To the Editor:
Approximately 2,500 years ago in present-day Turkey, an Ancient Greek Ionian wrote the following: “διαιτμασ τε χρσoμαι ἐπ' ὠφελεῃ καμνντων κατὰ δναμιν καὶ κρσιν ἐμν, ἐπὶ δηλσει δὲ καὶ ἀδικη εἴρξειν.” Direct translation of this passage to modern English was provided by von Staden
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: “…And I will use regimens for the benefit of the ill in accordance with my ability and my judgment, but from [what is] to their harm or injustice I will keep [them].”For human beings, learning begins when a specific action or experience is coupled with a specific result—a process that requires repetition, high-level cognition, and complex neural processing. However, despite our advanced ability to make these associations, it is not possible to predict the result of a specific action in the absence of a previously learned behavior or series of behaviors. It is the accumulation and integration of cogently linked cause-and-effect relations throughout life that allow us to hypothesize the outcome of some future action. The primary function of published research on any topic is to enhance our knowledge by providing documentation that a specific action produced a specific result within a defined set of circumstances. In medical research, we aim to determine which actions produce the most desirable results following the guidance of the Hippocratic Oath. Research in orthopaedic surgery is not an exception.
Research in rotator cuff surgery is not an exception either. Clearly, the past few decades of research has produced volumes of new basic science, biomechanical, and clinical data related to rotator cuff surgery. How do we make sense of all this “mess”? Perhaps it is necessary to take a step back, take a deep breath, and see the big picture.
Dr. Palomo has voiced his frustration regarding the evolution of arthroscopic rotator cuff repair techniques to the readers of Arthroscopy.
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His statements imply that the fluctuant path toward the current state of knowledge in arthroscopic rotator cuff surgery may be the result of motives that involve something other than the improvement of patient care. He states that certain repair techniques may have been developed to simply “fight” the findings of other researchers.In response to these statements, we challenge the readers to critically evaluate the historical timeline of each rotator cuff repair technique in terms of basic science, biomechanical, and clinical evidence. We suspect that, depending on the pathology involved, (1) the hypotheses of each study have aligned with the state of knowledge at the time of publication, (2) most basic science evidence tends to favor one technique over another, (3) most biomechanical evidence tends to favor one technique over another, and (4) most clinical evidence is equivocal. This may be because of an inability of validated outcomes measures to detect small differences in pain and/or function, the presence of underpowered clinical studies, or a true lack of difference between the different repair techniques, among many other possibilities. As a result, there are numerous “preferred” and “novel” techniques described in the literature that may or may not produce superior clinical results. However, it should be remembered that it is not the responsibility of the individual researcher or group of researchers to dictate which technique should be used for each patient. Rather, it is the surgeon's responsibility to determine the treatment method that is most likely to result in a favorable outcome according to current published evidence, the clinical situation at hand, and the surgeon's technical skill.
Dr. Palomo has also challenged us to improve the direction of our research in the realm of rotator cuff surgery, stating that perhaps we are moving in too many directions at an increasingly rapid pace. However, we argue that research in rotator cuff surgery is moving forward toward a common goal—that is, to provide patients with the best surgical options possible to decrease pain and improve function. Patients want to get better, to get better faster, and to get back to their desired activities without restrictions. Extensive biomechanical research, clinical research, and new technologic advances have helped us achieve this goal of improving treatment outcomes in patients with rotator cuff pathology. There is no question that we have witnessed progressive improvements in postoperative recovery times, retear rates,
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complication rates,5
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patient satisfaction,8
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and clinical outcomes scores3
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since the advent of arthroscopic rotator cuff surgery. We have also demonstrated our improved knowledge in the areas of anatomy,12
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pathoanatomy,12
tendon biology,15
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surgical techniques,18
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repair biomechanics,23
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and rehabilitation27
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through countless evidence-based studies. The evolution of surgical techniques and medical device technology is rapid and is driven by surgeons seeking simpler, safer, and more reproducible techniques. Innovative companies simply respond to that need. Where would arthroscopic procedures be today without innovation? Rapid design and manufacturing will facilitate even faster change in the future. Technology helps surgeons perform more precise, more reproducible, and less invasive outpatient procedures that improve patient safety and outcomes while also reducing healthcare costs. Furthermore, there is little doubt that surgeons, organizations, and companies who can keep up with technological innovation will continue to do so. All in all, we are charged with improving the quality of patient care, and as surgeons who strive to improve the quality of life of our patients, we should never be satisfied with the status quo.References
- “In a pure and holy way”: Personal and professional conduct in the Hippocratic Oath?.J Hist Med Allied Sci. 1996; 51: 404-437
- The rotator cuff repair mess.Arthroscopy. 2013; 29 (letter): 1902
- Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: A systematic review and meta-analysis of level I randomized clinical trials.J Shoulder Elbow Surg. 2014; 23: 586-597
- Clinical outcome and repair integrity after rotator cuff repair in patients older than 70 years versus patients younger than 70 years.Arthroscopy. 2014; 30: 546-554
- Prevention and management of stiffness after arthroscopic rotator cuff repair: Systematic review and implications for rotator cuff healing.Arthroscopy. 2011; 27: 842-848
- Incidence and treatment of postoperative stiffness following arthroscopic rotator cuff repair.Arthroscopy. 2009; 25: 880-890
- Complications after arthroscopic revision rotator cuff repair.Arthroscopy. 2013; 29: 1479-1486
- Arthroscopic repair of large subscapularis tears: 2- to 4-year clinical and radiographic outcomes.Arthroscopy. 2013; 29: 1471-1478
- Arthroscopic primary rotator cuff repairs in patients aged younger than 45 years.Arthroscopy. 2013; 29: 811-817
- Clinical outcome in all-arthroscopic versus mini-open rotator cuff repair in small to medium-sized tears: A randomized controlled trial in 100 patients with 1-year follow-up.Arthroscopy. 2013; 29: 266-273
- Long-term survivorship and outcomes after surgical repair of full-thickness rotator cuff tears.J Shoulder Elbow Surg. 2011; 20: 591-597
- Current perspectives on rotator cuff anatomy.Arthroscopy. 2009; 25: 305-320
- An anatomic study of the subscapularis insertion to the humerus: The subscapularis footprint.Arthroscopy. 2008; 24: 749-753
- Anatomy and dimensions of rotator cuff insertions.J Shoulder Elbow Surg. 2002; 11: 498-503
- Collagen production at the edge of ruptured rotator cuff tendon is correlated with postoperative cuff integrity.Arthroscopy. 2011; 27: 1173-1179
- The presence of fatty infiltration in the infraspinatus: Its relation with the condition of the supraspinatus tendon.Arthroscopy. 2011; 27: 463-470
- Histopathology of residual tendon in high-grade articular-sided partial-thickness rotator cuff tears (PASTA lesions).Arthroscopy. 2012; 28: 474-480
- Techniques for managing poor quality tissue and bone during arthroscopic rotator cuff repair.Arthroscopy. 2011; 27: 1409-1421
- Current trends in rotator cuff repair: Surgical technique, setting, and cost.Arthroscopy. 2014; 30: 284-288
- Mattress double anchor footprint repair: A novel, arthroscopic rotator cuff repair technique.Arthroscopy. 2004; 20: 875-879
- The evolution of suture anchors in arthroscopic rotator cuff repair.Arthroscopy. 2013; 29: 1589-1595
- Arthroscopic rotator cuff repair: Scientific rationale, surgical technique, and early clinical and functional results of a knotless self-reinforcing double-row rotator cuff repair system.J Shoulder Elbow Surg. 2010; 19: 83-90
- Arthroscopic single-row versus double-row suture anchor rotator cuff repair.Am J Sports Med. 2005; 33: 1861-1868
- Biomechanical analysis of two-tendon posterosuperior rotator cuff tear repairs: Extended linked repairs and augmented repairs.Arthroscopy. 2013; 29: 37-45
- Biomechanical comparison of 4 double-row suture-bridging rotator cuff repair techniques using different medial-row configurations.Arthroscopy. 2010; 26: 1281-1288
- Biomechanical evaluation of arthroscopic rotator cuff repairs over time.Arthroscopy. 2010; 26: 592-599
- Effect of two rehabilitation protocols on range of motion and healing rates after arthroscopic rotator cuff repair: Aggressive versus limited early passive exercises.Arthroscopy. 2012; 28: 34-42
- Rehabilitation after arthroscopic rotator cuff repair: Current concepts review and evidence-based guidelines.Int J Sports Phys Ther. 2012; 7: 197-218
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Footnotes
Note: The authors report the following potential conflict of interest or source of funding: P.J.M. receives support from Arthrex. P.J.M. and R.J.W. receive research support from the Steadman Philippon Research Institute. The Institute receives support from the following corporate sponsors: Smith & Nephew Endoscopy, Arthrex, Siemens Medical Solutions, ConMed Linvatec, Össur, Synthes, Inc., and Ceterix Orthopaedics.
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© 2014 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
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- The Rotator Cuff Repair MessArthroscopyVol. 29Issue 12
- PreviewI reached orthopaedic surgery led by the hand of my father, Jose M. Palomo, as well as Lorenz Böhler (The Treatment of Fractures) and Sir Reginald Watson-Jones (Fractures and Joint Injuries). Soon afterward, at the faculty of medicine, I learned about Sir John Charnley (The Closed Treatment of Common Fractures). Until that moment, a bony fracture meant some kind of cast and traction, as well as the dictum, “Close open fractures but don't open the closed ones.” I had to give up that knowledge to closely and religiously follow, in a successive and exclusive way, the immovable principles of Maurice Muller (AO plates and screws), Gerhard Küntscher and Josef Ender (intramedullary nails), R.
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