Selected

The American Academy of Orthopaedic Surgeons

Printed with permission of the
American Academy of
Orthopaedic Surgeons. A modified
version of this article, as well as
other lectures presented at the
Academys Annual Meeting,
appeared in March 2001 in
Instructional Course Lectures,
Volume 50. The complete
volume can be ordered online
at www.aaos.org, or by
calling 800-626-6726
(8 A.M.-5 P.M., Central time).

FRANKLIN H. S IM
Editor, Vol. 50

C OMMITTEE
J AMES H. B EATY
Chairman

FRANKLIN H. S IM
S. TERR Y C ANALE
D ONALD C. FERLIC
D AVID L. H ELFET
E X -O FFICIO
FRANKLIN H. S IM
Editor, Vol. 50

D EMPSEY S. S PRINGFIELD
Deputy Editor of The Journal of Bone and Joint Surgery
for Instructional Course Lectures

J AMES D. HECKMAN
Editor-in-Chief,
The Journal of Bone and Joint Surgery


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M I N I -O P E N R O T A T O R C U F F R E P A I R

Mini-Open
Rotator Cuff Repair
AN UPDATED PERSPECTIVE
BY KEN YAMAGUCHI, MD
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Once regarded as a cutting-edge procedure performed by only a select few

arthroscopists, the mini-open, or arthroscopically assisted, rotator cuff repair has quickly become a popular
procedure and, for many, the standard
of care for rotator cuff repair1-8. In just
five to ten years, the mini-open repair
has gained acceptance comparable with
that of formal open repair and, ironically, currently represents a sensible
middle ground between the traditional
formal open repair and the unproved,
newer completely arthroscopic techniques for rotator cuff repair9,10. From
several standpoints, the mini-open, or
arthroscopically assisted, approach to
rotator cuff repair combines many of
the advantages of the formal open repair and the completely arthroscopic
repair while avoiding many of their disadvantages. Mini-open repair represents an excellent transitional operation
in which a surgeon can become experienced in many of the arthroscopicspecific techniques, such as release,
tendon mobilization, and suture and
suture-anchor placement, that are necessary in order to perform completely
arthroscopic repairs. In the present
study, some of the relevant history regarding the mini-open repair, the relationship of the mini-open repair to the
formal open and arthroscopic repair alternatives, the specifics of the surgical

technique, and the overall results reported for the mini-open repair are reviewed. In addition, a rationale for the
use of the mini-open repair technique
for rotator cuff tears of all sizes and its
use as a transition procedure toward
complete arthroscopic repair (if desired) are described.
Historical Considerations
The advent of shoulder arthroscopy has
had an important impact on the evolution of rotator cuff treatment. Since the
initial description of arthroscopic subacromial decompression by Ellman and
Kay11 only ten years ago, there has been
a substantial trend toward the use of
more minimally invasive surgery to accomplish the same results as those seen
previously with the formal open repair.
It is important, however, to consider
formal open repair as the gold standard
or benchmark when examining the results of arthroscopic treatment. Many
of the fundamental principles required
for a successful outcome after a formal
open repair (Table I) are applicable to
the achievement of a good outcome after a mini-open or complete arthroscopic repair.
The surgical experience with formal open repair of the rotator cuff reported in the peer-reviewed literature
has been extensive12-26. Codman27,28 described his experience with rotator cuff

repair as early as 1911, when he noted

that twenty of thirty-one patients had a
successful result after repair of a fullthickness tear. In 1972, Neer29 reported
that nineteen of twenty patients had a
satisfactory result after rotator cuff repair with use of routine anterior acromioplasty. He also highlighted four
important principles for open rotator
cuff surgery: (1) use of anterior-inferior
acromioplasty or reshaping rather than
acromionectomy; (2) meticulous repair of the deltoid origin and avoidance
of procedures that may place this area at
risk for injury; (3) release, mobilization,
and repair of the torn rotator cuff tendons; and (4) early restoration of passive motion through surgeon-directed
and individualized rehabilitation. These
principles have been generally accepted
and have led to relatively uniform open
treatment of full-thickness rotator cuff
tears. Not surprisingly, many subsequent large series of rotator cuff repairs
have shown similarly good results. In a
series of 100 consecutive patients
treated with rotator cuff repair and
followed for a mean of 4.2 years, Hawkins et al.18 reported that 86% had no or
slight pain and that the mean postoperative improvement in abduction was
44. In a later series of 233 rotator cuff
repairs, Neer et al.22 reported that 91%
resulted in an excellent or satisfactory
rating. Multiple later series have shown


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TABLE I Fundamentals of Rotator

Cuff Repair

Glenohumeral inspection

Anterior-inferior acromioplasty

Release of the coracoacromial

ligament

Complete release and mobilization

of any fixed, contracted tendons
around the glenoid labrum,
superficial bursa, coracoid base
(coracohumeral ligament),
rotator interval, and posterior
interval (scapular spine)

Tendon-grasping suture placement

Secure bone fixation

Minimal deltoid surgical insult and

meticulous repair

Early restoration of passive motion

similar results for either small or massive repairs12-17,20,21,24-26. A common denominator for these studies has been
the adherence to strict surgical principles
of deltoid preservation, anterior-inferior
acromioplasty, cuff mobilization, and
then repair.
Despite a track record of good or
excellent results in a high percentage of
patients, the formal open repair has
been associated with some disadvantages. The open repair requires some
form of anterior deltoid takedown combined with a lateral deltoid split. If the
procedure is long and difficult, open repair could also be associated with some
traction injury. Although the surgical
injury to the deltoid generally has been
reported to heal in a predictable fashion, a 0.5% prevalence of deltoid avulsion has been noted in studies of open

M I N I -O P E N R O T A T O R C U F F R E P A I R

repairs by experienced shoulder

surgeons19,30-32. The rate of avulsion associated with operations by less experienced shoulder surgeons may be
substantially higher. Loss of the integrity of the anterior deltoid origin is a
devastating complication for which
there are no satisfying surgical options30,32,33. In the context of a rotator
cuff tear, the results following the loss
of anterior deltoid function have been
almost uniformly poor.
Fortunately, deltoid-related
complications from formal open approaches appear to be rare. However, a
formal open rotator cuff repair has two
additional disadvantages related to surgical insult to the deltoid. The deltoid
takedown and repair usually requires a
period of protection postoperatively in
order to avoid any inadvertent avulsion.
This may preclude accelerated rehabilitation in terms of active-assisted or active motion of shoulders with a smaller
rotator cuff tear. In addition, the open
repair appears to be associated with
more perioperative pain, although this
has not been formally quantitated, than
are the mini-open or complete arthroscopic alternatives1,6,8,34-36. The increased
pain may be related to the transdeltoid
approach required for a formal open
repair. This pain can hinder early rehabilitation and early motion as well.
Finally, formal open repair, while highly
successful over the long term, has been
associated with substantial recovery
times24,25. Full recovery is generally considered to require eighteen months.
These recovery times appear to be
longer than those for mini-open or
complete arthroscopic approaches and
again may be related to the surgical insult to the deltoid.

The arthroscopically assisted

miniapproach to rotator cuff repair
was developed in order to avoid anterior deltoid detachment. The procedure
was first described by Levy et al.3, in a
preliminary study, and then by Paulos
and Kody 6 in a long-term follow-up
study in 1994. They described a technique, performed with the patient in
the lateral decubitus position, in which
arthroscopic decompression was followed by open rotator cuff repair
through a lateral deltoid split6. As the
anterior-inferior acromioplasty had
been performed arthroscopically, an
anterior deltoid detachment was no
longer necessary. At that point, the
rotator cuff repair was essentially the
same as a complete open repair. All
releases were performed in an open
fashion, and then a combination of
transosseous sutures and suture anchors were used to secure bone-tendon
fixation. Paulos and Kody reported a
good or excellent result in sixteen of
their eighteen patients at a mean of
forty-eight months postoperatively 6. In
their opinion, the technique resulted in
less perioperative morbidity and, because the deltoid muscle was not detached, safer initiation of rehabilitation
exercises. Conceptually, the strategy of
arthroscopic decompression followed
by cuff repair through a lateral deltoid
split is appealing, and several subsequent studies have shown a comparable
rate of good and excellent results2-7.
Although the results reported
thus far have been encouraging, miniopen repair is not recommended for all
rotator cuff tears7. Surgeons who rely on
open rotator cuff releases and mobilization generally find the small lateral approach insufficient for repair of a large

TABLE II Comparison of Mini-Open Surgical Techniques

Releases

Placement of
Tagging Sutures

Placement of
Tendon-Gripping
Sutures

Bone-Tendon
Fixation

Arthroscopic

Open

Open

Open

Open

Arthroscopic

Arthroscopic

Arthroscopic

Open

Open

Joint
Inspection

Decompression

Arthroscopically
assisted open repair

Arthroscopic

Mini-open assisted
arthroscopic repair

Arthroscopic


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M I N I -O P E N R O T A T O R C U F F R E P A I R

TABLE III Comparison of Rotator Cuff Repair Techniques

Formal Open
Repair

Arthroscopically
Assisted Open
Repair

Mini-Open Assisted
Arthroscopic
Repair

Complete
Arthroscopic
Repair

Glenohumeral evaluation

No

Yes

Yes

Yes

Limited mobilization

Yes

Yes

Yes

Yes

Extensive mobilization

Yes

No

Yes

Yes

Limited deltoid surgical insult

No

No/yes

Yes

Yes

Tendon-gripping (Mason-Allen) sutures

Yes

Yes

Yes

No

Transosseous sutures

Yes

Yes

Yes

No

Suture anchors

Yes

Yes

Yes

Yes

Early passive motion

Yes

Yes

Yes

Yes

Early active-assisted motion

No/yes

Yes

Yes

Yes

Early active motion (small tears)

No

Yes

Yes

Yes

or massive tear. For this reason, small,

easily mobilized tears are the best indication for the originally described
mini-open repair4,7,9,10. However, with
increasing experience with arthroscopic mobilization and tagging of rotator cuff tears, large or massive tears
are becoming more amenable to repair
through mini-open lateral deltoidsplitting approaches.
Strategy and Indications
for Surgery
In general, two surgical strategies have
been used for the mini-open repair. The
more established method has been arthroscopic decompression followed by a
standard open repair through a lateral
deltoid split. This technique was initially described by Paulos and Kody 6. In
the alternative strategy, more extensive
arthroscopic assistance is used. Specifically, arthroscopic decompression is
performed, but extensive rotator cuff
mobilization is also done during the arthroscopic portion of the procedure.
Afterward, arthroscopic tagging sutures
or stay sutures are placed, and preparation of the greater tuberosity, dbridement of the rotator cuff tendon, and
placement of suture anchors might all be
done arthroscopically as well. The small
lateral deltoid split is then performed in
order to place tendon-gripping sutures
on the previously mobilized cuff and
to fix the cuff to bone with use of the

surgeons preferred method, whether

it be suture anchors or transosseous
sutures.
The two strategies of mini-open
repair are fundamentally different with
regard to the manner in which arthroscopic assistance is used (Table II). In
the more established method, arthroscopic surgery is used simply to perform a decompression; it plays a small
role in the actual performance of the rotator cuff repair. This method can be referred to by the traditional designation
of an arthroscopically assisted openrepair technique. In the second strategy,
the decompression and rotator cuff
repair are primarily performed arthroscopically and a small portal-extension
approach is performed simply to obtain
secure tendon-to-bone fixation of a
previously mobilized cuff. This surgical
strategy can be referred to as a miniopen assisted arthroscopic rotator cuff
repair. In the first case, the emphasis is
on open repair techniques; in the second, the emphasis is on arthroscopic
repair. Because a lateral open deltoidsplitting approach is used in both strategies, the term mini-open repair can be
applicable to both. However, the surgical techniques are distinctly different
and are associated with different advantages and disadvantages (Table III).
The more established arthroscopically assisted open-repair technique
requires less arthroscopic experience or

expertise. For surgeons who have less

experience with arthroscopy of the
shoulder, the technique is less technically demanding and more readily performed. However, this technique is
directly limited by the size of the lateral
deltoid split. When a smaller approach

Fig. 1

Release of superior glenoid adhesions. Adhesions that may occur between the glenoid
labrum and the undersurface of the rotator
cuff need to be released to obtain full mobilization of the cuff. This can often be done
more easily from an arthroscopic approach.
The arthroscope is posterior, and a multipolar
right-angle electrocautery device is inserted
from the standard anterior portal. The electrocautery device is then used to sharply
release adhesions between the rotator cuff
and the glenoid labrum. In this figure, the
multipolar electrocautery device is lifting the
rotator cuff up off the glenoid labrum to show
the completed release.


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Fig. 2

Release of the superficial surface of the rotator cuff from the overlying subacromial bursa
and acromion, which is important to obtain
full mobilization of the cuff. Often, this is
most easily accomplished by placing the
arthroscope in the lateral portal and a multipolar electrocautery device in the posterior
portal as shown here. The subacromial bursal adhesions are then released from the cuff
by sweeping the electrocautery device from
anterior toward posterior and then from lateral toward medial.

is used for large or massive rotator cuff

tears that are chronic in nature, it can
be difficult, if not impossible, to perform all necessary surgical releases
through a limited transdeltoid opening.
If repair of a large or massive rotator
cuff tear is attempted in this fashion,
the surgeon is essentially squeezing a
large operation through a small opening. Although a formal anterior deltoid
takedown is not performed in a classic
mini-open approach, an attempt to repair a large tear can still lead to substantial deltoid injury from traction
intraoperatively. This may help to explain why some surgeons have reported
increased episodes of frozen shoulder
and even deltoid injury following miniopen repair.
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 dbridement of cuff edges, extensive releases, cuff mobilization,
tuberosity preparation, and even suture-anchor placement, is done in an
arthroscopic fashion, if desired. Because
the rotator cuff has been previously
mobilized and tagged, the tendon edges

M I N I -O P E N R O T A T O R C U F F R E P A I R

can be delivered directly to the small

opening for placement of tendongripping 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.
The technique, however, is associated with some substantial disadvantages. A large amount of experience
with arthroscopy around the shoulder
is a prerequisite for most surgeons if
they are to have the expertise to perform all of the necessary surgical releases and suture placement. The
technique also relies heavily on uncompromising visualization of the rotator
cuff and the surrounding structures.
Without this, the surgeon can be easily
misled during rotator cuff preparation.
However, as technically demanding as
the arthroscopic portion of this procedure can be, it is still substantially easier
from a technical standpoint than complete arthroscopic repair. In addition,
compared with complete arthroscopic
repair, the mini-open repair may provide more secure bone-to-tendon fixation, as tendon-gripping Mason-Allen
sutures and bone augmentation can be
used37,38.

device is often helpful. At our institution, a universal locking head-and-arm

holder is used. Once the patient is positioned on the table with the medial aspect of the scapula in line with the
lateral aspect of the table, 20 mL of
0.25% bupivacaine hydrochloride containing epinephrine is injected into the
subacromial space. Early injection of
the bupivacaine hydrochloride with
epinephrine prior to preparation and
draping of the patient allows for enhanced vascular constriction from the
epinephrine. This step can substantially
decrease surgical bleeding and improve
visualization. Once the shoulder is prepared and draped, all osseous landmarks are carefully outlined with a
marking pen to help to facilitate accurate portal placement.
Accurate portal placement is especially important for advanced arthroscopic techniques about the shoulder.
The posterior portal is generally placed
approximately 1 to 2 cm inferior to the
posterior edge of the acromion and 2
cm medial to the posterolateral corner.
This portal is generally placed slightly
more superiorly than the usual posterior portal for arthroscopy in order to
obtain a better line of sight to the subacromial bursa for arthroscopic repair.
The anterior portal is positioned just

Surgical Technique
Open and arthroscopic shoulder surgery at our institution is performed
with the patient under regional anesthesia with an interscalene block and
supplemental laryngeal mask general
anesthesia. The interscalene block has
been a reliable and safe method for obtaining intraoperative and postoperative pain relief 39. The intraoperative
pain relief obtained with the block reduces the requirement for general anesthesia. Laryngeal mask anesthesia is
performed in addition to the interscalene block to obtain more reliable,
responsive control of systolic blood
pressure, which is essential for the more
complex arthroscopic techniques. The
patient is placed in a semisitting, upright beach-chair position with the
back elevated to approximately 70 to
80. A shoulder arthroscopy positioning

Fig. 3

Arthroscopic visualization of the rotator cuff.

An uncompromised view of the rotator cuff
should be obtained following the releases
and is necessary prior to the placement of
stay sutures or, if the surgeon prefers, complete arthroscopic rotator cuff repair. In this
case, the arthroscope is placed posteriorly
and is providing an anterior view. Both the
anterior and the posterior margin of the rotator cuff can easily be seen in this view.


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Fig. 4-A

M I N I -O P E N R O T A T O R C U F F R E P A I R

Fig. 4-B

Figs. 4-A and 4-B The Caspari suture punch is helpful in the insertion of stay sutures into the
rotator cuff. Fig. 4-A The suture punch can be inserted from the lateral portal. Fig. 4-B A monofilament suture or a shuttle-relay device is then inserted into the rotator cuff to pull traction into
the lateral deltoid split.

lateral to the palpable coracoid tip. The

lateral portal is generally placed 1 cm
posterior and 3 cm inferior to the anterolateral corner of the acromion. The
exact placement of this portal is determined by needle localization during
arthroscopy.
The arthroscope is first placed in
the glenohumeral joint through the
posterior portal. A standard glenohumeral inspection is performed. Of
particular importance is the careful visualization of the biceps tendon. Often
the lesion in the biceps tendon is in the
intertubercular groove portion and is
not readily seen on initial inspection of
the intra-articular portion. A hook

Fig. 5-A

should be used to pull the tendon into

the joint and ensure that there are no
structural problems with the tendon
laterally. When the tendon has a structural abnormality (such as a partial
tear, atrophy, or chronic enlargement),
either biceps tenodesis or tenotomy is
the treatment of choice40. When the
tendon looks either normal or just inflamed, surgical treatment for the biceps is not recommended. Next, the
rotator cuff tear should be visualized,
and its location and size should be determined. This helps the surgeon to
identify where the appropriate placement of the lateral portal should be.
Finally, the subscapularis should be

Fig. 5-B

carefully visualized to verify its integrity.

Rotator cuff mobilization starts
with an intra-articular release. This
should be performed with the arthroscope in the posterior portal and a hook
multipolar electrocautery device in the
anterior portal. Normally, a pouch is
present superior to the glenoid labrum
between the undersurface of the rotator
cuff and the superior or posterosuperior portion of the lateral aspect of the
glenoid neck. A hook probe should be
placed in this location to determine if
the rotator cuff is attached by scar tissue
to the superior part of the labrum. The
release is performed by taking the hook
multipolar electrocautery device and
sharply releasing adhesions between the
undersurface of the cuff and the superior portion of the glenoid labrum,
starting from anterior and progressing
toward posterior (Fig. 1). The electocautery device is oriented away from
the suprascapular nerve, which is medial. A circumferential release around
the posterior, anterosuperior, and posterosuperior parts of the labrum can be
accomplished all the way to the posterior portal. This release is probably the
most important way to mobilize the
cuff. In addition, it is probably more
readily performed with arthroscopy
than with an open procedure, in which
access to the posterior part of the
glenoid and the posterosuperior part
of the rim is difficult secondary to ob-

Fig. 5-C

Figs. 5-A, 5-B, and 5-C The mini-open approach. (Reprinted, with permission, from Bigliani LU. Rotator cuff repair. In: Post M, Bigliani LU, Flatow EL,
Pollack RG, editors. The shoulder: operative technique. Baltimore: Williams and Wilkins; 1998. p 144.) Fig. 5-A The anterolateral portal is extended. This portal usually measures between 3 and 4 cm in length. Skin incisions within the Langer lines are preferred. Fig. 5-B Once subcutaneous dissection is performed, a deltoid split is made in line with the previous portal wound to expose the tear. Fig. 5-C Stay sutures are then
placed. If arthroscopic preparation has been performed, the previously placed stay sutures can be brought out through the portal to pull the rotator
cuff into view.


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struction by the humeral head. Once

this intra-articular release has been performed, the arthroscope is withdrawn
and attention is directed to the subacromial space.
An arm-holder is used in order to
apply in-line traction on the humerus.
The arm is adducted, forward flexed,
and slightly internally rotated, which
opens up the subacromial space for
good visualization. The arthroscope is
then redirected into the subacromial
space from a posterior direction. Upon
entrance into the subacromial bursa, a
needle is used to localize the appropriate location for the lateral portal. The
lateral portal location should allow a
parallel orientation of the burr to the
undersurface of the acromion and
should also be centered over the middle
of the rotator cuff tear. In general, this
portal is located 1 cm posterior to the
anterolateral corner of the acromion
and 3 cm inferior to it. The portal is
made in the direction of the Langer skin
lines in a horizontal fashion.
A subacromial bursectomy is then
performed, initially starting out with a
full radius resector and usually followed
by use of a multipolar electrocautery
device. Care should be taken to visualize the cuff first to make sure that the
bursa, and not the rotator cuff, is being
debrided. The anteriormost portions of
the bursa are debrided first, and the
dbridement also includes excavation of
the soft tissues from the undersurface of
the acromion, from the anteroinferior
edge and posteriorly. The arthroscope is
then switched to the lateral portal, and
the electrocautery device is placed posteriorly (Fig. 2). The electrocautery device is swept from lateral toward medial
and then from anterior toward posterior, again excavating the bursa off the
rotator cuff all of the way medial to the
base of the acromion. Generally, the
bursa from the underlying rotator cuff
can be removed completely in this fashion. Because the arthroscope is placed
laterally, visualization can be obtained
all of the way around the teres minor
posteriorly and inferiorly. Excellent visualization of the subacromial space
and the undersurface of the acromion
should be obtained in this fashion. At

M I N I -O P E N R O T A T O R C U F F R E P A I R

this time, the arthroscope is replaced

into the posterior portal and, with use
of a burr placed into the anterior portal,
an anterior-inferior acromioplasty is
performed. The degree of acromioplasty performed and whether a coracoacromial ligament release is added
depend on the reparability41 of the cuff
tear and the size of the anterior-inferior
spur, if one is present. When the rotator
cuff is not reparable, the coracoacromial arch and, more specifically, the
anterior-inferior aspect of the acromion
and the coracoacromial ligament become important as secondary stabilizers
against superior migration of the humeral head. Resection of the coracoacromial ligament in the presence of a
massive rotator cuff tear can lead to a
loss of containment of the humeral
head such that it will migrate in an anterior-superior direction33. Because of
this, when the rotator cuff is not reparable, the coracoacromial ligament as well
as the anterior-inferior aspect of the acromion generally should be preserved.
At this point, a mini-open approach
through a lateral deltoid split can be
performed if the surgeon is not experienced with the more technically difficult arthroscopic procedures.
It should be noted that, throughout the subacromial procedure, careful
attention should be paid to bloodpressure control. As a general rule, systolic blood pressure should not exceed
120 mm Hg. The pump pressure is generally set at 40 mm Hg, but it can be
raised as high as 60 mm Hg as necessary
to control bleeding. Elevated pump
pressures, however, are associated with
more rapid soft-tissue distention and
edema, conditions that will eventually
obscure visualization. Following decompression, an uncompromised visualization of the rotator cuff should be
achieved (Fig. 3). The rotator cuff tear
should be seen from its most anterior
aspect all of the way to its most posterior aspect. This visualization is a prerequisite for additional arthrocopic
preparation of the rotator cuff.
At this point, an arthroscopic
shaver is placed into the lateral portal
and the greater tuberosity is debrided in
preparation for later rotator cuff repair.

The tuberosity is slightly decorticated,

and any extraneous soft tissue is removed. A formal bone trough is not
created; indeed, it is contraindicated if
a suture anchor is to be used. Next, the
shaver is used to debride any of the torn
cuff edge that appears to be nonviable
or attenuated. Care should be taken to
do only a limited dbridement.
Stay-suture placement is initiated
at this time. Several different devices for
suture placement are available. The
Caspari suture punch (Linvatec, Largo,
Florida) is delivered through the lateral
portal (Figs. 4-A and 4-B). A place in
the midportion of the rotator cuff tear
is selected, and the suture punch is used
to grasp the cuff at this location. The
suture punch is then used to assess the
mobility of the rotator cuff tendon. For
the majority of cases, a release of the
rotator cuff from the superior aspect of
the glenoid labrum and the superficial
bursa generally results in sufficient mobilization of the rotator cuff tissue. In
rare cases, when the cuff is assessed with
the suture punch, additional releases
are found to be necessary. When these
releases are necessary, the suture punch
is withdrawn and the arthroscope is
placed through the lateral portal. An
electocautery device is then placed into
the anterior portal and brought down
into the base of the coracoid, after
which a coracohumeral ligament release
is performed right down to the base of
the coracoid, on its superficial surface.
It should be noted that the base of the
coracoid has already been debrided on
the articular side during the circumferential glenoid release. The sharp dbridement can be performed from the
base of the coracoid all of the way out
laterally to the bicipital groove as a rotator interval release, when necessary, although this option is rarely needed.
Finally, if this release is not sufficient,
a posterior interval release can be performed arthroscopically. The arthroscope remains in the lateral portal, and
the electrocautery device is switched
back to the posterior portal. The base of
the acromion and the scapular spine
can be visualized quite readily from the
lateral portal, and the electrocautery device can then be delivered to this loca-


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tion. Next, the rotator cuff is mobilized

from the scapular spine and the base of
the acromion in a sharp fashion. Once
these releases have been done, the mobility of the cuff is reassessed by grasping the tissue with the Caspari suture
punch.
After all of these releases have
been performed, only in a rare case will
the rotator cuff not be reducible to the
greater tuberosity. At this point, multiple shuttle-relay devices (Linvatec) are
delivered by the Caspari suture punch
into the anterior, middle, and posterior
portions of the rotator cuff tear. In general, these stay sutures are separated by
1 cm, and the number required depends
on the transverse dimension of the rotator cuff tear. Use of a shuttle-relay device or, alternatively, a #1 proline suture
doubled onto itself allows the surgeon
to place the rotator cuff into a reduced
location and also to later pass either
transosseous sutures or suture anchors
into the cuff for bone fixation.
At this time, the mini-open approach is initiated (Figs. 5-A, 5-B, and
5-C). The horizontal lateral incision is
enlarged to a length of 3 to 4 cm. The
subcutaneous tissue is then undermined to expose the underlying deltoid
fascia. The deltoid is then split in line
with its fibers, incorporating the arthroscopic puncture site. This split is
generally carried up to the acromion
and distally for about 3 to 4 cm. As the
cuff has been previously mobilized and
stay sutures have been already placed, a
surprisingly small deltoid split is necessary at this time. An additional bursectomy can be performed at the split site
to improve visualization, but generally
this is not necessary because of the extensive bursectomy previously performed with the electrocautery device.
Rotation of the arm allows different
portions of the cuff to be visualized
through the deltoid split.
Bone-tendon fixation is performed at this time. If the tear is small
and easily mobilized, simple stitches
placed through suture anchors, which
are embedded in the superolateral aspect of the greater tuberosity, are preferred. For large tears under some
tension, Mason-Allen stitches in the

M I N I -O P E N R O T A T O R C U F F R E P A I R

cuff, once again placed through suture

anchors in the superolateral location on
the greater tuberosity, are preferred37,42.
Alternatively, transosseous fixation can
be used; however, many studies have
documented that the strength of suture
anchors placed in the superolateral portion of the greater tuberosity is equal to
or greater than that of transosseous
sutures42-44.
Results
The outcomes after mini-open or arthroscopically assisted rotator-cuff
repair performed through a lateral
deltoid-splitting approach have been
reported to be generally good and
comparable with the long-term results
seen in multiple series of open rotator
cuff repairs1,3-8,41. In 1990, Levy et al.3
reported a preliminary one-year
follow-up study of twenty-five patients
who had been treated with an arthroscopic subacromial decompression and
then a lateral deltoid-splitting open repair. Twenty of the patients had a good
or excellent result according to the
shoulder-rating system of the University of California at Los Angeles.
Paulos and Kody 6 reported what
we believe to be the first long-term results, in eighteen patients followed for a
mean of forty-six months. Sixteen patients had an excellent or good result
and only two patients, with a pending
Workers Compensation case, had a
poor result. Pain and function were
substantially relieved and improved. In
another long-term study, Liu and
Baker4 reviewed the cases of thirty-five
patients who had had a full-thickness
tear treated with an arthroscopically assisted approach. After a mean duration
of follow-up of 3.7 years, thirty patients
(86%) had an excellent or good result.
The outcome was found to be associated with the size of the tear, and patients with large and massive tears were
found to have a less satisfactory result.
In addition, the procedure was shown
to be associated with a shortened hospital stay and more rapid rehabilitation,
presumably because there is less softtissue damage. Blevins et al.2 reported
on a series of forty-seven patients that
included those who had had a repair of

a large rotator cuff tear in addition to

smaller or easily accessible tears. Thirtynine patients (83%) had a good or excellent rating according to The Hospital
for Special Surgery shoulder score. The
authors concluded that the procedure
was effective for larger rotator cuff
tears, but it was more technically demanding for those tears. Warner et al.7
reported on twenty-four patients who
had been specifically selected for arthroscopically assisted rotator cuff repair and were followed for a mean of
four years. In that focused series, seventeen patients underwent a transosseous,
arthroscopically assisted rotator cuff
repair when intraoperative selection
criteria showed an avulsion-type tear
configuration with good tendon quality
and an absence of subscapularis tendon
involvement. The authors showed that
arthroscopically assisted repair can
achieve excellent results in patients
selected according to such specific
criteria. The mean score for function
according to the American Shoulder
and Elbow Surgeons scale was 96 of 100
points, and the mean score for activities
of daily living was 89 of 100 points.
Open and arthroscopically assisted rotator cuff repairs were compared in two studies. Baker and Liu1, in
a study of thirty-seven patients, found
that sixteen (80%) of twenty patients
managed with an open procedure had a
good or excellent result compared with
fifteen of seventeen patients managed
with an arthroscopically assisted repair.
Eighteen (90%) of the twenty patients
who had had an open repair were satisfied compared with sixteen of the seventeen patients who had had an
arthroscopically assisted repair. The
shoulder strength and functional outcome did not differ significantly between the two groups; however, the
patients who had had an arthroscopically assisted repair had a shorter mean
hospital stay and returned to their previous level of activity a mean of one
month earlier.
Weber and Schaefer8 compared
sixty-nine patients who had had a miniopen repair with sixty patients who had
had a formal open repair in a retrospective series with a minimum duration of


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VO L U M E 83-A N U M B E R 5 M AY 2001

follow-up of two years. The mini-openrepair group required substantially less

parenteral narcotics and had shorter
hospital stays. The final outcome, however, was not substantially different for
the two groups. The authors concluded
that the primary advantage of a miniopen technique is that it offers a decrease in perioperative morbidity without compromising long-term results.
Overview
The mini-open arthroscopically assisted
repair of the rotator cuff has become a
popular procedure with proven clinical
results. The development of this procedure has followed a natural progression
toward less invasive means to accomplish rotator cuff repair. For many, it
represents a middle ground between the
traditional formal open repair and the
newer completely arthroscopic repair.
As arthroscopic rotator cuff repair becomes more refined and accepted35,36,45-47,

M I N I -O P E N R O T A T O R C U F F R E P A I R

the mini-open repair can also represent

an excellent transitional technique so
that the surgeon can someday accomplish the more technically difficult,
completely arthroscopic repair.
Whether used as the definitive procedure for rotator cuff repair or as a transitional procedure, the mini-open
repair can be thought of as two different
types of procedures: (1) an arthroscopically assisted open repair in which the
actual repair is performed primarily in
an open fashion, or (2) a mini-open assisted arthroscopic repair in which most
of the repair is performed arthroscopically and an open exposure is provided
just for bone-tendon fixation. With either strategy, the mini-open repair represents an excellent technique for
treating full-thickness rotator cuff tears
and offers many of the advantages of either formal open or complete arthroscopic repair while minimizing many of
the disadvantages.

Ken Yamaguchi, MD
Shoulder and Elbow Service, Department of
Orthopaedic Surgery, Barnes-Jewish Hospital,
Washington University School of Medicine,
One Barnes Hospital Plaza, Suite 11300 West
Pavilion, St. Louis, MO 63110
Printed with permission of the American
Academy of Orthopaedic Surgeons. A modified
version of this article, as well as other lectures
presented at the Academys Annual Meeting,
appeared in March 2001 in Instructional Course
Lectures, Volume 50. The complete volume can
be ordered online at www.aaos.org, or by calling
800-626-6726 (8 A.M.-5 P.M., Central time).
The author did not receive grants or outside
funding in support of his research or preparation of this manuscript. He did not receive
payments or other benefits or a commitment
or agreement to provide such benefits from a
commercial entity. No commercial entity paid
or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or
nonprofit organization with which the author
is affiliated or associated.

References
1. Baker CL, Liu SH. Comparison of open and
arthroscopically assisted rotator cuff repairs.
Am J Sports Med. 1995;23:99-104.
2. Blevins FT, Warren RF, Cavo C, Altchek DW,
Dines D, Palletta G, Wickiewicz TL. Arthroscopic assisted rotator cuff repair: results using
a mini-open deltoid splitting approach. Arthroscopy. 1996;12:50-9.
3. Levy HJ, Uribe JW, Delaney LG. Arthroscopic
assisted rotator cuff repair: preliminary results.
Arthroscopy. 1990;6:55-60.
4. Liu SH, Baker CL. Arthroscopically assisted
rotator cuff repair: correlation of functional
results with integrity of the cuff. Arthroscopy.
1994;10:54-60.
5. Liu SH. Arthroscopically-assisted rotator-cuff
repair. J Bone Joint Surg Br. 1994;76:592-5.
6. Paulos LE, Kody MH. Arthroscopically
enhanced miniapproach to rotator cuff
repair. Am J Sports Med. 1994;22:19-25.
7. Warner JJ, Goitz RJ, Irrgang JJ, Groff YJ.
Arthroscopic-assisted rotator cuff repair: patient
selection and treatment outcome. J Shoulder
Elbow Surg. 1997;6:463-72.
8. Weber SC, Schaefer R. Mini-open versus traditional open repair in the management of small
and moderate size tears of the rotator cuff
[abstract]. Arthroscopy. 1993;9:365-6.
9. Pollock RG, Flatow EL. The rotator cuff. Fullthickness tears. Mini-open repair. Orthop Clin
North Am. 1997;28:169-77.
10. Yamaguchi K, Flatow EL. Arthroscopic evaluation and treatment of the rotator cuff. Orthop
Clin North Am. 1995;26:643-59.
11. Ellman H, Kay SP. Arthroscopic subacromial
decompression for chronic impingement. Twoto five-year results. J Bone Joint Surg Br.
1991;73:395-8.
12. Adamson GJ, Tibone JE. Ten-year assessment
of primary rotator cuff repairs. J Shoulder Elbow
Surg. 1993;2:57-63.
13. Bigliani LU, Cordasco FA, McIlveen SJ, Masso

ES. Operative repairs of massive rotator cuff

tears: long-term results. J Shoulder Elbow Surg.
1992;1:120-30.
14. Gazielly DF, Gleyze P, Montagnon C. Functional
and anatomical results after rotator cuff repair.
Clin Orthop. 1994;304:43-53.
15. Grana WA, Teague B, King M, Reeves RB. An
analysis of rotator cuff repair. Am J Sports Med.
1994;22:585-8.
16. Gupta R, Leggin BG, Iannotti JP. Results
of surgical repair of full-thickness tears of
the rotator cuff. Orthop Clin North Am.
1997;28:241-8.
17. Hattrup SJ. Rotator cuff repair: relevance of
patient age. J Shoulder Elbow Surg.
1995;4:95-100.
18. Hawkins RJ, Misamore GW, Hobeika PE.
Surgery for full-thickness rotator-cuff tears.
J Bone Joint Surg Am. 1985;67:1349-55.
19. Karas EH, Iannotti JP. Failed repair of
the rotator cuff: evaluation and treatment
of complications. Instr Course Lect.
1998;47:87-95.
20. Kronberg M, Wahlstrom P, Brostrom LA.
Shoulder function after surgical repair of
rotator cuff tears. J Shoulder Elbow Surg.
1997;6:125-30.
21. Kirschenbaum D, Coyle MP, Leddy JP, Katsaros P, Tan F, Cody RP. Shoulder strength with
rotator cuff tears. Pre- and postoperative analysis. Clin Orthop. 1993;288:174-8.
22. Neer CS II, Flatow EL, Lech O. Tears of the
rotator cuff. Long term results of anterior
acromioplasty and repair. Orthop Trans.
1988;12:735.
23. Neer CS II, editor. Shoulder reconstruction.
Philadelphia: WB Saunders; 1990. p 41-142.
24. Rokito AS, Cuomo F, Gallagher MA, Zuckerman JD. Long-term functional outcome of
repair of large and massive chronic tears of
the rotator cuff. J Bone Joint Surg Am.
1999;81:991-7.

25. Rokito AS, Zuckerman JD, Gallagher MA,

Cuomo F. Strength after surgical repair of
the rotator cuff. J Shoulder Elbow Surg.
1996;5:12-7.
26. Romeo AA, Hang DW, Bach BR, Shott S.
Repair of full thickness rotator cuff tears.
Gender, age, and other factors affecting outcome. Clin Orthop. 1999;367:243-55.
27. Codman EA, editor. The shoulder: rupture of the
supraspinatus tendon and other lesions in or
about the subacromial bursa. Boston: Thomas
Todd; 1934.
28. Codman EA. Complete rupture of the supraspinatus tendon. Operative treatment with
report of two successful cases. Boston Med
Surg J. 1911;164:708-10.
29. Neer CS II. Anterior acromioplasty for the
chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am.
1972;54:41-50.
30. Mansat P, Cofield RH, Kersten TE, Rowland
CM. Complications of rotator cuff repair. Orthop
Clin North Am. 1997;28:205-13.
31. Mormino MA, Gross RM, McCarthy JA. Captured shoulder: a complication of rotator cuff
surgery. Arthroscopy. 1996;12:457-61.
32. Yamaguchi K. Complications of rotator cuff
repairs. In: Neviaser RJ, editor. Techniques in
orthopaedics. Philadelphia: Lippincott-Raven;
1997. p 33-41.
33. Wiley AM. Superior humeral dislocation. A complication following decompression and debridement for rotator cuff tears. Clin Orthop.
1991;263:135-41.
34. Gartsman GM. Arthroscopic management of
rotator cuff disease. J Am Acad Orthop Surg.
1998;6:259-66.
35. Gartsman GM, Brinker MR, Khan M. Early
effectiveness of arthroscopic repair for fullthickness tears of the rotator cuff: an outcome analysis. J Bone Joint Surg Am.
1998;80:33-40.


THE JOUR NAL

OF BONE & JOINT SURGER Y JBJS.ORG

VO L U M E 83-A N U M B E R 5 M AY 2001

36. Gartsman GM, Hammerman SM. Full-thickness

tears: arthroscopic repair. Orthop Clin North Am.
1997;28:83-98.
37. Gerber C, Schneeberger AG, Beck M, Schlegel
U. Mechanical strength of repairs of the rotator
cuff. J Bone Joint Surg Br. 1994;76:371-80.
38. Gerber C, Schneeberger AG, Perren SM,
Nyffeler RW. Experimental rotator cuff repair. A
preliminary study. J Bone Joint Surg Am.
1999;81:1281-90.
39. Brown AR, Weiss R, Greenberg C, Flatow EL,
Bigliani LU. Interscalene block for shoulder
arthroscopy: comparison with general anesthesia. Arthroscopy. 1993;9:295-300.
40. Sethi N, Wright R, Yamaguchi K. Disorders of

M I N I -O P E N R O T A T O R C U F F R E P A I R

the long head of the biceps tendon. J Shoulder

Elbow Surg. 1999;8:644-54.
41. Gartsman GM. Arthroscopic assessment of
rotator cuff tear reparability. Arthroscopy.
1996;12:546-9.
42. Burkhart SS, Diaz Pagan JL, Wirth MA, Athanasiou KA. Cyclic loading of anchor-based rotator
cuff repairs: confirmation of the tension overload phenomenon and comparison of suture
anchor fixation with transosseous fixation.
Arthroscopy. 1997;13:720-4.
43. Reed SC, Glossop N, Ogilvie-Harris DJ. Fullthickness rotator cuff tears. A biomechanical
comparison of suture versus bone anchor techniques. Am J Sports Med. 1996;24:46-8.

44. Barber FA, Cawley P, Prudich JF. Suture anchor

failure strengthan in vivo study. Arthroscopy.
1993;9:647-52.
45. Snyder SJ. Technique of arthroscopic rotator
cuff repair using implantable 4-mm Revo suture
anchors, suture Shuttle Relays, and no. 2 nonabsorbable mattress sutures. Orthop Clin North
Am. 1997;28:267-75.
46. Stollsteimer GT, Savoie FH III. Arthroscopic
rotator cuff repair: current indications, limitations, techniques, and results. Instr Course
Lect. 1998;47:59-65.
47. Tauro JC. Arthroscopic rotator cuff repair:
analysis of technique and results at 2- and 3year follow-up. Arthroscopy. 1998;14:45-51.