Rotator Cuff Arthroscopic Surgery
Even large tears can be repaired on an outpatient basis without an incision using several small arthroscopic portals. There is less pain and stiffness than with traditional open procedures.
Definition of the rotator cuff:
The rotator cuff consists of four tendons (tendons connect muscles to bones to move joints) that form a cowl that encapsulates the upper end of the arm bone, the humeral head, and holds it tightly in the socket or glenoid to form the shoulder joint. This enables the larger muscles, the pectorals, deltoid, and latissimus to move the shoulder joint smoothly in a rotatory motion. When the rotator cuff is torn, elevation of the arm is painful and weak because the ball is no longer held firmly in the socket when the larger muscles move it. In all cases of rotator cuff tear the supraspinatus is the first tendon to tear – except in unusual cases when the subscapularis tendon tears first as a result of injury. The supraspinatus is located at the top of the shoulder. After it tears, the tear spreads backward to the infraspinatus and forward to the subscapularis in severe cases. The fourth tendon, the teres minor is further down the back of the shoulder and only tears in very severe cases. The rotator cuff can tear completely or partially or have tendonitis in which it is painfully inflamed but still in continuity.
Causes of rotator cuff tear and tendinitis:
The rotator cuff thins naturally with age. Over the age of 80 complete rotator cuff tears are common in the normal population. Prolonged or repetitive elevation of the arm such that the elbow is not close to the torso will accelerate this process of rotator cuff degeneration in young people and result in tears as early as 35 years of age. Under the age of 35 complete tears are very rare but may occur in competitive throwers and weight lifters.
Diagnosis:
Patients have pain at the upper outer corner of the shoulder most commonly. The pain commonly is felt down the upper arm but usually not below the elbow. Elevation of the arm or placing the arm beyond the body commonly increases the pain. Night pain is very common. Inability to elevate the arm above the horizontal often indicates complete tear.
MRI, arthrogram (x-ray after injection of dye), MRI in combination with arthrogram, and ultrasound are used to diagnose rotator cuff tears. Open MRI scans, which have much weaker field strength than closed MRIs, have a high error rate and are not useful to diagnose small tears. Closed MRIs provide much higher accuracy but even they can make mistakes and in questionable cases an MRI arthrogram will be ordered.
At Illinois Sports Medicine we use ultrasound to locate rotator cuff tears. Many studies have found ultrasound to be as accurate as MRI for picking up rotator cuff problems. The benefits of ultrasound include convenience, speed, cost, and patient comfort.
Rotator cuff repair:
Completely torn rotator cuffs generally do not heal. They increase in size over time. Surgical repair is usually recommended except in older patients or patients for whom surgery would pose high risk. The smaller the tear is at the time of repair the better the ultimate result usually is: thus earlier repair is beneficial. Surgical repair usually consists of implanting one or more small suture anchors – about 5mm in diameter – into the humeral head and then using the sutures attached to it to repair the rotator cuff to the bone. This can be done with an open incision in which muscle may be detached from bone and later reattached; or arthroscopically in which no muscle is detached from bone.
While most rotator cuffs nationwide are still repaired using an open incision, Dr Prodromos has performed rotator cuff repairs exclusively arthroscopically, with no open incision and no detachment of muscle from bone for more many years. Small absorbable anchors are inserted into the shoulder and sutures attached to them are used to reattach the rotator cuff to the bone. Usually, rotator cuff repair is accompanied by acromioplasty. These procedures are done on an outpatient basis and require no special pain pumps or nerve blocks because tissue trauma is minimal. Pain is much less severe than with open repairs, since only three or four small punctures are made in the skin. Blood loss is negligible. Surgical time is often about two hours but may vary. The surgery is done on an outpatient basis in a hospital or surgicenter.
Results of rotator cuff repair :
In the vast majority of cases pain is significantly diminished, strength improved and motion preserved. However most patients do not have complete elimination of their symptoms; and occasionally a patient will develop stiffness requiring prolonged therapy to remedy. Rarely a patient may need a manipulation of the arm under anesthesia to restore motion. Some loss of motion at the extremes is common but is rarely a problem. Recurrent tears are unusual but can occur. Since prolonged or repetitive elevation of the elbow and arm away from the body cause rotator cuff tears to begin with, it is strongly recommended that patients, even after very successful repair, minimize these activities after repair to avoid recurrence. An activity modification program to accomplish this is individually designed for each patient under the guidance of our expert physical therapists.
Surgical Treatment of Partial Tears:
Most partial tears heal with properly designed physical therapy and activity modification without surgery. If they do not, then “debridement,” or “pruning” of dead tissue, from the undersurface of the cuff, can allow healthy tissue to grow in, much as occurs with pruning of dead wood from a tree. An acromioplasty is useful to remove bone that may be impinging on the cuff in many but not all cases.
Example of a very large rotator cuff tear and repair
Below is a video that shows a very large tear to the rotator cuff along with rupture of the biceps. This tear delaminated. The rotator cuff separated into 2 separate layers, each of which needs to be repaired separately.
