Arthroscopic and open repair of rotator cuff tears have been established in published research to have comparable clinical results, with each having distinct advantages and disadvantages. Some studies have looked at geographic variation in the number of rotator cuff surgical procedures performed. Others have explored variations in what surgeons deemed to be indications for rotator cuff surgery. Despite many investigations having addressed repair techniques, indications for surgery, and outcomes in selected patients, little has been reported on recent trends of rotator cuff repair use nationwide.
In a study published in the February 2012 Journal of Bone and Joint Surgery, Alexis C. Colvin, MD, and colleagues examined the rates of medical visits for rotator cuff pathology and for open and arthroscopic rotator cuff repair between 1996 and 2006 throughout the United States. The setting where the surgery was performed and the characteristics of patients—including age, sex, and comorbidities—were also analyzed in the study. “We wanted to determine if surgeons are now performing more arthroscopic rotator cuff repairs than in years past and where these repairs are being performed,” explains Dr. Colvin. “We also wanted to learn more about the characteristics of patients who had surgery in inpatient versus outpatient settings, surgical times associated with these procedures, and trends in anesthesia use.”
Rotator Cuff Repairs on the Rise
According to findings, the volume of all rotator cuff repairs increased by 141% from 1996 to 2006 (Table). While the number of arthroscopic procedures increased by 600%, the number of open repairs increased by only 34% during the time period assessed. “The number of open repairs increased for patients who were younger than 45,” says Dr. Colvin (Figure). “There was a much greater increase in the number of arthroscopic repairs, but this increase was seen across all age groups.” The increase in arthroscopic repairs could be influenced by several factors, such as improvements in surgical instrumentation and techniques that facilitate arthroscopic repair. Other studies have also indicated that several factors can increase the rates of arthroscopic repair, including younger surgeon age and higher volumes of shoulder arthroscopies.
Findings of the study also suggested that there has been a significant shift from inpatient to outpatient surgery to repair rotator cuff tears, a finding Dr. Colvin says may have an important effect on larger hospitals. “Outpatient surgery centers have increased in popularity and continue to expand their outreach into the community. Having more rotator cuff repairs performed in outpatient settings may alter the demands placed on hospitals to manage these patients as well as other sicker individuals.”
Surgical and operating room times were significantly longer for arthroscopic procedures than for open techniques in the study (84 min vs 66 min and 120 min vs 104 min, respectively). There was also a significant increase in the use of general anesthesia supplemented by a regional nerve block for open procedures. Over the decade, use of this anesthesia approach increased from about 3% in 1996 to about 15% in 2006. During the same timeframe, use of general anesthesia alone decreased from approximately 84% to 68%.
Changing Trends in Rotator Cuff Repair Treatment
There are several possible reasons as to why there has been an increase in rotator cuff repairs over the past decade, according to Dr. Colvin. “Americans are living longer, healthier, and more active lives than ever before,” she says. “As people age, their risk for a rotator cuff tear increases. We also observed higher rates in arthroscopic repairs and lower rates of inpatient surgical procedures, findings that reflect changes in medical practice. Surgeons have become more aggressive, offering surgical repair earlier in the course of treatment. Depending on patient characteristics and preferences, arthroscopy or open repair can be offered with similar safety and efficacy profiles.”
In future research, Dr. Colvin says it will be important to see how age and sex affect aspects of surgical intervention. “In past studies, women have reported more disability with lower or similar levels of rotator cuff pathology when compared with men, but women tend to be older when they undergo surgery for a rotator cuff repair. Women also appear to be less likely to have arthroscopic surgery as outpatients. Further elucidating the variables that are responsible for these differences in utilization of surgery may have significant ramifications. This information can be used to ensure that patients have access to the care they need and are educated appropriately on their need for surgical intervention.”
Colvin AC, Egorova N, Harrison AK, et al. National trends in rotator cuff repair. J Bone Joint Surg. 2012;94:227-233. Available at: http://www.jbjs.org/article.aspx?articleid=334916.
Bishop J, Klepps S, Lo IK, et al. Cuff integrity after arthroscopic versus open rotator cuff repair: a prospective study. J Shoulder Elbow Surg. 2006;15:290-299.
Morse K, Davis AD, Afra R, et al. Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. Am J Sports Med. 2008;36:1824-8.
Yamaguchi K, Levine WN, Marra G, et al. Transitioning to arthroscopic rotator cuff repair: the pros and cons. Instr Course Lect. 2003;52:81-92.
Green LB, Pietrobon R, Paxton E, et al. Sources of variation in readmission rates, length of stay, and operative time associated with rotator cuff surgery. J Bone Joint Surg Am. 2003;85:1784-9.
Dunn WR, Schackman BR, Walsh C, et al. Variation in orthopaedic surgeons’ perceptions about the indications for rotator cuff surgery. J Bone Joint Surg Am. 2005;87:1978-84.
Razmjou H, Davis AM, Jaglal SB, et al. Cross-sectional analysis of baseline differences of candidates for rotator cuff surgery: a sex and gender perspective. BMC Musculoskeletal Disord. 2009;24:10-26.