Indocyanine green fluorescence angiography-guided arthroscopic rotator cuff surgery: a randomized controlled trial

Abstract

Background: Indocyanine green (ICG) fluorescence angiography is used to evaluate tissue vascularity across various surgical fields. However, ICG has not been widely used in rotator cuff tendon surgery, which involves poorly vascularized tissue. In this study, we investigated the efficacy of ICG-guided arthroscopic rotator cuff repair (RCR) to evaluate the vasculature of the débridement margin and the tendon-bone interface and compared it with the conventional arthroscopic technique.

Methods: Patients with small-sized to medium-sized rotator cuff tears were recruited from February 2020 to February 2022 and were randomly assigned to either the ICG-guided RCR group or the conventional RCR group, with 32 patients in each group. Standard arthroscopic RCR was performed in both groups; however, in the ICG group, ICG was administered intravenously during surgery to assess blood perfusion in the tissue. Tear margin débridement was conducted while monitoring the enhancement of ICG, and suturing was performed after confirming the blood supply at the tendon-bone interface. The primary outcome was the retear rate, determined using the Sugaya classification based on magnetic resonance imaging conducted 6 months postsurgery. Secondary outcomes included the range of motion and patient-reported outcome measures, such as American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score (CMS), Single Assessment Numeric Evaluation (SANE), and pain visual analog scale (VAS), as well as the prevalence of complications. The minimal clinically important difference (MCID) for all patient-reported outcomes at 12 months postoperatively was determined using a distribution-based method.

Results: A total of 58 patients completed the trial and were included in the analysis. The mean age was 64.8 years (range, 48-82 years). There was no significant difference between the 2 groups at baseline. The retear rate was 0% in the ICG group and 6.9% in the control group (P = .150). At 6 months postoperatively, pain VAS at 6 months postoperatively was significantly lower in the ICG group (P = .003). At 12-month follow-up, 24 patients (82.7%) for pain VAS, 27 (93.1%) for ASES, 19 (65.6%) for CMS, and 25 (86.2%) for SANE achieved MCID in the ICG group and 23 patients (79.3%) for pain VAS, 25 (86.2%) for ASES, 19 (65.6%) for CMS, and 22 (75.8%) for SANE achieved MCID in the conventional group. Neither group showed operation-related complications.

Conclusion: ICG-guided arthroscopic RCR showed greater improvement in pain VAS at 6 months postoperatively compared to the conventional RCR group and demonstrated comparable outcomes in achieving the MCID at 1 year. Moreover, the procedure was performed safely without any adverse effects.

Keywords: ICG-guided arthroscopic rotator cuff repair; Indocyanine green; randomized controlled trial; real-time perfusion; rotator cuff tear; tendon blood supply.