Comparison of cost, surgical time, and clinical results between arthroscopic transosseous rotator cuff repair with lateral cortical augmentation and arthroscopic transosseous equivalent suture bridge: A propensity score-matched analysis

BACKGROUND

To reduce the healthcare burden, the clinical results of arthroscopic rotator cuff repair and the cost of the implants used have recently been focused upon. This study compared implant cost, surgical time, short-term clinical results, and cuff repair integrity 2 years postoperatively between arthroscopic transosseous rotator cuff repair using lateral cortical augmentation (TOA) and arthroscopic transosseous-equivalent suture bridge (TOE).

METHODS

This study included 220 patients with rotator cuff repairs performed by a single surgeon between December 2013 and December 2018. Overall, 70 TOA and 68 TOE cases met the inclusion criteria. The same surgeon performed the procedures at two different hospitals, and the techniques differed between the facilities. A total of 42 TOA patients were matched with 42 TOE patients. The patients were matched using a propensity score analysis by gender, age, and cuff tear size. The minimum follow-up period was 2 years. Implant cost and surgical time were compared between the two methods. The range of motion, clinical outcomes, and visual analog scale were evaluated. Magnetic resonance imaging was performed to examine cuff repair integrity 2 years postoperatively.

RESULTS

The follow-up rate was 81% (112/138 patients). Implant cost was significantly lower with TOA ($1,396 vs. $2,165; p < 0.001) than with TOE. The average surgical time in the TOA method was significantly shorter than that in the TOE method (82 vs. 109 min; p = 0.001). At a minimum 2-year follow-up, the mean active elevation, abduction, and clinical outcomes improved with both methods, although no improvements in external and internal rotations were observed with either method. There were no significant differences in the postoperative variables and retear rate (TOA, 12%; TOE, 19%; p = 0.548) between the two methods.

CONCLUSIONS

TOA and TOE achieved comparable clinical results; however, TOA was more cost-effective and had a shorter surgical time than TOE.

LEVEL OF EVIDENCE

Level Ⅲ, retrospective matched control study.

Can the Single Assessment Numeric Evaluation be used as a stand-alone subjective outcome instrument in patients undergoing rotator cuff repair?

BACKGROUND/HYPOTHESIS

There is no consensus to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. The Single Assessment Numeric (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis was that SANE will correlate with and be comparable in responsiveness to other subjective outcome measures that have been used in a stand-alone fashion in patients undergoing rotator cuff repair (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Western Ontario Rotator Cuff Index [WORC], and the Simple Shoulder Test [SST]). In addition, the SANE will be more relevant to each patient compared to the ASES, further supporting its use as a stand-alone shoulder-specific outcomes measure.

METHODS

A retrospective review of a database of patients undergoing rotator cuff repair was reviewed where the SANE was recorded with the ASES, WORC, and/or SST. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine if correlations differed in (1) preoperative and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean (SRM) and the effect size (ES) of all scores. Relevance and precision of the SANE and ASES were examined using 150 consecutive patients to determine the number of questions in each score that were not answered.

RESULTS

Correlation was excellent for the SANE and the ASES (n = 1838, r = 0.81, P < .0001), the WORC (n = 1793, r = 0.82, P < .0001), and the SST (n = 1836, r = 0.76, P < .0001). Correlation of preoperative scores was moderate and postoperative scores were excellent when comparing the SANE with all 3 scores. All scores were highly responsive, with the SRM of the SANE = 2.1, ASES = 2.2, WORC = 2.4, and the SST = 1.8. The ES of the SANE = 2.4, ASES = 2.7, WORC = 3.0, and the SST = 2.1. One hundred percent of the SANE scores were answered completely compared with 57% (P < .0001) of the ASES, with significant variability found in the answers to the "work" and "score" questions.

CONCLUSION

In patients undergoing rotator cuff repair, the SANE highly correlated and has equivalent responsiveness with the WORC, ASES, and SST, which have been used as stand-alone shoulder-specific outcomes measures. The SANE may provide the same information as the WORC, ASES, and SST regarding outcome with significant reduction in responder burden. This study supports that the SANE can be used as a subjective, stand-alone instrument for patients undergoing rotator cuff repair.

Risk Factors and Corresponding Management for Suture Anchor Pullout during Arthroscopic Rotator Cuff Repair

INTRODUCTION

Due to the aging of the population, the incidence of rotator cuff tears is growing. For rotator cuff repair, arthroscopic suture-anchor repair has gradually replaced open transosseous repair, so suture anchors are now considered increasingly important in rotator cuff tear reconstruction. There are some but limited studies of suture anchor pullout after arthroscopic rotator cuff repair. However, there is no body of knowledge in this area, which makes it difficult for clinicians to predict the risk of anchor pullout comprehensively and manage it accordingly.

METHODS

The literature search included rotator cuff repair as well as anchor pullout strength. A review of the literature was performed including all articles published in PubMed until September 2021. Articles of all in vitro biomechanical and clinical trial levels in English were included. After assessing all abstracts (n = 275), the full text and the bibliographies of the relevant articles were analyzed for the questions posed (n = 80). Articles including outcomes without the area of interest were excluded (n = 22). The final literature research revealed 58 relevant articles. Narrative synthesis was undertaken to bring together the findings from studies included in this review.

RESULT

Based on the presented studies, the overall incidence of anchor pullout is not low, and the incidence of intraoperative anchor pullout is slightly higher than in the early postoperative period. The risk factors for anchor pullout are mainly related to bone quality, insertion depth, insertion angle, size of rotator cuff tear, preoperative corticosteroid injections, anchor design, the materials used to produce anchors, etc. In response to the above issues, we have introduced and evaluated management techniques. They include changing the implant site of anchors, cement augmentation for suture anchors, increasing the number of suture limbs, using all-suture anchors, using an arthroscopic transosseous knotless anchor, the Buddy anchor technique, Steinmann pin anchoring, and transosseous suture repair technology.

DISCUSSION

However, not many of the management techniques have been widely used in clinical practice. Most of them come from in vitro biomechanical studies, so in vivo randomized controlled trials with larger sample sizes are needed to see if they can help patients in the long run.

Arthroscopic Anchorless Transosseous Rotator Cuff Repair Produces Equivalent Clinical Outcomes and Imaging Results as a Standard Suture Bridge Technique with Anchors

Purpose

To compare the clinical and imaging outcome of arthroscopic transosseous (TO)-equivalent rotator cuff repair (RCR) with anchors with arthroscopic anchorless TO RCR at a minimum of 2 years postoperatively.

Methods

The study population included patients who underwent RCR using either an anchorless TO technique with a TO suture passing device (group A) and those who were matched for tear size and underwent RCR using suture anchors for repair (group B). The inclusion criterion was an easily reducible rotator cuff tear with a sagittal extension of 2 to 4 cm. After a minimum of 2 years, clinical outcome scores and magnetic resonance imaging were obtained. Tendon quality and footprint integration were evaluated using the Sugaya classification.

Results

Seventy patients were included. A total of 45 were in group A and 25 were in group B. Group A had 2 bone tunnels and 4 sutures using an X-box configuration, and group B had a suture bridge construct of 4 anchors. Group A and B had identical anteroposterior tear size and were comparable for age. The Constant score improved from 50 ± 17.4 to 88 ± 8.6 in group A versus 48 ± 14.5 to 87 ± 7.2 in B. The Subjective Shoulder Value rose from 47 ± 19.1 to 95 ± 7.4 in group A vs from 47 ± 19.4 to 95 ± 7.6 in B. Neither the preoperative (P ≥ .502) nor postoperative scores (P ≥ .29) showed a significant difference. Magnetic resonance imaging showed 2 small retears in group A and one in B, resulting in an identical 4% retear rate. The mean Sugaya type was 2.02 versus 2.24 (P = .206) for groups A versus B.

Conclusions

Anchorless TO RCR is a valid alternative to suture anchor techniques. Clinical outcome data showed comparable results for both techniques after a follow-up of 2 years. The healing results as observed on magnetic resonance imaging were also equivalent for both groups.

Level of Evidence

Level III, retrospective comparative study.

Fixationssysteme und Techniken zur arthroskopischen Rotatorenmanschettenrekonstruktion

Arthroskopische Rotatorenmanschettenrekonstruktionen wurden initial mit einer einreihigen („single row“) Technik beschrieben. Im Rahmen technischer Weiterentwicklungen der arthroskopischen Chirurgie wurden diverse Techniken zur zweireihigen („double row“), transossären und transossär-äquivalenten Sehnenfixation entwickelt, nicht zuletzt durch eine zunehmende Verbreitung knotenloser Anker. Die klinischen Ergebnisse zeigen keine relevanten Unterschiede zwischen den jeweiligen Techniken. Biomechanisch sind zweireihige Rekonstruktionen jedoch durch Vergrößerung der Kontaktfläche an der Insertionsstelle und der erreichten Stabilität überlegen, insbesondere mit medial geknoteten Fäden, welche in eine laterale Reihe als sog. Suture-Bridge abgespannt werden. Klassischerweise wurden Schraubanker aus Metall für eine arthroskopische Sehnenfixierung verwendet. Im Laufe der letzten Jahre wurde das Anker-Portfolio jedoch durch moderne bioresorbierbare und nichtresorbierbare (PEEK) Schraub- und Einschlaganker sowie auch um reine Fadenanker (All-suture) erweitert. Ein allgemeingültiger Goldstandard für die Ankerverwendung existiert bis dato nicht, wobei die meisten gängigen Anker – zumindest bei guter Knochenqualität – ausreichende Stabilität gewährleisten. Beim Nahtmaterial kam es ebenso zu relevanten Weiterentwicklungen, sodass dem Versagen der Nähte heutzutage weniger Bedeutung zukommt. Das Aufkommen von bandartigem Nahtmaterial (Tapes) konnte in diversen biomechanischen Studien seine Überlegenheit nachweisen, jedoch ist bei geknoteten Techniken mit Tapes aufgrund des womöglich negativen Einflusses durch größere Knoten Vorsicht geboten. Nicht zuletzt ist die mediale Stichposition möglichst nahe des Rotatorenkabels von großer Bedeutung, da der häufigste Versagensmechanismus einer Rotatorenmanschettenrekonstruktion mit modernem Naht- und Ankermaterial weiterhin ein Hindurchschneiden der Fäden durch das vorgeschädigte Sehnengewebe ist.