Mark K. Bowen and Angelo DiFelice

1. Patients with chronic shoulder pain or weakness with a documented rotator cuff tear that has failed nonsurgical management (rest, local modalities, NSAIDs, physical therapy, and judicious subacromial cortisone injections)

2. Acute, traumatic full-thickness rotator cuff tears

3. Partial-thickness rotator cuff tears greater than 50%

Indications for associated acromioclavicular (AC) joint resection

• AC joint tenderness on physical examination

• Radiographic changes of AC joint arthritis

• Exposure optimization of a retracted supraspinatus tendon in chronic or massive rotator cuff tears

1. Active soft tissue or glenohumeral infection

2. Neuropathic joint

3. Chronic axillary nerve injury

4. Failed prior surgical treatment with associated deltoid insufficiency (relative)

5. Degenerative arthritis (relative); consider combining rotator cuff repair with shoulder arthroplasty

6. Patient’s overall medical condition (relative)

7. Parkinson’s disease or other diseases that cause uncontrolled muscle activity (relative)

8. Patient unable to comply with postoperative rehabilitation

1. Physical examination to include assessment of AC joint tenderness and/or pain with shoulder adduction

2. Obtain radiographs

a. Anteroposterior (AP) in plane of scapula (true AP)

b. AP shoulder (check distal clavicle for “spurs”)

c. Axillary view (check for os acromiale, glenohumeral arthritis)

d. Supraspinatus outlet view (assess acromion shape [types I–III], spinoacromial angle)

e. 25 degree caudal tilt (“Rockwood view”) (optional)

3. Consider magnetic resonance imaging (MRI): helps evaluate extent (“full” versus “partial” thickness) of rotator cuff tears, and presence of muscle atrophy or tendon retraction; observe mass effect of acromion and AC joint on supraspinatus tendon (impingement).

1. Small sagittal or oscillating saw for bone resection

2. 1.6-mm drill bit for deltoid reattachment

3. Small, half-circle curved free Mayo needle, and #2 braided nonabsorbable suture

5. Semi-sitting or beach chair position. The patient is moved as close to the side of the table as possible while still being stable. A beanbag-type McConnell head holder (McConnell Surgical Mfg., Greenville, TX) or AMSCO “captain’s chair” is useful to secure and stabilize the head in a safe neutral position. Care must be taken to pad all bony prominences.

6. The head may be secured gently with a padded strap or tape across a pad on the forehead. Care must be taken to avoid the strap or tape from sliding down over the eyes.

7. The procedure can be done with either general or interscalene block anesthesia.

1. A thorough preoperative evaluation is critical to a successful rotator cuff repair. A complete physical examination, review of plain radiographs, and MRI provide meaningful information to plan surgery and counsel patients preoperatively. The size of tear and the degree of tendon retraction and muscle atrophy can suggest the degree of difficulty in attempting to repair the rotator cuff and the possible need for postoperative abduction brace immobilization.

2. Check passive range of motion preoperatively and under anesthesia. Gentle shoulder manipulation may be necessary to release capsular adhesions. If adhesive capsulitis is severe, consider a staged manipulation and subsequent rotator cuff repair to minimize post-surgical loss of motion.

3. Mobilization of the rotator cuff tendon along its superior and inferior surfaces and release of a contracted coracohumeral ligament is important to minimize undesirable tension on the tissue and repair.

4. Define the anterior and posterior aspects of the rotator cuff tear and advance and secure these areas first. This closes the tear and relieves tension on the repair at the tuberosity.

5. A secure deltoid repair to the acromion is as important as the rotator cuff repair in restoring shoulder strength and function.

1. Make sure the patient is properly positioned on the operating room table. Avoid excessive cervical traction and brachial plexus traction. Ensure proper padding of all bony prominences to minimize risk of neuropraxias.

2. Avoid fracturing the acromion during either the acromioplasty or deltoid reattachment.

3. Do not mistake the flimsy bursal tissue for the rotator cuff tendon and use it in the cuff repair.

4. Avoid inadequate or insecure repair of the deltoid to the acromion.

1. A sling or abduction pillow is used postoperatively to protect the rotator cuff repair. The choice of postoperative protection depends on the type of patient, the quality of the tendon tissue, the tension on the sutures, and the adequacy of the cuff and deltoid repair.