Surgical Treatment

Surgery

Surgery can be helpful in the management of rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects). The surgical procedures can range from a simple smoothing of the roughened bone [Figure 11] to a resurfacing of the humeral head with a smooth prosthesis , such as a CTA head, fixed to the shaft of the arm bone (humerus) [Figure 12]. If the joint is unstable, a reversed prosthesis, such as the reverse Delta [Figure 13] may be needed. Consultation by the Shoulder and Elbow Service at the University of Washington regarding the diagnosis and treatment of cuff tear arthropathy may be requested by using our online referrals website.

If exercises do not improve the comfort and function of the shoulder, surgery may be necessary to create a smooth gliding surface on the humeral head (ball of the arm bone). This surgery may consist of rounding off any rough edges on the joint surface and removing interfering soft tissue as was performed for the individual whose shoulder is shown in the x-ray.

Surgical Procedure

Open Repair

· Intraoperative photograph of an open rotator cuff repair illustrating the typical size of a surgical incision.

· (Courtesy of Louis Rizio, MD.)

· Open repair is performed without arthroscopy.

· The surgeon makes an incision over the shoulder and detaches the deltoid muscle to gain access to and improve visualization of the torn rotator cuff.

· The surgeon reaches the rotator cuff by dissecting through muscle and other tissues.

· The surgeon will usually perform an acromioplasty (removal of bone spurs from the undersurface of the acromion) as well.

· The incision is typically several centimeters long. the surgeon makes a 10 to 12 centimetre incision in the side of the shoulder.

· Skin incisions are closed with stitches and dressings applied.

· Open repair was the first technique used to repair a torn rotator cuff;

The tendon is anchored to the bone in one of two ways:

1. small holes are drilled in the prepared area of bone.

Strong stitches are placed in the end of the torn tendon and then looped through the holes to anchor the tendon to the bone.

2. small, strong suture anchors, with stitches attached, are fixed into the bone.

These suture anchors are made of metal, plastic or a synthetic material that is eventually absorbed by the body.

The stitches are then passed through the torn end of the tendon and tied down to the anchors

http://www.rafflesmedicalgroup.com/web/Contents/Contents.aspx?ContId=1078

Mini-Open Repair

· In this intraoperative photograph, the typical incision size for a mini-open rotator cuff repair is shown in black on a patient''s left shoulder. The yellow area indicates the incision used to perform the arthroscopy.

· (Courtesy of Louis Rizio, MD.)

· As the name implies, mini-open repair is a smaller version of the open technique.

· The incision is typically 3 cm to 5 cm in length.

· This technique also incorporates arthroscopy to visualize the tear and assess and treat damage to other structures within the joint (it is used to asses the Shoulder Surgery Exercise Guide and remove the spurs under the acromion). Arthroscopic removal of spurs (acromioplasty) avoids the need to detach the deltoid muscle. The arthroscope is used to locate the tear.

· Once the arthroscopic portion of the procedure is completed, the surgeon proceeds to the mini-open incision to repair the rotator cuff.

^· Mini-open repair can be performed on an outpatient basis. Currently, this is one of the most commonly used methods of treating a torn rotator cuff; results have been equal to those for open repair. The mini-open repair has also proven to be durable over the long-term.¹⁴

All-Arthroscopic Repair

· Arthroscopic photographs of a rotator cuff tear (left) and the final repair (right). This was performed all-arthroscopically. Sutures (green) were used to reattach the tendon back to bone (arrow).

· (Courtesy of Louis Rizio, MD.)

· This technique uses multiple small incisions (portals) and arthroscopic technology to visualize and repair the rotator cuff.

· All-arthroscopic repair is usually an outpatient procedure. The technique is very challenging, and the learning curve for surgeons is steep. It appears that the results are comparable to those for mini-open repair and open repair.

The Surgical Procedure

Arthroscopy with small incisions: This is done through several small incisions, each less than one centimetre long. The arthroscope is a thin instrument containing a miniature video camera and light source. It allows the surgeon to see inside of the shoulder joint and perform the procedure while watching a video monitor.

The arthroscope is inserted through a small incision in the shoulder. Working through another small incision, the surgeon uses tiny cutting instruments to trim the edges of the tendon and then removes fragments of torn cuff tendon. Small grinding instruments may be used to remove a bone spur from the acromion and prevent further damage to a tendon. Small tears in the tendon are then repaired.

http://orthoinfo.aaos.org/topic.cfm?topic=a00406

http://www.rafflesmedicalgroup.com/web/Contents/Contents.aspx?ContId=1078

http://www.aafp.org/afp/980215ap/fongemie.html

http://www.orthop.washington.edu/UserFiles/File/matsen/2006_RR_Matsen_ReverseShoulder.pdf

If exercises do not improve the comfort and function of the shoulder, surgery may be necessary to create a smooth gliding surface on the humeral head (ball of the arm bone). This surgery may consist of rounding off any rough edges on the joint surface and removing interfering soft tissue as was performed for the individual whose shoulder is shown in the x-ray. [Figure 8].

Alternatively, the situation may require replacing the joint surface with a smooth metal prosthesis with a stem that is fixed by a press fit in the shaft of the bone as is shown in the diagram. [Figure 9].

In cases where rotator cuff tear arthropathy (shoulder arthritis associated with massive rotator cuff defects) is associated with instability of the joint, a reversed or “reverse Delta” prosthesis, may be needed to fix the fulcrum of shoulder movement. [Figure 10]