Rotator Cuff Tear

Other pathology may need to be managed at the time of surgery to address other sources of pain and ensure a lasting result. These include:

• An arthritic AC joint. An AC joint, that is clinically tender and arthritic on MRI can be a cause of incomplete pain relief after rotator cuff repair. The surgical management involves the removal of bone from both the clavicle and acromion to create an 8mm gap that prevents bone the painful bone ends making contact. The AC joint ligaments are preserved as much as possible to maintain AC joint stability.

• A degenerate, frayed, dislocating or inflamed long head of bicep tendonis is usually removed from the joint. This may be achieved by releasing the biceps from the socket and letting it retract into the bicipital groove (tenotomy) or by shortening the tendon and securing into the proximal humerus (tenodesis). Tenodesis is favoured in the more active patients as it restores muscle strength.

A damaged bicep tendon, being removed from the joint.

At the completion of surgery, the incisions (portals) are closed by sutures and the patient is taken to the recovery room in a sling.

Untreated Rotator Cuff Tear

A Rotator Cuff Tear is not life threatening but can impact on a patient’s quality of life, sleep and function.

The tear does not heal by itself and will gradually increase in size. The remaining attached muscles can be strengthened to help accommodate the tendon tear.

Rotator cuff tears can lead in the short term to pain, sleep disturbance, weakness and disability. In the long term, chronic large tears can lead to pain that can be difficult to control. There may be weakness performing tasks at arms length or overhead. If the tears are retracted a long way, the muscle belly has shrunk and lost fibres, the tears may become irreparable. Irreparable tears can progress to arthritis.

Normal muscle bellies on the shoulder blade

Loss of muscle with chronic tendon tears

Rotator Cuff Surgery Risks

As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages.

It is important that the patient is informed of these risks before the surgery takes place.

Complications can be general or specific to rotator cuff  surgery.

General complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

• Allergic reactions to medications
• Heart attacks, strokes, kidney failure, pneumonia, bladder infections.
• Complications from nerve blocks such as nerve damage.
• Blood Clots (Deep Venous Thrombosis)- Blood Clots can form in the arm or leg muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life threatening. If the patient suffers arm pain, redness or swelling, or have shortness of breath at any stage, contact Dr Harper, your GP or local hospital.

Serious medical problems can lead to ongoing health concerns, prolonged hospitalisation or rarely death.

Specific complications for surgery are rare but may include:

• Infection- Infections can occur superficially at the incision or in the joint space of the shoulder, a more serious infection. Infection rates vary but are generally <1% and are higher in diabetes. If an infection occurs it can be treated with antibiotics but may require further surgery.
• Shoulder Stiffness- Shoulder stiffness is a common complication after all types of shoulder surgery. It is important to maximize pain management and comply with physiotherapy. If a post-operative frozen shoulder occurs it usually resolves by 9-12 months after surgery.
• Damage to superficial skin nerves can occur with incisions around the shoulder
• Incomplete Tendon Healing or retear. Despite the surgeon’s best efforts not all rotator cuff repairs will completely heal. Usually if there is a residual defect it is smaller than before surgery and this often provides similar pain relief. The tendon that is repaired is damaged, it does not heal in the same way as the original tendon insertion and requires long term modifications in activity to prevent re-tear.

Preparation Rotator Cuff Surgery

If surgery is required, preparation is necessary to achieve the best results and recovery.

Preparing mentally and physically for surgery is an important step toward a successful result.

• Dr Harper will outline the treatment plan and
• patients will need to understand the process and their participation.

Performing a tailored exercise program before surgery (ie. pre-hab) with a physiotherapist may assist with surgical recovery.

Dr Harper will also need to discuss:

• any medications being taken, to see which ones should be stopped before surgery
• fasting times: do not eat or drink anything, including water, for 6 hours before surgery
• stop taking aspirin, warfarin, anti-inflammatory medications or drugs that increase the risk of bleeding one week before surgery to minimise bleeding
• stop or cut down smoking to reduce your surgery risks and improve your recovery

Report any infections (dental, skin, chest, urinary) to Dr Harper prior to surgery as the procedure cannot be performed until all infections have cleared up.

Post Surgery

The patient will wake up in the recovery room and then be transferred back to their hospital room.

• Pain medication will be provided to keep the patient comfortable.
• A bandage will be around the operated shoulder and the arm will be in a sling or brace.
• The sling will be worn for 6 weeks to facilitate healing.

                                                   

Dr Harper will see the patient prior to discharge and explain the findings of the operation and what was done during surgery.

• The bandage will usually be removed the morning after surgery and waterproof dressings applied. If the dressings remain clean, these can be left on until suture removal 10-14 days post surgery..
• It is normal for the shoulder to swell after the surgery. Placing Ice-Packs on the shoulder will help to reduce swelling. Ice packs should be applied to the area for 20 min 3-4 times a day until swelling has reduced.

The patient should keep a pillow under their elbow while lying in bed.

• During the first 6 weeks, while in the sling, light objects ( up to a can of drink) can be held or stabilised in the operated arm .
• It is recommended that the patient not drive during the first 6 weeks while wearing a sling due to safety reasons and the risk of injury to the surgical site.
• 10- 14 days after surgery Dr Harper will see the patient to monitor their progress and remove the sutures.
• It takes 12 weeks to establish healing with fibres that connect the tendon to bone.The patient will not be allowed to reach, lift the arm over head or perform any resistance / strength exercises until 12 weeks after the surgery.

6-12 Weeks Post Rotator Cuff Repair

• Sling can be removed. Reapplied for short periods only if pain. No sling after 8 weeks post surgery
• Can be active at waist level with elbow by side. No lifting more than 1kg in daily activities
• All 4 exercises 3 times per day, 10-20 repetitions per exercise

1. Shoulder Blade Exercises

• Elevation / depression
• Retraction (pictured) / protraction

2. Desk Slide Exercises: both hands are placed o a book and the non-operated shoulder slides the book forward and backward to stretch the operated shoulder.

3. External Rotation Exercises: with elbow locked in by side of body. Can be active if no infraspinatus tendon repair

4. Passive Elevation Exercises lying down. Use good arm to lift operated arm. Do not bring arm all the way down until final repetition. Gradually increase range

> 12 Weeks Post Rotator Cuff Repair

• Active arm elevation can start, initially while laying down, in water or with bent elbow (decreased lever arm).
• A rubber band strengthening program can commence with the upper arm and elbow remaining close by the chest.

Eating a healthy diet and not smoking will promote healing.