Repair of the rotator cuff. Mini-open and arthroscopic repairs

The repair of rotator cuff tears by traditional open subacromial decompression and rotator cuff tendon reapproximation has proved successful in restoring function and decreasing pain, but open rotator cuff repair has some inherent disadvantages. Postoperative detachment of the deltoid repair has been reported and results in significant morbidity. The open technique may also require a longer period of limited motion resulting in greater stiffness. Arthroscopically assisted mini-open repairs and, more recently, completely arthroscopic repairs of the rotator cuff have been developed and increasingly are being applied. Both techniques avoid detachment of the deltoid. The mini-open and arthroscopic approaches to rotator cuff repair have the added benefit of arthroscopic evaluation of the glenohumeral joint. The mini-open technique has the advantage of allowing the direct visualization of the cuff repair and allows surgeons to place the stitches in an open fashion, which is familiar to all surgeons. The mini-open technique also allows the placement of tension-absorbing stitches in the rare cases that they are needed. Mini-open techniques also allow the choice of bone anchors or osseous tunnels for fixation. The completely arthroscopic cuff repair has several potential advantages over the open and mini-open cuff repair techniques; first is the decreased disruption of the soft tissues, which may result in less scarring and adhesions. The procedure is the most cosmetically appealing of the techniques. Reduced postoperative pain is also cited as an advantage but has been demonstrated only in a single, nonrandomized study. Finally, if technical difficulties arise, the conversion to a mini-open repair can be done easily. In a few studies, arthroscopic cuff repair techniques have shown promise as an alternative to mini-open or open repair, but these results have been at the hands of a few surgeons who have extensive experience in arthroscopy of the shoulder. In contrast, the mini-open procedure requires modest arthroscopic skills and has a documented history of success. Nevertheless, arthroscopic rotator cuff repair is a viable and effective technique in the hands of surgeons with adequate skills, and this procedure is likely to become more commonly performed in the future as shoulder arthroscopic skills and instrumentation improve.