Open Rotator Cuff Repair

Aims

  1. Decompress the subacromial space to allow free passage of tendons
  2. repair tendon back to it’s anatomical position
  3. ± excision outer clavicle
  4. Biceps tenodesis
  5. AC joint
  • Chosen over arthroscopic technique for technical ease & better repair.
  • Other options. – arthroscopic SAD + mini open repair

Indications

  • Full or near full thickness tear usually of supraspinatus tendon
  • Significant pain
  • Loss of function
  • Failed nonoperative management

Contraindications

  • Massive tear (>5cm)
  • Localised sepsis

Consent / Preop Planning

  • Plain radiograph
  • U/S or MRI
  • Neers test +
  • Exclude
    • Frozen shoulder
    • Cervical radiculopathy
    • AC joint Osteoarthritis
    • Instability in young patient
  • Consent
    • Deltoid detachment
    • Axillary nerve palsy
    • Unable to repair / Repair failure
    • Loss of movement / Loss ROM / stiffness
    • Persistent pain
    • Weakness
    • Synovial fistula

Principles

  • Antero-inferior acromioplasty
  • Release of coracoacromial ligament
  • Complete release & mobilisation of cuff from glenoid labrum & superficial bursa ± coracoid base (coracohumeral ligament), rotator interval, & posterior interval (scapular spine)
  • Tendon-grasping suture placement (eg. Mason-Allen suture)
  • Secure bone fixation (eg. transosseous sutures, suture anchors)
  • Minimal deltoid surgical insult & meticulous repair
  • Early restoration of passive motion

Options

  • Open / miniopen / arthroscopic
  • Fixation options:
    • transosseous sutures, suture anchors
    • absorbable, nonabsorbable
  • Single row, double row

Position

  • Semi beach chair position, Lateral decubitus
  • Arm drape free

Landmarks

  • clavicle, AC joint, acromion, spine of scapular, coracoid process

Incision

  • Make a 6 cm incision along langers line from the lateral aspect at the middle of the acromion towards & just short of the coracoid

Superficial Dissection

  • Undermine skin edges & identify the anterior raphe in the deltoid. Divide this for a distance not exceeding 5cm to avoid the axillary nerve

Deep Dissection

  • Carry the dissection across the acromion, subperiostially elevate off the acromion, ensuring full thickness flaps for repair

Dangers

Nerves

  • Axillary nerve
  • Musculocutaneous nerve

Procedure

  • Resect a 1cm segment of C-A ligament
  • Resect thickened bursa (identifiable by unilaminar appearance & attachment to acromion)
  • Use ronguere or saw to excise that part of acromion projecting anterior to the anterior border of clavicle
  • Place blunt Hohmaan or Bristow to depress humeral head an resect deep part of anterior acromion, half thickness or 7mm at front & tapering back to middle of acromion
  • Smooth with rasp
  • Identify the tear in tendon. Debride edges
  • Gouge a trough at point of insertion
  • Non-absorbable sutures through tendon, then through bone
  • Check integrity of repair & free passage through sub acromial space
  • If deltoid attachment is thin or tenuous, it should be repaired through bone using heavy non absorbable sutures
  • Routine closure

Postop / Rehab

  • Immediate start of pendula exercises
  • 0-6/52 Sling
  • 6-10/52 Passive assisted
  • after 10/52: as tolerated

Warn patient it may take up to 6 months for pain to subside

Results

  • 85-90% pain relief with acromioplasty
  • Slight ↑ pain relief with repair of tendon
  • Unpredictable ↑ strength with repair

Complications / Dangers

Perioperative

General
  • Anaesthetic, general surgical
Local
  • Unable to repair tendon

Postoperative

Early
  • Infection
  • RSD
Late
  • Continued pain
  • Weakness