Commentary & Perspective

Commentary & Perspective on
"Atrophy of the Deltoid Muscle Following Rotator Cuff Surgery"
by Yukihiko Hata, MD, et al.

Commentary & Perspective by
Evan L. Flatow, MD*,
Lasker Professor of Orthopaedic Surgery, Leni and Peter May Department of Orthopaedic Surgery, Mt. Sinai Medical Center, New York, NY

The repair of rotator cuff tears has been a common orthopaedic procedure for almost a century^1,2. Neer et al. established the basic principles of routine decompression by acromioplasty and tendon repair to bone^3,4, but there have been challenges to this approach. Some authors have advocated repair without decompression⁵ or decompression without repair⁶. Nevertheless, open decompression and repair of the rotator cuff has been a very successful, durable procedure^7-9.

With the advent of minimally invasive approaches, certain aspects of this procedure became amenable to arthroscopic techniques, so that first mini-open and, more recently, a fully arthroscopic cuff repair have been reported^10-14. Much of the debate has centered around the ability of entirely arthroscopic techniques to effect a secure tendon-to-bone repair, and thus the mini-open repair has appealed to some surgeons as a technique which achieves the "best of both worlds": the reduced morbidity of an arthroscopic procedure, especially with respect to deltoid injury, and the security afforded by an open tendon repair¹⁴. However, higher than expected rates of stiffness and infection have been reported after mini-open repair^15,16, and it remains unclear whether this procedure is more than just part of a transitional strategy from open to arthroscopic techniques¹⁴. Indeed, the essential value of the mini-open technique rests on the presumption that the deltoid is substantially less damaged when split than when taken down and repaired. The current study is an attempt to make an objective assessment regarding the truth of this belief.

In this retrospective cohort study, the authors compared the results of open and mini-open rotator cuff repair. They found less postoperative anterior deltoid thickness as measured on standardized magnetic resonance imaging scans and slower return to work or sports in the "open" group. It must be noted, however, that although the differences in anterior deltoid thickness were significant, they were small—the average anterior deltoid thickness in the open group went from 18.4 mm preoperatively to 15.6 mm postoperatively, which was approximately 3 mm of difference. There were no frank deltoid detachments in either group. As in a previous study¹⁷, there were no differences in the final outcome with regard to the open and mini-open techniques, although active flexion was transiently better with the mini-open approach.

A concern about the applicability of these findings to general practice is that neither technique is widely used today. The "mini-open" repair does not include the use of arthroscopic acromioplasty: the bone resection is performed by osteotomes and rasps through the deltoid split. This is probably more in the tradition of a "conservative" open repair, as described by McShane and coworkers¹⁸. The open technique that they described transects the deltoid 2 cm distal to the anterior edge of the acromion, leaving a proximal stump of deltoid muscle to which the deltoid was later repaired with horizontal mattress sutures. This is certainly quite traumatic to the deltoid.

Most surgeons who use open techniques for rotator cuff repair currently use a "deltoid-on" approach, which involves elevating the deltoid subperiosteally^19,20 or repairing the deltoid through bone tunnels in the acromion. Also, postoperative bracing at 90^o of abduction (now uncommonly used) may have helped to reduce deltoid pull-off in the open group in this study. It is interesting that not a single retear of the cuff tendon repair was noted at follow-up, even though thirty-six patients had large tears preoperatively. This result is much better than the previously reported results for open or arthroscopic repairs^9,21,22.

We may conclude from this study that better deltoid preservation does result from less-traumatic approaches. The authors provide objective evidence that deltoid atrophy can be reduced when operative trauma to the deltoid is minimized, and their work supports current efforts to develop better minimally invasive approaches for shoulder surgery.

*The author did not receive grants or outside funding in support of his research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

References

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