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The Current Role of Open Rotator Cuff Repair PDF Print E-mail

Robin R. Richards M.D., FRCSC
Surgeon In Chief and Professor of Surgery
Sunnybrook and Women's College HSC and The University of Toronto
Toronto, ON

Open rotator cuff repair is one of the most reliable and successful operations in the orthopaedic armamentarium. I limit my indication for the procedure to those patients who have had intractable pain, including night pain, for a minimum of 12 months and find that the procedure reliably relieves symptoms with a relatively low complication rate.  

The advent of easily available noninvasive imaging has increased the clinicians' ability to select patients who are good candidates for the procedure. There are many reports in the literature documenting the success of open rotator cuff repair.

I tell patients that the success rate for the procedure, in terms of pain relief, is in the 80–85 percent range. I routinely inform them of the risk of infection, hemorrhage, nerve/muscle damage and the possibility of problems with the anesthetic, although these problems relatively rarely occur. I usually quote a 1-2 % complication rate unless I feel the rate will be higher. I always record the complication rate I quote to the patient. I inform patients that they will begin moving their shoulders immediately following surgery, that they will need to wear a sling for 10–14 days for comfort, that their hospital stay will be short and that the recovery following the procedure will be three months.

In my experience, most patients have reliable pain relief, although strength, endurance and motion are rarely normal following the procedure. I provide patients with an information package that includes illustrations and the instructions following surgery. I then leave it up to the patient, their family and their family doctor to make up their mind regarding the possibility of surgery. I do not make follow-up appointments but advise patients to contact my office if they have questions regarding the surgery.

In 2003, the open procedure is in evolution. Skilled shoulder arthroscopists can perform acromioplasty, which is a key component of the open procedure. Some surgeons can perform "mini-open" rotator cuff repairs and some skilled arthroscopists can perform arthroscopic rotator cuff repair. Although arthroscopic surgery leaves a smaller scar (or scars), I am not aware of any compelling scientific data indicating that the results of arthroscopic surgery are substantially better than open rotator cuff repair in the long-term. Having said that, I would be the first to acknowledge that, given the choice, most patients would opt for an arthroscopic repair if that were available to them.

Open rotator cuff repair is a procedure in evolution. Since there is significant transitioning from open to arthroscopic surgery, I will take this opportunity to comment on the advantages and disadvantages of open rotator cuff repair in 2003.

Disadvantages of Open Rotator Cuff Repair

Morbidity
Open rotator cuff repair is a painful procedure. Extensive dissection is required and patients must often remain in hospital overnight. Given the current restricted bed availability in most regions, it is desirable to perform the surgery arthroscopicaly, if possible; or if open surgery is required, to discharge the patient with a team in place to provide assistance to the patient. If discharge is planned following surgery, the patient must be accompanied and have someone available to assist with their personal care and provide instructions for their postoperative physiotherapy.

Complication Rate
In general, open surgery has a higher infection rate than arthroscopic surgery. Other complications such as scarring and stiffness can be seen following the procedure. The author suspects that the complication rate after open surgery is higher than that after arthroscopic surgery. Some complications such as deltoid pull-off are probably more frequently seen with open surgery, although they can certainly occur with arthroscopic surgery.

Advantages of Open Rotator Cuff Repair

Availability
Many Canadian surgeons have been trained to perform open rotator cuff repair. At this point in time, the arthroscopic procedure is not widely available and requires additional equipment that is not always accessible. Furthermore, there is a long learning curve for arthroscopic rotator cuff repair and unless one is willing to sub-specialize in the procedure, patients may be better served by the open procedure.

Conversion
Some patients (approximately five percent in my experience) have massive rotator cuff repairs that cannot be repaired by conventional techniques, either arthroscopic or open. The open procedure can be converted to alternative approaches (see illustration) such as the use of the deltoid flap

Efficiency
Excision of the distal clavicle and the subacromial bursa can be important adjuncts when performing rotator cuff repair. For many surgeons, it is faster and easier to perform the procedure open since the time taken in closing an open procedure is less than the additional time required to perform the arthroscopic procedure.

It will be interesting to look back in five or ten years and verify the relative frequency of open vs. arthroscopic rotator cuff repair in Canada and determine if scientific study has documented substantive differences in the short-term morbidity and/or the long-term results of the two procedures.

Figures 1-3: Use of a distally based flap of deltoid to repair a massive tear of the rotator cuff tendon.

Figure 1 Figure 2 Figure 3