High-yield overview

Surgical repair of full-thickness rotator cuff tears via anterolateral deltoid-splitting or deltopectoral approach. Gold standard for complex tears, revision cases, and when superior tissue visualization required. | intermediate

Critical Danger Structures - Know Location and Protection

Danger 1: Axillary Nerve

Location: Exits quadrangular space posteriorly with posterior circumflex humeral artery. Enters deltoid muscle 5-7cm inferior to lateral acromion edge. Innervates deltoid and teres minor, provides lateral upper arm sensation.

Protection: LIMIT deltoid split to <5cm from acromion. Split vertically in raphe between anterior/middle deltoid fibers. Tag edges with stay sutures. Most common nerve injury in open rotator cuff repair.

Danger 2: Suprascapular Nerve

Location: Passes through suprascapular notch beneath superior transverse scapular ligament. Runs 2-3cm medial to posterior glenoid rim at spinoglenoid notch. Innervates supraspinatus and infraspinatus muscles.

Protection: Avoid excessive medial dissection beyond glenoid rim. Protect during interval slides and capsular releases. Keep mobilization lateral to avoid nerve traction or direct injury.

Danger 3: Musculocutaneous Nerve

Location: Enters coracobrachialis muscle 3-8cm distal to coracoid tip (variable anatomy). Continues between biceps and brachialis. Provides motor to anterior arm flexors and lateral forearm sensation.

Protection: Relevant in deltopectoral approach. Identify coracoid and avoid dissection >3cm distal. Protect during subscapularis mobilization and biceps tenodesis. Retract tissues gently.

Danger 4: Cephalic Vein

Location: Lies in deltopectoral groove between deltoid (lateral) and pectoralis major (medial). Joins axillary vein. Variable size and connections.

Protection: In deltopectoral approach: identify vein, retract LATERALLY with deltoid to preserve venous drainage. Avoid injury during exposure. Ligate only if necessary to prevent hematoma.

Danger 5: Greater Tuberosity

Location: Lateral aspect of proximal humerus. Insertion site for supraspinatus (superior facet), infraspinatus (middle facet), teres minor (inferior facet). May be osteoporotic in elderly.

Protection: Avoid over-aggressive decortication. Insert anchors at 45° deadman angle for optimal purchase. Space anchors 5-10mm apart. Avoid excessive torque in osteoporotic bone to prevent fracture.

Mnemonic

REPAIRREPAIR - Rotator Cuff Assessment Framework

Mnemonic

ANCHORSANCHORS - Double-Row Repair Principles

Indications for Open Rotator Cuff Repair

Absolute Indications

Full-thickness rotator cuff tear in symptomatic patient with failed conservative management (PT, NSAIDs, corticosteroid injection for 3-6 months)
Acute traumatic tear in young active patient (<60 years) with good tissue quality
Massive or complex tear patterns requiring extensive mobilization and direct visualization (large L-shaped, massive U-shaped tears)
Revision surgery after failed arthroscopic repair requiring superior exposure and mobilization

Relative Indications

Surgeon preference for direct tissue visualization and palpation
Concurrent procedures best performed open (extensive subscapularis repair, complex biceps tenodesis, capsular releases)
Retracted tears (Patte Grade 2-3) requiring aggressive mobilization including interval slides
Patient factors: inability to tolerate beach chair positioning with traction, concerns about fluid extravasation in arthroscopy

Contraindications

Absolute:

Active infection (septic arthritis, overlying cellulitis)
Severe medical comorbidities precluding safe general anesthesia
Complete passive stiffness (frozen shoulder) - restore motion first before repair
Severe cuff arthropathy (Hamada Grade 4-5) - consider reverse total shoulder arthroplasty instead

Relative:

Advanced fatty infiltration (Goutallier Grade 4) - irreversible muscle changes, poor repair prognosis
Extremely poor tissue quality preventing secure fixation
Significant osteoporosis preventing anchor purchase
Patient unwilling/unable to comply with prolonged rehabilitation protocol (6-12 months)

Note: compensation/work-injury status and active smoking are prognostic risk factors for inferior outcomes, not contraindications - counsel accordingly rather than withholding indicated surgery.

Surgical Approaches - Selection and Anatomy

Deltoid-Splitting (Anterolateral) Approach

Indications:

Isolated posterosuperior cuff tears (supraspinatus, infraspinatus)
Medium to large tears without subscapularis involvement
Most common approach for standard rotator cuff repairs

Advantages:

Direct access to subacromial space and posterosuperior cuff
Smaller incision (6-8cm)
Faster approach development
Preserves deltopectoral interval

Disadvantages:

Risk of axillary nerve injury if split >5cm from acromion
Deltoid morbidity with potential detachment/failure
Limited access to subscapularis and anterior structures
Potential deltoid weakness even with intact repair

Anatomy: The deltoid muscle has three portions (anterior, middle, posterior) with raphe between them. The anterolateral approach splits the raphe between anterior and middle deltoid. The axillary nerve enters the deltoid 5-7cm below the lateral acromion edge - this is the critical anatomic constraint limiting the deltoid split.

Deltopectoral Approach

Indications:

Subscapularis tears requiring repair
Combined anterior and posterosuperior pathology
Need for extensive exposure (revision surgery, complex reconstructions)
Concurrent procedures (biceps tenodesis, AC joint excision, capsular releases)

Advantages:

Extensile exposure to entire rotator cuff
No deltoid detachment - lower deltoid morbidity
Superior access to subscapularis and anterior structures
Lower risk of nerve injury (internervous plane)
Can be extended distally for humeral shaft access if needed

Disadvantages:

Longer incision (10-12cm)
Cephalic vein at risk
More extensive dissection required
Less direct access to posterosuperior cuff
Need to work around coracoid and conjoint tendon

Anatomy: Interval between deltoid (lateral, innervated by axillary nerve) and pectoralis major (medial, innervated by medial and lateral pectoral nerves). The cephalic vein lies in this groove and should be retracted laterally with the deltoid. The approach exposes the subscapularis, coracoid, biceps tendon, and anterior capsule.

Clinical Pearl

Examiner Question: "Open vs Arthroscopic - which is better?": "Both techniques achieve equivalent functional outcomes when performed well by experienced surgeons. I select the approach based on tear characteristics and patient factors. I choose OPEN for: complex tear patterns requiring extensive mobilization (large L-shaped, massive U-shaped), revision cases, subscapularis involvement requiring substantial repair, concurrent procedures best done open, and when I want direct tissue palpation for difficult anatomy. Arthroscopic has advantages of less deltoid morbidity, potentially less stiffness, better cosmesis, and lower infection risk. The key is surgeon experience and patient selection."

Clinical Decision Scenarios

Use these scenarios to practise clinical reasoning and management decisions

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"A 58-year-old manual laborer presents with 6 months of shoulder pain and weakness after a fall. MRI shows a 4cm full-thickness supraspinatus and infraspinatus tear retracted to the glenoid rim with moderate fatty infiltration (Goutallier Grade 2). He has failed 3 months of physiotherapy. How would you manage this patient? Would you choose open or arthroscopic repair?"

PRACTICAL APPROACH

This is a large posterosuperior rotator cuff tear (4cm, involving 2 tendons) with Patte Grade 2 retraction and moderate fatty infiltration in a relatively young, high-demand patient who has failed conservative management. He is a surgical candidate. Regarding OPEN vs ARTHROSCOPIC: Both can achieve good outcomes when performed well. I would discuss both options with the patient. Factors favoring ARTHROSCOPIC: Standard approach for most cuff tears, no deltoid morbidity, lower infection risk, potentially less stiffness, better cosmesis. Factors favoring OPEN in this case: Large tear size with retraction may require extensive mobilization which I can perform more easily with direct visualization and palpation, ability to assess tissue quality directly, easier margin convergence if U-shaped component, lower threshold for interval slides. My DECISION: I would likely choose OPEN DELTOID-SPLITTING approach for this case given the size, retraction requiring mobilization, and my comfort with direct tissue palpation for large tears. However, experienced arthroscopic surgeons can achieve excellent results arthroscopically. The key is surgeon experience and patient selection, not inherent superiority of one technique.

CLINICAL SCENARIOStandard

CLINICAL PROMPT

"During an open rotator cuff repair via deltoid-splitting approach, you are having difficulty reducing a retracted supraspinatus tear to the footprint even after extensive subacromial and coracohumeral ligament releases. The tendon edge is retracted to the level of the glenoid rim. What additional mobilization techniques would you consider? What structures are at risk?"

PRACTICAL APPROACH

This is a challenging scenario with a Patte Grade 2 retraction where standard mobilization has been inadequate. I would consider INTERVAL SLIDES to gain additional mobilization. For an anterosuperior tear (supraspinatus), I would perform an ANTERIOR INTERVAL SLIDE: I release the rotator interval between the subscapularis and supraspinatus. Technique: (1) Identify the interval anterior to the supraspinatus insertion, (2) Use electrocautery to release the capsular tissues connecting these two tendons from the base of the coracoid extending laterally, (3) This allows the supraspinatus to slide posteriorly. For additional mobilization if infraspinatus also involved, consider POSTERIOR INTERVAL SLIDE: Release the infraspinatus from the posterior capsule at its attachment to the glenoid rim. The KEY STRUCTURE AT RISK is the SUPRASCAPULAR NERVE. The nerve passes through the suprascapular notch, courses along the spine of the scapula, and passes through the spinoglenoid notch approximately 2cm MEDIAL to the posterior glenoid rim where it innervates the infraspinatus. PROTECTION: I limit medial dissection to stay LATERAL to the glenoid rim, typically no more than 1-2cm medial. I perform releases under direct vision with gentle spreading technique rather than blind sweeping. If despite interval slides the tendon still will not reach the anatomic footprint without excessive tension, I would consider: (1) PARTIAL REPAIR to the greater tuberosity accepting that the tear will not be fully closed but providing some coverage and improved function, or (2) MARGIN CONVERGENCE if there is a U-shaped component to decrease the medial-lateral dimension. For massive irreparable tears, I would counsel the patient about options like SCR (superior capsular reconstruction) or reverse total shoulder arthroplasty for salvage.

CLINICAL SCENARIOAdvanced

CLINICAL PROMPT

"You are performing an open rotator cuff repair and have just placed your medial row anchors at the articular margin and passed the mattress sutures through the tendon. As you begin tying the knots, what tension are you aiming for? What are the consequences of over-tensioning versus under-tensioning? How do you assess appropriate tension?"

PRACTICAL APPROACH

Appropriate knot tensioning is CRITICAL for successful repair - this is one of the most important technical aspects. I am aiming for FIRM REDUCTION of the tendon to the footprint with complete contact but WITHOUT excessive compression that would cause tissue ischemia or suture cut-through. The goal is OPTIMAL BIOLOGICAL ENVIRONMENT for healing, not maximum mechanical strength at time zero. CONSEQUENCES OF OVER-TENSIONING: (1) Tissue ischemia - excessive compression impairs blood supply to the tendon compromising healing, (2) Suture cut-through - excessive force on poor-quality tissue causes sutures to tear through the tendon either immediately or in early post-op period, (3) Excessive strain on repair - creates high tension that will gap with even passive motion, leading to early failure, (4) Tendon necrosis at repair site from pressure. CONSEQUENCES OF UNDER-TENSIONING: (1) Persistent gaps between tendon and bone - impairs tendon-bone healing, (2) Loose repair - may gap with passive motion allowing synovial fluid intrusion and preventing biological healing, (3) Inadequate compression for healing, (4) Early mechanical failure with mobilization. ASSESSMENT OF APPROPRIATE TENSION: (1) VISUAL: The tendon should be in FULL CONTACT with the footprint surface with no visible gaps, but tissue should maintain normal color (not blanched white from ischemia), (2) PALPATION: Tendon should feel firmly reduced but not rock-hard or overly compressed, (3) TISSUE QUALITY: In good-quality thick robust tendon, I can tension more firmly; in poor-quality thin friable tendon, I tension more gently to avoid cut-through, (4) PASSIVE ROM TEST: After tying medial row, I test passive motion - the repair should remain stable and in contact through full passive forward flexion, abduction, and rotation without gapping. If it gaps with passive motion, there is too much tension and I need to perform additional releases or accept a partial repair. If there are gaps at rest, I need more tension. The goal is a stable anatomic repair with appropriate tension that will maintain contact through passive ROM and allow biological healing over 12-16 weeks.