Surgical Management
Of Supraspinatus And Infraspinatus Rotator Cuff Tears
Most rotator cuff
tears occur by avulsion of the tendon from the tuberosity. In some cases there
is a remnant of tissue that remains on the tuberosity. This tissue is often very
degenerative and of poor quality and cannot be used to repair the tendon. This
tissue, if it is present at the time of surgery, is removed to create a fresh
bone bed for the reattachment of the rotator cuff tendon. The principles of
surgical repair are the same if the surgery is performed by traditional open
surgery or arthroscopic surgery.
In most cases, primary repair (first-time surgery) is performed by arthroscopic tech- nique because it is less invasive by not having to make a major incision or detach any portion of the deltoid muscle. As a result, the surgery is less painful, there is less tissue damage, and therefore there is no risk for damage to the deltoid or need to repair the deltoid and there is less risk of infection or postoperative shoulder stiffness. The view of the damage and tissues is better with arthroscopic surgery. Open surgery in most cases is now reserved for more complex rotator cuff reconstruction in patients with massive chronic tears who may benefit from muscle transfer surgery or augmentation with tissue grafts.
In most cases, primary repair (first-time surgery) is performed by arthroscopic tech- nique because it is less invasive by not having to make a major incision or detach any portion of the deltoid muscle. As a result, the surgery is less painful, there is less tissue damage, and therefore there is no risk for damage to the deltoid or need to repair the deltoid and there is less risk of infection or postoperative shoulder stiffness. The view of the damage and tissues is better with arthroscopic surgery. Open surgery in most cases is now reserved for more complex rotator cuff reconstruction in patients with massive chronic tears who may benefit from muscle transfer surgery or augmentation with tissue grafts.
The principles of primary rotator cuff
repair include mobilization of the tendon to remove scar tissue and any
contracture of the capsule so that the tendon can be pulled laterally from its
retracted position to the prepared bed
of the tuberosity. Sutures are passed either through the tendon using suture
anchors or through tunnels made through the bone through which the sutures in
the tendon are passed and then tied over a bone bridge. When suture anchors are
used, they are placed directly into the tuberosity bone and the sutures are
then passed through the tendon. In either case, when the sutures are tied, the
tendon edge is placed in direct approximation to the tuberosity. An anatomic
repair places the tendon back to the bone to cover the entire original
footprint of the tendon to bone. In many cases there are splits in the tendon
in the mediolateral direction such that sutures are also placed in the sides of
the tear, thus effecting a tendon-to-tendon repair.
Protection of the repair after surgery
avoids active motion of the shoulder, specifically any lifting, reaching,
pushing, or pulling for 6 to 12 weeks, depending on the size of the tear and
the quality of the tissues and repair. During this time, there is protection of
the shoulder in a sling or pillow brace to place the shoulder in approximately
20 degrees of abduction. This position takes some tension off of the repair
site. Postoperative shoulder stiffness (frozen shoulder) is minimized by close
postoperative evaluation of shoulder motion by the surgeon or other health care
provider over the first 2 months after surgery. Starting with passive range of
motion during the first 6 to 8 weeks from surgery, therapy is individualized
based on the size of the tear, quality of the tissues and repair, and amount of
stiffness that occurred over the first few weeks after surgery.
