Open Rotator Cuff Repair: Where Does it Stand Now?

INTRODUCTION: With recent improvements to arthroscopic techniques, surgery for rotator cuff tears (RCT) has shifted from open repair to all-arthroscopic repair. Although evidence has not supported improved outcomes with arthroscopic techniques over the open rotator cuff repair, but as expected the incidence of performing open rotator cuff repair decrease from 43.1 to 24.9% from the last decade (USA).(1) The all-arthroscopic technique is preferable among shoulder surgeons and has been accepted as the gold standard for the repair of RCT because this approach is minimally invasive and causes less insult to the deltoid muscle, which are believed to reduce postoperative infection and favour rehabilitation. (2, 3) Despite the switch towards all-arthroscopic RCR, open repair is still performed with reliable clinical outcome. In some country setting, the main reason to favor open repair is because of the high cost – utility ratio in which arises from the consumables arthroscopic tools and implants. The second reason is massive retracted RCT or in the case for revision rotator cuff surgery in which non prosthetic arthroplasty is required. We investigated the merit of open versus arthroscopic RCR for large RCT by comparison of the clinical and radiological outcome with propensity matching score technique. METHODS: The outcomes of 112 patients who were treated for large, full-thickness, RCT either by open repair or arthroscopic repair were retrospectively reviewed. All patients included in this study were followed-up for at least 18 months and were imaged at a minimum of 12 months after surgery. Propensity score matching was used to select for controls matched by age, sex, body mass index and affected site. The post-operative functional and radiologic outcomes were compared. Radiologic evaluations were performed using 3 T MRI for (1) post-operative rotator cuff integrity, (2) deltoid origin status and, (3) regional acromio-humeral distance which measured at 3 regions of interests of the lateral acromion border (anterior third, middle third and posterior third). RESULTS: 1. The range of motion, muscle strength and functional scores improved postoperatively for both groups. Open group showed higher constant (p=0.012) and ASES score (p=0.047). Arthroscopic group showed better forward elevation (p=0.006) and external rotation (p=0.004) with less postoperative pain compared to open group (p<0.001). Operative time and hospitalization stay were shorter in arthroscopic group (p=0.007 and p<0.001). Re-tear rate was higher in arthroscopic group (25%) than open group (17.9%) without statistical difference (p=0.300). 2. The deltoid origin thickness was significantly greater in the arthroscopic group when measured at the anterior acromion as well as the anterior third and middle third of the lateral border of the acromion. There was no significant difference in deltoid origin thickness at the posterior third of the lateral acromion between groups. Deltoid integrity was significantly better with less scaring in the arthroscopic group. There was no full-thickness deltoid tear in either group. 3. AHD was significantly greater in open group when measured at the anterior third of the lateral acromion border compare to arthroscopic group (p=0.005). Re-tear rate was affected by AHD at the anterior third of lateral border of acromion for arthroscopic and open group (p=0.021, p=0.029). Re-tear rate was affected by AHD at middle third of lateral border of acromion for open group (p=0.046). CONCLUSIONS: Open rotator cuff is still warranted at the present day. Both repair technique showed comparable outcome for large size RCT. Open repair has superior functional score with lower re-tear rate while arthroscopic repair has superior ROM improvement, pain relief, shorter operation and hospitalization time. Imaging confirmed that open repair of RCT resulted in less thickness of the deltoid origin, especially at the anterior acromion to the middle third of the lateral acromion border at 12 months after surgery. Careful re-attachment of the deltoid origin is essential for open repair of RCT. Open RCR showed greater AHD at the anterior third of the lateral border of acromion. Regional AHD measured at anterior third of the lateral border of acromion significantly associated with re-tear rate following both open and arthroscopic RCR. Nevertheless, regional AHD measured at middle third of the lateral border of acromion significantly associated only with re-tear rate following open RCR. REFERENCES: 1. Day MA, Westermann RW, Bedard NA, et al. Trends Associated with Open Versus Arthroscopic Rotator Cuff Repair. HSS J 2019; 15: 133-136. 2019/07/23. DOI: 10.1007/s11420-018-9628-2. 2. Snyder SJ. Evaluation and treatment of the rotator cuff. Orthop Clin North Am 1993; 24: 173-192. 1993/01/01. 3. Gartsman GM, Khan M and Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am 1998; 80: 832-840. 1998/07/09.