Arthroscopic Transosseous
Cuff Repair

This is the first monograph dedicated exclusively to transosseous technology and the first book supported by the Transosseous Academy.
The book covers all of the aspects from etiopathogenesis and classification to imaging, from the rationale of supporting the use of transosseous to an extensive comparison between various repair techniques.
An historical background is covered together with an updated description of the features of the most recent arthroscopic devices used to repair the cuff using a transosseous approach. In the second half of the book, surgical indications and suggested rehabilitation protocols are provided.
In the last part, economical aspects are addressed.
The authors are well recognized in the international shoulder arena and share their extensive clinical experience about transosseous. With a forward by Prof. Gigante and Dr. S. Snyder this is a must have guide for anyone wanting to know more about and adopt what is still considered the gold standard in rotator cuff repair (RCR).

Biomechanics

BIOMECHANICAL STRENGHT OF ROTATOR CUFF REPAIRS: A SYSTEMATIC REVIEW AND META-REGRESSION ANALYSIS OF CADAVERIC STUDIES

This paper presents a finite element model (FEM) capable of reproducing in an original way the repair effect.
This can represent a new frontier in predicting repair performance and in comparing different repair approaches.
Two key factors are also measured through the model: extension of the footprint contact area and stress peaks at the interface tendon suture. We know from literature, the extension of the footprint contact between tendon and bone is an indicator (more important in larger tears) of the repair performance in the long term. Another weak point to be investigated (but less known and considered) is the importance not only to extend the contact pressure area but also limit and control the stress at the interface to avoid undesired failures. authors found that the double-row technique had an ICER of $571,500 for rotator cuff tears of <3 cm and $460,200 for rotator cuff tears of >/=3 cm. Thus, based on the authors’ analysis, the double-row technique appears to be a cost-ineffective option.

GAP FORMATION IN A TRANSOSSEOUS ROTATOR CUFF REPAIR AS A FUNCTION OF BONE QUALITY

This paper is about the measurement of the gap formation as a key predictor of repair performance. The rotator cuff repair (RCR) is stressed in a dynamic way allowing the time-zero-repair to be maintained over time. Some geometrical and environmental variables are addressed in the paper affecting the efficacy of the repair. In particular, tunnel shape and bone quality are discussed as well as its influence on the repair performance as evaluated in a biomechanical lab set up.


BIOMECHANICAL EVALUATION OF AN ARTHROSCOPIC TRANSOSSEOUS REPAIR AS A REVISION OPTION FOR FAILED ROTATOR CUFF SURGERY

In this paper a new and original biomechanical cadaveric set up was used to simulate a revision case. Surprisingly, the performance of a transosseous repair in a revision repair demonstrated equivalence to a primary repair (also comparable to an anchor repair) and the footprint contact area was still greater than with an anchor approach. The advantage of having no hardware is important in the case of a future revision as well as limiting the invasiveness of the future repair. Revising an anchor with a transosseous approach can be very effective way because the tuberosity is left more or less unaffected leaving space for further repairs and simplifying potential future procedures. The clear message is this: Anytime a repair is accomplished, a consideration of the future and the possibility of revision is key to adopting a repair strategy

Clinical Outcomes

Midterm clinical outcomes following arthroscopic transosseous rotator cuff repair

Arthroscopic TO rotator cuff repair technique leads to statistically significant midterm improvement in ROM and satisfactory midterm subjective outcome scores with low complication/failure rates in patients with average medium-sized rotator cuff tears with minimal fatty infiltration. Further work is required to evaluate radiographic healing rates with this technique and to compare outcomes following suture anchor repair.


Arthroscopic Transosseous Rotator Cuff Repair: Technical Note, Outcomes, and Complications

Overall, outcomes after arthroscopic transosseous rotator cuff repair are good. However, outcomes are not as good in patients undergoing revision repair as in those undergoing primary cuff repair. The procedure is not without complications (9.7% major, 6% minor).
Cortical augmentation may be used to supplement fixation, although this does not necessarily affect outcomes. Patients without such augmentation may be at increased risk for suture cutout through the bone.
This study has been performed in order to evaluate national trends (US) in the surgical setting and hospital costs of shoulder arthroscopy and rotator cuff repair (RCR).
The conclusion shows (time frame: 2001-2009) an overall 58.8% decrease in inpatient RCRs that was similar across all hospital settings, with an increase in RCR-associated hospital charges by 144.9%, whereas hospital costs only increased by 85.2%.

Practical Use and Future Developement

SUPERIOR CAPSULAR RECONSTRUCTION OF THE SHOULDER: THE ABC (ARTHROSCOPIC BICEPS CHILLEMI) TECHNIQUE

This “hot” and interesting topic (superior capsular reconstruction) as proposed in this article shows a completely new and original way of making use of the transosseous approach. Today, SCR is considered a technically demanding and expensive procedure, because of the cost of the allograft and the anchors used to fix it. The Arthroscopic Biceps Chillemi’s technique addresses these concerns in performing SCR while presenting numerous advantages including it being a safe, easy, time and cost-saving way compared to the other published techniques. This technique has only one conditional sine qua non: the presence of the long head of the biceps tendon (LHB), used as an autograft. This condition may be interpreted as a disadvantage in the presence of some anatomic variations of the intra-articular portion of the LHB and the very rare absence of the tendon or in case of partial or complete rupture of the LHB tendon associated with a rotator cuff tear.pic TO rotator cuff repair technique leads to statistically significant midterm improvement in ROM and satisfactory midterm subjective outcome scores with low complication/failure rates in patients with average medium-sized rotator cuff tears with minimal fatty infiltration. Further work is required to evaluate radiographic healing rates with this technique and to compare outcomes following suture anchor repair.

ARTHROSCOPIC TRANSOSSEOUS ROTATOR CUFF REPAIR: THE EIGHT-SHAPE TECNIQUE

The authors show an easy, reproducible and cost effective way to repair the cuff with a transosseous technique. The authors present a preliminary case series with a minimum follow up of 12 months.
The technique consists of the use of parallel tunnels and a unique suture tape that goes across them creating a large mattress effect and a stable tying on the lateral cortical bone.

Economics

COST-EFFECTIVENESS ANALYSES IN ORTHOPAEDIC SPORTS MEDICINE

This study has been performed to point out the cost-effectiveness analyses (CEAs) as a good approach in facing out and reducing health costs.
By this article “CEA” refers to 4 cost analysis methods like as:
• Cost-effectiveness analysis that refers to the cost per health unit gain
• Cost-utility analysis, it is similar the previous method but unlike that one cost-utility analysis are patient-centric and based on quality-adjusted life years (QALYs).
• Cost-benefit analysis that utilizes purely financial inputs to compare the expected monetary cost and benefit of a procedure. By this method health care consumers are queried to understand how much they are willing to pay for the intervention or to achieve a certain health state.
• Cost-identification (minimization) analysis is a form of nalysis that identifies the costs associated with certain interventions, with the presumed goal being to choose the least expensive option.
Then, on the basis of these 4 methods, Three studies evaluated the cost-effectiveness of rotator cuff repair and the management of rotator cuff associated injuries:
Mather at al that has demonstrated a lifetime age-weighted mean societal savings of $13,771 per rotator cuff repair, and this was associated with a mean QALY difference of 0.62. Mather at al (2013)
Vitale et al also evaluated the cost-effectiveness of rotator cuff repair; however, the authors used primarily direct cost calculations. The authors found that the mean lifetime gain in QALYs for an operative intervention was 0.81 using the Health Utility Index (HUI) and 3.43 using the EuroQol instrument. Thus, the calculated cost-effectiveness ratios were $13,092.84 per QALY using the HUI and $3091.90 per QALY using the EuroQol instrument.
Genuario et al assessed the cost-effectiveness of rotator cuff repair using a single-row versus double-row technique. The authors found that the double-row technique had an ICER of $571,500 for rotator cuff tears of <3 cm and $460,200 for rotator cuff tears of >/=3 cm. Thus, based on the authors’ analysis, the double-row technique appears to be a cost-ineffective option.

THE BURDEN OF ROTATOR CUFF SURGERY IN ITALY: A NATIONWIDE REGISTRY STUDY

During the 14-year study period, 390,001 RC repairs were performed in Italy, which represented an incidence of 62.1 RC procedures for every 100,000 Italian inhabitants over 25 years old. Approximately 65% of RC repair were performed annually in patients ages\65 years, thus affecting the working population. 246,810 patients (63.3%) from the North underwent RC repairs from 2001 through 2014, 78,540 patients (20.2%) from the Center, and 64,407 patients (16.5%) from the South. The projection model predicted substantial increases in the numbers of RC repairs.
Conclusions This study confirms that the socioeconomic burden of RC surgery is growing and heavily affecting the working population. According to the prediction model, hospital costs sustained by the national health care system for RC procedures are expected to be over 1 billion euros by 2025.

IMMEDIATE COSTS OF MINI-OPEN VERSUS ARTHROSCOPIC ROTATOR CUFF REPAIR IN AN ASIAN POPULATION

The subject of this study regards the immediate costs arising from a mini-open an arthroscopic rotator cuff repair.
So which is the less immediately expansive among them? The team who performed that (three fellowship-trained surgeons) performed arthroscopic repairs and one performed the mini-open repair and resulted that the cost of implants and consumables was significantly higher with arthroscopic repair. The duration of surgery was also significantly longer with that technique.
There was no difference in length of stay between the two techniques. There was also no difference in Constant scores or ASES scores, both preoperatively and at 1 year post- operatively.
In conclusion came out that the immediate costs of mini-open repair of rotator cuff tears are significantly less than that of arthroscopic repair. Most of the difference arises from the cost of implants and consumables. Equivalent functional outcomes from both techniques suggest that mini-open repair may be more cost-effective.

QUANTIFYING THE ECONOMIC IMPACT OF PROVIDER VOLUME THROUGH ADVERSE EVENTS

It comes out by this article that Procedures performed by surgeons with higher provider volumes offer advantages both to the individual patient and the health system, with studies documenting fewer adverse events, shorter surgical times, and decreased reoperation rates. With workforce requirements for surgeons growing, it is increasingly necessary to establish the most efficient structure of this workforce.
Substantial economic savings are realized when procedures are performed by high-volume providers as compared with low-volume providers in the areas of readmission, prolonged admission, and subsequent surgery.
The costs per case attributable to adverse outcomes for ACL reconstruction (in 2010 US$) were $496, $781, and $868 for high-, medium-, and low-volume providers, respectively. For rotator cuff repair, these numbers were $523, $640, and $872, and for total shoulder arthroplasty, $1692, $1876, and $2021, respectively.
The hypothesis was accepted; higher provider volumes for surgeons do convey substantial societal economic benefits. Policies to incentivize and facilitate a greater portion of procedures being performed by high-volume surgeons may increase the efficiency of resource utilization in health care delivery


CURRENT TRENDS IN ROTATOR CUFF REPAIR: SURGICAL TECHNIQUE, SETTING, AND COST.

This study has been performed in order to evaluate national trends (US) in the surgical setting and hospital costs of shoulder arthroscopy and rotator cuff repair (RCR).
The conclusion shows (time frame: 2001-2009) an overall 58.8% decrease in inpatient RCRs that was similar across all hospital settings, with an increase in RCR-associated hospital charges by 144.9%, whereas hospital costs only increased by 85.2%.

FACTORS INFLUENCING DIRECT CLINICAL COSTS OF OUTPATIENT ARTHROSCOPIC ROTATOR CUFF REPAIR SURGERY

There are limited information exists about factors affecting direct clinical costs of rotator cuff repair surgery and so this article have been developed to find out them and resulted significant correlations between higher total direct cost and the presence of a subscapularis repair being performed (P = .015) and total number of anchors used (P  .0001).
Moreover came up to light other factors influencing costs occurring in rotator cuff repair surgery, like as a Higher body mass index, severe systemic illness, biceps tenodesis using an anchor, and total sum of anchors were correlated with higher facility utilization costs.
Then a  Severe systemic illness, addition of a sub- scapularis repairand additional subacromial decompression were correlated with higher pharmacy costs.The addition of a subscapularis repair, total sum of anchors, and severe muscle changes to the supraspinatus were correlated with higher supply costs.

DIRECT COST ANALYSIS OF OUTPATIENT ARTHROSCOPIC ROTATOR CUFF REPAIR IN MEDICARE AND NON-MEDICARE POPULATIONS.

This study started by the challenge to provide an high quality care with contained cost, of course it would be a paramount goal in orthopaedic.
The present study have been performed by the hypothesis that the direct cost of outpatient arthroscopic rotator cuff repair was assessed to determine whether, due to an older population, rotator cuff surgery was more costly in Medicare-insured patients than in patients covered by other insurers. We hypothesized that operative time, implant cost, and overall higher cost would be observed in Medicare patients.

COMPARISON OF IMPLANT COST AND SURGICAL TIME IN ARTHROSCOPIC TRANSOSSEOUS AND TRANSOSSEOUS EQUIVALENT ROTATOR CUFF REPAIR

The subject of this article is the comparison in cost savings with arthroscopic transosseous (anchorless) double- row rotator cuff repair compared with double-row anchored (transosseous-equivalent [TOE]) repair.
These results have been brought to light that (having based the study on 344 patients, 178 with TOE repairs and 166 with anchor less repairs), the 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). 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. So it may be concluded that, compared with TOE repair, anchorless rotator cuff repair provides substantial implant- related cost savings, with no significant differences in surgical time for medium and large rotator cuff tears. Case time for TOE repair varied more with extremes in tear size.

THE INCIDENCE OF SUBSEQUENT SURGERY AFTER OUTPATIENT ARTHROSCOPIC ROTATOR CUFF REPAIR

The purpose of this study was to quantify the incidence and risk factors associated with subsequent shoulder procedures in individuals undergoing outpatient ARCR. On the basis of existing literature,27-30 we hypothesized that age and the exis- tence of a Workers’ Compensation claim would be associated with the need for subsequent surgical procedures.
For this study, diagnoses and procedures were classified by Current Procedural Terminology (CPT), fourth edition, and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. The American Medical Association officially introduced CPT code 29827 for ARCR in 2003. We queried the database from 2003 through 2014 to identify all isolated ARCRs performed. Any patient with additional shoulder CPT codes at the time of initial RCR was excluded, with the exception of subacromial decompression (CPT code 29826).
They identified by this study1,920 unique patients who underwent ARCR between 2003 and 2012. Elimination of patients with concomitant CPT codes other than acromioplasty and those with evidence of prior ipsilateral shoulder procedures yielded the final sample of 30,430 patients.
Similar to previous studies, our study used International Classification of Diseases, Ninth Revision (ICD-9) codes of 305.1 and V15.62 to identify patients with a history of tobacco use.
Differences in categorical variables were evaluated with the Fisher exact test (when possible) or c2 analysis. Multivariate logistic regression that controlled for age, sex, insurance, tobacco use, and acromioplasty at the time of initial surgery was performed to determine independent risk factors for subsequent surgery. P < .05 was considered statistically significant. This study has been conducted by a method that provided to examine the New York Statewide Planning and Research Cooperative Systems outpatient database from 2003 through 2014 to identify patients undergoing isolated ARCR with or without concomitant acromioplasty. Patients were longitudinally followed up for a minimum of 2 years to determine the incidence of subsequent ipsilateral shoulder surgery. Finally resulted that, on 30,430 patients, a total of 1,826 patients (6%) underwent subsequent ipsilateral outpatient shoulder surgery a mean of 24.3+/-27.1months after the initial ARCR. Of patients who underwent repeat surgery, 57.3% underwent a revision cuff repair. Patients who underwent additional outpatient shoulder surgery were significantly younger (53.7 +/- 10.9 years v 56.8 +/- 11.5 years, P < .001). Tobacco use was associated with an increased rate of subsequent surgery (7.3% v 5.9%P=.044) and accelerated time to reoperation (16.9 months v 24.7 months, P<.001). Independent risk factors for subsequent ipsilateral surgery after initial ARCR were presence of a Workers’ Compensation claim (odds ratio, 2.11; 95% confidence interval, 1.89-2.36; P<.001) and initial ARCR without acromioplasty (odds ratio, 1.20; 95% confidence interval,1.89-2.36;P<.0001). Finally, they identified a 6.0% incidence of repeat ipsilateral surgery after isolated ARCR. Although reasons for reoperation are likely multifactorial, younger age, Workers’ Compensation claim, and absence of acromioplasty at the time of initial ARCR remained independent predictors of subsequent outpatient procedures, whereas a history of tobacco use was associated with accelerated time to subsequent surgery