Rotator Cuff Repair (RCR) Arthroscopic vs Mini-open
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1 Rotator Cuff Repair (RCR) Arthroscopic vs Mini-open vs Open Sohail Bajammal, MBChB, MSc Jaydeep Moro, MD, FRCS(C)
2 Steps in EBM 1. Ask 2. Acquire 3. Appraise 4. Apply 5. Act
3 The Question - PICO(T) Population : Intervention: Control : Outcome : Time : In adult patients with RC tear, does arthroscopic repair compared with open or mini-open improve pain & functional outcome for 5 to 10 years?
4 The 4S Approach by Haynes Haynes, R B. Evid Based Med 2001;6:36-38
5 Search Strategy (4S) Sources: Systems: UpToDate, Clinical Evidence 0 Synopses: ACP Journal Club 0 Syntheses: 3 Systematic Reviews Studies: many, variable quality Terms: Rotator Cuff Tear
6 Syntheses (Systematic Reviews) Ejnisman et al Coghlan et al Grant et al
7 Ejnisman et al, CDSR 2006 Cochrane review: Interventions for tears of the rotator cuff in adults. Search to RCT & QRCT Only 2 arthroscopic vs. open
8 Ejnisman et al, CDSR 2006 Ogilvie-Harris et al., JBJS(B) 1993: Quasi-randomized, Tear size (1-4 cm) n=50, 90% available at 5 year Comparison of UCLA Score: Arthroscopic subacromial decompression & RC debridement vs. open repair and acromioplasty Similar pain relief, active FF & satisfaction Open: better function, strength & overall score
9 Ejnisman et al, CDSR 2006 Montgomery et al., JSES 1994: Quasi-randomized n=88, 5 & 9yr Comparison of UCLA Score: Arthroscopic subacromial decompression & RC debridement vs. open repair and acromioplasty
10 No Improvement Overall Results (UCLA)
11 Ejnisman et al, CDSR Weak evidence for the superiority of open repair compared with arthroscopic debridement.
12 Coghlan et al, CDSR 2006 Cochrane Protocol: Surgery for rotator cuff disease Awaiting results
13 Grant et al, J Hand Ther 2004 Evaluation of interventions for rotator cuff pathology: a systematic review Search to May studies of surgical intervention 41 case series (level 4 evidence) 2 quasi-randomized (level 2b) Results: 9-pages table
14 Grant et al, J Hand Ther 2004 the quality of the available evidence precludes drawing a conclusion about the advantage of one surgical intervention over another..the results from Ogilvie-Harris et al indicated the advantage of open surgery when compared with arthroscopic surgery for patients presenting with a rotator cuff tear
15 Studies
16 Levels of Evidence Therapy Trials
17 Search Strategy 1. exp Rotator Cuff/ OR rotator cuff tear$.mp. 2. exp Arthroscopy/ OR arthroscop$.mp and 2 4. Limit to 2003 to May Week citations 28 relevant 15 included
18 Kim et al, Arthroscopy 2003 Retrospective cohort, Level 3 n=76: 42 arthroscopic 34 mini-open salvage of failed arthroscopic Exclude <1cm, >5cm F/U: mean 39 months Results: No statistical difference in postoperative UCLA & ASES Large tears had lower postoperative scores
19 Modified UCLA
20 Severud et al, Arthroscopy 2003 Retrospective cohort, Level 3 n=64 shoulders: 29 mini-open trans-osseous sutures 35 arthroscopic metal bone anchors >5cm tear excluded F/U: minimum 24 mo, average 44 mo Results: Large tears (3-5 cm): 9 in arthroscopic vs 18 in mini No statistical difference UCLA score at final F/U Stiffness 14% in mini-open
21 Sauerbrey et al., Arthroscopy 2005 Retrospective cohort, Level 3 n=54 26 mini-open trans-osseous sutures 28 arthroscopic suture anchors F/U: 33 mo mini, 19 mo arthroscopic Modified ASES scores Results: Tear Size: 2.7 (1-8) cm² mini, 2 (1-12) cm² arthroscopic Significant improvement within each group No difference between the two groups
22 Ide et al., Arthroscopy 2005 Retrospective cohort, Level 3 n=100 (50 mini-open, 50 arthroscopic) F/U: mean 49 months Results: Similar pre-op tear size, duration symptoms, UCLA and JOA scores No statistical difference in scores between two groups Inferior outcome in large tear group compared to small/medium group, regardless of intervention
23 Youm et al., JSES 2005 Retrospective cohort, Level 3 n=84 (24 mini-open, 24 arthroscopic) F/U: 37.6 mo in mini, 35.2 mo in arthroscopic Results: Large (3-5cm) tears: 2 in mini, 12 in arthroscopic Similar post-op UCLA and ASES 3 re-operations in each group
24 Buess et al., Arthroscopy 2005 Retrospective cohort, Level 3 n=96 patients: A: Before Feb 2000: 30 open (12 classic, 18 mini) B: After Feb 2000: 66 arthroscopic suture anchors F/U: months Outcomes: VAS, Simple Shoulder Test, Satisfaction Results: Similar tear size, pre-op pain Significant pain relief in arthroscopic No significant difference in SST or satisfaction
25 Warner et al., Arthroscopy 2005 Retrospective cohort n=21 (12 mini-open, 9 arthroscopic) F/U: minimum 27 mo Simple Shoulder Test Results: No significant difference in overall SST
26 Chhabra et al, Arthroscopy 2005 In vitro cadaveric study Full-thickness 1 x 3-cm rotator cuff defects were created in 25 fresh-frozen cadaveric shoulders Randomized to 1 of 4 repair groups: (1) open repair with trans-osseous sutures (2) arthroscopic with 2 singly loaded suture anchors (3) arthroscopic with 2 doubly loaded suture anchors (4) arthroscopic with cuff tacks
27 Chhabra et al, Arthroscopy 2005 Repairs were cyclically loaded from N Numbers of cycles to 50% (5-mm gap) and 100% (10-mm gap) failure were recorded Results: The number of cycles to 100% failure was significantly higher for the arthroscopic doubly loaded suture anchor repairs compared with other repairs The number of cycles to 50% failure was significantly higher for all anchors versus open or tack repair
28 Chhabra et al, Arthroscopy 2005 Conclusions: Superior immediate postoperative fixation of RCR may be achieved with the doubly loaded suture anchors. However, additional evaluation is needed to examine the effects on the sustained strength of the repair throughout the healing process.
29 Wolf et al, Arthroscopy 2004 Case series of arthroscopic repairs Single surgeon experience 1990 to repairs 96 available for follow-up F/U: 4-10 years 98% of patients: good to excellent result according to the UCLA shoulder score
30 So what is the best option?
31 MacDermid et al., BMC Musculoskeletal Disorders 2006 Protocol of a randomized, multi-center, national trial JOINTS Canada Proposed sample 250 Arthroscopic vs mini-open Validated outcomes Recruitment for 2 yr, follow-up 2 yr Will have the answer in 5 years
32 Thank You
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