Rotator Cuff Repair


Description:

Tears of the rotator cuff tendon are common. The tendon typically pulls away from the bone to which it is attached. As a principal, tears of the rotator cuff tendons do not heal on their own and may get larger with time. They may cause pain and loss of function.

Tears of the tendon may be fixed surgically by releasing the scar tissue around the tendon and reducing it back to the bone from which it was torn. The tendon can then fixed to the bone in a number of ways, typically using a number of small anchors which are placed in the bone and to which stitches (sutures) are attached. These stitches (sutures) can be used to secure the tendon down to the anchor and bone.

This surgery can be performed under direct vision (open) or keyhole (arthroscopically). A Sub-Acromial Decompression (ASAD) is typically undertaken at the same time to remove excess bone from the tip of the shoulder blade.

The operation may be undertaken independently or in conjunction with other procedures; Sub-Acromial Decompression, Long Head biceps Tenotomy / Tendosesis and Acromio-Clavicular Joint Excision.


The purpose of the surgery:

The aim of the surgery is to relieve upper arm pain and weakness associated with a rotator cuff tear and to obtain healing of the torn tendon.


Alternative Treatment options:

Alternative treatments include steroid injections and physiotherapy. Most patients will have had a trial of non-operative management in the form of both physiotherapy and injections before considering surgery. Repeated injections in the presence of a rotator cuff tear should be used with caution because of potential effects on the tendon.


Anaesthetic:

The surgery is typically undertaken with the patient asleep and a nerve block to provide additional pain relief.


Incision and Dressings:

The vast majority of tears can be repaired as a keyhole procedure and are usually carried out through 4 or more small (5mm) incisions. These incisions do not normally require sutures or stitches but may be closed with an absorbable suture which does not require removal. Paper Butterfly stitches (Steri-StripsTM) are normally used to close the wounds and these are then covered by an OpsiteTM dressing. These dressings may in turn be covered by a large padded dressing immediately following the operation. This padded dressing is removed prior to being discharged home.

If a larger incision is required (open technique) an incision approximately 5cm long is made over the front or side of the shoulder. This is typically closed with an absorbable suture under the skin. Paper Butterfly Stitches (SteriStripsTM) are usually used and the wound covered with padding and a splash proof OpsiteTM dressing.


Rehabilitation:

Following the surgery immobilisation is usually required in a Polysling. The sling should be worn as instructed in the post-operative guidance. The sling is usually worn for 6 weeks following the surgery. The arm should be exercised as detailed in the post-operative rehabilitation guidelines. This typically involves maintaining movement while at the same time resting the tendons that have been repaired.

Please see the Rotator Cuff Repair rehabilitation guidelines.
Rehabilitation:
It can take some time to recover following a rotator cuff repair. Typically the arm will be supported in a sling for four to six weeks following the operation. The tendon should be rested and so bringing the arm away from the side should be avoided. Certain exercises will be started early under the supervision of a physiotherapist to keep the shoulder moving. The exercises will be gradually increased to improve strength and range movement. Commitment to the rehabilitation programme is very important.
Doing too much may jeopardise the success of the operation so do seek the advice of your surgeon or physiotherapist.
Following this period of immobilisation and rest the shoulder is likely to be stiff and this may take some time to recover. Recovery can take 6-12 months.
Although every case is unique, surgery can relieve pain for most people and rehabilitation can restore a functional (but often not full) range of motion.

Admission and Discharge:

You will normally be admitted the day of surgery and go home the same day. It may be necessary for you to stay in overnight particularly if you do not have a responsible adult to keep an eye on you overnight or if your operation is late on in the day.


Risks associated with the operation:

All operations are associated with a degree of risk but significant complications associated with a Rotator Cuff Repair are uncommon. The following risks are those which are serious or most commonly reported in the literature.

Infection (<1%):
Infection in shoulder surgery is very uncommon, particularly in keyhole (arthroscopic) surgery. If an infection were to develop it is typically a superficial infection, which can be treated with oral antibiotics. Rarely does an infection develop that requires re-admission to hospital and surgery to wash the infection out. Antibiotics are typically given before surgery to reduce the risk of infection further.

Anaesthetic Risks:
Anaestheic complications are rare but include Heart Attack (Myocardial Infarction, MI), Stroke (Cerbero-Vascular Accident, CVA) and a clot in the leg (Deep Vein Thrombosis, DVT) or lungs (Pulmonary Embolus, PE).

Neuro-Vascular Damage(<1%):
Damage to nerves or blood vessels is rare. Damage to the axillary nerve may occur as it passes close to the joint. Damage to this nerve may result in weakness and difficulty brining the arm out to the side (abduction).

Stiffness:
After the surgery and a period of immobilisation the shoulder is likely to be stiff. This stiffness should improve with time and graduated rehabilitation. Initial stiffness may be protective of the repair. It is rare that persistent stiffness requires surgical treatment.

Change in symptoms:
Continued pain (5%) The probability of symptom improvement is high it remains possible but rare that symptoms may remain unchanged or deteriorate.

Success and failure (20-80%):
The aim of the surgery is to repair the tendon and thereby allow it to heal to the bone. However, both the bone and the tendon have a relatively poor blood supply (avascular). Because of this and the relative biological inactivity the tendon may not heal to the bone despite a good surgical repair. The probability is largely dependent on the appearance of the tendon at the time of surgery and the duration of time the tear has been present. The shoulder will typically feel better following the surgery even if the tendon does not heal.


Further surgery (Re-operation)


Arthritis.
While the surgery itself is unlikely to significantly predispose the shoulder to arthritis, the presence of a rotator cuff tear does in itself predispose to arthritis.