Fig. 1
A horizontal lateral skin incision along the lateral margin of the acromion
To access these structures, the incision may be extended anteriorly along the anterior margin of the acromion.
The incision starts from the upper surface of the acromion, at the middle third, and goes down. This incision is suitable for a mini-open access, when the cuff tear is repaired after a preliminary arthroscopic phase, allowing diagnosis, debridement of soft tissue and acromioplasty. In this case, it meets the arthroscopic lateral portal in the distal portion (Fig. 2a, b).
Fig. 2
A vertical lateral skin incision, performed after prior arthroscopy. The incision starts on the superior surface of the acromion near its lateral margin (a) and passes through the arthroscopic lateral portal (b)
The superior, or saber, incision, starts from the upper surface of the acromion, slightly lateral to the acromio-clavicular joint, and descends vertically, reaching 3 cm or more from the anterior margin of the acromion. The skin is retracted with a self-retaining or manual retractor. The length of the incision depends on the size of the cuff tear. This incision is less aesthetic than the lateral one. Moreover, it may be necessary to extend it in case of massive postero-superior cuff tears.
The delto-pectoral approach allows the surgeon to expose the subscapularis tendon, the lesser tuberosity and the rotator interval. To expose the supraspinatus properly, and, above all, the infraspinatus, the incision needs to be extended as far as 1 cm caudally with respect to the anterior margin of the acromion and extended laterally along the edge of the bone. Length varies according to the size of the postero-superior cuff tear.
Detachment or Split of the Deltoid
Deltoid Detachment
Once the subcutaneous tissue has been dissected and the edge of the acromion has been identified, the deltoid is detached in close adherence to the bone margin. Detachment may be carried out through electrocautery. Complete detachment is often confirmed by spillage of a serous fluid from the subacromial space.
Extension of the deltoid detachment permits the cuff tear to be repaired. Post-operative recovery time is related to the degree of deltoid integrity. The extension may vary from 3 cm (for a small tear) to 6 cm (for a massive tear).
Deltoid Split
Splitting is carried out following the direction of the muscle fibres. The longitudinal extension and size of the split depends on the location and size of the cuff tear and may vary from 2 to 5–6 cm. A transverse stitch is applied only if dissection is longer than 5 cm.
Evaluation of the Cuff Tear
Preliminary Assessment
Once the subacromial space is exposed, the cuff tear needs to be identified. If the tear is not immediately observable, the humerus has to be rotated internally and externally so that the whole extension of the cuff may be evaluated. The initial inspection of the lesion allows the location and size of the tear to be assessed. The preliminary assessment also helps the surgeon to determine whether deltoid detachment or split should be enlarged posteriorly or anteriorly. Furthermore, this also makes it possible to determine whether or not the tear may be repaired.
Acromioplasty
This may not be necessary when the subacromial space is wide, the anterior margin of the acromion thin and the cuff tear small. It is essential when the subacromial space is narrow, there is a large or massive tear, or when an acromial spur makes the tear difficult to repair or because it is responsible for subacromial impingement.
Acromioplasty may be performed before or after bursectomy. Before proceeding to bone resection, it may be useful to detach the bursa from the deep surface of the acromion, if it is adherent to the bone (Fig. 3). This is performed using a 1.5-cm-wide chisel. In massive rotator cuff tears, some surgeons save the coracoacromial ligament to prevent upward migration of the humeral head [2]; in this case, the ligament is detached from the acromion and may be reinserted later. Others believe that it should always be excised because it can be a cause of persistent post-operative impingement.
Fig. 3
A longitudinal section of the deltoid muscle bundles
When the open-surgery phase is preceded by initial partial arthroscopic acromioplasty, the latter can be completed with a motorized bur, rather than an osteotome or a Luer.
Caudal acromio-clavicular joint osteophytes should be removed, if prominent. The removal can be performed using a Luer or a small rasp, or a motorized bur.
Bursectomy
The subacromial bursa has to be removed to permit adequate exposure of the tendon lesion. When the bursa is thick, it may be difficult to distinguish it from tendon tissue. The distinction can be made on the basis of the colour, friability and thickness of the tissue. Generally, the bursa is pink in colour, while the tendon is whitish (Fig. 4). If the tissue receives a number of stitches and traction is applied, the bursa will tear while the tendon is generally resistant to slight traction.
Fig. 4
A bursectomy is performed before the tendinous repair. The bursa is clearly distinguishable from the white tendon
A radical bursectomy is not necessary, especially if the bursa is thin. Preservation of the bursa may be useful as a source of fibrovascular tissue, which can facilitate repair of the tendon [3]. Once acromioplasty and bursectomy have been carried out, the characteristics of the lesion need to be carefully evaluated. In addition, the degree of degeneration of the tendon and the status of the long head biceps tendon have to be assessed.
Long Head Biceps Tendon
The biceps tendon may be: (1) intact and in good health, or present a synovial sheath inflammation; (2) partially broken or detached from the scapula – SLAP lesion; (3) absent, because it is completely broken and distally retracted; (4) medially dislocated and located on the front of the subscapularis tendon or between the bundles of this tendon; (5) dislocated within the joint cavity, medially to the humeral head.
The long head biceps tendon is easily visible when the supraspinatus is completely involved in the tear (Fig. 5). When the tear involves the postero-superior portion of the cuff, the biceps tendon is not visible; therefore, it should be sought by retracting the tendon stump medially to expose the area of the biceps groove. This is necessary especially when, preoperatively, a clinical diagnosis of complete rupture of the biceps tendon has not been formulated. Exposure is important to determine if it is partially broken or dislocated; as well as to avoid it being gripped by the sutures used during cuff repair. When the tear is far from the biceps groove, exposure of the biceps is not necessary, especially in the absence of clinical data possible partial rupture or dislocation.
Fig. 5
A supraspinatus tendon tear and lesion of the rotator interval. The biceps tendon is lifted by a hook. The tendon sheath is partially flushed, but maintains its integrity
Tenotomy is recommended when the tendon is widened and/or fissured (Fig. 6). In young patients, bicipital groove tenodesis is performed. Some surgeons dissect the tendon in all elderly patients even when it does not show degenerative changes. Normally, tenodesis is not indicated in the case of elderly patients.
Fig. 6
A longitudinal tear and associated inflammation of the long head of the biceps tendon
Repair of Postero-superior Cuff Tear
Partial Tears
Usually, partial tears of the bursal side of the postero-superior cuff present small lesions not exceeding 1–2 cm in its larger diameter. Generally, they affect the supraspinatus and involve a small area of the tendon (Fig. 7).
Fig. 7
A partial-thickness tear of the supraspinatus tendon on the bursal side
Currently, it is anachronistic to treat these injuries using the open technique. However, if a surgeon, unfamiliar with arthroscopic technique, decides to treat the cuff tear traditionally, he needs to detect an oval-shaped portion of tissue in which the partial lesion is contained; afterwards, this tissue is removed and the margins of the lesion repaired. Sutures must be applied at a short distance from the edge of the tendon section to avoid creating salience of the tendon, which knocks against the deep surface of the acromion during shoulder movement. When the lesion is close to the insertion of the bone, a triangular or crescent-shaped portion of the tendon is removed. In the case of a triangular section, the two margins are sutured starting from the apex of the triangle to obtain a straight base, which is successively fixed to the greater tuberosity.
Full-Thickness Lesions
Mobilization of the Tendon Stumps
This procedure is necessary in the case of large lesions, especially when the tears are massive. Mobilization can be achieved using arthroscopic grasping forceps or suture stitches. When strong traction is requested, suture stitches on the tear margins have to be applied starting with the most easily accessible portion of the tendon stumps. By pulling the suture stitches applied to this portion together, lateralization of the less accessible portion is facilitated. The internal or external rotation of the humerus or the downward traction of the limb may facilitate the application of suture stitches on the medial-most margins of the cuff tear. Sutures need to be applied on healthy tissue to avoid laceration during cuff mobilization (Fig. 8). Mobilization starts from the bursal side of the cuff, completing the phase already partially performed before acromioplasty. The cuff is detached from the lower surface of the postero-lateral portion of the acromion. The portion thus released is gradually fixed with sutures, continuing the procedure as far as it is necessary or possible. Subsequently, the articular side of the cuff has to be mobilized, because it is often adherent to the glenoid rim and to the base of the coracoid process (Fig. 9a).
Fig. 8
Application of suture stitches on the medial-most margins of the cuff tear. These sutures must be applied in a healthy tissue to avoid laceration during mobilization of the cuff
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