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ulie Bishop, MD,a Steven Klepps, MD,b Ian K. Lo, MD,c Justin Bird, MS,d James N. Gladstone, MD,d and

van L. Flatow, MD,d Columbus, OH, Billings, MT, Calgary, Alberta, Canada, and New York, NY

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rthroscopic rotator cuff repair (RCR) has been re-orted to have good clinical results but high retearates by ultrasound. We prospectively assessed post-perative cuff integrity and outcome after arthroscopicCR (40 patients) and compared these results withpen RCR (32 patients). Evaluation preoperatively andt 1 year included a physical examination and mag-etic resonance imaging. American Shoulder and El-ow Surgeons and Constant scores improved signifi-antly in both groups (P � .0001). Overall, 69% ofepairs in the open group and 53% in the arthroscopicroup were intact by magnetic resonance imaging. Of

ears less than 3 cm in size, 74% in the open groupnd 84% in the arthroscopic group were intact. Of

ears greater than 3 cm in size, 62% in the openroup and 24% in the arthroscopic group were intactP � .036). In the arthroscopic group, patients with anntact cuff had significantly greater strength of eleva-ion (P � .01) and external rotation (P � .02). Weonclude that open and arthroscopic RCRs have simi-ar clinical outcomes. Cuff integrity is comparable formall tears, but large tears have twice the retear ratefter arthroscopic repair. (J Shoulder Elbow Surg006;15:290-299.)

From Columbus Bone, Joint & Hand Surgeons, Inc, Columbus,bMontana Orthopedics and Sports Medicine, St Vincent’s Hos-pital, Billings, cArthroscopic and Reconstructive Shoulder Sur-gery Service, Faculty of Medicine, University of Calgary, Cal-gary, and dLeni and Peter W. May Department of Orthopaedics,Mount Sinai Hospital, New York.

upported in part by a Prospective Clinical Research Grant fromthe Orthopaedic Research and Education Foundation (primaryinvestigator, Evan L. Flatow, MD; 1996-1998; “Surgical repairof the torn rotator cuff tendon: a prospective analysis of function,quality of life, costs and factors that affect these analyses”) andby an Imaging Core Award from the National Institutes of Healthand General Clinical Research Center, Mount Sinai MedicalCenter (primary investigator, Evan L. Flatow, MD).

eprint requests: Evan L. Flatow, MD, 5 E 98th St, Box 1188,Mount Sinai Medical Center, Department of OrthopaedicSurgery, New York, NY 10029 (E-mail: Evan.Flatow@msnyuhealth.org).opyright © 2006 by Journal of Shoulder and Elbow SurgeryBoard of Trustees.

058-2746/2006/$32.00

Woi:10.1016/j.jse.2005.09.017

90

ince the first clinical report of rotator cuff repairRCR) by Codman10 nearly 100 years ago, manyeries have noted good results after openCR.2,4,11,14,17,20,30,33,43,58 Codman also intro-uced the end-result idea, considered the forerunnerf modern outcome studies. Despite this, most studiesf rotator cuff surgery have been retrospective charteviews.56 Vitale et al57 documented substantial re-ional variation in the rate of RCR, possibly resulting

n part from a lack of consensus as to expectedutcomes. In 1996 the senior one of us (E.L.F.) re-eived an Orthopaedic Research and Educationoundation Prospective Clinical Research Grant totudy the outcome of RCR prospectively in collabora-ion with the International Center for Health Outcomesnd Innovation Research Center of Columbia Univer-ity, New York, NY. This study, which used patient-erived, health-related quality-of-life measures, docu-ented significant improvements in pain, shoulder

unction, and patient quality of life, with a cost benefitdollars per quality-adjusted life-year) better thanany interventions, including open heart surgery and

enal dialysis.55

Patients from this well-documented study were en-olled in a second prospective study in which mag-etic resonance imaging (MRI) scans were obtainedt 1-year follow-up to allow comparison of tendon

ntegrity with clinical outcome. Several studies haveorrelated rotator cuff integrity as assessed by post-perative imaging with outcome and have shown cuffntegrity to be an important factor in patient out-omes.9,26,31,32,35,38,39,52,53 Many have shown thatetter function and pain relief can be obtained if theuff is intact postoperatively.25,28,32,53

As our service shifted to routine arthroscopic repairf full-thickness rotator cuff tears, it seemed advanta-eous to study the new technique prospectively. De-pite good clinical results reported with arthroscopicepairs,3,6,7,22,42,51,59,61 the biomechanical strengthf arthroscopic repair has been reported to be low-r,48 and cuff integrity after arthroscopic repair haseen inconsistent when assessed with ultra-ound.46,60 Repair integrity after open and miniopenechniques, as assessed by MRI or ultrasound, hashown more consistent and favorable results.28,32,38

ith the assistance of Mount Sinai’s National Insti-

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J Shoulder Elbow Surg Bishop et al 291Volume 15, Number 3

utes of Health General Clinical Research Center’smaging Core (New York, NY), a second prospectivetudy of arthroscopic RCR was set up, by use of theame outcome measures as the previous study ofpen and miniopen repairs. The goal was to evaluaterospectively clinical outcomes after both open/mini-pen and arthroscopic RCRs and to correlate theseith rotator cuff integrity after each respective repair

echnique.

ATERIALS AND METHODS

atient enrollmentInstitutional review board approval was obtained before

atients were enlisted in both groups. Forty-seven consecu-ive patients subsequently provided informed consent andere enrolled in the open RCR group. These patients weresubset of a larger ongoing study evaluating outcomes

fter open RCR between 1996 and 1999. A power analy-is revealed the need for at least 36 patients with postop-rative MRI in the arthroscopic RCR group to claim statisti-al significance. The collection period for the arthroscopicroup then began in May 2001 and continued until No-ember 2002. Subsequently, 55 consecutive patients pro-ided informed consent and were prospectively enrolled.ll patients had full-thickness rotator cuff tears diagnosed byRI preoperatively and then confirmed at the time of sur-

ery. Patients with concomitant disorders such as glenohu-eral arthritis, fracture, osteonecrosis, or labral pathologyere excluded. Patients who were unable or unwilling tondergo preoperative and postoperative MRI were alsoxcluded.

utcome assessmentThe preoperative evaluation consisted of a patient ques-

ionnaire and physical examination by an independentxaminer. The examination included measurement of rangef motion and strength testing with the use of a dynamom-ter in both forward elevation (FE) and external rotationER). This evaluation allowed the calculation of a generalealth score (Short Form 36) and several standard shoulder-pecific scores, including the Constant score, the Americanhoulder and Elbow Surgeons (ASES) survey, and a visualnalog scale (VAS) pain score.

adiographic assessmentAt a minimum of 1 year postoperatively, all patients

nderwent a clinical evaluation identical to the preopera-ive evaluation. They also underwent MRI at least 1 yearostoperatively. The protocol for follow-up MRI consisted oforonal images in both a T1 and Inversion Recovery formatith 3-mm slices, sagittal images in the Inversion Recovery

ormat with 3-mm slices, and axial images in the T1 formatith 4-mm slices. Of 72 patients, 13 (18%) either could not

eturn or had claustrophobia. These patients underwent MRIt another facility, including 7 open MRI studies. All scansere judged to be adequate to assess postoperative rotatoruff tendon repair integrity. The MRI reading of cuff integrityas determined by 3 independent examiners, and interob-

erver reliability was established. Any tendon defect filled p

ith fluid was considered a retear. No attempt was made toompare defect size at follow-up with preoperative tearize, as this was not thought to be reliable.

tatisticsStatistical evaluation was performed with paired and

npaired 2-tailed t tests by use of the GraphPad programGraphPad Software, Inc, San Diego, CA). A P value of lesshan .05 was considered statistically significant. Interob-erver reliability was established by computation of theimple � value. A � value above 0.75 represents excellentgreement between observers, a value between 0.4 and.75 is rated as fair to good agreement, and a value of less

han 0.4 is rated as poor agreement. Appropriate statisticalnalysis was ensured with the consultation of a biostatisti-ian at our center.

urgical technique: Miniopen or open RCROur surgical technique for open RCRs has been previ-

usly described1 and will not be restated except as it relateso this study. Whether the miniopen or open technique wassed, the rotator cuff tendon was repaired in a similarashion in all cases. Bursal, capsular, and interval releasesor tendon mobilization were performed sharply with a

ayo scissors, as needed.Once adequately mobilized, the rotator cuff was re-

aired to the prepared greater tuberosity with sutureslaced in a modified Mason-Allen fashion and passed

hrough bone tunnels, reinforced with CuffLink Bone Tunnelevices (Mitek Worldwide, Westwood, MA).

All patients’ arms remained in a sling for 6 weeks, andhey were allowed only passive range of motion during thisime period. At 6 weeks, gradual full active motion wasnstituted, progressing to resistive strengthening, which wasontinued for a total of 3 to 4 months.

urgical technique: Arthroscopic RCROur technique for arthroscopic RCR closely parallels our

pen technique with respect to capsular and interval re-eases for tendon mobilization.18 A radiofrequency probeas used to perform the arthroscopic releases. Medial

etraction, as well as the length of the tear from anterior toosterior, was measured by use of an instrument of known

ength.Once the rotator cuff was adequately mobilized, the

endon was repaired to the prepared greater tuberosity withuture anchors. The number of anchors and sutures usedas dependent on the size of the rotator cuff tear. Ifossible, medial fixation was also performed with a tendon-

ransfixing device (Cufftack [Mitek Worldwide] or SuretacSmith & Nephew, Inc, Andover, MA]); however, no tearas repaired with this alone. Use of this device was gen-rally possible more often in the smaller tears. We noonger use this device, and we now use 2 rows of anchors,edial and lateral, but this change occurred after the

epairs in this study were performed. An attempt was al-ays made to fix the cuff tendon to the lateral aspect of the

uberosity, if tension allowed, to cover the greatest amountf tuberosity footprint to maximize surface area and healing

otential.

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292 Bishop et al J Shoulder Elbow SurgMay/June 2006

Postoperative care was similar to that described previ-usly for open and miniopen repairs.

ESULTS

A total of 47 patients were included in the openCR group. Of the patients, 11 refused to undergoostoperative MRI, 3 were lost to follow-up, and 1ied, leaving 32 patients for evaluation. Of these, 24nderwent an open RCR and 8 had a miniopen RCR.our patients had distal clavicle resection, and twonderwent revision surgery. A total of 55 patientsere enrolled in the arthroscopic RCR group. Sevenatients refused to undergo postoperative MRI. Eightgreed but were unable to complete the MRI becausef scheduling difficulties or personal medical prob-

ems, thus leaving 40 patients for evaluation in thetudy. Of the 40 patients, 11 had distal clavicleesection and 1 underwent revision surgery.

verall results

The mean patient age was 64 years in both thepen and arthroscopic groups. The mean overall tearize was 2.6 cm in the open group and 3.0 cm in therthroscopic group. Overall, there were 41 womennd 31 men enrolled in the groups. There was noignificant difference between these demographics.

Overall, the patients in both groups experienced aignificant improvement in their ASES, Constant, andAS pain scores. ASES scores improved from 40 to5 in the open group and from 46 to 84 in therthroscopic group. Constant scores improved from3 to 80 in the open group and from 52 to 75 in therthroscopic group. VAS pain scores decreased from.2 to 1.1 in the open group and from 5.2 to 1.5 in

able I Comparison of overall shoulder outcome scores in open RC

Open RCR

Mean P value M

SES �.0001Preoperative 40 4Postoperative 85 8onstant �.0001Preoperative 53 5Postoperative 80 7

ain (VAS) �.0001Preoperative 8.2Postoperative 1.1

E (lb) �.005Preoperative 6.2Postoperative 12.8 1

R (lb) �.01Preoperative 10Postoperative 18 1

Significance of any difference in outcomes found between the 2 types of r

he arthroscopic group. All postoperative improve-

ents reached statistical significance (P � .0001).here was no significant difference in outcomes be-ween the 2 repair techniques (Table I).

Overall, strength improved significantly in FE andR in both groups (P � .03). FE strength improvedrom 6.2 lb to 12.8 lb in the open group and from 5.8b to 10.4 lb in the arthroscopic group (no differenceetween study groups). ER strength improved from 10

b to 18 lb in the open group and from 9.5 lb to 13.6b in the arthroscopic group (Table I). ER strength atollow-up was higher in the open repair group than inhe arthroscopic group (18 lb vs 13.6 lb, P � .05);his was the only measurement that showed a signifi-ant difference between repair groups.

ostoperative cuff integrity and outcomes: Intact versusorn

Patients were subdivided into those whose repairsere intact and those in whom full-thickness tendonefects were demonstrated on postoperative MRI. Aonsensus method (between two of us and a radiolo-ist) was used to determine cuff integrity. When aonsensus on integrity was reached, this was used ashe result for this report. A separate, independenttudy evaluating interobserver reliability was per-ormed to determine the validity of our readings. Weound that the interobserver reliability was 0.7, rep-esenting good to excellent agreement between ob-ervers. In the open group, 69% (22/32) of all re-airs were intact by MRI, resulting in a 31% (10/32)etear rate. In the arthroscopic group, 53% (21/40)ere intact and 47% (19/40) had a retear. Theseifferences were not found to be significant (Figure).

arthroscopic RCR groups

throscopic RCROpen group vs arthroscopic

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J Shoulder Elbow Surg Bishop et al 293Volume 15, Number 3

ears for those patients with an intact cuff more thanyear postoperatively and 63 years for those with a

etear. The mean preoperative tear size was 2.3 �.4 cm for those with an intact cuff after an openepair and 3.4 � 1.5 cm for those with a retear.either of these findings was statistically significant (P.05). In the arthroscopic group, the mean patient

ge was 61 years for those with an intact cuff and 67ears for those with a retorn cuff (P � .05). The meanreoperative tear size was 1.8 � 1.5 cm for thoseith an intact cuff and 4.3 � 1.4 cm for those whoseuff had retorn (P � .005).

In the open repair group, ASES, Constant, and VASain scores were slightly better in those patients whoaintained cuff integrity; however, these results did not

each statistical significance. Postoperative strength inE and ER was also better in those with an intact cuff, butgain, this was not statistically significant (Table II).

In the arthroscopic repair group, those patientsith an intact rotator cuff postoperatively had a sig-ificantly better outcome in several areas. There wassignificant improvement in ASES score (89 for thoseith an intact cuff versus 75 for those with a retear, P.03). The Constant score, though higher in the

ntact group, only trended toward significance (P �06). FE strength improved from 6.2 lb to 13.1 lb inhe intact group and from 5.8 lb to 8.1 lb in the retearroup; FE strength at follow-up was significantly better

f the cuff was intact (13.1 lb versus 8.1 lb, P � .01).R strength improved from 10.2 lb to 16.6 lb in thentact group compared with 8.6 lb to 10.7 lb in theorn group; ER strength was also significantly better inhe intact group (16.6 lb versus 10.7 lb, P � .02).lthough pain scores were slightly improved in the

ntact group, this was not significant.When the open and arthroscopic repair groups were

ombined, there were significant differences in outcomeith respect to tendon integrity at follow-up (Table II).SES scores averaged 89 for the intact cuffs and 77 for

he retorn cuffs (P � .01); Constant scores were 81 for

igure 1 Overall MRI results revealing postoperative rotator cuffntegrity for all sizes of tears fixed either in an open manner orrthroscopically.

he intact cuffs and 72 for the retorn cuffs (P � .01). FE r

trength was 13.7 lb for the intact cuffs and 8 lb for theetorn cuffs (P � .001). However, there was no signifi-ant difference in outcomes between study groups (openersus arthroscopic) for any of the scores mentionedreviously when the intact and retear groups were com-ared. In other words, if the tendon was intact at follow-p, the result was the same whether the repair had beenpen or arthroscopic.

ostoperative cuff integrity and outcomes: Small versusarge tears

Tears were categorized as small (�3 cm) or large�3 cm), and the functional outcome of repair, as wells postoperative cuff integrity, was analyzed basedn tear size (Table III).

In the open group, the mean tear size was 1.66 �.71 cm in the small-tear group and 4.3 � 0.7 cm in

he large-tear group (P � .0001). In the arthroscopicroup, the mean tear size was 1.25 � 0.9 cm in themall-tear group and 4.8 � 0.5 cm in the large-tearroup (P � .0001). There was no significant differ-nce in mean tear size within the small-tear andarge-tear groups between the open repair and ar-hroscopic repair groups, although there were moreassive tears in the arthroscopic group, as will beiscussed later. There was no difference in age orymptom duration with respect to tear size.

In the open repair group, 59% (19/32) of patientsad a tear size of less than 3 cm and 74% had intactuffs postoperatively by MRI. In the arthroscopic re-air group, 48% (19/40) of patients had a preoper-tive tear size of less than 3 cm and 84% of these had

ntact cuffs by MRI. This difference was not significant.n the open group, 41% (13/32) of patients had aear size greater than 3 cm and 62% of cuffs werentact. In contrast, in the arthroscopic group, 52%21/40) of patients had a tear size greater than 3 cmnd only 24% of the repairs were intact by postoper-tive MRI evaluation. This difference was statisticallyignificant (P � .036) (Figure 1).

With respect to functional outcomes, pain scores,nd FE and ER strength testing in the open repairroup, smaller tears tended to have better results;owever, these differences were not significant. Inontrast, the smaller tears in the arthroscopic groupid significantly better in all categories, except forain, where there was greater improvement, but thisas not statistically significant (P � .25).Overall, the outcome measurements did not show a

ignificant difference between groups whether the re-air was performed in an open or arthroscopic mannerxcept for ER strength. If tears were larger than 3 cm, theostoperative ER strength was significantly higher (16.4

b vs 8.8 lb, P � .05) when the rotator cuff tear was

epaired in an open manner.

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294 Bishop et al J Shoulder Elbow SurgMay/June 2006

ostoperative cuff integrity and outcomes: Massiveotator cuff tears

The tear size in each repair group was furtherubdivided into massive tears (�5 cm), and outcomes

able II Overall functional outcomes: Intact versus torn rotator cuff a

Open RCR

Intact (n � 22) Retear (n � 10) Intact

SESPreoperative 44 31 75Postoperative 88 80 89P value .22onstantPreoperative 56 50 51Postoperative 83 74 79P value .11

ainPreoperative 7.9 8.9 5Postoperative 0.7 1.8 1P value .06

E (lb)Preoperative 8.4 2.8 6Postoperative 14.4 9.1 13P value .1

R (lb)Preoperative 11 6.7 10Postoperative 18.8 16.6 16P value .6

values show the significance of any difference in postoperative outcomes wroup and the arthroscopic RCR group. No significant difference between t

able III Effect of tear size (�3 cm or �3 cm) on functional outcom

Open RCR

<3 cm (n � 19) >3 cm

SESPreoperative 43 3Postoperative 86 8P value .37onstantPreoperative 56 4Postoperative 84 7P value .12

ainPreoperative 7.9Postoperative 1.2P value .48

E (lb)Preoperative 9Postoperative 15.3 1P value .11

R (lb)Preoperative 12Postoperative 19.8 1P value .3

values demonstrate significance between outcomes listed with each study

ere assessed with respect to this variable. The ar- s

hroscopic group had more massive tears (43%, or7/40) compared with the open group (16%, or/32). The retear rate as seen on postoperative MRIas 60% for the open group and 88% for the arthro-

ther open or arthroscopic repair and combined

uff integrity

hroscopic RCR Overall

21) Retear (n � 19) Intact (n � 43) Retear (n � 29)

47 45 4175 89 77

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e cuff is intact or retorn. They are specific for outcomes within the open RCRtcomes of different repair types was found for this subgroup.

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J Shoulder Elbow Surg Bishop et al 295Volume 15, Number 3

32). Despite the high failure rate, all groups showedsignificant improvement in ASES, Constant, and

ain scores. However, no group showed a significantmprovement in strength (Table IV).

ISCUSSION

The objective of rotator cuff surgery is to relieveain and restore function. The abilities and limitationsf open RCR have been well known and studied over

he years. Arthroscopic RCR, on the other hand, haseen the subject of less investigation. Although a fewtudies on arthroscopic RCR have reported good out-omes,6,7,22,42,51,59 other studies have raised con-erning issues with regard to the biomechanicaltrength of the repair48 and high failure rates of cuffntegrity at follow-up.46,60 Clear indications for ar-hroscopic RCR, as well as an understanding of itsimitations, have not been well defined. Our study hasttempted to address these concerns by comparingpen RCR with arthroscopic RCR in a prospectiveashion. As cuff integrity has been shown to influenceutcome,9,26,31,32,35,38,39,49,53 this was carefully an-lyzed with MRI studies performed at least 1 yearostoperatively. The initial rotator cuff tear size waslso evaluated as a variable influencing outcome andepair technique.

Our results are comparable to those reported in theiterature for both open and arthroscopic repairs. Liund Baker38 reported an overall intact rate of 66%

able IV Functional outcomes of patients with massive tearsepaired in open manner or arthroscopically

Massive tears (>5 cm)

Open RCR(n � 5)

Arthroscopic RCR(n � 17)

SESPreoperative 39 47Postoperative 87 73P value �.01 �.0001onstantPreoperative 50 46Postoperative 74 69P value .08 �.002

ainPreoperative 8.6 4.6Postoperative 1.8 2P value �.0001 �.005

E (lb)Preoperative 5 4.3Postoperative 5.4 7P value .95 .19

R (lb)Preoperative 3 6.1Postoperative 12.4 8.3P value .2 .5

values show significance within repair groups.

ia arthrography after miniopen repairs. Harryman et p

l32 reported an overall intact rate of 65% by ultra-ound after open repair, and Gerber al28 reported a6% rate of cuff integrity with MRI after open repair ofassive tears (defined as complete detachment of �2

endons). Our combined (open and arthroscopic) in-act rate was 60% (43/72). Although the open repairroup fared better compared with the arthroscopicepair group with respect to cuff integrity (69% vs3%), there was no significant difference. Of note,

he arthroscopic group had more tears greater than 3m in size than the open group (21 vs 13).

When the repair groups are analyzed by tear size,he results are more striking. Tears greater than 3 cmn size repaired in an open manner had an intact ratef 62%, which was significantly better than the 24%ntact rate for arthroscopic repairs. However, theumber of massive tears in the arthroscopic groupith a tear size greater than 3 cm was much larger

han in the open group with a tear size greater than 3m. A similar difference was seen when repair tech-iques were compared with regard to massive tears40% intact in open group and 12% intact in arthro-copic group). These results are similar to those re-orted by Romeo and Cohen46 (33% intact) andamaguchi60 (6% intact) for large to massive tearsvaluated by ultrasound.

Interestingly, for tears less than 3 cm in size, ar-hroscopic repairs remained intact in 84% whereaspen repairs had a 74% intact rate. Although thisifference was not significant, it does give credibility

o the arthroscopic repair technique despite inferioresults for the larger tears.

There are several possible reasons for the higherate of rotator cuff integrity seen with the open tech-ique. The strength of arthroscopic RCR has beeneported to be lower than that of open repairs in 1ecent biomechanical study.48 Open repairs may betronger because of the use of the modified Mason-llen suturing technique,27 which is difficult to per-

orm arthroscopically. Because most biomechanicaltudies describe repairs failing at the suture-tendonnterface, increasing the strength at this interfaceeems to be a reasonable goal. Tendon quality maye degraded by the chronicity of a tear, repeated

njections, age, or other conditions.23,24,50 Modifiedason-Allen sutures may be better at distributing the

orce to both the suture and the tendon and, thus,ripping poorer-quality tendon tissue more securely

han simple sutures, which are typically used withrthroscopic suture anchor repairs.

The open repair also allows the use of boneunnels and reinforcement implants such as cuffinks or scaffold devices, which can improve thetrength of fixation.37 Although bone anchors haveeen shown to be stronger than bone tunnels ineveral studies,8,29,34 the geometry of fixation may

lay a role in enhancing open repairs. Surface

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296 Bishop et al J Shoulder Elbow SurgMay/June 2006

rea contact for tendon healing may be larger withn open repair and bone tunnel fixation, leading toreater potential for healing. Bone anchors, unlessdouble row (medial and lateral) is used, tend to

ull the tendon down at a steeper angle with aore narrow contact area of the tendon on the

uberosity for healing. Future studies may show thathe double-row technique, which we currently use,as strength and surface area properties similar tohose of the open repair fixation technique.13

The senior one of us (E.L.F.), who performed theserocedures, has 16 years of experience as an openotator cuff surgeon but less experience with arthro-copic repair. It is thus possible that a more experi-nced arthroscopic surgeon might have results thatompared more favorably with those of open repair.owever, we sought to compare 1 surgeon’s experi-nce, which may have relevance for surgeons con-emplating a shift from open to arthroscopic repair.

Another possible explanation for the inferior resultsor cuff integrity, seen especially with larger tears, ishat the reduced morbidity of arthroscopic repair mayave tempted us to operate on larger and less repair-ble tears. Indeed, there were only 5 massive tears in

he open group, but there were 17 in the arthroscopicohort. Only a randomized trial, which would beifficult in our treatment area, could clearly address

his issue.Arthroscopic repairs tend to produce less pain in

he immediate postoperative period. Patients may,herefore, have a tendency to use their arm andhoulder more actively and sooner than those with anpen repair, leading to early failure. This may bearticularly true for the larger tears, as arthroscopicepairs may be weaker in the early postoperativeeriod. This theory is substantiated by the work oferber et al,26 who reported that retears of the

otator cuff occur very early when they do occur.imilar findings were reported in their study evaluat-ng the results of repair of massive tears of the rotatoruff.28 Therefore, better compliance and stricter ad-erence to the early postoperative protocol are nec-ssary to protect the rotator cuff during this criticalime period. We currently immobilize patients’ armsompletely for 4 to 6 weeks after arthroscopic repairf larger tears and have not noted increased stiffness.

The higher failure rate after arthroscopic repair ofarge tears might also be explained by better tendonobilization in the open repair group. Small tears

arely require mobilization, and this may help explainhe improved rate of healing with arthroscopic repairf smaller tears. However, almost all large tears,specially those with retraction, require releases. Ar-hroscopic mobilization and assessment of rotator cuffeparability have been shown to be equal to the openethods in 1 study,21 but this depends largely on the

urgeon’s technical skills. Our goal was to perform t

dentical releases, in an open or arthroscopic man-er,1,40 to reduce as much tension in the torn tendons possible. Indeed, it is our impression that releasesre easier and more precise arthroscopically, when

he medial capsule and glenoid rim are directly visu-lized. Reduction in tendon tension has been shown

o improve rotator cuff healing and patient out-ome.12 However, as we do not have an accurateay of measuring tendon tension before or after

eleases, we do not have a way of clearly knowinghether our releases were indeed identical.We found age to be a significant factor with

egard to postoperative cuff integrity after arthro-copic RCR. Older patients had more retears. How-ver, this was not the case with open repairs, as theseatients were almost the same age (64 years vs 63ears) whether their cuffs were intact or retorn. Patientge was not significantly related to preoperative tearize in this study. However, larger tears were moreikely to retear, and patients with a retear after arthro-copic repair were more likely to be older.

We chose to use MRI for diagnostic testing, as it isommonly available, minimally invasive, and mostmportantly, accurate in both the preoperative andostoperative setting in assessing rotator cuff pathol-gy.5,19,41,47,54,62 We found high interobserver reli-bility when 3 independent observers evaluated post-perative rotator cuff integrity. Ultrasound has alsoeen shown to be effective but is highly operator-ependent and not widely available.60 The arthro-ram has also been used to assess rotator cuff pathol-gy and, in fact, may be the best technique foretermining if a watertight repair has occurred. How-ver, as pointed out by Harryman et al,32 a leak doesot accurately determine whether the reattachment ofendon to bone has failed. Because of its invasivenessnd the limited information it provides concerninguscle atrophy, arthrography has fallen out of favor.hether ultrasound or MRI is used postoperatively,

ertain repair techniques, such as margin conver-ence or repairs to the articular margin, may stillresent a challenge to image accurately postopera-

ively.Having evaluated possible reasons for cuff repair

ailure at a structural level, the question arises: doesuff integrity matter? Our study found, as have severalther investigators have found,9,26,31,32,35,38,39,49,53

hat postoperative rotator cuff integrity is significantlyelated to functional outcomes. When the arthro-copic and open repair groups were pooled, allcores except for pain scores were significantly betterith an intact rotator cuff postoperatively than with a

etear. A few studies have documented strength be-ore and after failed repairs,36,53 although no studyas looked at 2 patient groups as large as ours. Jostt al35 recently looked at 20 MRI-diagnosed rerup-

ures of open repairs and showed a significant im-

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J Shoulder Elbow Surg Bishop et al 297Volume 15, Number 3

rovement in abduction strength overall, which didorrelate to the size of the retear. We also found anmprovement in strength in both of our retear groups,imilar to the study of Jost et al; however, we did notnd this improvement to be significant. Interestingly,he data from our open group support their findinghat a watertight cuff is not mandatory for recovery ofbduction strength greater than 4 kg, contrary tohat has previously been reported.53 However, weave shown that an intact cuff leads to greatertrength (in FE and ER) than a retear. This finding wasrue when the open and arthroscopic groups wereooled, but when the patients were divided into thepen and arthroscopic groups, strength correlatedignificantly with cuff intactness only in the arthro-copically repaired group. This difference might bexplained by the larger number of massive tearsncluded in the arthroscopic group (17 vs 5 in thepen group), in which loss of 2 tendons could lead toiminished strength. Thus, we believe that postopera-

ive strength is dependent on tendon healing, regard-ess of the method of fixation.

Successful clinical outcomes are dependent notnly on strength, as many patients may be weak in

his regard, but also patient satisfaction with theirbility to perform their activities of daily living, re-ected in their ASES and Constant scores. Manytudies have shown improvement in these functionalcores, despite structural failure of the cuff after repairr with debridement alone.15,16,35,44,45,63 Our goalas to find the repair method capable of producing

he best results. In both groups, patients were noted toave better scores when the tears were smaller (�3m). Moreover, those with larger tears had a higherncidence of retear, and as retears were found toave worse results, this could explain these outcomes.nterestingly, although these differences only ap-roached significance in the open group, they wereignificant in the arthroscopic group. Thus, patientsndergoing arthroscopic RCR had significantly betterubjective outcomes when they had small tears andntact repairs. Further study needs to be focused onoth technical factors and biologic issues that wouldake larger tears more amenable to successful arthro-

copic repair.The strengths of this study were its prospective

esign, the use of independent examiners for clinicalutcomes and test measurements, and the fact that 1urgeon evaluated all patients, determined indica-ions for surgery, and performed all procedures.

The limitations of this study include the fact that notll patients completed the protocol for the open repairroup, as we had difficulty getting some patients tondergo postoperative MRI. This reduced the totalumber of patients we could include. As stated ear-ier, these patients were part of a larger overall study

valuating surgical outcomes, and a power analysis,

or the MRI portion, was not performed as it was forhe arthroscopic series. For both groups, using differ-nt MRI units (occasionally open units) also decreasedhe consistency of radiographic interpretation. For therthroscopic group, the majority of postoperative MRItudies were performed at the same institution. Inddition, lack of a specifically designed measuringevice to assess the size of the rotator cuff tear mayave led to over-reading some tears, especially in therthroscopic group. Whereas small tears were easy

o identify, quantifying the size of large tears wasore challenging. The final limitation was the pres-nce of surgical variances, such as the use of bothpen and miniopen techniques. This occurred be-ause of the development of miniopen repairs duringhe time period of the open study. Finally, althoughhis study was prospective, no randomization waserformed. During the first part of the study, tearsere routinely fixed in an open manner, and during

he second phase, they were routinely fixed arthro-copically. Thus, indications may have shifted some-hat, especially in that larger tears may have been

elected for arthroscopic surgery.In conclusion, both open RCR and arthroscopic

CR reliably provide satisfactory clinical results. Aigh rate of rotator cuff integrity is seen after repair ofears less than 3 cm in size with both types of repair.n contrast, when tears greater than 3 cm in size wereepaired, cuff integrity was found to be significantlyigher with an open repair. However, these data muste analyzed with the knowledge that more massive

ears were included in the arthroscopic group. Theize of the tear at the time of repair and the integrityf the rotator cuff at follow-up are both importanteterminants of functional outcomes after arthro-copic repair. In addition, ER and FE strength isignificantly better when the tear is initially smallnd if the repair has remained intact. The importancef tendon integrity at follow-up seen in this and pre-ious studies would seem to support further effortsimed at technical improvements to reduce retearates.49,52,58,59

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