Shoulder Surgery

Irreparable Rotator Cuff

The Irreparable Rotator Cuff

The irreparable rotator cuff presents a challenging problem to shoulder surgeons worldwide; there is often no clear consensus on which treatment is best. Therefore, it is important to carefully assess every case and tailor treatment options to the unique demands of each patient. If surgery is carried out sooner it may still be possible to achieve a primary tendon repair. However, with delays to surgery or in revision cases (tendon re-tear) the options may be limited and/or more complex.

The rehabilitation after surgery for an irreparable rotator cuff (and/or revision cases) is longer and the outcome may not be as reliable as with early primary repair. Improvements in biological augmentation and stem cell therapy are providing new options and hope for patients. 

 

Rotator cuff tendon tears may be so extensive that they cannot be repaired back to their original anchor point (insertion) on the humeral head. This may happen in a number of situations:

  • Acute (new) massive rotator cuff with tendon tissue loss
  • Chronic (old) massive rotator cuff tendon tear with fatty change to the muscle belly (due to disuse)
    • Usually these are missed tendon tears or tears that have been left untreated – rotator cuff tendon tears do not heal themselves – so the tear will increase over time. 
  • Failed surgical tendon repair
    • Re-injury to shoulder after surgery 
    • Tendon tissue weakness and suture cutout  
    • Anchor failure and loss of tendon fixation

Irreparable rotator cuff tears will result in loss of function and/or pain. 

Eventually an irreparable tendon tear will lead to shoulder joint arthritis – often referred to as rotator cuff arthritis (arthropathy).

This depends on a number of factors, such as: 

  • Age of the patient
  • Which tendons are irreparable (ie back, top or front) 
  • Which tendons remain and their quality
  • Occupation
  • Sporting demands
  • Other medical issues

The main surgical options currently are: 

  • Tendon repair with augmentation (biological patch/graft)
    • Involves using a biological patch/graft to reinforce the tendon repair to reduce re-tear rates 
  • Tendon transfer (lower trapezius, latissimus dorsi, pectoralis major) 
    • Another suitable tendon around the shoulder area is repurposed to restore the shoulder function that is lost 
  • Superior capsular reconstruction
    • A strong dermal allograft (donated tissue) or fascia lata autograft (your own tissue) is used to bridge the defect over the top of the shoulder where the rotator cuff has been lost 
  • Reverse shoulder replacement 
    • Shoulder joint function is restored by replacing the joint – the torn rotator tendons are not required for the “reverse” shoulder joint to function. 

There are three essential components to a good outcome from surgery

  •   Your surgeon
  •   You as a patient
  •   Your physiotherapist. 

Dr Pant utilises the JPL pathway for most patients and this will form the basis of your rehabilitation after surgery. 

The JPL pathway allows for self-directed, early passive shoulder range of movement: 

  •   Passive = assisted with your other arm
  •   Active = you move the affected arm independently

A sling will be required for at least 6 weeks after surgery. Depending on your procedure, you may require a sling for longer. 

Driving after shoulder surgery

  •  After shoulder surgery you will be in a sling and you will be unable to drive for at least 6 weeks. 
  • This does vary depending on the complexity of your surgery – some patients may be able to drive 12 weeks.
  • This will be individualised to your situation. 

Showering and getting dressed

  •  You may take the sling off to shower
  •  Lean forward and allow your arm to “dangle” to wash under your arms
  •  The dressings applied are waterproof and you may shower with them on
  •  Usually before you are discharged from Hospital, your dressings are changed after your morning shower.
  •  These “new” dressings are then kept intact until your review at 10-14 days
  •  When getting dressed, you may use your good arm to move your affected (operated arm) to place your arms through the sleeves carefully

 

Sleeping after Shoulder Surgery

  • Most patients find it difficult to lie flat after shoulder surgery.
  • Consider using a few pillows to prop yourself up and sleep at a slight incline; this may be necessary for 6-12 weeks after surgery.

Elbow and hand movement

  • Keep your elbow and hands joints moving and supple for the duration of time you are in the sling. The best time to move your elbow (into full extension and flexion) is when you are in the shower, just out of the shower and about to get dressed.

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. 

General risks: 

  • Infection
  • Bleeding
  • Wound healing problems
  • Damage to blood vessels or nerves
  • Sensory changes around the surgical scar

Specific risks relating surgery for an irreparable rotator cuff:  

  • Re-tear of tendon repair
  • Frozen shoulder
  • Avascular necrosis of humeral head
  • Bone infection around anchors

Patients who smoke, use tobacco products, have diabetes, or elderly are at higher risk of complications both during and after surgery. They are also more likely to have problems with wound healing. 

 

The surgical outcomes for an irreparable rotator cuff tear depend on many factors

  • Careful patient selection
  • Choice of surgical procedure 
  • Guided and consistent physiotherapy  

Depending on the choice of surgery the rehabilitation may be extensive. However, patients report an improvement in function and reduction in pain after surgery.

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