Open and Mini-Open Rotator Cuff Repair: State of the Art

Introduction

The goals of rotator cuff repair surgery are to relieve pain; decrease the likelihood of rotator cuff tear extension; and restore strength, motion, and function of the shoulder. The most predictable result is that of pain relief, whereas restoration of strength and motion is less predictable. Throughout the years, surgical techniques have evolved from all-open approaches with detachment of the anterior deltoid to all-arthroscopic techniques. This chapter focuses on contemporary open and mini-open rotator cuff repair techniques.

Procedure

The patient is positioned in a beach chair position with the arm draped free. The mini-open cuff repair is a hybrid of arthroscopic evaluation and debridement of the glenohumeral joint, subacromial space, bursa, and rotator cuff, followed by a small open approach for relocation of the cuff tendon back down to bone. In contemporary open repair, the entire procedure is done open, including an open anterior acromioplasty and cuff repair.

Patient History

Shoulder pain, typically with overhead use of the arm
Pain generally localizes to the anterolateral deltoid and radiates from the acromion to the deltoid insertion.
Symptoms typically have an insidious onset, and most patients cannot recall a specific traumatic event.
Pain symptoms may progress to pain at rest and pain at night that can interfere with sleep.
Patients may also experience mechanical symptoms, such as popping or clicking, as the humeral head rotates against a thickened, inflamed bursa or coracoacromial ligament.

Patient Examination

Inspection of the shoulder may demonstrate atrophy of the supraspinatus and infraspinatus, long head of the biceps tendon rupture, or acromioclavicular (AC) joint ganglion.
Tenderness with firm palpation over the anterolateral proximal humerus.
Shoulder range-of-motion testing may show decreased active range of motion due to cuff weakness or dysfunction from tearing.
With large or massive rotator cuff tears, the rotator cuff may no longer stabilize the humeral head, and the deltoid will pull the humeral head up and out of the glenohumeral joint in the form of a shrug.
Passive range of motion of the shoulder joint is usually preserved in full-thickness tears; however, long-standing immobilization may lead to secondary stiffness of the joint.

Imaging

Plain radiographs (including anteroposterior, Grashey, scapular-Y, and axillary views) may demonstrate cystic changes or sclerosis of the greater tuberosity at the insertion of the supraspinatus tendon and a subacromial traction spur.
In large and massive rotator cuff tears, a narrowed acromiohumeral interval may be seen.
Radiographic changes in the AC joint may also be seen and may include arthritic changes or an unfused os acromiale.
Magnetic resonance imaging findings may include increased signal of the rotator cuff on both T1- and T2-weighted sequences. In addition to full-thickness cuff tear lesions, partial cuff tears, tendon delamination, muscle atrophy or fatty infiltration, tendon retraction, and muscle scarring may be seen.
Ultrasonography has also been used to identify partial-thickness and full-thickness rotator cuff tears, but it requires a trained radiologist or surgeon experienced in these ultrasound diagnostic techniques.

Treatment Options

Nonoperative
- Activity modification and avoidance of painful overhead activities.
- Nonsteroidal antiinflammatory medications.
- Physical therapy with four-quadrant stretching and strengthening in addition to periscapular stabilization and strengthening exercises.
- Subacromial corticosteroid injections may help decrease acute inflammation and pain, as well as improve tolerance for therapies.
Operative
- Subacromial decompression and rotator cuff debridement.
- Open rotator cuff repair.
- Mini-open rotator cuff repair.
- All-arthroscopic rotator cuff repair.
- Tendon transfers.
- Reverse shoulder arthroplasty may be used in patients with pseudoparalysis and anterosuperior escape.

Surgical Anatomy

Rotator cuff muscles and tendons: supraspinatus, infraspinatus, teres minor, and subscapularis
Acromion, scapular spine, proximal humerus, coracoid, distal clavicle
Deltoid muscle, pectoralis major, trapezius
Axillary nerve
Coracoacromial ligament, subacromial bursa

Surgical Indications

Symptomatic full-thickness rotator cuff tears in which conservative management has failed.
Acute traumatic full-thickness rotator cuff tears with a resultant decrease in shoulder function.
Surgery should not be considered for asymptomatic rotator cuff tears.
The ideal tear to consider for mini-open rotator cuff repair surgery is a symptomatic tear that is small, minimally retracted, absent of rotator cuff atrophy, and absent of fatty infiltration.
Massive tears involving the subscapularis or dislocation of the biceps tendon, as well as tears requiring significant mobilization, are not ideal for a mini-open approach.

Surgical Technique Setup

Positioning

Beach chair position.
Head secured to the table and tilted slightly away from the operative shoulder.
Rolled-up towel placed along the medial border of the scapula.
The arm is draped free, and the hand is covered with an elastic bandage or stockinette up to the elbow.
A pneumatic arm positioner is very helpful to allow traction and stable arm positioning throughout the case. When none is available, a padded Mayo stand serves a similar purpose.
Prominent anatomic landmarks are palpated, identified, and marked. These should include the coracoid process, AC joint, posterolateral corner of the acromion, and lateral edge of the acromion.

Equipment

Standard arthroscopic instruments for the arthroscopic portion of a mini-open rotator cuff repair
Standard basic instruments, including scalpels, forceps, clamps, basic retractors, and self-retaining retractors
Skin marker and ruler
Local anesthetic mixed with 1:500,000 concentration of epinephrine
Bovie electrocautery and suction
Shaver, rasp, curettes, or rongeurs for bony footprint preparation
1/8th-inch drill bit and drill if bony tunnels are to be used for repair
Osteotomes, saw, or burr to facilitate open acromioplasty
Nonabsorbable sutures for stay sutures and traction stiches
Nonabsorbable No. 2 sutures for cuff repair, with choice dictated by surgeon preference
Suture anchors (if desired) for rotator cuff repair
Closing sutures of choice and sterile dressings
Sling for recovery
Pneumatic arm positioner or a padded Mayo stand

Surgical Exposure/Portals

Contemporary Open Rotator Cuff Repair

In open rotator cuff repair, the planned skin incision extends along the Langer lines from just lateral to the coracoid process over the anterolateral corner of the acromion, ending just lateral to the acromion at its midpoint. The length of the skin incision is typically 6 cm.
The skin, subcutaneous tissue, coracoacromial ligament, and AC joint tissues are infiltrated with a 1:500,000 concentration of epinephrine, typically combined with a local anesthetic, which will minimize skin and subcutaneous bleeding.
The skin and subcutaneous tissue are divided down to the deltoid fascia while avoiding incision of the fascia itself. The deltoid fascial envelope helps hold sutures for secure deltoid reattachment and minimizes damage to the muscle during retraction.
Skin and subcutaneous tissue flaps are developed to expose the superior AC joint, the posterolateral corner of the acromion, and anteriorly to a distance of at least 5 cm.
The deltoid muscle is split along the lines of its fibers in one of two areas. Splitting the deltoid in the raphe between the anterior and middle deltoid gives excellent exposure of the posterosuperior cuff, whereas splitting the deltoid anteriorly from the AC joint provides excellent exposure of retracted subscapularis tears.
The deltoid split is limited to a distance of 5 cm to protect the axillary nerve. A No. 1 nonabsorbable suture marks the distalmost aspect of the split so that the split will not be propagated during deltoid retraction.
The deltoid is bluntly dissected in line with its fibers from the acromion to the stay suture until the subacromial bursa is identified. Bleeding is controlled with electrocautery. Adhesions within the subdeltoid space are broken up with a blunt instrument or finger under the medial and lateral deltoid flaps, so that retractors may be placed.
Deep deltoid fascia may be swept off the coracoacromial ligament with a sponge and blunt retractors to facilitate release and excision of the ligament.
The deltoid must be elevated or detached from the anterolateral acromion, typically 2 cm off the anterior deltoid, to facilitate anterior acromioplasty. Care should be taken to protect the superior and inferior fascia of the deltoid to facilitate later repair, and a stay suture is placed in the corner of the detached deltoid fibers.
Traction on the arm opens up the subacromial space to facilitate further excision of adhesions and bursal tissues.

Short Description of the Surgical Exposure

In open rotator cuff repair, a 6-cm skin incision along the Langer lines is made from just lateral to the coracoid to just lateral to the midaspect of the lateral acromion. Depending on the tear pattern, the deltoid fascia is identified and split bluntly from the AC joint or at the deltoid raphe between the anterior and medial deltoid heads to 5 cm distally. The distal extent of the deltoid split is protected by placement of a stay suture, the coracoacromial ligament is excised, subdeltoid adhesions are broken up, and bursal tissues are excised. The anterolateral aspect of the acromion is exposed by either elevating or detaching 2 cm of deltoid origin and placing fascial stay sutures at the corners for later repair and to prevent further detachment. The acromion morphology is palpated to prepare for open acromioplasty, and any remaining bursal tissue is sharply excised from the underlying rotator cuff to facilitate cuff repair.

Step-by-Step Guide to Surgical Technique: Open Rotator Cuff Repair

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