Arthroscopic Rotator Cuff Repair
The rotator cuff refers to a group of tendons that attach to the humeral head (the ball of the shoulder joint). These tendons connect the muscles of the rotator cuff to the bone. These muscles help to raise the arm overhead and rotate the shoulder inward and outward. The rotator cuff also helps to maintain the humeral head in contact with the glenoid (the socket) providing dynamic stability to the joint and maintaining proper contact to allow for shoulder full range of motion and strength. These tendons can become partially or completely torn as a result of repetitive overuse injury (most common cause) or a single traumatic event (e.g. a fall or lifting a heavy object). Due to degeneration of the tendon with age, this condition is more common in individuals over the age of 40. As we age, the tendon becomes more susceptible to tearing. Younger or older athletes who use their arms overhead repetitively (e.g. baseball pitchers) or laborers who do repetitive overhead lifting or work also more commonly have rotator cuff tears.
In many cases, surgery is recommended for tears that involve the full thickness of the tendon and/or cause severe pain. In the case of small full thickness tears or partial tears, if the pain and/or functional loss does not respond to more conservative treatments then surgery is also an option. Nowadays, most rotator cuff repairs are done arthroscopically. This technique is minimally invasive, uses a few tiny incisions (portals) rather than one large incision, which results in less trauma to the surrounding soft tissues. As a result, patients typically experience less pain than with a large incision and less scarring.
Arthroscopic Rotator Cuff Procedure
The purpose of arthroscopic rotator cuff repair is to re-attach the torn tendon back to the bone. This is typically achieved using suture anchors that are made from all-stitch material, plastic, biocomposite material or rarely metal. These anchors are placed in the bone and their attached stitches are passed through the tendon to secure the tendon back down to the bone from which it was torn. This allows the tendon to heal back to the bone in its proper location. In many cases, patients may have other issues in the shoulder which can be addressed arthroscopically at the same time as the rotator cuff repair. These include: removal of bone spurs, removal of other degenerative tissue (“clean-up”), and occasionally treatment of tendinitis or tearing of the biceps tendon by performing a release of the tendon only (tenotomy) or release of the tendon with re-attachment in the upper arm through a separate incision (biceps tenodesis).
The arthroscopy is performed by inserting the arthroscope (a fiber optic device with a camera attached) through a portal into the shoulder joint. The picture is seen on a television monitor in HD. A diagnostic arthroscopy is performed and the structures of the shoulder joint are viewed directly. In many cases, new diagnoses are made that have not been seen on the MRI or ultrasound before surgery since arthroscopy in many cases is the best diagnostic test. The arthroscope allows the surgeon to precisely identify, target and treat shoulder joint abnormalities.
During the arthroscopic rotator cuff repair, the patient is asleep under general anesthesia. Patients also typically receive a nerve block right before surgery unless there is a contraindication. This nerve block helps patients with pain relief for several hours after surgery as well as decreasing the need for general anesthetic medications that can cause nausea after surgery. Once the surgery is completed, patients will have a sling and will be taken to the recovery room where they will be monitored until it is time to go home.
Risks of Shoulder Arthroscopy
As with any surgery, there are certain risks that are involved with arthroscopic rotator cuff repair. These include but are not limited to:
- Persistent pain
- Nerve or blood vessel injury
- Blood clot
- Need for repeat surgery
These complications are unusual and most people experience improvement in shoulder pain and function after surgery.
Recovery from Arthroscopic Rotator Cuff Repair
After surgery, the arm is immobilized in a sling to promote proper healing. The sling may be required to be worn for several weeks following surgery. Physical therapy often begins shortly after surgery to help restore range of motion and strength. Typically, range of motion early is done by a therapist moving the shoulder which progresses to the patient moving the shoulder on their own and then finally strengthening exercises once enough healing has occurred. It is important to commit to the physical therapy program and adhere to imposed activity restrictions in order to achieve the most effective surgical result. Physical therapy may be required for several months after surgery depending on progress achieved. Full recovery is typically seen at a year after surgery.