Open vs Arthroscopic Repairs
Strong evidence supports no difference in long-term (> 1 year) patient-reported outcomes or cuff healing rates between open and arthroscopic repairs; however, arthroscopic-only technique is associated with better short-term improvement in post operative recovery of motion and decreased visual analog scale (VAS) scores.

There were four high quality studies (Carr 2017, Liu, J. 2017, Mohtadi, N. 2008; Van der Zwaal, P. 2013) comparing the outcome of arthroscopic and either open or mini-open repair and two moderate quality studies comparing perioperative pain and morbidity between arthroscopic and open rotator cuff repair.  None of these six studies reported any significant difference in the outcome of any of the three techniques. Multiple other comparative stuides of lower quality exist regarding this topic, some with differing outcomes, but only the best available evidence was considered in the development of this recommendation. 

In a prospective, randomized high quality study, Carr et al. (2017) evaluated the outcome of 273 patients randomized to either open/mini-open, or all-arthroscopic repair.  There was no difference in outcome scores, with a 40% healing rate in both groups.  This study extended the preliminary results of Carr et al. study reported in 2014.

In a high quality prospective randomized study of 100 patients, Liu et al. 2017 showed no difference in outcome between all-arthroscopic and mini-open repairs for either patient reported outcomes, retear rates, or occurrence of adhesive capsulitis at one year.
Mohtadi et al. 2008 published a high quality study comparing open to mini-open repair showed no difference in PROs with either technique at average follow-up of 28 months.  No post-operative imaging was performed.

Van der Zwaal et al. 2013 presented a high quality study comparing all-arthroscopic to mini-open repair at one year.  Final PROs, retear rates, and presence of associated adhesive capsulitis were similar between both groups.

In evaluating the literature which forms the basis for this recommendation, two high-quality studies (Liu et al. 2017 and Van der Zwaal et al. 2013) showed faster short-term recovery with all-arthroscopic repair.  Liu et al. 2017 showed significant difference in both range of motion and VAS scores as well as superior scores on both the DASH and Constant PRJOs up to one-month postoperatively.  Liu concluded that the all-arthroscopic procedure has better recovery at short-term follow-ups.  Similarly, Van der Zwaal et al. noted improved range of motion, VAS, and DASH scores at six weeks comparing all-arthroscopic to mini-open repair.  They felt that “Patients do attain the benefits of treatment somewhat sooner (6 weeks) with the arthroscopic procedure.”

Risks and Harms of Implementing this Recommendation
There are no risks associated with implementing this recommendation.

Future Research
Given the conflicting information available regarding improvements in post-operative pain and early recovery with all-arthroscopic repair, further studies are needed in this area to establish benefits of this procedure.