Orthopedics Arthroscopic Versus Open Rotator Cuff Repair Research Paper

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Arthroscopic vs. Open Rotator Cuff

Orthopedics: Arthroscopic vs. Open Rotator cuff repair


Data was compiled to research Arthroscopic vs. open Rotator cuff repair. The findings suggest that regardless of the method utilized for repair there will more than likely be a need for maintenance repairs. Healing time is consistent between the two methods, and cost associated with both procedures is comparable. Researchers have indicated consistently through the research that there is a need for additional therapy of some sort after any procedure has been implemented. However, significant research does indicate that there is a higher level of skill associated with Arthroscopic procedures, this process has proven to be rather effective but intricate in nature; therefore calling for more experience than open rotator cuff procedures. Regardless of the technique utilized one thing remains consistent throughout the research; more often than non-additional repairs will have to be done, and method utilized should be due to the choice of the client in conjunction with the expertise of the surgeon.

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Damage to the rotator cuff that can be due to trauma, as from falling and injuring the shoulder; overuse in sports, particularly those that involve repetitive overhead motions; inflammation, as from tendonitis, bursitis, or arthritis of the shoulder; or degeneration, as from aging. The main symptom of rotator cuff disease is shoulder pain of gradual or sudden onset, typically located to the front and side of the shoulder and increasing when the shoulder is moved away from the body. A person with torn rotator cuff tendons may not be able to hold the arm up because of pain. With very severe tears, the arm falls because of weakness; this is called the positive drop sign. Diagnosis is made via observation and can be confirmed with X-rays showing bony injuries; an arthrogram in which contrast dye is injected into the shoulder joint to detect leakage out of the injured rotator cuff; or a magnetic resonance imaging (MRI) scan, which can provide more information than either an X-ray or an arthrogram. Treatment depends on severity (22).

Problems of the shoulder are common enough that they touch all of us. Chances are that if you have not personally suffered from a torn rotator cuff, you are aware of a spouse, family member, colleague or close friend who has. Shoulder injuries specifically, tom rotator cuffs -- can be caused by trauma or sports activities that involve repetitive overhead motion, such as golf, tennis, swimming and throwing. More commonly, individuals engaged in everyday activities like washing windows, gardening or lifting can experience shoulder injuries due to repetitive overhead arm movement. Each year, an estimated four million people in the United States seek medical attention for shoulder injuries. Nearly 300,000 will undergo surgical repair of the rotator cuff. The vast majority of these surgeries are performed by "open" or "mini-open" surgical techniques (23).

The reported rate of failure after arthroscopic rotator cuff repair has varied widely. The influence of the repair technique on the failure rates and functional outcomes after open or arthroscopic rotator cuff repair remains controversial (17).

Surgical options for rotator cuff disease that has failed to improve with conservative treatments include open or arthroscopic subacromial decompression (ASD) with or without rotator cuff repair (RCR). Arthroscopic approaches are being increasingly used because of purported advantages including earlier recovery, hypothesized to be due to preservation of the deltoid muscle with this approach; smaller scars; and the ability to access the glenohumeral joint to exclude other causes of shoulder pain. Researchers recently completed a Cochrane systematic review of randomised controlled trials to determine the effectiveness and safety of surgery for rotator cuff disease. Researchers identified six trials that had compared arthroscopic to open subacromial decompression and while it was not possible to draw firm conclusions due to their overall poor quality, none of the trials reported significant differences between trial arms in terms of comparative improvements in pain, function or participant evaluation of success, while four trials reported earlier recovery with arthroscopic decompression. There were also no differences between trial arms for adverse events including post-operative adhesive capsulitis (1).

The clinical outcomes of the surgical methods of rotator cuff repair (open, mini-open, and all-arthroscopic cuff repair) vary, as each method provides an array of advantages and disadvantages. Although the open surgical technique has long been considered the gold standard of rotator cuff repair, surgeons are becoming more adept at decreasing patient morbidity through decreased surgical trauma from an all-arthroscopic approach. In addition to a surgery-specific rotator cuff rehabilitation program, effective communication, and coordination of care by the physical therapist and surgeon are essential in optimal patient education and outcomes. In the ideal situation, a very well-educated therapist who has great communication with the treating surgeon can mobilize the shoulder early, re-establish scapulothoracic function safely and minimize the risk of stiffness and retear, while facilitating return to function, Treatment options can be individualized according to patient age, size and chronicity of tear, Surgical approach, and fixation method (21).

This is not a new notion. For years, orthopedic surgeons have sought a means to effectively perform arthroscopic surgery, a minimally invasive surgery technique, to repair torn rotator cuffs. Indeed, some surgeons around the country have seen success performing rotator cuff repairs arthroscopically, but it has been a difficult procedure to teach and perform and due to the limited visibility and complicated knot-tying involved, it has rarely yielded the same level of results as open surgery. Indeed, less than ten percent of rotator cuff repairs are currently performed through minimally invasive, totally arthroscopic surgery (23).

Researchers recommend that patients who have undergone an all-arthroscopic rotator cuff repair undergo an accelerated postoperative rehabilitation program. A rational approach to therapy involves early, safe motion to allow optimal tendon healing, yet maintenance of joint mobility with minimal stress. As the field of orthopedics and, particularly, rotator cuff repair continues to develop with new technologies, the patient, physical therapist, and doctor need to work together to ensure optimal outcomes and patient satisfaction (21).

The purpose of the research conducted by Lafosse was to evaluate the functional and anatomic results of arthroscopic rotator cuff repairs performed with the double-row suture anchor technique on the basis of computed tomography or magnetic resonance imaging arthrography in order to determine the postoperative integrity of the repairs. A prospective series of 105 consecutive shoulders undergoing arthroscopic double-row rotator cuff repair of the supraspinatus or a combination of the supraspinatus and infraspinatus were evaluated at a minimum of two years after surgery. The evaluation included a routine history and physical examination as well as determination of the preoperative and postoperative strength, pain, range of motion, and Constant scores. All shoulders had a preoperative and postoperative computed tomography arthrogram (103 shoulders) or magnetic resonance imaging arthrogram (two shoulders). There were thirty-six small rotator cuff tears, forty-seven large isolated supraspinatus or combined supraspinatus and infraspinatus tendon tears, and twenty-two massive rotator cuff tears. The mean Constant score (and standard deviation) was 43.2 +/- 15.1 points (range, 8 to preoperatively and 80.1 +/- 11.1 points (range 46 to postoperatively. Twelve of the 105 repairs failed. Intact rotator cuff repairs were associated with significantly increased strength and active range of motion (14).

Among many physicians it has been stated that there is not a significant difference between arthroscopic and open rotary cuff repair, however it is a matter of technique that often draws the line between the two styles of repair. Rotator cuff tears are the most common source of shoulder pain and disability. Only poor quality studies have compared mini-open to arthroscopic repair, leaving surgeons with inadequate evidence to support optimal, minimally-invasive repair (5).

Anatomic studies detailing rotator cuff tears in cadavers have noted a prevalence ranging from 17% to 72%. Traditional treatment of full thickness tears of the rotator cuff has consisted of open surgical repair . Reported satisfactory outcomes for open repair have ranged from 70% to 95%. Although the effectiveness of open rotator cuff repair is well established, significant pain and morbidity can be associated with the procedure. A significant limitation to rehabilitation after open repair is pain associated with reattachment of the deltoid to the acromion. More recently, reports have described the evolution of rotator cuff repair to help minimize deltoid trauma and expedite post-operative rehabilitation. Good results have been reported with arthroscopically-assisted "mini-open" repair, as well as completely arthroscopic techniques (6).

Rotator cuff repair has evolved from a classic open operative technique, which involved significant deltoid dissection and detachment, to a less invasive approach called the mini-open deltoid splitting approach. Long-term results were similar and rehabilitation was easier for patients who had the mini-open approach. Now more surgeons are repairing the rotator cuff with an all-arthroscopic technique, and this study compares Nottage's results with repairs done arthroscopically to the repairs they previously performed through the mini-open approach (10).

Investigators publish new data in the report 'Cost-effectiveness of open vs. arthroscopic rotator… [END OF PREVIEW] . . . READ MORE

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