More Information on Rotator Cuff Surgery.

Last updated Wednesday, January 26, 2005

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

When cuff repair is possible

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.

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