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Volume:5 Issue:1 Number:1 ISSN#:2563-559X
OE Original

Arthroscopic Versus Mini-open or Open Repair for Rotator Cuff Tear: Powered by OE M.I.N.D.

Authored By: OrthoEvidnece (Yaping Chang, Steve Philips, Meng Zhu, Aiden Scholey, Mohit Bhandari)

Guest Contributor: Moin Khan, MD., MSc., FRCSC, Dip. Sport Med

January 10, 2022

How to Cite

OrthoEvidence. Arthroscopic Versus Mini-open or Open Repair for Rotator Cuff Tear: Powered by OE M.I.N.D.. OE Original. 2022;5(1):1. Available from: https://myorthoevidence.com/Blog/Show/164






"Rotator cuff pathology is a leading cause of shoulder pain and is associated with significant functional limitations. Rotator cuff repair - performed via open or arthroscopic means results in substantial improvements to patients’ quality of life and function. Arthroscopic repair techniques are now commonplace and current best available evidence supports equivalent or better outcomes when compared to earlier more invasive approaches."



-- Dr. Moin Khan MD., MSc., FRCSC, Dip. Sport Med  --



HIGHLIGHTS


  • - With the updated search by December 30, 2021, OE M.I.N.D. contains data from 751 RCTs related to shoulder conditions with over 121,000 patients.

  • - For patients with rotator cuff tears, there was no significant difference between arthroscopic and mini-open/open repair in operative time.

  • - All-arthroscopic repair was associated with a small benefit in function compared to mini-open/open repair at 6 weeks, 3 months and 12 months follow-up. No significant difference between the two techniques was found in function at 6 months, or beyond 1 year follow-up.

  • - All-arthroscopic repair was associated with less pain compared to mini-open/open repair at 6 weeks, 3 months, 6 months and 12 months follow-up. Mini-open/open repair was associated with less pain when compared to all-arthroscopic technique beyond 1 year follow-up.

  • - There was no significant difference between all-arthroscopic and mini-open/open repair techniques in incidence of retear and adverse events.

  • - Both arthroscopic and mini-open repairs appear to be safe for treatment of rotator cuff tears. No serious adverse events were reported post surgery.

  • - In terms of surgical repair for rotator cuff tears, a total of 19 studies were found to be currently ongoing, aiming to recruit 702 patients from 31 sites based on data from clinicaltrials.gov.




Rotator cuff tear is a common condition due to overuse or injury. Over 20% of people have suffered rotator cuff tears and over 30% of those who present with shoulder dysfunction and pain may be diagnosed with a rotator cuff tear (Yamamoto et al., 2010). With the aim of getting the tendon to heal, surgical repair, by re-attaching the tendon to the bone, is often a necessary intervention for full-thickness rotator cuff tears and demonstrates improvements in patient function, pain and physical performance (Nazari et al., 2019; Sakha et al., 2021).


Arthroscopic, or mini-open / open repair are options for the management of rotator cuff tears. All-arthroscopic techniques begin with an arthroscopic examination of glenohumeral joint and subacromial bursectomy or decompression (removal of damaged tissue, bone spurs, part of the bursa, or other structures). In mini-open surgery, an initial arthroscopic examination maybe performed followed by a deltoid split to expose the rotator cuff tear. In all-arthroscopic techniques, the complete repair is performed using an arthroscope and small skin incisions which are generally less than 1 cm in length (Ghodadra et al., 2009). Depending on surgeons’ preference, open repair is sometimes applied for a rotator cuff tear. The surgical incision is several centimeters long and the deltoid might be detached to gain visualization and access to the torn tendon (Ghodadra et al., 2009; MedlinePlus, 2021).


As minimally invasive surgery has become more widespread and surgeons are trained in arthroscopic techniques, arthroscopic rotator cuff repair is more frequently performed than ever, for example, over 270,000 such procedures are done annually in the United States (Jain et al., 2014). Minimally invasive procedures are increasingly favored by surgeons due to quicker postoperative recovery, decreased pain and improved cosmetic appearance when compared to mini-open or open procedures (Nazari et al., 2019). On the other hand, all-arthroscopic techniques may be associated with higher surgical cost and require higher technical skill of the surgeons (Ghodadra et al., 2009; Nazari et al., 2019). If required, arthroscopic approaches can be converted to a mini-open technique during the procedure if difficulty arises due to issues such as poor tissue quality, difficulty with visualization or certain technical failures (MacDermid et al., 2021).


Most importantly, evidence from patient studies is required to facilitate clinical application of repair techniques. In this OE Original, we present analytics using OE M.I.N.D. that include a scoping review of published studies, meta-analysis results and quality of evidence, cumulative evidence synthesized by time, a profile of ongoing trials, and market analytic features for arthroscopic versus mini-open/open repair for rotator cuff tears. All of the data were extracted from randomized controlled trials (RCTs) by experienced medical literature reviewers. OE M.I.N.D. updates the data on a daily basis, with new trials and data being constantly added. The results in this OE Original were based on analyses performed on December 30, 2021.






1. OE M.I.N.D. Meta Analyzer --- Overview of the available evidence


Nearly 121,000 patients across 751 studies were reported for shoulder conditions. There are 160 treatments that were studied for rotator cuff tears, and 57 outcome measures were reported evaluating effectiveness and adverse events of arthroscopic rotator cuff repair compared to open rotator cuff repair (Figure 1).


Figure 1. Summary of research topic according to anatomical region, condition and treatment




 


2. OE M.I.N.D. Meta Analyzer --- Effectiveness of treatments


We identified 8 RCTs comparing the effectiveness of arthroscopic (i.e., all-arthroscopic) versus mini-open/open techniques for patients with rotator cuff tears. Of them, mini-open repair was performed in 7 studies (Cho et al., 2012; Kasten et al., 2011; Liu et al., 2017; MacDermid et al., 2021; Mardani-Kivi et al., 2019; van der Zwaal et al., 2013; Zhang et al., 2014) and open repair was performed in 1 study which was the earliest published study included in the current research topic (Shinoda et al., 2009).


Two RCTs followed up patients up to 6 months (Cho et al., 2012; Kasten et al., 2011) and all the rest of the included studies followed up patients for at least 1 year. The longest follow-up among these studies was a median of 34 months (Shinoda et al., 2009). The characteristics of the RCTs included in meta-analysis are presented in Table 1.



Table 1. Characteristics of RCTs included in meta-analysis

Author, Year

Country

Number of patients

Patients


All-arthroscopic repair

Mini-open/Open repair

Cho et al., 2012

South Korea

60

Supraspinatus tear (< 3 cm): 9 (15%) had a partial tear, 17 (28%) had a small-, and 34 (57%) had a medium-sized tear.


Either single-row or double-row repair technique with suture anchors to attach the supraspinatus to the greater tuberosity.

Mini-open. Through a 3-to 4-cm skin incision, a dissection was made to the raphe between the anterior and middle deltoid. After preparing the footprint using a ring curette or rasp, the torn tendon was repaired using either single-row or double-row repair technique with suture anchors.

Kasten et al., 2011

Germany

34

Isolated rupture of the supraspinatus tendon (mean tear size 2.6 cm)


One or two medial anchors with the sutures passed through the tendon about 2.5 cm medial of the tear edge in a mattress configuration. One lateral anchor with the sutures passed through the tendon in a lasso-loop; single-stitch configuration about 1 cm medial of the edge.

Mini-open. Through an anterolateral deltoid split, sutures were passed through the tendon in a Mason-Allen configuration about 2.5 cm medial of the tear edge. The sutures were passed from the medial part of the footprint to about 2.5 cm distal of the lateral edge of the footprint.

Liu et al., 2017

China

100

Supraspinatus and/or infraspinatus tendon tear with stage <3 fatty muscle infiltration


Either single-row or double-row repair technique with suture anchors to attach the supraspinatus to the greater tuberosity.

Mini-open. Through a 5-cm lateral incision, the deltoid muscle fibers were split by blunt dissection. Partial bursectomy was performed. The torn tendon was repaired using either single-row or double-row repair technique with suture anchors.

MacDermid et al., 2021

Canada

274

Small or medium rotator cuff tears


Anchors were placed; mattress or simple braided sutures were passed through the torn tendon. Side-to-side sutures were used at the apex of the tears.

Mini-open. A transverse or vertical incision and dissection of the deltoid fascia were made. The deltoid was split from the level of the acromion distally for 4 cm. The bone between the articular margin and the greater tuberosity was decorticated. Suture anchors or transosseous sutures were used along with side-to-side sutures.

Mardani-Kivi et al., 2019

Iran

60

Large or massive rotator cuff tears (> 3 cm). Had no evidence of extensive fatty infiltration in ruptured rotator cuff muscles.


All-arthroscopic repair with a suture anchor.

Mini-open. Through a 2-cm incision distal to the pectoral major muscle, after crossing the guidewire, the biceps tendon was tenodesed to the bicipital groove using an interference screw of appropriate size.

Shinoda et al., 2009

Japan

32

Rotator cuff tears: 11 (34%) had a small-, 9 (28%) had a medium-, 8 (25%) had a large-, and 4 (13%) had a massive-sized tear.


Two or four suture anchors were used to attach the rotator cuff to the footprint on the greater tuberosity, or the humeral head.

Open repair. Through a 7-cm incision, a small part of the anterior fiber of the deltoid was detached from the anterior acromion and split between the anterior and middle fibers of the deltoid. The same suture anchors and procedures as the all-arthroscopic group were applied.

van der Zwaal et al., 2013

Netherlands

100

Small to medium-sized full-thickness supraspinatus and/or infraspinatus tendon tear with stage <3 fatty muscle infiltration


Two to four medial anchors and one lateral anchor were used to secure the tendons.

Mini-open. Through a 5-cm lateral incision, the deltoid muscle fibers were split by blunt dissection. Partial bursectomy was performed. The same procedures as the all-arthroscopic group were applied.

Zhang et al., 2014

China

108

Rotator cuff tears (> 1 cm): 65 (60%) had a partial-, and 43 (40%) had a full-thickness tear


One to three suture anchors were placed along the lateral part of the footprint. The tendon was repaired via a modified Mason-Allen technique.

Mini-open. Through a 3–5 cm incision parallel to the deltoid fibers, the same suture anchors and procedures as the all-arthroscopic group were applied.


We are presenting the meta-analysis results of operative time, incidence of retear and adverse events at the longest follow-up, as well as function and pain within five time frames of follow-up: up to 6 weeks, 6 weeks to 3 months, 3 to 6 months, 6 to 12 months, and beyond 1 year post surgery. The 1 RCT (Shinoda et al., 2009) that compared arthroscopic and open repair reported outcomes of operative time and function beyond 1 year of follow-up, and we are also presenting results of the subgroup analysis by mini-open or open repair in comparison with arthroscopic repair in those two outcomes accordingly.





2.1 Operative time


In the comparison of arthroscopic versus mini-open/open rotator cuff repair for the outcome of operative time, a total of 192 patients from 3 studies published between 2009 to 2017 are included in the analysis. Two studies favour mini-open/open repair and 1 study shows no difference between the two techniques. The overall effect shows no significant difference in operative time between arthroscopic and mini-open/open repairs. The certainty of the evidence by GRADE assessment was rated as very low due to serious risk of bias, inconsistency and imprecision (Figure 2).


Figure 2. Forest plot of operative time

 Notes: ROB = risk of bias; red circle with a cross mark = high risk of bias.




2.2 Function (0 to 100, a higher score indicates better recovery)


All the included studies reported one or more of the following functional outcomes: American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), Constant Shoulder Score, UCLA Shoulder Rating Scale, Disability of Arm and Shoulder (DASH) score, and Japanese Orthopedic Association (JOA) score. We normalized these function measures on a 0 to 100 scale and meta-analyzed the values to assess patient recovery (Velentgas et al., 2013).


In the comparison of arthroscopic versus mini-open rotator cuff repair for the outcome of function within 6 weeks of follow-up, a total of 474 patients from 3 studies published between 2013 and 2021 are included in the analysis. The overall effect demonstrates that arthroscopic repair results in a significant improvement in function with patients experiencing, on average, a 5.57 [95% CI, 5.23 to 5.92] point improvement. The effect and 95% CI did not exceed the recommended minimally important difference (MID) of 8.3 points on the 0 to 100 Constant score (Hao et al., 2019). The certainty of the evidence was rated as very low due to serious risk of bias, inconsistency and imprecision (Figure 3a).


During 6 weeks to 3 months of follow-up, a total of 508 patients from 4 studies published between 2011 and 2021 were included in analysis. The overall effect demonstrates that arthroscopic repair results in a significant improvement with patients experiencing, on average, a 1.24 (95% CI, 0.89 to 1.58) point improvement. During 6 to 12 months of follow-up, the overall effect of 474 patients from 3 studies published between 2013 and 2021 demonstrates that arthroscopic repair results in a significant improvement with patients experiencing, on average, a 1.51 (95% CI, 1.2 to 1.81) point improvement. The effect and 95% CI during both periods of follow-up did not exceed the MID. The certainty of the evidence was rated as very low (Figure 3a).


In the comparison of arthroscopic versus mini-open repair for function during 3 to 6 months, and after 1 year, there is no significant difference between the arthroscopic and mini-open/open techniques, with very low certainty of evidence (Figures 3a, 3b).


The subgroup analysis by mini-open or open repair beyond 1 year of follow-up showed no significant difference between the two groups (the 95% CIs of mean difference include the “No effect” threshold of 0) (Figure 3b).


Figure 3a. Forest plot of function on a 0-100 scale

(Arthroscopic vs. mini-open repair, up to 12 months’ follow-up)

Notes: MID = minimally important difference; ROB = risk of bias; red circle with a cross mark = high risk of bias; yellow circle with an exclamation mark = have some concerns.





Figure 3b. Forest plot of function on a 0-100 scale (Arthroscopic vs. mini-open repair, arthroscopic vs. open repair, all studies; > 1 year’s follow-up)


Notes: ROB = risk of bias; red circle with a cross mark = high risk of bias; yellow circle with an exclamation mark = have some concerns.




2.3 Pain score (0 to 100, a higher score indicates worse pain)


Six studies including 637 patients reported visual analogue scale (VAS) pain or Shoulder Pain and Disability Index (SPADI) pain at several follow-up times. The MID of VAS pain score in patients with shoulder conditions is described as 1.5 points on the 0 to 10 scale, i.e., 15 points on a 0 to 100 scale after conversion (Hao et al., 2019).


In the comparison of arthroscopic versus mini-open repair for pain, the overall effect demonstrates that arthroscopic repair results in a significant reduction in pain in the four follow-up periods: at 6 weeks [568 patients from 5 studies; mean difference (MD), -5.38; 95% CI, -5.84 to -4.92), 6 weeks to 3 months (568 patients from 5 studies; MD, -1.79; 95% CI, -2.21 to -1.37), and 3 to 6 months (603 patients from 5 studies; MD, -0.62; 95% CI, -0.99 to -0.24), and 6 to 12 months (474 patients from 3 studies; MD, -0.1; 95% CI, -1.33 to -0.67). Nevertheless, these effects and 95% CIs did not exceed the MID of 15 points on the 0 to 100 pain VAS. We rated the certainty of evidence as very low (Figure 4).


Beyond 1 year of follow-up, the overall effect demonstrates that mini-open repair results in a significant reduction in pain (343 patients from 2 studies; MD, 2.1; 95% CI, 1.77 to 2.43). The effect and 95% CI did not exceed the MID of 15 points on the 0 to 100 pain VAS. We rated the certainty of evidence as low due to risk of bias and imprecision (Figure 4).


Figure 4. Forest plot of pain on 0-100 score

Notes: MID = minimally important difference; ROB = risk of bias; red circle with a cross mark = high risk of bias; yellow circle with an exclamation mark = have

some concerns.




2.4 Incidence of retear


In the comparison of arthroscopic versus mini-open rotator cuff repair for the outcome of retear at the longest follow-up, a total of 359 patients from 4 studies published between 2011 to 2017 are included in the analysis. All 4 studies show no difference between the two techniques. The overall effect demonstrates that there is no significant difference between arthroscopic and mini-open repair [relative risk (RR), 1.04; 95% CI, 0.76 to 1.41], with low certainty of evidence (Figure 5).


Figure 5. Forest plot of incidence of retear

Notes: ROB = risk of bias; red circle with a cross mark = high risk of bias; yellow circle with an exclamation mark = have some concerns.





2.5 Incidence of adverse events


In the comparison of arthroscopic versus mini-open rotator cuff repair for the outcome of adverse events (general complications) at the longest follow-up, a total of 659 patients from 5 studies published between 2012 to 2021 are included in the analysis. Two studies reported no treatment-related adverse events in either group (Cho et al., 2012; Zhang et al., 2014). Three studies reported adverse events including adhesive capsulitis, biceps tendinopathy, wound infection, anchor pullout and retained suture material (Liu et al., 2017; MacDermid et al., 2021; van der Zwaal et al., 2013). The overall effect shows no significant difference in adverse events between arthroscopic and mini-open repairs for all the studies (RR, 0.77; 95% CI, 0.38 to 1.54), with low certainty of evidence (Figure 6).


Figure 6. Forest plot of adverse events

Notes: ROB = risk of bias; red circle with a cross mark = high risk of bias; yellow circle with an exclamation mark = have some concerns.






We present a summary of the five outcome measures at the longest follow-up in Table 2.


Table 2. Summary and certainty of the evidence


Outcome

=< 6 weeks

> 6 weeks to 3 months

> 3 to 6 months

> 6 to 12 months

> 1 year to 3 years

Operative time

No difference^

Function

Favours arthroscopic repair^

Favours arthroscopic repair^

No difference^

Favours arthroscopic repair^

No difference^

Pain*

Favours arthroscopic repair^

Favours arthroscopic repair^

Favours arthroscopic repair^

Favours arthroscopic repair^

Favours mini-open repair^^

Retear*

No difference^^

Adverse events*

No difference^^


Notes: ^ Very low certainty evidence; ^^ Low certainty evidence; * For the outcomes of pain, retear and adverse events, only studies comparing arthroscopic versus mini-open repair were available for the meta-analysis results.





3. OE M.I.N.D. Forecaster --- Sequential meta-analysis


The trends in treatment effects over time show that, when new RCTs are reported and more patients are included in the analysis, precision of effects increases for all the outcomes at their longest follow-up (narrower 95% CI over time) (Figures 7,8).


Figure 7 shows that starting with the first reported study published in 2009, operative time of open rotator cuff repair was significantly shorter than that of arthroscopic repair and over time up to 2017, the overall effect demonstrated no significant difference in operative time between the arthroscopic and mini-open/open techniques (Figure 7).


For both function and pain, there was no significant difference between arthroscopic and mini-open repairs in the first few years with evidence from the published trials. The overall effects were in favour of arthroscopic repair after 2012 and have been moving toward the “No effect” threshold. Throughout all the publication years, when a statistical significance between the two techniques was demonstrated, the effect had never exceeded the MID (Figure 7).





Figure 7. Sequential meta-analysis result for operative time, function and pain





There is no significant difference between arthroscopic and mini-open repairs in terms of incidence of retear and this finding has remained consistent since 2011 (Figure 8).




Figure 8. Sequential meta-analysis result for incidence of retear





4. OE M.I.N.D Ongoing trials report


In terms of surgical repair for rotator cuff tear, a total of 19 studies were found to be currently ongoing around the world, aiming to recruit 702 patients from 31 sites. Twelve sponsors supported one or more studies. Eight ongoing studies (42.1%) are being conducted in Canada. Approximately half of them (10 of the 19 studies, 52.6%) are observational studies and nine (47.4%) are interventional studies (Figure 9).


Figure 9. Ongoing trials of rotator cuff repairs








5. OE M.I.N.D. Research Planning Tool


The OE M.I.N.D. Research Planning Tool provides us with an overview of characteristics of prior RCTs. For studies investigating effects of surgical repair for rotator cuff tears, the most frequently reported characteristics include: patient demographics, age (97.0% studies reported age); follow-up time point, 12 months (64.2% studies reported outcomes at 12 months’ follow-up); studies conducted at a single center (86.6%); Constant Shoulder Score (64.2%); and the country, Canada (16.4%) (Figure 10).


Figure 10. The most frequently reported characteristics of studies investigating effects of surgical repair for rotator cuff tears








6. OE MIND Academic Market Analysis --- Top Sponsors


For investigating effects of surgical treatment for rotator cuff tears, we found that since 2006, the manufacturers that have published the most research are Arthrex (N of studies=53), Smith & Nephew (N=24), ConMed (N=20), DePuy Synthes (N=14) and Mitek (N=12) (Figure 11).


The manufacturers with the largest cumulative sample size are Arthrex (N of patients=2,016), ConMed (N=809), Smith & Nephew (N=765), DePuy Synthes (N=501) and Mitek (N=323) (Figure 11).


Figure 11. Manufacturers with most research on surgical treatment for rotator cuff tears






Discussion


In this OE Original, we identified 8 RCTs that compared the efficacy of arthroscopic versus mini-open (7 RCTs) or open repair (1 RCT) for patients with rotator cuff tears. In our meta-analysis, no significant difference was found between arthroscopic and mini-open/open repairs in operative time.


Very low quality of evidence showed that arthroscopic repair was superior to mini-open/open repair in functional outcome (ASES, Constant Shoulder Score, UCLA Shoulder Rating Scale, DASH or JOA score) at shorter-term follow-ups of 6 weeks and 3 months, and during 6 to 12 months. These statistical differences and 95% CI did not exceed the recommended MID (Hao et al., 2019). There was no statistically significant difference between arthroscopic and mini-open/open repair techniques in function during 3 to 6 months and longer-term follow-up beyond 1 year.


Very low quality of evidence showed that arthroscopic repair was associated with less pain compared to mini-open/open repair at 6 weeks, 3 months, 6 months and 12 months’ follow-up. The 95% CI of the effect size (between-group difference) at all of the follow-up times did not exceed the recommended MID (Hao et al., 2019).


There was no difference between arthroscopic and mini-open/open repair in incidence of retear at the longest follow-up. No serious postoperative adverse events were reported after arthroscopic or mini-open/open rotator cuff repair in all the eligible RCTs.


Previously published systematic reviews of both RCTs and observational studies investigating effects of all-arthroscopic versus mini-open rotator cuff repair showed similar outcomes (Huang et al., 2016, NazariI et al., 2019). Although one surgical technique showed benefits over another in some outcomes at some follow-up times, the difference between the two techniques is too small to be clinically important for improvement in function, pain and physical performance (Sakha et al., 2021; NazariI et al., 2019). By and large, the findings in this OE Original are consistent with such results.


It would be valuable if we could investigate whether a subgroup effect exists by different severities of rotator cuff tear. However, we did not find sufficiently available data from the included RCTs to conduct such a subgroup meta-analysis. Our concerns during the evidence quality assessment included issues of imprecision, inconsistency and risk of bias. We rated down one level of GRADE assessment for imprecision regarding all the analyzed outcomes. Although the CIs of the function and pain outcome for meta-analysis of arthroscopic versus mini-open repair at some follow-up times excluded the no effect line, their CIs crossed the recommended MID values and clinical decisions would differ if the upper boundary versus the lower boundary of the CIs represented the true effect, for patients to achieve a minimally important improvement (Guyatt et al., 2011a). We rated down one level of GRADE quality of assessment for inconsistency for outcomes when the values of I2 were greater than 40% (Guyatt et al., 2011b). For all the outcomes, we also rated down one level of GRADE assessment for serious risk of bias due to lack of blinding to investigators and participants (Guyatt et al., 2011c).


Some studies reported that all-arthroscopic repair was associated with higher surgical costs compared to the mini-open technique (Liu et al., 2017; NazariI et al., 2019). There is a possibility that compared to the patients who receive mini-open or open repair, patients undergoing arthroscopic repair have less pain during their earlier recovery period post surgery, may return to work sooner, thus may reduce the disease-related costs. Patients may be less reluctant to start a post-operative rehabilitation program because of less pain in shorter-term follow-up (which is also a finding of our meta-analysis) so that the shoulder function might recover sooner (Liu et al., 2017). We are not able to perform a cost-effectiveness evaluation in this OE Original because of the lacking of relevant data in the included studies. Such findings will be valuable for policy-making and patient’s decision making.


Additional future research with larger sample sizes and with longer follow-up is needed to comprehensively evaluate the clinical outcomes and by subgroups of different severities of tear, and verify the findings of the current meta-analysis results.





Bottom line


Meta-analysis of 8 RCTs showed that for patients with rotator cuff tears, no significant difference was found between arthroscopic and mini-open/open repair in operative time. Arthroscopic repair was associated with a small benefit in function and pain when compared to mini-open/open technique at 6 weeks, 3 months and 12 months follow-up (for pain, also at 6 months). No significant difference between the two groups was found in function beyond 1 year follow-up. There was no significant difference between arthroscopic and mini-open/open repair techniques in incidence of retear and adverse events at the longest follow-up.







Related ACE Reports:

https://myorthoevidence.com/AceReports/Report/577

https://myorthoevidence.com/AceReports/Report/4609

https://myorthoevidence.com/AceReports/Report/6888

https://myorthoevidence.com/AceReports/Report/11973


Related OE Original:

https://myorthoevidence.com/Blog/Show/145







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