Management of Infection after Open Rotator Cuff Repair

Infection after open rotator cuff repair is uncommon: deep infections occur in approximately 0.3% to 2% of cases. Infections can be classified into three types based on their location and severity: superficial wound cellulitis or suture reactions; abscess formation superficial to the deltoid; and abscess formation deep to the deltoid. Superficial infections are characterized by erythema, tenderness and swelling with an onset of symptoms ranging from a few days to 6 weeks after surgery. Patients generally do not have a fluctuant mass, drainage, wound breakdown, fevers, chills or abnormal serologic findings. These superficial infections can be treated successfully with oral antibiotics. Abscess formation superficial to the deltoid is characterized by a fluctuant mass and drainage as well as erythema, tenderness, and swelling, with an onset of symptoms averaging 2.4 weeks after surgery. Patients generally do not have systemic symptoms or abnormal serology evaluations. Infection should be managed with an incision and drainage, with an exploration of the wound to be certain that the infection does not track deep to the deltoid. These localized infections can be incised and drained, leaving wounds superficial to the deltoid that can be packed and will heal by secondary intention with concurrent administration of antibiotics. Abscess formation deep to the deltoid is characterized by wound breakdown, adenopathy, a fluctuant mass, drainage, erythema, tenderness, and swelling, with an onset of symptoms averaging from a few days to 7 weeks after surgery. Patients may not have fevers, chills, or abnormal serologic evaluations. All patients with deep infection should undergo an incision and drainage with extensive debridement in the operating room. Deep infections will usually disrupt the original rotator cuff repair, and repeated debridement of suture and necrotic cuff tissue is usually required. A repeat rotator cuff repair using monofilament suture should be attempted. After debridement the deltoid and skin are closed over suction drains to prevent deficiencies in wound coverage, but some patients may require musculocutaneous flap coverage of the wound, particularly if the deltoid origin is compromised by the infection. In general, the best outcomes are expected when the rotator cuff repair is intact after treatment of the infection.