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.  

Conclusion: 

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.

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