Maximizing Results of Mini-Open Cuff Repair by Increasing Footprint Contact
By Edward G. McFarland, MD, Tae Kyun Kim, MD, PhD, and Atsushi Yokota, MD, PhD
While arthroscopic rotator cuff repair techniques have received increasing attention over the past decade, there are many options for the surgeon who treats rotator cuff disease. Open repair remains the "gold standard," but combined arthroscopic and mini-open techniques bridge the gap between purely open and purely arthroscopic techniques. There are many variables, involving both patient and surgeon, to consider when discussing any technique for repairing a torn rotator cuff. We believe that open and mini-open techniques remain a reasonable technique for most surgeons, and like many surgeons, in our hands these techniques provide the greatest latitude in treating rotator cuff disease.
Any discussion of the treatment of rotator cuff disease should be tempered by new knowledge in this area. The traditional concept of external or subacromial impingement as popularized by Neer has been questioned, and new concepts of rotator cuff disease include normal tendon senescence, internal impingement of the cuff against the superior glenoid, coracoid impingement, and tension overload. These competing theories reflect the uncertainty over what produces cuff tears and the pain that accompanies cuff disease. There is also increasing appreciation that the coracoacromial ligament is not a vestigial structure and along with the acromion prevents anterior-superior subluxation.1 Some have suggested that acromioplasty and coracoacromial ligament release are not necessary in all cases. Lastly, the deltoid attaches to the acromion via direct tendinous attachment; thus, arthroscopic acromioplasty releases some deltoid muscle by definition. The amount of deltoid released by any technique is only 1 of many factors influencing the surgical result, but most studies demonstrate that the major factor is the size of the rotator cuff tear. We do not hesitate to use open techniques for any tear due to these factors.
For the surgeon who has the training and experience to perform arthroscopic acromioplasties, there are several options for repairing torn rotator cuff tendons. The first option is to expand the lateral arthroscopy portals either vertically or in line with the skin creases horizontally. We prefer the latter since it is more cosmetically acceptable and can be more easily extended if more exposure is needed. The deltoid is then split in line with its fibers but not detached from the acromion. The cuff tear can be repaired to the tuberosity using either suture anchors, transosseous sutures through the greater tuberosity, or both. A second approach has been called the "advanced mini-open approach," which is promoted as a transition to all arthroscopic techniques. In this case, arthroscopic techniques are used to release adhesions and to place retention sutures in the cuff edges, and then a traditional mini-open repair is performed.2
Several studies have demonstrated that mini-open techniques have results similar to open techniques for small, medium, and large tears.3,4 Mini-open techniques are possible for massive tears, but the limited exposure makes mobilization and repair of tears this size difficult. Mini-open techniques are not indicated for repair of multiple tendons, particularly the subscapularis tendon. Lastly, tendon transfers such as with the pectoralis or latissimus cannot be accomplished with this approach.
There are several advantages to mini-open techniques. First, the surgeon does not need advanced arthroscopic skills except the ability to perform an arthroscopic acromioplasty and coracoacromial ligament release. Secondly, there is some evidence that sutures tied by hand have less creep than arthroscopic knots. Third, mini-open techniques are easily expanded by release of portions of the deltoid. Lastly, the learning curve is shorter and operative time may be shorter for surgeons who do not have the facilities or competent assistants available.
Open and mini-open techniques also offer the surgeon the ability to increase the rotator cuff tendon contact back to the "footprint" of the tendon on the greater tuberosity. Studies have shown that the rotator cuff tendons, particularly the supraspinatus, do not have 1 point of fixation but rather attach to the greater tuberosity over a broad area (see Figure 3A, below).5 The goal of surgery is to provide secure fixation to as much of the tendon as possible. As a result, several techniques have been devised to increase contact of the rotator cuff to the footprint. The first is to place 2 rows of transosseous sutures, but this increases the possibility of sutures being cut or of sutures losing fixation in the tuberosity. The second is to place a row of suture anchors medially and transosseous sutures laterally (see Figure 3B, below).3 This technique allows the use of transosseous sutures that have been found to increase contact to the footprint.6 This is currently our preferred method of repair of rotator cuff tendons whether the repair is performed open or as a mini-open technique. In cases where the tendon contact is still not as good as desired, we will tie the sutures from the lateral side of the humerus to the sutures from the suture anchors, which has the effect of pulling the lateral tendon edge directly into contact with the bone. Optimizing contact of the rotator cuff to the footprint can be easily accomplished with mini-open techniques that are within the technical expertise of most surgeons.
Drs. McFarland, Kim, and Yokota, Division of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore
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3. Fealy S, Kingham TP, Altchek DW. Mini-open rotator cuff repair using a two-row fixation technique: Outcomes analysis in patients with small, moderate, and large rotator cuff tears. Arthroscopy. 2002;18:665-670.
4. Shinners TJ, et al. Arthroscopically assisted mini-open rotator cuff repair. Arthroscopy. 2002;18:21-26.
5. Dugas JR, et al. Anatomy and dimensions of rotator cuff insertions. J Shoulder Elbow Surg. 2002;11:498-503.
6. Apreleva M, et al. Rotator cuff tears: The effect of the reconstruction method on three-dimensional repair site area. Arthroscopy. 2002;18:519-526.