Repair of Rotator Cuff Tears: Surgery for shoulders with torn rotator cuff tendons can lessen shoulder pain and improve function without acromioplasty.

Edited By: Frederick A. Matsen III, M.D., Winston J. Warme, MD
Last updated Tuesday, August 19, 2008

Considering surgery

Types of surgery recommended

When healthy tendons of the rotator cuff have been recently torn, it is often possible to perform a rotator cuff repair. When a repair cannot be accomplished because of insufficient tendon quantity and quality, the comfort and function of the shoulder are often improved by a "smooth and move" procedure in which the upper surface of the rotator cuff and the arm bone (humerus) are smoothed and immediate post-operative motion is used to prevent the reformation of scar tissue. Partial thickness cuff tears may be treated by detaching loose tendon fibers along with the "smooth and move" procedure.

A procedure known as acromioplasty has been advocated for the treatment of cuff disease. Recently, however, the routine use of this procedure has been questioned.

Who should consider rotator cuff surgery?

Rotator cuff surgery is considered for patients with either:

• acute tears of otherwise healthy tendons, or
• chronic tears that remain weak or painful after a gentle exercise program.

What happens without surgery?

Before cuff surgery is undertaken, the patient needs to:

1. be in optimal health,
2. understand and accept the risks and alternatives of surgery, and
3. understand the post-operative rehabilitation program.

In cases of chronic cuff tears, rotator cuff surgery can be performed whenever conditions are optimal. Sometimes the pain and stiffness from rotator cuff disease will stabilize at a level that is acceptable to the patient. In such cases the patient can delay surgery without compromising the potential for future surgery, as long as the surgeon monitors the cuff tear to make sure it is not enlarging. Sequential shoulder sonography is particularly useful in sequentially following the integrity of the cuff.

In the case of an acute rotator cuff tear in otherwise healthy tissue, the best chance of achieving an excellent result is surgical repair within the first month after the tear.

Rotator cuff surgery is not an emergency. If possible, acute rotator cuff tears should be considered for repair within the first month after the injury. Rotator cuff surgery in chronic cuff tears is an elective procedure that can be scheduled when circumstances are optimal. In both instances the patient has time to become informed and to select an experienced surgeon.

Surgical options

Several variations of cuff surgery are used to manage cuff tendon problems. One important goal of this surgery is to allow the smooth passage of the upper arm bone (humerus) beneath what is known as the coracoacromial arch. This is usually accomplished by removing scar tissue, chronic bursitis, bony prominences, and irregular tendon edges. The combination of this smoothing with immediate post operative motion is known as the "smooth and move" procedure. When there is sufficient quantity and quality of tendon tissue, the torn edge of the cuff tendon is anchored to the humerus from which it was torn, so that healing back to the bone can take place.

Some have advocated the repair of rotator cuff tears using shoulder arthroscopy. However, it is not clear that this more complicated approach has advantages over an expertly done direct open repair.

Others have suggested the use of various biological or artificial grafts or tendon transfers to bridge otherwise irreparable rotator cuff defects. The superiority of these complex procedures to the "smooth and move" procedure has yet to be demonstrated.

Effectiveness

In the hands of an experienced surgeon, rotator cuff surgery can effectively restore comfort and function to the shoulder of a well-motivated patient. Often, the greatest benefits are an improved ability to sleep on the affected shoulder and to perform usual activities of daily living. As long as the shoulder is cared for properly and subsequent injuries are avoided, the benefit can last for decades. However, it is important to recognize that surgery cannot improve the basic quality of the tendon tissue. Thus, repair of poor-quality tissue is often followed by recurrent tears.

Risks

The risks of rotator cuff surgery include, but are not limited to, the following:

• infection
• injury to nerves and blood vessels
• irreparability of the rotator cuff tendon
• stiffness of the joint
• re-tear of the repaired rotator cuff
• pain
• the need for additional surgeries

There are also risks associated with anesthesia. An experienced shoulder surgery team will use special techniques to minimize these risks, but cannot eliminate them completely.

Managing risk

Many of the risks of rotator cuff surgery can be managed effectively if they are promptly identified and treated.

Infections may require a "wash out" in the operating room and subsequent antibiotic treatment. Blood vessel or nerve injury may require repair. Stiffness may require exercises or additional surgery. Retear of the repaired rotator cuff may require consideration of additional surgery.

If the patient has questions or concerns about the course after surgery, the surgeon should be informed as soon as possible.

Repair of Rotator Cuff Tears

Surgery for rotator cuff tears at the University of Washington

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