The arthroscopically assisted open repair has limitations when dealing with large or massive rotator cuff repairs. The necessary surgical releases can be difficult, if not impossible, to perform through a small transdeltoid split. Significant traction on the deltoid during a difficult rotator cuff exposure, may be associated with increased episodes of frozen shoulder.
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 debridement of cuff edges, extensive releases, cuff mobilization, tuberosity preparation, and even suture anchor placement, is done in an arthroscopic fashion. The tendon edges may be delivered 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.
When compared to complete arthroscopic repair, the mini-open repair provides more secure bone-to-tendon fixation since tendon gripping sutures and bone augmentation can be used.
How is a Mini-Open Rotator Cuff Repair Performed?
The patient is placed in a semisitting, upright beach-chair position. A shoulder positioning device facilitates patient patient positioning. Once the shoulder is scrubbed, prepped and draped, all boney landmarks are carefully outlined with a skin marking pen to facilitate portal placement.
The arthroscope is placed in the glenohumeral joint through the posterior portal and a thorough evaluation of the joint is performed. The rotator cuff tear is identified and a lateral portal is created.
Rotator cuff mobilization starts with an intra-articular release. A hooked electrocautery device is used to release the cuff from the glenoid labrum. This allows mobilization of the entire cuff if necessary (anterior to posterior). Once the intra-articular release has been performed, the arthroscope is directed to the subacromial space.
Dr. Mazzara follows this with an arthroscopic subacromial bursectomy. The tuberosity (area of rotator cuff insertion) is slightly decorticated but a formal trough is not created. A shaver is used to debride any of the torn cuff edge that appears to be nonviable or attenuated. Stay sutures are placed in the edge of the cuff tear approximately 1 centimeter apart. Additional releases of the cuff from the glenoid are performed as necessary.
At this point the mini-open approach is initiated. A horizontal lateral incision (3-4 cm long) is made over the lateral edge of the acromion. The deltoid muscle fibers are split to expose the rotator cuff tear.
If the tear is small and easily mobilized, sutures are placed through the edge of the cuff tear which is then repaired using the suture anchors placed in the superolateral aspect of the greater tuberosity. For large tears under some tension, special intratendinous sutures are placed through the cuff and these are then repaired using the suture anchors placed in the superolateral greater tuberosity.
Following the repair, a layered wound closure is performed. An arm immobilized will be necessary for 4 to 6 weeks. Therapy is initiated after surgery depending on the size of the tear, quality of the tendon and the strength of the bone.
- Yamaguchi, K: Mini-open rotator cuff repair. JBJS, 83-A, 764-772, May, 2001.