Peter B. MacDonald M.D., FRCSC
Professor of Surgery
University of Manitoba
With the increasing popularity of arthroscopic shoulder procedures, the orthopaedic community is once again faced with the familiar "arthroscopic vs. open" debate as it applies to the treatment of rotator cuff tears. This is reminiscent of historic orthopaedic debates on the treatment of meniscal tears, chronic ACL insufficiency, shoulder impingement and shoulder instability. Over time, clinical practice favors the arthroscopic treatment despite initial skepticism and dearth of scientific evidence initially supporting the same.
Pros and Cons
The traditional arguments in favor of arthroscopic treatment apply here i.e. 1) decreased morbidity, 2) less deltoid disruption, 3) improved infection rates, 4) improved function, 5) more rapid recovery, 6) a more comprehensive view of pathology including additional pathology in the glenohumeral joint, 7) better cosmesis. The arguments against this approach over time have included technical difficulty including the "learning curve" as well as the important question of the security of the repair and its potential for healing in an all-arthroscopic approach. This was recently and once again brought into question by Schneeberger, Gerber et al10 in their in vitro analysis of arthroscopic repair techniques in which he questioned their ability to withstand high postoperative loading conditions.
There are three possible arthroscopic approaches to rotator cuff disease: 1) arthroscopic decompression without cuff repair, 2) arthroscopic decompression with "mini-open" repair and, 3) all-arthroscopic cuff repair. Option #1 had initial favor in articles by Ellman2 and Gartsman3,4 in small tears but was proved inadequate in a comparison study of repair vs. decompression alone by Montgomery7 and by Wilson14 who found that patients with healed rotator cuffs demonstrated better overall functional results. This discussion will concentrate on options #2 and #3.
All-arthroscopic cuff repair is probably the most technically challenging of common procedures done in the shoulder. It constitutes a natural extension of an arthroscopic-assisted mini-open repair. The latter has many of the advantages of an all arthroscopic repair with less of the technical demands pertaining to the mobilization and securing of the rotator cuff to the greater tuberosity. It is therefore recommended that an inexperienced shoulder arthroscopist wishing to make the transition to an all arthroscopic repair first perfect the decompression and "mini-open" technique. No matter which repair technique one chooses, the fundamental principles of rotator cuff repair, as emphasized by Yamaguchi et al16, should be adhered to. These include 1) preservation or meticulous repair of the deltoid, 2) adequate subacromial decompression, 3) surgical release to produce a freely mobile muscle-tendon unit, 4) secure fixation of the tendon to the greater tuberosity, and 5) closely supervised rehabilitation.
| Results of Arthroscopic Rotator Cuff Repairs Reported in the Literature** |
| Author || year || number || f/u || UCLA* || pre/post op || Constant pre || op/ post op || success rate % |
| Tauro || 1998 || 53 || 24 || 17 || 41 || |
| 92 |
| Stollsteimer and Savoie || 1998 || 48 || 34 || |
| 33 || |
| Gartsman || 1998 || 73 || 30 || 12.4 || 31.1 || 41.7 || 83.6 || 90 |
| Burkart || 2000 || 24 || 38 || 15.1 || 32.3 || |
| 96 |
| Hoffman || 2000 || 45 || 34 || |
| 46 || 91 || |
| Gleyze || 2000 || 87 || 25 || |
| 49.7 || 83.5 || 95 |
| Wolf || 2000 || 96 || 74 || |
| 32.3 || |
| Nottage and Severud || 2001 || 35 || 38 || |
| 32.6 || |
| 91 |
| Weber || 2001 || 126 || 36 || |
| 32.3 || |
| 92 |
| Murray || 2002 || 48 || 39 || 17.2 || 33.7 || |
| 96 |
| *UCLA: University of California Los Angeles rating score |
** adapted from Yamaguchi et al (16)
The literature on arthroscopic cuff repair contains many retrospective studies that have generally favorable results. The limitations of these studies are: 1) they are retrospective and non-randomized, 2) they are relatively short-term, 2-3 yrs follow-up, and 3) there is clearly a general lack of documentation of the status and integrity of the repair. We are currently analyzing the results of our arthroscopic repairs with ultrasound follow-up of the repair at a minimum of two years follow-up. The results published below represent the end-results of the most experienced of arthroscopic shoulder surgeons and therefore should be viewed with caution.
Points of Discussion: Which Is Better??
The best technique cannot be dogmatically proclaimed, but rather must be a function of the individual surgeon's experience and comfort level. A good open repair will always be superior to a badly performed arthroscopic one. There are also technical considerations related to size of tear, quality of tissue, available equipment and assistance, and patient expectations. Preoperative imaging, particularly MRI, can assist with planning and discussion of options with the patient. A surgeon wishing to make the transition to arthroscopic repair should do so in a stepwise and careful fashion first perfecting arthroscopic acromioplasty and "mini-open" technique.
The improvement of the armamentarium of arthroscopic instruments available will allow greater ease of arthroscopic repair in the future. Cadaveric skills labs are also becoming more common enabling surgeons to practice arthroscopic techniques and lessen the " learning curve".
To complement the existing literature, prospective randomized clinical trials are necessary. Currently the Canadian Shoulder Study Group (recently renamed JOINTS Canada: Joint Orthopaedic Initiative for National Trials of the Shoulder) is finalizing a randomized clinical trial proposed by Dr. Richard Holtby on all arthroscopic versus arthroscopic assisted rotator cuff repair.
- Burkart, S.: Arthroscopic repair of massive rotator cuff tear: Concept of margin convergence. Tech Shoulder Elbow Surg. 2000; 1:232-9.
- Ellman H.: Arthroscopic subacromial decompression: Analysis of one to three year results. Arthroscopy 1987;3 173-181
- Gartsman, G.: Arthroscopic management of rotator cuff disease. Journal of the American Academy of Orthopaedic Surgeons. 1998; 6: 259-266.
- Gartsman, G., Brinker, M., Khan, M.: Early effectiveness of arthroscopic repair for full-thickness tears of the rotator cuff: an outcome analysis. J Bone Joint Surg Am. 1998; 80: 33-40.
- Gleyze P., et al. Arthroscopic rotator cuff repair: a multi centric retrospective study of 87 cases with anatomic assessment. Rev Chir.Reparatrice Appar. Mot. 2000; 86:566-74.
- Hoffman, F., Schiller, M., Reif, G. Arthroscopic rotator cuff reconstruction. Orthopade. 2000; 29; 888-94.
- Montgomery., T, Yerger, B., Savoie, F. Management of rotator cuff tears: A comparison of arthroscopic debridement and surgical repair. J Shoulder and Elbow Surg 1994; 3:70-78.
- Murray, T. et al Arthroscopic repair of medium to larger full-thickness rotator cuff tears: Outcome at 2-6 year follow-up. J. Shoulder Elbow Surg. 2002; 11:19-23
- Nottage, W., Severud, E. A comparison of all arthroscopic vs. mini-open rotator cuff repair. Results at 45 months. Read at the Summer Institute Meeting of the AAOS; 2001 Sept 6-9 San Diego, Ca.
- Schneeberger, A., et al. Mechanical strength of arthroscopic rotator cuff repair techniques. J. Bone Joint Surg. 2002; 84:2152-2160.
- Stollsteimer, G., Savoie, F. Arthroscopic rotator cuff repair: current indications, limitations, techniques and results. Inst Course Lect. 1998;47:59-65
- Tauro, J. Arthroscopic "interval slide" in the repair of larger rotator cuff tears. Arthroscopy. 1999; 15: 527-30.
- Weber, S. A comparison of all arthroscopic vs. mini-open rotator cuff repairs. Read at the annual meeting of the Arthroscopy Association of North America; 2001 April 19-22; Seattle, Wa.
- Wilson, F. Arthroscopic repair of full thickness tears of the rotator cuff. Arthroscopy 2002;18:136-144.
- Wolf, E. All arthroscopic rotator cuff repair report. Read at the annual shoulder surgery controversies meeting; 2000 Oct-6-8 Costa Mesa, Ca.
- Yamaguchi, K. et al: Transitioning to arthroscopic rotator cuff repair: The pros and cons. J Bone Joint Surg. 2003 85-A:144-155.