import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Location**: Exits quadrangular space, runs 5-7cm inferior to acromion wrapping around surgical neck of humerus. **Protection**: Keep deltoid split WITHIN 5cm of acromion - NEVER extend beyond this landmark **Location**: Passes through suprascapular notch, runs 2-3cm medial to posterior glenoid rim in spinoglenoid notch. **Protection**: Avoid aggressive medial/posterior capsular releases during mobilization **Location**: Enters coracobrachialis muscle 3-8cm distal to coracoid tip (variable anatomy). **Protection**: Limit anterior dissection beyond coracoid, maintain awareness during subscapularis exposure **Location**: Runs in deltopectoral groove between deltoid and pectoralis major. **Protection**: If using deltopectoral approach variant, identify and protect (take laterally with deltoid or medially with pectoralis) **Location**: Insertion site for suture anchors, at risk in osteoporotic bone. **Protection**: Avoid over-aggressive decortication, use appropriate anchor size (4.5-5.5mm), limit anchor density, 45° deadman angle insertion ## Indications ### Absolute Indications - Full-thickness symptomatic rotator cuff tear requiring surgical repair - Failed non-operative management (3-6 months physiotherapy, NSAIDs, injections) - Functionally significant symptoms (pain, weakness, disability) - Patient medically fit for surgery with realistic expectations - Surgeon trained in mini-open technique ### Ideal Patient/Tear Characteristics - **Small to medium tears** (1-3cm) - best suited for mini-open exposure - **Crescent-shaped tear pattern** - simple reduction to footprint without complex mobilization - **Good tissue quality** - adequate for direct repair without augmentation - **Primary repair** - no prior failed surgery with extensive scarring - **Adequate bone quality** - for anchor fixation - **Mobile tear** - can reach footprint with reasonable mobilization ### Relative Contraindications - **Large/massive tears** (>5cm) - may require full open for adequate exposure and mobilization - **Complex tear patterns** (L-shaped, reverse L-shaped) - difficult to repair through limited incision - **Irreparable tears** - cannot reach footprint despite mobilization - **Severe osteoporosis** - inadequate anchor purchase (consider augmentation) - **Active infection** - manage infection first - **Significant glenohumeral arthritis** - may need arthroplasty instead - **Surgeon inexperienced** with technique ### Mini-Open vs Arthroscopic vs Full Open Decision **Choose MINI-OPEN when:** - Surgeon more comfortable with direct visualization than arthroscopic - Limited arthroscopic equipment availability - Small/medium crescent tear (1-3cm) - Primary repair with good tissue quality - Resource-limited setting **Choose ARTHROSCOPIC when:** - Surgeon expert in arthroscopic technique - All necessary equipment available - Any tear size/pattern if surgeon experienced - Minimize deltoid violation desired - Concurrent intra-articular pathology needing arthroscopic treatment **Choose FULL OPEN when:** - Massive/complex tear requiring extensive mobilization - Revision surgery with extensive scarring - Bone grafting or augmentation planned - Poor visualization through mini-open approach ## Preoperative Planning ### Clinical Assessment - **History**: Duration of symptoms, mechanism (traumatic vs degenerative), functional limitations, prior treatments - **Examination**: Active/passive ROM, strength testing (supraspinatus, infraspinatus, subscapularis), impingement signs, atrophy - **Imaging**: - **X-rays** (AP, lateral, axillary, outlet view): Assess for arthritis, acromial morphology, superior migration - **MRI**: Gold standard - assess tear size, pattern, retraction, muscle quality (Goutallier grading), fatty infiltration, bone quality - **Ultrasound**: Alternative if MRI contraindicated, operator dependent ### Tear Characteristics Planning - **Size**: Small (<1cm), medium (1-3cm), large (3-5cm), massive (>5cm) - **Pattern**: Crescent, U-shaped, L-shaped, reverse L-shaped - crescent best for mini-open - **Retraction**: Patte classification (grade 1-3) - assess if reachable - **Muscle quality**: Goutallier grade 0-4 fatty infiltration - grades 3-4 predict poor healing - **Tendon quality**: Assess for degenerative changes predicting tear-through ### Surgical Planning - **Approach**: Hybrid (arthroscopy + mini-open) vs pure mini-open - **Repair construct**: Single-row vs double-row based on tear size - **Anchor selection**: Size (4.5-5.5mm), number (2-4), type (threaded vs push-in) - **Suture selection**: #2 high-strength braided (FiberWire, Orthocord) - **Concurrent procedures**: Acromioplasty, distal clavicle excision, biceps tenotomy/tenodesis ### Patient Counseling - **Expected outcomes**: 85-90% good/excellent results, 10-30% re-tear risk (size/quality dependent) - **Rehabilitation**: 4-6 weeks sling, 6 weeks passive ROM only, 3+ months strengthening - **Return to function**: ADLs 3 months, unrestricted 4-6 months, overhead sports 6-9 months - **Complications**: Re-tear, stiffness, deltoid dysfunction, infection, nerve injury - **Alternative options**: Non-operative management, arthroscopic repair, full open repair ## Patient Positioning ### Beach Chair Position Setup - **Table Configuration**: Back elevated 60-70° from horizontal - simulates seated position - **Head**: Secure in foam headrest or horseshoe with neutral cervical alignment - prevent brachial plexus stretch - **Affected Shoulder**: Position at edge of operating table allowing circumferential access - **Arm Position**: 20-30° abduction, neutral rotation on padded arm board - allows manipulation throughout procedure - **Pressure Points**: Pad ischial tuberosities, heels, elbows - prevent pressure ulcers - **Blood Pressure**: Monitor on contralateral arm - beach chair can cause hypotension - **Stabilization**: Secure patient to prevent sliding with safety strap across hips **Positioning Pearls**: Beach chair provides familiar anatomical orientation and easier conversion to open if needed. CRITICAL: Ensure shoulder at table edge for posterior access if hybrid arthroscopy. Avoid excessive neck flexion/rotation causing brachial plexus traction. Maintain MAP >70mmHg to prevent cerebral hypoperfusion in upright position. ### Draping and Landmark Identification - **Skin Preparation**: Chlorhexidine or betadine from midline chest to mid-back, neck to elbow circumferentially - **Draping**: U-drape or split sheet allowing circumferential shoulder access - **Palpable Landmarks**: Mark with surgical pen: - **Acromion**: Anterolateral corner, lateral edge, posterolateral corner - **Clavicle**: Entire length - **AC joint**: Palpable prominence - **Coracoid process**: Anterior landmark - **Scapular spine**: Posterior landmark ### Incision Planning **HYBRID TECHNIQUE** (Arthroscopy + Mini-Open): - **Posterior portal**: 2cm inferior, 1cm medial to posterolateral acromion (soft spot) - 5-8mm stab incision - **Lateral portal**: Mid-lateral acromion 2-3cm inferior - 5-8mm stab incision - **Mini-open incision**: 3-5cm anterolateral incision from anterolateral corner of acromion extending distally and anteriorly in Langer's lines **PURE MINI-OPEN** (No Arthroscopy): - **Single incision**: 4-6cm anterolateral incision from anterolateral acromion extending distally along deltoid fibers - May be slightly longer than hybrid (no arthroscopic decompression phase) - Brachial plexus injury from excessive neck flexion/rotation or arm abduction - Hypotension in beach chair - maintain MAP >70mmHg - Pressure ulcers from inadequate padding - Eye injury from draping - protect eyes - Wrong-site surgery - TIME-OUT and marking ## Surgical Approaches ### Deltoid-Splitting Approach Anatomy **Deltoid Muscle Anatomy**: - Three portions: Anterior (clavicular), middle (acromial), posterior (spinal) - **Raphe**: Natural interval between anterior and middle deltoid fibers - site of split - **Axillary nerve**: Exits quadrangular space, runs 5-7cm inferior to acromion on deltoid deep surface - **Blood supply**: Posterior circumflex humeral artery (with axillary nerve), thoracoacromial artery, deltoid branch **Mini Deltoid Split Technique**: - **Location**: Split raphe between anterior and middle deltoid fibers - **Length**: 2-4cm vertical split - significantly less than full open (5-7cm) - **Safe Zone**: WITHIN 5cm of acromion to protect axillary nerve at 5-7cm - **Direction**: Parallel to muscle fibers distally from acromion - **Retraction**: Self-retaining retractors (mini-Gelpi, Army-Navy) provide exposure **Advantages of Limited Split**: - Less deltoid morbidity than full open - Lower risk of deltoid dysfunction - Less postoperative pain - Faster recovery - Still provides direct visualization (vs arthroscopic) ### Alternative: Deltopectoral Approach Some surgeons prefer modified deltopectoral for mini-open: - **Interval**: Between deltoid (axillary nerve) and pectoralis major (medial/lateral pectoral nerves) - **Cephalic vein**: Identify in groove, protect (take laterally or medially) - **Exposure**: Retract deltoid laterally to access rotator cuff - **Advantage**: No deltoid split - internervous plane - **Disadvantage**: More medial approach, cephalic vein at risk, may need clavipectoral fascia division ## Footprint Preparation ### Greater Tuberosity Anatomy - **Dimensions**: 2-3cm anteroposterior, 1-2cm medial-lateral - **Insertions**: Supraspinatus (superior), infraspinatus (posterior-superior), teres minor (posterior-inferior) - **Bone Quality**: Often osteoporotic in elderly with degenerative tears - **Vascularity**: Arcuate artery (from anterior/posterior circumflex humeral) supplies bone ### Preparation Technique 1. **Arm Positioning**: Extension 20-30° and external rotation brings tuberosity anterior into surgical field through mini-incision - CRITICAL for exposure 2. **Tissue Removal**: Remove residual torn tendon stump, fibrous scar tissue, bursal adhesions with rongeur or curette 3. **Decortication**: Create punctate bleeding bone surface: - Use curette or small burr (3.5-4.0mm) - Remove superficial cortex to bleeding cancellous bone - **CRITICAL**: Avoid EXCESSIVE removal weakening anchor purchase - Goal: Bleeding surface WITHOUT creating bony defect 4. **Hemostasis**: Use radiofrequency device or epinephrine-soaked sponge if excessive bleeding obscures field **Footprint Preparation Pearls**: Punctate bleeding critical for tendon-bone healing (fibrovascular interface). Balance adequate decortication (promote healing) vs excessive removal (weaken anchor fixation). In osteoporotic bone, minimal decortication and use larger anchors (5.5mm). Direct visualization in mini-open allows precise preparation. ## Suture Anchor Repair Techniques ### Single-Row Repair **Indications**: Small tears (<2cm), good bone quality, cost-consciousness **Technique**: - **Anchor Number**: 2-3 anchors - **Placement**: Lateral footprint edge at anatomic insertion - **Spacing**: 5-10mm apart - **Angle**: 45° deadman angle - optimal pullout resistance - **Suture Passage**: Mattress configuration through tendon 1cm from edge - **Knot Tying**: Sliding-locking knots with alternating half-hitches **Advantages**: Simpler, fewer anchors (lower cost), faster **Disadvantages**: Lower footprint contact area, higher re-tear rates than double-row ### Double-Row Suture Bridge Repair **Indications**: Medium tears (2-4cm), preferred technique for most tears **Technique**: - **Medial Row**: 2 anchors at articular margin with mattress sutures - **Lateral Row**: 2 knotless anchors 10-15mm lateral at lateral footprint edge - **Suture Bridge**: Free limbs from medial mattresses captured in lateral knotless anchors - **Configuration**: Creates broad compression zone of tendon on footprint - **Footprint Coverage**: Entire 2-3cm AP footprint covered **Advantages**: - Superior biomechanical strength (failure load, gap formation) - Increased tendon-bone contact pressure - Better healing rates (decreased re-tear) - No lateral knots (no subacromial impingement) **Disadvantages**: More anchors (higher cost), technically more complex **Double-Row Technique**: Medial row provides primary fixation at anatomic insertion (articular margin). Lateral row creates suture bridge compressing entire tendon onto footprint - increases contact area and pressure improving healing biology. Knotless lateral anchors avoid subacromial impingement from prominent knots. ### Margin Convergence Technique **Indications**: U-shaped or L-shaped tears with longitudinal component **Technique**: - Performed BEFORE anchor repair to footprint - Side-to-side repair of free margins using mattress sutures - Converts U-shape to crescent - Reduces medial-lateral tension on footprint repair - Improves vascularity to repair site **Challenge in Mini-Open**: Large U-shaped tears difficult through limited incision - may need full open ## Suture Management ### Suture Types - **Anchor Sutures**: #2 braided non-absorbable high-strength (FiberWire, Orthocord, Hi-Fi) - **Margin Convergence**: #2 braided non-absorbable or heavy absorbable (#2 Vicryl) - **Deltoid Closure**: #0 or #1 non-absorbable (Ethibond, FiberWire, Hi-Fi) ### Suture Passage Principles - **Mattress Configuration**: Horizontal or vertical mattress provides better tissue purchase than simple - **Tissue Bridge**: Minimum 5mm between suture passes prevents cut-through - **Distance from Edge**: 1cm from tear edge provides adequate tissue - **Quality Assessment**: Direct palpation in mini-open allows assessment of tissue quality and adjustment - **Tendon Thickness**: Take full thickness bites - inadequate purchase causes failure ### Knot Tying Technique - **Sliding-Locking Knots**: SMC, surgeon's sixth finger, Roeder - **Locking Mechanism**: First throw locks preventing slippage - **Alternating Half-Hitches**: Minimum 3 alternating half-hitches on alternating posts - **Backup Throws**: 2 additional backups for security (total 5-6 throws) - **Knot Pusher**: Use knot pusher to seat knots flush on tissue - **Tension**: CRITICAL - reduce tendon to footprint with firm contact but NOT over-tight causing blanching/ischemia - Over-tensioning: Causes tissue ischemia, suture cut-through, anchor pull-out - Under-tensioning: Creates gaps preventing healing - Inadequate mobilization: Excessive repair tension causing failure - Poor anchor placement angle: Reduced pullout strength - Anchor too medial: Joint penetration - Anchor too lateral: Inadequate footprint coverage ## Rotator Cuff Mobilization ### Mobilization Principles **Goal**: Allow tendon to reach footprint without excessive tension on repair **Assessment**: - Attempt to reduce tendon to footprint with gentle traction - If reaches easily - no mobilization needed - If won't reach or excessive tension - mobilization required - If cannot reach footprint despite aggressive mobilization - irreparable tear ### Mobilization Techniques **1. Adhesion Release (Bursal Side)** - Release adhesions between cuff and: - Undersurface of acromion - Deltoid muscle - Coracoacromial ligament - Use blunt dissection primarily with sharp dissection carefully as needed - Direct visualization and palpation in mini-open allows controlled release **2. Coracohumeral Ligament Release** - **Location**: From coracoid to rotator interval (anterior-superior) - **Indication**: Anterosuperior tears with anterior tightness - **Technique**: Identify and release ligament under direct vision - **Effect**: Mobilizes anterior cuff (supraspinatus, subscapularis) **3. Capsular Releases (Limited)** - **Indication**: Significant retraction preventing footprint reduction - **Technique**: Limited releases from bursal side of capsule - **DANGER**: Suprascapular nerve at risk 2-3cm medial to glenoid - avoid aggressive medial/posterior release - Perform minimal releases only as needed **4. Interval Slides** - **Anterior interval slide**: Release between supraspinatus and subscapularis (rotator interval) - **Posterior interval slide**: Release between supraspinatus and infraspinatus - Indication: Massive tears requiring significant mobilization - Less commonly needed in mini-open (limited to smaller tears) **Mobilization Pearls**: Goal is footprint reduction without excessive tension. Start with simple adhesiolysis. Progress to coracohumeral ligament release if anterior tightness. Capsular releases and interval slides reserved for significant retraction. Mini-open provides excellent tactile feedback - can feel tissue tension and adjust releases accordingly. Suprascapular nerve at 2-3cm medial - LIMIT medial releases. ### Irreparable Tears **Definition**: Cannot reduce to footprint despite maximal mobilization **Intraoperative Options**: - Partial repair (maximize coverage) - Superior capsular reconstruction (SCR) - Allograft augmentation - Convert to reverse shoulder arthroplasty (RSA) if pre-consented - Abandon repair, consider future RSA **Decision Making**: Discuss irreparable tear risk preoperatively based on MRI tear size, retraction (Patte grade 3), fatty infiltration (Goutallier 3-4) ## Deltoid Closure Technique ### Critical Importance Deltoid closure is CRITICAL STEP - failure causes serious morbidity: - Deltoid dysfunction and weakness - Chronic pain - Visible/palpable defect - Reoperative risk ### Closure Technique **1. Anatomic Re-approximation** - Use tagged stay sutures placed at initial split as guides - Align anterior and middle deltoid fibers anatomically - Ensure no gaps or overlapping **2. Suture Selection** - **HEAVY NON-ABSORBABLE SUTURES** mandatory - #0 or #1 braided non-absorbable (Ethibond, FiberWire, Hi-Fi) - NEVER use absorbable sutures - inadequate long-term strength **3. Suture Configuration** - Interrupted horizontal mattress OR interrupted figure-of-8 - Spaced 5-8mm apart along entire split (2-4cm) - Pass sutures through substantial muscle tissue - Avoid excessive tension causing ischemia **4. Verification** - Palpate closure - should be solid without gaps - No visible separation with arm movement - Secure but not over-tight (muscle perfusion) **Risk Factors**: Weak sutures, inadequate technique, excessive split length, poor tissue quality, infection, early aggressive ROM **Prevention**: Heavy non-absorbable sutures, mattress configuration, adequate bites, protect during early rehabilitation **Recognition**: Palpable defect, weakness, pain, instability feeling **Management**: Usually requires surgical re-repair with advancement if recognized early ## Layered Wound Closure ### Bursal Layer - **If adequate tissue**: Close with 2-0 absorbable (Vicryl) running or interrupted - **If inadequate**: Can leave open - not critical layer - Purpose: Creates tissue plane over repair ### Subcutaneous Layer - **Suture**: 2-0 absorbable (Vicryl) running or interrupted - **Technique**: Bury knots, achieve hemostasis - **Purpose**: Obliterate dead space, prevent hematoma ### Skin Closure - **Preferred**: Subcuticular 3-0 or 4-0 absorbable monofilament (Monocryl) - **Alternative**: Interrupted nylon or staples (remove 10-14 days) - **Purpose**: Cosmesis - mini-open incision (3-5cm) heals with minimal scar - **Enhancement**: Skin adhesive (Dermabond) over subcuticular closure ### Dressing - **Sterile dressing**: Absorbent gauze and tape or transparent dressing - **Immobilization**: Sling with pillow or abduction brace (neutral rotation) - **Local anesthetic**: Consider subacromial injection (20mL 0.25% bupivacaine) for postoperative analgesia ## Intraoperative Complications ### Neurovascular Injury **Axillary Nerve** - **Mechanism**: Deltoid split extended >5cm below acromion, excessive retraction, direct injury - **Recognition**: Nerve visible on deltoid deep surface if split too distal - **Prevention**: LIMIT split to <5cm from acromion, gentle retraction, awareness of anatomy - **Management**: If identified, protect and minimize manipulation. If injury suspected, consider intraop neuromonitoring or nerve exploration **Suprascapular Nerve** - **Mechanism**: Aggressive medial/posterior capsular releases during mobilization - **Recognition**: Usually not visible during mini-open approach - **Prevention**: Limit medial capsular releases, stay >2-3cm lateral to glenoid - **Management**: If injury suspected, document and monitor - most neuropraxias recover 3-6 months **Musculocutaneous Nerve** - **Mechanism**: Excessive anterior dissection beyond coracoid - **Recognition**: Rare with standard mini-open approach - **Prevention**: Limit anterior exposure, awareness during subscapularis work - **Management**: Document, monitor for recovery ### Anchor-Related Complications **Anchor Pull-Out** - **Mechanism**: Osteoporotic bone, wrong angle, excessive torque during insertion, inadequate purchase - **Recognition**: Anchor spins or pulls out with traction - **Management**: Remove, place larger anchor or reposition slightly different location **Intra-articular Penetration** - **Mechanism**: Anchor placed too medially - **Recognition**: May feel anchor "pop" through cortex, see joint penetration if arthroscopic phase - **Management**: Remove anchor, place more laterally on footprint **Greater Tuberosity Fracture** - **Mechanism**: Excessive decortication, osteoporotic bone, over-torquing anchor, multiple anchors close together - **Recognition**: Visible fracture line, tuberosity mobility - **Management**: If small fragment stable - proceed with repair carefully. If large unstable - may need revision to plate fixation and cuff repair ### Inadequate Repair **Irreparable Tear Identified** - **Management**: Maximal mobilization, partial repair (maximize coverage), consider SCR or abandon for future arthroplasty if pre-consented **Cannot Achieve Adequate Footprint Coverage** - **Management**: Margin convergence, convert to single-row vs double-row based on coverage, consider augmentation ## Postoperative Complications ## Outcomes ### Expected Functional Outcomes - **Pain Relief**: 85-90% achieve significant pain improvement - **Function**: 80-85% return to previous functional level - **Patient Satisfaction**: 85-90% satisfied or very satisfied - **ROM**: 90% achieve functional ROM (>120° forward flexion) - **Strength**: Gradual improvement over 12-18 months, may not fully normalize ### Structural Healing (Re-tear Rates) - **Overall**: 10-30% depending on tear characteristics - **Small tears (<1cm)**: 5-10% re-tear - **Medium tears (1-3cm)**: 15-25% re-tear - **Large tears (3-5cm)**: 30-40% re-tear - **Massive tears (>5cm)**: 40-60% re-tear (generally NOT done mini-open) - **Double-row vs single-row**: Lower re-tear with double-row (10-15% reduction) ### Prognostic Factors **Good Prognosis**: - Small/medium tear size - Crescent-shaped pattern - Acute/subacute tear (traumatic) - Good tissue quality - Minimal fatty infiltration (Goutallier 0-1) - Minimal retraction - Non-smoker - Good bone quality - Compliant with rehabilitation **Poor Prognosis**: - Large/massive tear - Chronic degenerative tear - Poor tissue quality - Advanced fatty infiltration (Goutallier 3-4) - Significant retraction (Patte 3) - Smoking, diabetes - Osteoporosis - Non-compliance with rehab - Workers' compensation claim ### Mini-Open vs Arthroscopic vs Open Outcomes **Meta-analyses show**: - **Equivalent structural healing rates** between techniques when performed by experienced surgeons - **Equivalent functional outcomes** and patient satisfaction - **Mini-open**: Less deltoid morbidity than full open, more than arthroscopic - **Mini-open**: Faster learning curve than arthroscopic - **Surgeon experience** more important than technique for outcomes **Technique Selection**: Based on surgeon expertise, tear characteristics, available resources - all techniques effective in appropriate hands ## Phase 1: Protection Phase (0-6 Weeks) ### Immobilization - **Sling**: Day and night including sleep - **Pillow**: Small pillow under arm for comfort (neutral rotation) - **Remove for exercises only**: 4-5 times daily - **Purpose**: Protect tendon-bone healing biology (6 weeks minimum for biological healing) ### Allowed Activities (PASSIVE ROM ONLY) **Week 0-2**: Pendulum exercises only - Lean forward, arm hanging, gentle circular movements - NO active shoulder muscle contraction - Elbow/wrist/hand active ROM encouraged **Week 2-6**: Therapist-assisted passive ROM - **Forward flexion**: Supine table slides to 90-120° (progress gradually) - **External rotation**: 30-40° in scapular plane (arm at side) - **Internal rotation**: To abdomen - **NO abduction** (stresses superior cuff) - **NO active ROM** (protects repair) ### Restrictions - **NO active shoulder ROM** (deltoid, rotator cuff contraction disrupts healing) - **NO lifting/carrying** even light objects - **NO reaching behind back** - **NO overhead activities** - **NO supporting body weight** with operative arm **Phase 1 Critical Concept**: Tendon-bone healing requires 6-12 weeks biological healing time. PASSIVE ROM only prevents stiffness while protecting repair from active muscle forces. Active motion before 6 weeks HIGH risk of re-tear. Patient education CRITICAL - most failures from non-compliance. ## Phase 2: Active Assisted Motion (6-12 Weeks) ### Mobilization - **Wean from sling**: Gradual discontinuation over 1-2 weeks - **Active-assisted ROM**: Begin transition to active control - Pulley-assisted forward flexion - Cane-assisted external rotation - Wall walks - **Progress to full active ROM**: Gravity-eliminated positions first - **Goal**: Full passive ROM, active ROM to 140-160° forward flexion by 12 weeks ### Strengthening Introduction - **Isometrics only**: Weeks 8-12 - Gentle submaximal contractions (20-30% effort) - No motion, muscle contraction only - Forward flexion, abduction, ER/IR - **Purpose**: Begin muscle re-education without stressing repair ### Restrictions - **NO resisted exercises** with weights/bands - **NO sudden forceful motions** - **NO lifting** >1-2kg - **NO sports** or demanding activities ## Phase 3: Strengthening Phase (12-16 Weeks) ### Progressive Resistance - **Active ROM against gravity**: All planes - **Resistance exercises begin**: Light resistance only - Theraband exercises (light resistance bands) - Light dumbbells 0.5-1kg - Focus on rotator cuff strengthening - **Scapular stabilization**: Critical for shoulder mechanics - **Progress resistance gradually**: Increase by 0.5kg every 2 weeks ### Functional Activities - **ADLs**: Return to most activities of daily living - **Light household tasks**: Dishes, cooking, light cleaning - **Avoid**: Overhead lifting, forceful pushing/pulling ## Phase 4: Advanced Strengthening (16+ Weeks) ### Full Strengthening Program - **Progressive weights**: 1-5kg depending on size/gender - **Functional patterns**: Sport/work-specific movements - **Proprioception**: Balance and dynamic stability exercises - **Endurance**: Higher repetitions, functional activities ### Return to Activity Guidelines - **Unrestricted ADLs**: 4-5 months - **Manual labor/lifting**: 6 months - **Non-contact sports**: 6 months - **Contact/overhead sports**: 9-12 months - **Full biological healing**: 12-18 months **Too Aggressive (Most Common Error)**: - Early active ROM before 6 weeks causes re-tear - Excessive resistance before 12 weeks stresses repair - Return to sports before 6 months risks failure **Too Conservative**: - Prolonged immobilization beyond 6 weeks causes stiffness - Inadequate strengthening causes persistent weakness - Fear-avoidance limiting recovery **Optimal Balance**: Protected passive ROM 0-6 weeks, gradual progression active ROM 6-12 weeks, strengthening 12+ weeks. Individualize based on tear size, tissue quality, repair quality, patient factors. ## References 1. **Morse K, Davis AD, Afra R, et al.** Arthroscopic versus mini-open rotator cuff repair: a comprehensive review and meta-analysis. *Am J Sports Med*. 2008;36(9):1824-1828. doi:10.1177/0363546508322769 - *Meta-analysis showing equivalent outcomes between arthroscopic and mini-open techniques with no significant differences in healing rates, functional scores, or patient satisfaction* 2. **Kasten P, Keil C, Grieser T, et al.** Prospective randomised comparison of arthroscopic versus mini-open rotator cuff repair of the supraspinatus tendon. *Int Orthop*. 2011;35(11):1663-1670. doi:10.1007/s00264-011-1262-2 - *Randomized trial demonstrating similar Constant scores and healing rates between techniques at 24 months, with mini-open having shorter operative time* 3. **Buess E, Steuber KU, Waibl B.** Open versus arthroscopic rotator cuff repair: a comparative view of 96 cases. *Arthroscopy*. 2005;21(5):597-604. doi:10.1016/j.arthro.2005.01.002 - *Comparative study showing mini-open and arthroscopic repairs achieve equivalent functional outcomes with similar complication rates* 4. **Liu SH, Baker CL.** Arthroscopically assisted rotator cuff repair: correlation of functional results with integrity of the cuff. *Arthroscopy*. 1994;10(1):54-60. doi:10.1016/s0749-8063(05)80293-8 - *Early description of mini-open technique demonstrating 88% good/excellent results with intact repairs correlating with better outcomes* 5. **Severud EL, Ruotolo C, Abbott DD, Nottage WM.** All-arthroscopic versus mini-open rotator cuff repair: a long-term retrospective outcome comparison. *Arthroscopy*. 2003;19(3):234-238. doi:10.1053/jars.2003.50036 - *Long-term follow-up showing no significant differences in UCLA scores, patient satisfaction, or re-tear rates between arthroscopic and mini-open repairs* 6. **Verma NN, Dunn W, Adler RS, et al.** All-arthroscopic versus mini-open rotator cuff repair: a retrospective review with minimum 2-year follow-up. *Arthroscopy*. 2006;22(6):587-594. doi:10.1016/j.arthro.2006.01.019 - *Retrospective comparison demonstrating similar healing rates (92% arthroscopic vs 93% mini-open) and functional outcomes at minimum 2 years* 7. **Sauerbrey AM, Getz CL, Piancastelli M, et al.** Arthroscopic versus mini-open rotator cuff repair: a comparison of clinical outcome. *Arthroscopy*. 2005;21(12):1415-1420. doi:10.1016/j.arthro.2005.09.018 - *Study showing equivalent ASES and UCLA scores between techniques with slightly less pain in arthroscopic group at early follow-up* 8. **Shinners TJ, Nordquist DS, Orwin JF.** Arthroscopically assisted mini-open rotator cuff repair. *Arthroscopy*. 2002;18(1):21-26. doi:10.1053/jars.2002.29876 - *Technical description of hybrid mini-open technique with arthroscopic decompression showing good outcomes and low complication rates* 9. **Millett PJ, Warth RJ, Dornan GJ, et al.** Clinical and structural outcomes after arthroscopic single-row versus double-row rotator cuff repair: a systematic review and meta-analysis of level I randomized clinical trials. *J Shoulder Elbow Surg*. 2014;23(4):586-597. doi:10.1016/j.jse.2013.10.006 - *Meta-analysis demonstrating superior structural healing with double-row repairs (lower re-tear rates) though functional outcomes similar to single-row* 10. **Galatz LM, Ball CM, Teefey SA, et al.** The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears. *J Bone Joint Surg Am*. 2004;86(2):219-224. doi:10.2106/00004623-200402000-00002 *Study showing healing rates inversely proportional to tear size - small tears 10% re-tear, medium 25%, large 40%, massive 60% - emphasizing importance of tear size in technique selection and prognosis*

Mini-Open Rotator Cuff Repair

Mini-Open Rotator Cuff Repair