Full Thickness Tears

Surgical Options


1.  Open antero-lateral approach 


Large / Massive Cuff Tear


2.  Deltopectoral approach


Large Subscapularis tear


3.  Arthroscopic Assisted Mini-open



- Small / Moderate Cuff Tear < 3cm

- no retraction



- arthroscopic SAD

- assess tear with scope

- repair RC through deltoid split



- avoids deltoid detachment from acromion

- small scar

- still have to immobilise shoulder for 6/52 to protect cuff tear


4.  Arthroscopic repair




Gartsman et al J Should Elbow surgery 2004

- prospective randomised trial

- no large tears, no previous surgery

- all arthroscopic single tendon repair, all type 2 acromion

- no difference in functional outcome whether had SAD or not


Advantages of performing SAD

- long history of successful use

- minimal complications

- aids visualisation in open and arthroscopic repairs


Biceps / SLAP


Franchesci et al Am J Sports Med 2008

- RCT 63 patients with RC tear and SLAP 2

- repair v tenotomy

- significantly better shoulder scores and ROM in tenotomy group




4 types of cuff tears


1.  Cresent shaped

- simple lateral repair


Supraspinatous tear Cresent ShapedSupraspinatous Tear Crescent Shaped


2.  U shaped

- larger

- need margin convergence, then lateral repair


Supraspinatous Tear U shaped


3.  L shaped


Tear of Suprapinatous laterally

- transverse extension

- at rotator interval anteriorly

- or in supraspinatous posteriorly


4.  Massive


Rotator cuff retracted to glenoid


1.  Open Rotator Cuff Repair



- large to massive tear



- deltoid taken off anterior acromion

- acromioplasty with saw

- bursectomy for exposure

- margin convergence if large tear

- suture anchor repair laterally

- single / double row / suture bridge configuration

- deltoid repaired via intra-osseous sutures



- reliable

- good results in terms of tendon healing and outcome



- longer, more painful recovery

- must protect deltoid repair 6/52

- no early mobilisation

- risk of deltoid dehiscence

- miss any intra-articular pathology if don't perform arthroscopy

- ? management of biceps





- lazy beachchair



- Neer type  

- over ACJ and anterior clavicle

- angle down between anterior and middle deltoid



- down to deltoid

- identify raphae between anterior and middle deltoid

- carefully open interval

- must no damage any underlying cuff / LHB

- must not extend incision > 5 cm from acromion or risk damaging anterior AXN

- take deltoid off anterior acromion with diathermy

- control acromial branch of the thoracoacromial artery



- Neer style 2 saw cuts

- take anterior acromion in line with anterior clavicle

- second cut takes angle of acromion superior to inferior

- make more generous in large to massive tear for exposure




Tear completely identified

- Edges trimmed

- Digital stripping of upper & lower surfaces from scar

- Mornihans retractors / Mason-Allen suture to grasp tendon

- assess tear geometry

- assess ability to repair to footprint


Techiques to mobiise retracted SS tendon


1.  Release CHL (runs from coracoid to free edge SS / into rotator interval)

2.  Release RC interval

3.  Mobilise above and below supraspinatous tendon

4.  Release above glenoid 1.5cm (beware suprascapular nerve)

5.  Interval slide - divide between SS and IS posteriorly, rotator interval anteriorly

6.  Medialise insertion - take away some of articular cartilage

7.  Repair SSC and IS for restoration of force couplet (if SS irrepairable)


Repair Options


1.  Direct suture of tendon

- margin convergence


2.  Suture of tendon to bone


A.  Anchors

- roughen footprint

- 1 or 2 row technique

- medial row downwards pressure

- lateral row pulls across


Shoulder Open Rotator Cuff Repair APShoulder Open Rotator Cuff Repair Lateral


B.  Trough made in bone

- in anatomical neck near GT

- drill-holes made in trough

- tendon sutured through drill-holes / anchors


C.  Intraosseous sutures

- suture passer

- tie over small poly plate (arthrex)


3.  Mc Laughlin Technique

- if direct suturing unfeasible

- Y closure performed

- tendon defect made triangular with base at insertion

- apex closed as far as possible with shoelace suture

- unclosed tendon edges sutured to cancellous bone of humeral head


Repair done with arm by side

- may be abduct to aid repair

- should be able to be brought by side at completion

- may need abduction pillow



- intra-osseous deltoid repair

- no 1 ethibond

- careful attention to this part of surgery


Large - Massive Tear 


Generous acromioplasty 

Excise distal clavicle for better exposure

Techniques as above


Post op


Must protect deltoid repair

- passive ROM 6/52, hand and elbow exercises, sling

- active ROM begin at 6/52

- strengthening at 3/12

- return to sport after 6/12


Poor prognosis

- large-massive tear

- fatty infiltration / atrophy

- older patient (>60)

- poor subacromial decompression

- excessive acromial resection

- damage to Deltoid

- improper rehabilitation

- smokers & DM


2.  Arthroscopic SAD + Mini open Rotator Cuff Repair



- perform subacromial decompression with arthroscope

- no need to detach deltoid

- made 2 - 5 cm deltoid split directly over tear and repair



- moderate size tear up to 3 cm



- posterior portal for camera

- lateral portal for SAD

- localise tear with needle

- make mini open incision over tear

- repair as above




Open v Mini-open


Mohtadi et al Am J Sports Med 2008

- RCT open v mini-open

- massive tears excluded

- mini open better shoulder scores at 3/12

- no difference at 1 or 2 years


Tear integrity


Papadopolous et al J Should Elbow Surg 2011

- ultrasound evaluation of tears at 3 years in 37 mini-open patients

- 48% intact in patients who tended to have smaller original tears and be 15 years younger

- most patients had satisfactory outcome





- up to 50%

- increased in older patients with larger tears


Cuff Arthropathy 

- 5% massive rotator cuff tears

- associated with rerupture

- high riding humeral head


Shoulder High RIding Humersu





- inadequate acromioplasty

- rerupture

- wrong diagnosis (frozen shoulder / cervical radiculopathy)


Difficulty using arm above shoulder height

- rupture of repair of FT tear

- deltoid detachment or denervation

- biceps tendon rupture




Deltoid avulsion


Axillary nerve injury


Acromial fracture


RC Tear / Anchor Pullout


Rotator Cuff Anchor Pull Out