Mini-open Rotator Cuff Repair

Abstract

Rotator cuff pathology is a common cause of shoulder pain and disability, and becomes more common with advancing patient age. Most symptomatic rotator cuff disease is seen in patients in their fifth and sixth decades. Tears of the rotator cuff are associated with pain and weakness and can result in significant disability.¹ However, it is also known that asymptomatic rotator cuff tears exist in a large percentage of patients, and the presence of asymptomatic tears increases with increasing age.¹,² The cause of a tear of the rotator cuff is debated, but is most likely related to a combination of several factors: (1) impingement against the subacromial arch, (2) age-related degeneration or atrophy, (3) overuse, and (4) trauma.¹,³ The rationale for repairing the torn rotator cuff is derived from multiple published studies demonstrating improved function and decreased pain after rotator cuff repair and rehabilitation. Although complete healing of the tendon does not always occur, rotator cuff repair is recognized as a beneficial procedure by (1) relieving pain, (2) improving strength, and (3) improving range of motion in the affected shoulder. The earliest report of rotator cuff repair comes from Codman in 1911.⁴ Since then, many studies have demonstrated good outcomes with improved pain and function following formal open repair of the rotator cuff with decompression of the subacromial space and acromioplasty.⁵–¹² The method by which the cuff is repaired, however, has changed over the past two decades, with a movement toward minimally invasive techniques, including both mini-open and arthroscopic repair. The mini-open or deltoid-splitting approach to the rotator cuff is a well-characterized procedure with excellent outcomes and is a useful and successful method of rotator cuff repair.

Arthroscopic visualization of joints was first described in 1931, and the advent of shoulder arthroscopy in the 1980s fundamentally changed the approach to diagnosis and treatment of pathology, including rotator cuff tears.¹³–¹⁵ The rotator cuff could be visualized arthroscopically and tears could be identified and characterized. The ability to visualize the anatomy of the shoulder through the arthroscope inevitably led to strategies to treat rotator cuff tears by less invasive means. Prior to arthroscopy, rotator cuff tears were treated by formal open repair with approaches that violated the deltoid insertion on the acromion. The deltoid was removed from the acromion in order to perform an acromioplasty and decompression, and repaired to the acromion at the end of the procedure. This approach carried the risk of deltoid avulsion, a rare but catastrophic complication.¹⁶–¹⁸ Diagnosis and characterization of tears by arthroscopy led to the description of the arthroscopically assisted, mini-open, or deltoid-splitting repair technique of rotator cuff repair.¹⁹ The success of the mini-open technique was followed by the description of completely arthroscopic rotator cuff repair, which has also been successful. However, mini-open repair remains a viable alternative to arthroscopic repair and has advantages over both arthroscopic and formal open repair.