More Information on Rotator Cuff Surgery.
Last updated Wednesday, January 26, 2005
Figure 2 - Strong repair of the deltoid Figure 3 - Progressive supine press When cuff repair cannot be achieved
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.
How useful was this page or article?
|
|