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Mini-Open Rotator Cuff Repair
Rotator cuff injuries are among the most common shoulder problems seen by orthopedists. Although conservative management has been discussed, open repair for the symptomatic rotator cuff tear has been supported by a wide number of authors with predictably good results. The operative morbidity is not insignificant, however, and although many patients support the outcome, few patients found the prolonged recovery and perioperative pain desirable. With the advent of shoulder arthroscopy, arthroscopic evaluation of the shoulder joint and rotator cuff at the time of cuff repair became practical. With the exception of Grana and coworkers, evaluation of the glenohumeral joint was felt to be of significant benefit. Exclusion of open surgery on the patient with false-positive diagnostic studies; evaluation of tear shape, size, and reparability; and evaluation and treatment of concomitant soft tissue problems to the biceps, articular cartilage, and labrum were felt by most to be important advantages of arthroscopic assessment of the joint prior to repair.
Although treatment accuracy improved with arthroscopic assessment prior to rotator cuff repair, it did not improve the morbidity or recovery. Arthroscopic debridement of the rotator cuff rather than repair was attempted in the hopes of improving the perioperative morbidity, but the outcomes were not generally as good as open repair, especially with longer-term follow-up. Arthroscopic-assisted or “mini-open” rotator cuff repair was described by several authors in the early 1990s, with two comparative studies showing less perioperative pain and accelerated recovery compared to traditional open repair. More recently, all arthroscopic techniques have been described, using staples, bioabsorbable implants, bone tunnels, and suture anchors. Early results with all-arthroscopic technique have been encouraging, but the procedures are technically difficult. Implant costs and the use of disposable devices for suture passage can dramatically increase cost with all-arthroscopic techniques. The only published comparative study showed that although an all-arthroscopic technique further decreased operative morbidity over mini-open repair, complications were modestly increased, and both recovery of function and outcome were not significantly improved over mini-open repair. Laboratory data also suggests that the tensile strength of simple sutures may not be adequate to maintain cuff integrity during healing. Current arthroscopic techniques do not allow more than simple and mattress sutures. Given the reproducibility of mini-open repair for the average practicing orthopedist, this technique will remain an important part of the armamentarium of the shoulder surgeon for the near future.
Indications
1. Partial thickness tears greater than 50% of the thickness of the cuff.
2. Small and moderate-size tears.
3. Large tears can be managed with experience, provided the cuff edge is identified and tagged arthroscopically, and the arm rotated for exposure.
Contraindications
1. Massive cuff tears (best managed with either arthroscopic debridement or open repair)
2. Any skin disruption
3. Active infection, local or remote
Physical Examination
1. Anterolateral tenderness
2. Pain with resisted abduction
3. Pain and later weakness in external rotation with larger tears
4. Positive impingement sign
Diagnostic Tests
1. Standard radiographs to include axillary and scapular lateral projections
2. Plain contrast arthrogram (still accurate and cost effective means of diagnosis)
3. Magnetic resonance imaging scanning if additional information about the glenohumeral joint is useful
Special Considerations
Successful completion of mini-open repair requires basic arthroscopic skills. One needs to be able to finish the diagnostic examination of the glenohumeral joint in under half an hour to allow the open repair to proceed without compromise by intraoperative swelling. If the diagnostic exam is not complete by then, or if additional glenohumeral procedures or difficulty with the acromioplasty takes more than an hour, then traditional open repair should be undertaken.
Preoperative Planning and Timing of Surgery
1. Argument exists about whether early intervention is appropriate for complete tears of the rotator cuff or whether surgical treatment should be deferred until the patient fails conservative management. Although good early results can occur with conservative management, extension of the tear will occur in a significant number of patients. For this reason, the physiologically young patient should consider early repair.
2. Informed consent is critical to the happy patient. The options of an irreparable tear, false-positive diagnostic study, and open repair should be reviewed with the patient in detail preoperatively.
Special Instruments
1. Basic arthroscopy instruments
2. Suture anchors designed for rotator cuff use, if this is the surgeon’s preference
Anesthetic Options
General anesthesia is preferred; scalene block can be used for unusual circumstances.
Patient and Equipment Position
1. In lateral decubitus position (author’s preference). This allows the arthroscopic portion to be completed in the lateral position with distal traction. At this point, the patient is left lateral and the open portion of the procedure performed. The traction unit remains on and assists in exposure by pulling the humerus away from the acromion, freeing up the assistant. If a large tear requiring additional posterior exposure is identified, this can be done without repositioning.
2. Beach chair.
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