REPAIR OF THE ROTATOR CUFF: Mini-open and Arthroscopic Repairs

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The role of arthroscopy for treatment of patients with disorders of the shoulder has shown remarkable advances over the past 2 decades. Burman8 and Wantanabe42 described shoulder arthroscopy in 1931 and 1935, respectively, but shoulder arthroscopy was not commonly used until Wiley and Older45 developed arthroscopic techniques for the shoulder and applied them for diagnostic purposes. The course of advancement in shoulder arthroscopy has paralleled that of the knee. Initially, it was used for only the purpose of joint inspection, but over time, through the work of dedicated surgeons, the number of procedures, and their complexity have rapidly grown. These advances have been aided by the increasingly sophisticated instrumentation first used in knee arthroscopy. Support of arthroscopic procedures has also been buoyed by the improved outcomes demonstrated with knee arthroscopy.

Numerous techniques for the arthroscopic treatment of patients with shoulder pathology have been published. Ellman13 popularized the arthroscopic technique for subacromial decompression, which has subsequently been modified and refined by other surgeons.* The débridement of labral tears and subacromial decompression are now commonly performed arthroscopically. Arthroscopic decompression has more recently been combined with “mini-open” repair of the rotator cuff, which allows for the repair of the cuff without disruption of the deltoid origin.27, 36, 37, 38, 40 The most recent development is the fully arthroscopic repair of the rotator cuff. The first arthroscopic cuff repairs were performed using metal staples.25 Current techniques have been described by Gartsman et al, 19 Snyder, 39 Wolf and Bayliss, 46 and others using suture anchors with various methods of suture passage and knot tying.

Many techniques have been described for the repair of rotator cuff tears using arthroscopic and open techniques. This article is limited to techniques that the authors use. A discussion of the limitations and applications of the mini-open technique and arthroscopic repairs is also presented.

Section snippets

INDICATIONS

The indications for mini-open or arthroscopic rotator cuff repair are the identical indications used for open repairs. This includes patients with shoulder pain or weakness that limits work, sports, or other activities of daily living. All patients should have an appropriate course of conservative treatment before the consideration of operative intervention. The exception may involve younger or more active patients who have evidence of a large rotator cuff tear caused by an acute traumatic

Portals

The procedure is performed in the beach-chair position by one senior author (LDF) and in the lateral decubitus position by the other (FHS). The appropriate positioning of the patient is critical to the performance of the procedure. Interscalene block anesthesia and general endotracheal anesthesia are acceptable and can sometimes be combined, decreasing the amount of general anesthetics required, and can be used for early postoperative pain control.

Arthroscopic portals are placed using an eleven

Rotator Cuff Preparation

When the intra-articular pathology has been addressed and the subacromial decompression and distal clavicle resection are done, attention is directed to the repair of the rotator cuff. Assessment of the shoulder for arthroscopic cuff repair is initiated. Three areas of concern must be evaluated: (1) tendon excursion–tension, (2) tendon quality, and (3) bone quality.

Tendon excursion–tension is assessed using an arthroscopic tissue grasper placed laterally. The supraspinatus tendon is pulled

Preparation

The rotator cuff is prepared in the same fashion as the arthroscopic repair. The shaver is used to debride any degenerative cuff tissue back to a normal margin. Both the bursal and articular sides are mobilized using the shaver and blunt dissection. The area for reattachment is abraded to expose a bleeding cancellous bed. Small cuff tears and partial thickness cuff tears are marked with a no. 2 PDS suture placed arthroscopically with a spinal needle to simplify the localization of the cuff

POSTOPERATIVE REHABILITATION

Postoperatively, regardless of the repair technique, patients are placed in a sling or small abduction pillow depending on the quality of the tissue, tension in the repair, and stability of the repair. Protected passive range of motion is started immediately. Active assisted range-of-motion exercises are initiated at 3 or 4 weeks after surgery. Active exercises and a strengthening program are usually started 6 weeks after surgery, but the postoperative regimen must be individualized according

Indications

The indications for arthroscopic repair have not been fully delineated. The criteria used by Gartsman and Taverna20 was a tear that could be placed at or within 10 mm of the anatomic insertion point when traction was applied with either a grasping instrument or a traction suture. Tauro41 indicated that all patients in whom the rotator cuff could be pulled lateral to the articular surface with moderate tension after mobilization procedures were candidates. Snyder39 reported good results

Mini-Open Repairs

The goal of rotator cuff repair is to relieve pain, improve strength and function, and prevent the progression of pathology. Previous studies looking at the results of classic open rotator cuff repairs have been performed and reported pain relief in 71% to 100% of patients, with functional improvement in 72% to 82% of patients.3, 10, 11, 29, 33 The results of mini-open cuff repairs have been comparable with the results of open procedures. In 1990, Levy et al27 reported their results in 25

TRANSITION FROM MINI-OPEN TO ARTHROSCOPIC REPAIR

The transition from the mini-open technique to arthroscopic repair of the rotator cuff should not be done abruptly. The purely arthroscopic technique should be developed in a methodic pattern as adequate arthroscopic skills are developed and familiarity with the techniques are gained. The number of procedures that need to be done in a year for a surgeon to maintain an adequate skill level depends on the surgeon, but a reasonable number would be a minimum of 25. Significantly fewer procedures do

SUMMARY

The repair of rotator cuff tears by traditional open subacromial decompression and rotator cuff tendon reapproximation has proved successful in restoring function and decreasing pain, but open rotator cuff repair has some inherent disadvantages. Postoperative detachment of the deltoid repair has been reported and results in significant morbidity. The open technique may also require a longer period of limited motion resulting in greater stiffness.

Arthroscopically assisted mini-open repairs and,

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    Address reprint requests to Larry D. Field, MD, Mississippi Sports Medicine and Orthopedic Center, 1325 East Fortification Street, Jackson, MS 39202

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    Mississippi Sports Medicine and Orthopaedic Center, Jackson, Mississippi

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    References 1, 12 14, 15, 21, 31, 35, 36 and 40.

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