Treating Rotator Cuff Tears Through a Coracoacromial Mini-Open Approach

Abstract

The purpose of this study is to present a “smart,” open, minimally invasive surgical technique for rotator cuff repair of the shoulder. On the basis of an anatomic study by Tichy, we use a coracoacromial mobile window: We split—not detach—the deltoid muscle by respecting its fibers' orientation and resect the coracoacromial ligament before repairing the torn rotator cuff tendons with anchors. The described approach is fast, is technically uncomplicated, and can be carried out with a standard set of instruments. In cases of rotator cuff tears for which arthroscopic treatment would be very demanding, as well as in situations in which there are technical problems and/or limited access to arthroscopic equipment, this approach may serve as a backup strategy.

Numerous surgical techniques and approaches have been described and established for the treatment of rotator cuff tears of the shoulder.1, 2, 3, 4, 5, 6 However, each of these techniques is accompanied by certain pitfalls or disadvantages in terms of ease of handling, time required for the procedure, costs of the intervention,⁷ or the (poor) clinical8, 9 and biomechanical¹⁰ outcome of the operated shoulder. Therefore, a practical approach should be minimally invasive yet guarantee an appropriate size for accessing the instruments, relatively undemanding in terms of surgical handling, and anatomically intuitive. The latter has not been the case in most (historical) approaches for rotator cuff repair, such as those established by Codman (1911), Bateman (1963), or Neer (1972).¹¹ In all of these approaches, the deltoid muscle was detached and limited recovery was reported with regard to range of motion and postoperative pain.¹

Therefore, we developed a surgical approach based on an anatomic study of rotator cuff tears.¹² In this study, the described approach was shown to be superior—with respect to other established approaches—because it does not detach the deltoid muscle. In addition, it yields a lower risk of damaging key anatomic structures because there is only a small risk of damaging major blood vessels. However, the longitudinal split of the deltoid muscle must not be overextended because the axillary nerve passes about 5 cm horizontally from the acromioclavicular fixation of the deltoid muscle. Furthermore, this approach performed better when its postoperative biomechanical stability was tested.11, 12

We applied our findings in the clinical context for the first time in 2008. Because of the high satisfaction of patients, sudden pain relief, and fast regeneration of functionality, this approach was established as the standard approach for the treatment of rotator cuff tears in our clinic. Indications pro intervention are a radiologically manifest tear (e.g., on magnetic resonance imaging) and the corresponding clinical presentation of the rotator cuff tear.

Surgical Technique

Patient Positioning and Setup

Patients are seated in the beach-chair or semi-sitting position and undergo either intubation anesthesia or local anesthesia of the brachial plexus.¹³ Sterile washing of the operation site precedes sterile covering of the patient. Thereafter, an assistant holds the affected arm in an adducted and internally rotated position to relax the damaged structures. The surgeon may stand on the side of the affected shoulder, with the first assistant next to him or her (cranially with respect to the patient), while a second assistant may be standing on the opposite side.

Exposure of Rotator Cuff

The landmarks for this intervention are the coracoid process and acromioclavicular joint. For optimal esthetic results, the skin is incised—following its strain lines (Langer lines)—between those 2 landmarks at a length of 3 to 4 cm (Figs 1 and 2, Table 1). The deltoid muscle is then split dully along its fibers' orientation just above the coracoacromial ligament at a length of 3 to 4 cm. A longer incision may result in a lesion of the axillary nerve. The deltoid muscle is not detached from its origin at the acromion (Fig 3). Inserting 2 antistatic spreaders to establish a surgical window of deltoid muscle and skin exposes the coracoacromial ligament. The latter is then resected under complete visualization of its dimensions. Before the actual site of the rotator cuff tear is accessed, the subacromial bursa has to be removed (Figs 4 and 5). The rotator cuff (tear) is now visualized (Fig 6). Changing the adducted, internally rotated position of the arm will move the rotator cuff and help the surgeon grasp the torn tendons (Fig 7).

Fig 1.

Important landmarks are the acromion and coracoid process (Proc)—both are connected by the incision line of the skin (blue) (patient in semi-sitting position, right shoulder, view from ventral).

Fig 2.

The skin is already incised and thus exposes the view onto the fascia of the deltoid muscle (patient in semi-sitting position, right shoulder, view from ventrolateral).

Table 1.

Treatment Algorithm

1. Arthroscopic examination of shoulder

2. Coracoacromial skin incision

3. Deltoid muscle split

4. Resection of coracoacromial ligament

5. Resection of bursa

6. Refreshening of footprint

7. Placement of anchor

8. Refixation of torn tendons

9. Closure of deltoid muscle split

10. Single shot of antibiotics

11. Closure of skin

12. Sterile wound dressing

Fig 3.

The deltoid muscle is split (blue) along its fibers' orientation without detaching it from its footprint (patient in semi-sitting position, right shoulder, view from ventral).

Fig 4.

The coracoacromial ligament (orange) and the subacromial bursa (green) are resected (blue lines) (patient in semi-sitting position, right shoulder, view from ventral).

Fig 5.

The coracoacromial ligament is exposed at its complete length (patient in semi-sitting position, right shoulder, view from ventrolateral).

Fig 6.

The origin and onset of the supraspinatus and subscapularis muscle are shown (patient in semi-sitting position, right shoulder, view from ventral). The supraspinatus muscle has a lesion and is somewhat retracted.

Fig 7.

The rotator cuff lesion is exposed (patient in semi-sitting position, right shoulder, view from ventrolateral). The torn ends of the supraspinatus muscle are grasped with Kocher clamps.

Refixation of Torn Rotator Cuff Tendons

The retracted end or ends can now be reconnected to the humeral head by placing a Mitek anchor (Healix Ti with braided Orthocord; DePuy, Raynham, MA)¹⁴ at the proximal side of the tuberculum majus (Figs 8 and 9). However, because of occasionally severe retractions of the supraspinatus and subscapularis muscle, a prior mobilization of muscles and tendons may be required before placing the anchor. We usually use a 4.5-mm anchor. For patients with adipose tissue or large patients, a 5.5-mm anchor is recommended because forces acting on the material are expected to be higher. Degenerated tendons of poor quality that cannot be grasped with forceps need to be resected and must not be incorporated into the repair. In cases of very small tears, however, a tendon repair without an anchor may be considered a treatment option. In such cases, single nonabsorbable stitches are placed to close the slit-like tear and to prevent the tendon from further damage. As soon as the tear has been repaired, the arm is moved to examine the repair's stability through the surgical window.

Fig 8.

An anchor (blue) is placed, and the ends of the torn tendon are sutured together (patient in semi-sitting position, right shoulder, view from ventral).

Fig 9.

The anchor has already been placed, and the tear has been closed (patient in semi-sitting position, right shoulder, view from ventrolateral).

Wound Closure and Postoperative Care

The wound is rinsed with isotonic sodium chloride solution. Releasing the spreader from the deltoid muscle results in an almost perfect adaption (Fig 10) of the split. The wound is closed in layers starting with a fasciorrhaphy of the deltoid muscle (Fig 11); a single shot of cephalosporin is administered, subcutaneous single stitches are placed, and an intracutaneous skin closure is performed (Fig 12) and covered with sterile wound dressing (Video 1).

Fig 10.

The deltoid muscle is self-relapsing when removing the spreader (patient in semi-sitting position, right shoulder, view from ventral).

Fig 11.

The deltoid muscle split is reclosed by single stitches (blue) (patient in semi-sitting position, right shoulder, view from ventral).

Fig 12.

The skin is closed with an intracutaneous suture line (patient in semi-sitting position, right shoulder, view from ventral).

Oral narcotics and cryotherapy with a cryo-cuff are prescribed to patients for postoperative pain management. We abstain from placing patients in a sling or abduction splint. Rather, patients undergo mobilization immediately with passive assisted range of motion for 4 weeks. Sutures are removed after 10 days (Fig 13), and about 4 weeks after the intervention, patients begin a progression-to-strengthening program.¹⁵

Fig 13.

Wound on day 10 postoperatively (patient in semi-sitting position, right shoulder, view from lateral). Wound dressing and suture were just removed.

Discussion

On the basis of our study, we showed that no important anatomic structures are critically threatened and the involved muscle tissue is treated with maximal care. The direct exposure of the lesion and the possibility to stretch and manipulate retracted rotator cuff muscles or tendons are most beneficial for the operative handling and a stable repair. These are crucial for the repair of retracted tendons for which mobilization by an arthroscope is most challenging or impossible. The relatively short duration of this intervention (medium duration, 30 minutes) and patients' great contentment regarding small or non-persisting scars add further value to this technique (Table 2).

Table 2.

Advantages and Disadvantages

Advantages

Simple operative handling—even for large tears

Easy to perform intraoperative, passive range-of-motion control with testing of suture intactness

Short intervention time

Satisfying esthetic result

Retear due to suture or anchor insufficiency not reported

Disadvantages

There is a relative risk of axillary nerve injury.

Tears with retracted tendons and atrophic muscles may impose a surgical challenge.

Complex injuries with humeral, clavicular, or scapular fractures or omarthrosis impose relative contraindications.

Emphasizing the logistic and surgical conveniences and the anatomy-adjusted features of this approach, we propose its use as an elective technique or as a backup treatment option for situations that are very challenging to handle in an all-arthroscopic manner. If a standard primary arthroscopic exploration is performed, a subsequent decision to perform a secondary open treatment can be combined with the described approach.1, 16, 17

As stated earlier, many techniques for the treatment of rotator cuff tears of the shoulder already have been described. Starting with Codman, followed by Bateman, De Palma, Neer, and other authors,⁶ many variations of open surgery for rotator cuff tears have been described with increasing frequency. This process reached a preliminary climax with the description of the modern mini-open and all-arthroscopic techniques, which are widely established, commonly used techniques with similar outcomes.¹⁸ Whereas the primary mentioned, historically used techniques were associated with unsatisfying functional results and often with “maximally invasive” surgery, the later techniques (mini-open, all-arthroscopic) showed similar appealing recovery rates but were noted to have difficulties treating massive and retracted tears.

From an economical point of view, the “smart open” approach yields several benefits. Aside from the short operation time, expenditures for operation instruments are low because cost-intensive arthroscopic operation devices may not be required if the primary exploration is performed in an open manner. Another strength is the fast-tracked “de-hospitalization,” which allows day-care hospital treatment or release on the first postoperative day.

The advantage of this smart open approach to the already established mini-open technique is its capability of managing retracted cuff tendons. It pursues anatomic conformity and minimal invasiveness.

Just as with other techniques, surgeons using this approach may encounter difficulties in cases of degenerative tears with end-stage atrophic, degenerated muscles and tendons that are impossible to be mobilized from the scapula. In such cases, only physiotherapeutic measures and effective pain management will help overcome severe limitations to patients' well-being.19, 20

In general, this approach represents a solid method for the treatment of rotator cuff tears of all dimensions and can be regarded as a sustainable backup strategy if other established techniques yield major difficulties.

Supplementary Data

Video 1

Surgical treatment (patient in semi-sitting position, left shoulder, view from ventral): (1) skin incision, (2) split of deltoid muscle, (3) resection of coracoacromial ligament, (4) identification of torn tendons, (5) preparation of footprint, (6) placement of anchor, (7) refixation of torn rotator cuff tendons, (8) closure of deltoid muscle split, (9) local application of cephalosporin, and (10) closure of skin.