What is the Rotator Cuff?
Rotator Cuff is a term which refers to four tendons that pass through the sub-acromial space of the shoulder. Each component tendon has its own name:
- Teres Minor
They are collectively called “The Rotator Cuff”. They blend into a hood-like structure that that is attached to the front, top and back of the head of the humerus. The direction that the head of the humerus moves within the shoulder joint socket is determined by which component of the rotator cuff is pulling the most. The tendons along with the bursa that lines their upper surface, pass backwards and forwards through the small space between the head of the humerus and acromion. This is called the Sub-Acromial Space.
What Causes Rotator Cuff Tears?
Rotator Cuff Tendon Tears develop in a number of ways. Multiple factors may be involved. Mechanisms include:
- Acute Injury such as a fall
- Repetitive Low Grade Injuries
- Chronic Shoulder Impingement
- Secondary to Shoulder Dislocation
- Occupational Tasks
- Sporting Activities
- Degeneration of Tendons with age
- Soft tissue Inflammatory Conditions
- Weakening effect of some Medications
- Any Combination of the above
When is Rotator Cuff Repair Necessary?
The symptoms and functional impairment of a rotator cuff tear may be mild and manageable simply with some common sense activity modification. Other treatments that may be applicable include anti-inflammatory medication, physiotherapy or a cortisone injection. If symptoms fail to respond, relapse or worsen, surgery may be considered. Factors such as the severity and duration of pain and degree of sleep disturbance due to pain are considered. Interference with ability to pursue leisure activities and employment duties is relevant. Larger acute tears may cause very significant and lasting shoulder weakness. Surgery may need to be considered with more urgency in such cases due to the fact that the torn tendon retracts and can be more difficult to repair.
What is Rotator Cuff Repair?
The goal of a Rotator Cuff Repair is the restore the anatomy of the torn rotator cuff tendons to as close to normal as possible. This provides the best chance of allowing the shoulder to obtain the best possible comfort and function if non-surgical treatments have failed. The tendon has usually come away from its attachment to the humerus. More rarely there may be a tear through the substance of the tendon itself.
Rotator Cuff Tendon Repair may be performed either with an Open Surgical Technique or an Arthroscopic Surgery. Although the technicalities of the 2 techniques are different the ultimate goal of the best possible shoulder comfort and function is the same. It is important to remember that although arthroscopic surgery uses smaller incisions the repaired tendon still needs to bond securely to the bone. This is a biologic process that cannot be accelerated by technique whether arthroscopic or open. Premature or aggressive rehabilitation also poses a risk of re-tearing of the tendon regardless of the surgical technique. Although Mr Lyons performs many arthroscopic rotator cuff decompression surgeries where the rotor cuff is intact, his preference in treating significant tendon tears is to use an open technique. He will discuss the pros and cons in this regard.
The area of the humerus where the tendon has torn away needs to be freshened. This will provide a healthy bed for tendon healing. The tendon is secured to the bone using a series of strong sutures or soft tissue anchors. Sometimes the extent of the tear or tendon tissue of poor quality means that only a partial repair can be achieved. In cases of more extreme tendon damage a debridement or clearance of the ragged tendon is required. This type of salvage procedure still has a good chance of achieving a more comfortable and functional shoulder.
An important part of rotator cuff repair is to make sure that the repaired tendon has sufficient room to pass under the acromion without catching. This is achieved by reshaping the underside of the acromion to prevent the repaired tendon catching under it. A tight band of tissue called the Coraco-Acromial Ligament is also released to prevent a rubbing effect on the tendon. Thickened portions of the sub-acromial bursa are also removed.
So in summary the key steps of a Rotator Cuff Repair are:
- Sub-Acromial Decompression (Acromioplasty)
- Sub-Acromial Bursectomy
- Coraco-Acromial Ligament Release
- Repair of Healthy Rotator Cuff Tendon
- Debridement of Non-Repairable Tendon
Patients undergoing arthroscopic rotator cuff surgery will usually stay in hospital overnight given that Mr Lyons performs all of his surgeries during an afternoon operating session. The more common open rotator cuff repair surgery that he performs usually requires a 2 night or rarely a 3 night stay in hospital.
Once the surgery pain is easing and the physiotherapist has instructed you on a gentle home based exercise program you can return home. It is recommended for the first 2 weeks after surgery you use a sling when out doors or travelling in a car. You will be able remove the sling at home for very light waist level activities. You will have a small dressing on your shoulder. You will be able to get it wet briefly in the shower and pat it to dry. You should not drive until you discuss this with Mr Lyons at your first post-surgery visit.
Mr Lyons will meet with you at his office approximately 2 weeks after surgery. Stitches will be removed. Depending upon your progress he will advise the next steps in your rehabilitation. You will start to use the sling less. Then you will gradually explore gentle every-day use of your shoulder.
You will meet with Mr Lyons about 6 to 8 weeks after surgery. It takes about this long for the repaired tendon to become strong enough to safely start a more formal program of stretching and strengthening exercises. This sometime requires additional guidance from the physiotherapist. Mr Lyons will advise if this is necessary. It can take as long as 3 or 4 months from the time of surgery before you are getting close to a peak recovery. Further gains in mobility strength and confidence can occur over even more months.
Risks and Complications
All surgery has potential risks and complications. There are general risks associated with any background medical conditions you have. Most shoulder surgeries are performed while you are under general anaesthetic. The anaesthetist will be mindful of potential hazards.
Mr Lyons will take all reasonable precautions to ensure your safety during and after your surgery. Risks and complications specific to Rotator Cuff Tendon Repair include:
- Wound Infection
- Local Bruising
- Nerve Damage
- Shoulder Stiffness
- Muscle Weakness
- Re-tearing of the Tendon
- Persisting Pain