Open Rotator Cuff Repair

Indications Open repair is chosen for symptomatic full-thickness rotator cuff tears where direct visualisation and tissue palpation help most. Absolute indications

• Full-thickness rotator cuff tear in a symptomatic patient who has failed conservative management (physiotherapy, NSAIDs, corticosteroid injection over 3–6 months)
• Acute traumatic tear in a young active patient (less than 60 years) with good tissue quality
• Massive or complex tear patterns requiring extensive mobilisation and direct visualisation (large L-shaped, massive U-shaped tears)
• Revision surgery after failed arthroscopic repair, needing superior exposure and mobilisation Relative indications
• Surgeon preference for direct tissue visualisation and palpation
• Concurrent procedures best performed open (extensive subscapularis repair, complex biceps tenodesis, capsular releases)
• Retracted tears (Patte Grade 2–3) requiring aggressive mobilisation including interval slides
• Patient factors: inability to tolerate beach-chair positioning with traction, or concerns about fluid extravasation in arthroscopy Contraindications Absolute
• Active infection (septic arthritis, overlying cellulitis)
• Severe medical comorbidities precluding safe general anaesthesia
• 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 change, poor repair prognosis
• Extremely poor tissue quality preventing secure fixation
• Significant osteoporosis preventing anchor purchase
• Patient unwilling or unable to comply with a prolonged rehabilitation protocol (6–12 months) Compensation or work-injury status and active smoking are prognostic risk factors for inferior outcomes, not contraindications — counsel accordingly rather than withholding indicated surgery. Which approach, and why The choice between the two open exposures is dictated by which tendons are torn and what else must be done:

Open versus arthroscopic. Both techniques achieve equivalent functional outcomes when performed well by experienced surgeons. Choose OPEN for complex tear patterns needing extensive mobilisation, revision cases, substantial subscapularis involvement, concurrent open procedures, and when direct tissue palpation is wanted. Arthroscopy offers less deltoid morbidity, potentially less stiffness, better cosmesis and a lower infection risk. Surgeon experience and patient selection matter more than the technique itself.

The goal is to expose the tear, assess it, mobilise the tendon back to the footprint without excess tension, and re-attach it with a durable double-row construct — then close the deltoid soundly. The exposure is laid out as the first steps below.

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The five danger structures — know each location and how to protect it:

Rehabilitation — balance protection against stiffness. Tendon-to-bone healing takes 12–16 weeks; too-aggressive motion fails the repair, too-conservative motion stiffens it. | Phase | Timing | Immobilisation | Motion | |-------|--------|----------------|--------| | 1 | 0–6 weeks | Sling or abduction brace at all times except exercise and hygiene | Passive only — table slides to 90–120° flexion and 30–40° external rotation; pendulums. NO active motion | | 2 | 6–12 weeks | Wean sling for activities of daily living | Active-assisted ROM (wand, pulley); progress to full passive ROM; light isometrics under 20% if comfortable | | 3 | 12–16 weeks | None for light activity | Active ROM against gravity; progressive resistance (Theraband, 1–5 lb); cuff and scapular strengthening | | 4 | 16+ weeks | None | Advanced strengthening (5–10+ lb); sport- and work-specific training; plyometrics for athletes | Return to driving at 6–8 weeks (off narcotics), light work at 8–12 weeks, heavy overhead labour at 4–6 months, golf or swimming at 4–6 months, throwing sports at 6–9 months, and contact sports at 9–12 months. For a subscapularis repair, limit external rotation to 0–20° for the first 6 weeks. Massive tears may need 8 weeks of passive-only protection with lower ROM and strength goals, and workers'-compensation patients often progress more slowly (maximum medical improvement at 9–12 months). Full biological remodelling takes 12–18 months. Early active motion equals repair failure — patient education and a written protocol are essential.

Epidemiology. Full-thickness rotator cuff tears are common and increase with age, found in a substantial proportion of asymptomatic older adults and in the majority of those over 70. Most degenerative tears are managed non-operatively; surgical repair is reserved for the symptomatic tear that fails structured conservative care, and for acute traumatic tears in active patients, where earlier repair limits retraction and fatty infiltration. Classification (reference). Tears are described by size, pattern, retraction (Patte) and fatty infiltration (Goutallier) — the same axes used intra-operatively in the REPAIR framework:

Outcomes. Structural healing on post-operative imaging falls with tear size: small tears 90–95%, medium 80–90%, large 70–85%, massive 50–70%, revision 40–60%. Around 80–90% of patients achieve good-to-excellent pain relief and satisfaction, 70–85% a functional range of motion, and 60–80% functional (rarely normal) strength. Poor-outcome predictors are large or massive tear size, age over 65, chronicity over 6 months, Goutallier Grade 3–4, poor tissue quality, smoking, diabetes, workers' compensation, and rehab non-compliance. Open versus arthroscopic — evidence. Meta-analysis (Morse 2008) shows no significant functional difference between all-arthroscopic and mini-open deltoid-splitting repair, with lower infection and stiffness favouring arthroscopy. Surgeon experience and patient selection outweigh the technique. Single- versus double-row. Double-row suture-bridge constructs are biomechanically superior — higher load to failure, larger footprint contact, better gap resistance (Park 2007: 77.6% versus 39.6% footprint contact). Clinically the functional advantage is modest (Sheibani-Rad 2013 meta-analysis), so double-row is preferred for medium and large tears while a well-executed single-row repair remains acceptable for small tears or poor tissue and bone. Technique evidence. Margin convergence reduces strain at the tear edge by 20–40% (Burkhart 1996) and is mandatory for U-shaped tears. Routine acromioplasty is not required — recent RCTs show no outcome difference, so it is selective (Type 3 acromion or anterior spur). Modern suture anchors match the biomechanics of historical transosseous tunnels and are faster to place. Guidelines, registries and global practice | Body / source | Position relevant to cuff repair | |---|---| | AAOS (US) Clinical Practice Guideline | Surgical repair is an option for symptomatic full-thickness tears; routine acromioplasty not required; non-operative care reasonable for many degenerative or irreparable tears | | BOA / BESS (UK) | Structured physiotherapy first for atraumatic degenerative tears; earlier surgery for acute traumatic tears in active patients to limit retraction and fatty infiltration | | AO Foundation / international consensus | Tear pattern, retraction (Patte) and fatty infiltration (Goutallier) drive reparability and technique selection, not chronological age alone | Global practice varies: arthroscopic repair predominates in well-resourced settings; open repair remains essential where arthroscopy access or training is limited, and for complex, revision and subscapularis cases everywhere. Double-row constructs cost more for a modest, inconsistent functional gain, so single-row remains defensible in resource-limited settings. For irreparable tears, the realistic salvage pathway (superior capsular reconstruction, tendon transfer, reverse TSA) depends on regional availability.