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Abstract & Commentary
Synopsis: This retrospective analysis of one surgeon’s experience compares the results of mini-open rotator cuff repair with arthroscopic repair and shows that the results are similar except for an increased incidence of shoulder fibrosis in the mini-open repair group.
Source: Severud EL, Nottage WM, et al. All-arthroscopic versus mini-open rotator cuff repair: A long term retrospective outcome comparison. Arthroscopy. 2003;19(3):234-238.
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.
Severud and associates mined Nottage’s surgical database to find 64 shoulders that underwent rotator cuff repair by either the mini-open or all-arthroscopic approach and that met the following inclusion criteria: surgically proven full-thickness tear no greater than 5 cm; no intra-articular pathology such as SLAP lesions or arthrosis; and no neurologic disorder. Seventeen patients of the original 82 were excluded from the study because they could not be located or they refused to participate in the study. All patients underwent arthroscopic examination of the shoulder joint and arthroscopic subacromial decompression, and 15 patients underwent clavicular coplaning. Both groups began passive range of motion postoperatively and progressed to active-assisted range of motion by 4 weeks. Resisted exercises were started at 3 months.
Tear sizes in the mini-open group included 1 small tear (< 1 cm), 10 medium tears (1-3 cm), and 18 large tears (3-5 cm). The arthroscopic group included 3 small, 23 medium, and 9 large tears. There was no difference between the 2 groups in terms of patient age or steroid injections. There were 6 workman’s compensation claims in the arthroscopic group compared to 3 in the mini-open group.
At a minimum 2-year follow-up, the UCLA and ASES scores for the mini-open group were 31.4 and 90, respectively, and for the arthroscopic group were 32.6 and 91.7, respectively. The outcomes were statistically similar, and there was no difference in outcome scores among the 3 groups of tear sizes. Range of motion was better at 6- and 12-month follow-up for patients in the arthroscopic group, but they were the same at final follow-up between the 2 groups.
The mini-open group included 4 patients who could not elevate their shoulders higher than 120° by 12 weeks postoperatively, and 2 of those patients underwent manipulation. The arthroscopic group did not have any fibrosis complications.
Comment by John C. Richmond, MD, and Michael Codsi, MD
Severud et al published a good comparison between 2 techniques of rotator cuff repair. Although it is retrospective, they used 2 outcome measures commonly used in the literature that allows the reader to easily compare their results with the many other published papers in the literature. They had good follow-up (78%), one surgeon did the repairs, and the post-op rehabilitation was the same for both groups. In addition, they appropriately described the patient characteristics that have been found to adversely affect rotator cuff repair outcomes, such as duration of symptoms, steroid injections, worker’s compensation claims, and tear size. It is interesting that none of these factors played a role in their outcomes. They did not include massive tears in their analysis, which would likely show worse results in both groups. The small numbers in the study likely account for their inability to find a difference in these risk factors. Any comparison between 2 treatments should include a power analysis that specifies exactly how many patients need to be included to avoid a type II-beta error. Without this analysis, Severud et al cannot claim that there is no difference between the treatment groups.
Other studies have been published that show arthroscopic repair provides durable outcomes with similar UCLA scores at a minimum 2-year follow-up.1-3 This study shows again that arthroscopic rotator cuff repair works well in general, but it does not show which preoperative characteristics will affect the outcome scores. The skill of the surgeon in arthroscopic techniques of rotator cuff repair is likely the most important determinant of which technique should be used.
Dr. Codsi is a resident in
orthopaedic surgery, Tufts University, Boston, Mass.
Dr. Richmond is Professor of Orthopaedic Surgery, Tufts University School of Medicine, Boston, MA.
1. Tauro JC. Arthroscopic rotator cuff repair: Analysis of technique and results at 2 and 3 year follow-up. Arthroscopy. 1998;14:45-51.
2. Gartsman GM, et al. Early effectiveness of arthroscopic repair for full-thickness tears of the rotator cuff: An outcome analysis. J Bone Joint Surg Am. 1998; 80-A:33-40.
3. Wilson F, et al. Arthroscopic repair of full-thickness tears of the rotator cuff: 2-14 year follow-up. Arthroscopy. 2002;18:136-144.