Healthcare delivery accounts for a substantial share of global greenhouse-gas emissions, yet comparative life-cycle evidence for clinically similar surgical techniques remains limited. Arthroscopic and mini-open repair are the two predominant operations for full-thickness rotator cuff tears. This study asked: (1) Do twelve-month pain, function and complication rates differ between arthroscopic and mini-open rotator cuff repair? (2) Does arthroscopic repair generate a higher per-procedure environmental footprint than mini-open repair when quantified by life-cycle assessment? (3) Which factors independently predict per-procedure carbon emissions?

We hypothesized that twelve-month clinical scores and complication rates would not differ significantly between techniques, whereas arthroscopic repair would generate a higher per-procedure carbon footprint because of greater use of powered instrumentation, video monitoring and fluid-management systems.

A retrospective comparative cohort of 927 patients (692 arthroscopic; 235 mini-open) who underwent primary rotator cuff repair at a single tertiary centre between January 2019 and April 2025 was analysed. Clinical outcomes were Visual Analog Scale (VAS), American Shoulder and Elbow Surgeons (ASES), Constant–Murley and University of California Los Angeles (UCLA) scores, recorded preoperatively and at twelve months. Environmental impacts were quantified with a gate-to-gate life-cycle assessment (LCA) based on hospital-specific inventory data (operating-room energy, anaesthetic gases, solid waste, irrigation fluid and sterile-supply consumption). The minimum follow-up was twelve months.

(1) Both techniques produced significant improvement in all clinical scores (all p < 0.001), and no statistically significant between-group differences were detected (VAS p = 0.940; ASES p = 0.765; Constant–Murley p = 0.677; UCLA p = 0.845). Complication rates were comparable (14.6% vs 15.3%, p = 0.870). (2) Arthroscopic repair was associated with 18% greater total carbon emissions (49.4 ± 11.2 vs 41.9 ± 10.8 kgCO₂e; p < 0.001), higher energy consumption (19.6 ± 4.5 vs 15.7 ± 3.3 kW h; p < 0.001) and greater waste generation (6.7 ± 1.1 vs 5.1 ± 0.9 kg; p < 0.001). (3) Mini-open technique (β = −9.36; p < 0.001), smaller tear size, regional anaesthesia (β = −8.35; p < 0.001) and shorter hospital stay (β = 2.14 per day; p < 0.001) independently predicted lower total emissions.

In this retrospective cohort, twelve-month clinical scores did not differ significantly between techniques, whereas arthroscopic repair generated a higher gate-to-gate carbon footprint. Modifiable factors, notably anaesthetic technique and length of stay, offer practical targets for emission reduction. Because predefined equivalence margins were not tested and the LCA boundary was gate-to-gate with a one-year clinical horizon, these data should not be used as a sole determinant of technique choice; prospective multicentre evaluation is required.

III; retrospective comparative study.