OPEN REPAIR OF ROTATOR CUFF TEARS

The primary goal of rotator cuff repair is pain relief, and this can be accomplished with open or arthroscopic techniques. Functional improvement depends on the age of the patient, the size of the tear, and the postoperative rehabilitation program. Surgery is appropriate for acute rotator cuff injuries in patients with a defined injury who are suddenly unable to externally rotate the arm against resistance. Surgery is contraindicated in patients with rotator cuff tears and stiffness; the stiffness must be corrected before repair.



OPEN REPAIR OF ROTATOR CUFF TEARS
■ Place the patient in a semi-upright position with the head elevated 30 to 35 degrees (beach chair position). Place a towel or an intravenous bag medial to the scapula to stabilize it. This degree of head elevation usually places the superior acromial surface perpendicular to the floor allowing the acromial osteotomy to be made perpendicular to the floor. Drape the arm free to permit shoulder rotation.
■ Outline the bony contour of the shoulder including the lateral acromial border, coracoid, and acromioclavicular joint.
■ Outline the proposed skin incision along the Langer line 4 to 6 cm long and infiltrate it with 10 mL of  1 : 500,000 epinephrine to minimize bleeding.



■ After mobilization of the subcutaneous tissue, identify the raphe between the anterior and middle deltoid and split it from a point 5 cm or less distal to the acromial border (to avoid axillary nerve injury) toward the anterolateral acromion.
■ The deltoid can be left attached or can be detached from the corner of the acromion depending on the surgeon’s preference. We prefer to leave the deltoid attached initially, detaching it later if the procedure warrants.

■ To use this approach, elevate a flap of deltoid with its periosteal attachment and the periosteal attachment of the trapezius approximately 2 cm onto the superior acromial surface.
■ Carry this medially as far as the acromioclavicular joint (the anterior capsule of which usually is included in the flap) and 1 cm along the lateral acromion. Occasionally these periosteal attachments are tenuous after elevation and the deltoid must be detached, to be secured later to the acromion through drill holes. We have found that using electrocautery with a Bovie needle for elevation usually ensures thicker flaps.
■ The importance of correct deltoid detachment cannot be overemphasized. A secure cuff of tissue must be maintained for later defect closure or reattachment to the acromion. Without secure deltoid attachment, the results of the acromioplasty would be compromised by lack of deltoid function.
■ After completing the anterior limb of the elevation, resect the coracoacromial ligament. We use the electrocautery for this as well because the acromial branch of the coracoacromial artery is contained within the ligament and electrocautery allows exposure of the entire subacromial space.
■ With the subacromial space exposed, resect the bursa along with all adhesions and soft tissue coverage from the acromial undersurface. The bursa can be quite thick and easily mistaken for the rotator cuff tendon. The bursa can be identified by its continuity with the acromial undersurface and its unilaminar appearance as opposed to the multilaminar appearance of the rotator cuff.



■ After bursal resection use an oscillating saw or rongeur to remove the portion of the acromion that projects anterior to the anterior border of the clavicle. This removes a portion of the offending acromial hook and squares off the surface allowing easier completion of the acromioplasty with an oscillating saw or an osteotome. We prefer an oscillating saw for this portion of the procedure because it affords more control than an osteotome, which may propagate a fracture line into the posterior acromion.
■ Begin the osteotomy at the anterosuperior aspect of the acromion and continue it through the junction of the anterior and middle thirds of the acromion, including the entire anterior acromion from medial to lateral.
■ Use a curved, blunt Hohmann or malleable retractor to depress the humeral head and protect the cuff during this portion of the procedure.
■ Smooth out any rough surfaces with a rasp.
■ Palpate the acromioclavicular joint undersurface and remove any bony spurs.
■ If severe degenerative changes are present, resect the distal 1.0 to 1.5 cm of the lateral clavicle. Preoperative
radiographs and symptoms should indicate the necessity of this additional procedure, and it should not be done routinely.
■ If the clavicle is resected, leave the superior acromioclavicular capsule intact to make deltoid repair in this area easier. Do not extend the clavicular cut beyond 1.5 cm to avoid violating the coracoclavicular ligaments and making the distal clavicle unstable.
■ After standard acromioplasty, evaluate the rotator cuff tear carefully.
■ Tears usually begin at the supraspinatus insertion, and the end retracts into its fossa under the acromioclavicular joint. Most tears not only are transverse but also have a longitudinal component making them oval or triangular. All but the smallest tears need to be advanced anteriorly and laterally, not just laterally, to restore anatomical position and correct muscle-tendon unit length. In tears of more than 2 to 3 cm the infraspinatus tendon is involved as well.
■ When the defect has been identified and its size approximated, attention is turned to the repair itself. Usually some degree of mobilization is necessary.


■ Begin mobilization posteriorly with the infraspinatus, using a blunt probe or a finger to release adhesions
inside and outside the joint. Do not dissect below the level of the teres minor to avoid injury to the axillary
nerve in the quadrangular space or the suprascapular nerve in the area of the spinoglenoid notch near the inferior border of the supraspinatus fossa. Supraspinatus and subscapularis muscles have fascial attachments to the coracoid base via the coracohumeral ligament. Lateral mobilization of the retracted cuff is facilitated by release of these attachments.
■ Continue mobilization anteriorly to the supraspinatus. If necessary more exposure can be gained by resecting the distal 1.0 to 1.5 cm of the clavicle at the acromioclavicular joint, but this should not be done unless concomitant acromioclavicular arthrosis exists. Release of the coracohumeral ligament in this area allows further mobilization of the supraspinatus laterally.


■ If the supraspinatus and infraspinatus tendons are retracted so far that adequate length cannot be obtained
with tendon mobilization, incise the capsule at its insertion into the glenoid labrum. If necessary carry this
incision from the 8-o’clock position posterior to the 4-o’clock position posterior.
■ The use of a second posterior incision over the scapular spine to increase mobilization has been described,
but we have no experience with this technique.
■ Debride the end of the mobilized tendon to obtain a raw edge, taking care not to confuse the tendon with
the overlying bursa. The goals of mobilization are to obtain tissue of adequate strength, to position it anatomically
for repair without damage to innervation and without compromise of deltoid function, and to
decompress the subacromial space to prevent further mechanical impingement on repaired cuff tissue.
When these goals are accomplished the actual repair can be performed. We believe that the best results bination
with suture anchor fixation. This reduces tension on the primary trough repair and increases the
surface area of tendon-to-bone healing.
■ With no. 2 nonabsorbable suture, use a double loop technique, superior to inferior and inferior to superior
in a horizontal mattress manner. This helps push the tendon down into the trough.

■ Use a rongeur or burr to create a shallow trough running the length of the exposed bone of the greater
tuberosity to accommodate the thickness of the supraspinatus and infraspinatus tendons. Bevel the proximal edge with a burr or rasp.

Place two or three rotator cuff suture anchors immediately medial to the trough at a 45-degree angle and
pass the suture through the rotator cuff tendon 3 to 5 mm medial to the sutures in the free end of the
tendon.

■ Drill holes for sutures 2 to 3 cm distal to the trough and connect them to the trough using a no. 5 Mayo needle, a towel clip, or a specialized instrument (Concept, Largo, FL). Take care not to fracture the thin cortical bone in this area, which may be osteoporotic. Space the holes at least 5 mm (preferably 1 cm) apart on the cortical humeral surface to give an adequate surface over which to tie the knots.
■ Tie the suture of the anchor down on top of the tendon with four or five knots to prevent impingement of the suture material. The use of strong sutures rather than Kocher clamps or hemostats to pull on the tendon while suturing avoids crush injury to the tendon. We occasionally make longitudinal incisions along the extremes of the free tendon edge to allow placement of the tendon in the trough. These can be sutured before closure.
■ Next secure the sutures from the suture anchors over the tendon completing the double-row repair.
■ If the lateral humeral cortex is fractured during tying down of the suture or construction of the suture tunnel, the anchors can be used as a salvage procedure. The anchors seem to have adequate holding power in cancellous bone and are reasonable alternatives in problematic situations. Use these sutures for additional leverage when tying down the trough sutures and tie them on top of the tendon with four knots to prevent impingement of the suture material.
■ Suture the deltoid periosteum from side to side, or, if necessary, through drill holes into the acromion with nonabsorbable sutures, ensuring that the reattachment is secure. Close the wound in layers in routine fashion.