All-Arthroscopic Versus Mini-Open Double Row Rotator Cuff Repair – A Prospective Randomised Control Study Based on Functional and Radiological Outcomes

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K. Jithesh a, Jimmy Joseph Meleppuram b, Aebel Raju b, Ayyappan V. Nair c, Arun Mundakkal a, Ajayakumar Thankappan b, Pradeep Kumar Thammanassery a, Prince Shanavas Khan b,*

  1. Journal of Orthopaedics – 2024
    LINK:  https://doi.org/10.1016/j.jor.2024.01.005

This prospective study evaluated trends in rotator cuff repair in India by comparing All-Arthroscopic (AA) and Mini-Open (MO) techniques in 60 patients. Functional outcomes (UCLA, Oxford scores) and repair integrity (MRI/USG, Sugaya grading) were assessed over 12 months. The AA group demonstrated superior functional outcomes, with a higher proportion of excellent/good results (53.3% vs. 30.0%), while radiological outcomes were comparable between groups. Tear size showed no correlation with outcomes. These findings support the growing preference for AA repair in India, offering improved functional recovery despite higher costs.

1.    Introduction

Rotator cuff tears constitute a prevalent malady encountered within the routine orthopaedic practice, manifesting primarily as shoulder pain and compromised functional capabilities. Repair of torn rotator cuff muscles is very crucial for the maintenance of good shoulder function since most of them may progress to complete tears in future if unattended.

Numerous methodologies have been delineated for the surgical repair of rotator cuff injuries, and the most frequently used modalities include open surgery, mini-open surgery and arthroscopic repair.1 They are more comprehensively elucidated as a sequential progression in the evolution of rotator cuff repair, commencing with open surgery, followed by the mini-open approach, and ultimately culminating in the all-arthroscopic procedure. Over an extended period, the mini-open technique has stood as a cornerstone for surgeons, as numerous authors have reported approximately 90 % of patients achieving favourable to outstanding outcomes following a mini-open repair.2,3

* Corresponding author. Department of Orthopaedics, Apollo Adlux Hospital, Angamaly, Kochi, Kerala, 683576, India. E-mail address: drpskhan@gmail.com (P.S. Khan).  https://doi.org/10.1016/j.jor.2024.01.005 Received 24 November 2023; Received in revised form 4 January 2024; Accepted 6 January 2024   Available online 10 January 2024 0972-978X/© 2024 Published by Elsevier B.V. on behalf of Professor P K Surendran Memorial Education Foundation.

In light of the introduction of innovative instrumentation and enhanced methodologies, a gradual trend is emerging toward a more minimally invasive approach, driven by the progressive utilisation of arthroscopy. The comprehensive adoption of the all-arthroscopic approach affords a multitude of advantages, notably encompassing a reduced incision size, facilitated access to the glenohumeral joint, concurrent address of intra-articular pathologies, diminished soft tissue dissection, and a decreased likelihood of deleterious effects on the deltoid musculature, resulting in less postoperative pain and better satisfaction matched to other methods. The immediate-term results of all- arthroscopic procedures have demonstrated considerable promise, and they have exhibited favourable comparisons with outcomes achieved through open and mini-open techniques.4–6

Although behind the promising results, most published studies comparing the MO technique to AA do not provide a valid consensus on whether either technique offers superior outcomes. There’s considerable debate regarding whether all-arthroscopic rotator cuff repairs yield comparable results to mini-open repairs, warranting further examination within the Indian population. To the best of our insight, studies comparing both the techniques regarding functional and radiological outcomes are skimpy in this part of the country. Hence our study was focused on the patients who underwent repair for rotator cuff tears in a tertiary care centre, to analyse the functional outcome and radiological repair integrity between all-arthroscopic and mini-open rotator cuff repair.

2.    Materials and methods

Patients who underwent arthroscopic or mini-open rotator cuff tear repairs from January 2018 to January 2020 were included in the study and were followed up for a minimum of one year post-operatively. Patients meeting any of the following criteria were excluded from the study: those with a history of prior surgery on the affected shoulder, significant issues in the opposite shoulder, cognitive impairment or language difficulties, a specific preference for a particular surgical technique, or those unable to undergo an MRI or USG scan for any reason.

After obtaining institute ethics committee approval, a predefined proforma was used to collect the socio-demographic and clinical history of the study participants. After tedious statistical calculations, it was found that a sample size of 30 would be required in each group for performing the competent study. A computer-based randomisation method was meticulously employed to allocate patients into either the mini-open or arthroscopic repair groups during the initial visit to the OPD. Patients were thoroughly informed that their treatment allocation would be determined randomly, and those with specific treatment preferences were excluded from the study. Comprehensive counselling was conducted, providing patients with information on outcomes associated with both repair techniques according to current literature. Only patients amenable to both arthroscopic and mini-open repair were included. Subsequently, specific outpatient department (OPD) days were assigned to each category, with patients attending OPD 1 [Monday, Wednesday, Friday] allocated to the all-arthroscopic (AA) group, and those attending OPD 2 [Tuesday, Thursday, Saturday] included in the Mini-Open (MO) Group. These patients were preoperatively assessed clinically and radiologically using UCLA, Oxford Shoulder Scoring Systems and MRI respectively, to evaluate the degree of impairment and magnitude of tear. The rehabilitation protocols were consistently applied to both study groups, ensuring uniformity in the postoperative recovery process. The prognosis of the patient is to be followed post- operatively with clinical examination using the same Shoulder Scoring Systems and radiologically with USG at six months and one year.

3.    Results

In this study, a total of 60 patients who had undergone rotator cuff injury repair at our medical facility were enrolled. Among them, 30 patients received treatment through the all-arthroscopic rotator cuff repair approach (AA Group), while the remaining 30 patients underwent mini-open repair (MO Group). The demographic data of the participants are shown [Table 1].

The majority (68.3 %) of the participants were males with M: F preponderance of 2.1:1. The patients were comparable by the gender distribution between the groups (p = 0.781). Patients were also comparable between the groups on the side of rotator cuff injury (p = 0.559) operated for, with the most patients having an injury on the right side amidst both the groups. Among both the groups the aetiology of cuff tears was found mostly due to trauma, but they were comparable

Table 1

Demographic information about the study participants. 

Parameters                 Group A Assessed                    Arthroscopic Technique (n = 30)Group B Mini- Open Technique (n = 30)Overall (N = 60)P Value
Age (Years) Mean                         60.563.5620.196
SD                             7.99.48.65  
Gender Distribution Male                          21 (70 %)20 (66.7 %)41 (68.3 %)0.781
Female                       9 (30 %)10 (33.3 %)19 (31.7 %)  
Side of Injury Left                             7 (23.3 %)9 (30 %)16 (26.7 %)0.559
Right                           23 (76.7 %)21 (70 %)44 (73.3 %)  
Etiology of injury Degenerative              9 (30 %)9 (30 %)18 (30 %)0.284
Traumatic                   21 (70 %)21 (70 %)42 (70 %)   

between the groups (p = 0.284). The patients with the degenerative aetiology were older when compared with the traumatic cause and this was statistically insignificant (p = 0.007). The mean tear size was 2.2 cm with a minimum of 1 cm and a maximum of 4 cm. Even though the mean tear size was larger among the patients in the MO group when compared to the AA group (2.3 cm vs. 2.1 cm), it didn’t have any statistical significance (p = 0.117).

Comparing the difference in the extent of movement (abduction, flexion, extension, external and internal rotation) before the surgical procedure and one year post-surgery among the groups it was found that the all arthroscopic group exhibited a 20.3-degree increase in abduction, while the mini-open group experienced a 19.3-degree improvement. In terms of flexion, the AA group demonstrated a 16.6-degree enhancement, while the MO group showed a 16.0-degree change. For extension, there was a 10.3-degree improvement in the AA group and a 9.0-degree change in the MO group. The AA group showed a 2.7-degree increase in external rotation, whereas the MO group had a 4.0-degree improvement. Finally, there was an 11.8-degree improvement in internal rotation in the AA group and a 12.2-degree change in the MO group, but none of this disparity was found to be statistically significant (p = 0.863, 0.894, 0.727, 0.605, 0.848 respectively) [Table 2].

On further analysis, it was found that at one year of follow-up, a greater percentage of patients in the arthroscopic group (53.3 %) achieved an excellent or good outcome based on the UCLA scoring system, as compared to those in the mini-open group (30.0 %). This difference was found to be statistically significant with a p-value of 0.047 at six months. At one year, the majority showed improvement in their UCLA scores, with only four patients receiving a fair or poor score (Table 3).

In our study, the AA group had better Oxford score compared to the MO group, with 3.3 % versus 10.0 % respectively at one-year post- operative follow-up. This distinction was found to be statistically significant with a p-value of 0.031 [Table 4].

We found no notable disparity in the radiological outcome based on the Sugaya grading system between the two groups, as indicated by a non-significant p-value of 0.481. It is worth mentioning that a single patient in the arthroscopic group had a Type V grading due to a re-tear, while none of the patients in the mini-open group experienced a re-tear. After one year of follow-up, there was a significant improvement in the radiological score, with most patients in both groups progressing from Type III to Type II and from Type IV to either Type II or Type III [Table 5].

Finally, we derived that the tear size was comparable between the two groups and there was no significant association for the tear size with the functional and radiological outcomes according to the grading scores.

Table 2

Range of Motion ( degrees) in All-Arthroscopic (AA) versus Mini-Open (MO)

Groups 

Groups

Follow-up             Change in      Mean            value Mean (SD)                Mean (SD)     abduction     difference

Mean

AA99.0 (28.1)               119.3 (14.8)20.31.00.863
MO93.0 (28.4)               112.3 (16.3)19.3   
 Flexion [degrees]   Preoperative            Follow-up Mean (SD)                Mean (SD)Change in flexion MeanMean difference  
AA84.3 (24.0)               101.0 (13.9)16.60.60.894
MO83.7 (20.6)               99.7 (11.8)16.0   
 Extension [degrees]   Preoperative            Follow-up Mean (SD)                Mean (SD)Change in extension MeanMean difference  
AA49.7 (14.7)               60.0 (11.1)10.31.30.727
MO49.0 (16.3)               58.0 (10.6)9.0   
 External rotation (ER) [degrees]   Preoperative             Follow-up         Change in ER Mean (SD)                Mean (SD)       MeanMean difference  
AA28.7 (7.8)                  31.3 (7.3)        2.71.30.605
MO28.3 (10.8)                32.5 (5.0)        4.0  Internal rotation IR [degrees]   Preoperative Follow-up Change in IR Mean (SD) Mean (SD) MeanMean difference  
AA42.5 (6.8)                  54.3 (7.8)        11.80.40.848
MO43.5 (9.2)                  55.7 (8.0)        12.2   
Table 3 Functional outcome of patients (UCLA scoring) between the groups (N= 60). 

UCLA category                   P Value

Table 4

Functional outcome of patients (Oxford scoring) between the groups (N = 60). 

Groups

Group A                 Group B n (%)                    n (%)

Score 30-3923 (76.7)13 (43.3)                        0.031
Score 20-296 (20.0)14 (46.7)
Score 0-191 (3.3)3 (10.0) 
Table 5 Radiological outcome (Sugaya grading) betweenthe groups (N = 60). 

Sugaya grading                   p value

Type I                                          –                                    –                                   0.481

Type II       15 (50.0)       19 (63.3) Type III               12 (40.0)       8 (26.7) Type IV                 2 (6.7)           3 (10.0)

Type V                                         1 (3.3)                           – 

4.    Discussion

The objective of rotator cuff repair is to relieve discomfort and enhance functionality by increasing shoulder strength and the ability to move through a greater range of motion.

In the past, open and mini-open approaches were used to treat rotator cuff tears. However, current research suggests that minimally invasive arthroscopic methods are now the widely accepted standard of care worldwide. 5 In an era where arthroscopic rotator cuff repair dominates with a preference rate of 77.9 % in the United States compared to 53.33 % for open surgery, this study explores the current demographic trends and preferences for shoulder procedures in India, shedding light on potential shifts in surgical techniques.7 This study aimed to evaluate the functional and radiological results of mini-open and all-arthroscopic techniques in patients with rotator cuff injuries. As there is limited research on this topic among the Indian population, this study aimed to provide a better understanding of which management approach is more effective.

Our study discovered that the majority of participants were males (68.3 %), with a male-to-female ratio of 2.1:1, and the average age was 62 years with a standard deviation of 8.7. The groups were similar in terms of age, gender, and the cause of injury. However, patients with degenerative causes were found to be significantly older than those with traumatic causes (65.9 years vs. 59.7 years), with a p-value of 0.007. The higher mean age in our study can be explained by the increasing elderly population in our country due to improved healthcare facilities, as well as the fact that the prevalence of rotator cuff injuries rises with age.8,9 This is supported by our findings, which demonstrate that degenerative causes are more common in older patients than in those involved in road traffic accidents. These results are consistent with research conducted in other regions.5,6,8–11

There were no statistically significant enhancements in the range of motion, including abduction, flexion, extension, internal rotation, and external rotation, during the late postoperative period. At one year follow-up, there was no significant difference in the degree of improvement in the range of motion between the two groups. In a meta- analysis conducted by Ji X et al., the pooled analysis showed that there was no difference in the extent of motion between the procedures.12 Similar results were also reported by a meta-analysis conducted by Morse K et al., Huang R et al., Shan L et al. and Nazari G et al.13–16 It is important to note that the meta-analysis mentioned earlier incorporated various study designs in addition to RCTs, which could potentially undermine the accuracy of the effect estimates. Therefore, further research is needed to strengthen this observation’s clinical significance. Even the research by Cho CH et al. and Zhang Z et al. have supported our study findings.17,18 However, studies by Severnd El et al. Karakoc Y et al. and Sakha S et al. concluded that the range of motion had significantly higher improvement among the patients in the all-arthroscopic repair group.19–21 The inconsistent outcomes may be attributed to the small sample sizes of the individual studies.

During the one-year follow-up period, it was observed that patients in the All-Arthroscopic (AA) group exhibited a higher percentage of excellent/good outcomes, as determined by the UCLA scoring system than those in the MO group (53.3 % vs. 30.0 %) (p = 0.047). According to the Oxford scoring scale, patients in AA group had better score compared to the MO group (p = 0.031). While some studies, such as those by Cho CH et al., Sauerbrey AM et al., Verma NN et al., Chebbi PK et al., and Thakor KN et al. have found no significant difference in functional outcomes between the two techniques, our study’s findings are consistent with those of Severnd El et al. Karakoc Y et al., and Sakha S et al., which suggest that patients in the all arthroscopic group experience better functional outcomes.17,19–23 It should be noted that all of these studies had relatively small sample sizes, so these results should be interpreted with caution and backed up by clinical significance.

Our research did not detect any substantial disparity in the radiographic results between the two groups as per the Sugaya grading system. (p = 0.481). This finding is consistent with the results of a study by Bayle X et al. which also used Sugaya scoring for radiological assessment.24 Similar results were also reported by several other studies conducted globally.17,23,25,26 It is important to note that patients who had less favourable functional and radiological outcomes were followed up at one year, Both groups demonstrated a substantial improvement in their range of motion and pain levels.

The study observed that the mean tear size was more extensive in the mini-open group compared to other group, but was not significant statistically. The study also found no significant relationship between tear size and functional outcomes (UCLA scoring and Oxford scoring) as well as radiological outcomes. The results of this study were consistent with prior research conducted by Pearsall AW et al., where they similarly observed no substantial disparity in tear size between the mini-open and arthroscopic groups.27 The average tear size in their study was similar to our research. A separate investigation conducted by Kose KC et al. ¨ involved a comparison between mini-open and arthroscopic repair methods, and their findings led to the conclusion that there were no notable distinctions between the groups concerning factors such as tear sizes, pre-and postoperative Constant-Murley and UCLA scores, along with satisfaction levels.25 In contrast, Chung SW et al. reported in their study that larger tear size, higher grade of fatty infiltration, and open or mini-open surgery were associated with stiffness during the final follow-up.28 However, our study did not find a similar association.

To compare the functional and radiological outcomes of the patients, the functional scale scores were correlated with the Sugaya grading. The study found a correlation between the two outcomes and noted that there were almost equal proportions of patients with excellent outcomes in both categories. Although the literature suggests that all-arthroscopic techniques have better functional outcomes and less postoperative pain, our study found that the incidence of re-tear was higher in this technique. Complications were systematically measured, including Complex Regional Pain Syndrome, surgical site infection, fracture, retear, implant failure, osteonecrosis, symptomatic venous thromboembolism and postoperative stiffness. One patient in the AA group had a Type V Sugaya grading due to re-tear, while none of the patients in the mini-open group experienced a re-tear. This finding is consistent with the studies by Sakha S et al. and Zhang Z et al., which reported significantly higher re- tear rates among patients in the arthroscopic group. This was attributed to the trauma following a history of falls sustained by a patient after surgery on the operated shoulder, which was subsequently managed using an all-arthroscopic repair technique.18,21

5.    Conclusion

In conclusion, our study in the South Asian context suggests an economic justification for the widespread adoption of arthroscopic surgery, aligning with the country’s limited healthcare budget.29 Despite a small sample size raising concerns about generalizability, standardized assessments like the UCLA shoulder score highlight improved function and reduced postoperative pain with arthroscopy. While statistically insignificant movement differences were observed, the arthroscopic group exhibited significantly better UCLA and Oxford scores, supporting the transition to arthroscopic techniques. Policymakers should prioritize measures for the broader adoption of these advanced healthcare options, and future large-scale trials are essential for definitive evidence. The study is limited by the absence of a sufficiently matched comparison group with small numbers, introducing potential bias and reducing external validity. Additionally, the lack of long-term follow-up limits insights into the persistence and sustainability of observed effects over time.

Credit Authors Statement

All Authors have contributed to the work in this journal, Jithesh was the principal investigator and the first author and was involved in data collection, statistical analysis, observation.jimmy Joseph involved in manuscript editing services, prrof reading alongwith Aebel Raju, Ayyappan V Nair was monitoring the progress in the research discussions and was the mentor for writing. Arun Mundakkal was involved in drafting the manuscript alongside principal investigator. Ajayakumar T and Pradeep Kumar was conceptualizing the study and proposing the methodology. Prince Shanavas Khan was the chief surgeon and the ideologist and did the final manuscript verification and he is the corresponding author.

Funding

This study has not received any remuneration or support for the financial disclosure.

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