The presentation I'm about to start is on the rotator cuff repair surgical arthroscopic releases. How do you ensure attention-free repair? Number of companies that I am consultant for receive royalties or on the board should not have any impact on the information we share. Rotator cuff tears, as you know, very common diagnosis. Many of our patients get started with non-operative treatment and when we see them in the office, you can see they try to perform as we ask them, but they have compensating movements, particularly with their core and their scapula. We sometimes need injection tests to help with the physical findings and imaging studies will often tell the truth as to which tendons are evolved. There are a number of patients that we see do not improve with non-operative treatment and we consider surgical repair. Early treatment seems to be our best approach to the maximum functional gains. Pain relief is what the patient is asking for, but in reality, what we really want to do is make sure that the problem doesn't grow worse, the tear doesn't get larger, the muscles don't deteriorate further, and we're trying to avoid some long-term consequences of a chronic rotator cuff tear. The problem with some shoulders, however, is that the patient has a stiff shoulder. The question you need to ask, is this a stiff shoulder or is this a problem with the rotator cuff tear becoming stiff? What you need to ascertain with your physical exam is the passive range of motion. That's the motion you're assisting the shoulder through. If the passive range of motion is limited, then one possibility is adhesions or adhesive capsulitis, degenerative arthritis. But if the passive motion is complete and the active motion is deficient, then this is due to the rotator cuff tear, pain, or potentially weakness. As you can see from these pictures, the patient with diabetes in the upper right-hand corner has limited motion most likely related to his adhesions, not uncommon with some of our diabetic patients. The patient in the lower right, however, is a very common finding where individuals lose their internal rotation as in this individual's right arm and they're no longer able to be symmetric with the other side. However, you would like to know before you got to the operating room, are you dealing with a stiff shoulder or a stiff shoulder due to the rotator cuff tear? The timing of repairs would be one of the reasons. When you have an acute tear, history of a trauma followed by inability to move the arm, that may be our best opportunity to get in early and fix the problem before the tissue starts going through chronic changes. The chronic tears, however, are a more common setting for us in our orthopedic practices. In fact, some people are doing quite reasonably well with their chronic tears until they have a new injury that creates an extension of the prior injury. When we deal with ease of reduction of the tendon and tendon healing, clearly the acuity of the situation or the closer to the time of the actual tear certainly can impact healing and whether or not we're dealing with a tight shoulder. We do know that if we delay the repair, which is what is done in some cases, we deal with more muscular atrophy. We could see on the scapula on the lower left, the infraspinatus, supraspinatus fosses with decreased muscle girth compared to the other side. If we put the scope inside the shoulder, we realize that tissue losses, muscle retraction, fibrotic changes will make this a more difficult tendon reconstruction and clearly more difficult for the patient to undergo the recovery process. There are different tear patterns that we should consider. The anterior superior tear, meaning the subscapularis supraspinatus, the tear that surrounds the rotator interval, may be one of the most common tear patterns that are associated with stiffness of the shoulder. The more common posterior superior tears, that's the supraspinatus infraspinatus tears, have actually less scar tissue more commonly. Typically, they have some superior migration of the humeral head, particularly if the upper border of the subscapularis is involved. That being said, they have good passive range of motion, but their active range of motion may produce a drop arm test, a lag sign, other factors that show that their active range of motion is deficient. But if we're dealing with an active patient and they have a chronic tear that now has become functionally weak, that would be a good tear to address early and not late to avoid the stiffness. When we start trying to figure out what's a low tension repair, what's a high tension repair, you can tell quickly when the scope's in the shoulder, which tendons will reach the footprint. Although we'd like to cover the footprint, it is clearly a challenge when these tendons retract, and particularly if they become somewhat fibrotic, they're not as flexible. The patient on your right, however, has the multiple delaminations. These can often be easily reconstructed and cover the entire footprint quite different than what you're looking at with your picture on the left. The imaging is also helpful. If you see hardware in a shoulder from a previous repair, that will generally give you a stiffer shoulder if that's a failed repair or a recurrent rotator cuff tear. The picture on the right is a degenerative arthritic shoulder. As you might feel, the passive range of motion is difficult in this shoulder, which would suggest it's not just the rotator cuff problem, but also the articulation of the glenohumeral joint. When you're in the operating room, the first thing you should do is put the patient through a range of motion and measure their passive range of motion under anesthesia. If there are adhesions, you can manipulate the shoulder, both in elevation, external rotation, followed by cross chest and internal rotation prior to placing the scope within the shoulder. This is what the initial step may be. We did a little manipulation on this shoulder that was stiff. You could see the subscapularis, you could see some damaged capsule in front. Our first instrument is used to release the capsule from the bursal and articular side, expose the subscapularis, and basically, to breathe the tissue of the rotator interval lateral to the coracochromal ligament. Here, we're now working on the tissue adjacent to the long head of the biceps. We're going to move up the arm to further release this tissue. When we deal with some of these shoulders with this anterior tear, this is a subscapularis pattern. You see the medial comma sign, the biceps subluxation. Again, we want to get medial to the comma sign. Now, we can actually place an anchor and lift the subscapularis out of the hole. Once we have it suspended here, we can do further releases in a safe fashion, releasing the articular capsule and the bursal tissue and avoid working deep within a hole. The capsulotomy is a common procedure that I'd like to do before after I fix the subscap, but before I go into the bursa. Here are my scopes anteriorly. I'm working from superiorly to inferiorly. I've gone to the bottom of the teres minor. I'm carefully lifting the tissue because the axillary nerve will come into view. I'm basically coming through the typical posterior portal. I will do not only articular releases, but I'm also going to take the mild debridement I'm showing of the bursal tissue to demonstrate the free margins of the tendon. The decompression is a common step for me. I don't have to take a lot of bone away unless it's necessary from the preoperative films, but I do get a better view of the large and extensive rotator cuff, and I get to mobilize the tendons in a preferred fashion. As we get to the front of the shoulder, this is often the area. The supraspinatus is the tendon that's the hardest one to repair at times. This is a shorter extension over the tuberosity, and often it gets fixed adjacent to the rotator interval, particularly the coracoid process due to the coraco-humeral ligament. Although we can get this tendon to reach the tuberosity, we are not in any way trying to cover the footprint which would only increase the tension of our repair. This is a posterior view of an anchor going to go just on the margin of the articular surface. We're not going to try to lateralize it. We'll use a combination of mattress sutures and simple sutures. The mattress sutures being placed, tying them first, they'll create some additional resistance of pull-out, and then we'll take our simple suture and cover it. As you can see, the supraspinatus leading edge is being fixed to just the articular margin graded tuberosity without an attempt of double row fixation in this particular shoulder to avoid over-tensioning the repair. Now, we have the scope in the lateral portal. I'm underneath the clavicle. I did a small debridement and I'm making a space in front of the supraspinatus. That's a supraspinatus muscle and tendon. I'm working in the front gutter, and I'm going to come down on the coracoid process. My role here is to divide the coraco-humeral ligaments. If my assistant could gently externally rotate the arm, as I'm working on the lateral margin of the coracoid, I can go on the top of it, I could go on the lateral margin, and I could go on the undersurface. I don't want to go medial where the suprascapular nerve is. Occasionally, we might want to use our biceps tendon to help us with this. In this particular case, this is a muscle tendon tear. There's still tendon on the tuberosity, so I do not want to put an anchor and pull everything over medially. I'm going to try to use the biceps to bridge this problem. I put a stay suture, a free suture in the biceps. I cut it from the superior labrum. I take it out through the rotator interval. Then what I'm going to do is bring it on top as I re-approximate the medial supraspinatus muscle and partial tendon to the lateral tendon, and incorporate the biceps as a graft to reinforce the deficient area in between. That's my posterior view, and this is my lateral view of the biceps serving as a graft to help the supraspinatus reach its destination on the tuberosity with lower tension. But we're not done. We have the infraspinatus to deal with. I'm viewing lateral portal. My anchor is in the posterior margin of the greater tuberosity. Again, you see I'm not trying to really lateralize it. I'm basically going to create mattress sutures that will incorporate the multiple layers of the infraspinatus. These mattress sutures will not only bring it to the anchor, but also bring it over the top and reduce the size of the defect. The mattress sutures will be secured, and I basically can close down my supraspinatus anteriorly, my infraspinatus posteriorly, and I may need some margin convergent sutures between. Post-operatively, the patient's placed in the typical brace with less internal rotation. They start pendulum exercises the next day. They start their assisted external rotation in and out of the sling. About one week later, I start some table slides where they could put their elbow on the table and slide their arm forward, and I increase their external rotation from zero degrees to 20 or 30 degrees depending on the comfort. I may slow this down if I have a subscapularis repair, but as you gain external rotation, the patient senses less stiffness, and that's the goal of this talk. About five weeks later is when the patient will start some flexion. I like to start it in a supine position, and internal rotation or behind the back movements do not begin until eight weeks. This puts a lot of stress on your supraspinatus and your rotator interval stitches. Wait eight weeks so you have some initial healing, and again, the strengthening can begin about 12 weeks. The results of this have been very promising. Although you're sometimes dealing with a stiff shoulder, you'd feel that there may be some patients that you need to go back to. It's very uncommon to have to go back and release adhesions. But it's important that you prepared your patients for the difficulties that are going to come. When they are a stiff shoulder preoperatively, they are likely to have some additional pain than your typical patients who have an acute tear or not as stiff preoperatively. Many of these shoulders when I re-image them, either through ultrasound or MRIs, show that the shoulder is now closed. Their functional gains and their return to work have been very well, and in fact, they're rarely compromised when compared to shoulders that don't have stiffness. That's as long as you don't have advanced osteoarthritis. Advanced osteoarthritis can give you some difficulties, probably not just a rotator cuff issue, and you need to do some separate planning for those particular patients. In conclusion, it's not uncommon for a patient that has stiffness to have pain and those that have pain have stiffness. Try to ascertain, is this a passive loss of motion, meaning the joint is stiff, or is this a loss of motion due to the deficiency or the stiffness of the rotator cuff tear? Your preoperative preparation and equally as important, your preoperative conversations with your patient to prepare them for what they're about to undergo is extremely important. It'll create less anxiety and less phone calls because you and the patient and eventually the physical therapist are all on the same page. There's no such thing as a no tension repair. The rotator cuff in all of us listening have tension in their rotator cuff with their arms at their side. But what you're trying to achieve is a low tension repair so that the goal is not to just cover the tuberosity, but create a construct that will heal predictably, but not apply extra stretch to the muscle tendon junction. You need to be aware of your rehabilitation. You may need to make adjustments. Some patients start physical therapy at five weeks, some start at three weeks. This is due to the size of the tear, the quality of your repair, and potentially the flexibility of the shoulder and the tissues you're trying to repair. Thank you for your attention. I wish you all luck at the orthopedic learning center and see you soon.

rotator cuff repair

surgical arthroscopic releases

rotator cuff tears

non-operative treatments

surgical repair