Reply to the Letter to the Editor: Advantages of Arthroscopic Transosseous Suture Repair of the Rotator Cuff without the Use of Anchors

Abstract

To the editor,We appreciate the valuable comments of Bicanic and colleagues, which describe previously reported transosseous suture methods, limitations, costs, possible pullout of the sutures, and complexities of the suturing in the procedure we reported.The hybrid technique of anchor and transosseous sutures reported by Cicak et al. [2], and the transosseous suture technique using a hollow needle reported by Matis et al.[5], differ from our technique. We make a long straight bone tunnel from the lower margin of the greater tuberosity to the footprint. With our procedure, large tears where the stump of the torn rotator cuff does not emerge across the top of the humeral head under traction can be repaired by expanding decortication of the footprint to the inner side. However, there is a high retear rate.The extra cost of prolonged operation time is generally attributable to personnel expenses. Our technique requires two surgeons, one anesthesiologist, and three nurses. In our hospital, doctors and nurses are paid ¥ 12,500/hour and ¥ 3200/hour, respectively. Therefore, the total personnel costs are ¥ 47,100/hour (¥ 12,500 9 3 + ¥ 3200 9 3). The anchor method uses an average of 2.3 anchors [3]. These cost ¥34,300 each in Japan. The total cost of the anchors is ¥ 78,890 (¥ 34,300 9 2.3 anchors). The polyester threads used in our procedure cost ¥840. Therefore, the anchors cost ¥ 78,050 more (¥ 78,890 À ¥ 840) than the polyester threads. This is equivalent to personnel expenses for 99 minutes (¥ 78,050 7 ¥ 47,100 9 60).The anchor method is cheaper only if the procedure is 99 minutes shorter than our approach. The overall average operating time for our procedure is approximately 105 minutes in 384 cases [4]. In order for a procedure using anchors to be less expensive, it would have to be 99 minutes shorter than that, or about 6 minutes in length (105 minutes -99 minutes = 6 minutes), which seems quite unrealistic.In our procedure, knot tying is performed at the lower margin of the greater tuberosity where the bone cortex is solid. Additionally, the knots are not sliding, but static. Therefore, no rupture of sutures due to friction in the bone tunnel occurred in our cases. Breakage of (or pullout from) the bone tunnel occurred only in one osteoporotic patient (0.3%). In comparison, the frequency of anchor pullout is reportedly 2.4% [1]. Our procedure is more suitable for osteoporotic patients.

Optimal Angle of the Bone Tunnel for Avoiding Axillary Nerve Injuries During Arthroscopic Transosseous Rotator Cuff Repair: A Magnetic Resonance Imaging–Based Simulation Study

“…23,25 Equally important, the cost analysis performed by various authors has clearly shown the cost advantage of ATORCR versus arthroscopic anchor-based repair, even after taking into consideration the longer operative time. 3,17,25…”

“…23,25 Equally important, the cost analysis performed by various authors has clearly shown the cost advantage of ATORCR versus arthroscopic anchor-based repair, even after taking into consideration the longer operative time. 3,17,25 During ATORCR, the entry of the drill wire has been described by some authors in terms of its distance from the greater tuberosity. 8 The axillary nerve has been variously reported to lie about 35 to 53.5 mm from the tip of the greater tuberosity.…”

Arthroscopic Transosseous Suture Without Implant for Rotator Cuff Tears: Absorbable Mattress Sutures Versus Non-Absorbable Sutures

“…In 2013, we calculated the cost, including surgical time and personnel expenses, and found that our procedure is cheaper than the anchor method, unless the latter is completed within 6 minutes [18] . The only surgical material used is polyester thread and PGA thread.…”

Clinical and Economic Advantages of Anchorless Arthroscopic Transosseous Suture Repair of the Rotator Cuff

“…We compared the surgical cost between ATOS repair and the anchor method. 26 The difference in terms of cost according to surgical method is attributed to the use of surgical materials and professional fees. .…”