Open Cuff Repair Technique for Rotator Cuff Repair
The choice between open, mini-open, or arthroscopic rotator cuff repair cannot be definitively recommended based on current evidence, as no technique has proven superior for patient outcomes including pain relief, function, or healing rates. 1
Evidence-Based Recommendation
The American Academy of Orthopaedic Surgeons explicitly states they cannot recommend for or against a specific technique (arthroscopic, mini-open, or open repair) when surgery is indicated for full-thickness rotator cuff tears (Grade: Inconclusive). 1 This recommendation is based on one level II study and two level III studies that failed to demonstrate superiority of any single approach. 1
When Open Repair May Be Considered
While no definitive indications exist, open repair techniques remain viable options in the following clinical contexts:
Tear Characteristics
- Medium to massive rotator cuff tears where extensive mobilization and visualization are required 1
- Irreparable tears requiring partial repair, debridement, or muscle transfers (latissimus dorsi or teres major), which may be technically easier through open approaches 1
- Complex tear patterns requiring extensive cuff mobilization, including elevation off the glenoid neck and scapular fossa 2
Surgeon-Specific Factors
- Limited arthroscopic experience, particularly during the learning curve for arthroscopic techniques 3, 4
- Surgeon preference and expertise, as technical proficiency with the chosen method is more important than the approach itself 5
Comparative Outcomes Data
Pain and Function
- Research suggests arthroscopic repair may provide slightly better pain relief (4.4-point improvement on VAS) compared to open techniques, though both approaches yield significant improvements 6, 4
- No significant difference in functional outcomes (Simple Shoulder Test, UCLA scores) between open and arthroscopic repairs at mid-term follow-up (27-84 months) 6
- Patient satisfaction rates are comparable: 92.4% for arthroscopic versus 80% for open repair (not statistically significant) 4
Healing Rates
- Tendon-to-bone healing correlates with better outcomes regardless of surgical technique, with intact repairs demonstrating superior results compared to re-tears 1
- Healing success depends more on patient factors (age <65 years, recent tear, no smoking, acromiohumeral distance >6mm, Goutallier grade <2) than surgical approach 2
Technical Principles for Open Repair
When performing open rotator cuff repair, adhere to these evidence-based principles:
- Decorticate the bony reattachment site, as healing proceeds primarily from bone 2
- Release the cuff adequately to enable reattachment without tension when the elbow is by the side 2
- Ensure permanent bone-to-tendon contact until healing is complete through appropriate suture technique 2
- Consider both suture anchors and bone tunnels as fixation methods, as no evidence supports preferential use of either technique 1
Critical Pitfalls to Avoid
- Do not use non-cross-linked porcine small intestine submucosal xenograft patches, which demonstrate less favorable outcomes and 20-30% hypersensitivity reaction rates (Grade: Moderate recommendation against) 1
- Do not assume open repair is superior for large tears, as tear size does not correlate with differential outcomes between techniques 6, 4
- Do not neglect postoperative rehabilitation, which should include arm abduction positioning and gentle, passive therapy during the first 12 weeks 2, 5
Practical Algorithm for Technique Selection
Given the inconclusive evidence, base your decision on:
- Your technical expertise and comfort level with each approach 5
- Tear complexity and size, with consideration of open approach for massive tears requiring extensive mobilization 2
- Need for concomitant procedures (muscle transfers, subscapularis repair, SLAP repair) that may be facilitated by open visualization 4
- Patient factors predicting healing, which matter more than surgical technique 2