What do patients know? “Patients think that arthroscopy is best, but they are getting their data from Oprah, ” argues Dr. John J. Brems. “They don’t have all the facts.”
Patients may not have all of the facts, but we do! “We do have the data on arthroscopy and it shows that this technique is better, ” counters Dr. Reuben Gobezie.
In an Orthopaedic Crossfire® debate entitled, “Arthroscopic Rotator Cuff Repair: The Optimal Approach, ” Dr. Reuben Gobezie of University Hospitals Case Medical Center in Cleveland, Ohio, argues persuasively that in part because it is less invasive and because it is easier to treat associated pathology, arthroscopic cuff repair is optimal. Dr. John J. Brems of Cleveland Clinic in Ohio pulls out the ultimate argument and says that if he were on the table, “No hesitation…I would want mine done open.”
Dr. Gobezie: “Inevitably, patients will think that the surgeon doing an arthroscopic cuff repair is ‘better’ than one who does an open repair. They think they’ll have less pain with arthroscopic cuff repair or that they’ll rehab more quickly, etc. They encounter patients who have large incisions…hence the question we often get, ‘Doc, are you going to open me up?’ In a set of reasonably well powered studies comparing open and arthroscopic cuff repair, they looked at overall shoulder outcome scores, and found that both groups—arthroscopic and open—improved in outcomes. These studies really don’t help us in distinguishing between open and arthroscopic.”
“There are data on healing/tearing rates after arthroscopic and open repair as well as arthroscopic studies looking at how patients did within the cohort study…those who had a healed cuff repair and those who did not. The vast majority show statistically significant improvement in patients with regard to strength and function if they had a healed repair versus those who had failed cuff repairs.”
“If we take the same measure and ask if the outcome scores are different between those patients who had a healed cuff versus those who had a failed cuff repair, you see a similar thing. The vast majority of studies show that if your cuff heals then the patient is going to have a better outcome overall. Bottom line: if you look at the literature, five out of eight studies showed increased strength with healed repairs; six out of nine studies showed improved statistical outcome scores.”
“With arthroscopic cuff repair it is easier to treat associated pathology, whether it’s a chondroplasty for arthritis, a biceps tear pathology which you can see easier with a scope, or AC [acromioclavicular] joint arthritis. What is more invasive? Here is a paper out of Fukuoka University in Japan from 2009 asking, ‘Is it more invasive to have an arthroscopic cuff repair versus an open?’ They looked at 17 arthroscopic cases versus 15 open cases, and measured C-reactive protein, hemoglobin, and IL6 levels (Interleukin-6 is a potent marker for inflammation)—they found that IL6 was lower in arthroscopic cuff repair patients. This does support the hypothesis on a molecular level that arthroscopic cuff repair is less invasive than open…and perhaps provides support for the hypothesis that adhesive capsulitis and rehab may be faster in the arthroscopic cuff repair group.”
“For this debate, we have an active, older male who wants to play tennis and doesn’t have adhesive capsulitis and is otherwise healthy. A coronal plane retraction beyond the footprint, relatively good cuff tissue…we’ll need some releases to bring it back. I typically do about 95% of my cuffs with a double row suture bridge technique. Placing the first anchor at the footprint junction…you take the suture and pass it through. Place a second anchor and you will have two medial row footprints…if you do it right you should have a big healthy cuff of tissue lateral so it can heal to the footprint and the lateral row anchors.”
Dr. Brems: “Reuben, my good friend and talented surgeon, I’d absolutely have mine done open. We have a 60-year-old executive who is an avid tennis player, with two years of minor symptoms; he has had injections and physical therapy. He has severe sleep interruption…tried many medications…and the MRI scan shows a large cuff tear, poor tissue quality. Some cuff tears can be treated with arthroscopic technique, but not ALL cuff tears should be.”
“Patients want arthroscopic surgery, but based on what? On marketing…on instantaneous, but unrealistic outcomes of highly visible athletes. That’s where they get their data—Oprah Winfrey and the like. The Internet is ubiquitous and often inaccurate…but do patients really know about the biology of tendon tears, their chronicity, etiology, etc.? Open cuff repair isn’t a sign of inadequacy…it may be an indication of surgical insight.”
“In this specific tear, why is open cuff repair better? Consider the tear size, tear configuration, tissue quality, fat replacement, bone quality, and delamination. The cuff repair that my colleague showed you was not this gentleman’s cuff tear. That was a relatively fresh cuff tear. This is a very chronic, very thin, poor quality tissue…with significant fat replacement. So except in acute tears, ‘retraction’—I believe—is an orthopedic myth. In chronic large tears, which we commonly see, the tendon isn’t just retracted—it’s GONE. Retraction implies that you can put sutures in it, grab it and pull it back to where it came from. Oftentimes we’re left with very little tendon tissue.”
“The bony footprint in these types of tears is osteopenic and anchor failure is not uncommon. Because of that, we’d recommend the double row technique, but studies suggest that this might impact the vascularity of the repaired tissue tendon.”
“Open technique permits large bone tunnels and transosseus fixation techniques with a very low risk of fixation failure. In arthroscopic technique you get kind of a spot welding along where the anchors may be, whereas with open technique you can get better seaming and apposition along the entire construct of bone to tendon.”
“The differences between arthroscopic and open technique…difference one: arthroscopic is the winner—the length and permanency of the scar favors this technique. Difference number two: how long you hate your doctor. Arthroscopic surgery is less painful, but pain can be a good thing, especially in younger, active patients. If they have no pain, they think they can start doing activities before the tendon is actually healed appropriately. That may part of the explanation of the higher failure rate. Difference three: open is the clear winner, with better outcomes over the long span of time. And isn’t that what we are obligated to provide our patients?”
“What is not different? Patients do not heal faster, do not return to work any sooner—or they shouldn’t because the tendon has not healed. They don’t return to sports quicker. Some now argue that healing is more robust with open technique because of better blood supply and the bony trough.”
“Outcomes are better and more robust with open cuff surgery. An ultrasound follow-up of 127 patients with arthroscopic repair showed that the progression from a single tear to multiple tears increased the likelihood of re-tear by at least nine times. This was published in 2009 in the Journal of Shoulder and Elbow Surgery. Study after study shows a high tear rate, but the arthroscopists feel that because they are not immediately symptomatic that their outcomes are as good—just because they have pain relief. But when you look at cuff integrity, it clearly favors the open technique.”
“Many open repairs do stand the test of time, but this man’s cuff should be repaired open, notwithstanding my colleague’s feelings.”
Moderator Thornhill: “So we could say that you guys totally disagree with one another. Reuben, John said that the integrity of the repair is better open and you said it isn’t.”
Dr. Gobezie: “Actually, Dr. Thornhill, I didn’t say it wasn’t…the data did. The problem is that there aren’t as many studies looking at open…”
Moderator Thornhill: “Just answer the question, Reuben.”
Dr. Gobezie: “[Laughing] Yes, I think it’s open…it has a higher healing rate.”
Dr. Brems: “To the audience: with a show of hands, if you had this tear, how many would want this done arthroscopic? Open? Reuben, you lose!”
Moderator Thornhill: “John, what do you tell this avid tennis player…let’s say he was a USTA 4.0 before. Can he get back to that?”
Dr. Brems: “Unlikely. I tell him that it will be an ongoing process, that he’ll not actively use his arm for probably 12 weeks, he’ll have six months of strengthening, that he’ll likely be getting better for up to one year postop in terms of strength and endurance. I don’t low ball my expectations, but I don’t want to be unrealistic.”
Moderator Thornhill: “Rehab. How do you manage these people?”
Dr. Gobezie: “Six weeks of passive range of motion—I try to get them to 140 degrees of passive forward elevation by six weeks postop. Then six weeks of active, and depending on the cuff tear size, for massive tears I don’t do strengthening because of fatty degeneration, etc., I don’t think they’re ever going to be strong. But with the regular healthy cuff tissue I say strengthen over the next three months.”
Moderator Thornhill: “Researchers at Columbia recently reported on the incidence of arthroscopic decompressions and procedures; in 1996 there were about 5, 000 in the state of New York and in 2006 about 19, 000. Are we doing too many of these, John?”
Dr. Brems: “I think so. Like with reverses, intoxication of acromioplasties.”
Moderator Thornhill: “Thank you both.”
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I wish I had gone to Dr.Brems first, if I had done that I wouldn’t have all the problems that I had to go through… My replacement has lasted 28 years, and now its worn out.. I don’t know if Dr. Brems is still practicing but I wouldn’t go to someone else.. Whoever reads this and can tell me if Dr.Brems is still in practice, please let me know.. Email—- rgp1961@yahoo.com…Thank you