Tuesday, September 20, 2011

Rotator Cuff 10 - Surgery for rotator cuff tears - repair

The decision to repair a rotator cuff tear requires consideration of a number of factors.

Is the tear acute and the result of a definite injury? In such a case, surgery deserves strong consideration in that repair is often most successful if performed soon after the tear occurs (say within a few weeks on months).

If the tear is chronic (long standing), are the symptoms related to weakness, to stiffness, or to catching and grinding? Has the shoulder had a good attempt at non-operative management to resolve these symptoms? (there is no rush for surgery when the tear is chronic).

Is it likely that the tear is reparable?

Is the patient prepared to avoid active use of the shoulder of the shoulder for three or so months while the tendon repair heals and remodels? Note that any active use of the arm with the elbow away from the side puts a load on the repair and many challenge its successful healing.

Should the repair be done with a mini open approach or using arthroscopic techniques? Here it is important to recall that the goal of repair is the secure reattachment of the torn tendon back to the bone from which it became separated, not the size of the skin incision. Here's the skin incision I use.

It almost always heals with a barely visible scar, even when appearance is very important, as in this man (can you see the scar?)

The surgeon should use the method that in that surgeon's hands yields the most secure repair. My personal preference now and for the last 40 years is for a mini-open approach that does not in any way compromise the deltoid muscle and that enables complete mobilization and secure repair of the tendon - to a groove in bone if necessary. Doing it securely the first time is the key for us. I also avoid shaving the acromion in that in my view there is no evidence that this improves the results on one hand and in that it adds unnecessarily to the procedure on the other.

So, in my hands the priorities in treating disorders of the rotator cuff are:
(1) to preserve the deltoid – our mini-open surgical approach is conducted through the superior ‘deltoid-on’ approach (which I will describe in more detail later).

(2) to assure smoothness of the humeroscapular motion interface – thus the upper aspect of the humerus and cuff must present a smooth convexity to articulate with the concave undersurface of the coracoacromial arch. All hypertrophic bursa and excrescences of the tuberosities are removed leaving a smooth proximal humeral convexity.
Sutures are placed so that the knots do not lie on the superior aspect of the cuff or tuberosity. "Top knots" (such as those shown below) are avoided. 

 (3) to maintain the normal mobility of the glenohumeral joint – thus limiting scar must be resolved and the cuff tendons must be released from the glenoid and coracoid if necessary before reattachment. 

(4) to assure an even distribution of tension on the cuff insertion spreading the load among multiple sutures – thus differential tightness at the area of cuff repair is avoided.

(5) to assure that if cuff tendon reattachment is performed, that it is sufficiently robust to heal and to allow early motion after surgery – thus multiple sutures securing the tendon edge into a bony trough are preferred. The trough excludes joint fluid from the repair site and allows for the possibility of some slip of the tendon while maintaining tendon to bone contact.


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