[Massive tears of rotator cuff - comparison of mini-open and arthroscopic techniques. Part 1. Mini-open technique].

PURPOSE OF THE STUDY: In Part 1 of this study we evaluate the results of surgical repair of massive rotator cuff tears by a "mini-open" technique. In Part 2 we will compare them with the results of reconstructions performed by arthroscopic surgery.

MATERIAL: Between 1995 and 2006, 99 repairs of massive rotator cuff (RC) tears were carried out in our department. The patient group included 73 men and 23 women at an average age of 55.7 years (range, 37 to 74 years). In 69 cases surgery was performed on the dominant (right) upper extremity. Surgical repair was indicated on the basis of clinical, radiological and arthrographic examination of the patients. Those who underwent surgery by the mini-open technique and in whom the RC tear was massive but repairable (grades 3 and 4 on the Bateman classification or grade III /a, b/ on the Gschwend classification) were included in the group evaluated here (N = 63). The RC re-attachment was done by several techniques, i. e., intraosseous sutures, Mitek RC anchors and Spiralok anchors (Mitek).

METHODS: Surgery is carried out in a beach-chair position. Using deltoid splitting we expose the shoulder joint. At present we use Neer's acromioplasty only when a type II or a type III acromion is present. After releasing and mobilizing RC muscles and preparing the bone for re-attachment, we reduce the size of tear with end-to-end suture and re-attach the RC tendons to the humerus. We close the incision in two layers. The arm is then immobilized in a brace for 4 to 6 weeks and a long-term (6 months) rehabilitation is recommended. During the period of study, we first employed intraosseous sutures, then Mitek RC anchors and finally Spiralok anchors (Mitek). After the initial "single-row" technique using simple sutures we adopted a "double-row" technique with mattress sutures and, subsequently, the modified Mason-Allen technique combining mattress and simple vertical sutures. The double- row technique allowed us to extend the area of contact for re-attachment and increased the strength of fixation. The results were evaluated on the basis of the UCLA (University of California at Los Angeles) shoulder rating system and the Constant scoring system. Using the school marking system (1, best; 5, worst) we asked about patients' satisfaction with surgery and their willingness to undergo the same operation again.

RESULTS: Out of the 63 patients undergoing surgery by the mini-open technique, 51 were available for follow-up. The pre-operative average Constant score was 39 points (range, 26 to 79) and UCLA score was 13 points (range, 6 to 22). The average follow-up was 51.6 months (range, 15 to 131 months). The post-operative average Constant score was 84.8 points (56 to 100) and by this criterion there were 70.6 % of excellent and 17.6 % of good results. The average UCLA score was 29.14 points (range, 22 to 35) and, based on this evaluation, there were 15.7 % of excellent and 54.9 % of good results. Satisfaction with the operation was reported by 96 % of the patients.

DISCUSSION: Although with the mini-open technique we can achieve very good outcomes even in massive tears of the rotator cuff, the results are nevertheless worse than in small or medium RC tears. Our results are comparable with those of other authors. In the open procedure we prefer the mini-open deltoid splitting technique, because it does not require detachment of the deltoid from the acromion. For fixation, anchors loaded with two sutures seem more convenient, as well as the double-row suture anchor technique with modified Mason-Allen suture that, according to Gerber, is stronger and provides better conditions for healing.

CONCLUSION: Repair of massive rotator cuff tears by the mini-open technique, if indicated early, gives very good results on condition that an adequate surgical technique is used and good-quality post-operative care, including rehabilitation, is provided. This approach can be fully recommended. Its results are comparable with those achieved by arthroscopy. This, in addition, permits inspection of the glenohumeral joint for co-existing pathologies. However, since 2005 we have preferred doing all RC repairs by arthroscopic surgery.