Rotator Cuff Repair

Introduction

The rotator cuff is a combination of 4 muscles arising from shoulder blade. These muscles combine together and join forming one tendon, a hood or ‘cuff’, that surround the top of the shoulder joint. These 4 muscles are:

  • Supra-spinatus.
  • Infra-spinatus.
  • Sub-scapularis.
  • Teres minor.

With the help of the deltoid muscle, the rotator cuff allows the arm to pivot around the shoulder joint, to lift the arm forward and sideways as well as provide shoulder stability and strength. Tears in the rotator cuff usually occur at the attachment of the tendon to the bone rather within the muscle and often arise in the supraspinatus. However, massive tears can involve the other tendons. 

The majority of rotator cuff tears are age related, known as "chronic tears". As we age, the tendon wears and degenerates. As a result, by the age of 60, approximately 50 % of people will have some abnormality of the rotator cuff. Occasionally rotator cuff tears may be the result of an injury, "acute tears", or may be caused or irritated by bone spurs that form on the acromion above the tendon (supraspinatus). Rotator cuff tears are also more commonly seen in people who repeatedly use their arms above their heads or use the same shoulder motions such as tradesmen, (plasterers and painters) and sports people, (swimmers, rowers and tennis players).

Symptoms

  • Pain. In most cases pain is the predominant feature. It occurs with use of the arm particularly lifting the arm to and above shoulder height.  The pain may be more noticeable at night especially if lying on affected side.
  • Weakness and associated loss of power. This may occur depending on the size of the tear.
  • Crepitus or crackling sensation when moving the shoulder in certain positions.

Diagnosis of rotator cuff tear

The diagnosis of rotator cuff tear is based on patient's history, clinical examination and special tests which include X-Rays, ultrasound and MRI scan. The X-ray may reveal the acromial spur which can cause impingement and tearing of the supraspinatus tendon. The MRI reveals whether the tear is partial (tendon not completely severed) or full thickness (there is a hole in the tendon) and indicates whether the tear is surgically repairable.
In many cases, patients can be managed conservatively with:

  • Rest and modification of activities.
  • Simple pain killers such as paracetamol and / or non-steroid anti-inflammatory medication.
  • Steroid injection around the rotator cuff tendons- usually under ultrasound scan guidance to increase accuracy.
  • Physiotherapy to strengthen rotator cuff muscles provided it doesn’t aggravate the problem

If conservative treatment fails to relieve the symptoms of rotator cuff tear, then Dr Lane may recommend surgery.

Indications for rotator cuff repair

  • Failure of non-surgical (conservative) treatment 
  • Active patient who uses arms overhead in work or sport
  • Symptoms lasting 6 to 12 months
  • Large tear (more than 3 cms) and surrounding tissue good quality
  • Significant impairment and weakness
  • Tear related to a recent, acute event injury

Pre-operative Patient education

At the time of consultation, Dr Lane will give a comprehensive explanation of the procedure, expected recovery and surgical risks. Educational leaflets supplied by the Australian Orthopaedic Association are also supplied for further patient information. If there are any concern prior to surgery, further consultation is encouraged with Dr Lane.

If you have a pre-existing medical condition, you may be reviewed by a further specialist such as a cardiologist or other specialised physician and anaesthetist prior to surgery.

The goal of surgery is to reattach the tendon to the bone (head of humerus). This is commonly achieved using anchors. Anchors look like very small screws that have an eyelet through which a couple of sutures are passed. The anchors are placed in the bone where the tendon needs to be reattached. Sutures in the tendon are then attached to the anchors and knotted in place to restore anatomical insertion of the tendon into the bone.

There are a few surgical approaches that can be used, either alone or in combination. The type of surgery is mainly determined by the size of the tear and if there are any additional problems such as bicep tendon tears, osteoarthritis, bony spurs or other soft tissue tears. These additional problems can be addressed as well as the rotator cuff tear, at the time of surgery. 

Arthroscopic Repair

This is the least invasive method to repair a torn rotator cuff and is applicable to small tears. Through small incisions the arthroscope is introduced into the shoulder joint and small surgical instruments are then inserted into the joint to enable repair. Arthroscopic removal of the acromial spur (acromioplasty) can be performed at the same time. This spur often contributes to the tear by rubbing on the tendons. The advantage of this procedure is that it is potentially less painful.

Mini-op repair

A small incision, usually about 3 to 5 cms long, is made to repair the torn tendons in medium to large tears. During the tendon repair the surgeon views the shoulder structures directly rather than through a video monitor. An arthroscopic acromioplasty is often performed before open repair of rotator cuff. The majority of repairs can be treated with this technique.

Open Surgical Repair

When the tear is large or complex, a fully open repair may be necessary. This involves a longer skin incision and split in the deltoid muscle to achieve adequate exposure to repair the torn tendons. It usually involves a longer rehabilitation period to allow healing of the rotator cuff repair and deltoid muscle.

Pre-operative instructions

Anti-inflammatory drugs such as Feldene, Naprosyn, Nurofen, Brufen, Voltaren, Mobic and Celebrex should be stopped 5 days before surgery. These drugs increase the risk of bleeding. Aspirin or other blood thinning drug use prior to surgery will be discussed with Dr Lane, as this would depend on the patients underlying medical condition. The shoulder to be operated on should be free of cuts, scratches and sores as this can increase the risk of infection. If you have damage to your skin, your surgery will be postponed until healed.

The majority of rotator cuff repairs are done as an outpatient basis but occasionally, if the tear is large, may require up to 2 days in hospital. The reception staff will give clear instructions about your admission location and time. You should not eat or drink 6 hours before your surgery.

Bring to hospital:

  • List of current medications.
  • Relevant X-rays.
  • Medicare, DVA or Private Healthcare cards.

Once your details have been taken in the admissions area:

  • The duty nurse will take your clinical details and baseline observations.
  • A theatre gown will be given to wear.
  • The shoulder to be operated on will be inspected by the nursing staff, washed with an anti-septic solution and then covered with a sterile drape.
  • TED stockings will be applied to the legs to reduce the risk of thrombosis after surgery.

You will be taken to the theatre complex by the nursing staff and then into the anaesthetic bay next to the operating room. There you will meet Dr Lane and the anaesthetist.

Rotator cuff repairs are usually performed under a general anaesthetic (when you are completely asleep). The anaesthetic may also involve a regional nerve block to aid post-operative pain relief. After the surgery, Dr Lane infiltrates the wound with local anaesthetic to augment pain relief after surgery. Intravenous antibiotics will be infused prior the surgery to reduce the risk of post-operative infection.

Procedure

The type of surgery required will depend on the size of the tear and if additional problems as mentioned above.

Once the patient is asleep under general anaesthetic:

  • If arthroscopic shoulder surgery performed, the patient will be lifted onto side with shoulder to be operated on upper most, and the arm lifted with heist and weighted upwards. 
  • If open surgery, the patient lying on back and slightly head up.

The shoulder, upper chest and arm are prepped with anti-septic solution and patient covered with sterile drapes with window for operative site.

Arthroscopic and open procedure may take 1 to 2 hours.

Once the surgery is complete, the incision sites are closed with either steri-strips or sutured depending on their size. Primapore dressings and then bulky padding applied over the operative site. 

You will be taken to the recovery room and once adequately awake, comfortable, and observations normal will be discharged home. A script will be given for pain relief. It is important that someone takes you home.

Post-operative Instructions

After surgery, the arm is put in a sling. This helps protect the repair while the tendons heal and should be worn until seen by Dr Lane. It is important that the dressings are kept dry. The outer padding can be removed 3 days after surgery, leaving the primapore intact. You will be given some simple passive exercises to do at home. 

You will be reviewed by Dr Lane 10 to 14 days following surgery. At this visit your sutures or staples will be removed (if necessary), and receive further exercise programme to follow. It is important that during the first 6 weeks that active elevation and abduction (movement of the arm away from the body) is avoided. Most patients are sent for a course of physiotherapy to aid rehabilitation. It can take up to 12 weeks for the rotator cuff tendon to heal back onto the bone so if active movement is commenced prematurely then there is a higher chance that the rotator cuff tendon will not heal.

You will be seen again by Dr Lane at the 6-weeks post-operative stage, to assess your recovery and advised on further guided rehabilitation. A complete recovery can take up to 6 months and your commitment to rehabilitation is the key to a successful outcome.

Factors that lead to poor recovery include:

  • Poor tendon / tissue quality.
  • Large or massive tear.
  • Aged over 65 years.
  • Smoker.
  • Poor patient compliance with rehabilitation.

Risks

General Complications associated with Anaesthesia (rare)

  • Death.
  • Myocardial Infarction (heart attack).
  • Stroke.
  • Pneumonia.
  • Deep venous Thrombosis.

Local Complications (uncommon)

  • Bleeding.
  • Nerve injury – This typically involves the nerve that activates your deltoid muscle.
  • Infection – Patients are given antibiotics during the procedure to lessen the risk of infection.
  • Deltoid detachment – During surgery, this muscle is split to provide better access to the rotator cuff tear. It is stitched back on at the end of repair.
  • Stiffness – Rehabilitation lessens the risk of stiffness.
  • Tendon Re-tear – The larger the tear the higher the risk of re-tear. Repeat surgery is needed only if there is severe pain or loss of function.

Patients who are smokers, diabetic and have multiple pre-existing medical conditions are at a higher risk of adverse complications.