HEALTH & MEDICINE :: AUGUST/SEPTEMBER 2007
All-Arthroscopic Rotator Cuff Repair
The rotator cuff is a group of four muscles that surround the shoulder joint and assist with elevation and rotation of the arm. These muscles attach to the arm bone (humerus) by way of tendons. Tears of one or more of these rotator cuff tendons can occur due to injury or to chronic degenerative changes. The incidence of rotator cuff tears has been shown to increase with age. Rotator cuff tears may or may not be symptomatic. Those tears resulting from an acute injury usually cause immediate pain and most often require surgical repair. Tears that occur more slowly over time may cause no symptoms at all in some people and in others may become symptomatic at some point. It is not yet clear why some people with a rotator cuff tear have no pain while others may be very symptomatic.
The chief complaint in a patient with a symptomatic rotator cuff tear is shoulder pain which may radiate down the arm to the elbow. The pain is typically worse with overhead use or reaching behind to the back. Many times, the pain is worse at night and may wake the patient from sleep. Weakness of the arm may also be noted by the patient and may be a sign of a larger tear. Radio-graphs (Xrays) will sometimes show bony changes associated with the presence of a cuff tear, however, a magnetic resonance image (MRI) is usually required to confirm the diagnosis of a rotator cuff tear. This imaging allows visualization of the tendons and is useful in determining size of the tear, degree of retraction of the tear
Figure 1: Open incision revealing cuff tear
Figure 2: Absorbable anchor with suture
Figure 3: Secure fixation of rotator cuff tendon to bone
Nonoperative treatment of cuff tears can be successful, particularly when dealing with chronic tears. This can consist of medication to alleviate pain (Tylenol, anti-inflammatory medication, etc.), physical therapy, and/or cortisone injections into the area around the rotator cuff. Operative management of a cuff tear is appropriate if this nonoperative treatment fails to adequately alleviate pain. The surgical management of a cuff tear involves reattaching the rotator cuff tendon to the bone so that healing can occur. The initial period required for healing of the tendon to the bone is 4 to 6 weeks and as a result, the use of a sling is recommended during this time to avoid re-tearing of the repair. Restoration of normal strength in the tendon can take up to 4 months, at which time full activities are usually allowed.
The traditional technique used to repair a cuff tear requires an open incision and detachment or splitting of an important muscle (the deltoid muscle) to visualize the tear (Figure 1). This allows for direct exposure of the tear, removal of bone spurs, and repair of the cuff tissue. This approach however, can result in an incision that is cosmetically unappealing, greater postoperative pain and an extended period of rehabilitation. The introduction of the arthroscope (camera capable of looking into a joint) has resulted in significant advances in repair techniques for cuff tears. No direct exposure of the tear site is required as visualization is achieved with the camera placed through very small skin incisions (~1 centimeter). Removal of spurs can be performed arthroscopically without having to detach or split the deltoid muscle. All-arthroscopic repair of the rotator cuff tear is now possible due to recent advances in instrumentation and surgical technique. Absorbable or metal anchors (Figure 2) are placed into the bone and the sutures attached to these anchors are passed through the torn tissue with special suture-passing instruments. These sutures are then tied arthroscopically to secure the torn tendon back to the bone thus allowing healing of the tendon to the bone (Figure 3).
The arthroscopic repair technique, while technically challenging, has been shown in numerous recent studies to result in less pain and accelerated rehabilitation compared to the open technique. Advancements in arthroscopic suture techniques are now resulting in repairs that are as biomechanically strong or stronger than open repairs. The all-arthroscopic rotator cuff repair represents the current “state of the art” in achieving the goals of less postoperative pain, quicker and easier rehabilitation and lower rates of re-tearing of the rotator cuff.
Dr Manifold is a board certified Orthopaedic surgeon in Dover, Delaware, specializing in knee and shoulder disorders. He completed his fellowship training in knee replacement and reconstruction at The Insall Scott Kelly Institute/Beth Israel Medical Center, New York, and completed an Orthopaedic residency at New York Orthopaedic Hospital/ Columbia-Presbyterian Medical Center, New York. He graduated medical school from Temple University School of Medicine, Philadelphia. Dr. Manifold’s office practice is at Tooze, Easter & Manifold, MD, PA 720 S. Queen St. Dover, DE. To schedule an appointment, call 302-735-8700.
