In general, two surgical strategies have been used for the mini-open
repair. The more established method has been arthroscopic decompression
followed by a standard open repair through a lateral deltoid split. This
technique was initially described by Paulos and Kody6. In the alternative strategy, more extensive
arthroscopic assistance is used. Specifically, arthroscopic decompression
is performed, but extensive rotator cuff mobilization is also done during
the arthroscopic portion of the procedure. Afterward, arthroscopic
tagging sutures or stay sutures are placed, and preparation of the
greater tuberosity, débridement of the rotator cuff tendon,
and placement of suture anchors might all be done arthroscopically
as well. The small lateral deltoid split is then performed in order
to place tendon-gripping sutures on the previously mobilized cuff
and to fix the cuff to bone with use of the surgeon’s
preferred method, whether it be suture anchors or transosseous
sutures.
The two strategies of mini-open repair are fundamentally different
with regard to the manner in which arthroscopic assistance is used
(Table II).
In the more established method, arthroscopic surgery is used simply
to perform a decompression; it plays a small role in the actual
performance of the rotator cuff repair. This method can be referred
to by the traditional designation of an arthroscopically assisted
open-repair technique. In the second strategy, the decompression
and rotator cuff repair are primarily performed arthroscopically
and a small portal-extension approach is performed simply to obtain secure
tendon-to-bone fixation of a previously mobilized cuff. This surgical
strategy can be referred to as a mini-open assisted arthroscopic
rotator cuff repair. In the first case, the emphasis is on open
repair techniques; in the second, the emphasis is on arthroscopic repair.
Because a lateral open deltoid-splitting approach is used in both
strategies, the term mini-open repair can be applicable to both.
However, the surgical techniques are distinctly different and are
associated with different advantages and disadvantages (Table III).
The more established arthroscopically assisted open-repair technique
requires less arthroscopic experience or expertise. For surgeons
who have less experience with arthroscopy of the shoulder, the technique
is less technically demanding and more readily performed. However,
this technique is directly limited by the size of the lateral deltoid
split. When a smaller approach is used for large or massive rotator
cuff tears that are chronic in nature, it can be difficult, if not
impossible, to perform all necessary surgical releases through a
limited transdeltoid opening. If repair of a large or massive rotator
cuff tear is attempted in this fashion, the surgeon is essentially "squeezing" a
large operation through a small opening. Although a formal anterior
deltoid takedown is not performed in a classic mini-open approach,
an attempt to repair a large tear can still lead to substantial
deltoid injury from traction intraoperatively. This may help to
explain why some surgeons have reported increased episodes of frozen
shoulder and even deltoid injury following mini-open repair.
In contrast, a mini-open assisted arthroscopic repair should
not be limited by the size of the lateral deltoid split. All rotator
cuff preparation, including débridement of cuff edges,
extensive releases, cuff mobilization, tuberosity preparation, and
even suture-anchor placement, is done in an arthroscopic fashion,
if desired. Because the rotator cuff has been previously mobilized and
tagged, the tendon edges can be delivered directly to the small opening
for placement of tendon-gripping sutures and then fixation to bone.
Because a majority of the surgery has been performed arthroscopically,
the time requirement and the exposure for the deltoid-splitting
portion should be reduced and deltoid injury should be minimized.
The technique, however, is associated with some substantial disadvantages.
A large amount of experience with arthroscopy around the shoulder
is a prerequisite for most surgeons if they are to have the expertise
to perform all of the necessary surgical releases and suture placement. The
technique also relies heavily on uncompromising visualization of
the rotator cuff and the surrounding structures. Without this, the
surgeon can be easily misled during rotator cuff preparation. However,
as technically demanding as the arthroscopic portion of this procedure
can be, it is still substantially easier from a technical standpoint
than complete arthroscopic repair. In addition, compared with complete arthroscopic
repair, the mini-open repair may provide more secure bone-to-tendon
fixation, as tendon-gripping Mason-Allen sutures and bone augmentation can
be used37,38.
Open and arthroscopic shoulder surgery at our institution is
performed with the patient under regional anesthesia with an interscalene
block and supplemental laryngeal mask general anesthesia. The interscalene
block has been a reliable and safe method for obtaining intraoperative
and postoperative pain relief39.
The intraoperative pain relief obtained with the block reduces the
requirement for general anesthesia. Laryngeal mask anesthesia is
performed in addition to the interscalene block to obtain more reliable,
responsive control of systolic blood pressure, which is essential
for the more complex arthroscopic techniques. The patient is placed
in a semisitting, upright beach-chair position with the back elevated to
approximately 70° to 80°. A shoulder arthroscopy positioning device
is often helpful. At our institution, a universal locking head-and-arm
holder is used. Once the patient is positioned on the table with
the medial aspect of the scapula in line with the lateral aspect
of the table, 20 mL of 0.25% bupivacaine hydrochloride
containing epinephrine is injected into the subacromial space. Early
injection of the bupivacaine hydrochloride with epinephrine prior
to preparation and draping of the patient allows for enhanced vascular
constriction from the epinephrine. This step can substantially decrease surgical
bleeding and improve visualization. Once the shoulder is prepared
and draped, all osseous landmarks are carefully outlined with a
marking pen to help to facilitate accurate portal placement.
Accurate portal placement is especially important for advanced
arthroscopic techniques about the shoulder. The posterior portal
is generally placed approximately 1 to 2 cm inferior to the posterior
edge of the acromion and 2 cm medial to the posterolateral corner.
This portal is generally placed slightly more superiorly than the
usual posterior portal for arthroscopy in order to obtain a better
line of sight to the subacromial bursa for arthroscopic repair.
The anterior portal is positioned just lateral to the palpable coracoid
tip. The lateral portal is generally placed 1 cm posterior and 3
cm inferior to the anterolateral corner of the acromion. The exact placement
of this portal is determined by needle localization during arthroscopy.
The arthroscope is first placed in the glenohumeral joint through the
posterior portal. A standard glenohumeral inspection is performed.
Of particular importance is the careful visualization of the biceps
tendon. Often the lesion in the biceps tendon is in the intertubercular
groove portion and is not readily seen on initial inspection of
the intra-articular portion. A hook should be used to pull the tendon
into the joint and ensure that there are no structural problems
with the tendon laterally. When the tendon has a structural abnormality (such
as a partial tear, atrophy, or chronic enlargement), either biceps
tenodesis or tenotomy is the treatment of choice40.
When the tendon looks either normal or just inflamed, surgical treatment
for the biceps is not recommended. Next, the rotator cuff tear should
be visualized, and its location and size should be determined. This
helps the surgeon to identify where the appropriate placement of
the lateral portal should be. Finally, the subscapularis should
be carefully visualized to verify its integrity.
Rotator cuff mobilization starts with an intra-articular release. This
should be performed with the arthroscope in the posterior portal
and a hook multipolar electrocautery device in the anterior portal.
Normally, a pouch is present superior to the glenoid labrum between
the undersurface of the rotator cuff and the superior or posterosuperior
portion of the lateral aspect of the glenoid neck. A hook probe
should be placed in this location to determine if the rotator cuff
is attached by scar tissue to the superior part of the labrum. The release
is performed by taking the hook multipolar electrocautery device
and sharply releasing adhesions between the undersurface of the
cuff and the superior portion of the glenoid labrum, starting from
anterior and progressing toward posterior (Fig. 1). The electocautery
device is oriented away from the suprascapular nerve, which
is medial. A circumferential release around the posterior, anterosuperior,
and posterosuperior parts of the labrum can be accomplished all
the way to the posterior portal. This release is probably the most
important way to mobilize the cuff. In addition, it is probably
more readily performed with arthroscopy than with an open procedure,
in which access to the posterior part of the glenoid and the posterosuperior
part of the rim is difficult secondary to obstruction by
the humeral head. Once this intra-articular release has been performed,
the arthroscope is withdrawn and attention is directed to the subacromial
space.
An arm-holder is used in order to apply in-line traction on the humerus.
The arm is adducted, forward flexed, and slightly internally rotated,
which opens up the subacromial space for good visualization. The
arthroscope is then redirected into the subacromial space from a
posterior direction. Upon entrance into the subacromial bursa, a needle
is used to localize the appropriate location for the lateral portal.
The lateral portal location should allow a parallel orientation
of the burr to the undersurface of the acromion and should also
be centered over the middle of the rotator cuff tear. In general,
this portal is located 1 cm posterior to the anterolateral corner
of the acromion and 3 cm inferior to it. The portal is made in the
direction of the Langer skin lines in a horizontal fashion.
A subacromial bursectomy is then performed, initially starting out
with a full radius resector and usually followed by use of a multipolar
electrocautery device. Care should be taken to visualize the cuff
first to make sure that the bursa, and not the rotator cuff, is
being debrided. The anteriormost portions of the bursa are debrided
first, and the débridement also includes excavation of the
soft tissues from the undersurface of the acromion, from the anteroinferior
edge and posteriorly. The arthroscope is then switched to the lateral
portal, and the electrocautery device is placed posteriorly (Fig. 2). The electrocautery
device is swept from lateral toward medial and then from anterior
toward posterior, again excavating the bursa off the rotator cuff
all of the way medial to the base of the acromion. Generally, the
bursa from the underlying rotator cuff can be removed completely
in this fashion. Because the arthroscope is placed laterally, visualization
can be obtained all of the way around the teres minor posteriorly
and inferiorly. Excellent visualization of the subacromial space
and the undersurface of the acromion should be obtained in this
fashion. At this time, the arthroscope is replaced into the posterior
portal and, with use of a burr placed into the anterior portal,
an anterior-inferior acromioplasty is performed. The degree of acromioplasty
performed and whether a coracoacromial ligament release is added depend
on the reparability41 of the cuff
tear and the size of the anterior-inferior spur, if one is present.
When the rotator cuff is not reparable, the coracoacromial arch
and, more specifically, the anterior-inferior aspect of the acromion
and the coracoacromial ligament become important as secondary stabilizers
against superior migration of the humeral head. Resection of the coracoacromial
ligament in the presence of a massive rotator cuff tear can lead
to a loss of containment of the humeral head such that it will migrate
in an anterior-superior direction33.
Because of this, when the rotator cuff is not reparable, the coracoacromial
ligament as well as the anterior-inferior aspect of the acromion
generally should be preserved. At this point, a mini-open approach
through a lateral deltoid split can be performed if the surgeon
is not experienced with the more technically difficult arthroscopic
procedures.
It should be noted that, throughout the subacromial procedure, careful
attention should be paid to blood-pressure control. As a general
rule, systolic blood pressure should not exceed 120 mm Hg. The pump
pressure is generally set at 40 mm Hg, but it can be raised as high
as 60 mm Hg as necessary to control bleeding. Elevated pump pressures,
however, are associated with more rapid soft-tissue distention and edema,
conditions that will eventually obscure visualization. Following
decompression, an uncompromised visualization of the rotator cuff
should be achieved (Fig. 3). The rotator cuff tear should
be seen from its most anterior aspect all of the way to its most posterior
aspect. This visualization is a prerequisite for additional arthrocopic
preparation of the rotator cuff.
At this point, an arthroscopic shaver is placed into the lateral portal
and the greater tuberosity is debrided in preparation for later
rotator cuff repair. The tuberosity is slightly decorticated, and
any extraneous soft tissue is removed. A formal bone trough is not
created; indeed, it is contraindicated if a suture anchor
is to be used. Next, the shaver is used to debride any of the torn
cuff edge that appears to be nonviable or attenuated. Care should
be taken to do only a limited débridement.
Stay-suture placement is initiated at this time. Several different
devices for suture placement are available. The Caspari suture punch
(Linvatec, Largo, Florida) is delivered through the lateral portal
(Figs. 4-A and 4-B). A place in the
midportion of the rotator cuff tear is selected, and the suture
punch is used to grasp the cuff at this location. The suture punch
is then used to assess the mobility of the rotator cuff tendon.
For the majority of cases, a release of the rotator cuff from the
superior aspect of the glenoid labrum and the superficial bursa
generally results in sufficient mobilization of the rotator cuff
tissue. In rare cases, when the cuff is assessed with the suture
punch, additional releases are found to be necessary. When these
releases are necessary, the suture punch is withdrawn and the arthroscope
is placed through the lateral portal. An electocautery device is
then placed into the anterior portal and brought down into the base of
the coracoid, after which a coracohumeral ligament release is performed
right down to the base of the coracoid, on its superficial surface.
It should be noted that the base of the coracoid has already been
debrided on the articular side during the circumferential glenoid
release. The sharp débridement can be performed from the
base of the coracoid all of the way out laterally to the bicipital
groove as a rotator interval release, when necessary, although this
option is rarely needed. Finally, if this release is not sufficient, a posterior
interval release can be performed arthroscopically. The arthroscope
remains in the lateral portal, and the electrocautery device is
switched back to the posterior portal. The base of the acromion
and the scapular spine can be visualized quite readily from the
lateral portal, and the electrocautery device can then be delivered
to this location. Next, the rotator cuff is mobilized from the scapular
spine and the base of the acromion in a sharp fashion. Once these releases
have been done, the mobility of the cuff is reassessed by grasping
the tissue with the Caspari suture punch.
After all of these releases have been performed, only in a rare case
will the rotator cuff not be reducible to the greater tuberosity.
At this point, multiple shuttle-relay devices (Linvatec) are delivered
by the Caspari suture punch into the anterior, middle, and posterior
portions of the rotator cuff tear. In general, these stay sutures
are separated by 1 cm, and the number required depends on the transverse dimension
of the rotator cuff tear. Use of a shuttle-relay device or, alternatively,
a #1 proline suture doubled onto itself allows the surgeon
to place the rotator cuff into a reduced location and also to later
pass either transosseous sutures or suture anchors into the cuff
for bone fixation.
At this time, the mini-open approach is initiated (Figs. 5-A, 5-B, and 5-C). The horizontal
lateral incision is enlarged to a length of 3 to 4 cm. The subcutaneous
tissue is then undermined to expose the underlying deltoid fascia.
The deltoid is then split in line with its fibers, incorporating
the arthroscopic puncture site. This split is generally carried
up to the acromion and distally for about 3 to 4 cm. As the cuff
has been previously mobilized and stay sutures have been already placed,
a surprisingly small deltoid split is necessary at this time. An
additional bursectomy can be performed at the split site to improve
visualization, but generally this is not necessary because of the
extensive bursectomy previously performed with the electrocautery
device. Rotation of the arm allows different portions of the cuff
to be visualized through the deltoid split.
Bone-tendon fixation is performed at this time. If the tear is small
and easily mobilized, simple stitches placed through suture anchors,
which are embedded in the superolateral aspect of the greater tuberosity, are
preferred. For large tears under some tension, Mason-Allen stitches
in the cuff, once again placed through suture anchors in the superolateral
location on the greater tuberosity, are preferred37,42.
Alternatively, transosseous fixation can be used; however, many
studies have documented that the strength of suture anchors placed
in the superolateral portion of the greater tuberosity is equal
to or greater than that of transosseous sutures42-44.