Arthroscopic Arthroscopic Rotator Cuff Rotator Cuff

RepairsRepairsPresentation Designed For Patient Presentation Designed For Patient

EducationEducation

Updated 2/11

University Orthopaedics & University Orthopaedics & Sports MedicineSports Medicine

OfficesOffices

Clifton (Medical Clifton (Medical Arts BuildingArts Building

WestchesterWestchester www.ucortho.comwww.ucortho.com 513-475-8690513-475-8690

University Orthopaedics & University Orthopaedics & Sports MedicineSports Medicine

SurgerySurgery

Holmes Hospital (Clifton)Holmes Hospital (Clifton) Outpatient Surgery CenterOutpatient Surgery Center

Mercy FairfieldMercy Fairfield MainMain Outpatient Surgery CenterOutpatient Surgery Center

Westchester Medical CenterWestchester Medical Center University Pointe Ambulatory Surgical University Pointe Ambulatory Surgical

Hospital (ASH)Hospital (ASH) University HospitalUniversity Hospital

AnatomyAnatomy What is the rotator What is the rotator

cuff?cuff? Supraspinatus Supraspinatus InfraspinatusInfraspinatus Teres MinorTeres Minor SubscapularisSubscapularis

What does the What does the rotator cuff do?rotator cuff do? Holds the humeral Holds the humeral

head (ball) in glenoid head (ball) in glenoid (cup)(cup)

Stabilizes the Stabilizes the shoulder jointshoulder joint

Rotator Cuff TearsRotator Cuff Tears

IncidenceIncidence How common is How common is

it? it? Very Very Rare in patients Rare in patients

younger than 40younger than 40 Incidence Incidence

steadily steadily increases with increases with ageage

Signs and symptomsSigns and symptoms PainPain

ShoulderShoulder Side of armSide of arm Often worse at nightOften worse at night Often worse with Often worse with

overhead activitiesoverhead activities WeaknessWeakness

Very large tearsVery large tears

What causes Rotator Cuff What causes Rotator Cuff Tears?Tears?

Sometimes they are simply Sometimes they are simply degenerativedegenerative

Patients who perform a lot of Patients who perform a lot of repetitive overhead activities may repetitive overhead activities may develop rotator cuff tearsdevelop rotator cuff tears

Traumatic-fall on the shoulder, or Traumatic-fall on the shoulder, or pull on the armpull on the arm

Incidence increases with ageIncidence increases with age

Natural History of RCTsNatural History of RCTs Usually begins in Usually begins in

anterior insertion of anterior insertion of supraspinatus tendonsupraspinatus tendon

Usually begins on Usually begins on articular surface as articular surface as partial tear and partial tear and progresses to full progresses to full thickness tearsthickness tears

Progresses from tendon Progresses from tendon to tendon enlarging like to tendon enlarging like a “hole in a sock”a “hole in a sock”

Once full thickness tear Once full thickness tear occurs it does not heal occurs it does not heal back to bone without back to bone without helphelp

Rotator Cuff Tear

Exposed cartilage on the humerus bone (ball)

↑→

““Footprint” of cuffFootprint” of cuff

Broad area of Broad area of greater tuberosity greater tuberosity (supraspinatus)(supraspinatus)

Other tendons are Other tendons are similarsimilar

From the articular From the articular margin to the margin to the “shoulder” of the “shoulder” of the greater tuberositygreater tuberosity

NOT just a linear NOT just a linear stripe!stripe!

Rotator Cuff Tears-Rotator Cuff Tears-DiagnosisDiagnosis

HistoryHistory

Physical ExamPhysical Exam

X-raysX-rays Often normalOften normal

MRIMRI Best test Best test

Rotator Cuff Tear ↓

Rotator Cuff Tears-Rotator Cuff Tears-TreatmentTreatment

Anti-inflammatory medications-decreasing Anti-inflammatory medications-decreasing inflammation causes decreased paininflammation causes decreased pain

Selective cortisone shots-steroids are very Selective cortisone shots-steroids are very potent anti-inflammatory medications and go potent anti-inflammatory medications and go directly to the source with little systemic directly to the source with little systemic absorptionabsorption

Physical Therapy-strengthening the remaining Physical Therapy-strengthening the remaining intact rotator cuff stabilizes the shoulder. intact rotator cuff stabilizes the shoulder. Treatment of choice for partial thickness tearsTreatment of choice for partial thickness tears

Surgery-most full thickness tears of Surgery-most full thickness tears of significant size should be surgically repaired. significant size should be surgically repaired. The fully torn cuff will not heal down to bone The fully torn cuff will not heal down to bone without help and will likely get bigger.without help and will likely get bigger.

SurgerySurgery

OpenOpen Make incisions and Make incisions and

move muscle out of move muscle out of the way in order to the way in order to expose the torn expose the torn tissuetissue

ArthroscopicArthroscopic Arthro=jointArthro=joint Scope=cameraScope=camera ““Look around joint Look around joint

with camera”with camera”

Arthroscopic Repair-Arthroscopic Repair-AdvantagesAdvantages

Less dissection = less Less dissection = less stiffnessstiffness

Preserves deltoid Preserves deltoid musclemuscle

Lower infection rateLower infection rate Better visualizationBetter visualization Ability to Ability to

evaluate/address other evaluate/address other pathologiespathologies ““Shopping Spree”Shopping Spree”

Less pain in early post-Less pain in early post-op periodop period

DECREASE RISK OF DECREASE RISK OF MAKING PATIENT MAKING PATIENT WORSEWORSE Torn biceps tendon that can be

addressed arthroscopically at the time of surgery

↑

Arthroscopic Repair-Arthroscopic Repair-AdvantagesAdvantages

Small tears easily Small tears easily repairedrepaired

Biggest advantage Biggest advantage is with larger tearsis with larger tears Can see betterCan see better Easier to mobilize Easier to mobilize

torn tissuetorn tissue Determining if it is Determining if it is

can be fixedcan be fixed Avoid big muscle Avoid big muscle

dissectiondissection

Arthroscopic Rotator Arthroscopic Rotator Cuff RepairCuff Repair

First performed in mid 90’sFirst performed in mid 90’s

Techniques and equipment continue Techniques and equipment continue to evolve such that it is an excellent to evolve such that it is an excellent optionoption

AnesthesiaAnesthesia Anesthesiologist Anesthesiologist

administers nerve block administers nerve block in pre-op holding area in pre-op holding area after giving some IV after giving some IV medicationsmedications Typically lasts about 18 Typically lasts about 18

hourshours General anesthesiaGeneral anesthesia

Patient then placed under Patient then placed under general anesthesiageneral anesthesia

Patient is positioned such Patient is positioned such that full access to the that full access to the shoulder can be obtainedshoulder can be obtained

Skin cleaned with Skin cleaned with sterilizing prepsterilizing prep

PortalsPortals Surgery done thru Surgery done thru

poke holes called poke holes called portalsportals

Typically 4-5 portals Typically 4-5 portals are utilizedare utilized

Cannulas are placed Cannulas are placed thru the portals for thru the portals for easier passage of easier passage of instruments and instruments and suturessutures

TechniqueTechnique

Complete inventory of the shoulder is Complete inventory of the shoulder is performed with the cameraperformed with the camera

Goal is to fix the rotator cuff to its Goal is to fix the rotator cuff to its anatomic positionanatomic position

Therefore, the pattern (personality) of Therefore, the pattern (personality) of the tear is evaluated the tear is evaluated

Next the cuff is fixed to bone with Next the cuff is fixed to bone with various techniques depending on the various techniques depending on the tear patterntear pattern

RepairRepair Sutures can be used to Sutures can be used to

close the tear side to close the tear side to side like a zipperside like a zipper

Finally, suture anchors Finally, suture anchors (screws with attached (screws with attached sutures are used to fix sutures are used to fix the cuff to bonethe cuff to bone Screw goes in boneScrew goes in bone Suture passed thru the Suture passed thru the

cuff and tied to bring cuff and tied to bring the tissue back to bonethe tissue back to bone

Address Associated Address Associated PathologyPathology

Sometimes other parts of Sometimes other parts of the shoulder also cause the shoulder also cause pain and can be addressed pain and can be addressed at the time if surgeryat the time if surgery Biceps tendonBiceps tendon

The tendon can simply be cut The tendon can simply be cut (tenotomy) or cut and sewn (tenotomy) or cut and sewn down to bone (tenodesis)down to bone (tenodesis)

End of the collarbone End of the collarbone (clavicle)(clavicle)

Take out end of collarbone Take out end of collarbone (distal clavicle resection)(distal clavicle resection)

Bone spurs on the shoulder Bone spurs on the shoulder blade bone (acromion)blade bone (acromion)

Smooth bone (subacromial Smooth bone (subacromial decompression)decompression)

Torn biceps tendon

↑

↑Smooth shoulder blade bone

SurgerySurgery

Most surgeries can be done with all Most surgeries can be done with all arthroscopic techniquesarthroscopic techniques

Sometimes incisions must be made to Sometimes incisions must be made to address pathology that cannot be address pathology that cannot be fixed with the camerafixed with the camera

This decision is often made at the time This decision is often made at the time of surgery after the shoulder is of surgery after the shoulder is evaluated with the cameraevaluated with the camera

Post opPost op Wake up in a slingWake up in a sling If pre-op block was successful then you If pre-op block was successful then you

should be pretty comfortable with a numb should be pretty comfortable with a numb armarm

Go home same dayGo home same day Start taking your pain medications as soon Start taking your pain medications as soon

as you get home prior to your block as you get home prior to your block wearing off. wearing off.

It can be very difficult to “catch up” if you It can be very difficult to “catch up” if you have no pain medication in your system have no pain medication in your system when your block wears off.when your block wears off.

Post-op-MedicationsPost-op-Medications

Pain medicationsPain medications Take these as neededTake these as needed Not well tolerated on an empty stomach Not well tolerated on an empty stomach

so make sure you eat something first so make sure you eat something first even if just crackerseven if just crackers

Nausea medicationsNausea medications Sometimes patients are nauseated after Sometimes patients are nauseated after

surgery from the anesthesiasurgery from the anesthesia Usually wears off in 24 hoursUsually wears off in 24 hours Can take medication if neededCan take medication if needed

Post opPost op Leave dressing intact for first 72 hours after surgery. Leave dressing intact for first 72 hours after surgery.

Reinforce if neededReinforce if needed May remove and shower at 72 hours post opMay remove and shower at 72 hours post op Do not scrub your woundsDo not scrub your wounds Simply wash your neck with soap and water and let the Simply wash your neck with soap and water and let the

soap and water run offsoap and water run off Do not soak your wounds until permitted to do so by Do not soak your wounds until permitted to do so by

your physician. NO BATH, SWIMMING OR HOT TUBS.your physician. NO BATH, SWIMMING OR HOT TUBS. If your wounds are dry, may leave open to the airIf your wounds are dry, may leave open to the air If oozing then put on a clean dry dressing and call your If oozing then put on a clean dry dressing and call your

doctordoctor Do not put any ointments on your wounds. This Do not put any ointments on your wounds. This

includes antibiotic ointments (Neosporin, Polysporin, includes antibiotic ointments (Neosporin, Polysporin, etc)etc)

It is easiest to wear a button shirtIt is easiest to wear a button shirt Wear your sling all the time except to showerWear your sling all the time except to shower

Post opPost op

Your first follow-up appointment Your first follow-up appointment should be 5-7 days post opshould be 5-7 days post op

Please make an appointment to go to Please make an appointment to go to physical therapy immediately after physical therapy immediately after your first post op appointment.your first post op appointment.

Post-Op RehabPost-Op Rehab Start passive range of Start passive range of

motion (the therapist motion (the therapist moves your shoulder moves your shoulder for you) at 1 weekfor you) at 1 week

Sling for 4-6 weeksSling for 4-6 weeks Start active range of Start active range of

motion (you move the motion (you move the shoulder yourself) shoulder yourself) when sling comes offwhen sling comes off

Start strengthening at Start strengthening at 8-12 weeks8-12 weeks

No sports, lifting for No sports, lifting for 4-6 months4-6 months

Frequently Asked Frequently Asked QuestionsQuestions

Will I have therapy post op?Will I have therapy post op? Yes. Initially 2-3 times per week then less often. Yes. Initially 2-3 times per week then less often.

Exercises must be done at home too! Exercises must be done at home too! How long do I have to wear the sling?How long do I have to wear the sling?

4-6 weeks. Longer when in an uncontrolled 4-6 weeks. Longer when in an uncontrolled environmentenvironment

When can I go back to work?When can I go back to work? This is highly variable depending on what you doThis is highly variable depending on what you do For desk jobs it could be as early as a couple For desk jobs it could be as early as a couple

daysdays Labor jobs with lifting, 4-6 monthsLabor jobs with lifting, 4-6 months

QuestionsQuestions

Any further questions should be Any further questions should be directed to your therapist or surgeondirected to your therapist or surgeon

Please call the office with questions Please call the office with questions or concernsor concerns

513-475-8690513-475-8690 www.ucortho.comwww.ucortho.com

Thank YouThank You