Chapter 24

Open Rotator Cuff Repair

John W. Sperling

Chapter Synopsis

• This chapter provides an overview of open rotator cuff repair. Preoperative considerations, surgical technique, postoperative rehabilitation, and published results are discussed.

Important Points

• It is very important to rule out other potential processes that can mimic shoulder pain, such as cervical radiculopathy.

• The surgeon needs to clearly understand the ability of the patient to comply with postoperative rehabilitation and restrictions.

• Advanced imaging studies such as magnetic resonance imaging and ultrasound provide important information about the size of the tear, amount of retraction, and muscle degeneration.

Clinical and Surgical Pearls and Pitfalls

• Systematic releases of the rotator cuff are essential to mobilize the tendon and reduce tension on the repair.

• A strong and meticulous repair of the deltoid is essential to avoid postoperative dehiscence.

• Careful identification of both the deep and superficial deltoid fascial layers is critical during the exposure and later repair.

Multiple facets need to be incorporated for a successful rotator cuff repair to be achieved. The process starts with a thorough understanding of the patient’s symptoms, motivation, and ability to comply with postoperative restrictions. Careful examination together with appropriate imaging studies allows proper surgical planning.

Preoperative Considerations

History

Evaluation of the patient with a rotator cuff tear begins with a thorough history. It is critically important to understand the severity of the symptoms and the patient’s ability to comply with postoperative restrictions. The surgeon also needs to elucidate the primary complaint, whether it is pain, weakness, or loss of motion, to better determine and guide the patient’s expectations.

The history ascertains the patient’s dominant extremity as well as occupation. The duration of pain and dysfunction is determined, as well as whether they started with a specific traumatic event. To understand the severity of pain and the degree to which it interferes with the quality of life, patients are asked to rate the pain on a scale of 1 to 10 at rest, with activities, and at night. The patient is also asked about specific alleviating and aggravating factors. Last, patients are asked to localize the pain—whether it occurs over the anterolateral aspect of the shoulder or radiates in a more radicular pattern down the entire arm, possibly consistent with a neurologic component of pain.

If possible, the results of prior studies are obtained, and prior treatment attempts and their results are reviewed. With a history of prior shoulder surgery, operative notes and images can help further delineate the pathologic process.

A focused review of systems is performed to rule out the possibility of other pathologic processes that frequently cause or mimic shoulder pain, such as inflammatory arthritis, cervical radiculopathy, and even thoracic neoplasias. A list of medications and associated medical problems should be recorded.

Physical Examination

Physical examination includes inspection and palpation of the entire shoulder, followed by specialized functional tests. Inspection assesses soft tissue swelling, deformity, or atrophy. Palpation comprises an examination of the cervical spine, acromioclavicular joint, and bicipital groove. The neurovascular examination of the extremities includes assessment of strength, sensation, and reflexes.

Subsequently, active and passive shoulder motion is recorded for forward flexion, abduction, internal rotation, and external rotation. Strength is graded on a scale of 1 to 5 for internal rotation, external rotation, flexion, extension, and abduction. Impingement tests have been found to be fairly nonspecific but can help elucidate a diagnosis of subacromial impingement; weakness is suggestive of a tear of the rotator cuff. More specialized tests include the lift-off and belly press tests for subscapularis function, as well as external rotation strength, and the lag sign for infraspinatus function; these allow more sensitive assessment of muscle strength.

Imaging

Radiography

Three radiographic views are routinely obtained: 40-degree posterior oblique views with internal and external rotation and an axillary view. One may observe superior subluxation of the humeral head and a decrease in the acromial-humeral distance with significant rotator cuff deficiency. One caveat is that with posterior subluxation, there can be the false appearance of superior humeral head subluxation. There may be sclerosis or rounding of the greater tuberosity with rotator cuff disease as well. The axillary view allows assessment of glenohumeral cartilage loss and subluxation. In addition, one may choose to obtain a Neer outlet view to evaluate acromial morphologic features.

Advanced Imaging Studies

Multiple options are available to further investigate the integrity of the rotator cuff, including arthrography, computed tomographic arthrography, magnetic resonance imaging, and ultrasonography. The decision of which test to perform is based on the individual surgeon’s preference. Magnetic resonance imaging provides important additional information about tear size and configuration, degree of retraction, and muscle atrophy or degeneration.

Indications and Contraindications

After the information obtained from the history, physical examination, and imaging studies has been integrated, one determines the diagnosis and can present treatment options to the patient. It is critical to understand the patient’s goals and expectations for surgery. Clearly, the primary indication for rotator cuff surgery is pain relief; recovery of strength and function is less predictable. Contraindications include active or recent infection, significant medical comorbidities, and an inability to follow the postoperative restrictions and rehabilitation regimen.

A detailed conversation with the patient then occurs concerning treatment options. The risk, benefits, and alternatives to surgical repair are discussed in detail. The decision to employ specific techniques, such as open versus arthroscopic repair, is based on the individual surgeon’s preference and familiarity with each technique. I individualize this decision for each patient on the basis of the age of the patient, the physical demands on the shoulder, the size and configuration of the tear, and a primary or revision setting. My practice consists primarily of performing arthroscopic rotator cuff repair. However, the technique of open repair may be particularly useful in the revision setting when multiple anchors are already present within the humeral head. In addition, open repair may be considered in the young, active heavy laborer with a large rotator cuff tear.

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