By Todd C. Battaglia, MD, MS
Initially, open repair held one distinct advantage, in that repair strength was better than that achievable with the early available arthroscopic equipment. However, improvements in arthroscopic techniques and technology have progressed to the point that repair strength is at least as good, and with some methods, better, than open techniques. In addition, arthroscopic repair offers a number of distinct benefits. First, for open repair, a portion of the deltoid muscle must be detached for adequate exposure, and then repaired at the conclusion of the surgery. This adds to pain, increases healing requirements, and leads to the potential post-operative complication of deltoid dehiscence (splitting open after repair). Conversely, the small incisions used for arthroscopy do not require any detachment of the deltoid. Second, open techniques allow no visualization of the biceps, labrum, joint surfaces or other structures inside the joint that are commonly abnormal in conjunction with rotator cuff tears. Arthroscopy allows visualization and concurrent treatment of all these structures. Third, only arthroscopy allows assessment and treatment of partial thickness tears without disrupting the whole tendon, particularly those on the deep (joint-side) surface of the tendon. In open repairs, the cuff is viewed only from the superficial (bursal) surface, and undersurface tears will not ever be seen. Fourth, and most critically, arthroscopy provides complete visualization of the entire rotator cuff - this permits a much more thorough assessment of the tear pattern, and allows the surgeon to more accurately determine the best strategy for a complete and tension-free repair.
With each passing year, fewer and fewer rotator cuff tears are repaired using open techniques. In fact, for today's shoulder specialists, there are almost no rotator cuff tears that cannot be repaired arthroscopically. Interestingly, it is sometimes offered that some tears are “too large” or “too complex” for arthroscopic repair. This is false - such tears are precisely the ones best suited for arthroscopic repair – using the camera, they can be seen better and repaired more accurately and strongly.
