Stephen C. Weber, M.D.
A.
Open repair. Good results reported by Ellman, Cofield, and numerous others.
Anticipate about an 85% success rate.
1.
Advantages:
a.
easy to do
b.
no special equipment required -
c.
allows direct visualization of cuff repair and
acromioplasty
d.
Good long term follow-up. Several studies with >10
year follow-up show generally stable results with time.
2.
Disadvantages:
a.
deltoid detachment required. This increased
perioperative morbidity in all comparative studies reported (Baker and Liu,
Weber)
b.
False positive studies (arthrogram 2%, MRI 10%) will
lead to unnecessary open exploration
c.
Unrepairable tear will be opened. Although Rockwood
showed good results with open debridement and acromioplasty, other authors have
made patients worse, especially by causing anterosuperior instability, which is
virtually untreatable.
d. Significant intraarticular pathology will be missed except in very large tears:
1.
radiographically silent DID as discussed by ElIman
2.
Significant inferior surface partial cuff tears, which
are
3.
not well handled by acromioplasty alone (Weber,
others).
4.
rare SLAP lesions and instability will go unnoticed
e. Grana, et. al. only author to show no difference between mini open and open repair. In his hands, arthroscopic evaluation never once changed treatment. This high degree of preoperative clinical accuracy is unlikely to be duplicated by many surgeons
B.
Arthroscopic debridement. Good initial results reported by ElIman and Esch
for full thickness tears. Early results of debridement of small to moderate
size tears very equivalent to open repair.
1.
Advantages:
a.
simple to do with modest arthroscopic skills
b.
low morbidity
c.
few complications
d.
avoids many of the problems of open repair noted above
2.
Disadvantages:
a.
even early results sometimes unpredictable
b.
Some good long term results, but Ellman and others
showed that results generally deteriorated with time
c. Savoie, et. al. in his prospective, randomized study showed that repair clearly favored over debridement, with a significant percentage of debrided patients going on to cuff arthropathy.
C.
Mini open repair. Multiple studies presented in the early 90’s of
retrospective reviews of arthroscopic evaluation and acromioplasty followed by
open repair through a deltoid splitting incision. Appeared to combine
advantages of open repair (direct visualization of repair, palpation of
acromioplasty, long -~ term success of repair) with arthroscopic visualization
and decreased morbidity.
1.
Advantages:
a.
easy to do with modest arthroscopic skills
b.
allows for arthroscopic correction of intraarticular
pathology c. well established improvement in perioperative morbidity in two
large studies with no increase in complication or compromise in outcome
c.
cost effective. Decrease in hospital time leads to
significant decrease in cost
d.
easy to "bail out" to full open procedure if
desired
e.
avoid opening patients with false positive studies
f.
avoid opening patients with unrepairable defects
g.
no truly long terms studies, but in theory should hold
up as well as open repair.
2.
Disadvantages:
a.
does require basic arthroscopic skills. Should complete
acromioplasty in about 1/2 hour to avoid compromise of exposure with swelling
b.
if basic arthroscopic skills do not allow recognition of
pathology, inserting arthroscope does not improve outcome and increases cost.
c.
not possible to do outpatient for all authors (30% in
our 1993 AAOS study)
D.
All arthroscopic repair. Intellectually attractive procedure which is
perceived by virtually all patients and many surgeons to be superior to open
procedures. Early retrospective series by Snyder, Wolf, Tippett, and others
demonstrated that skilled surgeons could apply these new techniques with one to
two year results comparable to prior series of open repair.
1.
Advantages:
a.
patients like it "sell surgery"
b.
has all the advantages of mini open repair in terms of
diagnosis and arthroscopic treatment of intraarticular pathology
c.
the assertion of improvement in perioperative morbidity
born out in prospective, nonrandomized study (Weber, 1997 AAOS) d. can convert
at any time to mini open if needed without compromise.
2.
Disadvantages
a.
patients like it "sell surgery." Like other
arthroscopic techniques, patient and surgeon perception of "minor surgery
make it prone to abuse. Indications for repair remain the same.
b.
While some authors report no complication and no
failures (Gartsman, JBJS) these outstanding results have not been -duplicated
by others (Weber, Wolf). Expect worse results as these techniques are applied
in the community
c.
Paulos in laboratory studies clearly showed cuff
requires fixation for 12 weeks to heal. Three to six weeks of fixation not
adequate if cuff closure surgeon’s goal. Christian Gerber’s meticulous work in
the laboratory with sheep shows that efforts to improve strength of initial
repair will be rewarded with more healed repairs. Mini open repair allows more
options (sutures through tunnels, Masoneuve suture) to do this.
d.
Technique requires suture anchors, which don’t always
stay in bone. Must see anchor go into bone, and test intra-operatively; not all
currently espoused techniques allow this. Loose anchors will migrate, sometimes
dangerously, and must be removed. Improved anchors have decreased, but not
eliminated this problem.
e.
reports of improved outcome with all arthroscopic
repair NOT
born out in comparative studies.
f.
temptation to accept marginal arthroscopic repair over
adequate
open repair to be avoided.
g.
cost. Virtually all arthroscopic passers disposable
now, and not
inexpensive (Arthrex passer only exception). Suture anchors not
cheap either, with "second generation" anchors even more
expensive, for reasons unclear. Hospital will mark these items up
300-400%. In my hospital, this leads to an increase in charges of
$2170 over mini open repair through bone tunnels. Direct billing
of surgeon for anchors, and disposable anchors will obviate some
of these problems.
A. Remember that most of us will be judged by outcome in the long run, not perioperative morbidity. Pick the procedure that in your hands offers the best outcome.