PCL 4- Surgical repair of rotator cuff tendinopathy

SURGICAL REPAIR OF ROTATOR CUFF TEARS

The need to surgically repair a torn rotator cuff depends upon your age, activity level, and the severity of your tear.

- Surgical repair is usually recommended for people with a complete rotator cuff tear, especially if the person is young and/or active. Surgery is usually recommended soon after the injury, if possible, to prevent the tendon and muscle from shrinking.

- Conservative treatment is usually recommended first if one does not have a complete rotator cuff tear or are older, less active, or if there is minimal pain. Conservative treatments (eg, stretching and strengthening exercises, injection of a steroid) are usually recommended first.

- Surgery may be recommended if patient does not improve after stretching and strengthening exercises and have persistent pain, limited strength, have arthritis or spurs that cause pain and interferes with rehabilitation, or if a new injury occurs and the patient has a previous rotator cuff injury.


Surgery...

Surgery may be used to treat a rotator cuff disorder if the injury is very severe or if nonsurgical treatment has failed to improve shoulder strength and movement sufficiently. Subacromial smoothing involves shaving bone or removing growths on the upper point of the shoulder blade (acromion). It removes scar tissue and damaged tendon and bursa from the joint. The surgeon may also remove small amounts of bone from the underside of the acromion and the acromioclavicular joint (acromioplasty). The goal is to take away roughness while keeping as much of the normal supporting structures as possible. This surgery creates more room in the subacromial space so that the rotator cuff tendon is not pinched or irritated and can glide smoothly beneath the acromion.

There are several ways to repair the rotator cuff, including open and arthroscopic techniques.
• Open-shoulder surgery involves making a larger incision in the shoulder, to open it and directly view the repair.
• Arthroscopy uses a thin viewing scope called an arthroscope that is inserted into a joint through a small incision in the skin. Then the surgeon will remove loose fragments of tendon, bursa, and other debris from the shoulder (debridement). Additional instruments are then arthroscopically inserted to shave the bone or remove growths.


What Is Done In Rotator Cuff Surgery?

During rotator cuff surgery, the patient is put in a half-sitting position, with the head supported. Most operations are performed under general anesthesia, where the patient is asleep. Sometimes a regional (or local) anesthetic is used to block the nerves leading to the arm. In that case, the patient is conscious but cannot feel pain. Usually a sedative is also given, putting the patient in a conscious but dreamy state.
Rotator cuff surgery usually takes one to two hours.

Types of procedures include:
• Impingement surgery
• Rotator cuff repair
• Arthroscopic surgery


Impingement Surgery (Also Called Acromioplasty Or Subacromial Decompression)

If the space between the upper arm and the part of the shoulder blade known as the acromion is too narrow, the rotator cuff cannot move freely. Rotator cuff tendons get pinched between the two bones, gradually damaging the rotator cuff.
To resolve this problem, the surgeon shaves a small portion of bone from the underside of the acromion, giving the tendons more room to move and preventing them from being pinched. The surgeon also removes any bone spurs and either excises or removes swollen or irritated bursa.
Impingement surgery is sometimes performed to relieve severe, chronic tendinitis that does not respond to nonsurgical treatment. Impingement surgery is also done as part of most rotator cuff repair surgeries.

Rotator Cuff Repair

In order to repair a torn rotator cuff, the surgeon reattaches the damaged tendon (or tendons) to the upper arm (humerus). (Some rotator cuff injuries involve more than one torn tendon.)

This surgery involves several key steps:
• In order to gain access to the injured rotator cuff, the surgeon makes a two- to three-inch incision in the shoulder, then cuts through the deltoid muscle.
• The surgeon removes any scar tissue that has built up on the tendon.
• The surgeon carves a small trough at the top of the upper arm, then drills small holes through the bone.
• Finally, the surgeon sews the tendon to the bone, with the sutures going through the tiny holes in the upper arm. (Sometimes a surgeon will use permanent anchors to attach the tendon to bone.)
During this operation, the surgeon also removes bone spurs and releases any ligaments that are pressing on the tendon. If a bursa is inflamed, the surgeon excises or removes it. The surgeon also may remove a small portion of the acromion to make sure the repaired rotator cuff has enough room to move.
Afterwards, the patient's arm is placed in a sling. With time, healing occurs, as scar tissue connects the tendon to bone. Because tendons receive such poor blood supply, this is a slow process.

Arthroscopic Surgery

Arthroscopic surgery is a technique for performing an operation using pen-shaped instruments with a miniature video camera attached to the end.
• The surgeon makes a small incision in the shoulder about the size of a buttonhole.
• He or she then inserts the thin tube that contains the tiny video camera and surgical instruments.
• The surgeon performs the operation with these remotely controlled instruments while watching on a video screen.
Because arthroscopic surgery requires only limited surgical access, the incision is much smaller than is necessary for open surgery, resulting in fewer risks. The patient's recovery time is also shorter.
However, because repairing a torn rotator cuff can be a complicated procedure, it is often performed as an open procedure. However, arthroscopic repairs are becoming more common, especially for small size tears.


After Surgery...

You may go home a few hours after waking up from anesthesia. In some cases, the doctor may suggest that you stay overnight for help with pain management and for observation.

Discomfort after surgery may be relieved by:
• Applying ice to the surgical site 3 times a day.
• Taking pain medicines as prescribed.
• Immobilizing and protecting your shoulder by wearing a sling as directed. Your health professional will advise you whether you need a sling after surgery. Some health professionals do not recommend this, because the shoulder joint may become stiff.
With a doctor's approval, you may be able to return to light work within a few days after surgery even if you are using a sling.

Risks

In addition to the general risks of surgery, such as blood loss or problems related to anesthesia, complications of subacromial smoothing surgery for rotator cuff disorders may include:
• Persistent pain.
• Nerve damage.
• Stiffness.
• Infection.

Benefits of Arthroscopic Surgery

The benefits of needing only arthroscopic surgery for subacromial smoothing rather than open surgery include:
• A shorter recovery time.
• A shorter hospital stay, which may cost less.
• Keeping the deltoid muscle attached, which aids rehabilitation.
• The surgeon's ability to inspect and debride both surfaces of the rotator cuff, rather than just the outside.
• Detecting other damage to the inside of the shoulder joint.

After Surgery

Physical therapy after surgery is crucial for a successful recovery. A typical rehabilitation schedule includes the following:
• Range-of-motion exercises may start the day after subacromial smoothing surgery.
• Strength training may begin several weeks after arthroscopic surgery.
When normal shoulder strength and range of motion return, usually after about 6 to 8 weeks, one can gradually resume playing sports.


Arthroscopic Surgery vs Traditional "Open" Surgery?

Open surgery, a procedure using larger incisions and enabling the surgeon to look inside the joint, may be better for certain procedures under certain circumstances.
Arthroscopic surgery has some advantages--smaller incisions, less tissue damage--but these are usually not helpful if the overall procedure cannot be performed as well

Return to activities

After surgical repair, most people require 6 months of rehabilitation before strength and shoulder function return to normal. Post-surgical rehabilitation is necessary and use of the shoulder must be limited. Immediately after surgery, you will be allowed to use the affected arm with your elbow at your side for eating, using the keyboard, using the telephone, and driving. Above-the-shoulder activities are not usually allowed for three months after surgery.
Sporting activities can be gradually restarted, including golfing at four months, light weight lifting at four months, swimming at five months, and throwing and tennis playing at five to six months.


Rotator Cuff Tendinopathy and Swimming...

Swimming is rough on the rotator cuff, especially if the form is not good. Most triathletes do not have good swimming form.

So the athlete is encouraged to have a coach video tape their swimming stroke and make sure shoulder movements during swimming are showing proper form.

Rotator cuff exercises during healing are generally not done until after a few Prolotherapy sessions. If caught early only a few session of Prolotherapy are needed. If the problem has been going on a long time then up to six sessions may be needed. Soft tissue oral nutritional supplements again are ordered. The athlete can of course cycle and run during the Prolotherapy healing. Often times, the triathlete can do some swimming drills as these do not cause the pain. If a drill reproduced the pain, this then is not practiced.