Rotator Cuff Repair
What is a Rotator Cuff?
The shoulder joint is a ball and socket joint formed by the union of the head of the upper arm bone (humerus) and the shoulder socket (glenoid).
The Rotator Cuff is a group of four tendons that join the head of the humerus to the deeper shoulder muscles to provide stability and mobility to the shoulder joint.
The four rotator cuff muscles include the:
- Supraspinatus
- Infraspinatus
- Subscapularis
- Teres minor
What is a Rotator Cuff Tear?
Rotator Cuff Tear is the medical term for when the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, however other areas of the rotator cuff may also be involved.
The torn tendon often begins by becoming frayed, and as the damage progresses the tendon can completely tear.
Types of Rotator Cuff Tears
There are two types of tears:
- Partial tear; damage of the soft tissue but does not completely sever it
- Full-Thickness Tears; when the tissue is split into two pieces.
Causes of Rotator Cuff Tear
Common causes of Rotator Cuff Tears include:
- Injury
- Degeneration
- Repetitive stress
- Lack of blood supply
- Bone spurs
Rotator Cuff Tear Symptoms
Rotator Cuff Tear usually causes pain and sufferers to have the following symptoms:
- A weakness of the arm
- The crackling sensation when moving the shoulder (crepitus)
- Difficulty with above shoulder height level lifting
- Night pain
Diagnosis of Rotator Cuff Tear
To diagnose a Rotator Cuff Tear, diagnostic methods include:
- Consultation - During this consultation, your doctor will:
- Take a medical history
- Perform a physical examination
- Assess the shoulder’s range of motion
- Imaging tests - In order to clearly understand the nature of any loss of the joint space or bone spur formation imaging scans are required:
- X-rays - the first imaging tests performed are usually x-rays. Because x-rays do not show the soft tissues of your shoulder like the rotator cuff, plain x-rays of a shoulder with rotator cuff pain are usually normal or may show a small bone spur
- MRI - can create detailed images of both hard and soft tissues, and will produce a much clearer image of the rotator cuff. An MRI can produce cross-sectional images of internal structures required if the diagnosis is unclear.
- Ultrasound - can allow the doctor to examine the inside of your affected area in motion.
Non-Surgical Treatment for Rotator Cuff Tear
Treatments can include:
- Rest from pain provoking activities
- Physiotherapy
- Steroid injection
Rotator Cuff Arthropathy
When the rotator cuff is torn, it can cause wear and tear to the shoulder joint and lead to shoulder arthritis. Conventional surgical methods such as total shoulder joint replacement have been shown to be significantly ineffective in the treatment of Rotator cuff arthropathy.
Symptoms of Rotator Cuff Arthropathy
Patients with rotator cuff arthropathy may feel pain (usually at night) and weakness within the involved shoulder. Patients may have had a prior rotator cuff repair or a history of multiple repairs. The most common symptom is the inability to raise the arm above the shoulder to perform overhead activities.
Arthroscopic Rotator Cuff Tear Surgery
If the non-surgical treatments do not resolve the patient’s symptoms, the patient may then require surgery for Rotator Cuff Tear.
- Two or three small incisions (portals) are made. In one portal, the arthroscope is inserted to view the shoulder joint.
- A sterile solution is pumped to the joint which expands the shoulder joint, giving the surgeon a clear view and room to work.
- With the images from the arthroscope as a guide, the surgeon can look for any pathology or anomaly. The large image on the television screen allows the surgeon to see the joint directly and to determine the extent of the injuries, and then perform the particular surgical procedure, if necessary.
In some cases
- the front (anterior) edge of the acromion is removed along with some of the bursal tissue and last four or five millimetres of the clavicle to increase subacromial space for the rotator cuff tendons.
- Holes are drilled into the humerus to accommodate the suture anchors.
- Using suture anchors that are inserted into the humerus bone
- Strong sutures from the anchors are placed in the torn ends of the rotator cuff tendons
After the surgery, the incisions (portals) are closed by sutures and the patient is taken to the recovery room.
Untreated Rotator Cuff Tear
A Rotator Cuff Tear is not life-threatening but can severely impact a patient’s quality of life and function.
It can affect anyone: elite athletes and the active individual, manual labourers and office workers.
Preparation for Rotator Cuff Surgery
Once your doctor decides that surgery is required, preparation is necessary to achieve the best results and a quick, problem-free recovery.
Preparing mentally and physically for surgery is an important step toward a successful result.
- your doctor will create a treatment plan and
- Patients will also need to understand the process and their role in it
Participating and completing a tailored exercise program before (ie. pre-hab) with a trained physiotherapist will achieve the best result after surgery.
Your doctor will also need to:
- Discuss any medications being taken with your doctor or physician to see which ones should be stopped before surgery
- Do not eat or drink anything, including water, for 6 hours before surgery
- Stop taking aspirin, warfarin, anti-inflammatory medications or drugs that increase the risk of bleeding one week before surgery to minimise bleeding
- Review blood replacement options (including banking blood) with your doctor
- Stop or cut down smoking to reduce your surgery risks and improve your recovery
Report any infections to your doctor prior to surgery as the procedure cannot be performed until all infections have cleared up.
Post Surgery
The patient will wake up in the recovery room and then be transferred back to their hospital room.
- Pain medication will be provided to keep the patient comfortable.
- A bandage will be around the operated shoulder and the arm will be in a sling or brace.
- The sling will be worn for about 4-6 weeks to facilitate healing.
Your doctor will see the patient prior to discharge and explain the findings of the operation and what was done during surgery.
- The bandage will usually be removed 48 hours post-surgery and place dressings provided by your surgeon over the area.
- It is normal for the shoulder to swell after the surgery. Placing Ice-Packs on the shoulder will help to reduce swelling. Ice packs should be applied to the area for 20 min 3-4 times a day until swelling has reduced.
- The patient will not be allowed to lift anything over your head or anything greater than 1 kilo for the first 6 weeks.
- 7-10 days after surgery your doctor will see the patient to monitor their progress and remove the sutures.
The patient will be given specific instructions regarding activity and a rehabilitation program of exercise and strengthening.
Eating a healthy diet and not smoking will promote healing.
Differences Between Conventional and Reverse Shoulder Replacement
Conventional shoulder replacement surgery involves replacing the ball of the arm bone (humerus) with a metal ball and the socket (glenoid cavity) of the shoulder blade (scapula) with a plastic socket.
If this surgery is used to treat rotator cuff arthropathy, it may result in the loosening of the implants due to the torn rotator cuff. Therefore, a specifically designed surgery was developed called reverse total shoulder replacement to be employed in such cases.
In reverse total shoulder replacement, the placement of the artificial components is essentially reversed. In other words, the humeral ball is placed in the glenoid cavity of the shoulder blade (scapula) and the plastic socket is placed on top of the arm bone.
This design makes efficient use of the deltoid muscle, the large shoulder muscle, to compensate for the torn rotator cuff.
Ideal Candidates for Reverse Shoulder Replacement
Reverse total shoulder replacement may be recommended for the following situations:
- Completely torn rotator cuff that is difficult to repair
- Presence of cuff tear arthropathy
- Previous unsuccessful shoulder replacement
- Severe shoulder pain and difficulty in performing overhead activities
- Continued pain despite other treatments such as rest, medications, cortisone injections, and physiotherapy
Reverse Shoulder Replacement Procedure
Reverse total shoulder replacement surgery is performed with the patient under general anaesthesia.
- Your surgeon makes an incision over the affected shoulder to expose the shoulder joint
- The humerus is separated from the glenoid socket of the scapula (shoulder blade)
- The arthritic parts of the humeral head and the socket are removed and prepared for insertion of the artificial components
- The artificial components include the metal ball that is screwed into the shoulder socket and the plastic cup that is cemented into the upper arm bone
- The artificial components are then fixed in place
- The joint capsule is stitched together, the tissues approximated and the wound is closed with sutures.
Postoperative Care for Reverse Shoulder Replacement
Patients can get out of the bed on the same day of the surgery but usually, stay in the hospital for 1-2 days. General Postoperative instructions include:
- Take all prescribed medications as instructed
- Undergo gentle range of motion exercises to increase your shoulder mobility
- Physiotherapy will be recommended to strengthen the shoulder and improve flexibility
- Avoid overhead activities for at least 6 weeks
- Don’t push yourself up out of a chair or bed using your shoulder muscles
- Avoid lifting heavy objects
Risks and Complications of Shoulder Surgery
As with any major surgery, there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.
It is important that the patient is informed of these risks before the surgery takes place.
Medical (general) Complications
Medical complications include those of the anaesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:
- Allergic reactions to medications
- Blood loss requiring transfusion with its low risk of disease transmission
- Blood Clots (Deep Venous Thrombosis)- Blood Clots can form in the arm muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life-threatening.
- Heart attacks, strokes, kidney failure, pneumonia, bladder infections.
- Infections can occur superficially at the incision or in the joint space of the shoulder, a more serious infection. Infection rates vary; if it occurs it can be treated with antibiotics but may require further surgery.
- Damage to nerves, blood vessels, local tissue, or nerve damage, while rare but can lead to weakness or loss of sensation in part of the arm. Damage to blood vessels may require further surgery if bleeding is ongoing.
- Wound irritation or wearing out of any implant components
Serious medical problems can lead to ongoing health concerns, prolonged hospitalisation or rarely death.
Specific Surgery Complications
Specific complications for surgery are rare but may include:
- Dislocation or instability of the implanted joint
- Fracture of the humerus or scapula
- Shoulder Stiffness- Shoulder stiffness with loss of range of motion is a common complication that can be greatly minimized with strict adherence to your occupational therapy program prescribed by your surgeon.
- Arm length discrepancies
- Damage to the joint- Joint damage to the cartilage or other structures can occur during surgery and may require another operation to repair.
If the patient suffers arm pain, redness or swelling, or have shortness of breath at any stage, contact our practice.
