Traditionally, surgical repair of a torn rotator cuff has been performed through an open or mini-open approach which requires a 1.5 to 4cm. incision, with a slow recovery period and considerable post-operative pain. For patients at HSS, however, and at selected institutions throughout the country, arthroscopic repair, which involves performing the same procedure but with a minimally invasive technique, is making a dramatic difference in comfort while yielding excellent results. According to John D. MacGillivray, MD, an assistant attending orthopaedic surgeon at HSS, many individuals with rotator cuff disease do not require surgical treatment, but when surgery is indicated most patients are eligible for arthroscopic repair of rotator cuff tendon tears.
Rotator cuff tears
"For many years, an open surgery was the only option available," explains Dr. MacGillivray. "But in the early 1990s some orthopaedic surgeons began performing mini-open procedures, in which a smaller incision was made, and the repair performed with the aid of arthroscopy." The technique provided a better view of the area while minimizing the trauma to the deltoid muscle that overlies the shoulder joint. By the late-1990s, shoulder surgeons at HSS, with the benefit of smaller instruments and enhanced techniques, began doing the entire procedure arthroscopically. "Improved instrumentation has facilitated arthroscopic rotator cuff repairs and the degree of post-operative pain is dramatically diminished," he remarks. Specialists experienced in this technique, such as Dr. MacGillivray, can perform a very high percentage of rotator cuff repairs arthroscopically.
Arthroscopic rotator cuff repair is done as an ambulatory procedure under regional anesthesia, with patients able to return home the same day. Arthroscopy of the glenohumeral joint (the ball and socket portion of the shoulder joint) is performed to identify and treat other associated problems, such as biceps tendon injury, loose bodies, or a torn labrum (a rim of cartilage that surrounds the glenoid, the cup portion of the shoulder joint). A partial rotator cuff tear (<50% tear of the thickness of the rotator cuff tendon) can be trimmed with a shaver at this time.
The arthroscope is then placed in the subacromial space and a subacromial decompression is performed, a procedure that involves opening up the space in which the rotator cuff tendon passes. This procedure involves removing a bone spur and irregularities on the underside of the acromion (the roof of the shoulder) which can be a cause of rotator cuff irritation and tearing. The torn tendon is then reattached to the bone with the use of suture anchors and sutures.
"As a result of advances in arthroscopic suturing techniques, we've become more aggressive in treating rotator cuff tears," says Dr. MacGillivray. "Most patients will still initially undergo a trial of physical therapy to see if surgery can be avoided, but for those who do not respond, we recognize the value of initiating surgery sooner rather than later," he adds. Delaying surgery in patients who need it can result in progression of a partial tear to a full tear, the propagation of a small tear to a larger one, fatty infiltration of the damaged tendon and muscle, and muscle atrophy and weakness.
According to Dr. MacGillivray, even those patients with very large tendon tears may benefit. "In some cases, using a technique called margin conversions, we are able to cover the humeral head with grafted tissue to hold the tendon's place in the joint. When the tendon tissue is insufficient for direct repair, we place a patch of donated tissue in the area." When these tissue grafts are required shoulder surgeons usually perform a mini-open repair.
Factors that affect the outcome of surgery include the age of the injury-in long-standing tears the tendon tissue may be quite thin and retracted-and the quality of the bone to which the torn tendon must be anchored. When either is weakened, sutures may not hold.
The reduction in discomfort notwithstanding, Dr. MacGillivray cautions patients that recovery from arthroscopic rotator cuff surgery is not dramatically different from open surgery. "The biology of healing of tendon to bone is the same and, depending on the quality of the tissue, healing can take 6 to 10 weeks." Because patients may feel well quickly, it's particularly important that they exercise care in protecting the joint during the healing period. Shoulder surgeons prescribe a very specific and detailed rehabilitation program following surgery which must be strictly followed. Generally this includes wearing a sling for the first two to three weeks, and participating in a physical therapy program that begins one week after surgery and typically lasts for three to four months. Strengthening exercises begin after the 6-10 week healing period; after 12 weeks the patient may return to most activities, but participation in vigorous sports may be restricted for four to six months.
While arthroscopic surgery does represent a viable option for many patients with rotator cuff injury, some considerations can make a person ineligible. These include a long-standing tear accompanied by arthritic changes, previous infection, and nerve or muscle damage.
Looking to the future, Dr. MacGillivray anticipates that advances will make arthroscopic repair possible in more complex rotator cuff tears, and he advises individuals who are interested in arthroscopic surgery to seek out an orthopaedic surgeon who is well-versed in the technique. Dr MacGillivray points out, "As with any other surgery, the more you do, the better you get."
Summary Prepared by Nancy Novick Images 1, 2, 3 provided courtesy of Russell F. Warren, MD