Arthroscopic Rotator Cuff Repair is a minimally invasive keyhole procedure to repair rotator cuff tendon tears. It is often done as a part of other keyhole procedures in the shoulder, such as a subacromial decompression and acromioplasty, biceps tenodesis, and AC joint excision.
Surgery generally involves an overnight stay with a sling required for 6 weeks after surgery. Therapy using the JPL protocol commences 2 weeks after surgery and strengthening is allowed at 3 months. When all of the pain generators in the shoulder are treated, it is a successful operation and restores function and quality of life.
The principle of arthroscopic rotator cuff surgery is to reattach the torn tendon back to the humerus (ball) and address any other areas of concern at the same time – biceps tendon, shoulder spur, bursitis, acromioclavicular joint, and shoulder joint capsule. The procedure is almost always carried arthroscopically (keyhole) and involves an overnight stay in hospital. Patients are in a sling for six weeks and start rehabilitation using the JPL protocol at two weeks post-surgery.
The main area of concern is the torn rotator cuff (supraspinatus tendon tear is the most common); the following areas are also addressed if needed:
The decision to address these areas is best made in the office during your consultation – this is based on a careful history, physical examination, imaging review (MRI), and discussion with the patient about their expectations and functional requirements. In a small number of cases, unexpected findings are made at surgery and Dr Pant will undertake the treatment that provides you with the best outcome.
The procedure is performed under a General Anaesthetic where you will be positioned on your side and the affected arm secured in a special arm holder.
Bone Spur and Bursa
Rotator Cuff Tear
AC Joint Resection
Surgery is a carefully choreographed process and you are being treated by a sub-specialist shoulder surgeon and a highly experienced team; however, all surgeries inherently carry some risk of complications, such as (all are below 1%). General risks include:
Frozen shoulder progresses through three phases (which may each last 2-3 months)
Individuals with a natural history of frozen shoulder
Outcomes after frozen shoulder
Reoperation and failure of surgery
When performing a shoulder reconstruction, your surgeon is using your own tissue to repair what is damaged. The weakest point in the repair is your own tissue. The longer the history of damage and frequency of trauma prior to surgery, the more likely the tissue quality is poor. Other factors like Smoking and Diabetes may also reduce your tissue quality.
Re-tear of the rotator cuff tendon repair
Failure of Biceps Tenodesis (Re-anchoring of the tendon)
There are three essential components to a good outcome from surgery:
Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery; it will be modified to suit your individual circumstance.
The JPL pathway allows for self-directed, early passive shoulder range of movement:
After the surgery you will be in a sling and protect your shoulder to allow the rotator cuff repair to heal. At two weeks after the surgery, Dr Pant will see you at your review appointment and discuss the JPL rehabilitation protocol with you. This JPL physiotherapy protocol will commence two weeks after your surgery.
The therapy program will focus on flexibility and range of motion exercises initially. These gentle stretches will improve your range of motion and prevent shoulder stiffness. As the rotator cuff repair begins to heal you will be able to progress to exercises that strengthen your shoulder muscles. Shoulder strengthening is commenced at 12 weeks post rotator cuff repair surgery.
A sling is required for the first 6 weeks after your surgery; the sling is worn for a further 6 weeks outside of the house (to remind others you have had shoulder surgery). In some instances you may only need a sling for 1-2 weeks – Dr Pant will discuss these cases with you.
The type of sling is selected specific to you and your shoulder surgery:
Driving after shoulder surgery
Showering and getting dressed
Sleeping after Shoulder Surgery
Elbow and hand movement
The way to achieve the best outcome after rotator cuff surgery starts with an accurate diagnosis, through patient education, excellent surgical technique, adequate post-surgery pain relief, careful rehabilitation and collaboration with your physiotherapist.
The outcome after rotator cuff repair is generally excellent with the resolution of symptoms and restoration of function. It is not possible, however, to restore the shoulder back to “normal” as your surgeon is using your own tissue to repair what is torn.
There are many factors that contribute to a successful outcome after rotator cuff repair:
It is important to remember that when performing a rotator cuff repair your surgeon is using your own tissue to repair what is damaged. The weakest point in the repair is usually your own tissue. The longer the history of damage and frequency of trauma prior to surgery, the more likely the tissue quality is poor. Other factors like Smoking and Diabetes may also reduce your tissue quality.
This area is typically very strong and not a source of common failure
This is the weakest point and the most common reason for failure of surgery (usually due to poor tissue quality)
There are special techniques in tissue management and suture choice to reduce failure rates.
The retear rate of the rotator cuff tendon repair ranges from 5-20% – the larger your tear, the more likely you are to have a retear of your repair. The failure rate after a biceps tenodesis is reported to be between 2-6%; however, in the Sydney Shoulder Unit experience, it is less than 1%.
The rotator cuff tendons are poor in blood supply and generally wear out over time. Tears can be partial thickness or full thickness. If you have a tear in your shoulder tendon then it will not heal by itself.
However, grey hairs and cuff tears do go hand in hand; not all patients with a torn rotator cuff need surgery. If the tendon tear occurs slowly over time then your shoulder will compensate and cope well by using the other tendons and muscles.
If you have an injury or a fall and sustain a large traumatic tear then you may lose shoulder function suddenly. In such cases it is best you consider surgery to reattach the torn tendon sooner.
In wear and tear cases, when the tear becomes very large, your shoulder function may deteriorate and you may need to see a shoulder surgeon. If you have left the tendon tear too long, the rotator cuff muscles may be replaced with fat and waste away; this may mean that reattachment is not possible.
This 48 year old gentleman works as a metal fabricator and presented with several months of new shoulder pain; he was finding it difficult to undertake overhead work and was limited with daily activity around the house.
MRI scans demonstrated a large rotator cuff tear with biceps tendonitis. Given the tear size and limitation in function – he proceeded with surgery.
He underwent keyhole shoulder surgery to re-anchor the biceps tendon (biceps tenodesis) and repair the rotator cuff (double row repair). An excellent repair was obtained with restoration of the anatomical footprint.
He commenced JPL rehabilitation at 2 weeks post-operatively; and an abduction sling was worn for six weeks in total. Strengthening commenced at 3 months post-surgery.
This 53 year old lady presented with right-sided shoulder pain after injuring her shoulder at work. She underwent a period of rest, cortisone injection and 3 months of physiotherapy without improvement.
After a careful history and examination, an MRI scan was undertaken. The MRI showed a Rotator Cuff Tear with Biceps Tendonitis.
The images taken at surgery (key-hole) demonstrate significant biceps tendonitis with inflammation and thickening of the tendon. The biceps tendon was taken out of the shoulder joint and re-anchored under the arm-pit (biceps tenodesis). The bursitis and bone spur was cleaned out and the rotator cuff tear was repaired with 4 anchors with good compression of the tendon foot-print.
She was discharged home the following day after surgery and placed in a sling for six weeks. She underwent JPL rehab which commenced at two weeks post-surgery. Strengthening commenced at months under the guidance of her physiotherapist.
She no longer has her previous shoulder pain and has good power of her rotator cuff.
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