Arthroscopic Rotator cuff repair
What does this surgery involve?
This is a keyhole operation that allows the direct repair of the torn tendon back to the bone. Multiple keyholes (portals) are used. There is usually a minimum of 4 keyholes. However, as many as 9 may be required for a more complex tendon repair.
During the surgery a full internal assessment of the shoulder takes place. The tear is assessed for its reparability and if needed other smaller procedures can be carried out at the same time (see below).
The bony surface, from which the tendon has torn and to which it is repaired, is roughened with the use of a burr (bone smoothing device). High strength stitches are then passed through the tendon, which is then held firmly against the bone using small devices called anchors (see picture) that are inserted into the bone. The tendon is therefore brought into close contact with the roughened bone, which enables healing to occur over approximately 12 weeks. At the end of the surgery the keyholes are closed with stitches that are removed at the first follow-up appointment at two weeks after your procedure.
What happens after the operation?
For most patients this operation will be a day case procedure. Patients who have their surgery carried out in the afternoon will, in all likelihood, be booked for an overnight stay. Depending on the individual’s recovery most will still go home the same day.
All patients require a sling after surgery in order to protect the repaired tendon whilst it heals back to the bone. Patients with small tears and good quality tendons should only require 4 weeks in a sling since it is generally possible to achieve a “secure repair” in this scenario. Those with larger tears and/or with poorer quality, thinner tendons usually require 6 weeks in a sling since the repair is likely to be “insecure” and potentially liable to re-tear in the first few weeks after surgery if not treated with care. Driving is not possible whilst in a sling, therefore the earliest that patients may drive after this surgery is between 6-8 weeks, although some may take longer.
Once the sling is removed and the mobility of the shoulder starts a degree of stiffness is to be expected. This will improve gradually. Strength then needs to be built with the help of regular physiotherapy sessions and home exercising.
Office or non-manual workers may go back to work after 2-4 weeks but those who have manual occupations will need at least 3 months off work or on light duties, possibly longer. I will discuss this with you prior to the surgery.
The overall recovery after surgery until full improvement in your symptoms has been achieved is between six months to a year, and possibly even longer than this.
Are there any additional procedures that may be necessary during rotator cuff surgery?
The biceps tendon may be an additional source of pain in patients with a rotator cuff tear. If it looks inflamed or worn it is treated in one of two ways – either detaching it from its insertion into the shoulder socket (this is called a tenotomy) or detaching it and reattaching the tendon lower down the arm (this is called a tenodesis). There are pros and cons to each technique that are discussed on the relevant page.
In the sub-acromial space (the space under the tip of the shoulder) any bony spurs that may rub on the tendon repair are removed using a high speed rotating burr. This procedure is called a subacromial decompression and is described in further detail on the relevant page. The vast majority of patients who undergo a rotator cuff repair will also require a subacromial decompression, both to increase the working space available for the repair and to release stem cells from the bone to aid with tendon healing.
What are the potential complications involved in this procedure?
Scars: There will be multiple keyholes (or portals) which heal well and rarely cause problems. Fine stitches are used and removed between ten to fourteen days after the surgery.
Bleeding: There is very little blood loss. The dressings may be blood stained however most of this is the fluid used to wash through the joint during the operation.
Infection: This is a very rare although potentially serious risk. Recent studies suggest the infection rate is between 0.5-1% for arthroscopic rotator cuff repair. The real risk for this operation may well be less. The majority of infections are superficial (in the skin around the keyholes) and will settle with a course of antibiotics. However, if you are unfortunate enough to get a deeper infection involving the anchors or suture materials, this is generally managed with further surgery to wash the joint out and potentially to remove the anchors. The main advantage of arthroscopic (keyhole) procedures over mini-open or open rotator cuff repairs is a significantly lower infection rate; in one recent study infection was 8 times less likely in patients who had an arthroscopic repair compared with those who had mini-open or open repairs.1
Swelling: The shoulder may get quite swollen during the operation. The fluid used to expand the space during surgery will leak into the surrounding tissues. Most of this drains into the dressings or gets absorbed by the body. Usually the shoulder is of normal size by the next day.
Stiffness: This is a common complication. It takes between six to eight weeks for tendon tissue to attach relatively firmly to the bone, and 12 weeks for full bonding. In view of this the shoulder is protected by means of a sling for between four to six weeks. Understandably, after a period of immobilisation the joint will be stiff. This is variable but usually improves with time.
Variable recovery: Some patients never take a painkiller after the operation and others have to for six weeks or longer. Most will fall between these two extremes.
Failure of the repair: For smaller tears the success rate is very high. One would rarely see recurrent tears. However, the larger the tear and the poorer the quality of the tendon the greater is the risk of failure. Re-tear/failure rates in large tears with poor quality tendon tissue can be as high as 40%.
Very rare complications
Nerve/ Blood vessel injury: There are no major nerves or blood vessels in the vicinity of the area in which the surgery takes place hence this must be considered a theoretical one.
Deep Vein Thrombosis and Pulmonary Embolus: The overall risk for such a complication is estimated 1 in 2000, i.e. very rare. A thrombosis is a clot that can form in the veins due to immobility. When it travels to the lungs it is called an embolus. You will be given special stockings that compress your calf and compression cuffs whilst on the operating table. There is usually no need for medication/ injections to thin the blood unless you have significant risk factors. Usually the risk of bleeding by far outweighs that of a blood clot.
Implant complications: Modern anchoring devices hold well within bone and it is very rare for these to fail. The anchors that we use are partially absorbable and, over a long time, are incorporated into the bone. Broad tape is fastened securely within these anchors and is passed through the torn tendon – the tape compresses the tendon against the bone, enabling healing of tendon to bone. The tape is very strong and tends not to fail. Usually the weak link is the tendon itself, which can be frayed and worn in some cases.
References
Vopat et al. Risk factors for infection after rotator cuff repair. Arthroscopy March 2016; 32(3): 428-434