Arthroscopic and open rotator cuff sutures

Preliminary remarks

The rotator cuff consists of 4 connected muscles arising from the scapula and connecting to the head of humerus where they are attached with their tendons (see figures 1 and 2).
It moves the arm to the side and up, rotates it outwards and inwards and stabilizes the arm at the upper body.
Due to an accident or increasing wear due to high mechanic strain, a tear of one or several tendons may occur. The incidence of rotator cuff tears increases with age, so that formerly there was the predominant opinion that rotator cuff tears were a disease coming with age which did not require special treatment. This opinion has been proven wrong in the last two decades.

Fig. 1: Lateral view of the schoulder with the insertion of the rotator cuff muscles

Fig. 2: Lateral view of the tendons

Treatment objective

The objective of the surgical treatment is to regain muscle power and movability and to eliminate pain. The surgical procedure depends on the individual situation. Depending on localization, extent and age of the tear, a suture and refixing, resp., of the tendon to the humerus is intended using an arthroscopic technique. The open surgery technique is used increasingly less often.
If the tear cannot be sutured in an arthroscopic way, an open procedure must be used, but as a rule the refixable tears may be reconstructed arthroscopically with good success.
If the torn tendon has shrunken back so far that it can no longer be fixed to the head of humerus and if the associated muscle has decreased as well, it can be replaced by means of a muscle/tendon transfer.
In addition, the space below the acromion is expanded (acromioplastic) since otherwise the seam under the shoulder roof is chafed.

Arthroscopic surgery technique

Fig. 3 and 4: Illustration of a tyoical rotator cuff lesion and milling of a bony trough to improve the healing of the refixed tendon.

Fig. 5: Suture anchor with 2 sutures

Fig. 6: Screwing the suture anchor into the prepared bony trough.

Fig 7: Loading of the torn tendon

Fig. 8: Refixed tendon with a medial and a lateral row of sutuer anchors (double row technique)

Fig. 9: Arthroscopic acromioplasty

Arthroscopic surgery technique

Latissimus dorsi transfer

Fig. 10: Positioning and skin incision. After the arthroscopy and the treatment of the long head of the biceps tendon the skin is incised along the posterior axillary fold.

 

Fig. 11: Prepared tendon of the latissimus dorsi muscle before the detachement (red line)

Fig. 12: Rotator cuff defect and detached tendon of the latissimus dorsi muscle.

Fig.13: Transferred and fixed latissimus dorsi muscle.

For an arthroscopic or open rotator cuff suture, the patient has to stay at the clinic for about 4 - 5 days. In case of muscle transfer, the stay in the clinic is between 5 and 6 days. The patient arrives in the afternoon of the day before surgery.

Follow-up treatment

After a rotator cuff reconstruction, a temporary immobilization using a tube bandage (Gilchrist bandage) is required for about 2 days. Then, the arm is immobilized by means of an abduction splint for further 3 weeks. In case of large, extended tears requiring a muscle transplant, the shoulder is immobilized using an abduction splint for 3 weeks. In order to assure optimum healing and regeneration, an intensive, phase-adjusted physiotherapy with manual treatment, lymphatic drainage, cooling, moist warmth, massages and electrotherapy is required. The tendon takes at least 12 weeks to heal; and it takes 5 - 6 months until the arm and shoulder have regained their full function. For a muscle transfer, a therapy time of at least 6 months has to be scheduled.

Inability to work

In case of office, teaching, management or similar work, a return to work is reasonably possible after 3 - 6 weeks. Patients receiving a muscle transfer should expect an inability to work for 3 months. Patients performing heavy physical work will need the full rehabilitation time before returning to work.
Driving is possible after 6 - 8 weeks.

Ability to do sport

Depending on the type of sport, training may be resumed after about 3 months, and in case of muscle flap plastics after about 6 months. Before resumption of training, a control examination should be performed at our clinic in order to identify possible deficits in muscle power and movements and modify the individual training program.