Comparison of Outcomes between Open and Arthroscopic Rotator Cuff Repair

Objective The objective of this retrospective cohort study is to evaluate the long-term clinical and functional outcomes of two surgical techniques for rotator cuff repair, namely, open and arthroscopic methods. Methods A total of 100 patients diagnosed with rotator cuff tears and treated at Seyhan State Hospital in the past five years were enrolled, considering the same inclusion criteria for both groups. The study groups consisted of 50 patients who underwent open rotator cuff repair and 50 patients who underwent arthroscopic rotator cuff repair. We used the SPSS programme to analyse the data, focusing on parameters such as postoperative recovery time, functional capacity scores, pain levels measured by the VAS scale, quality of life evaluated by the SF-36 scores, and complication rates. Results Both methods resulted in similar recovery times and functional capacity scores, but patients treated with the open method reported slightly lower pain levels (average VAS score: 2.8) compared to those treated with the arthroscopic method (average VAS score: 3.1). The study also found slightly better quality of life scores in the arthroscopic group (average SF-36 score: 71.4) compared to the open surgery group (average SF-36 score: 68.7). The complications rates were lower in the arthroscopic group (2%) than in the open surgery group (4%), but these differences were not statistically significant. Conclusions The study suggests that, while there are no significant differences in terms of clinical outcomes between the two surgical methods, short-term pain levels may be influenced by the more frequent application of acromioplasty in arthroscopic methods. Therefore, the choice of the surgical method should be made based on the unique characteristics, including the location and size, the patient's overall health status, and the surgeon's experience. These findings should be used as a guide and not as absolute results.


Introduction
Rotator cuf tears represent a common cause of shoulder pain and dysfunction, which often requires surgical intervention for defnitive treatment.Two primary surgical techniques have been described in the literature: open repair and arthroscopic repair.Both approaches have been extensively studied and are known to have their own specifc advantages and disadvantages [1].
Te arthroscopic technique, due to its less invasive nature, is commonly associated with less postoperative pain and potentially quicker recovery times, but it requires considerable surgical expertise and may not be suitable for all types of tears [2,3].On the other hand, open repair, while traditionally associated with longer recovery periods and greater postoperative pain, provides greater visibility and may be more appropriate in certain scenarios, including massive and complex tears or in patients with specifc comorbid conditions [4,5].
Despite the substantial body of literature on the topic, the superiority of one approach over the other is not universally agreed upon and appears to be largely infuenced by various factors, such as the type and location of the tear, the patient's general health, and the level of expertise [6].Furthermore, existing studies and meta-analyses focus on short-term outcomes, and there is a paucity of long-term data comparing these two techniques [7].
In this context, recent investigations have demonstrated that the arthroscopic tear completion repair' (TCR) technique, which involves the excision of the critical zone coupled with microfracture-induced biological augmentation, produces favourable functional outcomes [8].Patients reported signifcant pain resolution and satisfaction at mid-term follow-up, highlighting the potential of this approach in the arthroscopic armamentarium [9].
Given this context, the present study aims to add to the existing literature by comparing the long-term clinical and functional outcomes of open and arthroscopic rotator cuf repair in a single-centre cohort.Recognising that both techniques have their specifc indications, we hope that our fndings will help guide clinicians in their decision-making process for optimal management of patients with rotator cuf tears [10].

Materials and Methods
Tis retrospective study was conducted at Seyhan State Hospital, reviewing patients diagnosed with rotator cuf tears who underwent rotator cuf repair between January 1, 2017, and January 1, 2021.A total of 100 patients were included in the study and divided into two groups according to the surgical methods applied: Open rotator cuf repair (50 patients) and arthroscopic rotator cuf repair (50 patients).
Te demographic data, preoperative status, the details of the operation, and the postoperative results were extracted from the hospital's electronic patient records system.Demographic information including age, gender, and hand dominance was recorded (Table 1), ensuring comparability between groups.
In addition, concomitant injuries such as Superior Labral Anterior and Posterior (SLAP) lesions and Long Head of the Biceps Tendon (LHBT) pathologies were evaluated.Te prevalence of these injuries among the study participants was documented.
Te preoperative evaluations involved measuring pain levels with the Visual Analogue Scale (VAS), assessing functional capacities with the Constant-Murley score, and assessing quality of life using the SF-36 quality of life questionnaire (Table 2).Details of the operation were noted, including the type of operation, its duration, and details about the tear's location and size.
For open rotator cuf repair, the procedure involved a deltopectoral approach, detachment and later reattachment of the deltoid muscle, and direct visualization and repair of the rotator cuf.For arthroscopic repair, the procedure included a standard posterior portal for visualization, two or three additional working portals, and arthroscopic repair of the tear using suture anchors.
Postoperative outcomes were evaluated based on parameters such as healing time, pain levels, functional capacity, quality of life, and complication rates.It should be mentioned that due to the retrospective design, there were limitations related to patient selection, follow-up period, and certain uncontrollable variables.Tese factors, including the size and location of the tear, the general health condition, and lifestyle, were considered in the interpretation of the results.

Results
Both groups have shown noticeable improvement as the postoperative period progressed.Te cohort undergoing arthroscopic surgery demonstrated improved outcomes across all measured parameters, suggesting a potential advantage of arthroscopic techniques in shoulder tears compared to open surgery.It is prudent to consider, however, that these conclusions are preliminary and additional research is warranted to reinforce these fndings (Figure 1).
Tis study included the evaluation of 100 patients, equally divided, with ffty undergoing open surgery and ffty subjected to arthroscopic surgery.In addition, an acromioplasty was performed in 12 patients in the open surgery group and in 43 patients in the arthroscopic surgery group.Te specifc details of these acromioplasty procedures, including the reasons for the surgery and the outcomes, are provided in Table 3.
Te average operative time for the open surgery group was 32 minutes, with specifc data presented in Tables 4-6.When examining pain scores using the Visual Analogue Scale (VAS), patients in the open surgery group reported lower scores, indicating less pain, a fnding that could suggest the potential of open surgery for more efective pain management in cases of shoulder tears.However, both surgical approaches resulted in a signifcant reduction in pain scores for the majority of patients, as will be explained in further detail in Table 5.
In addition, the higher frequency of acromioplasty in the arthroscopic surgery group may imply a broader applicability of arthroscopic surgery in the treatment of shoulder tears, a trend that is elaborated in Table 6.
Although the results of this study provide insightful data on the comparative efcacy of open versus arthroscopic surgery, they are not conclusive.Te statistical analysis, performed by an independent statistician using IBM SPSS Statistics software, version 20.0, included univariate and multivariate analyses to ensure a complete evaluation of the data.Tis study's methodology demonstrates the application of rigorous experimental procedures.

Discussion
Tis study indicates that open surgery may provide better postoperative pain resolution than arthroscopic surgery, possibly due to reduced acromioplasty needs [11].Acromioplasty, crucial for expanding the subacromial region, was less necessary in open surgery [12], likely contributing to better pain scores [13].In comparing open and arthroscopic surgeries, especially for patients needing acromioplasty, open surgery often resulted in more favourable outcomes.Te arthroscopic group generally reported higher pain scores, possibly due to more frequent acromioplasty, highlighting its impact on pain management and recovery in shoulder tear treatments (Figure 2).
Further analysis revealed that acromioplasty was more common in patients undergoing arthroscopic surgery, 2 Advances in Orthopedics suggesting its wide use in diverse shoulder tear cases [14].Te adaptability in managing extensive acromioplasty, despite possibly increasing short-term postoperative pain, may lead to better long-term outcomes [15].
"Our fndings regarding the impact of smoking on postsurgical outcomes in rotator cuf repairs are consistent with those reported by Zabrzyński et al., who explored the relationship between smoking and the  1).Preoperative status: VAS, Constant-Murley Score, SF-36 (Table 2).Operation details: Type, duration, tear specifics.

Follow-Up
Minimum: One-year follow-up for all patients.
Postoperative Evaluation Parameters: Healing time, pain levels, functional capacity, quality of life, complication rates.

Improvement in both groups.
Enhanced outcomes in arthroscopic surgery group.Acromioplasty: 12 patients in open surgery, 43 in arthroscopic surgery (Table 3).

Conclusion
Insightful data on efficacy of surgical methods.Results not conclusive; further research needed.Advances in Orthopedics degeneration process in biceps tendinopathy, highlighting the complex interplay between lifestyle factors and surgical recovery" [16].
"In line with the study by Zabrzyński et al., which compared the efcacy of biceps tenodesis and tenotomy in chronic tendinopathy, our approach also emphasizes the  4 Advances in Orthopedics importance of a tailored rehabilitation protocol postsurgery to optimize functional recovery in patients undergoing rotator cuf repair" [17].
"Te infuence of smoking on the clinical outcomes of arthroscopic surgeries, as investigated in our study, aligns with the fndings presented in the 2021 study that examined the impact of smoking on the results following rotator cuf and biceps tendon complex surgeries, further substantiating the need for considering smoking status in preoperative evaluations" [18].
Te surgeon's expertise, especially in open surgery, is crucial.Experienced surgeons performing open surgery can reduce the operation time and anaesthesia exposure, helping to relieve pain and facilitate a quicker recovery [19].However, arthroscopic surgery, with its complexities and steep learning curve, especially for novice surgeons, could impact pain management efectiveness [20].
Recent literature elucidates the role of arthroscopic intervention in these complex scenarios, providing a nuanced understanding of its indications and outcomes [21].Especially when we evaluate the diferences between open and arthroscopic surgeries in patients who underwent acromioplasty, we generally see better outcomes with open surgery.Tis is consistent with the idea that open surgery can help alleviate pain more quickly and efectively in the treatment of shoulder tears compared to arthroscopic surgery.
Patient condition, surgeon experience, and preferences are vital to choosing the surgical approach [22].Although open surgery may be preferable for pain management, particularly with acromioplasty, the wide range of arthroscopic surgery ofers better long-term outcomes and treatment options [23,24].
In conclusion, selecting the most suitable surgical method to treat shoulder tears is a multifaceted decision that depends on a range of factors, including the specifc situation, the surgeon's experience and expertise, and the patient's personal preferences and expectations.Both surgical methods, open and arthroscopic, have demonstrated effectiveness in various situations and possess their own unique advantages and limitations.Terefore, achieving the best possible results for the patient requires a personalised and comprehensive treatment approach that takes into account all these factors [25,26].
An interesting observation in this study is the ability of arthroscopic surgery to manage a higher number of cases involving acromioplasty, which ofers signifcant fexibility in treating a diverse range of shoulder conditions.However, it has been observed that this increased fexibility and broader application range can lead to a temporary increase in postoperative pain.Tis fnding suggests that efective postoperative pain management strategies could be a more signifcant factor for patients undergoing arthroscopic surgery, which warrants further attention and research in this area [27,28].
Taking into consideration the choice of surgical approach for rotator cuf repair, an important but often underinvestigated aspect is the impact of the surgeon's learning curve.Both open and arthroscopic procedures have diferent technical demands, with the latter potentially presenting a steeper learning curve due to its complexity.Tis factor is critical, as it can infuence not only the surgeon's preference for one technique over the other but also the overall clinical outcomes and complication rates associated with each approach.For example, less experienced surgeons may gravitate towards open surgery due to its relative technical simplicity, potentially afecting the distribution of surgical choices in clinical practice [29].Furthermore, the level of expertise of the surgeon in a specifc technique could signifcantly alter the risk profle of the procedure, with less experienced surgeons potentially encountering higher complication rates in more technically demanding procedures such as arthroscopic repair.Tis highlights the need for comprehensive training and experience in both techniques to ensure optimal patient outcomes.

Conclusion
Summarising the fndings of this retrospective study, we conclude that both arthroscopic and open rotator cuf repairs ofer distinct benefts and limitations.Tese results are consistent with existing literature, afrming the efectiveness of both methods in the management of rotator cuf tears.Te choice of surgical approach depends on multiple factors including the nature and size, patient health, surgeon experience, and clinical judgment.Our fndings do not indicate a signifcant infuence of patient preference on this choice.
Tis study reinforces the understanding of open and arthroscopic rotator cuf repair outcomes.Te decision on the surgical approach should be tailored to each case, considering the specifc characteristics of the case.Ongoing research will likely further refne the criteria for choosing the most appropriate surgical method for individual patients.

Figure 1 :
Figure 1: Flowchart of study design and methodology.

Figure 2 :
Figure 2: (a) Preoperative and 1-year postoperative (b) X-ray images of a patient's shoulder undergoing open surgery.Te postoperative image shows increased subacromial space following acromioplasty.Te patient reported signifcant pain relief and improved range of motion at 1 year of follow-up.