Open rotator cuff repair is becoming a less prevalent technique for rotator cuff surgery; nonetheless, clinical situations still arise where this technique may be preferred to arthroscopic repair. These scenarios include revision surgery for failed arthroscopic repairs and massive, chronic tears in younger and more active patients. For this reason, it is important for orthopedic surgeons to be aware of and know how to manage potential complications that may arise with open rotator cuff repair, both intraoperatively and postoperatively.
Intraoperatively, many of the potential complications are related to surgical technique and require vigilance on the part of the surgeon to prevent.
Axillary Nerve Injury
When obtaining proper exposure for the repair, the surgeon must be aware of the axillary nerve’s course and be careful not to cause a direct or traction injury. Typically, the nerve is present 5 cm distal to the deltoid origin and can be palpated as a means to identify its location. As such, a skin line is made 5 cm distal to the lateral border of the acromion as a visual cue of the typical course of the axillary nerve. Furthermore, during the split of the anterior and middle heads of the deltoid fascia, a stay suture can be placed into the deltoid proximal to the axillary nerve to avoid retraction, causing excessive splitting distally into the nerve during exposure ( Fig. 31.1 ). If a traction injury occurs, this will be recognized postoperatively by deltoid muscle atrophy. As traction injuries may resolve with time, observation is often recommended; however, direct injury to the nerve such as laceration requires repair.
Excessive Tendon Resection
In preparation of the tendon for repair, it is important to only debride degenerative tendon to healthy fibers; excessive debridement can make the repair difficult by potentially requiring medialization of the repair, placement of the repair under undue tension, or need for augmentation. Excessive resection can lead to an irreparable tendon. Identification of degenerative tendon is accomplished by assessing its overall quality via indicators such as its ability to hold suture and its visual appearance (fraying, delamination, thinning, etc.).
Most surgeons will perform a concomitant acromioplasty while repairing the rotator cuff. This component of the procedure can also lead to complications if not performed correctly. Excessive removal of acromial bone can lead to shortening and challenges with reattachment of the deltoid fibers. This can result in weakness and loss of cosmesis and the normal shoulder contour. Further, if excessive acromial resection occurs in the presence of a massive rotator cuff tear, especially involving the anterosuperior rotator cuff (subscapularis and supraspinatus), the patient is at risk for anterosuperior escape and superior instability of the glenohumeral joint. Conversely, if too much acromion is left and not debrided, then issues can arise with persistent pain from residual impingement. Ideally, the surgeon removes the anterior acromial bone in a diagonal fashion from inferoposterior to superoanterior. The acromioclavicular (AC) joint can serve as a landmark for resection in that the acromial bone is often resected in line with the lateral course of the AC joint ( Fig. 31.2 ). Rarely, an acromial fracture can occur in patients with a thin acromion or with excessive resection. If this occurs intraoperatively it can be managed with a tension band repair technique. If not discovered until after surgery, then weight-bearing restrictions can be enforced to allow for bony healing.
Other intraoperative complications to be aware of that are quite rare include suprascapular nerve injury, articular cartilage damage that may require debridement or microfracture, greater tuberosity fracture during preparation of the surface for repair of the tendon, and migration of anchors in the humeral head. The course of the suprascapular nerve is fairly well described and is most at risk during mobilization of massive posterosuperior tears involving the supraspinatus and infraspinatus. Releases and posterior interval slides at the level of the spinoglenoid notch are in closest proximity to the nerve and should be performed with caution. To assist in protecting the nerve, the key is to identify the coracoid and scapular spine as anatomic landmarks to use as aiming targets for the release. The suprascapular nerve lies typically 2 cm medial to the glenoid face at the base of the scapular spine in the spinoglenoid notch. Therefore, during a release, it is essential to stay parallel to or level with the rotator cuff fibers and to be certain to not drift inferiorly. Furthermore, as the release gets closer to the base of the scapula spine, perineural fat will be visualized, indicating that the nerve is in close proximity. Although all of these complications have been reported in the literature, their management is individualized.
Postoperatively, there is a greater amount of data on the frequency of complications. Large database studies have demonstrated overall complication rates between 1.48% and 2.1% for open rotator cuff repair, , whereas smaller, single-institution studies have reported complication rates between 4% and 8%. , It has also been shown that, in comparison with arthroscopic repair, open repair is associated with an increased complication frequency, with 1.6 to 2.0 times greater odds of a postoperative complication occurring. , Unplanned readmissions have also been seen in 1.6% of open repairs, and there is also 1.8 times greater odds of unplanned readmission associated with open repair compared with arthroscopic repair. Rates for reoperation for any reason range from 0% to 1.1%. , , ,
Stiffness is possibly the most common postoperative complication of open rotator cuff repair, and is typically not captured in large database studies. The incidence of postoperative stiffness is quite variable, with ranges reported between 1.4% and 20%. , , Its occurrence has been associated with increased age and a normal biceps tendon. It also thought to be related to local deltoid injury during retraction. In most cases, recovery is seen in an average of 6 months after surgery (range from 2 to 18 months) with increases in external rotation seen first, followed by forward elevation and abduction. To prevent stiffness, it is recommended to have patients begin passive or assistive exercises early after repair in close coordination with a physical therapist. It is also important to have these efforts continue for 6 months to 1 year after surgery. Manipulation under anesthesia is a treatment option for patients who remain stiff within 16 weeks of surgery, but this must be used judiciously because manipulation too soon after surgery can damage the repair. For patients who remain stiff more than 6 months after surgery and who have plateaued with physical therapy, a magnetic resonance imaging scan should be obtained to check on the healing status of the rotator cuff, and an arthroscopic release can be considered.
Retear and Failure to Heal
Retearing of the repair postoperatively is difficult to distinguish from a repair that never healed. We hold the belief that “retears” within the first 3 to 6 months after surgery more likely represent repairs that never healed initially. Previous arthroscopic studies have shown that the large majority of retears happen within the first 6 months after surgery. For open rotator cuff repairs, there are little reported outcome data before 1 year after surgery, making it difficult to make any claims regarding nonhealing versus retearing. Regardless, incidence of retearing has been reported to range from 9% to 25%. , , Typically this is secondary to active and/or resistive exercises being begun too soon postoperatively because this phase should not start until at least 3 weeks after surgery. In many patients, if a retear does occur in the early postoperative period, repeat surgical treatment is not needed. Pain relief from the acromial decompression and physical therapy to prevent stiffness are enough to prevent a poor outcome. However, if a patient suffers an acute setback in strength or range of motion during the rehabilitation process, then revision surgery should be considered.
During the approach to an open rotator cuff repair, the deltoid may be elevated. One complication that can arise from this operative technique is detachment of the deltoid. This is more likely to occur if the surgeon incises across the deltoid rather than subperiosteally elevating it. It is also important to have a strong repair when closing, with careful identification and layered repair of both the superficial and deep deltoid fascias. We advocate for a layered repair using bone tunnels in the acromion and permanent, heavy-braided sutures. Furthermore, if active use or strengthening of the operative shoulder begins too soon, then this repair is also at risk of failing. If the deltoid detaches, intervention is not needed. Patients will experience tenderness anteriorly for a time, but they rarely have longstanding issues with strength or pain relief. Postoperative rehabilitation should not be impacted by this. Acute tears are often indicated for surgical management, whereas chronic tears can be challenging and may be irreparable or require graft augmentation to enhance healing of repair.
Anterosuperior escape or instability can be observed postoperatively after open repair. On physical examination, such a complication is evident by prominence of the humeral head anteriorly with forward elevation of the arm or a pseudoparalysis preventing forward elevation and abduction. The etiology of this complication is multifactorial and includes massive rotator cuff tears often involving the subscapularis, too-aggressive acromioplasty, and failure to repair the coracoacromial ligament and/or deltoid fascia, resulting in anterior deltoid compromise. Historically, management options consisted of coracoacromial arch reconstruction and hemiarthroplasty. Currently, the more commonly used treatment option is a reverse shoulder arthroplasty, but other options also exist such as a subcoracoid pectoralis major muscle transfer. Anterosuperior instability/escape is rarely seen after arthroscopic rotator cuff repair and acromioplasty because of the limited surgical dissection required. Because this complication is unique to open rotator cuff repair, it may suggest that arthroscopic repair is the optimal surgical treatment option for massive rotator cuff tears where the repair integrity and/or healing potential is not predictable, such as is seen with chronic or acute-on-chronic massive rotator cuff tears, older patients, history of prior failed repairs, and irreparable rotator cuff tears with substantial muscle atrophy and fatty infiltration.
Infection and Wound Dehiscence
Because of the larger incision required for an open rotator cuff repair, there is increased risk for wound infections and dehiscence. Studies show 3 to 8 times increased odds of an infection happening in an open procedure compared with arthroscopic repair. , Still, the incidence of these complications is quite low, with rates ranging from 0.3% to 1.0%. , , , Identification of this complication is based largely on clinical examination with signs of erythema, increased pain, purulent drainage, and abscess formation. Serological values can be elevated, including white blood cell count, C-reactive protein, and erythrocyte sedimentation rate. Typical bacteria include methicillin-resistant Staphylococcus aureus and Propionibacterium acnes. , Treatment includes serial debridements and administration of intravenous antibiotics. It is possible even in deep infections to retain the hardware associated with the repair. ,
There are a bevy of rare postoperative complications that have been identified in large database studies as well. These include myocardial infarction, failure to be weaned from a ventilator, sepsis, pneumonia, reintubation, urinary tract infection, deep vein thrombosis, pulmonary embolism, capsulitis, complex regional pain syndrome, and need for blood transfusions. , , , Patient-related factors frequently play a significant role in these postoperative complications and should be considered in the preoperative evaluation.