Last Updated: Monday, February 4, 2013
This is the information which might be shared with patients as they consider rotator cuff repair. Before it can be applied to a specific clinical situation however it needs to be tailored to the patient the problem and the surgeon.
The rotator cuff
The rotator cuff is composed of four tendons that blend together to help stabilize and move the shoulder. Loss of the integrity of the rotator cuff is a common cause of shoulder weakness. Shoulders with large rotator cuff defects have difficulty raising the arm or rotating it out to the side. Strong rotator cuff tissue requires a major force to tear it. Weakened degenerative cuff tissue can be torn easily even while carrying out activities of daily living.
Surgery or non-operative treatment?
When rotator cuff tears are relatively recent and when a significant force was required to tear the tendon the chances of regaining shoulder strength by rotator cuff repair surgery are good. Conversely when the defect is long-standing and occurred without a major injury the quality and quantity of tissue available for repair may not be sufficient for the restoration of good shoulder function. Thus with long-standing shoulder weakness from rotator cuff defects a good try at strengthening the remaining muscles may be worthwhile before considering surgical repair. If surgery is undertaken proper postoperative care is particularly important.
Who should consider this surgery?
Surgical exploration and attempted cuff repair is an option for the patient who understands the limitations of this procedure. Prompt surgical exploration of the rotator cuff is considered for physiologically young patients with acute tears. Repair should be carried out before tissue loss retraction and atrophy occur. For tears older than 12 months a period of stretching and gentle strengthening exercises can indicate the potential for nonoperative management. Exploration is considered for patients with functionally significant weakness from longer-standing tears refractory to nonoperative management provided that their expectations are realistic.
About the surgery
The goal of cuff repair surgery is to improve the strength and muscular balance of the shoulder. This operative procedure is considered when the shoulder demonstrates weakness from a cuff defect and when there appears to be a substantial chance of achieving a durable functional repair. These conditions are most likely met in a traumatic tear where a physiologically sound cuff has been torn acutely by a substantial injury. In this situation the quality and quantity of tendon for repair should be excellent. By contrast with chronic massive degenerative tears the quantity and quality of the cuff are less likely to be optimal for surgical repair. In this situation the surgeon and the patient must understand preoperatively the potential limitations imposed by the tissue in the shoulder.
It must be remembered that there are several ways in which surgery may worsen the function of a cuff-deficient shoulder. These need to be reviewed before each cuff operation. The most serious is compromise of the deltoid muscle. The deltoid may be compromised by nerve injury. This injury may involve the intramuscular motor branches to the anterior third of the muscle resulting from a too-distal split of the muscle in the surgical approach. Deltoid denervation may also arise from axillary nerve injury when searching for cuff tendons laterally and posteriorly around the quadrangular space. Normally the deltoid has a strong tendon of origin between its anterior and middle thirds. This tendon attaches to the anterior lateral corner of the acromion. Postoperative function of the deltoid may be compromised by failure to achieve a strong reattachment of this tendon and the anterior muscle fibers after acromioplasty. This is particularly a problem when a large anterior acromial resection is performed requiring stretch of the deltoid for reattachment. Failure of the anterior deltoid origin devastates the most important motor for shoulder elevation.
Figure 1 - The tendon near the deltoid is split longitudinally Scarring in the humeroscapular motion interface (see Chapter 2) between the acromion and deltoid and the cuff and humerus can restrict humeroscapular motion negating any benefit achieved from restoring cuff integrity. This complication results from immobilization of the cuff against the acromion and deltoid after surgery.
Loss of superior stability can result when the coracoacromial arch is sacrificed without reestablishing stability with a durable cuff repair. In this situation deltoid contraction pulls the head of the humerus anterior superiorly rather than elevating it. The deltoid becomes stretched so that the humeral head seems to be just below the skin. Patients who lose stability and deltoid function are some of the most unhappy we encounter after previous repair attempts. Primum non nocere (first of all do no harm).
Not all surgical cases are the same, this is only an example to be used for patient education.
Surgical technique
The cuff is approached though an acromioplasty incision in the skin lines perpendicular to the deltoid fibers. This incision offers an excellent exposure and the opportunity for a cosmetic closure particularly in comparison with the skin incisions parallel to the deltoid fibers. Great care is taken to preserve the tendon fibers of the deltoid origin to permit a strong repair. The deltoid has an important tendon of origin between its anterior and middle thirds. Arising from the anterior lateral corner of the acromion this tendon is not only the guide to exposure of the cuff but is also the key to reattachment of the deltoid origin at the conclusion of the surgery. This tendon is split longitudinally for 2 cm distal to the acromion in line with its fibers taking care to leave some of the tendon on each side of the split. The split is continued up over the acromion and into the trapezius insertion. For 1 cm on either side of this split the deltoid origin is sharply dissected off the acromion so the strong bony attachment fibers remain with the muscle. These fibers provide a strong "handle" on the muscle so a solid repair can be achieved. Splitting the parietal layer of the bursa on the deep aspect of the deltoid provides a view of the rotator cuff. Before a "reflex" acromioplasty is performed the quality and quantity of the cuff tissue are observed to determine the likelihood of cuff reparability. Hypertrophic bursa and scar tissue are resected to allow a good view of the cuff tissue. We characterize cuff tears using a simple system based on the number of tendons torn. In Type 1 only one tendon (almost always the supraspinatus) is torn. In Type 2 two tendons (usually the supraspinatus and infraspinatus) are torn. In Type 3 the supraspinatus infraspinatus and subscapularis are torn. Type 1 is broken down into Type 1A-a partial thickness-tear and Type 1B-the full thickness tear confined to a single tendon. We judge the quality of the cuff tissue in terms of its ability to hold a strong pull applied to a suture passed through its edge. Finally it is critical to note the amount of tissue that has been lost. The extent of tissue loss and the ability of the remaining tissue to hold suture are the major determinants of cuff reparability. If there is major tissue loss and residual tendon of poor quality it becomes evident that a robust repair cannot be performed.
A smoothing operation may be performed
In this situation where primary stability from an intact cuff cannot be restored it is important not to perform a routine acromioplasty which would jeopardize the secondary stabilization offered by the coracoacromial arch. Under these circumstances sacrifice of coracoacromial arch support deprives the shoulder of its last vestige of superior stability allowing anterosuperior "escape" of the humeral head when elevation is attempted.
For this reason when a strong rotator cuff repair is impossible as a result of the limited quantity and quality of the residual cuff tissue we do not perform a routine acromioplasty. Instead we perform only a smoothing of the undersurface of the coracoacromial arch to allow unimpeded passage of the humeral head and residual cuff beneath. Any debris scar or thickened bursa in the subacromial area is excised. It is often helpful to smooth the upper surface of the uncovered proximal humerus particularly if the uncovered tuberosities are prominent or irregular.
A strong repair of the deltoid to the acromion is then carried out (see figure). Depending on the quality of the tissues this may be accomplished by a side-to-side repair of the surgical split in the deltoid tendon and trapezius fascia. Drill holes in the acromion are used as necessary for secure reattachment. The full thickness of the deltoid including the deltoid side of the bursa is incorporated in the sutures to be certain that it does not impede smooth motion in the humeroscapular motion interface.
A subcuticular skin closure reinforced with paper tapes provides optimal cosmesis. The patient is returned to the recovery room with the arm in continuous passive motion from zero to 90 degrees of flexion to minimize the tendency to form adhesions in the humeroscapular motion interface.
The postoperative management must be tailored by the surgeon to match the patient and the surgery. Often the patient is taught passive mobilization of the shoulder to 140 degrees of elevation and 40 degrees of external rotation and is discharged when these goals are achieved comfortably. Light use of the shoulder with the arm at the side is allowed as comfort permits. Sling immobilization is unnecessary. Strengthening of the deltoid and residual cuff muscles is started six weeks after surgery. The best exercise we have found for optimizing active elevation is the progressive supine press (see figure). In this exercise small increments are used to train the remaining muscles to optimal advantage. Note that the scapular muscles are also put to work in these exercises.
Figure 2 -
Strong repair of the deltoid
Figure 3 - Progressive supine press
When a massive cuff defect coexists with a detached denervated or dysfunctional deltoid the shoulder is without effective glenohumeral motors.
Salvage option
Under these circumstances a glenohumeral arthrodesis provides a salvage option. By securing the humeral head to the scapula the scapular motors can be used to power the humerus through a very limited range of humerothoracic motion. We prefer a fusion technique which preserves all remaining deltoid function and which uses decortication of the humerus and glenoid 6.5 mm compression screws across the joint with or without a neutralization plate from the scapular spine across the joint and down the humeral shaft.
Figure 4 -
Position of fusion
The best candidates for this procedure are those patients with:
- permanent and severe weakness due to loss of cuff and deltoid function;
- a good understanding of the limitations and potential complications of a shoulder fusion;
- intact scapular motors;
- good motivation; and
- minimal complaints of pain.
To establish the limitations of shoulder fusions we studied the humerothoracic motion of twelve patients who had glenohumeral arthrodeses at least two years prior to the time of study. Elevation in the plus 90 degrees (anterior sagittal) plane averaged 47 degrees. Elevation in the minus 90 degrees (posterior sagittal) plane averaged 22 degrees. External rotation averaged 9 degrees and internal rotation 46 degrees. These ranges of motion were similar to the scapulothoracic motion measured in normal subjects. Only one of the patients could reach his hair without bending his neck forward only five could reach their perineum six could reach the back pocket seven the opposite axilla and ten the side pocket.
We studied normal in vivo shoulder kinematics to predict the functions which would be allowed by various positions of glenohumeral arthrodesis assuming that the scapulothoracic motion would remain unchanged. Using the normal scapulothoracic motions we were able to model the functional effects of fusion positions (reported in relation to the thorax). We found that activities of daily living could be best performed if the joint was fused in 15 degrees of flexion 15 degrees of abduction and 45 degrees of internal rotation. This position of fusion with a low angle of elevation and relatively high degree of internal rotation facilitated reaching the face opposite axilla and perineum (see figure). However all positions represented major compromises of normal function.
If inspection of the cuff at surgery reveals good quality tissue in sufficient quantity for a robust repair primary glenohumeral stability from concavity compression can usually be restored.
Standard anteroinferior acromioplasy
Thus a standard anteroinferior acromioplasty is performed to improve exposure and to protect the repair from abrasion. A flexible osteotome is directed so that the anterior undersurface of the acromion is resected in the same plane as the posterior acromion. Rough spots are smoothed with a motorized burr (see figure 5).
The goal of repair is a strong fixation of the tendon to the humerus under normal tension with the arm at the side. The desired attachment site is at the sulcus near the base of the tuberosity. This goal is facilitated by using three stages of sequential release. These releases are required because the cuff is usually retracted and because tissue is lost in chronic cuff disease. Unless these releases are carried out increased tension in the repaired tendon will predispose to tightness of the glenohumeral joint and will additionally challenge the repair site. The humeral head is rotated to present the different margins of the cuff defect through the incision rather than enlarging the exposure to show the entire lesion. The deep surface of the cuff is searched for retracted laminations. All layers of the cuff are assembled and tagged with sutures.
By applying traction to these sutures the cuff is mobilized sequentially as necessary to allow the torn tendon edge to reach the desired insertion at the base of the tuberosity. First the humeroscapular motion interface is freed between the cuff and the deltoid acromion coracoacromial ligaments coracoid and coracoid muscles. Next the coracohumeral ligament/rotator interval capsule is sectioned around the coracoid process to eliminate any restriction to the excursion of the cuff tendons and to minimize tension on the repair during passive movement (see figure 6). This release of the coracohumeral ligament and rotator interval capsule also contributes to the comfort and ease of motion after the surgical repair by minimizing the capsular tightening effect of cuff repair. At this point the ease with which the cuff margins can be approximated to their anatomic insertion at the base of the tuberosity is evaluated. If good tissue cannot reach the sulcus the third release is carried out. This release divides the capsule from the glenoid just outside the glenoid labrum (see figure 7) allowing the capsule and tendon of the cuff to be drawn further laterally toward the desired tuberosity insertion without restricting range of motion.
After the necessary releases have been completed a judgment is made concerning the site at which the cuff can be implanted into the bone without undue tension while the arm is at the side. Ideally the site of implantation will be in the sulcus at the base of the tuberosity. In large cuff defects a somewhat more medial insertion site may be necessary. Often when a medial insertion site is required for a large cuff defect the new insertion lies in an area where the articular cartilage has been damaged by abrasion against the undersurface of the acromion.
The repair is accomplished as a tongue in groove (see figure 8) with the cuff tendon drawn into a trough near the tuberosity providing a smooth upper surface to glide beneath the acromion. This groove provides the additional advantage that if some slippage occurs in the suture fixation of the cuff to bone contact between the tendon and bone is not lost. Nonabsorbable sutures passed through the tendon margin are then passed through drill holes in the distal tuberosity (see figure 9) so that the knots will not catch beneath the acromion. The knots are tied over the tuberosities so that they will lie out of the subacromial space. If there is a longitudinal component to the tear it is repaired side-to-side with the knots buried out of the humeroscapular motion interface. The repair is checked throughout a range of motion to 140 degrees of elevation and 40 degrees of external rotation to assure that it is strong it is not under excessive tension and it will permit smooth subacromial motion. If additional resection of the undersurface of the acromion is required to allow smooth passage of the repaired tendon it is performed at this time.
After a careful and robust deltoid repair using nonabsorbable sutures and cosmetic skin closure the patient is returned to the recovery room.
The postoperative management must be tailored by the surgeon to the patient and the procedure. We often place the affected arm in zero to 90 degrees of continuous passive motion (see figure 10). Immediate postoperative motion is valuable because there is a tendency for scarring between the raw undersurface of the acromion and the upper aspect of the rotator cuff or proximal humerus. Immediate postoperative continuous passive motion is facilitated if the surgery is performed under a brachial plexus block which provides analgesia for up to 18 hours after surgery. Continuous passive motion is continued for up to 48 hours after surgery but does not appear to be necessary after that. The patient is expected to perform passive exercises in flexion and external rotation. Before discharge the patient should be able to attain comfortably 140 degrees of passive flexion and 40 degrees of passive external rotation. A progress chart mounted on the patient's wall helps to document progress toward these discharge goals (see figure 11).
Postdischarge management must consider the magnitude of the tear and the strength of the repair. It is unlikely that the repair will have substantial strength until at least three months after surgery. As is the case with repairs of the anterior cruciate ligament major cuff repairs may require six to twelve months to regain useful strength. Thus in the first several postoperative months the emphasis is placed on maintaining passive motion and avoiding loading of the repair.
Figure 5 -
Rough spots are smoothed
with a motorized burr
Figure 6 -
Minimizing tension on the repair
Figure 7 -
Release dividing the capsule
from the glenoid
Figure 8 -
Tongue in groove repair
Figure 9 -
Drill holes in the distal tuberosity
Figure 10 - Continuous passive motion
Figure 11 - Progress chart
Partial thickness defects of the cuff may manifest clinically as the inability to use the cuff forcefully against resistance by pain on isometric abduction or external rotation (a positive "tendon sign") or by crepitance with rotation of the partially elevated arm (a positive "abrasion sign").
Partial defects
These partial defects are more likely to be associated with shoulder stiffness than larger full thickness defects because the larger defects in the cuff provide the equivalent of a capsular release. Nonoperative management must emphasize stretching in internal rotation cross-body adduction and elevation. When a comfortable normal range of passive motion is reestablished gentle progressive strengthening of the cuff muscles is instituted. An emphasis is always placed on gentle and comfortable progress of this rehabilitation program.
Figure 12 -
Consolidating split
laminations of cuff
In many respects the treatment of a partial cuff tear is analogous to the treatment of a partial Achilles tendon tear or tennis elbow. The functional deficits are likely to be related to tension on a partially torn tendon. Treatment requires first stretching and then gentle strengthening. Surgery is usually considered only if symptoms persist in spite of regaining normal passive motion and if the patient is prepared for an extended recovery period.
In planning surgical management for refractory problems from partial thickness tears it must be determined if the patient's functional deficits are related to tension on a partially torn tendon as indicated by a positive tendon sign. In this case completion of the detachment and reattachment as for a full thickness tear may be necessary. This procedure will tighten the shoulder and is not a suitable treatment for a contracted shoulder. Alternatively the symptoms may be related to secondary subacromial abrasion from the slight superior instability resulting from the tendon defect as well as the associated thickening of the intervening bursa. Under these circumstances the abrasion sign (rotating the partially elevated arm beneath the coracoacromial arch) should reproduce the patient's symptoms. In the second instance an anterior inferior acromioplasty and bursal resection may be of benefit as long as normal shoulder flexibility has been restored to eliminate the effect of a tight posterior capsule. Anterior acromioplasty does not treat shoulder stiffness which must be eliminated by exercises or by surgical releases.
The decision to complete a partial thickness cuff defect may be influenced by surgical findings. The thickness of the cuff can be determined at acromioplasty by inspection for superior surface defects. For deep surface or intratendinous lesions the cuff thickness is determined by palpation by injecting saline or dilute methylene blue solution in the joint or by using a depth gauge or calibrated nerve hook. A tenotomy can also be performed in the most suspicious area along the line of the tendon fibers to explore the full thickness of the tissue. If as is usually the case the defect is near the anterior insertion of the supraspinatus a longitudinal tenotomy and capsulotomy are performed along the anterior aspect of the supraspinatus in the rotator interval capsule. This cut is then extended at right angles posteriorly through the partially detached cuff at its insertion to the greater tuberosity turning back the flap of cuff until tendon of full thickness is encountered. Next an attempt is made to retrieve and consolidate any split laminations of cuff which may have retracted medially (see figure 12). These are usually on the deep articular surface where the cuff lesion begins and may have retracted medially up to 1 cm. Release of the coracohumeral ligament and rotator interval capsule from the base of the coracoid will minimize tension on the repair. Then the full thickness defect is repaired in the manner previously described. The shoulder is then put through a full range of motion to verify that the acromioplasty is adequate to protect the repaired tendon from acromial abrasion.
Postoperative management is tailored by the surgeon for the patient but often is the same as for the full thickness defects.
Patients are usually pleased with the results of cuff surgery. Yet it may be difficult to determine what aspect of the treatment program is responsible for the improvement.
Cuff integrity and quality of result of surgery
It is known that many patients with deficient cuffs are surprisingly comfortable and functional and therefore never undergo surgery. It is also known that the tissue encountered at surgery is not infrequently insufficient to allow a durable repair yet the patient is improved after surgery. These observations bring up the question of the relationship of cuff integrity to the quality of the result after cuff surgery. To help answer this question we undertook a study of 105 of our own surgical repairs of chronic rotator cuff tears in 89 patients at an average of five years postoperatively. The patients' ages at the time of repair averaged 60 years (range 32 to 80). Eighty-six (82%) of the shoulders had no prior attempt at repair of the cuff.
In all of the surgeries an anterior-inferior acromioplasty was carried out. The involved tendon or tendons were mobilized as necessary. A bony trough was created in the humerus to reattach the mobilized tendons. The site of reattachment was usually in the sulcus adjacent to the humeral articular surface. In some cases the trough was placed somewhat more medially if after mobilization the tendons did not reach their original anatomic attachment without undue tension when the arm was at the side. The cuff was protected from active use for three months postoperatively.
We correlated the functional result with the integrity of the cuff as determined by expert ultrasonography. Expert ultrasonography was selected because of its superior accuracy to cost ratio and practicality.
We characterized the status of the cuff at surgery and at follow-up in terms of the integrity of the different tendons. No patient who had a partial thickness tear repaired had a full thickness retear. In 80 percent of shoulders with repaired full-thickness supraspinatus tears the cuff was found to be intact at follow-up. Only 57 percent of cuffs that had tears involving both the supraspinatus and infraspinatus were intact at an average follow-up of six years. Less than one-third of the cuffs which had tears involving all three major tendons were intact after repair at an average of four years of follow-up. It is evident therefore that the rotator cuff is more likely to develop a secondary defect after the repair of a large tear. This may be a reflection of the age of the patient the quality of the tissue the quantity of tissue the effect of tendon mobilization on tendon viability or the greater difficulty in getting healthy tendon securely implanted in bone when there is a major deficiency in the cuff.
Figure 13 -
Active flexion as a function
of cuff integrity at followup
Figure 14 -
Ability to perform activities
of daily living as a function
of cuff integrity at followup
Figure 15 -
Active flexion of the shoulders
in which the repaired cuff was intact
Patients were generally satisfied with the results of surgery even when expert sonography showed that the cuff was no longer intact. This result indicates that patient satisfaction is not a reliable indication of cuff integrity.
Shoulders with intact repairs at follow-up had the greatest range of active flexion as compared to those with large recurrent defects (see figure 13). These patients also demonstrated the best function in activities of daily living. Where the cuff was not intact the degree of functional loss was related to the size of the recurrent defect (see figure 14). These results indicate that integrity by ultrasound correlates with cuff function.
Patients with intact repairs of large tears had just as good function as did those with intact repairs of small tears. We found an overall greater incidence of recurrent defects in shoulders with repeat repairs. However shoulders with intact cuffs after repeat repairs functioned as well as did those with intact primary repairs (see figure 15).
From this study we concluded that the integrity of the rotator cuff at follow-up (and not the size of the tear at the time of repair) is the major determinant of the outcome of surgical repair. An intact repair of a recurrent tear is likely to yield a result comparable to that of an intact repair of a primary tear. Likewise intact repairs of large tears yield results comparable to intact repairs of small tears.
The chances of the repair of a large tear remaining intact however are not as good as those for a small tear. Older patients tended to have larger tears and to have a higher incidence of recurrent defects.
These are typical instructions given to a patient after a rotator cuff repair. However the program will vary with the surgeon the patient and the repair. If you have had such a repair only your surgeon can give you instructions on the postoperative management. Do not do any exercises after surgery except after consultation with your physician.
Healing period
After a cuff repair the tissue remains quite weak until your body has time to complete the bonding of the tissue to bone. This may require as much as six months. Use of the arm before the healing is complete can cause the repair to fail. On the other hand immobilizing the shoulder for a long period of time to protect the repair can cause shoulder stiffness. For these reasons careful postoperative rehabilitation is an essential part of your surgery. Because each patient and each surgery are different it is essential that the postoperative management be tailored by the surgeon to meet the patient's individual situation.
Rehabilitation program
There are two aspects of the rehabilitation program: preventing unwanted scar formation and protecting the repair.
Protect your repair by being careful that your arm does not participate in lifting pushing or pulling and that it is not raised away from the side under its own power. Unless we tell you otherwise you may use your hand for typing or writing as long as the elbow is kept at your side. Raising the arm even a small amount places demands on your repair and should be avoided. We will tell you how long these restrictions need to be in effect. During this time you should not drive!
Figure 16
Figure 17
While your shoulder is healing passive motion is necessary to prevent unwanted scar tissue formation. Passive motion means that the shoulder is moved but not under its own power. These exercises must be comfortable for you--if you have problems doing them comfortably let your doctor or therapist know. Your operated shoulder is moved by your other hand while the muscles of the operated shoulder are completely relaxed. You can move your shoulder passively by standing up and bending over at the waist allowing the operated arm to dangle down in a relaxed way. Passive motion is also easily done while you are lying on your back. Grasp the arm of your operated shoulder with the opposite hand and slowly help the arm up to a vertical position and then over your head (see figure 16). On lowering it back down you will need to concentrate on keeping the operated shoulder completely relaxed.
A second exercise is performed while you are lying down with both your elbows bent to a right angle. Using a cane or dowel or yardstick gently push the wrist of the operated shoulder out to the side while keeping your elbow at the side (see figure 17).
These precautions against active use and the passive motion exercises are continued until your surgeon tells you it is time to start the next phase of exercises. Please do not change your program just because it seems time to do so. If you have any questions please let your doctor know.
