Saturday, April 16, 2016

Rotator cuff repair - are anchors worth the cost?

Comparison of implant cost and surgical time in arthroscopic transosseous and transosseous equivalent rotator cuff repair

These authors compared the costs associated with arthroscopic transosseous (anchorless) double-row rotator cuff repair with double-row anchored (transosseous-equivalent [TOE]) repair carried out from 2009 to 2012 by a single surgeon.

The study excluded revision repairs, subscapularis repairs, patients with poor tendon quality or excursion requiring medialized repair, and partial repairs. 

178 patients had TOE repairs and 166 had anchorless repairs.  Before December 2010, fixation of the rotator cuff was used in a TOE with from 2 to 4 medial row anchors at the articular margin, depending on tear size.  An average of 1.9 lateral row anchors were used in the TOE group, with an average of 4.0 total anchors used per case in the TOE cohort (3.0 anchors in small tears, 3.5 anchors in medium tears, 4 anchors in large tears, and 6 anchors in massive tears).  In December of 2010, rotator cuff repair fixation was switched from the standard TOE double-row technique to an all arthroscopic transosseous double-row repair. In the arthroscopic transosseous group, medial fixation points were placed at the articular margin using a 2.9-mm  drill oriented vertically through a superior portal just off the  margin of the acromion. A hooked device was inserted into the vertical drill hole, facilitating a 2.5-mm  horizontal drill hole to be placed laterally (typically 1.5 cm off the lateral edge of the greater tuberosity) that would line  up with the vertical drill hole. A shuttle suture for later use was then passed through the transosseous tunnels with the device. These steps were repeated, so that 2 to 4 tunnels were  placed, depending on the size of the rotator cuff tear. An average of 2.2 tunnels were used in the transosseous cohort (1.75 for small tears, 2.1 for medium tears, 2.6 for large tears,  3 for massive tears). Three to 4 #2 heavy, braided sutures were shuttled into each tunnel with horizontal mattress sutures for medial row fixation and bridging sutures for rotator cuff footprint compression.

Average implant cost for TOE repairs was $1014.10 ($813.00 for small, $946.67 for medium, $1104.56 for large, and $1507.29 for massive tears). 

This was significantly more expensive compared with anchorless repairs, which averaged $678.05 ($659.75 for small, $671.39 for medium, $695.55 for large, and $716.00 for massive tears). 

It is of interest that not only were the costs less for the anchorless repairs, the increase in cost with increasing tear size was much greater for the TOE approach.

Average total operative time in TOE and anchorless groups was not significantly different (99 vs. 98 minutes). There was larger (although not statistically significant) case time variation in the TOE group.

Comment: This type of study is of importance because it poses the question, "what is the incremental benefit to the patient of the increased cost of the TOE approach?" In order to answer that question, we need data on the clinical outcomes: improvement in patient-reported shoulder function and retear rates in relation to the costs of the two procedures. The burden of proof would seem to lie with the advocates of the more expensive TOE approach.


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