Arthroscopic Rotator Cuff Repair in Simple Terms

Hi, I'm Patrick Denard from the Oregon Shoulder Institute. And the goal of this presentation is to really give a simple overview of what's the rotator cuff and what's involved in rotator cuff repair. Because a lot of people have questions about what that is. And sometimes it's hard to picture that. So I wanted to give some explanations with some illustrations that I think will help make it more clear what's involved in this procedure. So what is the rotator cuff? Well, there's 4 rotator cuff muscles. In the back we have what's called the infraspinatus and the teres minor. On top is the supraspinatus, and in the front is the subscapularis. The most commonly torn tendon is the supraspinatus. So muscle inserts in the bone via tendon. Most commonly, the tendon tears away from the bone. Actually, about 50% of people at age 65 have a tear of the supraspinatus tendon, and most of them don't even know that's occurring. What does the rotator cuff do? The rotator cuff helps move your shoulder up and then rotate in and out. And particularly what it does is help stabilize the ball and socket joint. So when the rotator cuff is torn, the ball and socket joint can become unstable and you can also develop arthritis over time. And that's because the shoulder is a very mobile joint. It's the most mobile joint in the body. And so in order to maintain stability, you have to have that rotator cuff muscle. So what's the tear? As I said, really what happens is the tendon tears off the bone. You can see an image on the left here, which is a schematic illustration. That white is trying to show the tendon. And the red is the muscle. And then this is an arthroscopic view, what it looks like. That's looking in with a camera. This yellow area here is the bone of the, of the head or the humeral head. And there's a rotator cuff tear with that edge of the tendon that's torn off the bone and pulled back. So what do we do with a repair? With a repair, what we do is put anchors typically in the bone. And those anchors have sutures. We pass those sutures through the tendon and repair the tendon down to the bone. Because the only way to get the tendon to heal is to get it back down to the bone. And the only way to do that right now, to get that back down to the bone, is surgically. We just want that tendon to heal into the bone. So we use a combination of sutures, and that can be what's called a double-row repair or a single-row repair. But it really varies based on the individual person and their tear pattern. So let me show you a video illustration of that as well, just to kind of get another picture of that. This is a, uh, demonstration of a right shoulder. So this is what a repair can look like in this illustration. So again, we talked about the rotator cuff muscles. Again, in the front we have the subscapularis, on the top the supraspinatus, in the back the teres minor and the infraspinatus. So typically what we'll do is I'll put in a scope inside the shoulder. That's through just a small stab incision. That scope is about 5 millimeters in diameter, about the size of a pencil. And then we can introduce other little portals through stab incisions. And with those portals, we can put, use instruments to introduce things like anchors into the bone. Sometimes those anchors are made of a hard material that's a calcium composite or a plastic, polyether ether ketone. Other times they're actually made of suture material that sort of balls up under the bone. Metal anchors are an option as well. I typically don't use those metal anchors. But you see in this illustration, first here, this is a double-row repair. Anchors are placed right up against the articular margin or right against the cartilage, and then the sutures are passed through the tendon, and then they're brought out to other anchors. This is what's called a knotless repair because it's a linked construct. And we'll— but again, the important thing here is really adapting the repair to the tear pattern for the individual person. Hopefully that gets the idea, but again, the idea is to get compression of the tendon down to the bone. Okay, prepping for surgery is really important. I think really success, you know, to have success you got to be prepared. This really starts with nutrition prior to surgery. I really advocate that all my patients take vitamin D, for instance, and you'll see my packet, I have a list of other medications that I really think are beneficial. We have a preoperative visit prior to surgery that's done within 30 days of rotator cuff repair. At that time we go over any outstanding questions. Get fit for a sling, give you your preoperative medications, and then also we like to do a therapy visit if possible to kind of go over the aftercare. Another key thing besides nutrition is I really advocate benzoyl peroxide. That's a cream that you apply over the shoulder for about 3 days prior. That cream reduces a bacteria in the skin called C. acnes. C. acnes is the most common cause of shoulder infection. That is very rare after a shoulder scope because we do this all arthroscopically, but nonetheless, we want to take any steps we can to prevent any infection after procedure. And then it's important not to eat or drink anything the night before surgery. The day of surgery, this is typically done in an outpatient surgery center environment. Sometimes it'll be done on the, at the hospital if somebody has other medical problems or if there's a certain insurance requirement. But either way, people go home the same day after rotator cuff repair. The procedure itself will take about an hour to do, but it's really a bigger commitment for each person because they have to come in a couple hours early prior to the procedure, then have the procedure, which takes about 45 minutes to an hour, maybe an hour and a half for a very large or massive tear, and then you got a couple hours of recovery, then go home. So it's essentially a whole day event even though the surgery itself is quite short. What are the risks and complications of a rotator cuff repair done with a shoulder scope? Well, like I said, the risk of infection or any complication with a shoulder scope is very low. Overall, the risk of complication with a shoulder scope is 1 in 100. If you look at infection, it's 1 in 5,000. A common question people ask, what are the healing rates? So not all tears actually heal. Of course, that's our goal, but it really is based on a variety of factors. Some of those are based on what we do as the surgeon. So we can do some simple modifications to improve the chances of healing. But a lot of it actually has to do with the actual tear size itself and the muscle quality. Generally speaking, if somebody has a small or medium-sized tear, you're gonna have an 80 to 90% chance of getting the tendon to heal. If you get a large or massive tear, that goes down. And it depends if they're chronic tears, you can drop to 50% or even less. Now it's important to note that it doesn't mean that people don't do well. Even with a large or massive tear, you can get partial healing and improvement in function. And that's really what people are seeking is improvement in pain, improvement in function after rotator cuff repair. What are the alter— Alternatives to a rotator cuff repair. These are the standard things we offer in orthopedics in general. Anti-inflammatories, Aleve, ibuprofen. We can do injections as well. Steroid injections are a consideration. Even PRP is a consideration. We took a look at steroid injections in particular. There's some things that we should have, we should take caution with though. Particularly with steroid injections, if we do an injection within 3 months of surgery, it raises the risk of infection. Also, data shows that if you have 2 injections in the year prior to rotator cuff repair, it raises the risk of revision procedure. So if somebody's really thinking about rotator cuff repair, we think that's— that we need to do that to prevent them from the tear getting larger over time, I really try to be very careful about steroid injections. PRP, or platelet-rich plasma, that's— you take blood off your own body. We draw some blood, spin it down, get the growth factor-rich area, which is where the platelets are, and then inject that back in. There is a recent study actually which shows that this is as effective as steroid. The downside of PRP is that it is an out-of-pocket expense currently, as in the time of this recording, 2022, and so it's not approved by insurance. There is some data that shows that PRP can improve healing after a rotator cuff repair. It's not a substantial difference, but it is small differences that meet what we call statistically significant, meaning that if you test it and compare it with and without, there's a difference. But it's not a huge difference. And then finally, therapy can be quite effective for rotator cuff tears. If you look at the data on physical therapy for treatment of rotator cuff tears, it's quite good. The problem though is that this doesn't get the tendon to heal. So if somebody's younger, we worry about the tear getting larger with time. We start to see that both groups with therapy or surgery will do well initially, but if you go further out, you see that surgery can tend to do better. And also if we have a traumatic tear, people with a traumatic tear where they've fallen and torn the tendon off, those do best if you get to them earlier rather than later. So if you wait later on, the results go down. So in those cases, I typically advocate doing a repair. But probably the number one reason we do a repair, the number one and two, is that if somebody's failed all these things. And then the second one would be if they have a tear and they're younger and we're worried about the risk of progression over time. So we're trying to prevent it from becoming a bigger problem. What does a rehab look like after rotator cuff repair? For me, this really varies by the patient. I use a customized rehab plan to meet the needs of every individual patient. It really varies on the tear size and the repair and the tissue quality at that time. What we do is we give a customized rehab plan afterwards. It really spells out the exact dates that somebody's in a sling, and when they can progress in their certain exercises. That time in the sling will vary generally from 4 to 6 weeks. Sometimes there's some exception where it may be 2 weeks, but generally it's 4 to 6 weeks. 4 weeks for a small or medium-sized tear, 6 weeks for a large, massive, or revision repair if somebody's had a previous failed repair, and then we'll progress up. What about pain, pain after surgery? I use a multimodal approach to pain. What I mean by this is we try to hit the pain pathways from multiple different aspects. An example would be would be using anti-inflammatories. An example would be using Tylenol, which works by another mechanism. Ice is another multimodal approach. Overall, if you look at the packet, you'll see that we use a variety of different methods, and 25% of our patients do not require narcotics after a rotator cuff repair. One of the big decisions at the time of the procedure is whether to have a nerve block or local anesthetic prior to the procedure. And what is that? People ask about this all the time. So nerve block, picture on the left, what you're doing is you're injecting a numbing medication or an anesthetic up at the neck where the brachial plexus comes off. The brachial plexus are the nerves that come down the neck and they run down to the shoulder. As you can imagine, if you inject local anesthetic there or numbing agent, you're gonna have complete blockade. And many times you'll have loss of motor function, meaning that the arm will feel kind of floppy afterwards. Positive side of that, complete pain control. How long does that last? 12, 18 hours, sometimes a little bit more, but generally in the 12 to 18 hours if you look at the studies. Downsides of this, there is a risk of nerve injury 'cause you're injecting that around the neck. Now, it's generally pretty safe because it's done with an ultrasound machine, so the nerves are visualized. If you look at studies though, a couple of percent of people will have some degree of symptoms, that is persistent numbness in their hands for a few months after procedure. That generally will go away over time. The risk of a permanent or severe injury is low. It's less than 1%. Other option is to do local anesthetic. Similar, you still take a numbing medication, but rather than putting the neck, you put it around the shoulder. One example is putting around the suprascapular nerve, which is right up here, right next to the shoulder itself, and then injecting around the skin to surround the shoulder. Now, if you look at that You won't have risk of nerve injury, but because you're not providing as complete of a blockade, your pain afterwards will generally be a little bit higher. So people who have the local injection typically, or often, will require more pain medication afterwards. Now, if you go out to say 24 or definitely 36 hours, there's no difference between the two. So what I'll typically tell people is a lot of this comes down to your philosophy. If you're really worried about the experience of pain afterwards, if you feel like you got a low pain tolerance, if you got a long way to travel, I think doing the nerve block is probably the best way to go. Or also if you're just really sensitive to narcotics, if you get nauseated really easy with narcotics. If your mindset is that, you know, you feel like, uh, I really want to, I, I'm really just gonna try to get through this with a minimal risk as possible. And you have the attitude that pain will, will pass, so to speak, then I think in that case, perhaps a local is the best for you. So it's an individual choice. I think the important thing is that somebody's informed about what the options are. What about recovery? How long does it take to recover? This is a graph of my patients. And if you look here, we follow out to 2 years. You see continued improvement. But really, if you compare 6 months to 2 years, there's not really a statistical difference between the groups. Okay. So maximum recovery generally is reached by about 6 months with perhaps maybe some slight increase beyond that point in time. But key in here on the far left, you can see that most of that improvement is actually in the first 3 months. So I'll tell people, you know, take 6 months for full recovery, but generally By 3 months, you're about 70% recovered. Afterwards, people wanna know, what can I do? Okay, so you're gonna have a sling. Right away, everybody can move their hand, their wrist, and their elbow. So you can go elbow up and down. The key is you're not taking your shoulder up, you're not going out to the side. You can take the sling off when you're sitting at the side. So you're sitting on the couch, you can rest your arm there, kind of mimic the position of the sling, which is just at the side. But again, you're not taking it, you're not moving it up and down. And then I tell people if they're up moving around or sleeping, they gotta have a sling on. I would say really sleeping is the hardest thing. Unfortunately, it's just one of those things you gotta get through with, with the sling. But the problem is if you're sleeping, you know, you don't really know what you're doing with your shoulders. So it's important to protect that repair. You can shower the day after the procedure. We use absorbable sutures underneath the skin with glue over the top. So those are waterproof. So that self-care is possible and you can imagine You can drink a glass of water right away. You can type. You can write because you can use your hand, your wrist, and your elbow. You're just not raising up with the shoulder. And then activities. So immediately afterwards, I actually want people walking around. This is good to just get general blood flow going. Also, I think it lowers the risk of a clot in the legs or deep vein thrombosis. That's very low risk with a shoulder scope, but still we want to take steps to prevent that. Again, you gradually advance through the rehab plan, but then people ask about sports. It's generally 4 to 6 months. It's gonna vary by the sport. Golf, 3 months to chip, 4 months, sorry, 3 months to putt, 4 months to chip, 6 months for full swing. Tennis, pretty similar. Volleying is okay around the 3 to 4 month, but full serve, stuff like that, it's gonna be 6 months. Other activities we can talk about on a specific basis. So I hope this gives you some more insight in what's involved in a rotator cuff repair and what a rotator cuff tear is all about. If you have additional questions, please feel free to ask me, and I hope you have a quick and speedy recovery. Thank you.