This document discusses a minimally invasive surgical approach for rotator cuff tears. It begins by outlining general principles for rotator cuff repair surgery. It then describes the anatomy of the coracoacromial arch and its importance in rotator cuff pathology. The document details the surgical technique for repairing rotator cuff tears via a mini-open approach while preserving the coracoacromial arch. Post-operative rehabilitation is described as focusing on gentle strengthening exercises over 3-4 months. Clinical outcomes for patients who underwent this procedure showed significant improvements in function and pain. The document advocates that this minimally invasive approach can achieve successful rotator cuff repairs without the need for acromioplasty.

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Rotator Cuff Tears:
a Minimally Invasive Approach
Frederick A. Matsen, III, MD
University of Washington
Orthopaedics and Sports Medicine

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General Principles

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The arch - an essential
articular surface

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Codman
recognized the
importance of
the arch and
the second
articulation

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Proximal humeral convexity (cuff
tendon and tuberosity) articulates
with the coracoacromial arch

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The coracoacromial arch is
part of the normal articulation

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The coracoacromial arch is
part of the normal articulation

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The coracoacromial arch is
part of the normal articulation

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The coracoacromial arch is
part of the normal articulation

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The coracoacromial arch is
part of the normal articulation

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The coracoacromial arch is
part of the normal articulation

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Is the acromion the cause of
cuff pathology?

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Coracoacromial Arch

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Coracoacromial Arch

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“Spur” does not encroach on
rotator cuff tendon

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“Spur” does not encroach on
rotator cuff tendon

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Acromioplasty geometry

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Acromioplasty geometry

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Partial cuff tears on the
articular (not acromial) side
50% 95%

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Codman:
Cannot explain cuff pathology
from contact with acromion

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Cuff tendon fails
on the deep side
Not here
But here

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Humeral
decentering
with cuff
failure,
CA arch
provides
backstop

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Decentering slackens deltoid

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Even the severest of chronic
tears can respond to
rehabilitation as long as the
arch is intact and smooth.

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Preserve the coracoacromial arch
Codman: “the coracoacromial
ligament has an important duty
and should not be thoughtlessly
divided at any operation”.

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Acromioplasty can lead to
adhesions

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Acromioplasty can lead to deltoid
detachment

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Acromioplasty can
lead to
anterosuperior
escape

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Treatment Considerations

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405 patients, complete supraspinatus tears,
average age 62, 61% male
Comfort
Strength
Range
Function

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Indication for cuff tear surgery
(same for open and arthroscopic)
I have a good chance of
improving my patient’s comfort
and function by restoring:
1. Smoothness of the subacromial articulation
2. Flexibility
3. Stability
4. Strength - ability to durably reattach tendon
determined by tendon quality and technique

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Restoration of normal cuff
insertion is a lofty surgical goal
Bone Calcified Fibrocartilage Fibrocartilage Tendon

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The better the tendon the more trauma it
takes to tear it
Smoking, steroids,
age
Traumatic

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Chronic tears are more likely to have
• Tendon atrophy
• Muscle atrophy (cuff and deltoid)
• Bone atrophy
• Stiffness

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Reattachment considerations
Onlay vs. Inlay
Inlay excludes joint fluid, allows slip
potential, increases contact between
tendon and healing cells from bone.

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Wilson’s Way (from Codman)

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Minimally invasive approach

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Minimally invasive approach

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Minimally invasive approach

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Minimally invasive approach

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Inspect cuff

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Inspect cuff

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Remove hypertrophic bursa

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Free humeroscapular motion
interface

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Repair if can get good tissue
to insertion site with arm at the
side.

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Repair good tissue to a trough
with arm at the side leaving a
smooth upper surface.

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Repair good tissue to a trough
with arm at the side leaving a
smooth upper surface.

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Extralabral releases

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Trough optimizes contact,
excludes joint fluid, allows slip

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Trough optimizes contact,
excludes joint fluid, allows slip

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Traction sutures

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Release from coracoid

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Side to side closure

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Drilling holes

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Better bone further distal

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Suture to trough

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Double sutures in central holes

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Suture to cuff

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Suture to cuff

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Suture to cuff

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Suture to cuff

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Suture to cuff

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Suture to cuff

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Suture to cuff

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Final repair

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Codman: Smooth upper
surface of cuff insertion

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Codman: smooth upper
surface of cuff insertion

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Check for smoothness

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Avoid
‘top knots’

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Top knots

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Closure

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Closure

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Optimal cosmetics

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Codman: “I find that my
tendency has been, as the years
go by, to allow more motion and
to allow it sooner”

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Rehabilitation
• First 12 weeks: gentle passive
exercises (pendulum, rotation)
• No NSAIDs
• Three months: Gentle, progressive
strengthening

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Gentle progressive
strengthening
Phase 1 Phase 3 Phase 4

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Gentle progressive
strengthening
Phase 1 Phase 3 Phase 4

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Gentle progressive
strengthening
Phase 1 Phase 3 Phase 4

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Gentle progressive
strengthening
Phase 1 Phase 3 Phase 4

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73 patients, repair full thickness
defects, ave 60 yo, 67% male, 59 mo fu

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Patient gender
0
2
4
6
8
10
12
Ingo Outcome
Total
SST
Functions
Males
All Patients
Females

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Number of tendons torn
0
2
4
6
8
10
12
Ingo Outcome
Total
SST
Functions
Supra
Supra + Infra
Subra, Infra and
Subsc

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Individual Functions
0
20
40
60
80
100
Ingo Outcome
Percent
of
patients
able
to
perform
function
Comfort at side
Sleep comfortably

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Individual Functions
0
20
40
60
80
100
Ingo Outcome
Percent
of
patients
able
to
perform
function
Place hand
behind head
Tuck in shirt
behind
Wash back of
other shoulder

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Individual Functions
0
20
40
60
80
100
Ingo Outcome
Percent
of
patients
able
to
perform
function
Coin on shelf
One pound on
shelf
Eight pounds on
shelf

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Individual Functions
0
20
40
60
80
100
Ingo Outcome
Percent
of
patients
able
to
perform
function
Carry 20 lbs
Toss underhand
Do usual work
Throw overhand

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Prospective study: 73 patients
• No infections
• No cosmetic concerns
• No deltoid problems
• No manipulations
• No re-operations

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Acromioplasty is not
necessary for successful cuff
surgery.

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Getting patients back
to enjoying life

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Getting back to enjoying life

91. University of Washington
Orthopaedics and Sports Medicine

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What if cuff can’t be repaired?
“Smooth and Move”

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Smooth

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Smooth

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Move

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22 patients, 64 yo,
59% males, 55 mo fu