Rotator Cuff Repair Explained: What to Expect Before, During & After Surgery

Hi, I'm Dr. Patrick Denard from the Oregon Shoulder Institute. I'm a shoulder specialist, and this video is intended to help my patients understand their rotator cuff repair surgery, to answer questions in advance, because being informed helps you get through this process much better. And I think that, that is a collaborative relationship, and we have protocols based around evidence, but the more you understand, the better this process is going to be for you so you can prepare in advance. So I'm going to go over several things here for rotator cuff and kind of talk about beginning with the anatomy. So what is the rotator cuff? It's a series of 4 muscles that surround the ball and socket joint. These 4 muscles are subscapularis, supraspinatus, infraspinatus, and teres minor, moving front to back, help stabilize the shoulder and control rotational range of motion of the shoulder. Now, the shoulder is the most mobile joint in the body, and therefore the rotator cuff is very critical to movement of shoulder and keeping pain in the shoulder down, allow you to do all activities you want to do. What happens with a tear is the tendon detaches from the bone. This can occur in two ways. Most commonly, it's degenerative. If you look at the data, a lot of people don't quite realize, how did I get a rotator cuff tear? But actually, about 50% of people at age 65 have a full thickness rotator cuff tear. That means it occurs over time and there's genetic relationship. Work is a factor, but it's much less of a factor. The second big category is traumatic, meaning somebody falls on an outstretched arm, the tendon avulses or pulls off the bone. And these are managed differently. So if somebody has an acute, meaning traumatic, rotator cuff tear, the data says you're going to do better by having surgery earlier. And that makes sense. The tendon just got detached. The quicker you put it back down, the better somebody's going to do. Not that you can't do well later, but you do better by early repair. The more degenerative tears, oftentimes you start with conservative treatment, especially if somebody is older, say in their late 60s, 70s. There's data showing that physical therapy can be effective. But if somebody is on the younger side, say less than those ages, even if they haven't done a lot, there's probably consideration for repair because we don't want that tear to get larger over time because tears do not heal themselves. Therapy can rehab and help people get better, but the tear doesn't actually heal without surgery. So if you think about the progression over time, you want to try to get to these earlier when they are smaller to get a more reliable repair. How are they repaired? There's a lot of steps in this, but just breaking it down, once you get in there, basically speaking, what you do is you place anchors into the bone. These are typically smaller than the size of a pencil eraser, so they're anywhere from 2. 6 millimeters in size to 5 millimeters in size in terms of diameter. Those are placed in the bone, those have sutures, and those sutures are passed through the rotator cuff to repair the tendon down to the bone. And that's done all arthroscopically in my hands, which means little stab incisions where I look in with a camera and introduce instruments through little other stab incisions and cannulas in order to repair the rotator cuff down. Now, an arthroscopic approach is really the best way to do this because it's less invasive. And it allows one to see very clearly because if you can see with a camera, you can identify the tear pattern, and no one tear is really the same. That allows one to repair it in an anatomic manner and to address the repair or adapt the repair to the tear pattern. So I use a variety of techniques, and it really is patient-specific. I don't do it any one way for everybody. Doing that would be just really approaching it from a very basic standpoint. A rotator cuff is really complex and really adapted to every single person. This is an animation really showing what this looks like, just to kind of show again. Essentially here, this shows a rotator cuff repair where sutures have been placed in the bone and passed through tendon to bring it down. We typically do this in what's called a double row manner, meaning that if the tendon is mobile enough, we want to do two rows of anchors to really trap or compress the tendon down to the bone. That really provides the best chance of healing. So again, arthroscopic, meaning looking in there with a camera, we introduce instruments and, and pass those through cannulas, put anchors in the bone. It looks quite large here, but again, these are anywhere from a couple of millimeters to 5 millimeters in size. Anchors are placed, they're passed through the rotator cuff with specialized devices. Those sutures are then brought out to other anchors. We can either tie knots or use what's called knotless technology, but the basic idea is to get the rotator cuff down to the bone. If it becomes more— somebody has poor tissue quality, I'll use more complex suture weaves which are called ripstop configurations to really try to optimize the biomechanical fixation at time zero. And then if it gets very, very sophisticated, we may do other things like patching, whether that's considering dermal grafts or synthetic tissue to really augment the repair at the time of the procedure. But the Bottom line is getting the tendon down to the bone so the tendon can heal. Now, part of this for me is really making sure bone is preserved because tendon heals to bone. So that's really, really key from a technical aspect. Prepping for this rotator cuff surgery does not begin at the time of surgery, it begins months in advance. One of the things I like to do is emphasize nutrition. A lot of people think that they eat well. The reality is your body's need for fuel goes up after surgery. Your protein requirements double. So it's critical to supplement In addition to eating well, I typically advise the THRIVE Protocol, which provides a pathway that has high protein with high leucine, higher than you'll get in over-the-counter protein, as well as certain vitamins and minerals that have been shown to be associated with rotator cuff healing. I like to get a vitamin D level in my— all my patients because a third of people in the United States are vitamin D deficient. Vitamin D deficiency is associated with a higher rate of failure of rotator cuff. If you are low, we can give you high-dose treatment to get you up. I also advise that people take vitamin C twice a day because there's some studies suggesting that there's an association with rotator cuff healing using that approach. And all this information is in my 20+ page packet, but this just gives you a high-level overview of that. Prior to surgery, we have people do a preoperative visit where they get a chance to go over all the questions in advance. Of the surgery. What I really advise is somebody's gone through all my instructions so they have a clear understanding, then they can clarify what their additional questions are beyond after reading through that packet. An important thing to consider is benzoyl peroxide prior to surgery. You can get that over the counter. That is also called Clearasil. Now that's used for acne treatment, as many people know, but the reason that's important is that bacteria that live around the shoulder called C. acnes, also that produce acne, are actually the leading cause of shoulder infections. So the risk of shoulder infection after a shoulder arthroscopy or rotator cuff repair is very, very low, but we want to take every step we can to reduce that. So I do that on my end with several steps at the time of the surgery, but a simple thing that a patient can do is prior to surgery put benzoyl peroxide around the shoulder to reduce that burden. It's important not to eat or drink anything the night prior to surgery. However, I would advise carbohydrate loading. Now, if you think about this, the anesthesiologists require that you don't eat or drink anything 8 hours prior to the procedure, and they do that so that your stomach is clear, so it keeps it safe for them. The downside is you have less energy on board, and if you carbohydrate load the night prior to the procedure, it actually stores up glycogen in your body so you have that immediate energy store to help you get through the procedure, just like somebody does preparation for an athletic event like a marathon, etc. So again, that's in the THRIVE protocol. If you don't use a THRIVE protocol, you can use alternatives using carbohydrate loading with a carbohydrate drink the night prior as well. That information is in my packet. The day of surgery, this is an outpatient procedure, meaning you'll go home the same day. It's a general anesthesia, meaning you go to sleep for it. This procedure is typically pretty brief. 1 hour is typically the max. It really varies anywhere from 30 minutes to an hour and 15 minutes depending on the complexity of the procedure. Again, just through small stab incisions, very, very low risk. You bring your sling to the procedure, which we provide in advance in most cases, unless somebody's coming from out of town, in which case we will get you a prescription, we'll bring it to you. And we will fit it at the time of the procedure. Risk and complications. The risks with shoulder arthroscopy or shoulder rotator cuff repair are very, very low. The risk of infection, you know, is really 1 in several thousand. Overall complication rate is 1 in 100. Really the biggest thing here is healing variability. And this is where I really put a lot of emphasis on trying to maximize healing potential for people. This is a multifactorial approach. So nutrition is really key. This is, there are studies showing this is one of the biggest factors within somebody's control. There are other things that you can do as well. You can consider biologics such as platelet-rich plasma and bone marrow aspirate. You can consider patching the rotator cuff as well. This information is in my packet. And then of course, there's interest in peptides as well. Which are short-chain amino acids. And I can help guide somebody through all those processes and alternatives. The issue really is that those options are not covered by insurance. So there's something that somebody can consider and do, but it's an à la carte approach, for lack of a better term, at this point in time. But they're certainly available. What are the alternatives? I think it's be— before anybody does surgery, they need to understand their alternatives. Physical therapy, injections, activity modification. If you look at the success of therapy, it's actually 70% of people get better with a 6-week course of therapy for rotator cuff. It is important to note, however, that that does not heal the rotator cuff. So you can get better, but if you look at long-term outcomes of surgery compared to therapy, those who do surgery do better, especially at the 10-year mark. And that's because with surgery, you can have a higher chance of getting the tendon to heal. You can't get every tendon to heal, but with therapy you have no chance, and with surgery you have a very good chance depending on your tear. So this really comes down to how much it affects somebody and their age and kind of putting that together with their function to decide on the individual level. And that's something we would have done in clinic to really help somebody make that decision. Injection alternatives, platelet-rich plasma, steroids, an alternative. However, with steroids, you really want to avoid steroid within 3 months of shoulder surgery, whether it's replacement or repair, because that raises the risk of infection. And doing multiple steroid injections has a catabolic effect because it's not just anti-inflammatory, it breaks down tissue. So that can have some detriment on long-term outcomes of rotator cuff repair. Activity modification is something that people talk about. I don't really think this is realistic unless somebody is really unhealthy or older, because the reality is we all want to live a healthy, active life. Rehabilitation— what does it look like afterwards with rotator cuff? It's, it's highly variable because it's really, it's no one-size-fits-all all. It's a customized plan that's based on the evidence, uh, of all the literature out there that I have, and it's tailored to the repair, um, that you have. So as a general concept, Phase 1 is protect the repair, get rid of swelling. Phase 2 is restore range of motion. Phase 3 is strengthen. Phase 4 is get back to activity. But that can vary in terms of what sling time looks like. So for instance, with a very small tear and perhaps augmentation, we might do a sling for comfort only. If it's a large tear where the chance of healing is lower, that may be 6 weeks in a sling, and that's an individualized discussion that we typically have in clinic in advance. What does pain management look like? Now, it's a low-risk procedure, minimally invasive, so we can get you through this without the need for narcotics. In my series of uh, patients were looked at this and studied this. 25% of my patients do not take a single narcotic. How do we accomplish that? We use a multimodal approach, meaning that we try to hit non-narcotic pathways like anti-inflammatories with Tylenol and ibuprofen, which actually work by different mechanisms. Also using a nerve pain medication for a couple of nights. We do provide a couple of opioids. However, it's very rare for somebody to use a refill. And again, 25% of people can get through without using any of those. In addition, I think a cold compression unit is very valuable. There is randomized controlled data, I mean, Level 1 evidence that says that's effective for reducing pain and leads to lower narcotic usage. And that's really important because you want to avoid narcotics because they have a lot of downsides, um, after the procedure, both in terms of your cognitive, your mental awareness, but also in terms of constipation, etc. So your goal is to try to limit narcotics as much as possible and hopefully even take zero. You can even do things like meditation, stuff like, you know, mindfulness, and really relaxation with music as well has been shown to reduce pain after procedure. At the time of the surgery, for the immediate pain afterwards, you really have two choices. One is a nerve block, the other is a local anesthetic. With a nerve block A needle is placed in the neck that's close to the brachial plexus, which is the group of nerves that goes down your arm and numb up those nerves. That provides sensory loss and motor loss temporarily, meaning complete blockade that lasts about 12 to 18 hours. Upside of that is complete pain relief. Downside of that are twofold. One is that some people really don't like the feeling of not having control over their arm for that 12 to 18 hours. Second, is there is a small risk of nerve injury that you should be aware of. Because you're injecting a needle around the neck, there's risk of permanent injury to those nerves. That's less than 1%, but it can occur. Secondly, if you look closely at the data, a lot of people won't talk about it, but if you look closely, a few percent of people will have some numbness that persists in the hands for a few months that goes away over time. The other option is to do a local anesthetic, meaning you don't have the nerve block in the neck, I inject local medication or numbing medication around the shoulder. I hit some of the close to the, some of the major nerves, but not in the neck. There's not a risk of nerve injury doing this. However, the blockade is not as complete. So typically if somebody has a nerve block, they're gonna have zero pain after surgery. If they do a local anesthetic, they might have 3, 4, 5 outta 10 pain. If you look 24 hours, there is no difference. So how do you decide? It's a personalized approach or a personal decision. Most people choose to do the nerve block because the overall risk is very low. They get complete pain relief, which means less narcotics right out of the gate. Other people, uh, are more stoic. They may say, hey, I have a really high pain tolerance, pain is temporary, this too shall pass, that kind of thing. They may be more candidates for a local anesthetic, or especially if they're worried about the potential for any numbness, etc., afterwards. Another guideline is travel. If somebody is traveling several hours away, driving several hours away, or flying after the procedure, it's probably better to do the nerve block. Again, the risk is overall low, and that's going to provide you complete pain relief. That's going to make that travel home more easy. If, on the other hand, you're in the local area and have a short trip home, perhaps that local anesthetic is another consideration. What does the recovery look like? The majority of the recovery occurs in the first 6 months. I typically tell people— this is looking at our scores here of my patients— this is an ASCS score, American Shoulder and Elbow Surgeons score, which is a validated questionnaire we look at. And you see that most of the recovery first 6 months— in fact, the vast majority of it is within the first 3 months. So typically, say like this graft 70%, uh, people will typically rate their shoulder as 70% at 3 months, maximal recovery at 6 months. Now you can get some small gains between 6 months and a year, but it typically really levels out especially after that. Some of these scores don't, or some, some of the function that people have isn't picked up in the scoring system. That's where those kind of small gains occur. But effectively by 6 months you're not limited in anything. So it's a low-risk procedure that has very good outcomes, as you see here, but it does take some time to recover that you have to get— be aware of. What does care look like afterwards? I encourage my patients to be moving right away. I want them walking right away, for instance. That's very good for your body and getting your general health back. We do a customized rehabilitation plan that typically involves some early exercises that you that you can do based on what can be done safely within the repair or tear pattern. It's okay to take the sling off. And in fact, I would actually encourage that when you are sitting on a couch, you take the sling off and you rest it on a pillow. That's because the frame or pillow on the inside will often push in the inside of the arm and cause a little bit of swelling, which can be detrimental for the hands. So we avoid this by moving the hands early, et cetera. But when you are awake and aware, you can take the sling off and rest it to the side. Away from the body is a good position because when you're away from the body, you're taking tension off the rotator cuff. The more you're down at the side, the more tension there is on the rotator cuff repair. So being up to the side takes tension off the rotator cuff repair. You can shower the day after the procedure. Another question that comes up is driving. There's studies showing that driving is safe 2 weeks after surgery in a sling. I definitely have people do it earlier, but that's what the data supports. What does return to activity look like? So again, early on you're walking right away, you're doing exercises on your own for the first couple weeks, you go work with a formal physical therapist at the 4 to 6 week point depending on the tear itself. 3 months you're advancing back into some general kind of normal activities, probably not doing anything that accelerates the arm or heavy lifting, but you're gradually working your way up. In 6 months, you're fully released for everything, including things like golf, tennis, et cetera. People ask about golf a lot. What does that look like? I typically say putting at 3 months, chipping at 4 months, full swing at 5 to 6 months. This can vary. And of course, if you have specific questions, we will absolutely go over those because I think, you know, the biggest goal for people, or one of the biggest goals for people aside from being able to sleep and get rid of pain at night, is to get back to their function. And I'll help walk you through that. So I hope that this gives you a good overall understanding that helps support the packet information. Again, please read that packet because it really goes into a lot of detail, but this gives you some broad strokes to help you understand your rotator cuff repair. I wish you a speedy recovery and know that we are here for you every step of the way should you need us. Thank you.