Rotator Cuff Repair…….
february 9th 2018
All-Arthroscopic Vs. Mini-Open Surgery
A hundred and seven years ago (back in 1911), the first rotator cuff repair was performed by Dr. Codman- a famous Boston surgeon. The technique of Dr. Codman went through some modifications in 1970’s and remained to be the first choice in cases of massive rotator cuff tears up to this day. In 1994, a mini-open approach was introduced to the medical community. Compared to open surgery, mini-open repair provided satisfying results- almost as effective as the open technique. As the trend of minimally invasive surgery suppresses traditional surgical techniques, all-arthroscopic cuff repair slowly becomes a routine procedure.
One small cut makes all the difference between those two!
The all-arthroscopic procedure, just like its name says is carried out only with the help of arthroscope. No additional incisions are needed, like in case of mini-open surgery. It is (most often) outpatient procedure- there is no need for the hospital stay. Every mini-open surgery starts as arthroscopic, and at some point, 1-2 inch incision is made to expose the rotator cuff tear
Short overview of the procedures
1. Arthroscope insertion
The arthroscope is, basically, a tiny camera used to inspect a joint visually. The surgeon does not have direct visual contact with the joint structures (like in open surgery) but observes the operating field on a computer monitor.
2. Debride of a joint
The pieces of a damaged cuff, loose pieces of tendons, bone fragments, etc. are removed at this stage.
3. Acromion smoothening
In some cases, bone spurs form in the area of the acromion (pathological bone structures). Those need to be removed with a specialized tool.
4. The examination of a rotator cuff
The surgeon carefully inspects rotator cuff for tears. If tears are absent, the procedure ends at this point. If there are tears, depending on the extent of damage, the surgeon decides whether the tear can be repaired with the guidance of arthroscope or mini-open surgery is needed (in such cases, a 1-2 inch incision is made through which the thorn tendon is repaired).
5. Placing anchors and suturing the tear
Using a specialized drill, the surgeon makes holes in the bone which will hold anchors. Anchors are important because they stabilize the sutured tear. The procedure ends here. The arm is placed in a sling.
Which one is better?
Cons of all-arthroscopic surgery fit into the limitations of all minimally invasive surgical techniques. The operating field is tight and quite limited, so bigger tears cannot be resolved this way. Because it is relatively new technique, long-term effects of all-arthroscopic surgery have not been described yet (simply, not enough time passed since it became routine procedure).
On the other hand, a huge plus is that patient is admitted to the hospital before procedure and dismissed almost immediately after the surgery. The risk of infections and other surgical complications is reduced to a minimum. Recovery time is significantly shorter, and the studies suggest no difference in clinical outcomes can be found between the patients whose cuffs were repaired arthroscopically and those who went under mini-open surgery1.
Essentially, these two techniques are not opposed to each other, so it doesn’t make too much sense to compare them. We can say they are equally good. Open surgery is the best for big interventions with severe damage (rare). Mini-open surgery is the method of choice for moderate size ruptures and tears with the, particularly delicate location. All-arthroscopic surgery is the method of choice for small ruptures.