Joy C MacDermid1,2, Dianne Bryant3,2, Richard Holtby4,2, Helen Razmjou5,2, Kenneth Faber6,2, Robert Balyk7,2, Richard Boorman8,2, David Sheps7,2, Robert McCormack9,2, George Athwal6,2, Robert Hollinshead8,2, Ian Lo8,2, Ryan Bicknell10,2, Nicholas Mohtadi8,2, Martin Bouliane7,2, Donald Glasgow11,2, Marie-Eve Lebel6,2, Aleem Lalani7,2, Farhad O Moola9,2, Robert Litchfield12,2, Jaydeep Moro13,2, Peter MacDonald14,2, J W Bergman11,2, Jeff Bury11,2, Darren Drosdowech6,2. 1. Departments of Surgery and Physical Therapy, University of Western Ontario, London, Ontario, Canada; Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada. 2. Investigation performed at the University of Western Ontario, London, Ontario, Canada. 3. Departments of Surgery and Physical Therapy, University of Western Ontario, London, Ontario, Canada. 4. Department of Orthopaedic Surgery, Holland Orthopaedic & Arthritic Centre, Toronto, Ontario, Canada. 5. Department of Rehabilitation, Holland Orthopaedic & Arthritis Centre, Sunnybrook Research Institute, Toronto, Ontario, Canada. 6. Department of Surgery, University of Western Ontario, London, Ontario, Canada; Roth McFarlane Hand and Upper Limb Centre, St. Joseph's Health Care, London, Ontario, Canada. 7. Department of Surgery and Glen Sather Sports Medicine Clinic, University of Alberta, Edmonton, Alberta, Canada. 8. Department of Surgery, University of Calgary, Calgary, Alberta, Canada. 9. Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada. 10. Department of Surgery, Queen's University, Kingston, Ontario, Canada. 11. Department of Surgery, University of Alberta, Edmonton, Alberta, Canada. 12. Department of Surgery, University of Western Ontario, London, Ontario, Canada; Fowler Kennedy Sport Medicine Clinic, London, Ontario, Canada. 13. Department of Surgery, McMaster University, Hamilton, Ontario, Canada. 14. Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.
Abstract
BACKGROUND: Patients with complete rotator cuff tears who fail a course of nonoperative therapy can benefit from surgical repair. PURPOSE: This randomized trial compared mini-open (MO) versus all-arthroscopic (AA) rotator cuff repair. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients with rotator cuff tears were randomized to undergo MO or AA repair at 9 centers by 23 surgeons. The primary outcome (Western Ontario Rotator Cuff Index [WORC]) and secondary outcomes (American Shoulder and Elbow Surgeons [ASES] score, Shoulder Pain and Disability Index [SPADI] pain subscale, 12-Item Short Form Health Survey [SF-12], reported medication use, adverse events), as well as measurements of range of motion and strength, were collected at 1 month before surgery; at 2 and 6 weeks postoperatively; and at 3, 6, 12, 18, and 24 months postoperatively. A blinded radiologist evaluated rotator cuff integrity on magnetic resonance imaging (MRI) at baseline and 1 year. Intention-to-treat analysis of covariance with the preoperative WORC score, age, and tear size as covariates assessed continuous outcomes. Sex differences were assessed. A meta-analysis synthesized the primary outcome between MO and AA repair with previous trials. RESULTS: From 954 patients screened, 411 were ineligible (276 because of recovery with physical therapy), 449 were screened at surgery (175 ineligible), and 274 completed follow-up (138 MO and 136 AA). The AA and MO groups were similar before surgery. WORC scores improved from 40 preoperatively to 89 (AA) and 93 (MO) at 2 years, for an adjusted mean difference of 3.4 (95% CI, -0.4 to 7.2). There were no statistically significant differences between the AA and MO groups at any time point. All secondary patient-reported outcomes were not significantly different between the MO and AA groups, except the 2-year SPADI pain score (8 vs 12, respectively; P = .02). A similar recovery in range of motion and strength occurred in both groups over time. MRI indicated minimal improvement in muscle relative to fat (AA: n = 3; MO: n = 2), with most worsening (AA: n = 25; MO: n = 24) or remaining unchanged (AA: n = 70; MO: n = 70). Opioid use was significantly reduced after surgery (from 21% to 5%). The meta-analysis indicated no significant standardized mean difference between groups in the primary outcome across all pooled studies (standardized mean difference, -0.06 [95% CI, -0.34 to 0.22]). CONCLUSION: Both AA and MO rotator cuff repair provide large clinical benefits, with few adverse events. There is strong evidence of equivalent clinical improvements. TRIAL REGISTRATION: NCT00128076.
BACKGROUND: Patients with complete rotator cuff tears who fail a course of nonoperative therapy can benefit from surgical repair. PURPOSE: This randomized trial compared mini-open (MO) versus all-arthroscopic (AA) rotator cuff repair. STUDY DESIGN: Randomized controlled trial; Level of evidence, 1. METHODS: Patients with rotator cuff tears were randomized to undergo MO or AA repair at 9 centers by 23 surgeons. The primary outcome (Western Ontario Rotator Cuff Index [WORC]) and secondary outcomes (American Shoulder and Elbow Surgeons [ASES] score, Shoulder Pain and Disability Index [SPADI] pain subscale, 12-Item Short Form Health Survey [SF-12], reported medication use, adverse events), as well as measurements of range of motion and strength, were collected at 1 month before surgery; at 2 and 6 weeks postoperatively; and at 3, 6, 12, 18, and 24 months postoperatively. A blinded radiologist evaluated rotator cuff integrity on magnetic resonance imaging (MRI) at baseline and 1 year. Intention-to-treat analysis of covariance with the preoperative WORC score, age, and tear size as covariates assessed continuous outcomes. Sex differences were assessed. A meta-analysis synthesized the primary outcome between MO and AA repair with previous trials. RESULTS: From 954 patients screened, 411 were ineligible (276 because of recovery with physical therapy), 449 were screened at surgery (175 ineligible), and 274 completed follow-up (138 MO and 136 AA). The AA and MO groups were similar before surgery. WORC scores improved from 40 preoperatively to 89 (AA) and 93 (MO) at 2 years, for an adjusted mean difference of 3.4 (95% CI, -0.4 to 7.2). There were no statistically significant differences between the AA and MO groups at any time point. All secondary patient-reported outcomes were not significantly different between the MO and AA groups, except the 2-year SPADI pain score (8 vs 12, respectively; P = .02). A similar recovery in range of motion and strength occurred in both groups over time. MRI indicated minimal improvement in muscle relative to fat (AA: n = 3; MO: n = 2), with most worsening (AA: n = 25; MO: n = 24) or remaining unchanged (AA: n = 70; MO: n = 70). Opioid use was significantly reduced after surgery (from 21% to 5%). The meta-analysis indicated no significant standardized mean difference between groups in the primary outcome across all pooled studies (standardized mean difference, -0.06 [95% CI, -0.34 to 0.22]). CONCLUSION: Both AA and MO rotator cuff repair provide large clinical benefits, with few adverse events. There is strong evidence of equivalent clinical improvements. TRIAL REGISTRATION: NCT00128076.