After the Honeymoon

Soon after we were married, my wife and I realized that our biological clocks were set in widely disparate time zones. I would awaken before sunrise, fumble in the darkness for appropriate clothing, and then tiptoe into the kitchen of our small apartment to assemble a cold breakfast before quietly slipping off to the hospital. I knew that Trish would be climbing out of bed a few hours later, just in time to catch a bus to the Chicago Loop. After work, I usually managed to keep my eyes open through dinner before sleep overwhelmed me. Trish, of course, would be wide awake for several more hours. My mind occasionally rose to a level of marginal consciousness when she crawled into bed beside me. After a few months of this routine, we realized that we would need to find a common pathway if our waking time together was to amount to more than dinner table conversation. The honeymoon was over. After ignoring all difficulties like typical newlyweds, we would have to confront and resolve them if our marriage were to last. As orthopaedic surgeons, our torrid love affair with arthroscopic rotator cuff repair began in a flurry of passion. After a sedate long-term commitment to open repair methods, we were swept away by a seductive new technique that appealed to both sides of our brains. Intellectually, the advantage of repairing a deep structure with minimal disruption of overlying tissues made perfect sense. Functionally, we saw that patients seemed to have less postoperative pain and were therefore more inclined to resume early use of the limb. Economically, we felt that the potential savings of a reliable outpatient procedure would more than offset the possible cost of additional anchoring devices. Finally, arthroscopic cuff repair was fun and, frankly, sexy. Eventually, we were shaken out of our reverie. For many of us, the report of Galatz et al was the wake-up call. As appealing as they were to both patients and surgeons, arthroscopic repair techniques were not failure-proof. In fact, beneath the surface beauty of their apparent success might lurk the monster of anatomical failure waiting to make its clinical presence known. Our honeymoon with arthroscopic rotator cuff repair was over. Although we became aware that this new technique did have its limitations, we did not abandon it. We were committed to our relationship with arthroscopic cuff repair and sought ways to make it more successful. Like dutiful spouses, we looked for means to improve our outcomes. Some surgeons modified their rehabilitation protocols, while others began seeking biological methods to enhance healing. Many investigated ways to make the insertional footprint of the repaired tendon more anatomic. When orthopaedic surgeons experience difficulties in their relationship with a surgical procedure, professional counseling is often sought from laboratory researchers. Apreleva et al had noted in 2002 that passing simple sutures through transosseous tunnels, one of the methods used in open-cuff repair, came closer to restoring the anatomic insertion of the rotator cuff than single-row suture anchor techniques. Lo and Burkhart suggested that a double row of anchors would allow the same goal to be accomplished arthroscopically. A torrent of research ensued that examined the surface area and pressure distribution of a number of double-row and other “transosseous equivalent” techniques. While the outcomes of these studies have been promising, they have only hinted at what we really wanted to know: whether double-row techniques would produce better clinical results. Two reports that appear in the current issue of AJSM provide some of the best evidence to date on the clinical success of the double-row techniques recommended by these “professional counselors. ” These articles were submitted about 6 weeks apart. They are similar prospective, controlled studies that compare the 2-year results of singleand double-row arthroscopic rotator cuff repair using clinical scoring scales and contrast imaging. “Can a Double-Row Anchorage Technique Improve Tendon Healing in Arthroscopic Rotator Cuff Repair? ” by Charousset et al was the first to arrive. These authors repaired the rotator cuffs of 35 patients with simple sutures attached to laterally placed anchors. In 31 other patients, the lateral sutures were supplemented by Cuff Tacks placed through the tendon more medially. As an illustration of one of the potential difficulties of conducting a randomized controlled trial, this study started out with a randomized design that had to be altered when the Cuff Tack was withdrawn from the market. Constant scores and subjective ratings assessed 2 years after the surgery were largely excellent and similar in both groups. Objective healing was evaluated by CT arthrography 6 months after surgery. These imaging studies showed watertight healing in 77% of the double-row repairs and 60% of the single-row repairs. Although the disparity between these values did not attain statistical significance, the difference in complete anatomic healing (61% vs. 40%) was significant. In “Equivalent Clinical Results of Arthroscopic SingleRow and Double-Row Suture Anchor Repair for Rotator Cuff Tears,” Franceschi et al randomized 60 patients equally between single-row repair and a double-row method designed to emulate the technique of Lo and Burkhart. These authors assessed their results about 2 years after surgery with the UCLA score and magnetic resonance imaging arthrography. Clinically, both groups improved postoperatively to UCLA scores of about 33. Imaging of the single-row group revealed 14 cases of complete healing, 10 of partial healing, and 2 full-thickness defects, while the DOI = 10.177/0363546503262911