Rotator cuff tears are a common condition affecting the shoulder joint. Initial open repair techniques were associated with several complications, including severe early postoperative pain, deltoid detachment and/or weakness, risk for infection, and arthrofibrosis.1-3 In addition, open procedures cannot address other possible diagnoses, such as labral tears and loose bodies. These disadvantages promoted the development of an arthroscopically assisted mini-open technique.4 Superior long-term results, with more than 90% of patients achieving good to excellent results,5-13 established the mini-open rotator cuff repair (RCR) as the gold standard.3,6,10,12,14-16
Recently, as instrumentation for arthroscopy has improved, enthusiasm for all-arthroscopic techniques (hereafter referred to as arthroscopic repair) has grown. The appeal of arthroscopic repair includes potentially less initial pain, ability to treat intra-articular lesions concurrently, smaller skin incisions with better cosmesis, less soft-tissue dissection, and low risk for deltoid detachment.3,17 The potential advantages of arthroscopic repair can lead to perceptions of quicker healing and shorter recovery, which are not supported by the literature. However, arthroscopic repair is technically more challenging, time-consuming, and expensive than open or mini-open repairs,18,19 and though some investigators have reported a trend toward fewer complications,3 the long-term outcome of arthroscopic RCRs has not been shown to be better than that of other techniques.
Given that no differences have been shown between the emerging arthroscopic repair technique and mini-open repair with respect to range of motion or clinical scores in the short term,3 it is unclear what perceptions influence choice of technique for one’s own personal RCR.
We conducted a study to determine which RCR technique medical professionals (orthopedic attendings and residents, anesthesiologists, internal medicine attendings, main operating room nurses, and physical therapists) preferred for their own surgery and to analyze perceptions shaping those opinions. Orthopedic surgeons have the best concept of rotator cuff surgery, but anesthesiologists and nurses have a “front row seat” and opinions on types of rotator cuff surgery. Physical therapists, who treat patients with rotator cuff tears, also have a working knowledge of rotator cuff surgery. Finally, internists represent a rotator cuff injury referral service and may have patients who have undergone rotator cuff surgery. We hypothesized that most medical professionals, irrespective of specialty or career length, would prefer arthroscopic RCR because of its perceived superior outcome and fast recovery.
Materials and Methods
This cross-sectional, descriptive, survey-based study was approved by our institutional review board (IRB) and offered via 3 emails between April 2011 and June 2011 to attendings (orthopedists, internists, anesthesiologists), residents, and allied health professionals (AHPs; operating room nurses, physical therapists) involved in orthopedic care at our institution. Each email contained a hyperlink to the online survey (Appendix), which took about 10 minutes to complete and explored respondent demographics, exposure to the different techniques, and opinions regarding different aspects of RCR surgery and recovery.
There were 84 respondents. The sexes were equally represented, and age ranged from 25 to 78 years (Table 1). Of the respondents, 41 (49%) were attendings, 20 (24%) were residents, and 23 (27%) were AHPs. Of the attendings, 13 (32%) were orthopedic surgeons, 26 (63%) were primary care physicians, and 2 (5%) did not specify their specialty. Four orthopedic surgeons had fellowship training in sports medicine or shoulder and elbow surgery. The attendings were overall more experienced in their profession than the other groups were, with 68% reporting more than 5 years of experience.
Descriptive statistics, including means and standard errors, were calculated. Fisher exact test was used to compare preferences of RCR type according to type of training and years of experience. Significance was set at P ≤ .05.
Results
Overall Responses (Table 2)
Of the 84 respondents, almost half (46%) preferred deferring their choice of RCR to their surgeon. Most of the other respondents preferred the arthroscopic technique (26%) or the mini-open repair (23%). There was no association between technique preference and medical professional type. Most respondents (63%) had never assisted in or performed rotator cuff surgery.
Seventy-four percent of all respondents indicated they thought arthroscopic, mini-open, and open RCRs are safe, and about half thought these procedures are fast. About half expressed no opinion about the cost-effectiveness of arthroscopic, mini-open, or open RCRs (54%, 52%, and 48%, respectively), and slightly more than half expressed no opinion about whether arthroscopic, mini-open, or open RCR provide the best outcome (58%, 60%, and 62%, respectively). Significantly (P < .05) more respondents thought arthroscopic and mini-open repairs, rather than open repairs, promote quick healing (64% and 45%, respectively, vs 15%), good cosmetic results (81% and 51%, respectively, vs 10%), and patient satisfaction (50% and 48%, respectively, vs 30%). However, a significant (P < .05) number also thought arthroscopic and mini-open repairs are harder to learn/more challenging to perform than open repairs (52% and 38%, respectively, vs 17%).