There was substantial disagreement about the number of procedures needed to become proficient in the different repair techniques. Overall, however, there was consensus that arthroscopic and mini-open repairs had longer learning curves than open repair. Given the lack of agreement among orthopedic department chairmen and sports medicine fellowship directors regarding the minimum exposure needed (during residency) to become proficient in diagnostic shoulder arthroscopy,28 this finding is not surprising. Guttmann and colleagues29 attempted to quantify the learning curve for arthroscopic RCR by tracking operating time as a surrogate measure. They found that RCR operative time decreased rapidly during the initial block of 10 cases to the second block of 10 cases, but thereafter improvement continued at a much lower rate.29 None of our respondents thought the learning curve for arthroscopic RCR was under 10 cases, but no group, not even the attendings who performed RCRs, could agree on the minimum number of cases needed for proficiency. The longer learning curve for arthroscopic RCR did not discourage the respondents who preferred arthroscopic or mini-open RCR.
Cost was not an influential factor in opinions about which RCR method is optimal. Medical professionals were ambivalent about the cost-effectiveness of the different procedures, with most expressing no opinion on cost. Multiple investigators have shown that arthroscopic RCR costs as much as $1144 more than mini-open RCR,18,27 which has many of the advantages of arthroscopic repair but not the costly implants and instruments. As our medical community becomes more cost-conscious, concern about this factor may increase among medical professionals.
Our study had several limitations. Its results must be interpreted carefully, given they represent the viewpoints of a nonrandomized sample of motivated respondents at one institution. A selection bias excluded surgeons who were uncomfortable with RCR and unwilling to report any shortcomings. The conclusions cannot be generalized to other medical professionals or to other institutions. Furthermore, to develop a simple, straightforward survey focused on a specific type of rotator cuff tear, and to avoid confusion, we assumed that the treatment preference for the described tear was generalizable to all encountered tears. However, some surgeons have reported different repair techniques for different types and sizes of rotator cuff tears.25
Conclusion
Most of our surveyed medical professionals were willing to defer to their surgeon’s decision about which technique would be appropriate for their own personal RCR. There is a trend nationally, and at our institution, for increased use of arthroscopic RCR. Although medical professionals readily acknowledge it is unclear which repair method provides the best ultimate outcome, many perceive fast recovery and good cosmetic results with arthroscopic and mini-open repairs. When medical professionals are counseling patients, we need to recognize these personal biases because many patients defer to their surgeon’s counsel. For some medical professionals, cosmesis can be an important factor, but cost, procedure duration, potential technical challenges of arthroscopic repair, and other considerations may make other techniques more desirable for others.
