The rate of medical visits for rotator cuff pathology and the US incidence of arthroscopic rotator cuff repair (RCR) have increased over the past 10 years.1 The increased use of RCR has been justified with improved patient outcomes.2,3 Advances in surgical techniques and instrumentation have contributed to better outcomes for patients with rotator cuff pathology.3-5 Several studies have validated RCR with functional outcome measures, cost–benefit analysis, and health-related quality-of-life measurements.6-9
Healthcare reimbursement models are being changed to include capitated care, pay for performance, and penalties.10 Given the changing healthcare climate and the increasing incidence of RCR, it is becoming increasingly important for orthopedic surgeons to critically evaluate and modify their practice and procedures to decrease costs without compromising outcomes.11 RCR outcome studies have focused on comparing open/mini-open with arthroscopic techniques, and single-row with double-row techniques, among others.4,12-18 Furthermore, several studies on the cost-effectiveness of these surgical techniques have been conducted.19-21Arthroscopic anchorless (transosseous [TO]) RCR, which is increasingly popular,22 combines the minimal invasiveness of arthroscopic procedures with the biomechanical strength of open TO repair. In addition, this technique avoids the potential complications and costs associated with suture anchors, such as anchor pullout and greater tuberosity osteolysis.22,23 Several studies have documented the effectiveness of this technique.24-26 Biomechanical and clinical outcome data supporting arthroscopic TO-RCR have been published, but there are no reports of studies that have analyzed the cost savings associated with this technique.
In this study, we compared implant costs associated with arthroscopic TO-RCR and arthroscopic TO-equivalent (TOE) RCR. We also evaluated these techniques’ operative time and outcomes. Our hypothesis was that arthroscopic TO-RCR can be performed at lower cost and without increasing operative time or compromising outcomes.
Materials and Methods
Our Institutional Review Board approved this study. Between February 2013 and January 2014, participating surgeons performed 43 arthroscopic TO-RCRs that met the study’s inclusion criteria. Twenty-one of the 43 patients enrolled and became the study group. The control group of 21 patients, who underwent arthroscopic TOE-RCR the preceding year (between January 2012 and January 2013), was matched to the study group on tear size and concomitant procedures, including biceps treatment, labral treatment, acromioplasty, and distal clavicle excision (Table 1).
The primary outcome measure was implant cost (amount paid by institution). Cost was determined and reported by an independent third party using Cerner Surginet as the operating room documentation system and McKessen Pathways Materials Management System for item pricing.
All arthroscopic RCRs were performed by 1 of 3 orthopedic surgeons fellowship-trained in either sports medicine or shoulder and elbow surgery. Using the Cofield classification,27 the treating surgeon recorded the size of the rotator cuff tear: small (<1 cm), medium (1-3 cm), large (3-5 cm), massive (>5 cm). The surgeon also recorded the number of suture anchors used, repair technique, biceps treatment, execution of subacromial decompression, execution of distal clavicle excision, and intraoperative complications. TO repair surgical technique is described in the next section. TOE repair was double-row repair with suture anchors. The number of suture anchors varied by tear size: small (3 anchors), medium (2-5 anchors), large (4-6 anchors), massive (4-5 anchors).
Secondary outcome measures were operative time (time from cut to close) and scores on pain VAS (visual analog scale), SANE (Single Assessment Numeric Evaluation), and SST (Simple Shoulder Test). Demographic information was also obtained: age, sex, body mass index, smoking status (Table 1). All patients were asked to fill out questionnaires before surgery and 3, 6, and >12 months after surgery. Outcome surveys were scored by a single research coordinator, who recorded each patient’s outcome scores at the preoperative and postoperative intervals. Follow-up of >12 months was reached by 17 (81%) of the 21 TO patients and 14 (67%) of the 21 TOE patients. For >12 months, the overall rate of follow-up was 74%.
All patients followed the same postoperative rehabilitation protocol: sling immobilization with pendulums for 6 weeks starting at 2 weeks, passive range of motion starting at 6 weeks, and active range of motion starting at 8 weeks. At 3 months, they were allowed progressive resistant exercises with a 10-pound limit, and at 4.5 months they progressed to a 20-pound limit. At 6 months, they were cleared for discharge.