Several factors may account for these evolving beliefs. We hypothesized that a biased favorable view of arthroscopic repair outcome might influence opinions. However, our results did not support the hypothesis. Medical professionals in our cohort were equivocal about the best RCR technique. No consensus was evident among attendings, residents, or AHPs. This lack of clinical agreement about rotator cuff surgery has been observed elsewhere—for example, among members of the American Academy of Orthopaedic Surgeons (AAOS)21 and the European Society of Sports Traumatology, Knee Surgery, and Arthroscopy.22 Despite theoretical advantages of arthroscopic repair, there has been no documented significant difference in patient outcomes when compared with other techniques.23 To our knowledge, there have been only a few clinical studies comparing the different RCR techniques. A meta-analysis of 5 clinical studies comparing arthroscopic and mini-open RCR techniques showed no difference in clinical outcomes or complication rates.8 The 2012 AAOS clinical practice guidelines for RCR reflect these observations.24 That consortium of leading shoulder surgeons could not recommend a modality of surgical rotator cuff tear repair given the lack of conclusive evidence.24
At our institution, arthroscopic, mini-open, and open RCRs were performed by 36%, 9%, and 55% of our surgeons, respectively. A survey of AAOS surgeons showed that, of those who perform RCRs, 14.5%, 46.2%, and 36.6% used arthroscopic, mini-open, and open techniques, respectively.21 The greater use of open repairs at our institution might reflect the seniority of our faculty. Dunn and colleagues21 found that surgeons who preferred open RCR had been in practice longer than those who preferred the arthroscopic or mini-open technique. Of our 4 faculty who performed arthroscopic repairs, 3 were less than 5 years from completing their training. In contrast, all faculty who performed mini-open or open repairs were more than 5 years from completing their training. Furthermore, mean age of the surgeons who performed arthroscopic repair was 39.8 years (range, 32-51 years), and these surgeons were significantly younger than those who performed mini-open or open repair (mean age, 56.3 years; range, 41-78 years). Younger surgeon age has been associated with higher rates of arthroscopic repair.25
Attendings unaccustomed to arthroscopy may find it more challenging than the younger generation of surgeons, who are exposed to it early in training. Dunn and colleagues21 noted that the likelihood of performing an arthroscopic repair was influenced by the surgeon’s experience level. Fellowship-trained shoulder and sports medicine surgeons are also more likely to perform arthroscopic repairs than those with training limited to orthopedic residency.25 Arthroscopic RCR demands a high level of technical skill that many acquire in fellowship training.26 Mauro and colleagues26 found that surgeons trained in a sports medicine fellowship performed 82.6% of subacromial decompression and/or RCR procedures arthroscopically, compared with 54.5% to 70.1% for surgeons trained in other fellowships. In our cohort, with the exception of 1 surgeon, all fellowship-trained shoulder and sports medicine surgeons performed arthroscopic RCRs.
Although no conclusive evidence in the literature supports arthroscopic over the other repair types, the demand for arthroscopic RCR has rapidly increased relative to that for the others. Between 1996 and 2006, use of arthroscopic RCR increased 600%, from 8 to 58 per 100,000 population.20 In that same period, use of open RCR increased by only 34%.20 Similarly, Mauro and colleagues26 found that the proportion of subacromial decompression and RCRs performed arthroscopically rose from 58.3% in 2004 to 83.7% in 2009. Using the 2006 New York State Ambulatory Surgery Database, Churchill and Ghorai27 found that 74.5% of RCRs with acromioplasty were performed arthroscopically.
Respondent-indicated factors that may have contributed to the more favorable opinion of arthroscopic and mini-open repair include quick healing, good cosmetic results, and better perceived patient satisfaction. The literature supports these perceptions. Baker and Liu14 found shorter hospital stays and quicker return to activity with arthroscopic repair compared with open repair. Vitale and colleagues25 also noted that, compared with open or mini-open repair techniques, arthroscopic repair resulted in shorter hospitalization and quicker overall recovery.
If these selected health care professionals with some inside information on rotator cuff surgery have biases that affect their selection of rotator cuff procedures, we should acknowledge that nonmedical personnel, in particular our patients, also have biases. The knowledge base of patients may be further influenced by friends or family members who have had rotator cuff surgery, by lay publications, and by the Internet. Satisfaction with any surgical procedure depends not only on the success of the surgery and the rehabilitation but also on patient and provider expectations. Such expectations are influenced, in part, by biases.
Our medical professionals had similar opinions on safety, recovery, cosmesis, and overall outcome of the RCR techniques, but different opinions on procedure durations and associated training requirements. All residents except one indicated open repair was a quick procedure. In contrast, a significant number of AHPs thought open repair was time-consuming. The attendings considered all the methods fast. The residents’ opinions were the most consistent with the true operating times reported. According to the literature, total operating time for mini-open repair ranges from 10 to 16 minutes faster than that for arthroscopic repair.18,20,27 Ultimately, procedure duration did not affect the respondents’ technique preference for RCR.