What is Rotator Cuff Repair?
The surgeon performs the surgery through several small (3-5 mm) puncture holes around the shoulder. A camera is inserted and allows visualization of not only the rotator cuff tear but also the shoulder joint surface itself and other structures that may be causing dysfunction or discomfort.
The space where the rotator cuff lies has inflamed soft tissue that is removed by the surgeon and often the roof (the acromion) is smoothed using a burr. Occasionally, the joint between the acromion (the roof) and the clavicle (collarbone) is painful or arthritic and it is opened up using a motorized burr during surgery.
Once the tendons are cleared of tissue and well visualized, they are repaired. After a full thickness tear, the tears retract and stiffen with time. Rarely, it is not possible to mobilize the retracted tendons enough to complete a repair. The surface of the bone is freshened to produce bleeding. This bleeding is crucial to healing as the tendons themselves have a very poor blood supply.
Five millimeter anchors made from biocompatible material are screwed into the bone. Each anchor has two very strong sutures attached. The sutures are passed through the torn tendon then are secured firmly down to the bone, often with the help of a second row of anchors.
Healing of the tendon into the bone is slow and takes about 10-12 weeks before it is strong enough for the arm to be used under its own power. The poor blood supply slows healing. During this period of time it helps to keep the arm moving but this has to be done using the other arm or with the help of a friend or therapist. A single strong pull by the repaired muscle-tendon unit is enough to disrupt the repair during this time.
A graphic representation of anchor placement to repair the cuff
Following tendon repair the shoulder will always lose motion. This motion generally has to be regained over several months. It may take up to 12 months in some cases, particularly if the tear was large and the repair difficult.
Between two and five anchors are used to perform the repair. If one of the tendons of the biceps muscle (long head) is torn or producing pain, this may be cut or secured at a different location at the same time.
What is the long head of the biceps?
The biceps has two attachments around the shoulder. The short head is outside the shoulder joint, and the long head is in the shoulder. The long head may have disease to it such as tearing within the tendon or partial detachment of the tendon. If this is the case then the long head of biceps will be cut and either left or reattached lower down into the humerus. If it is not reattached studies show no difference in strength or pain. The main reason for reattachment is to avoid asymmetry in the appearance of the biceps muscle called a “Popeye” muscle. The Popeye muscle occurs at a slightly lower rate in patients who have had a tenodesis (reattachment) compared to tenotomy.
If the tendon is reattached this is done commonly by a separate incision in the arm pit area and it is anchored into the humerus.
Expectations and Complications
- Your shoulder will be very sore for the first two weeks and sleep will be difficult. An ache often persists for 10-16 weeks postoperatively. This is normal.
- Stiffness: Stiffness is normal after rotator cuff repair. Some patients get very stiff, forming plenty of scar tissue. Although this is a nuisance, with time these patients generally form a sound repair and do well long term. Clicking with range of motion is very common and persists for many months and sometimes forever. If it is not painful there is nothing to worry about.
- Infection:Thankfully this is very rare with arthroscopic surgery and occurs in less than 1 in 1000 cases.
- Failure to heal: Rotator cuff repairs retear and the rate at which they retear depends largely on the size and age of the tear prior to surgery. Small full thickness tears retear at a rate of around 10% at 1-2 years. Large or massive tears can fail at a rate around 40%! Interestingly, even these patients are better off than prior to the surgery, but do not do as well as those who heal. If the shoulder continues to be painful, revision surgery can be considered however the results of revision surgery, as you can imagine are far less reliable than first time repairs.
- Nerve damage, chronic pain, blood clots or medical complications can all result from any surgery but thankfully after arthroscopic rotator cuff repair these unusual complications are rare.
Does it Work?
Rotator cuff repair is highly successful in appropriately selected patients. Outcomes depend on a number of factors including age and activity level of the patient, status of the muscle and tendon before surgery, size and age of the tear. Physiotherapy is crucial after rotator cuff repair. Having surgery if you do not have access or money to pay for physiotherapy is virtually pointless.
Rotator cuff surgery is very painful for several weeks postoperatively. Despite the small incisions on the skin a great deal of work goes on in and around the shoulder joint leading to discomfort that can last 10-16 weeks.
Postoperative expectations and requirements