Chapter 40 Rotator Cuff Repair
Arthroscopic and Open
Surgical Overview
• The muscles of the rotator cuff consist of the subscapularis, supraspinatus, infraspinatus, and teres minor.
• The primary function of the rotator cuff is to balance the force couples about the glenohumeral joint during active elevation of the upper extremity. With this in mind, the primary goal of rotator cuff repair surgery is to restore, as closely as possible, the anatomical cuff configuration and these biomechanical force couples.
• In 1911, Codman first described open surgical repair of the supraspinatus. Since then, rotator cuff repair techniques have evolved significantly, and the introduction of shoulder arthroscopy in 1980 dramatically changed the way rotator cuff repairs are performed.
• Surgical techniques progressed from open to arthroscopic-assisted mini-open repair techniques during the early to mid-1990s.
• The trend now seems to be the progression to an all-arthroscopic surgical technique.
1 The advantages associated with an all-arthroscopic rotator cuff repair are deltoid preservation; smaller skin incisions; better visualization and evaluation of the glenohumeral joint and rotator cuff defect; improved ability to mobilize and release the rotator cuff; decreased postoperative pain and stiffness; and improved rehabilitation potential.
• Overall, the results of arthroscopic repairs appear to be very promising. Wolf et al. showed good to excellent results in 94% of patients who underwent arthroscopic rotator cuff repair.
• Surgery initially involves positioning the patient in the lateral decubitus or upright beach chair position.
1 Bony landmarks are identified and marked, and the arthroscope is placed into the joint space via posterior, anterior, and lateral portals.
2 The glenohumeral joint is then inspected via the arthroscope to help identify possible concomitant intra-articular pathologies.
4 The amount of retraction of the rotator cuff is assessed, as is cuff mobility, using grasper hooks.
6 Excursion of the cuff is determined to identify the exact area of bony preparation and the anatomical “footprint” of the cuff.
7 The torn tendon edges are débrided of devascularized tissue, and sutures are placed through the torn edges.
9 Acromioplasty and/or subacromial decompression may not be needed at the time of rotator cuff repair if the acromion does not compromise the subacromial space and/or if the cuff tear is secondary to trauma or intrinsic tendinopathy caused by eccentric tendon overload.
Rehabilitation Overview
• The rehabilitation program following rotator cuff repair must take into account the healing time of surgically repaired tissue.
• The program should balance the aspects of tissue healing and appropriate interventions to restore range of motion (ROM), strength, and function.
• Factors that influence the rate at which a patient can be progressed through the program include surgical technique, quality of the tissue repaired, size of the tear, and location of the tear.
• Good tissue quality will allow a secure repair, which may allow for a faster rehabilitation than a more tenuous repair of poorer quality tissue. Tissue quality can be influenced by conditions, such as rheumatoid arthritis, diabetes, and by the chronicity of the tear, previous surgery, repeated injections, or chronic steroid use. These can increase the risk of suture pull-out.
• Functional outcome is also directly related to the size of the tear.
1 Tear size, not age, is more of a factor in predicting a successful outcome after rotator cuff repair.
• The location of the tear will also affect interventions.
1 For example, a small tear of the supraspinatus may allow for early activation of the internal and external rotators, whereas a tear extending into the infraspinatus and teres minor or the subscapularis will delay strengthening of the corresponding musculature.
2 The therapist must take into account what structures are involved to avoid disruption of healing tissues in the early phases of rehabilitation. Communication with the referring surgeon is essential to determine this information.
Postoperative Phase I: Maximum Protection (Weeks 0 to 3)
GOALS
• Gradually increase shoulder ROM (surgeon directed) external rotation (ER) to 45 degrees, internal rotation (IR) to 45 degrees, and forward flexion (FF) to 120 degrees
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