Open Rotator Cuff Repair

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • The primary goal of surgical management of rotator cuff tears is pain relief and this is accomplished with predictable results.
    • Improvement of function is a secondary but important consideration.
      • Functional improvement is not as predictable as pain relief and depends on the age of the patient, the age and size of the tear (which suggests the quality of the tissue and the condition of the muscle), and the postoperative rehabilitation program.
  • In elderly patients or those with low activity demands, attempt a short course of conservative treatment (approximately 6 weeks).
  • If there is no improvement, we proceed to surgery to minimize the atrophy of the rotator cuff musculature.
    • Surgery is appropriate for an acute rotator cuff injury in a young patient or in an older patient (60 to 70 years of age) with a defined injury who suddenly is unable to rotate the arm externally against resistance.
  • The approach chosen depends on the type of tear and the quality of the residual tissue.
    • For small and moderate-sized tears (up to 3 cm) without significant retraction, a standard anterior incision for acromioplasty is used.
    • Large tears (3 to 5 cm) are more challenging and usually require mobilization of tissues.
  • Acromioplasty should be performed along with repair.
    • The results of repair without decompression are not as good as those using the combined procedure.
    • The following principles described by Neer should be adhered to during acromioplasty:
      • Release (but not resection) of the coracoacromial ligament
      • Removal of the anterior lip of the acromion
      • Removal of part of the acromion anterior to the anterior border of the clavicle
      • Removal of the distal 1 to 1.5 cm of clavicle if significant degenerative changes are found
CONTRAINDICATIONS

Any significant preoperative stiffness must be corrected before rotator cuff repair to avoid severe postoperative stiffness.

EQUIPMENT
  • Oscillating saw
  • Drill
  • Burr osteotome
  • Hohmann retractors
  • Malleable retractors
ANATOMY
  • The rotator cuff is composed of four muscles:
    • Supraspinatus
      • Arises from supraspinatus fossa of scapula
      • Inserts into superior portion of greater tuberosity
      • Innervated by suprascapular nerve (C5)
      • Supplied by suprascapular artery
        • The suprascapular artery is a branch of the thyrocervical artery, which arises from the subclavian artery.
    • Infraspinatus
      • Arises from infraspinatus fossa of scapula
      • Inserts into middle portion of greater tuberosity
      • Innervated by suprascapular nerve (C5)
      • Supplied by suprascapular artery and circumflex scapular artery
        • The circumflex scapular artery is a branch of the subscapular artery.
    • Teres minor
      • Arises from lateral scapula
      • Inserts into inferior portion of greater tuberosity
      • Innervated by axillary nerve
      • Supplied by circumflex scapular artery and posterior circumflex humeral artery
        • The posterior circumflex humeral artery is a branch of the axillary artery.
    • Subscapularis
      • Arises from subscapular fossa of scapula
      • Inserts into lesser tuberosity of humerus
      • Innervated by upper and lower subscapular nerve
      • Supplied by the circumflex scapular artery, the dorsal scapular artery, the suprascapular artery, and the lateral thoracic artery
  • The rotator cuff has three functions:
    • Rotating the humerus with respect to the scapula
    • Compressing the humeral head into the glenoid fossa
    • Providing muscular balance
      • The concavity-compression effect and mechanical depression of the humeral head counteract the superiorly directed force produced by the deltoid.
      • In essence, the rotator cuff serves to center the humeral head within the glenoid, to allow the deltoid to function without causing subluxation or dislocation.
  • Layers of the shoulder
    • The shoulder can be divided into four supporting layers:
      • I
        • Deltoid muscle
        • Pectoralis major muscle
      • II
        • Clavipectoral fascia
        • Conjoined tendon, short head of the biceps muscle, and coracobrachialis muscle
        • Coracoacromial ligament, posterior scapular fascia, and superficial bursal tissue
      • III
        • Deep layer of the subdeltoid bursa
        • Subscapularis, supraspinatus, infraspinatus, and teres minor muscles
      • IV
        • Glenohumeral joint capsule and synovium
        • Coracohumeral ligament
  • Axillary nerve anatomy
    • The axillary nerve is an important structure at risk during the anterolateral surgical approach.
    • It is derived from the posterior cord of the brachial plexus, C5-C6.
    • It innervates the deltoid and teres minor muscles.
    • It runs posterior under the glenohumeral joint.
    • It courses through the quadrangular space with the posterior circumflex humeral artery.
    • It is then runs transversely across the deep surface of the deltoid, approximately 7 cm below the tip of the acromion.
      • Dissection of the deltoid below 7 cm puts the axillary nerve at risk. 

        Clinical Pearls: Some surgeons advocate placing a stay suture at the apex of the deltoid split to prevent overdissection.

    • Axillary nerve palsy can result in significant weakness of the deltoid muscle and restriction of forward elevation.

PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing this procedure
The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • An abduction pillow, low-profile pillow sling, or a shoulder immobilizer is worn up to 6 weeks.
  • This is then removed for assisted exercises in flexion and external rotation to avoid adhesions, disuse atrophy, and disruption of the repairs.
  • Somewhat empirically we advance to isometric exercises of external rotation at 6 weeks, and at 12 weeks active motion is permitted.
    • Patients are cautioned that overaggressive use of the extremity can lead to disruption of the repair for 6 to 12 months.
COMPLICATIONS
  • Acromioplasty complications
    • The worst common complication is loss of anterior deltoid function.
      • This is caused by either axillary nerve injury or detachment of the deltoid from the acromion.
    • Other complications include infection, seroma formation, hematoma, synovial fistula, biceps rupture, pulmonary embolus, acromial fracture, and reflex sympathetic dystrophy.
  • Rotator cuff repair complications
    • Complications of rotator cuff repair occur with tears of all sizes, but especially with large and massive tears.
      • Large amounts of retracted friable tissue are difficult to repair, and repair can be quite tenuous.
    • Because the suprascapular nerve lies only 1.8 cm from the posterosuperior glenoid rim, cuff mobilization should not exceed this.

      Clinical Pearls: If more mobilization is necessary, capsular stripping, as reported by Warren, can be done.

    • Transposition of the upper portion of the subscapularis tendon can result in anterior instability and weakness of internal rotation.
    • Transposition of the teres minor and infraspinatus muscles can result in external rotator weakness.
      • Free grafts have been used with very little success and are not recommended.
    • Despite an excellent technical result, some patients do not return to previous activity levels. Some develop postoperative stiffness from immobilization and some have persistent night pain.
RESULT ANALYSIS

The clinical results of rotator cuff repair in symptomatic patients who have been followed for as long as 10 years are good to excellent in a high percentage of cases, even though rerupture of the cuff is known to occur in 20% to 65% of patients.

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