Rotator cuff repair, arthroscopic or open?

Arthroscopic Versus Open Rotator Cuff Repair: Which Has a Better Complication and 30-Day Readmission Profile? 

These authors sought to compare the 30-day postoperative complications and unplanned readmission rates, using the National Surgical Quality Improvement Program database, after open or arthroscopic rotator cuff repair (RCR) performed from 2007 through 2014. 

The open group contained 3,590 cases (21.8%) and the arthroscopic group had 12,882 cases (78.2%), for a total of 16,472 patients undergoing RCR. 

They found that the open RCR group had a higher prevalence of patients aged 65 years or older and comorbidities such as hypertension, diabetes, chronic obstructive pulmonary disease, smoking, and alcoholism (P < .05).

These patients had a higher risk of any adverse event when compared with arthroscopic RCR patients (1.48% vs 0.84%; RR, 1.17; 95% CI, 1.05-1.30; P ¼ .0010). They were also at higher risk of return to the operating room within 30 days (0.70% vs 0.26%; RR, 1.36; 95% CI, 1.09-1.69; P ¼ .0004). Open RCR patients had longer average hospital stay (0.48 2.7 days vs 0.23 4.2 days, P ¼ .0007), whereas arthroscopic RCR had a longer average operative time (90 ± 45 minutes vs 79 ± 45 minutes, P < .0001). 

Comments: Although the authors concluded that "arthroscopy was associated with lower risks of any adverse event and return to the operating room during the initial 30-day postoperative period", this is not actually a comparison of two methods of cuff repair, it is a comparison of two populations of patients, one older and sicker and one younger and healthier. It is not unexpected that the first group had more complications and longer stays overall.

In addition, it is of interest that some of the complications were more prevalent in the arthroscopic group, including thromboembolic events.

It would be of interest to see a multivariate analysis of the effect of the preoperative age and health of the patient on each of these complications.

In conclusion, these data do not provide an argument for arthroscopic RCR as opposed to open surgery. Such an argument would need to be based on a matched set of patients, which was not used in this study.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Repair of rotator cuff tears - is arthroscopic repair better than open repair?

Clinical effectiveness and cost-effectiveness of open and arthroscopic rotator cuff repair [the UK Rotator Cuff Surgery (UKUFF) randomised trial].

First, thanks to our past fellow, Mac McElvany,  for bringing this Level I study to our attention.

The authors point out that uncertainty exists regarding the best management of patients with degenerative tears of the rotator cuff in patients aged ≥ 50 years.

They conducted a two parallel-group randomised controlled trial involving 19 teaching and district general hospitals in the UK with 273 patients, comparing arthroscopic surgery and open rotator cuff repair. Tears were small or medium in size <3 cm) in 75% of the shoulders. The average age of the patients was 63 years. 40% were women. Patients had symptoms for an average of 2.5 years prior to treatment.

The questionnaire response rate was > 86%.For both the intention-to-treat analysis and the per protocol analysis, there was no statistical difference between the groups: the mean Oxford Shoulder Score (OSS) improved from 26.3 [standard deviation (SD) 8.2] at baseline to 41.7 (SD 7.9) at 24 months for arthroscopic surgery and from 25.0 (SD 8.0) at baseline to 41.5 (SD 7.9) at 24 months for open surgery. Total quality-adjusted life-years accrued at 24 months averaged 1.34 (SD 0.05) in the arthroscopic repair group and 1.35 (SD 0.05) in the open repair group, a non-significant difference of 0.01 (95% CI -0.11 to 0.10).

At 8 months, 77% of participants reported that shoulder problems were much or slightly better, and at 24 months this increased to 85%. 

There were no significant differences in mean cost between the arthroscopic group and the open repair group for any of the component resource-use categories, nor for the total follow-up costs at 24 months. 

The rate of re-tear was not significantly different across the randomised groups (46.4% and 38.6% for arthroscopic and open surgery, respectively). The participants with tears that were impossible to repair had the lowest OSSs, the participants with re-tears had slightly higher OSSs and the participants with healed repairs had the most improved OSSs. 

Comment: As in the preceding post, these authors have studied the most common type of cuff defect: degenerative (as opposed to traumatic) see this link. These results fail to show an advantage of arthroscopic over open repair. Once again the retear rate after repair of relatively small degenerative tears is seen to be high.  Mindful of results like these, we continue to consider the 'smooth and move' procedure (see link) in the management of atraumatic tears.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Will I be able to return to hang gliding after my bilateral open repairs for shoulder dislocation?

While repairs for shoulder instability are no longer a major part of our practice, we still receive follow-ups from folks from years back. One interesting cases is that of a physician in his late 40's who had bilateral shoulder dislocations that were a problem - especially when he landed his hang glider. He had bilateral open Bankart repairs. It is great to see him catch a thermal at the end of this video clip.

This is what you'd like to avoid if you are a hang glider - an inflight dislocation!

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post. 

Bankart surgical repair for dislocating shoulders

While many surgeons prefer arthroscopic repair for shoulders with recurrent dislocations, increasingly patients are coming to our office requesting open Bankart repair because of the lower redislocation rate.
See also this post.

Here is some information regarding our approach to recurrent traumatic anterior shoulder (glenohumeral) instability and its management by anatomic open surgical repair without suture anchors.


Starting with the basics, the shoulder is normally stabilized by concavity compression - the rotator cuff pressing the humeral head into the glenoid concavity.

This video shows that the capsule of the normal shoulder is lax so as not to abnormally restrict the range of motion.

Here is a video showing how the glenoid labrum contributes to the glenoid concavity, like an "O" ring.

This labrum provides a 'suction cup' effect, adding to stability of the joint as shown in this video.

The contribution of the labrum to stability is shown in this video as well as the loss of stability when the labrum is absent.

With a traumatic dislocation, the labrum is torn from the glenoid socket.

This video provides another view of the intact and torn labrum.

 In patients who have experienced a traumatic anterior dislocation and who have recurrent dislocations of their shoulder, it is important to assess the integrity of the bony glenoid socket. This can be accomplished with plain x-rays (no CT scan is needed). The necessary views include an AP in the plain of the scapula and an axillary view.

We also obtain an apical oblique which enables us to see the anteroinferior glenoid rim as well as the posterior-lateral aspect of the humeral head (where a Hill Sachs lesion occurs).

 The apical oblique view below shows the Hill-Sachs defect flattening the upper left aspect of the humeral head and a moderate sized bony glenoid defect of the anterior-inferior glenoid (bottom right).

In the absence of a significant bony glenoid defect, stability can be restored by placing sutures through the lip of the glenoid and using these sutures to repair the soft tissues torn away from the lip.

If however, there is a substantial bony glenoid lip defect

 It may be necessary to add back bone using a bone graft secured with screws.

Fortunately, the great majority of individuals do not require a bony procedure. Our technique for the anatomic Bankart is shown here. First the skin incision, concealed in the normal skin crease.

This video shows the careful incision of the subscapularis tendon to expose the joint.

And here is a video of the Bankart lesion.

This video shows roughening of the anterior aspect of the glenoid.

Holes are then drilled at the edge of the glenoid as shown here.

In this video we are passing suture through the holes in the glenoid and then through the detached labrum.

Here is the labral suturing.

Finally the subscapularis is repaired.

 Here is a diagram of the repair of the capsule and labrum as well as that of the subscapularis

Here is a close up view of the repaired capsule and labrum, restoring the "O" ring and its contribution to stability.

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To see the topics covered in this Blog, click here

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.


See the countries from which our readers come on this post.

Open Bankart repair for traumatic anterior shoulder dislocations and instability

Many orthopaedic surgeons these days are unfamiliar with the open technique for Bankart repair for traumatic instability. In these cases the glenoid labrum is separated from the bony glenoid socket as shown here.

This procedure is designed to restore the suction cup effect and the concavity compression mechanism of shoulder stability.

We've summarized the technique here and provided some highlights below.

roughening the glenoid to enhance healing
drilling holes in the glenoid lip
passing sutures through the glenoid lip
suturing the labrum
subscapularis repair

See also the videos on the mechanics of shoulder stability.

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Use the "Search the Blog" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty,  and rotator cuff surgery.

See the countries from which our readers come on this post.

Rotator Cuff 10 - Surgery for rotator cuff tears - repair

The decision to repair a rotator cuff tear requires consideration of a number of factors.

Is the tear acute and the result of a definite injury? In such a case, surgery deserves strong consideration in that repair is often most successful if performed soon after the tear occurs (say within a few weeks on months).

If the tear is chronic (long standing), are the symptoms related to weakness, to stiffness, or to catching and grinding? Has the shoulder had a good attempt at non-operative management to resolve these symptoms? (there is no rush for surgery when the tear is chronic).

Is it likely that the tear is reparable?

Is the patient prepared to avoid active use of the shoulder of the shoulder for three or so months while the tendon repair heals and remodels? Note that any active use of the arm with the elbow away from the side puts a load on the repair and many challenge its successful healing.

Should the repair be done with a mini open approach or using arthroscopic techniques? Here it is important to recall that the goal of repair is the secure reattachment of the torn tendon back to the bone from which it became separated, not the size of the skin incision. Here's the skin incision I use.

It almost always heals with a barely visible scar, even when appearance is very important, as in this man (can you see the scar?)

The surgeon should use the method that in that surgeon's hands yields the most secure repair. My personal preference now and for the last 40 years is for a mini-open approach that does not in any way compromise the deltoid muscle and that enables complete mobilization and secure repair of the tendon - to a groove in bone if necessary. Doing it securely the first time is the key for us. I also avoid shaving the acromion in that in my view there is no evidence that this improves the results on one hand and in that it adds unnecessarily to the procedure on the other.


So, in my hands the priorities in treating disorders of the rotator cuff are:
(1) to preserve the deltoid – our mini-open surgical approach is conducted through the superior ‘deltoid-on’ approach (which I will describe in more detail later).

(2) to assure smoothness of the humeroscapular motion interface – thus the upper aspect of the humerus and cuff must present a smooth convexity to articulate with the concave undersurface of the coracoacromial arch. All hypertrophic bursa and excrescences of the tuberosities are removed leaving a smooth proximal humeral convexity.

Sutures are placed so that the knots do not lie on the superior aspect of the cuff or tuberosity. "Top knots" (such as those shown below) are avoided. 

 (3) to maintain the normal mobility of the glenohumeral joint – thus limiting scar must be resolved and the cuff tendons must be released from the glenoid and coracoid if necessary before reattachment. 

(4) to assure an even distribution of tension on the cuff insertion spreading the load among multiple sutures – thus differential tightness at the area of cuff repair is avoided.

(5) to assure that if cuff tendon reattachment is performed, that it is sufficiently robust to heal and to allow early motion after surgery – thus multiple sutures securing the tendon edge into a bony trough are preferred. The trough excludes joint fluid from the repair site and allows for the possibility of some slip of the tendon while maintaining tendon to bone contact.

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How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).