Arthroscopic shoulder surgery for the treatment of rotator cuff tears: why, when and how it is done.

Edited By: Christopher J. Wahl, M.D., Suzanne L. Slaney, PA-C, ATC, MMS
Last updated Tuesday, May 16, 2006

Figure 9a. Arthroscopic views of the repair of small to medium-sized rotator cuff tears. (A) A cuff tear as visualized from above.

Figure 9b. Arthroscopic views of the repair of small to medium-sized rotator cuff tears. . (B) A suture anchor has been placed in the bone at the rotator cuff attachment (red arrow), and the sutures have been brought out through the torn cuff edge (white arrows).

Figure 9c. Arthroscopic views of the repair of small to medium-sized rotator cuff tears. (C) The completed rotator cuff repair. The joint is no longer visible from above the rotator cuff.

Figure 10. The margin convergence technique of repair of massive rotator cuff tears (A-D). (A) A massive tear, retracted to the edge of the glenoid socket as viewed from above and to the rear of the shoulder joint. Note the cuff edge just above the blue suture.

Figure 10 - (B) One suture has been placed and tied (red arrow), and another has been placed (blue arrow).

Figure 10 - (C) As the sutures are tied, the rotator cuff is ?sewn shut? over the joint.

Figure 10 - (D) The completed cuff repair. Note that the joint surfaces are no longer visible.

About the procedure

Technical details

Rotator cuff repair, either arthroscopic or through a “mini-open” incision is a highly technical procedure; each step plays a critical role in the outcome.

After the patient is comfortably positioned in a seated position and anesthetic has been administered, the shoulder is given a sterile washed and draped for surgery. The surgeon begins by examining the shoulder while the patient is asleep or the shoulder relaxed so he or she can assess the relative stability of the joint, the range of motion, and feel for any abnormal grinding or catching of the joint. 

Next, one or two very small (1cm) incisions, or “portals” are made, usually one in the front and one behind the shoulder joint.  Through these small portals, hollow instruments called “canulas” are placed that irrigate the inside of the shoulder joint with sterile saline and “inflate” the joint with clear fluid.  The canulas allow the placement of an arthroscopic camera and specially designed instruments within the shoulder joint.

The surgeon maneuvers the camera around the joint while he or she watches a video monitor of what the camera “sees”.  A highly-skilled surgeon can evaluate all of the important structures within the joint, test their stability and integrity, and look for signs of ligament injuries, cartilage wear (or arthritis), and bony injuries that can be caused by or lead to shoulder instability or dislocation.  Most often, the surgeon will take photographs of the interior of the joint to help to explain to the patient what was found, and how it was corrected.  This portion of the surgery is called a “diagnostic arthroscopy” and is absolutely necessary to assure the success of any surgical procedure in the shoulder (even if an MRI had been obtained prior to the procedure).  This is because the arthroscopic examination of the joint is still the “gold standard”, or best way to understand ALL of the factors that could be present and may need to be addressed to treat the problem.

Once the surgeon understands what structures within the joint are injured or torn, he or she will choose the best possible surgical approach to treat the problem.  A highly-skilled surgeon who is comfortable with the anatomy of the joint and who has exceptional skills with specially-designed arthroscopic instruments and implants can usually address the problem without the need for large incisions.

For the most common type of rotator cuff tears, the tendon of the rotator cuff muscle called the supraspinatus will have torn and pulled back slightly from its normal attachment at the greater tuberosity atop the humerus.  These smaller tears which are “non-retracted” or “minimally-retracted” only need to be freshened or débrided back to stable, healthy tendon tissue, then mobilized back to the tuberosity and fixed in place.  (Figure 9)  When using an all arthroscopic technique, the surgeon will employ special devices called “suture anchors” to hold the tear in position when it heals.  These “anchors” can be made of metal or absorbable compounds.  They are screwed or pressed into the bone of the attachment site and the attached sutures are used to tie the edge of the rotator cuff in place. 

As tears become larger, they deform and the tendon tissue “shrinks”.  Thus, larger tears need to be refashioned, repaired side-to-side, or “zipped” closed using a technique called margin convergence.  This technique is analogous to zippering shut an open tent flap.  The rotator cuff tissue is freed from a scarred, retracted position and repaired side-to-side to ‘close the tent flap’ and restore the tissue over the top of the humeral head. (Figure 4), (Figure 10)  The repaired cuff tissue is then fixed to the site it originally tore away from using specially-designed implants called suture anchors.  These are metallic or absorbable plastic devices that secure sutures to the bony attachment.  The sutures are then sewn through the torn edge of the cuff to complete the repair. 

To avoid abrasion of the repaired cuff on the undersurface of the bony roof over the joint (called the acromion), most surgeons perform an arthroscopic acromioplasty—a technique to remove ‘bone spurs’ from above the repaired tissue.  Occasionally, the site where the end of the collar bone (clavicle) meets the roof over the shoulder is found to be arthritic.  If there are bone spurs below the clavicle, these can be removed using the arthroscope and special instruments as well. 

At the conclusion of the procedure, any incisions are closed using absorbable or removable sutures.  The patient’s shoulder is placed into a postoperative sling to protect the shoulder during the early postoperative period.

Absorbable “suture anchors” or implants are gradually absorbed and the sutures attached are incorporated into the healing tissues.  When metallic anchors are used (a matter of surgeon preference), these are buried in the bone, and do not affect the integrity of the bone or the shoulder joint.  Further surgery is NOT normally required to remove the suture anchors after healing. 

Anesthetic

Arthroscopic and traditional open shoulder stabilization procedures may be performed under a general anesthetic or under a regional block that makes the shoulder and arm numb during and for several hours after the procedure. The patient may wish to discuss their preferences with the anesthesiologist prior to surgery.

Length of arthroscopic rotator cuff repair and shoulder surgery

The procedure takes approximately 2 to 2 ½ hours, however, the preoperative preparation and postoperative recovery can easily double this time. Patients usually spend 1 or 2 hours in the recovery room.  Patients who undergo arthroscopic procedures almost always are comfortable enough to be discharged home.  Those undergoing more traditional open procedures may require one night’s hospitalization.

Surgery for Rotator cuff tears, arthroscopic, minimally-invasive and open management at the University of Washington

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