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Rotator cuff repair

The rotator cuff is a group of muscles and tendons that surround the shoulder joint, keeping the head of upper arm bone firmly within the shallow socket of the shoulder.

A rotator cuff injury can cause a dull ache in the shoulder, which often worsens when you try to sleep on the involved side.

Rotator cuff injuries occur most often in people who repeatedly perform overhead motions in their jobs or sports. The risk of rotator cuff injury also increases with age. Many people recover from rotator cuff disease with physical therapy exercises that improve flexibility and strength of the muscles surrounding the shoulder joint.

Sometimes, rotator cuff tears may occur as a result of a single injury. In those circumstances, medical care should be provided as soon as possible. Extensive rotator cuff tears may require surgical repair, transfer of alternative tendons or joint replacement. Tears resulting from major injury can usually be repaired successfully if surgery is not delayed more than several weeks.

Weakened degenerative cuff tissue is more easily torn even by normal activities. Durable repair of these tears may not be possible because of the lack of sufficient quantity and quality of tendon tissue. For these reasons patients should seek prompt evaluation of shoulder weakness by an experienced shoulder surgeon especially if the weakness comes on suddenly or after an injury.

Hospital Stay: Hospital Stay: 3 days
Duration: Duration: 2 hrs
Cost Estimate: Cost Estimate: 3500 USD - 5600 USD These are indicative prices in Indian Hospitals

Injuries to the shoulder are common. Athletes and construction workers often have rotator cuff injuries due to repetitive movement and overuse of the shoulder. The rotator cuff may be damaged from a fall or other injury to the shoulder. Damage may also occur slowly over time. In older patients, there may not be an injury or event to cause the tear. The damage may be due to:

  • Strain or tear in the rotator cuff.
  • Bursitis in the shoulder.
  • Tendinitis in the shoulder.

Recurrent pain, limited ability to move the arm, and muscle weakness are the most common symptoms.
If medical treatments are not satisfactory, rotator cuff repair surgery may be needed. Medical treatments for rotator cuff injury may include the following:

  • Rest
  • Nonsteroidal anti-inflammatory medications
  • Strengthening and stretching exercises
  • Steroid injections

Rotator cuff surgery may be performed using an arthroscope. An arthroscope is a small, tube-shaped instrument that is inserted into a joint. It consists of a system of lenses, a small video camera, and a light for viewing. The camera is connected to a monitoring system that allows the doctor to view a joint through a very small incision. The arthroscope is often used in conjunction with other tools that are inserted through another incision.

An open repair may be performed if the rotator cuff injury cannot be repaired using arthroscopy. In some cases, a tendon graft and joint replacement may be necessary.
There may be other reasons for your doctor to recommend rotator cuff repair.

Risks

As with any surgical procedure, complications can occur. Some possible complications may include:

  • Bleeding
  • Infection
  • Stiffness
  • Re-rupturing of rotator cuff
  • Damage to nerves and vessels
  • Embolism

Before the procedure

  • Your doctor will explain the procedure to you and offer you the opportunity to ask any questions that you might have about the procedure.
  • You will be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.
  • In addition to a complete medical history, your doctor may perform a complete physical examination to ensure you are in good health before undergoing the procedure. You may undergo blood tests or other diagnostic tests.
  • Notify your doctor if you are sensitive to or are allergic to any medications, latex, tape, and anesthetic agents.
  • Notify your doctor of all medications and herbal supplements that you are taking.
  • Notify your doctor if you have a history of bleeding disorders or if you are taking any blood-thinning medications, aspirin, or other medications that affect blood clotting. It may be necessary for you to stop these medications prior to the procedure.
  • If you are pregnant or suspect that you are pregnant, you should notify your doctor.
  • You will be asked to fast for 8 hours before the procedure, generally after midnight.
  • You may receive a sedative prior to the procedure to help you relax. Because the sedative may make you drowsy, you will need to arrange for someone to drive you home.
  • You may meet with a physical therapist prior to your surgery to discuss rehabilitation.
  • Based on your medical condition, your doctor may request other specific preparation.

During the procedure

Rotator cuff repair may be performed on an outpatient basis or as part of your stay in a hospital. Procedures may vary depending on your condition and your doctor’s practices.
Rotator cuff repair may be performed while you are asleep under general anesthesia, or while you are awake under local or regional anesthesia. If regional anesthesia is used, you will have no feeling from your shoulder down. The type of anesthesia will depend on the specific procedure being performed. Your doctor will discuss this with you in advance.

Generally, rotator cuff repair surgery follows this process:

  1. You will be asked to remove clothing and will be given a gown to wear.
  2. An intravenous (IV) line may be started in your arm or hand.
  3. You will be positioned on the operating table.
  4. The anesthesiologist will continuously monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery.
  5. The skin over the surgical site will be cleansed with an antiseptic solution.
  6. The doctor will make an incision in the shoulder area. The incision will vary depending on the type of surgery (open surgery, arthroscopy, or a combination of both) that may be performed.
  7. The arthroscope (if used) will be inserted through the incision.
  8. Other incisions may be made to introduce other small grasping, probing, or cutting tools.
  9. Injured tendons and muscles will be repaired or replaced with a graft tendon from another part of the body.
  10. Bone spurs will be removed.
  11. The incision(s) will be closed with stitches or surgical staples.
  12. A sterile bandage or dressing will be applied.

After the procedure

After surgery you will be taken to the recovery room for observation. Your recovery process will vary depending on the type of anesthesia that is given and the type of surgery that is performed. The circulation and sensation of the arm will be monitored. Once your blood pressure, pulse, and breathing are stable and you are alert, you will be taken to your hospital room or discharged to your home.
You may be given an immobilizer or sling before you go home.
Once you are home, it is important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The stitches or surgical staples will be removed during a follow-up office visit.
Take a pain reliever for soreness as recommended by your doctor. To help reduce swelling, you may be asked to apply an ice bag to the shoulder several times per day for the first few days. You should keep the sling or immobilizer on as directed by your doctor.
Your doctor will arrange for an exercise program to help you regain muscle strength, flexibility, and function of your shoulder.

Notify your doctor to report any of the following:

  • Fever
  • Redness, swelling, bleeding, or other drainage from the incision site
  • Increased pain around the incision site
  • Numbness or tingling in the affected arm or hand

You may resume your normal diet unless your doctor advises you differently.

You should not drive until your doctor tells you to. Other activity restrictions may apply. Full recovery from the surgery may take several months.

Outlook /Prognosis

Surgery to repair a torn rotator cuff is usually successful in relieving pain in the shoulder. The procedure may not always return strength to the shoulder. Rotator cuff repair can require a long recovery period, especially if the tear was large.
When you can return to work or play sports depends on the surgery that was done. Expect several months to resume your regular activities. Some rotator cuff tears may not fully heal. Stiffness, weakness, and chronic pain may still be present.

These poorer results are more likely when the following are present:

  • The rotator cuff was already torn or weak before the injury.
  • Larger tears
  • After-surgery exercise and instructions are not followed.
  • Older patients (over age 65)
  • Smoking

Shoulder is made up of three bones: your upper arm bone/humerus, your shoulder blade, and your collarbone/clavicle. The shoulder is a ball-and-socket joint: The ball, or head, of your upper arm bone fits into a shallow socket in your shoulder blade.
Your arm is kept in your shoulder socket by your rotator cuff. The rotator cuff is a network of four muscles that come together as tendons to form a covering around the head of the humerus. The rotator cuff attaches the humerus to the shoulder blade and helps to lift and rotate your arm.
There is a lubricating sac called a bursa between the rotator cuff and the bone on top of your shoulder. The bursa allows the rotator cuff tendons to glide freely when you move your arm. When the rotator cuff tendons are injured or damaged, this bursa can also become inflamed and painful.

A rotator cuff tear may result from an acute injury such as a fall or may be caused by chronic wear and tear with degeneration of the tendon or a combination of both acute and chronic causes. Impingement of the front of the scapula, “the acromion”, on the tendon is believed to be a major cause of cuff tears in individuals older than 40 years.
Several factors contribute to degenerative, or chronic, rotator cuff tears:

  • Repetitive stress – Repeating the same shoulder motions again and again can stress your rotator cuff muscles and tendons. Baseball, tennis, rowing, and weightlifting are examples of sports activities that can put you at risk for overuse tears. Many jobs and routine chores can cause overuse tears, as well as we progress in age.
  • Lack of blood supply – As we get older, the blood supply in our rotator cuff tendons lessens. Without a good blood supply, the body’s natural ability to repair tendon damage is impaired. This can ultimately lead to a tendon tear.
  • Bone spurs – As we age, bone spurs/ overgrowth often develop on the underside of the acromion bone. When we lift our arms, the spurs rub on the rotator cuff tendons. This condition is called shoulder impingement, and over time will weaken the tendon and make it more likely to tear.

When one or more of the rotator cuff tendons is torn, the tendon no longer fully attaches to the head of the humerus. Most tears occur in the supraspinatus muscle and tendon, but other parts of the rotator cuff may also be involved. In many cases, torn tendons begin by fraying. As the damage progresses, the tendon can completely tear, sometimes with lifting a heavy object.
Typically, you will feel pain in the front of your shoulder that radiates down the side of your arm. It may be present with overhead activities such as lifting or reaching. You may feel pain when you try to sleep on the affected side. You may note weakness of your arm and difficulty with routine activities such as combing your hair or reaching behind your back.
If the tear occurs with injury, you may experience acute pain, a snapping sensation, and immediate weakness of the arm. These symptoms can occur more easily after injury in an ageing patient.

The signs and symptoms of a rotator cuff tear depend on the size and extent of the tear and the length of time that it has been present. In most cases, pain is the predominant feature. This occurs because of inflammation around the damaged tendon, as well as mechanical catching of the tendon in its tunnel under the acromion. The pain occurs with use of the arm, particularly elevation to and above shoulder height. Pain also occurs at night, which is particularly disabling because of the interference with sleep. Weakness, associated loss of power and movement may occur, depending on the size of the tear.

Once the rotator cuff tears, it does not heal, and surgery may be necessary to repair the tendon. If extensive tears are not treated, the result is deteriorating shoulder function, the onset of widespread arthritis in the shoulder region, and increasing pain over time. The ability to offer surgery to repair torn tendons depends on many factors and unfortunately not all patients are candidates for successful surgery.

The most common symptoms of a rotator cuff tear include:

  • Pain at rest and at night, particularly if lying on the affected shoulder
  • Pain when lifting and lowering your arm or with specific movements
  • Weakness when lifting or rotating your arm
  • Crepitus or crackling sensation when moving your shoulder in certain positions

Tears that develop slowly due to overuse also cause pain and may cause arm weakness. You may have pain in the shoulder when you lift your arm to the side, or pain that moves down your arm. At first, the pain may be mild and only present when lifting your arm over your head, such as reaching into a cupboard. Over-the-counter medication, such as aspirin or ibuprofen, may initially relieve the pain.
Over time, the pain may become more noticeable at rest, and no longer goes away with medications. You may have pain when you lie on the painful side at night. The pain and weakness in the shoulder may make routine activities such as combing your hair or reaching behind your back more difficult.

There are different types of tears:

  • Partial Tear –This type of tear damages the soft tissue, but does not completely sever the tendon.
  • Full-Thickness Tear – This type of tear is also called a complete tear. It splits the soft tissue into two pieces. In many cases, tendons tear off where they attach to the head of the humerus. With a full-thickness tear, there is basically a hole in the tendon.

A rotator cuff tear can extend or get larger over time. This can occur with repetitive use or a re-injury. It is common for patients with known rotator cuff disease to have acute pain and weakness following a minor injury. This likely represents extension of an existing tear. If you know you have a rotator cuff tear then worsening pain and decreasing strength may mean the tear is getting larger.
Early diagnosis and treatment of a rotator cuff tear may prevent symptoms such as loss of strength and loss of motion from setting in. A consultation with an orthopedic surgeon is recommended, and an Ultrasound/MRI is usually required to confirm the diagnosis. Appropriate surgical or non-surgical treatment can then begin.

The goal of any treatment is to reduce pain and restore function. There are several treatment options for a rotator cuff tear, and the best option is different for each person. In planning your treatment, your doctor will consider your age, activity level, general health, and the type of tear that you have. Surgical treatment is not necessary if pain and loss of function are not significant problems depending on your age and the circumstances of how the tear occurred.

  • Non-surgical treatment includes analgesics and/or anti-inflammatories, and physiotherapy to strengthen the rotator cuff muscles provided it does not aggravating the problem. Particularly useful in the early stages are steroid injections but their benefit usually reduces with repeated injections. Injections should be administered under USS guidance to increase their accuracy.
  • Surgery is recommended if you have persistent pain or weakness and loss of function that does not improve with nonsurgical treatment. Frequently, patients who require surgery will report pain at night and difficulty using the arm for lifting and reaching. Many will report ongoing symptoms despite several months of medication and limited use of the arm.

Non-surgical treatment options may include:

  • Rest – Your doctor may suggest rest and limiting overhead activities.
  • Activity modification – Avoid activities that cause shoulder pain.
  • Non-steroidal anti-inflammatory medication – Drugs like ibuprofen reduce pain and swelling.
  • Strengthening exercises and physiotherapy – Specific exercises will restore movement and strengthen your shoulder. Your exercise program will include stretches to improve flexibility and range of motion. Strengthening the muscles that support your shoulder can relieve pain and prevent further injury.
  • Steroid injection – If rest, medications, and physiotherapy do not relieve your pain, an injection of a local anaesthetic and a cortisone preparation may be helpful. Cortisone is a very effective anti-inflammatory medicine.

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