Rotator cuff repair
What is rotator cuff repair?
The rotator cuff is formed from four muscles and tendons that attach your arm to the top of your shoulder blade. The aim of a rotator cuff repair is to alleviate pain in the shoulder and to improve power, strength and movement. The operation is suitable for people who have tears in the shoulder tendons as the result of the normal degenerative ageing processes with or without an additional injury and where the tendon tear is not so big or so longstanding that a repair operation is unlikely to help.
After the operation you should have considerable less pain and your shoulder will work much better, although the amount of strength that is restored depends upon the quality of the muscles and tendons before surgery.
What does this involve?
Rotator cuff repair is carried out in hospital under general anaesthetic with local anaesthetic also used to numb the nerves in the whole of the arm. This technique is called a regional block and is similar to the idea of an epidural anaesthetic frequently used in childbirth. This regional block not only means that a lighter general anaesthetic is required, reducing postoperative sickness and nausea, but also provides excellent pain relief afterwards. The operation usually takes around an hour and a half.
You will not be able to eat for eight hours prior to surgery although you will be able to drink small amounts of water up to four hours before. You would normally be admitted the evening before the operation and normal checks will be carried out.
A small incision will be made at the front of your shoulder, or arthroscopically through a number of small incisions around the shoulder. The first step is to remove the bone at the front of the shoulder (the acromion) and additionally to sometimes remove the very end of the collarbone if the joint between it and the acromion is part of the problem (the acromio-clavicular joint). This helps create a better view of the damaged tendons and means the tendons will no longer be under pressure once the repair is completed.
The damaged tendons are then freed and mobilised to allow them to be repositioned back on the edge of the shoulder joint where they have detached. The area of bone to which they need to be attached is then roughened to create an environment in which healing of tendon to bone can occur. Stitches are then inserted into the tendon and secured down through the bone through drill holes or using special little harpoons. The stitches are tightened to firmly hold the tendon against the bone and hold everything in the right place while natural healing occurs.
The incisions in the skin are closed with stitches that need removing after one or two weeks and waterproof dressings are applied.
When will I recover?
The operation requires a one night stay in hospital and your arm is placed into a special shoulder immobilising sling. Exercises and physiotherapy start on the day of surgery and your physiotherapist will teach you all you need to know for the first couple of weeks of recovery after discharge.
As a general guideline, your tendons take six weeks to start to securely heal to the bone and during this time they need to be protected from significant forces being passed through them. If your shoulder repair is overloaded in the early stages, the stitches can pull out of the tendon and the repair can fail. Most people need to retain the sling for six weeks but some exercises during this time are essential to stop the whole arm becoming very stiff.
After six weeks people wean themselves out of the sling and increased exercises and movements are encouraged. Most people can return to driving a car at around eight weeks and have regained good ordinary use of the shoulder by three to four months. Physiotherapy and exercises continue for six to nine months. The long recovery period reflects not only time spent getting over the operation but also time spent getting muscles that have done little for a prolonged period of time to start working well again. Activities such as running and swimming can generally start between two and three months. Golf can be resumed at four to five months but more vigorous activities such as racquet sports and sailing are rarely undertaken earlier than six months.
In addition to regular treatment with a physiotherapist, follow up is required with your surgeon. This is to monitor and guide progress and to look out for complications which are fortunately uncommon. The success rate of surgery very much depends on the initial size of the tear in the tendons and the quality of the tendons and muscles. A good assessment of this can be usually obtained preoperatively with a careful examination and the use of scans.