The Procedure
A rotator cuff repair (RCR) is performed when the rotator cuff tendons have been torn off their attachment to the humerus bone. There are four tendons in the rotator cuff – supraspinatus, infraspinatus, teres minor, and subscapularis. Depending on the severity of it, a rotator cuff tear may involve single or multiple tendons. The surgery is performed arthroscopically (aka., minimally invasive or keyhole surgery) where the tendons are reattached using anchors.
The anchors with sutures attached are screwed into the bone. The tendon is then reattached to the bone where the anchors are placed using the sutures. The most advanced surgical techniques usually involve double-row repairs, where two rows of anchors are used to securely reattach the tendon to a large surface area of the bone. This allows the healing process to occur over a greater area and increase the likelihood of a stronger repair.
Pre Op
Whilst you wait for your surgery date, there are a few things to do:
- Speak to your health fund to confirm if the hospital fee for your surgery is covered on your policy
- Speak to your anaesthetist to confirm their fees
- Register your details with the hospital
- Read through, complete and return your paperwork to our office
- Plan your transport to and from the hospital. You won’t be able to drive yourself home after the surgery, so make sure you have a travel plan in place
- If required, arrange any recommended pre op physio appointments
- If required, get any pre op pathology tests (e.g., blood tests)
- Use benzoyl peroxide 5% wash on your shoulder for 5 applications: twice a day for two days, and then again on the morning of the surgery. This will help reduce your risk of infection from Cutibacterium acnes.
- Pack a bag for your hospital stay including regular medications in the original packaging, a loose button-up shirt to wear after surgery, nightwear, personal items including toiletries. If you have sleep apnoea, you must bring your CPAP machine.
- If you are on any blood thinners ring my office and confirm when to stop taking them before the operation.
- If you are on any diabetic tablet medications ring your anaesthetist and confirm whether you need to stop taking them before the operation
- Confirm your admission details with my office one to two business days prior to surgery
Though this can seem overwhelming, you will be provided with detailed instructions on what needs to be done so your surgery journey can be as smooth as possible.
Complications
As RCR is performed arthroscopically, the risks are significantly lower compared to open surgery. Nevertheless, any surgery carries risks, including:
- Bruising & haematoma: this will vary between each person, however bruising is a normal side effect of surgery and will resolve with time.
- Infection: for RCR, the risk of infection in around 1 in 300. It’s quite unusual and rare for an infection to develop, however they can occur.
- Frozen shoulder occurs in maybe 5% of cases: any RCR surgery can result in frozen shoulder, where the shoulder is mildly stiff and painful, however it is a condition that will always improve, usually over a few months. Incidentally, frozen shoulder can help with the RCR recovery as it can act as an internal splint protecting the repair and helping it heal safely. Frozen shoulder will recover of its own accord over time
- Retear: retearing the tendons can be as high as 40%, which is why post-op recovery and healing following surgery is very important. With a good surgical repair and careful postop immobilisation of the shoulder retear of the repair has fortunately become quite rare.
- Nerve injury: in RCR surgeries, the risk of nerve injuries is around 1 in maybe 4000. Nerve injuries are very rare in this type of procedure.
- Anaesthetic risks: as RCR is performed under a general anaesthetic (GA), there are the usual risks associated with this. In Australia, the risk of mortality from GA is around 1 in 100,000. Fortunately, Australia is one of the safest places to undergo a GA. For context, the risk of death in a car accident in Queensland is around 1 in 10,000.
- DVT and PE: deep vein thrombosis and pulmonary embolism are blood clots that form in either the lower limbs or your lungs. If left untreated, DVT and PE can have serious effects, however if treated promptly, the risks are significantly lowered. More information can be found here
- Wound issues: some superficial issues can develop on the wounds after surgery, however most will require a small intervention to resolve the problem.
- Sling issues: wearing the sling during your recovery can result in some swelling sitting in certain areas along your shoulder and arm. This mostly resolves quite rapidly, however residual swelling can be present for several months after surgery.
- Numbness and tingling in the fingers: this can occur when the ulnar nerve gets stretched behind the elbow when your arm is at a 90-degree angle whilst wearing the sling. Stretching the arm and releasing the sling so that your elbow sits in a much more extended position can help fix this issue.
Day of Surgery
Your admission details will be confirmed one to two business days prior to surgery. You will need to make note of your admission time and your fasting time. Your admission time may be as early as 6am. If you aren’t local to Brisbane, it is usually recommended that you stay the night before in case your admission is early.
When you arrive at the hospital, you will go through the admissions process and then be taken through to the surgical waiting area. Your anaesthetist will have a short consultation with you before you go into theatre and under general anaesthetic. I will say hi to you before the surgery in the anaesthetic bay of the operating theatre and mark your operation site with you.
Your hospital stay will usually be one night. The nurses will change your dressings the morning after surgery. You will be discharged usually around 10am. I will see you before your discharge. I will provide you with a folder containing a detailed postoperative pack including a letter telling you what I found at surgery and exactly what I did in your operation along with information about your rehabilitation and postoperative care. Remember to have someone available to take you home from the hospital.
Post Op Recovery & Healing
Patients will be in a sling for six weeks following surgery, as such they will be unable to drive. Additionally, patients will need to take time off work, as well as other recreational physical activities, to allow adequate rest and healing to occur. Exact durations are variable, however it can be up to three months post-surgery before returning to work.
The most crucial part of the healing process following RCR happens between the tendon and the bone. Immediately after the tendon is reattached during surgery, a small layer of clot forms between the tendon and the bone. Specialised cells called fibroblasts travel from the bloodstream to the clot and help to form collagen fibres during the healing process. The most significant formation of collagen happens in the first 4 to 6 weeks after surgery.
Initially, the collagen is formed in a haphazard way, however it needs to be modelled into structured matrixes where the collagen fibres run parallel to each other. As the paralleled matrix forms, the stronger the connection between the tendon and the bone. This remodelling process usually occurs over a 6 to 12 month period, however it is most rapid in the first 4 to 12 weeks after surgery. Most of the remodelling is completed within 4 to 6 months postoperatively.
During the healing process, light loading across the shoulder and light physiotherapy help to stimulate the remodelling process and further strength the connection between the tendon and the bone.
A review with Dr Cutbush will be organised at around 6 weeks post-op. Usually, patients are reviewed at 6 weeks, 12 weeks, 6 months, 12 months and 24 months post-op. For these review appointment an MRI scan may be requested of the patient prior to the appointment.
Rehabilitation
Postoperative rehabilitation after rotator cuff repair surgery is complex and requires the input of an experienced physiotherapist.
I will typically advise immobilisation of the shoulder for the first 3 months following surgery in order to protect the repair and avoid retear of the rotator cuff. The shoulder will be immobilised in a sling for the first 6 weeks. If the tear is a large tear and at risk of retear I will often advise a further 6 weeks of partial sling immobilisation with the sling being worn when leaving the house. Rarely will I recommend 12 weeks of full-time sling immobilisation. I will check the repair at 6 and 12 weeks with an MRI to confirm that the repair is intact and to guide the rehabilitation protocol.
In the first 6 weeks after surgery, the shoulder needs to be immobilised which requires wearing a sling. Light exercises can be undertaken, as advised by the physiotherapist, that don’t place any strain or pressure on the rotator cuff repair.
From week 7 postoperatively, if the sling no longer needs to be used, shoulder exercises can be increased a little, though they remain light. The physiotherapist will give instructions on exercises involving lifting the arm to restore the range of motion to the shoulder.
At 12 weeks after surgery, light strengthening exercises can be commenced depending on the MRI results.
Rehabilitation takes between 6 and 12 months after surgery. The postop rehabilitation after a rotator cuff repair is the longest of all the shoulder rehabs. The shoulder tends to ache and the rehab seems to take forever.
Physiotherapy Guidelines
Day One Physio Guidelines
The hospital physio will demonstrate how to fit your sling and how to eat, shower and dress whilst in your sling. Please make sure you go through these things with the physio so that you get them really clear in your mind before you leave hospital.
The rotator cuff tendons have poor blood supply and have limited healing potential. Reasonable healing of the tendon takes at least 12 weeks, hence the caution during the first 3 months and need for care from day one.
Day one (PHASE ONE – Early Healing Protective Phase)
- Education and precautions – “protective phase”
- New collagen network requires gentle stresses to positively affect fibre orientation – strict passive exercises only
- Immobilisation in sling at all times other than washing or doing exercises
- ADL (activities of daily living) advice – no active motion of shoulder, no lifting, light use of hand in sling only, no tucking in shirts, no weight bearing, pillow under elbow when sleeping if required
- Pain management advice – correct sling fit is paramount, ice
Patient seen day one in hospital:
- Education and precautions “protective phase”
- No active motion of the shoulder joint
- Immobilised in a sling at all times except for washing and physio exercises
- Ultra sling often chosen because it helps to prevent internal rotation and tension on the repair and limits contracture of rotator interval.
- Ensure good fit of sling, patient able to don/doff correctly, if incorrect size then new sling needs to be arranged
- Demonstrate activities of daily living (showering, dressing etc)
- Shoulder passive only movements to minimise chances of excessive GH (glenohumeral) stiffness
- Passive pendulum, if small repair OK to perform small circular motion, do not do body swings as research indicates no GH (glenohumeral) motion in this exercise and patient unsteady.
- Passive forward lean – check surgeons passive limit range generally 120 degrees, if large tenuous repair for slow rehab delete this exercise. If subscapularis repair, perform with elbow bent and resting on table
- Passive external rotation – generally 20 degrees, if subscapularis repair 0 Elbow Extension/flexion – 4 times a day, if LHB (long head biceps) tenodesis, assistive active range with precautions of no load on biceps
- Wrist/hand ROM (range of motion) – care no forceful grip
- C spine ROM (cervical spine range of motion)
- Gentle scapular neutral exercises / general posture
Follow up:
See local physiotherapist week 1-2 with good understanding of post op rehab guidelines and precautions
Results After Surgery
Generally, rotator cuff repair surgery will achieve good to excellent results in 90 to 95% of patients, with improvement in pain and function within six months after the procedure. Several factors can affect the long-term results of RCR surgery.
- Patient compliance: the repair is a temporary reattachment of the tendon to the bone, with long-term success of the procedure dependent on the healing process. If the tendon is subjected to too much stress during recovery, the repair can fail. This is why adhering to the recommended recovery protocols is essential to achieve good long-term results.
- Degenerative changes: if a tendon tear has been left for a long time, the muscle can atrophy or waste, which can result in the muscle being replaced with fibrous, fatty tissue. When this occurs, the muscle has a very poor chance of functioning again. Long-standing tears can also result in arthritic changes in the shoulder, which can often hinder the success of surgery relieving the symptoms of pain and dysfunction. Unfortunately, significant arthritic changes will be a contraindication for surgery.
- Size of the tear: large tendon tears mean more strain is placed on the sutures that are used during surgery to reattach the torn tendon to the bone. Larger tears can also be technically difficult. Large tears can also cause the tendon to retract from where they normally attach to the humerus, and in some cases, become so scarred that it is impossible to stretch them back to their normal position.