Study of Rotator Cuff Repair Techniques: We Really Are Trying

Abstract

For some strange reason, in early May 2010 I developed a severe upper back pain and had a little shortness of breath. So I decided to do what I always do when stressed and sat down to read the current issue of Arthroscopy for comfort. I was looking for the scientific articles and thought that, somehow mistakenly, my wife had put a green cover on the New York Post editorial page. There I found the unexpected source of my pain via a voodoo doll mechanism. Burkhart and Cole1Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar opined on single-row and double-row cuff repair and some of the research that had been done. Burkhart and Cole are supported in their opinions by the editors as leading international experts who are questioning established thought so that they might advance our knowledge.2Lubowitz J.H. Poehling G.C. Controversy in arthroscopy: Bring it on.Arthroscopy. 2010; 26 (editorial): 573-574Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Anything but suture-bridge technology to fix cuff tears was severely taken to task. Burkhart and Cole said the truth is elusive. Our Level I article was downgraded as using older-generation repairs and not just being underpowered but being “grossly” underpowered.3Burks R.T. Crim J. Brown N. et al.A prospective randomized clinical trial comparing arthroscopic single-row and double-row rotator cuff repair.Am J Sports Med. 2009; 37: 674-682Crossref PubMed Scopus (212) Google Scholar Our study was apparently used by some to erroneously justify using cheaper and easier procedures. It is not every day that your study is held up as potentially contributing to blocking finding the truth or obscuring orthopaedics with “irrelevant or poorly understood facts.” Wow. Where had we gone so wrong after hundreds of hours of work and several years of dedication? Maybe some background would help. In planning our study we sought to use what we believed was the best of both worlds at that time. We started the institutional review board process in mid 2004 and the study in early 2005. In 1997 Burkhart4Burkhart S.S. Johnson T.C. Wirth M.A. Athanasiou K.A. Cyclic loading of transosseous rotator cuff repairs: Tension overload as a possible cause of failure.Arthroscopy. 1997; 13: 172-176Abstract Full Text PDF PubMed Scopus (214) Google Scholar wrote, “In most rotator cuff tears, there is a degenerative factor that results in loss of tissue substance at the distal end of the torn fibers. The effect of this tissue loss is that the muscle-tendon units comprising the tear are shortened in comparison to the intact muscle-tendon units at the margins of the tear.” He also warned, “The first implication is that rotator cuff tears should not be repaired under significant tension or they will fail . . . . Therefore, we should try to achieve a relatively tensionless apposition of the free margin of the cuff to a bone bed beneath it, even if that bone bed is a bit medial to the anatomic insertion of the tendon.” Burkhart5Burkhart S.S. Pagan J.L. Wirth M.A. Athanasiou K.A. Cyclic loading of anchor-based rotator cuff repairs: Confirmation of the tension overload phenomenon and comparison of suture anchor fixation with transosseous fixation.Arthroscopy. 1997; 13: 720-724Abstract Full Text PDF PubMed Scopus (285) Google Scholar wrote another article to prove this point and ultimately wrote on the principles of cuff repair in 2000,6Burkhart S.S. A stepwise approach to arthroscopic rotator cuff repair based on biomechanical principles.Arthroscopy. 2000; 16: 82-90Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar stating, “The crescent-shaped margin of the tear must be respected in the repair and therefore the suture anchors should be placed in a crescent array just 4 or 5 mm off the articular surface to avoid tension overload at any of the fixation points.” Using these principles, Burkhart et al.7Burkhart S.S. Barth J.R. Richards D.P. et al.Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration.Arthroscopy. 2007; 23: 347-354Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar did only single-row repair and reported on repair of patients with a mean age of 66.5 years with massive cuff tears and up to 75% fatty muscle infiltration. Multiple authors have shown this to be a patient group at very high risk of failure because of age, size of tear, and fatty infiltration.8Nho S.J. Shindle M.K. Adler R.S. et al.Prospective analysis of arthroscopic rotator cuff repair: Subgroup analysis.J Shoulder Elbow Surg. 2009; 18: 697-704Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 9Boileau P. Brassart N. Watkinson D.J. et al.Arthroscopic repair of full-thickness ears of the supraspinatus: Does the tendon really heal?.J Bone Joint Surg Am. 2005; 87: 1229-1240Crossref PubMed Scopus (954) Google Scholar, 10Liem D. Lichtenberg S. Magosch P. Habermeyer P. Magnetic resonance imaging of arthroscopic supraspinatus tendon repair.J Bone Joint Surg Am. 2007; 89: 1770-1776Crossref PubMed Scopus (214) Google Scholar, 11Goutallier D. Postel J.M. Gleyze P. et al.Influence of cuff muscle fatty degeneration on anatomic and functional outcomes after simple suture of full-thickness tears.J Shoulder Elbow Surg. 2003; 12: 550-554Abstract Full Text Full Text PDF PubMed Scopus (664) Google Scholar, 12Gladstone J.N. Bishop J.Y. Lo I.K.Y. Flatow E.L. Fatty infiltration and atrophy of the rotator cuff do not improve after rotator cuff repair and correlate with poor functional outcome.Am J Sports Med. 2007; 35: 719-728Crossref PubMed Scopus (632) Google Scholar Despite the risk factors and the use of single-row anchor repair, elevation improved by a mean of 62° in those patients, to a final mean of 166°. External rotation improved by 25° to 61° at follow-up. As mentioned by Burkhart and Cole1Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar in the opinion piece, strength is very important in evaluating rotator cuff results. Burkhart et al.7Burkhart S.S. Barth J.R. Richards D.P. et al.Arthroscopic repair of massive rotator cuff tears with stage 3 and 4 fatty degeneration.Arthroscopy. 2007; 23: 347-354Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar found that postoperative external rotation strength increased by 2.3 grades to 4.5 of 5 and elevation strength increased 1.5 grades to 4.3 of 5 at follow-up. All of this would seem to form a fairly unbeatable basis for single-row repair. In early 2000 or so, double-row repair was becoming noticed. Burkhart and Cole1Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar criticized our study as having only a triangle technique and not even really a double row. However, the construct we used had been researched and published as double row by Mazzocca et al.13Mazzocca A.D. Millett P.J. Guanche C.A. et al.Arthroscopic single-row versus double-row suture anchor rotator cuff repair.Am J Sports Med. 2005; 33: 1861-1868Crossref PubMed Scopus (296) Google Scholar and used clinically by Huijsmans et al.14Huijsmans P.E. Pritchard M.P. Berghs B.M. et al.Arthroscopic rotator cuff repair with double-row fixation.J Bone Joint Surg Am. 2007; 89: 1248-1257Crossref PubMed Scopus (183) Google Scholar as they reported in The Journal of Bone and Joint Surgery and is typically referenced to support double-row repair. In that article the authors stated, “In our experience, the majority of the cases require no more than two or three anchors for a standard double-row repair of a small or medium-sized tear.” Lafosse et al.15Lafosse L. Brozska R. Toussaint B. Gobezie R. The outcome and structural integrity of arthroscopic rotator cuff repair with use of double-row suture anchor technique.J Bone Joint Surg Am. 2007; 80: 1533-1541Crossref Scopus (334) Google Scholar published results, again frequently referenced to support double-row repair, using a mean number of 3.7 anchors (Mitek G2; DePuy Mitek, Raynham, MA) (not state of the art). Sugaya et al.16Sugaya H. Maeda K. Matsuki K. Moriishi J. Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: Single-row versus dual-row fixation.Arthroscopy. 2005; 21: 1307-1316Abstract Full Text Full Text PDF PubMed Scopus (542) Google Scholar used 3.2 anchors for double-row repair. Furthermore, Lo and Burkhart17Lo I.K.Y. Burkhart S.S. Double-row arthroscopic rotator cuff repair: Re-establishing the footprint of the rotator cuff.Arthroscopy. 2003; 19: 1035-1042Abstract Full Text Full Text PDF PubMed Scopus (271) Google Scholar described double-row repair and said, “Depending on the size of the tear, the medial and lateral row will each require 1 or 2 anchors.” We used a mean of 3.2 double-loaded screw-in anchors for double-row repair, so we seemed similar to other authors. Lo and Burkhart also said, “One should avoid the temptation of routinely pulling the rotator cuff laterally and placing the repair under tension to obtain a double-row repair. This will undoubtedly fail due to tension overload”—hence our reluctance to apply double-row repair to very large tears at the time in our study. So, using this information, we began our study. Unfortunately, when doing a scientific study, one does not have the luxury to change techniques whenever one wants. In the rapidly moving field of orthopaedics, most any prospective study seems out-of-date by the time it is published because we surgeons have already moved on to the “contemporary state-of-the-art” approach. Our study picked the best that was out there at the time, and we did our best to determine whether there was a difference. Of course we could have a type 2 error; more patients would have strengthened our study. However, as we stated in the article, for our largest area of potential difference, external rotation strength, 80 patients would have been required to be significant if current trends held. For a Constant score difference, it would have taken over 200. So, if there were differences, they would likely be fairly small, and their clinical impact might be more difficult to appreciate. The Level I study of Franceschi et al.18Franceschi F. Ruzzini L. Longo U.G. et al.Equivalent clinical results of arthroscopic single-row and double-row suture anchor repair for rotator cuff tears.Am J Sports Med. 2007; 35: 1254-1260Crossref PubMed Scopus (340) Google Scholar and their results were also criticized as “preventing one from deriving a valid conclusion based on the results.”1Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar I would agree with the editors and have the highest level of respect for the readers. I think they can determine that a study of 2 different techniques does not mean it can be generalized to all techniques for a given area. Critical readership recognizes limitations in conclusions. However, in another Level I study, by Grasso et al.,19Grasso A. Milano G. Salvatore M. et al.Single-row versus double-row arthroscopic rotator cuff repair: A prospective randomized clinical study.Arthroscopy. 2009; 25: 4-12Abstract Full Text Full Text PDF PubMed Scopus (174) Google Scholar which had 80 patients randomized to single- or double-row repair, there were no significant clinical differences. Regarding Burkhart and Cole's concern on strength,1Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar again Grasso et al. found no strength differences between single- and double-row repair. Thus in all Level I studies, there are different double-row techniques, different surgeons, and different types of follow-up measures but similar results. Faults are present with all the studies, but the weight of data adds bricks to the base of the discussion. Burkhart and Cole1Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar really are not supporting double-row repair, just linked bridging of the double row with suture bridges. They cite the paper by Gartsman et al.20Gartsman GM, Drake G, Edwards TB, Elkousy H, Hammersman SM, O'Connor D. Ultrasound evaluation of arthroscopic full-thickness supraspinatus rotator cuff repair: Single-row versus double-row suture bridge (transosseous equivalent) fixation—Results of a randomized, prospective study. Presented at the 2009 Closed Meeting of the American Shoulder and Elbow Surgeons, New York, NY, October 2009.Google Scholar evaluating single-row repair and suture-bridge double-row repair with higher healing rates for suture-bridge repair of 93% compared with 80%. They refer to this as evidence of clear superiority over single-row repair. However, just as double-row constructs have changed, so have single-row constructs. Barber et al.21Barber F.A. Herbert M.A. Schroeder A. et al.Biomechanical advantages of triple-loaded suture anchors compared with double-row rotator cuff repairs.Arthroscopy. 2010; 26: 316-323Abstract Full Text Full Text PDF PubMed Scopus (62) Google Scholar recently published a study on triple-loaded anchor single-row constructs having better biomechanical properties than suture-bridge constructs. Ko et al.22Ko S.H. Lee C.C. Friedman D. et al.Arthroscopic single-row supraspinatus tendon repair with modified mattress locking stitch: A prospective, randomized controlled comparison with simple stitch.Arthroscopy. 2008; 24: 1005-1012Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar reported that the type of stitch in a single-row repair can improve healing rates. Thus the study of Gartsman et al. is already out-of-date before publication because they only used double-loaded and not triple-loaded anchors for the single-row repairs. And on it goes …. Burkhart and Cole1Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar cite Duquin et al.23Duquin R.T. Buyea C. Bisson L.J. Which method of rotator cuff repair leads to the highest rate of structural healing? A systematic review.Am J Sports Med. 2010; 38: 835-841Crossref PubMed Scopus (260) Google Scholar as having evidence on review of the literature that double-row cuff repair is better. However, Reardon and Maffulli,24Reardon D.J. Maffulli N. Clinical evidence shows no difference between single- and double-row repair for rotator cuff tears.Arthroscopy. 2007; 23: 670-673Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar Wall et al.,25Wall L.B. Keener J.D. Brophy R.H. Clinical outcomes of double-row versus single-row rotator cuff repairs.Arthroscopy. 2009; 25: 1312-1318Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar and Nho et al.26Nho S.J. Slabaugh M.A. Seroyer S.T. et al.Does the literature support double-row suture anchor fixation for arthroscopic rotator cuff repair? A systematic review comparing double-row and single-row suture anchor configuration.Arthroscopy. 2009; 25: 1319-1320Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar in their systematic reviews could not find a difference. One last thought: Voigt et al.,27Voigt C. Bosse C. Vosshenrich R. et al.Arthroscopic supraspinatus tendon repair with suture-bridging technique.Am J Sports Med. 2010; 38: 983-991Crossref PubMed Scopus (120) Google Scholar in the May 2010 issue of the American Journal of Sports Medicine, reported on 51 patients who underwent repair by a suture-bridge technique evaluated with magnetic resonance imaging at 1 year; 28.9% were not healed, and these were just supraspinatus tears. These are clearly not superior results to those that we showed or even Gartsman et al.20Gartsman GM, Drake G, Edwards TB, Elkousy H, Hammersman SM, O'Connor D. Ultrasound evaluation of arthroscopic full-thickness supraspinatus rotator cuff repair: Single-row versus double-row suture bridge (transosseous equivalent) fixation—Results of a randomized, prospective study. Presented at the 2009 Closed Meeting of the American Shoulder and Elbow Surgeons, New York, NY, October 2009.Google Scholar showed for single-row repair. Of concern is that the authors reported that 13% of the patients had a medial cuff failure closer to the musculotendinous junction with an intact footprint. This is a new type of failure not typical with single-row approaches and could present a re-repair challenge. An identical cuff failure photograph is shown in the Sugaya et al.16Sugaya H. Maeda K. Matsuki K. Moriishi J. Functional and structural outcome after arthroscopic full-thickness rotator cuff repair: Single-row versus dual-row fixation.Arthroscopy. 2005; 21: 1307-1316Abstract Full Text Full Text PDF PubMed Scopus (542) Google Scholar article from 2005 and in the Trantalis et al.28Trantalis J.N. Boorman R.S. Pletsch K. Lo I.K.Y. Medial rotator cuff failure after arthroscopic double-row rotator cuff repair.Arthroscopy. 2008; 24: 727-731Abstract Full Text Full Text PDF PubMed Scopus (121) Google Scholar article from 2008. Cho et al.29Cho N.S. Yi J.W. Lee B.G. Rhee Y.G. Retear patterns after arthroscopic rotator cuff repair: Single-row versus suture bridge technique.Am J Sports Med. 2010; 38: 664-671Crossref PubMed Scopus (204) Google Scholar recently reported on 27 suture-bridge repair failures (a fairly large number), and 74% of them were similar, with a medial failure. Also recently, Yamakado et al.30Yamakado K. Katsuo S. Mizuno K. et al.Medial-row failure after arthroscopic double-row rotator cuff repair.Arthroscopy. 2010; 26: 430-435Abstract Full Text Full Text PDF PubMed Scopus (66) Google Scholar reported on medial-row failures in double-row repair. So there may be more to learn. I have no horse in the race on techniques of rotator cuff repair. I hope we can all improve, whatever our approach to patients with a torn cuff. However, I do not believe that there is always a one-size-fits-all approach for every situation. I have to disagree with Burkhart and Cole,1Burkhart S.S. Cole B.J. Bridging self-reinforcing double-row rotator cuff repair: We really are doing better.Arthroscopy. 2010; 26: 677-680Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar and I do not think we should apologize for techniques that work and happen to be less expensive and maybe easier to do as well. We need to use our best assessment of the patient, tear pattern, tissue and bone quality, and so on and do the repair that is considered to be best in that situation. Undoubtedly, there are times when different approaches might seem to be the most appropriate in a given case. I wish we spent more time discussing enhancing biology, improving rehabilitation, and evaluating outcomes uniformly and seeing their impact on quality of health at this point. Let's encourage science, promote even better studies, and better help our patients, displacing our opinions from the discussion. The healthy debate, for example, on single-bundle versus double-bundle anterior cruciate ligament reconstruction has studies that support both sides. Only over time can we gain a balance of what is probably true for most surgeries done by most surgeons. As I like to say, though, this is all just one man's humble opinion. Bridging Self-Reinforcing Double-Row Rotator Cuff Repair: We Really Are Doing BetterArthroscopyVol. 26Issue 5PreviewSingle-row versus double-row repair of rotator cuff tears is currently a controversial topic. In this Level V article, we articulate why we believe that second-generation double-row repair techniques, which use bridging sutures to link the 2 rows of suture anchors together in a self-reinforcing manner, are producing superior clinical and biomechanical results. Full-Text PDF Author's ReplyArthroscopyVol. 26Issue 8PreviewWe welcomed Dr. Burks' letter to the editor because we believe no good “Level V Evidence” report reviewing a controversial topic should be presented without a chance for rebuttal. Thus we were pleased that Dr. Burks took the time and effort to address the issues raised in our Level V article, entitled “Bridging Self-Reinforcing Double-Row Rotator Cuff Repair: We Really are Doing Better,” in the May issue of Arthroscopy.1 We can certainly identify with Dr. Burks' explanation of the “voodoo doll mechanism” of pain generation that occurs when a colleague strongly disagrees with one's findings or beliefs. Full-Text PDF