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Surgery Of The Subacromial Space, Our Experience With 71 Cases.

 Jiménez Martín A*,Angulo Gutiérrez J,González Herranz J,Rodriguez de la Cueva JM,Díaz del Río J,Lara Bullón J.

* Hospital Nuestra Señora de Valme. Seville.

Address for Correspondence:  

Antonio Jiménez Martin.
Urb. Al-Alba, c/Brisa, nº 10, D. C.P. 41020. Sevilla.
Tel: 609012308



Objectives: Subacromial syndrome with cuff involvement can be treated with the classic, mini-open or arthroscopic methods. Our objective is to review 71 shoulders interventions in our centre and to study the results of these techniques. 
Materials and Methods: We analysed age, sex, NMR lesions, type of repair, complications, Constant, DASH and UCLA scales, among others. 
Results: Median age: 50 years; standard deviation: 9.97 years; Positive Yochum (91.5%), partial tear (25.4%), complete tear (33.8%). Classic repair (70.4%), arthroscopic (4.2%) mini-open (25.4%), with harpoons (45.1%), transbone suture (15.5%), section of the coracoacromial ligament (59.2%) and perforations in the zone of Codman (12.7%). The final DASH results were better for the arthroscopy (57.33 points). There were statistically significant results when making before and after comparisons of the surgical treatment (the open and mini-open techniques): Significant differences were not found between the Constant and UCLA tests (p=0.00) in our series, but there were regarding the number of harpoons (p=0.032), with more being used in the open techniques. 
Conclusions: In our series we did not find significant differences regarding the outcomes of the classic and mini-open techniques. We consider the mini-open technique to be effective, and useful in the cases where arthroscopic experience is limited.

J.Orthopaedics 2008;5(2)e18

acromioplasty, rotator cuff, Constant, UCLA, DASH

It has been attempted to treat the pathology of the subacromial syndrome by means of interventions where an acromioplasty was made with later repair of rotator cuff tears.
Various methods of approaching this intervention have been described. The classic open methods of Neer1or McLaughlin2;3 are highlighted and others such as that of Cabot4 (classic open acromioplasty, but with minimal incision, and without the support of arthroscopy), Gartsman5, Yukihiko Hata6, McFarland7, Bateman8, Neviaser9 or Watson10. On the other hand there are the methods with arthroscopic support, with later mini incision or “mini-open”, such as those of Liu11, Paulos and Kody12, Blevins13, Shinners14, or Fearly15; or those solely with arthroscopic support as described by Ogilvie-Harris and Demazière16, Gartsman17or Burkhart18.
Various studies have been made that try to compare the benefits and damages of the accomplishment of the different techniques, using the UCLA19;20(University of California-Los Angeles) or Constant and Murley21 tests. Our objective is to evaluate 71 interventions on subacromial syndromes using traditional techniques, arthroscopy with the aid of mini-incisions and in one case arthroscopy alone, evaluating the clinical results obtained with a minimum follow-up of at least 2 years.

Figure 1. NMR: Observe the reduction of the subacromial space and the discontinuity in fibres of the rotator cuff. Zlatkin 3, Tavernier IV and Seeger 3.

Figure 2. Distribution of surgical techniques. The predominance of the traditional technique (70.4%) is emphasised, as opposed to the mini-open (25.4%) or arthroscopic (4.2%) procedures.


Figure 3. Positioning of harpoons in the insertion zone of the cuff or “footprint”.

Table 1. Results of the DASH test. In all the groups an evident improvement is reached, although the results obtained with the arthroscopic technique are better than those obtained with the traditional or mini-open techniques.




Traditional surgery

Artroscopic surgery

Miniopen surgery

Preoperatory results




Postoperatory results






Material and Methods :

We made a descriptive, retrospective study, where 71 shoulder interventions were included, of which 54 were men, and 17 were women (76.1% and 23.9%, respectively). The mean age was 50.87 years, with a median of 50 years and a standard deviation of 9.97 years, with an asymmetry of 0.083 years, a minimum of 28 years and a maximum of 75 years. A right side predominance was emphasised: 70.4%, against the left, 29.6%.

In this study the following aspects were considered at the time of data collection:

n       PERSONAL DATA: Name, age, history number, sex, telephone number, profession, associated pathologies. Exploration: Gerber, Yochum, Yegarson, Neer, Hawkins, Jobe.

n       DIAGNOSTIC TESTS: Echography, Rx, NMR: tendinitis, tendinosis, calcifications, partial or complete tears etc. Staging of the cuff lesions according to Zlatkin, Tavernier and Seeger.

n       SURGICAL INTERVENTION: Pre-operative days, post-operative days, open/traditional acromioplasty, mini-open or arthroscopic. Repair of the rotator cuff with transbone sutures or harpoons. Type of anaesthesia used. Codman perforations. Section of the coracoacromial ligament.

n       COMPLICATIONS AND SEQUELAE: Re-tears, infection, persistent pain, harpoon movement.

n       REHABILITATION: Time, type of rehabilitation.

n       Constant’s Test.

n       U.C.L.A. Test

n       D.A.S.H. Test

n       Iconographic study. 

The data from the field study were analysed statistically by means of the SPSS program, with the intention of making a descriptive study and to state the distribution of the patients by confidence intervals to describe the statistically significant results that arose.

Results :

At the time of asking for the working or daily habits of the patients, we found a predominance of mechanical activities with trades such as bricklayer in 11.3% of men, or housewife, in 11.3% of women. Other trades such as agriculturist, plasterer, waiter, truck driver, warehouse worker, painter or mechanic were emphasised.

At the time of investigating for possible concomitant pathologies, we discovered rheumatoid arthritis alone in 1.4%, arthrosis alone in 42.3%, rheumatoid arthritis and arthrosis in 4.2% and others such as the associations of arthrosis, rheumatoid arthritis and diabetes in 1.4%, arthrosis and diabetes in 1.4%, arthrosis and psoriasis in 1.4%, arthrosis and consolidated fracture in bad position in 1.4%, arthrosis and subacromial syndrome after glenohumeral arthroplasty in 1.4%, sequelae of greater tubercle fracture treated with cerclage in 1.4%, sequelae of greater tubercle fracture treated by means of osteosynthesis with screw and acromioplasty in 1.4% and sequelae of open acromioplasty 3 years before in another 1.4%.

Exploration gave the following signs, Gerber: 49.3% positive and 50.7% negative, Yegarson: 8.5% positive and 91.5% negative, Yochum: 91.5% positive and 8.5% negative, Jobe: 83.1% positive and 16.9% negative and finally, Neer: 45.1% positive and 54.9% negative.

Magnetic resonance found tendinitis of the supraspinatus in 53.5%, tendinosis in 19.7% (although for many tendinitis is synonymous with tendinosis), osteophytes in 38.0%, partial tear in 25.4%, complete tear in 33.8%, bursitis in 23.9%, tenosynovitis in 23.9%, old fractures of the greater tubercle in 7%, decrease in the subacromial space in 100% and bony cysts in 11.3%.

In the NMR different stages were described according to Zlatkin, with types 0 in 1%, 1 in 12.70%, 2A in 22.50%, 2B in 9.90% and 3 in 50.70%. With the staging of Tavernier we obtained the following distribution: I in 1%, IIA in 8.50%, IIB in 16.90%, III in 21.10%, IV in 16.90% and V in 32.40%. The staging of Seeger, gave: type 1 in 4%, 2A in 43.70%, 2B in 16.90% and 3 in 32.40%. (See Figure 1.)

The distribution of acromioplasties was the following: traditional or open method in 70.4%, arthroscopic in 4.2% and mini-open in 25.4%. Subacromial syndrome without tear: 39.4%. There were cases of subacromial syndrome with rotator cuff tear in 60.6%, the repair of the rotator cuff was made in 60.6%, using transbone suture in 15.5% and the positioning of harpoons in 45.1%. We made the exeresis of osteophytes in 16.9% and perforations in the zone of Codman in 12.7%. (See Figures 2 and 3).

The number of pre-operative days had a median of 1 day, with a standard deviation of 0.563 days, the number of post-operative days had a median of 2 days, with standard deviation of 2.131 days. On the other hand, the number of harpoons used had a median of 1 harpoon and a standard deviation of 1.2 harpoons, with a minimum of 0 harpoons and a maximum of 4 harpoons. The time of the intervention had a median of 105 minutes with a standard deviation of 31.81 minutes, with minimums of 45 minutes and maximums of 180 minutes. Lastly, the time of rehabilitation had a median of 4 months, with a standard deviation of 1.8 months, with a minimum of 0 months and a maximum of 9 months. Other surgical acts were the Bristow procedure in 1.4%, bursectomy in 14.1%, bursectomy and screw extraction in 1.4%, extraction of harpoon in 1.4%, exeresis of the supra-external tubercle in 1.4%, fistulectomy in 1.4%, interposition of the biceps in 1.4% and reinsertion of the rotator cuff on the prosthesis in 1.4%.

The distribution of the intraoperative risk was ASA I: 32.4%, II: 53.5% and III: 14.1%. The type of anaesthesia used was balanced general: 5.6%, general with intubation: 62%, general without intubation: 2.8%, interscalenic locoregional: 11.3%, brachial locoregional: 5.6% and intersternocleidomastoid locoregional: 12.7%.

The percentage of repair of the rotator cuff differed according to the type of surgical procedure, thus in the open acromioplasties 70% of the cases were repaired, in the arthroscopic the rotator cuff was not repaired and in the mini-open 44.4% of the cases were repaired. The type of repair also differed according to the procedure used: thus, in the open/traditional methods transbone suture was made in 16% of the cases and harpoons were placed in 54%, of a total of 70% of repaired cuffs, whereas in the mini-open, transbone suture was made in 16.7% and harpoons were placed in 27.8%, of a total of 44% of repaired cuffs. The partial section of the coracoacromial ligament differed according to the procedure used, thus, in open/traditional acromioplasties it was made in 64%, in arthroscopic in 0% and in the mini-open in 55.6%. The exeresis of osteophytes was also different, in the open/traditional procedures it was 20%, in the arthroscopic it was 0% and in the mini-open it was 11.1%. Lastly, the perforations in the zone of Codman were more frequent in traditional or open acromioplasties at 16%, the arthroscopic at 0% and in the mini-open at 5.6%.

Different sequelae arose such as persistent pain in 19.7% of the cases, crepitation in 8.5%, pain on hyperabduction in 21.1%, keloid scar in 4.2%, limitation on attempted movement in 21.1%, movement of harpoon in 2 cases, 2.8% of the total, in the group of traditional acromioplasties. Re-intervention for infection in 1 case, another case with fistula from a previous intervention for fracture of the greater tubercle, deltoid atrophy and molestations in the deltoid region in 2.8% and 1 case of retractable capsulitis in one open acromioplasty that prolonged the rehabilitation to more than 1 year. It is significant that among the sequelae, in our series, persistent pain was greater in the open/traditional group and in the arthroscopic than in the mini-open group, crepitation was greater in the open group, painful hyperabduction was more frequent in the arthroscopic group (33.3% as opposed to 22.2% in the traditional group and 16.70% in the mini-open group), keloid scars did not arise in the arthroscopic group, nevertheless, they did appear in 4% of the open/traditional group and in 5.6% of the mini-open group. The limitation of mobility was greater in our series for the arthroscopic group with values of 33.3%, as opposed to 24% of the open/traditional group or 11.10% of the mini-open group. 

Rehabilitation was centred on kinestherapy in 95% of all the patients, although pulley-mechanotherapy in 45.10% and pendular exercises in 39.40%, are also highlighted.

We did not find statistically significant differences regarding pre-operative days between the different techniques, p=0.586. There were no statistically significant differences regarding post-operative days between the different techniques, p=0.232. Statistically significant differences were found regarding the number of harpoons used between the different techniques, p=0.032. Statistically significant differences were not found regarding the time of operation, p=0.42, nor for the time of rehabilitation, p=0.924. 

The U.C.L.A. scores ran from intolerable pain:  91.5%, one function: Disabled 95.8%, only for light activities 1.4%. A prior active flexion: <30º: 31%; 30-45º: 57.7%; 45-90º: 8.5%; 90-120º: 2.8% and a muscular strength for the flexion: 0:33.8%; 1:60.6%; 2:4.2%; 3:1.4%; to the post-operative tolerable pain values: 13%, pain at rest: 18.30%, pain with heavy activities: 19.7%, occasional pain: 19.7% and no pain: 29.60%. Function: Light activities: 7%; little: 11.3%; more: 26.8%; slight restriction: 29.6%, normal activity: 25.4%. Prior active flexion: Less than 30º = 0º; 30-45º: 2.8%; 45-90º: 7%; 90-120º: 11.3%; 120-150º: 26.8%; More than 150º: 52.1%.  A progression took place from a pre-operative average of 3.49 points, with a standard deviation of 1.34 points, to an post-operative average of 25.01 points, with a standard deviation of 8.106 points, passing from bad pre-operative results in 100% to the integrated post-operative distribution for bad results in 19.70%, regular in 39.40%, good in 22.50% and excellent in 18.30%. A statistically significant global improvement took place regarding the difference produced between the pre-operative and the post-operative values in all the groups: p= 0.001, with margins in - 19.596; - 23.446. Statistically significant partial improvement in the open/traditional group: p= 0.000, statistically significant partial improvement in the mini-open group: p=0.000 and partial improvement, although not statistically significant in the arthroscopy group: p=0.102.

The Constant test showed a global improvement, in that bad pre-operative scores in 100% changed to post-operative scores after open/traditional acromioplasties of bad in 26%, regular in 28%, good in 20% and excellent in 26%; in the arthroscopic, bad in 33%, regular in 33% and good in 33%, without excellent results, and finally, with post-operative results in the mini-open techniques that were bad in 17%, regular in 33%, good in 16.70% and excellent in 33%.  This global improvement in the Constant scores was statistically significant, with p=0.000, a 95% confidence interval for the difference between the pre-operative and post-operative results, with reductions in the scores of between 57.793 and 48.038, with a mean reduction of 52.915 points. Statistically significant differences were obtained in each individual technique, however, there were no statistically significant differences when comparing the results of one technique with those of another. 

In the D.A.S.H test the following outcome measures were obtained: in the open/traditional group a pre-operative mean of 126.10 points was obtained, with a standard deviation of 10.181 points, and a post-operative mean of 75.24 points, with a standard deviation of 32.131 points. In the arthroscopic group the pre-operative mean was 123.33 points, with a standard deviation of 8.145 points, and a post-operative mean of 57.33 points, with a standard deviation of 14.189 points.

Finally, in the mini-open interventions, the pre-operative mean was 130 points, with a standard deviation of 7.404 points, and a post-operative mean of 65.89 points, with a standard deviation of 28.130 points.

Statistically significant improvements in D.A.S.H outcome measures took place, with p=0.000 and a 95% confidence interval for the difference, with a lower limit of 47.812 points and an upper of 61.906 points, a statistically significant improvement in the open group with p=0.031, with lower and upper limits of 14.668 and 117.332 points respectively, with a statistically significant improvement in the mini-open group with p=0.000, with lower and upper limits of 49.242 and 78.980 points respectively and, in general, with a statistically significant improvement in all the items when making pre- and post-operative comparisons. (See Table 4).

Discussion :

In our series we have tried to compare different surgical procedures at the time of approaching subacromial syndrome, as well as the repair of the rotator cuff. We found a general improvement after the interventions, nevertheless, we did not find statistically significant differences between the different techniques. Throughout recent history multiple studies have been published where these possible differences are expressed. Open techniques have been proposed, such as that described by Gartsman5 in 1997, who made a revision of massive tears in the rotator cuff with a series of 33 patients, who underwent debridement of adhesions and subacromial decompression by means of open acromioplasty. His study was based on the tests of Constant and Murley21and that of the University of California in Los Angeles (UCLA)19;20, verifying a functional improvement in the shoulder with a significant reduction of pain with p= 0.001 and an increase in the range of movement with p= 0.016. Post-operatively there were no cases of dehiscence in the transdeltoid suture, the pain decreased and the abduction improved p=0.0022. The UCLA scale went from 11.5 points to 21.0 points finally. The Constant and Murley test results went from 31.2 points to 52.4 points finally. Nevertheless, although the function of the shoulder improves after the intervention, a diminution occurs in the range of movement and remaining strength in comparison with the non affected opposite shoulder. This is one of the conclusions reached by Kronberg22 in his 1997 work, where 37 patients with traditional repairs to cuff tears were studied. Comparing both shoulders, those with intervention reached a mean score of 77 points in the Constant test as opposed to a mean score of 92 points in the shoulders without intervention.
Nevertheless, other authors prefer traditional surgery without arthroscopy, but with different approaches. Thus, Yukihiko Hata6 applied a less invasive approach in a group of 22, by means of a trans-acromial incision of about 3 cm in length and making a prior acromioplasty with liberation of the coracoacromial ligament. Prior arthroscopy had been made. This group was compared with another of 36 patients to whom the classic technique was applied. There were no significant differences between the groups where the UCLA test gave 33.2 and 32.8 points in both groups respectively at follow-up one year after the surgery. However, the active mobility in forward flexion in the group with the mini approach was greater (157.1º +/- 9.5º) than in the group with the classic open technique (149.2 +/- 13.7º) at 3-6 months after the surgery. With the mini approach the patients returned to their sports or daily activities earlier than the traditional group.
McFarland7 described lateral acromioplasty that would be indicated fundamentally in patients with massive tears of the rotator cuff, where the acromion in its anterior segment and the coracoacromial ligament have to be preserved.
Other authors have preferred to use the techniques with mini-approaches and arthroscopic support, in this way, Levy23, described the arthroscopic decompression and suture of the tear by means of a small route of approach or “mini-open”, obtaining an improvement in pain, functionality, movement and strength, with a satisfaction of 96%. Paulos and Kody12 also proposed the technique of repair by lateral transdeltoid mini-approach with arthroscopic decompression, in a study of 18 patients of whom 88% reached a favourable result in the UCLA test. Blevins13 made revisions in 64 patients with interventions for repair of the rotator cuff by means of arthroscopy and assistance with a mini-approach, obtaining a reduction in subacromial compression or “impingement” from 96% to 16%. Shinners14 developed a study on 67 patients using arthroscopic repair assisted with a mini-approach, obtaining a mean of 32.3 points in the UCLA test. There were no significant differences in the UCLA test results with respect to the size of the tear (p<0.4286) or the age of the patient (p< 0.1131). Stephen Fearly15 later applied prior visualisation with arthroscopy and a mini-approach in various tears, with 83% of the patients returning to their prior activities after the intervention.
In general, arthroscopic surgery of the rotator cuff involves a series of advantages, as reported by Yamaguchi24, who indicated that the greatest advantage of the mini-open and arthroscopic techniques over the traditional approach is based on the small incisions, the preservation of the deltoid musculature, with less damage, less tissue dissection, less post-operative pain, shorter stays in hospital14, easier rehabilitation, better visualisation and access to the glenohumeral joint, facilitating the diagnosis and the treatment of associated intra-articular diseases such as synovitis, bicipital tendinitis, capsular-labral diseases and glenohumeral arthritis. For Burkhart18, arthroscopy allows treating rotator cuff tears irrespective of the size of the tear or the number of tendons involved, allowing the better appreciation of the configuration of the tear that is obtained with the arthroscope and by the development of the repair technique called “margin convergence”.
Similarly, there are various studies, like the one of Liu11, that establish that the mini-open approach allows results similar to the traditional open technique to be obtained, but involving a shorter hospital stay, faster rehabilitation, better cosmetic result, better evaluation and treatment of glenohumeral diseases and preservation of the deltoid insertions. A value of 32.7 points in the UCLA test was reached in his series of 44 patients. The mini-open technique combines the benefits of the open technique with the advantages of making a small and cosmetic scar in the deltoid, that does not violate the insertion of the musculature in the acromion, nevertheless Fearly15, for example, does not recommend its use in cases of subscapularis tears, since in these cases the open or traditional technique would be preferred. Paulos and Kody12 also found a 94% satisfaction among their patients treated by means of arthroscopy assisted mini-open approach. Also Blevins13 , was able to achieve a reduction in “impingement” from 96% of the pre-operative cases to 16% post-operatively with the mini-open technique. The active elevation increased significantly, from 129º to 166º. Baker and Liu25 compared the open technique with the mini-open assisted arthroscopically. In a retrospective study on 37 patients they obtained good results in 80% of the traditional or open group, nevertheless, in the group with the mini-open approach good results were obtained in 85% of the cases, with a shorter hospital stay and an earlier return to their labour activities. Yukihiko Hata26 studied the atrophy of the deltoid after rotator cuff surgery. For this he grouped 43 cases treated in the traditional open way and 45 with an arthroscopic manner assisted with a mini-approach or “mini-open”. It was observed that the weakness of the anterior segment of the deltoid was not manifest in the mini-open group, however, in the traditional group an atrophy occurred that was measurable in NMR up to approximately 60%. The period required to return to work in the mini-open group was 2.4 months, which was shorter than the time required for the return to work with the traditional approach, which was 3.4 months. Vives27 studied subacromial syndrome in golf players, for which he grouped 15 patients who had the traditional open technique and 16 who had the arthroscopic technique with mini-open. There were no significant differences regarding the driving distances when comparing the pre- and post-intervention data. Yukihito Hata6 made a comparative study of a group of 36 patients who had the traditional intervention with another group of 22 patients where a mini-approach of 3cm was used, emphasising that there were no significant differences between groups in the UCLA test, referring to post-operative values of the UCLA test of 33.2 and 32.8 in both groups respectively at follow-up one year after the surgery. With the mini technique the patients returned earlier to their previous activities.
Also, other studies have been developed where arthroscopy was evaluated as an exclusive technique. In fact, the exclusively arthroscopic repair has produced better results than even the traditional open forms. A proof of this is the review of Tauro28 on 53 patients modifying the values of the UCLA scale from 16 to 45 points post-operatively, with less postsurgical pain and easier rehabilitation, compared with those that had a classic traditional or open approach. Ogilvie-Harris and Demazière16, published a study in 1992 where they compared 2 types of treatments, a group of 22 patients where arthroscopic subacromial decompression was used, against 23 patients where the traditional open technique was applied. Similar results were obtained regarding the improvement of pain and the active range of flexion. In 1998 Gartsman17 made another review of 73 purely arthroscopic repairs, with a minimum follow-up of 2 years. Good to excellent post-operative results were obtained in 84% of the patients in the UCLA test. In 2001 Burkhart18, made a study where he evaluated the arthroscopic repair of the cuff on 59 cases with the UCLA test. For Burkhart the results were independent of the size of the tear with a p>0.05 and the results obtained by means of suture of the tendon to the bone or margin convergence were similar, emphasising the functional improvement presented in the UCLA test with a p<0.0001. These results were not influenced by the size of the tear or by the number of tendons involved. The results that Burkhart obtained led him to state that the arthroscopic technique gives superior results than the open procedures in the cases of large or massive tears. Severud29 compared 35 patients who had the purely arthroscopic technique with 29 patients who had the mini-open technique, with a follow-up of 44.6 months. The mean final score obtained with the UCLA scale was 32.6 points for the arthroscopic group and 31.4 points for the mini-open group. In general the results are similar, but the low rate of fibrosis in the arthroscopic group leads the author to prefer the exclusively arthroscopic form. Weber30 made a study where he analysed 126 shoulders operated on with the exclusively arthroscopic technique and 154 by means of the mini-open techniques. No significant differences between the 2 groups were found at the end of the follow-up in the ASES, UCLA or SST assessments. In 1999 Weber31 made a comparative study between the arthroscopic and mini-open procedures, with it being remarkable that only 6 of the 33 patients with the traditional or open procedure did not require narcotics in the recovery room, whereas 31 of the 32 patients with the arthroscopic procedure did not require these drugs, a finding which supports the view that the arthroscopic procedure causes less post-operative pain. Warner32 made a study where he included 9 patients operated on in an exclusively arthroscopic manner and 12 with a repair with a mini-open procedure. The SST or Simple Shoulder Test was used which revealed a significant reduction in the pain levels, whilst there were no large differences between the groups regarding the pre- or post-operative flexions or the external rotation. The group with the arthroscopic intervention showed an increase in the strength of the intervened member (p<0.01), something not so evident in the group with the mini-open intervention (p=0.26). Seung-Ho Kim33 tried to evaluate the differences existing between 42 patients where the technique applied was exclusively arthroscopic and another 34 patients where the mini approach was used after having tried a previous arthroscopy without success. Using the UCLA test and the ASES (American Shoulder and Elbow Surgeons shoulder rating scale) he observed improvements regarding the pain, mobility of the shoulder and the return to daily activity, without seeing clear differences between both techniques, however, the larger the tear the lower were the test results.
Fearly15 considered that the accomplishment of an arthroscopic subacromial decompression with mini-open can be an effective alternative to the exclusively arthroscopic repair of the rotator cuff, because it allows an intense mobilisation of the retracted tendons and a medial liberation of the adhesions. Herrera34 considers that the arthroscopic procedures are the best, semi-sterile, with a continuous washing of the surgical field. The conversion from an arthroscopic method to an open or a mini-open method supposes an increase in the risk of developing an infection by the saprophytic flora of the skin, by agents such as Propionibacterium acnes, Staphylococcus epidermidis, aureus or Pseudomonas aeruginosa. Although the rate of deep infection after the repair of the rotator cuff with an open or standard technique can be determined at 0.27-1.7%35;36, the rate of infection after the approach with mini-incision would be determined at 1.9%.
The strange method of the study made in 1994 by Grana37 is highlighted, where it is explained that the arthroscopic evaluation did not in itself affect the functional result, but which increased the cost by 2000 dollars for each patient. The arthroscopy can help to define the size of the tear, which can condition the type of approach used, but for Grana the arthroscopic treatment of glenohumeral problems would not alter the functional result, it would be expensive, non-effective and in addition he would not recommend it. We do not share this idea.
In our series we have not had excessive complications, in fact, there were specific cases, nevertheless, the surgery of the rotator cuff is not free of complications, as in the series of Gartsman with the appearance of 2 seromas and a case of infection. Vives27 in his series describes 2 cases of infection, with positive cultures for Staphylococcus epidermidis. Herrera34 describes a rate of infections of 1.9% after the 360 acromioplasties performed with the mini-open procedure. The treatment consisted of the debridement and irrigation of the articular cavity and revision of the rotator cuff repair together with intravenous antibiotherapy during an average of 4.2 weeks, observing sensitivity to ciprofloxacin, vancomycin, clindamycin and kefzol. After the intravenous treatment it was possible to continue with oral treatment with amoxicillin-clavulanic acid and/or ciprofloxacin for 2 weeks. The agent most involved, in up to 86% of the cases, was Propionibacterium acnes. The conversion from an arthroscopic method to an open, supposes an increase in the risk of developing an infection by the saprophytic flora of the skin, as has been commented previously. Settecerri36 also observed 16 cases of infection after the repair of the rotator cuff between 1975 and 1994, where the most frequent agent was Propionibacterium acne in 6 cases, coagulase negative Staphylococcus in 4 cases, Peptostreptococcus magnus in 1 case and the association of Propionibacterium and coagulase negatives in another case. Mirzayan38 studied deep infection after rotator cuff repair and found agents in the following order of frequency, Staphylococcus epidermidis, Staphylococcus aureus and Propionibacterium species. Also, cutaneous hypersensitivity in the lateral portal has been described by Kim33, transitory paresthesias in the hand of the intervened side described by Burkhart18, keloid scars33, reactions to the suture material used, as Severud29 explains, persistence of the clinical picture of subacromial compression, with re-interventions (Blevins13), reappearance of osteophytes and subacromial clinical picture (Shinners14), reduction in strength when trying to elevate objects in some series with p=0.0007, or difficulties for working overhead can be caused by the resection of the coracoacromial ligament as reported by Rockwood39, Nirschl40and Flatow41. The atrophy of deltoids26, reviewed by Groh42, that would take place in the classic intervention by the involvement of the insertion point of the deltoid or by damage in the axillary nerve. The preservation of deltoid function is essential, as has been described by authors such as Adamson43, Bigliani44, Neviaser45 or Iannotti46, since it provides 50%42 of the strength for the elevation of the arm in the scapular plane. Also tears of the long portion of the biceps29 have been described, re-tears of the cuff29 as described by Cabot4 or Blevins13, which in some cases required revision surgery, this time open27. Also adhesions and frozen shoulder have been described after rotator cuff surgery, as described by Mormino47. Ankylosis or fibrosis, defined as a failure to reach a flexion greater than 120º has been described in patients in whom the mini-open has been used.
Postsurgical pain can be corrected with the accomplishment of interscalenic blockades, which also determines a reduction in the anaesthetic requirements during the intervention.  


With acromioplasty and the repair of the rotator cuff we were able to improve the clinical picture of subacromial syndrome. The progression of the surgery has brought about the boom in arthroscopic procedures. We consider that the mini-open technique with prior arthroscopic support is an alternative that will allow the progressive step to an exclusively arthroscopic system, that can be used without requiring large learning curves, especially in those shoulder cases which are not yet controlled with arthroscopic procedures.

Reference :


  1. Neer CS 2nd. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report. J Bone Joint Surg Am.1972 Jan;54(1):41-50. 
  2. McLaughlin HL. Lesions of the musculotendinous cuff of the shoulder. The exposure and treatment of tears with retraction. 1944. Clin Orthop Relat Res.1994 Jul;(304):3-9. 
  3. McLaughlin HL. Repair of major cuff ruptures. Surg Clin North Am.1963 Dec;43:1535-40. 
  4. Cabot A, Cabot JC. Minimal incision acromioplasty. Orthopedics.2002 Dec;25(12):1347-50. 
  5. Gartsman GM. Massive, irreparable tears of the rotator cuff. Results of operative debridement and subacromial decompression. J Bone Joint Surg Am.1997 May;79(5):715-21. 
  6. Hata Y, Saitoh S, Murakami N, et al. A less invasive surgery for rotator cuff tear: mini-open repair. J Shoulder Elbow Surg.2001 Jan-Feb;10(1):11-6. 
  7. McFarland EG, Park HB, Kim TK, et al. Limited lateral acromioplasty for rotator cuff surgery. Orthopedics.2005 Mar;28(3):256-9. 
  8. Bateman JE. The diagnosis and treatment of ruptures of the rotator cuff. Surg Clin North Am.1963 Dec;43:1523-30. 
  9. Neviaser JS. Surgical approaches to the shoulder. Clin Orthop Relat Res.1973 Mar-Apr;(91):34-40. 
  10. Watson M. Major ruptures of the rotator cuff. The results of surgical repair in 89 patients. J Bone Joint Surg Br.1985 Aug;67(4):618-24. 
  11. Liu SH. Arthroscopically-assisted rotator-cuff repair. J Bone Joint Surg Br.1994 Jul;76(4):592-5. 
  12. Paulos LE, Kody MH. Arthroscopically enhanced "miniapproach" to rotator cuff repair. Am J Sports Med.1994 Jan-Feb;22(1):19-25. 
  13. Blevins FT, Warren RF, Cavo C, et al. Arthroscopic assisted rotator cuff repair: results using a mini-open deltoid splitting approach. Arthroscopy.1996 Feb;12(1):50-9. 
  14. Shinners TJ, Noordsij PG, Orwin JF. Arthroscopically assisted mini-open rotator cuff repair. Arthroscopy.2002 Jan;18(1):21-6. 
  15. Fealy S, Kingham TP, Altchek DW. Mini-open rotator cuff repair using a two-row fixation technique: outcomes analysis in patients with small, moderate, and large rotator cuff tears. Arthroscopy.2002 Jul-Aug;18(6):665-70. 
  16. Ogilvie-Harris DJ, Demaziere A. Arthroscopic debridement versus open repair for rotator cuff tears. A prospective cohort study. J Bone Joint Surg Br.1993 May;75(3):416-20. 
  17. Gartsman GM, Khan M, Hammerman SM. Arthroscopic repair of full-thickness tears of the rotator cuff. J Bone Joint Surg Am.1998 Jun;80(6):832-40. 
  18. Burkhart SS, Danaceau SM, Pearce CE Jr. Arthroscopic rotator cuff repair: Analysis of results by tear size and by repair technique-margin convergence versus direct tendon-to-bone repair. Arthroscopy.2001 Nov-Dec;17(9):905-12. 
  19. Burkhart SS. Arthroscopic debridement and decompression for selected rotator cuff tears. Clinical results, pathomechanics, and patient selection based on biomechanical parameters. Orthop Clin North Am.1993 Jan;24(1):111-23. 
  20. Ellman H, Hanker G, Bayer M. Repair of the rotator cuff. End-result study of factors influencing reconstruction. J Bone Joint Surg Am.1986 Oct;68(8):1136-44. 
  21. Constant CR, Murley AH. A clinical method of functional assessment of the shoulder. Clin Orthop Relat Res.1987 Jan;(214):160-4. 
  22. Kronberg M, Wahlstrom P, Brostrom LA. Shoulder function after surgical repair of rotator cuff tears. J Shoulder Elbow Surg.1997 Mar-Apr;6(2):125-30. 
  23. Levy HJ, Uribe JW, Delaney LG. Arthroscopic assisted rotator cuff repair: preliminary results. Arthroscopy.1990;6(1):55-60. 
  24. Yamaguchi K, Ball CM, Galatz LM. Arthroscopic rotator cuff repair: transition from mini-open to all-arthroscopic. Clin Orthop Relat Res.2001 Sep;(390):83-94. 
  25. Baker CL, Liu SH. Comparison of open and arthroscopically assisted rotator cuff repairs. Am J Sports Med.1995 Jan-Feb;23(1):99-104. 
  26. Hata Y, Saitoh S, Murakami N, et al. Atrophy of the deltoid muscle following rotator cuff surgery. J Bone Joint Surg Am.2004 Jul;86-A(7):1414-9. 
  27. Vives MJ, Miller LS, Rubenstein DL, et al. Repair of rotator cuff tears in golfers. Arthroscopy.2001 Feb;17(2):165-72. 
  28. Tauro JC. Arthroscopic rotator cuff repair: analysis of technique and results at 2- and 3-year follow-up. Arthroscopy.1998 Jan-Feb;14(1):45-51. 
  29. Severud EL, Ruotolo C, Abbott DD, et al. All-arthroscopic versus mini-open rotator cuff repair: A long-term retrospective outcome comparison. Arthroscopy.2003 Mar;19(3):234-8. 
  30. Weber S.C. All-arthroscopic versus mini-open repair in the management of tears of the rotator cuff: A prospective evaluation (abstract). Arthroscopy.2001.17(suppl 1). 
  31. Weber SC. Arthroscopic debridement and acromioplasty versus mini-open repair in the treatment of significant partial-thickness rotator cuff tears. Arthroscopy.1999 Mar;15(2):126-31. 
  32. Warner JJ, Tetreault P, Lehtinen J, et al. Arthroscopic versus mini-open rotator cuff repair: a cohort comparison study. Arthroscopy.2005 Mar;21(3):328-32. 
  33. Kim SH, Ha KI, Park JH, et al. Arthroscopic versus mini-open salvage repair of the rotator cuff tear: outcome analysis at 2 to 6 years' follow-up. Arthroscopy.2003 Sep;19(7):746-54. 
  34. Herrera MF, Bauer G, Reynolds F, et al. Infection after mini-open rotator cuff repair. J Shoulder Elbow Surg.2002 Nov-Dec;11(6):605-8. 
  35. Post M. Complications of rotator cuff surgery. Clin Orthop Relat Res.1990 May;(254):97-104. 
  36. Settecerri JJ, Pitner MA, Rock MG, et al. Infection after rotator cuff repair. J Shoulder Elbow Surg.1999 Jan-Feb;8(1):1-5. 
  37. Grana WA, Teague B, King M, et al. An analysis of rotator cuff repair. Am J Sports Med.1994 Sep-Oct;22(5):585-8. 
  38. Mirzayan R, Itamura JM, Vangsness CT Jr, et al. Management of chronic deep infection following rotator cuff repair. J Bone Joint Surg Am.2000 Aug;82-A(8):1115-21. 
  39. Rockwood CA Jr, Williams GR Jr, Burkhead WZ Jr. Debridement of degenerative, irreparable lesions of the rotator cuff. J Bone Joint Surg Am.1995 Jun;77(6):857-66. 
  40. Nirschl RP. Rotator cuff surgery. Instr Course Lect.1989;38:447-62. 
  41. Flatow, E. L. Coracoacromial ligament preservation in rotator cuff surgery. J.Shoulder and Elbow Surg.1994.3:573 .
  42. Groh G.I, Simoni M, Rolla P, et al. Loss of the deldoid after shoulder operations: an operative disaster. J Shoulder Elbow Surg.1994.3:243-53. 
  43. Adamson G.J, Tibone J. E. Ten-year assessment of primary rotator cuff repairs. J Shoulder Elbow Surg.1993.2:57-63 .
  44. Bigliani L.U, McIlveen S. J Cordasco F. A, et al. Operative management of failed rotator cuff repairs. Orthop Trans.1998.12:674. 
  45. Neviaser R.J, Neviaser T. Reoperation for failed rotator cuff reapir: Analysis of fifty cases. J Shoulder Elbow Surg.1992.1:283-286. 
  46. Iannotti JP. Full-Thickness Rotator Cuff Tears: Factors Affecting Surgical Outcome. J Am Acad Orthop Surg.1994 Mar;2(2):87-95. 
  47. Mormino MA, Gross RM, McCarthy JA. Captured shoulder: a complication of rotator cuff surgery. Arthroscopy.1996 Aug;12(4):457-61. 



This is a peer reviewed paper 

Please cite as : Jiménez Martín A : Surgery Of The Subacromial Space, Our Experience With 71 Cases.

J.Orthopaedics 2008;5(2)e18





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