Punch vs. Drill Tunnel Use for Anchor Tunnel Creation and Correlation With Post-operative Pain
Phase: NA
Conditions: Rotator Cuff Tears
Sponsor: Matt Smith

 
 
Punch vs. Drill  
 
Protocol version 3 – 2/24/2020 
 
 
 
Researcher and Protocol Identification: 
Title:   Punch vs. Drill tunnel use for anchor tunnel creation and correlation with post-operative 
pain 
 
1. Principal Investigator/Advisor 
Name: Matthew J. Smith, MD 
Job Title: Assistant Professor of Orthopaedic Surgery 
Department/Unit Name: University of Missouri Department of Orthopedics 
Office Address:  1100 Virginia Ave, Columbia, MO 65212 
Email: smithmj@health.missouri.edu  
2. Sub-Investigator 
Name: Chris Loftis, MD 
Job Title: Resident Physician, PGY-4 
Department/Unit Name: University of Missouri department of Orthopaedics 
Phone:  615-480-1777 
Email: loftisc@health.missouri.edu 
3. Sub-Investigator 
Name: James Cook, DVM, PhD 
Job Title: Chief, Orthopaedic Research Division 
Department/Unit Name: University of Missouri department of Orthopaedics 
Email: cookjl@health.missouri.edu  
4. Sub-Investigator 
Name: David Ajibade, MD 
Job Title: Sports Fellow 
Department/Unit Name: University of Missouri department of Orthopaedics 
Email: ajibaded@health.missouri.edu  
 
 
 
Objective:    
To determine if different techniques used in the creation of suture anchor socket creation can 
influence post-op pain following rotator cuff repair 
 
Hypothesis: 
We propose that the use of an arthroscopic drill for creation of anchor socket will result in less 
pain post-operatively when compared to the use of the punch. 
 
Clinical significance: 
Arthroscopic rotator cuff repair has become a mainstay of treatment for rotator cuff 
tears requiring surgical intervention and has been reported to decrease pain and increase 
function to levels similar to open approaches while requiring smaller incisions and less soft 

tissue disruption.3-5  Development of reliable and effective procedure-specific instrumentation, 
primarily in the form of suture anchor systems, has been a key reason for the successful 
progression in arthroscopic rotator cuff repair.1-3,5-7  
   
Even with advanced instrumentation, it has become evident that a subset of patients 
experience pain and functional limitations in the acute post-operative period.4,8,9  Studies have 
demonstrated that rotator cuff tear size does not correlate with post-operative pain in 
patients,10 and that pain scores may not be improved by using an arthroscopic repair versus an 
open repair.4,19  Austin et. al. observed that 56 patients having undergone rotator cuff repair for 
full thickness rotator cuff tears suffered sleep disturbances for up to 3 months after surgery.18  
The causes for increased post-operative pain in patients following rotator cuff repair remain 
poorly understood.  As such, all relevant variables, including technical components of the repair, 
should be critically evaluated in an effort to optimally address post-operative pain for patients.   
 
Because arthroscopic rotator cuff repair most commonly uses suture anchors inserted 
into proximal humeral bone to re-attach tendon(s), the authors sought to examine technical 
components of suture anchor insertion.  The sockets for insertion of suture anchors used in 
rotator cuff repair are made most often with use of a surgical punch that, in theory, corticates 
the socket to optimize anchor thread purchase and pull-out strength.  However, use of a punch 
may cause significant micro-trauma to proximal humeral bone as it fractures trabeculae to 
create the socket, as opposed to use of a drill bit which cuts and removes trabeculae to create 
the socket.  These fractures occurring as the result of stress-induced microtrauma to bone have 
a well-documented role in causing pain.11-14 These microfractures are also associated with bone 
marrow lesions seen on MRI.  Importantly, bone marrow lesions in the greater tuberosity have 
been reported to occur after arthroscopic rotator cuff repair using punch-socket suture anchors, 
and can remain present for 6 – 12 months.15-17 Taken together, these findings give credence to 
the theory that punch-induced microfractures may contribute to postoperative pain after 
arthroscopic rotator cuff repair. 
 
Study Design: 
- 
Randomized prospective cohort study. 
 
1. Inclusion criteria 
a. Patient’s aged 18-80 years old with diagnosis of rotator cuff tear having failed 
non-operative management and being indicated for surgical intervention with 
use of suture anchors. 
2. Exclusion criteria 
a. Glenohumeral arthrosis 
b. Previous shoulder surgery 
c. Psychiatric diseases 
d. Rheumatologic diseases 
e. Fibromyalgia 
f. Spine diseases 
 
- 
50 Patients will be randomized to have bone sockets formed with either a punch (25) or 
a drill (25) at the time of surgery. 
- 
Patients will follow up at their standard of care visits at 2 weeks, 6 weeks, 3 months, and 
6 months  
- 
PROMIS SF v2.0 – Physical Function 10a, PROMIS SF v1.0 – Pain Interference 6a, SANE, 
ASES, VAS scores will be collected at each visit for research purposes. 

- 
Patients will record their pain levels and number of pain pills they took for three days 
post-op for research purposes. 
- 
MRI of the shoulder of the first 5 patients in each group will be obtained at 2 weeks 
post-op for evaluation of bone marrow edema pattern in the proximal humerus for 
research purposes. 
 
 
Training in the policies protecting the rights and welfare of human subjects in 
research: 
All staff involved in this study has had IRB-approved training according to The University of 
Missouri Healthcare guidelines 
 
Publication of private information: 
Investigators intend to publish the results of this study without identifying the subjects; and 
every attempt will be made to follow strict confidentiality. The results of this research may 
appear in scientific publications without identifying the patients.  
 
Future contact with research patients: 
Research patients/caregivers may be contacted to participate in future research. 
 
Possible risks to research patients:  
Potential for loss of confidentiality.  Each patient will be assigned a random subject number. The 
key linking numbers to subjects will be locked away in the offices of University of Missouri, 
Missouri Orthopedic Institute.  All published information will be through de-identified subject 
numbers.  The key linking the patient and all identifiable personal information will be destroyed 
10 years post-study completion to allow for complete data analysis and use of data for 
publication writing. 
 
Patients will be randomized 1:1 into either the punch or drill. The surgeon does not 
determine the procedure; there is always the potential risk that the other procedure may 
result in more post-op pain. 
 
Possible benefits:  
Research patients enrolled in the study will not benefit directly from this study itself; however, 
information gained from this study could benefit patients being treated in the future. 
Specifically it may help determine a new standard of care for patients with upper extremity 
injuries with resultant hand stiffness. 
 
Costs to subjects: 
No costs will be incurred by the subjects above and beyond the standard medical practice. 
 
References: 
 
1.  Fineberg M,Wind W, Stoeckl A, Smolinski R: Current practices and opinions in 
shoulder surgery: Results of a survey of members of the American Orthopaedic 
Society for Sports Medicine and the Arthroscopy Association of North America. 

22nd Annual Meeting Abstracts of Podium Presentations. Phoenix, AZ: 
Arthroscopy Association of North America, 2003, p 19. 
2. Abrams JS, Savoie FH III: Arthroscopic rotator cuff repair: Is it the new gold 
standard? 72nd Annual Meeting Proceedings. Rosemont, IL: American Academy 
of Orthopaedic Surgeons,2005, p 71. 
3. Lafosse L, Brozska R, Toussaint B, Gobezie R. The outcome and structural 
integrity of arthroscopic rotator cuff repair with use of the double-row suture 
anchor technique. J Bone Joint Surg Am 2007;89:1533-41. 
4. Pham TT, Bayle Iniguez X, Mansat P, Maubisson L, Bonnevialle N. 
Postoperative pain after arthroscopic versus open rotator cuff repair. A 
prospective study. Orthop Traumatol Surg Res 2016;102:13-7. 
5. Sugaya H, Maeda K, Matsuki K, Moriishi J. Repair integrity and functional 
outcome after arthroscopic double-row rotator cuff repair. A prospective outcome 
study. J Bone Joint Surg Am 2007;89:953-60. 
6. Goldberg JA, Chan KY, Best JP, Bruce WJ, Walsh W, Parry W. Surgical 
management of large rotator cuff tears combined with instability in elite rugby 
football players. Br J Sports Med. 2003;37:179–181; discussion 181. 
7. Burkhart SS, Lo IKY.  Arthroscopic rotator cuff repair. Journal of the American 
Academy of Orthopedic Surgeons.  2006:14:333-346. 
8. Cho CH, Song KS, Hwang I,Warner JJ. Does rotator cuff repair improve 
psychologic status and quality of life in patients with rotator cuff tear? Clin 
Orthop Relat Res 2015;473:3494-500. http://dx.doi.org/10.1007/s11999-015-
4258-1 
9. Potter MQ, Wylie JD, Granger EK, Greis PE, Burks RT, Tashjian RZ. One-year 
patient-reported outcomes after arthroscopic rotator cuff repair do not correlate 
with mild to moderate psychological distress. Clin Orthop Relat Res 
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10. Dunn WR, Kuhn JE, Sanders R, An Q, Baumgarten KM, Bishop JY, et al. 
Symptoms of pain do not correlate with rotator cuff tear severity: a cross-sectional 
study of 393 patients with a symptomatic atraumatic full-thickness rotator cuff 
tear. J Bone Joint Surg Am 2014;96:793-800. 
http://dx.doi.org/10.2106/JBJS.L.01304 
11. Kehanov L, Eberman LE, Games KE, Wasik M.  Diagnosis, treatment, and 
rehabilitation of stress fractures in lower extremity runners.  Journal of Sports 
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12. McCormick F, Nwachukwu BU, Provencher MT. Stress fractures in runners. Clin 
Sports Med. 2012;31(2):291–306. 
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14. Astur DC, Zanatta F, Arliani GG, Moraes ER, Pochini AC, Ejnisman B.  Stress 
fractures: definition, diagnosis, and treatment.  Revista Brasileira de Ortopedia.  
2016; 51(1):3-10. 
15. McCauley TR, Disler DG, Tam MK.  Bone marrow edema in the greater 
tuberosity of the humerus at MR imaging: association with rotator cuff tears and 
traumatic injury.  Magnetic Resonance Imaging.  2000;18(8):979-984. 

16. A.D. Vellet, P.H. Marks, P.J. Fowler, T.G. Munro. Occult posttraumatic 
osteochondral lesions of the knee: prevalence, classification, and short-term 
sequelae evaluated with MR imaging. Radiology, 178 (1) (1991), pp. 271-276 
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repair.  Arthroscopy 2005; 21:1090-8