Arthroscopic approaches to rotator cuff surgery have been evolving for the past decade to the point where a complete arthroscopic rotator cuff repair can be performed on a wide range of patients. Advances in the type of equipment and varying techniques allow orthopedic surgeons to visualize more and, in many ways, perform a better repair with less tissue damage than standard open or mini-open techniques. The main priority, as with any rotator cuff repair, is to anchor the torn tendon back onto the humeral bone where it belongs and allow it to heal. The healthier the tendon and more secure the fixation, the higher the chance for healing and successful rehabilitation.
Initially there was much concern over whether large rotator cuff tears would be able to be fixed entirely through a series of arthroscopic portals. Fortunately, a number of innovative surgical devices and techniques have been developed to assist in the re-approximation and repair of these complex problems. While counseling my patients, I inform them that in many respects, a complete arthroscopic rotator cuff repair can be likened to building a ship in a bottle. Both activities require experienced training, specialized instruments, and a certain amount of patience to do well.
During the procedure, multiple small incisions measuring approximately a quarter of an inch each are strategically placed around the shoulder to allow placement of the arthroscope throughout the joint. These incisions serve as “portals” that offer many different vantage points within the shoulder for arthroscopic camera visualization or for instrument placement. Without good visualization, an adequate evaluation and assessment of the rotator cuff tear cannot be accomplished. The arthroscope also allows the surgeon to examine the interior components of the shoulder and detects additional pathology that can be addressed or documented during the procedure. Often, there is a significant amount of inflamed bursal tissue that envelops the rotator cuff. This inflamed tissue has to be cleared (bursectomy) to make out the underlying rotator cuff tear pattern and the tear dimensions. Determining the tear pattern and quality of the tendon makes mobilizing and anatomically reattaching the tendon much easier.
Repairing the tendons involves first removing any degenerative cuff tissue that does not appear healthy. An area of humerus is then prepared with a surgical burr to form a clear bone area for attachment of the torn tendon. Special suture anchors are placed in the humerus and the sutures have to be passed through the torn tendon and then tied in order to anchor the tendon back onto the bone. The tear in the tendon is then sewn together and anchored to the humerus by using the suture anchors. In placing anchors and sutures our view is excellent and with camera magnification we are more critical of our technique. The learning curve for this technique can be steep and frustrating, but made increasingly easier with sports medicine fellowships such as the one I completed at University of California San Diego.
The operation is done as an outpatient procedure, which means the patient typically goes home the same day. A sling with a pillow that holds the arm away from the body is worn for up to three to six weeks. Exercises are started soon after surgery and a supervised physical therapy rehabilitation program is implemented. Although the repair must be protected to keep the sutures from pulling free, early range of motion exercises have been shown to lead to a better recovery.
Presently, results of arthroscopic repairs have shown equivalence to open and mini-open techniques with the advantage of increased mobility and improved cosmesis. The increased motion is thought to be a result of less traumatic scar tissue around the joint. In many cases, the patient’s range of motion is restored more rapidly to the point where patients have to be cautioned about excessive activity in the early healing phase. After all, no matter the size or number of incisions used in the repair, once the tendon is re-approximated to the bone it requires the same amount of time to heal.
Overall, arthroscopic repair of the rotator cuff has been an excellent addition to our treatment regimen. The dramatic improvement in arthroscopic instruments, video equipment and surgical techniques will only further our expertise and help establish this procedure as a treatment of choice for rotator cuff repairs.
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