Rotator Cuff

Background:

The shoulder is perhaps the most complicated joint in the body.  It is really a set of four joints, including the SCJ (sternoclavicular joint: articulation of the collar bone with the breast bone), ACJ (acromioclavicular joint: collarbone to shoulder blade), GHJ (glenohumeral joint: ball-and-socket joint), and STJ (scapulothoracic joint: where the shoulder blade glides on the chest wall).  The purpose of the shoulder is to allow a great deal of range of motion to facilitate positioning of the arm and hand.  Stability is a subservient concern, hence, the predilection of instability problems in the shoulder joint complex.  This is especially evident in the GHJ.

The GHJ is a “ball and socket” type joint, very much like a golf ball on a tee.  The socket is very shallow deepened slightly by the addition of a thin rubbery peripheral lining called the labrum.  There are some thickenings in the lining of the shoulder joint that resemble ligaments, but these are not always robust.  The critical factor for stability is the rotator cuff, a set of four muscles and tendons attached to the margin of the humeral head.

Rotator Cuff Disease:

Rotator cuff disease encompasses a spectrum of problems which are, to a large degree, age-dependent processes.  In patients in the 4th decade of life, inflammatory conditions such as bursitis and rotator cuff tendonitis predominate.  In the 5th decade, the cuff begins to show signs of tendinosis, or degeneration.  Typically in the 6th decade, frank cuff tears are seen more commonly.  Of course, there may be overlap, and tears can be seen at any age, especially after trauma. 

Rotator Cuff Evaluation:

The rotator cuff is evaluated in the same and usual clinical manner that health care professionals use for any orthopedic condition: a history, physical exam, X-rays, and occasionally by MRI, with or without contrast injection.

Management of the Acute Injury:

Initial management of the recent cuff injury includes:  rest with a sling, ice, and prevention of reinjury.  Return to sports and activity generally can occur with several weeks or months as pain subsides and motion and muscle function is recovered, however, A SIGNIFICANT RISK OF RECURRENT INJURY IS THE RULE.

Rehabilitation is useful for all types of cuff injury.  This means relative rest, range of motion and stretching exercises to restore flexibility, and low resistance high repetition strengthening exercises to restore cuff strength.  These are best accomplished with the aid of a physical therapist experienced in the care of rotator cuff disease and injury.

Cuff Tear:  Surgical Treatment

Surgery is designed to repair the tear, if possible, and also to remove any bone spurs along the overlying acromial roof (decompression, or acromioplasty). It can be done either using an arthroscope and small incisions, or via a formal open approach.  In either case, it is an outpatient one-day surgical procedure.

The surgery has several basic steps:

1- assessment of the glenohumeral joint and undersurface of the cuff, 2- assessment of the bursa and upper cuff surface, 3- decompression (acromioplasty), 4- preparation of the attachment site on the humerus and adjacent cuff tendon, 5- repair of the cuff, either tendon-to-bone (end-to-bone), or tendon-to-tendon (side-to-side), or a combination of both techniques.

1- assessment of the glenohumeral joint and undersurface of the cuff:

View of the undersurface of the rotator cuff tendon in the glenohumeral shoulder joint from the posterior (back) portal with a shaver inserted via the anterior (front) adjacent to the long head biceps tendon.  The supraspinatus cuff tendon is right of the shaver, while the humerus is to the left.

2- assessment of the bursa and upper cuff surface:

View of the upper surface of the rotator cuff tendon  from the lateral (side) portal with a probe inserted.  The supraspinatus cuff tendon has an abraded, roughened appearance, from impingement against the overlying acromial spur….

…seen here above a cautery tool, inserted via an anterior (front) portal.  The spur is covered by soft tissue, itself also rough from impingement against the top of the cuff.  The cautery tool is used to remove this soft tissue and thereby expose the undersurface of the acromial spur in preparation for its removal, in order to eliminate or reduce impingement.

View from the lateral portal.  The spur is now visible, and can be removed with a burr.

3- decompression (acromioplasty):

View of bursa of left shoulder looking from lateral portal, with burr in posterior portal, commencing acromioplasty, i.e.- resection of the spur overlying the upper cuff surface.

View of bursa of left shoulder looking from lateral portal, with burr in posterior portal, continuing acromioplasty.  A flatter profile is the goal…

…and is confirmed with a probe inserted from the rear portal.

The deltoid muscle/tendon origin from the leading edge of the acromion is left undisturbed.

4- preparation of the cuff and insertion site for repair:

The cuff tear is seen in the bursal space from the lateral (side) portal and can be inspected and debrided.

View in the bursa of left shoulder looking from posterior portal, with shaver in lateral portal, debriding the edges of the supraspinatus tendon surrounding the tear, as well as the bone “footprint”, i.e.- prospective attachment site..

View in the bursa of left shoulder looking from posterior portal, with biting forceps in lateral portal, more aggressively debriding the edges of the supraspinatus tendon surrounding the tear.

View of bursa of left shoulder looking from posterior portal, with grasping forceps in lateral portal, assessing the mobility of the prepared cuff edge to the freshened humeral bone insertion site.

5A- repair of the cuff, tendon-to-bone (end-to-bone):

View of bursa of left shoulder looking from posterior portal.   A screw-in implant with preattached sutures is inserted into the humerus through a separate lateral portal just lateral to the cuff insertion area…

…and is advanced into the bone…

…until countersunk below the surface…

…and then tested by pulling vigorously on the sutures to ensure adequate purchase.

View is now from lateral portal again.  A pair of color-coded sutures protrudes from the anchor hole, and will now need to be passed through the free margin of the cuff tendon to repair it back to the humeral surface.

A strand of each suture pair is passed using a suture passage tool, first anteriorly (forward)…

…and then posteriorly (in the rear of the cuff)…

…and then each pair is tied using an arthroscopic knot-tying technique using a knot-pushing tool through a clear cannula.

The knots are completed and the repair is complete, with the cuff edge secured back to the bone.  Now healing can begin.

5B- repair of the cuff, tendon-to-tendon (side-to-side):

Sometimes it is easier to repair the gap in the cuff by sewing the edges together.  Some patterns of tears are appropriate for this technique.  This is a view from the lateral portal looking through a “V-type” tear defect into the underlying joint.  The edges are first debrided to bleeding tissue with a shaver.

Sutures are placed one at a time starting medially, bringing the edges together…

…one stitch at a time, working laterally toward the camera in the lateral portal…

…until the gap is closed and the tear is eliminated.  Healing may now begin.

Click link below for cuff repair video:

Post-operative Care

A good result rarely is achieved without good rehabilitation and physical therapy, and without compliance of the patient with the doctor’s instructions and limitations, and that of the therapist.

After repair, the shoulder is protected in a sling for several weeks while therapy is slowly and carefully undertaken.  Healing takes time, and therefore return to vigorous activities and sports must be delayed.  Range of motion and strength are gradually restored while protecting the repair site, and return to unlimited activities can be expected between 3 and 6 months after surgery, depending on the size of the tear, security of the repair, and age and goals of the patient.

Even if the surgery is done well, the therapy is meticulous, and the patient is compliant, complete healing cannot always be guaranteed.

Surgical risks include, but are not limited to:  inherent risks of anaesthesia, potential permanent loss of motion (and frozen shoulder), failure of the procedure to resolve all symptoms, failure of the tear to heal, retear of the cuff, avulsion of the deltoid muscle (more common in open procedures), nerve injury, infection, and hardware-related problems, among others.