Sunday, December 29, 2013
Surgery for rotator cuff tears: repair, smooth and move, CTA arthroplasty, reverse total shoulder
There two basic surgical procedures that are considered in the management of a rotator cuff tear:
(1) An attempt at surgical repair of the tendon back to the area on the humerus from which it was torn
(1) An attempt at surgical repair of the tendon back to the area on the humerus from which it was torn
(2) A smooth and move procedure, in which the thickened bursa and scar tissue are removed along with the rough edges of the residual cuff and prominent humeral bone leaving a smooth convex surface to articulate with the concave coracoacromial arch coupled with a gentle manipulation of the shoulder to restore complete passive range of motion. Importantly, to preserve the stabilizing effect of the coracoacromial arch, we avoid acromioplasty or sectioning of the CA ligament.
The strongest indication for a surgical repair is a traumatic rotator cuff tear in an otherwise healthy patient and shoulder. When a fall or other injury results in weakness or inability to use the arm normally x-rays are necessary to exclude a fracture and an MRI or ultrasound should be considered to evaluate the possibility of a rotator cuff tear. This evaluation needs to take place promptly, in that if a significant acute tear is present, the optimal time for repair is within the first six weeks before atrophy of the tendon, muscle and bone begins.
The strongest indication for a surgical repair is a traumatic rotator cuff tear in an otherwise healthy patient and shoulder. When a fall or other injury results in weakness or inability to use the arm normally x-rays are necessary to exclude a fracture and an MRI or ultrasound should be considered to evaluate the possibility of a rotator cuff tear. This evaluation needs to take place promptly, in that if a significant acute tear is present, the optimal time for repair is within the first six weeks before atrophy of the tendon, muscle and bone begins.
Aside from this situation, there is no urgency in considering or performing surgery for a rotator cuff tear - there is ample time for a gentle rehabilitation program and for consideration of the surgical options.
With a chronic cuff tears, the surgeon and the patient need to consider the likelihood that a durable repair can be achieved. We've found that some straightforward characteristics can be very informative about the quantity and quality of the tendon available for a repair attempt and have posted them here. A thorough review of the literature indicates that the quantity and quality of the residual tendon (not the surgical technique used) is the primary determinant of the durability of a surgical repair. It is also recognized that if a repair is undertaken, the shoulder needs to be protected from loading (i.e. not used for work, play or activities of daily living) for months afterwards. From this we can see that a repair attempt should not be undertaken unless the condition of the tendon is amenable for a durable repair. We inform patients desiring rotator cuff surgery that we will perform a repair if the quantity and quality of the tendon allows good quality cuff to be reattached to the anatomical footprint without undue tension with the arm at the side; otherwise we perform a smooth and move which allows them immediate postoperative use of the arm. This approach is supported by the many articles reviewed in this blog demonstrating that the results of attempted repair are similar whether or not the repair remains intact.
We prefer a minimally invasive open approach to rotator cuff surgery in that it is expeditious, allows examination of the shoulder throughout a full range of motion, and (because the deltoid remains intact) does not delay recovery. Our technique for cuff tendon reattachment is shown here. Basically, we use an 'inlay' technique in which the tendon is securely inserted into a groove made at the normal cuff attachment site and held there securely with multiple sutures to distribute the load. We prefer this method to 'onlay' techniques because it exposes the tendon edge to the stem cells and growth factors activated by the creation of the bony groove, because it allows for multiple sutures to create the strongest possible repair and because it allows for the possibility of some stress relaxation in the repair without loss of contact between the tendon edge and bone.
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