Surgical Technique: Arthroscopic Transosseous Repair
Surgery was performed with the patient in either the beach-chair position or the lateral decubitus position, based on surgeon preference. Our technique is similar to what has been described in the past.22,28 The glenohumeral joint is accessed through a standard posterior portal, followed by an anterior accessory portal through the rotator interval. Standard diagnostic arthroscopy is performed and intra-articular pathology addressed. Next, the scope is placed in the subacromial space through the posterior portal. A lateral subacromial portal is established and cannulated, and a bursectomy performed. The scope is then placed in a posterolateral portal for better visualization of the rotator cuff tear. The greater tuberosity is débrided with a curette to prepare the bed for repair. An ArthroTunneler (Tornier) is used to pass sutures through the greater tuberosity. For standard 2-tunnel repair, 3 sutures are placed through each tunnel. All 6 sutures are next passed (using a suture passer) through the rotator cuff. The second and fifth suture ends that are passed through the cuff are brought out through the cannula and tied together. They are then brought into the shoulder by pulling on the opposite ends and tied alongside the greater tuberosity to create a box stitch. The box stitch acts as a medial row fixation and as a rip stitch that strengthens the vertical mattress sutures against pullout. The other 4 sutures are tied in vertical mattress configuration.
Statistical Analysis
After obtaining the TO and TOE implant costs, we compared them using a generalized linear model with negative binomial distribution and an identity link function so returned parameters were in additive dollars. This comparison included evaluation of tear size and concomitant procedures. Operative times for TO and TOE were obtained and evaluated, and then compared using time-to-event analysis and the log-rank test. Outcome scores were obtained from patients at baseline and 3, 6, and >12 months after surgery and were compared using a linear mixed model that identified change in outcome scores over time, and difference in outcome scores between the TO and TOE groups.
Results
Table 1 lists patient demographics, including age, sex, body mass index, smoking status, and concomitant procedures. The TO and TOE groups had identical tear-size distributions. In addition, they had similar numbers of concomitant procedures, though our study was underpowered to confirm equivalence. Treatment techniques differed: more biceps tenodesis cases in the TO group (n = 12) than in the TOE group (n = 2) and more biceps tenotomy cases in the TOE group (n = 8) than in the TO group (n = 1).
TO implant cost was significantly lower than TOE implant cost for all tear sizes and independent of concomitant procedures (Figure 1).
Operative time was not significantly different between the TO and TOE groups. Mean (SD) operative time was 82.38 (24.09) minutes for the TO group and 81.71 (17.27) minutes for the TOE group. With all other factors controlled, mean operative time was 5.96 minutes shorter for the TOE group, but the difference was not significant (P = .549).
There was no significant difference in preoperative pain VAS (P = .93), SANE (P = .35), or SST (P = .36) scores between the TO and TOE groups.
Discussion
RCR is one of the most common orthopedic surgical procedures, and its use has increased over the past decade.9,21 This increase coincides with the emergence of new repair techniques and implants. These advancements come at a cost. Given the increasingly cost-conscious healthcare environment and its changing reimbursement models, now surgeons must evaluate the economics of their surgical procedures in an attempt to decrease costs without compromising outcomes. We hypothesized that arthroscopic TO-RCR can be performed at lower cost relative to arthroscopic TOE-RCR and without increasing operative time or compromising short-term outcomes.
Studies on the cost-effectiveness of different RCR techniques have been conducted.19-21 Adla and colleagues19 found that open RCR was more cost-effective than arthroscopic RCR, with most of the difference attributable to disposables and suture anchors. Genuario and colleagues21 found that double-row RCR was not as cost-effective as single-row RCR in treating tears of any size. They attributed the difference to 2 more anchors and about 15 more minutes in the operating room.
The increased interest in healthcare costs and the understanding that a substantial part of the cost of arthroscopic RCR is attributable to implants (suture anchors, specifically) led to recent efforts to eliminate the need for anchors. Newly available instrumentation was designed to assist in arthroscopic anchorless repair constructs using the concepts of traditional TO repair.22 Although still considered to be the RCR gold standard, TO fixation has been used less often in recent years, owing to the shift from open to arthroscopic surgery.24 Arthroscopic TO-RCR allows for all the benefits of arthroscopic surgery, plus the biological and mechanical benefits of traditional open or mini-open TO repair. In addition, this technique eliminates the cost of anchors. Kummer and colleagues25 confirmed with biomechanical testing that arthroscopic TO repair and double-row TOE repair are similar in strength, with a trend of less tendon displacement in the TO group.
Our study results support the hypothesis that arthroscopic TO repair provides significant cost savings over tear size–matched arthroscopic TOE repair. Implant cost was substantially higher for TOE repair than for TO repair. Mean (SD) total savings of $946.91 ($100.70) (P < .0001) can be realized performing TO rather than TOE repair. In the United States, where about 250,000 RCRs are performed each year, the use of TO repair would result in an annual savings of almost $250 million.6Operative time was analyzed as well. Running an operating room in the United States costs an estimated $62 per minute (range, $22-$133 per minute).29 Much of this cost is indirect, unrelated to the surgery (eg, capital investment, personnel, insurance), and is being paid even when the operating room is not in use. Therefore, for the hospital’s bottom line, operative time savings are less important than direct cost savings (supplies, implants). However, operative time has more of an effect on the surgeon’s bottom line, and longer procedures reduce the number of surgeries that can be performed and billed. We found no significant difference in operative time between TO and TOE repairs. Critical evaluation revealed that operative time was 5.96 minutes shorter for TOE repairs, but this difference was not significant (P = .677).
Our study results showed no significant difference in clinical outcomes between TO and TOE repair patients. Both groups’ outcome scores improved. At all follow-ups, both groups’ VAS, SANE, and SST scores were significantly improved. Overall, this is the first study to validate the proposed cost benefit of arthroscopic TO repair and confirm no compromise in patient outcomes.
This study had limitations. First, it enrolled relatively few patients, particularly those with small tears. In addition, despite the fact that patients were matched on tear size and concomitant procedures, the groups differed in their biceps pathology treatments. Of the 13 TO patients who had biceps treatment, 12 underwent tenodesis (1 had tenotomy); in contrast, of the 10 TOE patients who had biceps treatment, only 2 underwent tenodesis (8 had tenotomy). The difference is explained by the consecutive course of this study and the increasing popularity of tenodesis over tenotomy. The TOE group underwent surgery before the TO group did, at a time when the involved surgeons were routinely performing tenotomy more than tenodesis. We did not include the costs of implants related to biceps treatment in our analysis, as our focus was on the implant cost of RCR. As for operative time, biceps tenodesis would be expected to extend surgery and potentially affect the comparison of operative times between the TO and TOE groups. However, despite the fact that 12 of the 13 TO patients underwent biceps tenodesis, there was no significant difference in overall operative time. Last, regarding the effect of biceps treatment on clinical outcomes, there are no data showing improved outcomes with tenodesis over tenotomy in the setting of RCR.
A final limitation is lack of data from longer term (>12 months) follow-up for all patients. Our analysis included cost and operative time data for all 42 enrolled patients, but our clinical outcome data represent only 74% of the patients enrolled. Eleven of the 42 patients were lost to follow-up at >12 months, and outcome scores could not be obtained, despite multiple attempts at contact (phone, mail, email). The study design and primary outcome variable focused on cost analysis rather than clinical outcomes. Nevertheless, our data support our hypothesis that there is no difference in clinical outcomes between TO and TOE repairs.