Open surgery still plays a substantial role in modern rotator cuff repair

With the advancement of arthroscopic surgery in the repair of rotator cuff tears, the gold standard of open surgery has begun to be slowly replaced. However, the literature has shown similar results when comparing arthroscopic and open rotator cuff repair.

“The gold standard in our literature has always been the open repair technique and as arthroscopic techniques have improved, they have always been compared to the open technique,” Joseph A. Abboud, MD, associate professor of shoulder and elbow surgery at The Rothman Institute, told Orthopedics Today.

“Obviously, there are gross differences in the surgical approach,” he added, “but the general goals remain the same. Essentially, you are repairing tissue back-to-bone and the goal is to get it to heal and optimize function for the patient.”

Gregory P. Nicholson, MD, associate professor in the Department of Orthopedic Surgery at Rush University Medical Center and partner at Midwest Orthopedics at Rush, said while all surgeons should be confident in performing both open and arthroscopic surgery, they should perform the technique most beneficial for their patients.

“Arthroscopy has been such an improvement in the patient experience that patients expect you to do it ‘through the scope’ [or] ‘minimally invasive’ and if you tell them you are going to do an open repair, they may look at you and say ‘Well this guy does not know what he is doing, he is not up on all the new modern techniques,’” Nicholson said. “I think surgeons need to be upfront with their patients on why they are doing what they are doing, but I think it is about [constant] self-education.”

Image: Cushman R

Arthroscopic vs open surgery

According to Leesa M. Galatz, MD, professor and chair of the Leni & Peter W. May Department of Orthopaedic Surgery, Icahn School of Medicine at Mount Sinai, arthroscopic repair has a distinct advantage over open surgery in that it provides better pain control, less stiffness and can be performed as an outpatient procedure to help reduce costs. Compared with arthroscopic surgery, surgeons need to take down the deltoid to access the tear in an open surgery, which adds an additional aspect to the procedure.

“It is almost like you have another repair to protect. So, not only did you repair the rotator cuff, but you have done a repair of the muscle you took down to access the cuff, so you have to protect that as well,” Galatz, who also is system chair of orthopaedic surgery at Mount Sinai Health System, said.

John D. Kelly IV, MD, director of Shoulder Sports Medicine at the University of Pennsylvania and Editorial Board member for Orthopedics Today, said arthroscopic surgery can lead to less postoperative inflammation and the ability for patients to mobilize their shoulders quicker.

“No one has ever proved this conclusively, but I think the healing time may be a little better with the arthroscopic [procedure] because there is less inflammation,” he said. “But in terms of precisely addressing pathology, precisely affecting reduction to the tear [there] is no question that the arthroscope gives [surgeons] those benefits.”

Arthroscopic surgery has advanced rotator cuff repair, Nicholson told Orthopedics Today, by making it easier for surgeons to not only see and address the pathology, but also by creating a smoother patient recovery with less morbidity.

Arthroscopic repair does present several disadvantages, however, as Abboud said.

“Depending on how you have trained or what era you are from, [arthroscopy] can have a steep learning curve as far as the technique,” he said. “If you are not well trained arthroscopically, it is a harder skillset to learn, which may translate to longer OR times, longer anesthetic times and, potentially, a weaker repair.”

Abboud, who is also of the Department of Orthopedic Surgery at the Sydney Kimmel Medical College at Thomas Jefferson University, said surgeons can perform an open repair without implants or a lot of disposable equipment.

“When you do an open repair [you] can theoretically not use any implants,” he said. “You can use what we call bone tunnels or transosseous tunnels, which simply use a needle and suture.”

Although performing arthroscopic rotator cuff repair has become more common, Nicholson reminded open rotator cuff repair is still an important skillset for surgeons.

“Open rotator cuff repair surgery is not a bad thing,” he said. “[There is] significant evidence to say in a large or massive tear, an open surgical approach and technique leads to a higher healing rate than an arthroscopic surgery. In small and medium-sized tears, arthroscopic surgery probably does just as good, if not better, with less morbidity than an open repair.”

Nicholson added, “There is no shame in saying, ‘I cannot handle this arthroscopically, I need to do it through an open approach.’”

Surgical results

Galatz said it is believed if a rotator cuff tear is not repairable arthroscopically, it also cannot be repaired through open surgery. Despite that, Nicholson pointed out there are many considerations surgeons should take into account when deciding whether or not to repair a rotator cuff tear and these include both tendon quality and mobility.

“[The] body of evidence in North America was saying if I cannot repair it arthroscopically, I cannot repair it at all, so I will just debride it and not repair it,” Nicholson said. “We know that a repaired, healed rotator cuff does better than a non-healed one, but a lot of things go into determining if it is worth repairing. That is an important piece of information we do not talk about that much when we are talking about surgery.”

When comparing surgical results of an arthroscopic repair to an open repair at 6 months to 12 months, Galatz said the results are similar, with Kelly stating 6 weeks to 9 weeks is when surgeons will see differences in pain and stiffness.

“The literature would show early on, the arthroscopy patients have less pain and by 3 months, the differences definitely tend to nullify and become distinct,” Kelly told Orthopedics Today. “So it is just an early on pain and discomfort.”

However, Mark E. Morrey, MD, MSc, of the Mayo Clinic, said failure to heal may have more to do with the patient’s biology than with the technique or instruments used during surgery.

“The issue now is the tissue side or what the patient brings to the table, not what we bring to the table, not our instrumentation, not our bells and whistles and gadgets, but the patient’s [biology], their individual tendon makeup,” Morrey said.

According to Abboud, “You could do the best arthroscopic or the best open approach, but if the biology is not supportive of healing, the outcome is still going to be poor.”

In a recently published study, Andrew J. Carr, ChM, DSc, FRCS, FMedSci, and his colleagues randomly assigned 273 patients with degenerative rotator cuff tendon tears to receive arthroscopic or open rotator cuff repair to see if either surgery had better clinical effectiveness. At 24 months, results showed the Oxford Shoulder Score improved from 26.3 to 41.7 for arthroscopic surgery and from 25 to 41.5 for open surgery. Oxford Shoulder Scores were the most improved in participants with healed repairs and lowest in participants with impossible to repair tears. Carr and his colleagues also found 77% of participants reported much or slightly better shoulder problems at 8 months, which increased to 85% at 24 months. On average, the arthroscopic repair group accrued 1.34 total quality-adjusted life-years and the open repair group accrued 1.35 total quality-adjusted life-years at 24 months.

“The [UK Rotator Cuff Surgery] UKUFF trial reveals there is no evidence of difference in effectiveness between open and arthroscopic repair,” Carr told Orthopedics Today. “Surgeons can perform either open or arthroscopic repairs and expect similar outcomes for their patients.”

“The number one reason why people have rotator cuff surgery is because of pain,” Nicholson said. “The second reason is the functional impact. They feel weaker or they cannot elevate their arm in conjunction with the pain. Both arthroscopic and open surgery, if done well [and] respecting the principles of success of rotator cuff surgery, they are both going to be good and predictable at relieving pain and improving that patient’s ability to rehabilitate successfully and get back to their activity level.”

Cost differences

Carr and his colleagues found no significant differences in mean costs for any of the component resource use categories or total follow-up costs at 2 years postoperatively between the arthroscopic and open repair groups. According to intention-to-treat analysis, overall treatment cost was £2,567 for arthroscopic surgery and £2,699 for open surgery at 2 years. Per-protocol analysis, however, showed arthroscopic repair was more costly compared with open surgery.

“The cost is directly related to the material you are utilizing,” Morrey said. “For example, on average, utilizing anchors and the arthroscopic types of instruments is more expensive than utilizing a suture and a needle, but it is dependent on how people are doing the open or arthroscopic repairs.”

Besides the tools utilized, Nicholson noted OR time, surgeon fees and anesthesia fees also play a role in overall cost. According to Abboud, although arthroscopy may seem more costly in most cases, costs cannot be generalized and should be considered on a case-to-case and surgeon-to-surgeon basis.

“I would say the current 30-[year-olds] to 40-year-olds who grew up in the era where arthroscopy was more prevalent, they may be more facile with arthroscopic techniques and that may translate into reasonably quick OR times for the arthroscopic techniques,” Abboud said. “You may have others still in their learning curve and their OR times for arthroscopic techniques may, in fact, be significantly longer.”

Failure rate also has an impact on the overall cost of surgery for both arthroscopic and open surgery, Abboud said.

“If you execute arthroscopic surgery better and you are more facile at it, then there may be an argument that your failure rate, your revision burden is going to be less and the cost to the patient, the insurers and society is going to be less and vice versa. The same thing could be said about open [surgery],” he said. “So that is difficult to quantify, but we know that if we decrease our revision burden, we definitely save the health care system a fair amount of money and we obviously save the patient a fair amount of potential pain and suffering.”

Perform what you know

According to Kelly, it is important for surgeons to know how to perform arthroscopic surgery, stating it will “raise the bar for your game because your patients will benefit.” Galatz said more residents today are trained to use arthroscopic surgery than open surgery and some residents may never perform an open rotator cuff repair. As for surgeons who primarily fix rotator cuff tears through open surgery, she said they should also become familiar with arthroscopic repair so they can perform the procedure when needed.

“At the end of the day, the most important thing is that the patient has a good operation,” Galatz said. “You can get good results with both procedures. However, you do not want to do a lesser quality operation arthroscopically because your skills are not as good. It is important, I think, to maintain those skills and acquire them if you have not already.”

Similarly, Morrey stated surgeons who primarily perform arthroscopic surgery should be familiar with open repair.

“For example, if you are doing an arthroscopic approach and you cannot get a good repair or the suture anchors are pulling out or the bone quality is not good, then it may help you to open and do multiple sutures,” Morrey said. “[You] need to be able to do what is in the patient’s best interest based on what you are seeing at the time of surgery. Having said that, I would say [gaining] the proper training to accomplish both of those or to accomplish one well is important.”

“You have to have a level of experience and training, whether that requires multiple courses or continuing education or just a result of your prior training,” he added. “I think it is important to get comfortable and gain some familiarity with the techniques before doing them.”

Conversely, Abboud noted surgeons who are not adept at performing the surgery their patients prefer should refer them to another surgeon with the desired level of expertise and spend time improving their own skills in that technique.

“You have to do what you are trained well to do,” Nicholson said. “Now every rotator cuff approach or surgery or repair, be it small, medium or large, is being done arthroscopically and done well and that is appropriate.”

He added surgeons who learn to perform arthroscopic surgery when they know how to perform open surgery will help prepare them for future techniques.

“We are giving you a framework for growth and development with the principles of care in treatment and that is the important thing, because we do not know what the next technique is going to be 10 [years] to 15 years from now,” Nicholson said. – by Casey Tingle

• Reference:
• Carr AJ, et al. Health Technol Assess. 2015;doi10.3310/hta.19800.

• For more information:
• Joseph A. Abboud, MD, can be reached at the Rothman Institute, 925 Chestnut St., 5th Floor, Philadelphia, PA 19107; email: joseph.abboud@rothmaninstitute.com.
• Andrew J. Carr, ChM, DSc, FRCS, FMedSci, can be reached at the Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Old Rd., Oxford OX3 7LD UK; email: andrew.carr@ndorms.ox.ac.uk.
• Leesa M. Galatz, MD, can be reached at Mount Sinai Hospital, 50 East 98th St., New York, NY 10029; email: leesa.galatz@mountsinai.org.
• John D. Kelly IV, MD, can be reached at the University of Pennsylvania School of Medicine, 3400 Civic Center Bldg., Philadelphia, PA 19104; email: john.kelly@uphs.upenn.edu.
• Mark E. Morrey, MD, can be reached at the Mayo Clinic, 200 1st St. NW, Rochester, MN 55901; email: morrey.mark@mayo.edu.
• Gregory P. Nicholson, MD, can be reached at Rush University Medical Center, 1725 W. Harrison St., #1063, Chicago, IL 60612; email: gregory.nicholson@rushortho.com.

Disclosures: Abboud reports he has performed design work for Cayenne Medical and MinInvasive and receives research support from OrthoSpace. Morrey reports he owns stock in Tenex. Nicholson reports he is a designer and consultant for Tornier. Galatz and Kelly report no relevant financial disclosures.

 

Can biologic augmentation be useful in the repair of a rotator cuff tear?

Indications needed

Failure of biologic healing remains a significant concern for the surgical treatment of advanced rotator cuff disease. Failure of tendon repair healing continues to complicate modern surgery techniques and is related to several factors including advanced patient age, larger tear size, advanced muscle degeneration, poor tissue quality and revision surgery. In an effort to improve healing and surgical outcomes, the use of tendon augmentation patches has gained modest popularity in recent years for tears deemed to be at higher risk for structural failure. Like many advances in surgical techniques, often the initial promise and popularity for new technology outweighs the clinical science that proves or disproves its efficacy. This paradigm applies to the use of graft augmentation for rotator cuff repair surgery as well.

The initial popularity for rotator cuff repair augmentation was dampened by the clinical performance of xenografts. The initial xenograft constructs offered no improvement over conventional repair in terms of clinical outcomes or tendon healing rates and suffered from potential complications, such as sterile joint reactions. In recent years, allograft tissue has gained popularity for the management of large to massive cuff tears and there has been a small, but growing body of evidence that demonstrates these grafts are safe and may improve the rate of tendon healing. However, most research related to this subject involves either lower quality studies performed without meaningful control groups, studies with small subject numbers with limited power and retrospective comparisons or are subject to study bias. Furthermore, the potential effect of variable technique (the use of the graft as purely an augmentation covering poor tissue vs. spanning a defect over missing tissue) upon clinical outcome has not been fully defined. Study design limitations make critical examination of the potential benefits of graft augmentation challenging given the current “apples vs. oranges” comparisons. One prospective trial showed an improved rate of tendon healing of larger tears and a statistically significant difference in clinical outcomes favoring graft augmentation; however, the difference in outcomes would not meet modern definitions of a minimal clinically important difference.

Recognizing the limitations in the current research, I believe there may be selected indications in which graft/tissue augmentations may be clinically indicated. This relates to younger patients with large to massive rotator cuff tears with reasonable cuff muscle health. Unfortunately, these are relatively rare patients. Younger and more active patients likely have a greater need for return of muscle strength, which is related to structural healing of the repair. Several studies have suggested better tendon repair healing in augmented repairs. Until more definitive research is available, I believe graft augmentation should be reserved to situations where it is believed that healing is a premium and there is a reasonable chance of healing. In many practices, these are revision repairs in patients younger than age 60 years with intraoperative findings of poor tissue quality or tendon loss. Like any new technology, indications will change based on science and there is much more to be studied with graft augmentation for rotator cuff repairs.

Jay D. Keener, MD, is an associate professor, fellowship director and chief of Shoulder and Elbow Service at Washington University, St. Louis.
Disclosure: Keener receives research support from the National Institute of Health and Zimmer Biomet; is a consultant for Arthrex; and receives royalties from Genesis and Shoulder Innovations.

Patches for augmentation

Recurrence of a rotator cuff tear after repair or failure of the rotator cuff to heal occurs in approximately 10% to 80% of repairs and the frequency depends upon the age of the patient, cuff tear size, quality of the tissue and repair technique. Failure to heal the tendon can result in greater weakness of the shoulder and potential for progression of cuff tear size over time. Techniques to improve healing include biologic augmentation with platelet-rich plasma or use of synthetic or biologically derived tissue grafts (patches). When applied under tension over a primary repair using multiple sutures, dermal patches have been shown to share approximately 30% of the load seen at the primary repair and decrease gap formation during cyclic loading. Non-crosslinked human and certain porcine dermal grafts have demonstrated incorporation into the native tissue.

A few randomized clinical trials show improvement in healing with significantly fewer recurrent tears as defined by postoperative imaging. Widespread and frequent use of patches for augmentation has not occurred given that many of the commercially available grafts do not have randomized trials to support efficacy and some grafts have been shown to have immunologic adverse side effects. As such, all graft augmentation has seen decreased utilization. There are barriers to the use of patches due to the preference of arthroscopic surgery for most primary repairs and the difficulties for suturing and tensioning the graft using an all arthroscopic approach. Lastly, the increased cost associated with the graft and the increased operative time has been an additional barrier to widespread use. The clinical need to improve rotator cuff healing remains, and refinement of the graft augmentation remains a viable supplement to primary repair.

Joseph P. Iannotti, MD, PhD, is Maynard Madden professor and chair of the Orthopaedic and Rheumatologic Institute at the Cleveland Clinic.
Disclosure: Iannotti reports no relevant financial disclosures.