Arthroscopic, open and mini-open approach for rotator cuff repair: no difference in pain or function at 24 months

Comparison of Locking-Loop Suture Bridge Repair and Single-Row Suture Anchor Repair in Small to Medium Rotator Cuff Tears: A Prospective Cohort Study With Clinical and Ultrasound Evaluations

Background

Single-row (SR) and double-row repair techniques have been described to treat rotator cuff tears. We present a novel surgical strategy of arthroscopic-assisted mini-open repair in which a locking-loop suture bridge (LLSB) is used.

Purpose

To compare the functional outcomes and repair integrity of LLSB technique to the SR technique for arthroscopic-assisted mini-open repair of small to medium rotator cuff tears.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 39 patients who underwent LLSB repair (LLSB group) and 44 patients who underwent SR suture anchor repair (SR group) from 2015 to 2018. We evaluated all patients preoperatively and at 3, 6, 12, and 24 months postoperatively using the visual analog scale (VAS) for pain, Oxford Shoulder Score (OSS), and American Shoulder and Elbow Surgeons (ASES) score. Also, shoulder sonography was performed at 12 months postoperatively to evaluate repair integrity using the Sugaya classification system. The independent-sample t test was used to analyze functional outcomes (VAS, OSS, and ASES scores), and the Fisher exact test was used to analyze postoperative sonography results.

Results

Patients in both the LLSB and SR groups saw a significant improvement on all 3 outcome measures from preoperatively to 24 months postoperatively (P < .001 for all). However, when comparing scores between groups, only the scores at 3 months postoperatively differed significantly (VAS: P = .002; OSS: P < .001; ASES: P = .005). Shoulder sonography at 12 months postoperatively revealed no significant difference in repair integrity between the LLSB and SR groups (retear rate: 10.26% and 6.82%, respectively; P = .892).

Conclusion

Better outcome scores were seen at 3-month follow-up in the LLSB group, with no difference in retear rates compared with the SR group at 12 months postoperatively. The LLSB technique was found to be a reliable technique for rotator cuff repair of small- to medium-sized tears.

Rotator cuff repair with single row technique provides satisfying clinical results despite consistent MRI retear rate

BACKGROUND

The number of shoulder arthroscopies is steadily increasing to treat glenohumeral joint disorders, among which the rotator cuff tear is the most common. The prevalence of this condition ranges from 13% to 37% in the general population without considering the number of asymptomatic patients. The gold standard procedure for rotator cuff repair is still undefined. The purpose of this study is to evaluate a population who underwent a single row (SR) rotator cuff repair and correlate their clinical results with MRI findings.

MATERIALS AND METHODS

Sixty-seven consecutive rotator cuff procedures were retrospectively selected. All patients were diagnosed with a full-thickness rotator cuff tear and subsequently treated with an arthroscopic SR repair technique. Each patient was clinically assessed with the DASH questionnaire and the Constant-Murley Score to grade their satisfaction. Moreover, rotator cuff repair integrity was evaluated by MRI and graded using the Sugaya score.

RESULTS

Mean follow-up was 19.5 ± 5.7 months. The mean Constant score was 82.8 ± 13.0 points, with 55 patients reporting excellent results. No patient scored less than 30 points, which could be deemed as unsatisfying. Meanwhile, on the DASH questionnaire, 6.1% of our patients rated their clinical outcome as unsatisfying, whereas 75.8% rated their outcome as excellent. Postoperative MRI classified 45 patients (83.3%) as either Sugaya type I, II, or III, whereas 9 patients (16.7%) presented a Sugaya type IV consistent with a full-thickness cuff retear. Of these nine patients, five (55.6%) and three (33.3%) reported excellent results for the Constant score and DASH questionnaire, respectively. The Mann-Whitney test reported that the retear group had worse scores than the intact repaired cuff group for pain (8.3 ± 5.0 versus 13.1 ± 3.4), Constant Score (68.8 ± 18.5 versus 83.1 ± 11.6), and DASH (66.2 ± 22.1 versus 44.2 ± 14.9). Still, range of motion (ROM) differences were not significant, except for better forward flexion in the intact group (p < 0.039).

CONCLUSIONS

Both groups with intact repaired and retorn cuffs showed improvement in their condition, but unexpectedly, there is no significant  correlation between patient satisfaction and rotator cuff integrity.

LEVEL OF EVIDENCE

IV.

The Relevance of Open Rotator Cuff Repair in 2021

BACKGROUND

The last decade has seen a large increase in rotator cuff surgery and arthroscopic surgery. We were asked to define the relevance of open rotator cuff repair in 2021.

PURPOSE

To define whether there are proven advantages to arthroscopic or open rotator cuff repair surgery.

METHOD

We reviewed the recent literature regarding recent trends, anaesthetic time, rehabilitation, post-operative pain, complications, economic considerations, the learning curve and outcomes. We outlined the senior authors' technique preferences, rationale and patient reported outcomes.

RESULTS

There is no clear evidence of proven advantage in arthroscopic rotator cuff repair compared to open rotator cuff repairs, with regard to outcomes or the other aspects reviewed. There were no differences in the outcomes of arthroscopic and open repairs in the senior authors practice with his procedure indications.

CONCLUSIONS

Open rotator cuff repair surgery remains a valid option and has some appeal in specific indications and in settings where arthroscopic resources are limited. We believe surgeons should learn both techniques and the principles of good patient selection, tissue handling, and fixation techniques are of paramount importance in both arthroscopic and open rotator cuff surgery.

Update on all-arthroscopic vs. mini-open rotator cuff repair: A systematic review and meta-analysis

Purpose

To provide an updated comparison between modern arthroscopic and mini-open repairs for treating rotator cuff tears.

Methods

Multiple online databases were searched from 2010 to October 1st, 2020. A meta-analysis was conducted for patient-reported outcomes and complications.

Results

Eleven studies were included. Majority of patients underwent mini-open repair (MOR) compared to arthroscopic repair (AR) (57.4% vs 42.6%). A meta-analysis found statistically significant differences (p < 0.05) in patient-reported outcomes favouring AR. While retear rates were higher in AR (p = 0.03) analysis of retear rates for arthroscopic double row and mini-open repairs, yielded no differences between groups (p = 0.48).

Conclusion

Patients undergoing AR for rotator cuff tears had improved post-operative clinical outcomes in some functional outcomes compared to MOR. Modern arthroscopic double row repair result in similar failure rates to open repair techniques.

Level of evidence

Level III, Systematic Review of Level I-III studies.

How can we define clinically important improvement in pain scores after biceps tenodesis?

BACKGROUND

Patient postoperative pain is an important consideration following biceps tenodesis. The visual analog scale (VAS) for pain is one of the most commonly used measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain.

PURPOSE

To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing open subpectoral (OSPBT) or arthroscopic suprapectoral biceps tenodesis (ASPBT) at 1 year from surgery; and to identify preoperative predictors of achieving each outcome end point.

METHODS

Data from consecutive patients who underwent isolated biceps tenodesis between January 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome (PRO) scores were recorded at 1 year postoperatively. In order to quantify the clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated.

RESULTS

A total of 165 patients were included in the final analysis. The VAS pain score threshold for achieving MCID was defined as a decrease of 12.9 (0-100). PASS was defined as achieving a 2-year postoperative score of 27.4 points (0-100), and SCB was defined as a decrease of 25.1 (0-100) at 1-year follow-up. The rates of achieving MCID, PASS, and SCB were 73.3%, 52.8%, and 45.9%, respectively. Multivariate regression analysis demonstrated that ASPBT (P = .01) and a lower preoperative Constant-Murley score were predictive of achieving the MCID (P = .01). In contrast, a lower preoperative score on the SF-12 Physical Component Summary (P = .01) and a higher score on the preoperative American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (P < .001) were predictive of achieving the SCB and PASS, respectively. Preoperative duration of symptoms >6 months was predictive of a reduced likelihood to achieve PASS.

CONCLUSION

This study identified scores for VAS pain that can be used to define clinically significant outcome after biceps tenodesis. Specifically, a decrease in pain score of 12.9 was a clinically important improvement in VAS pain, whereas a decrease of 25.1 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.

Rotator Cuff Repair: Single Row Repair Versus Double Row Repair and Superior Capsular Reconstruction

The surgical management of rotator cuff (RC) tears has progressed considerably in recent decades. Arthroscopic procedures now represent the mainstay of contemporary treatment approaches. The success of repair is predicated upon the achievement of a secure, durable repair that promotes tendon-to-bone healing. Both single and double row (DR) suture anchor configurations have been described to achieve stable fixation. Although consensus is lacking with regard to the clinical superiority of one configuration over another, trends in the literature suggest that DR repairs may optimize the likelihood of tendon healing and restoration of shoulder strength. In cases of truly irreparable RC tears, superior capsular reconstruction is a promising alternative to open tendon transfer and arthroplasty procedures. The purposes of this concise review are to: (1) explain our preference for a DR repair configuration in almost all circumstances; and (2) advocate superior capsular reconstruction as a viable treatment tactic for truly irreparable RC tears in the absence of significant glenohumeral arthritis.

Surgical repair of large-to-massive rotator cuff tears seems to be a better option than patch augmentation or débridement and biceps tenotomy: a prospective comparative study

BACKGROUND

This prospective study compared the outcomes after 3 different treatments for large and massive rotator cuff tears.

METHODS

Patients with a diagnosis of large-to-massive rotator cuff tears were prospectively included. Patients were allocated in 3 groups: (1) arthroscopic complete repair (repair group), (2) open repair and xenograft patch augmentation (patch group), and (3) arthroscopic débridement and tenotomy of the long head of the biceps (débridement group). Patients were evaluated preoperatively and postoperatively at 3, 6, 12 and 24 months. The primary outcome measure was the Constant-Murley score.

RESULTS

The study included 32 consecutive patients. The mean improvement in the Constant-Murley score was +29.1 for the repair group (P < .01), +32.2 for the patch group (P < .01), and +20.1 for the débridement group (P < .01) at the final follow-up examination. No differences were found between the repair and patch groups, but the difference became significant between the débridement group and the patch group (P < .001) and also between the débridement group and the repair group (P < .002) at 12 months and the final follow-up. Moreover, 5 complications occurred in 11 patients in the patch group, whereas there was only 1 complication in the repair group and no complications in the débridement group.

CONCLUSION

The use of porcine dermis patches to augment repairs of massive and irreparable rotator cuff tears is not recommended because there is no benefit compared with repair without augmentation and patches result in more complications.