Rotator Cuff Repair

Supraspinatus repair or Subscapularis repair
Summary

This operation is performed for a rotator cuff tear.  The aim of the operation is to secure the torn tendon of the rotator cuff muscle to the bone to allow it to heal.  A subacromial decompression is performed at the same time to increase the subacromial space to allow the rotator cuff muscles that surround the shoulder joint more room to move.  The operation is performed under a general anaesthetic using keyhole surgery but can also be performed through a mini-open procedure.

Factors to Consider

You have been diagnosed with a rotator cuff tear.  This commonly causes pain around the outer aspect of your shoulder particularly when lifting your arm above shoulder height or at night, when you are sleeping.  The symptoms can be very similar to those felt with subacromial impingement.

Rotator cuff tears are more common the older you get and can be considered a normal part of getting older.  Many rotator cuff tears can be managed with physiotherapy by improving the strength of the remaining rotator cuff muscles.  However, if you have already tried physiotherapy but your symptoms have not improved then a rotator cuff repair is most likely the best option to manage your symptoms.

Description of Surgery

The operation can usually be performed as a daycase procedure but you will need to ensure that there is someone to drop you off and pick you up from the hospital.  You will also need to have a responsible adult at home with you on the night of the operation.

The operation is performed through 3 or 4 small (less than 1cm) cuts to your shoulder.  If the tear is quite large the operation is sometimes performed through a small (8cm) incision.  The surgeon is able to look at your shoulder joint to make sure nothing else is contributing to your symptoms.  The surgeon will then enter the space between the rotator cuff tendon and acromion and perform a subacromial decompression to allow enough space for the rotator cuff to heal.

The rotator cuff tear can then be freed to allow it to sit back on to the humerus.  Bone anchors, similar to climbing anchor bolts, are placed into the bone and the rotator cuff tendon is stitched back into place.

It is possible that there are other problems that are contributing to your symptoms that your surgeon will have identified before your operation.  These could include acromioclavicular (AC) joint arthritis or inflammation in your long head of biceps tendon.  These can almost always be managed at the same time as your rotator cuff repair but the operation may take longer.  It is still very likely that the surgery will be performed as a daycase procedure.

Anaesthetic

The operation is performed under a general anaesthetic and so you will be given instructions as to when you need to stop eating and drinking (normally the night before) before you come into hospital.  

It is common for you to be offered a nerve block to help with the pain.  The nerve block allows excellent pain relief immediately after the operation.  It is considered a safe method of providing pain relief with few complications (less than 1%).  You will wake up with a numb arm, similar to when you sleep on your arm awkwardly.  The block wears off within 12-24 hours and so it is important to take pain killers the night after the surgery even if you don’t have pain when you go to sleep.

The anaesthetist will talk more about the nerve block when they see you.  If you do not want a nerve block your pain can be well controlled with local anaesthetic given during the operation.

What are the risks?

All operations involve an element of risk.  The risks for this particular operation are small but it is important that you are aware of them.

The risk of infection is very small and is thought to be about 1%.  Most infections will settle simply with antibiotics.

Damage to nerves and blood vessels around the shoulder can occur but this is rare.

There is a small risk (less than 5%) of worse pain and stiffness around the shoulder in the form of a frozen shoulder.  This usually settles with physiotherapy but occasionally you will require an injection or further surgery to settle your symptoms.

There is a risk that your surgeon is unable to repair your rotator cuff tear if the tear has got too large.  If this happens the surgeon will inform you of this.  It is likely that you will still get some benefit from the operation due to the other procedures that will have been performed at the same time but the overall benefit may not be as much as originally anticipated.

There is also a risk that the rotator cuff repair may not heal or retear.  There is, however, good evidence that your symptoms are still likely to improve even if this were to happen although not as much as when the rotator cuff repair fully heals.

After Surgery

Pain

Local anaesthetic or a nerve block will be used during the operation and so you will feel comfortable when you first wake up.  The nerve block can make your whole arm feel numb.  This can last up to 12 hours but the shoulder may be sore after it wears off.  You will be given a combination of pain killers to go home with.  A rotator cuff repair can be very painful and so it is important to take regular pain relief. 

You may also be given an icepack.  The nurses will show you how to place the icepack on your shoulder.  The icepack should be taken off after 15 minutes  and can be used every 2 hours.

Remember, the aim of the operation is to get your arm moving normally again and so good pain relief will help you achieve this faster.  

Sling

You will wake up with your arm in a sling.  The arm should be comfortable but it is important to let the nurses know if you have pain so that further pain killers can be given.  You will need the sling during the first 4-6 weeks as the rotator cuff tear heals.  You will be able to take your arm out of the sling during this time but some movements will be restricted.  A good “rule of thumb” is to keep your arm below shoulder height during this time.

Remember, the surgery was performed to put the rotator cuff tendon back to where it should be but this needs to be protected until your body heals it there.

Dressings

There will be dressings applied to the wounds following your operation.  These can occasionally come off and will need to be replaced during the first 2 weeks after surgery to protect the wound.  

The dressings are splash proof but not waterproof and so you should avoid getting them wet.

The wounds are closed using non-dissolvable stitches.  The stitches will need to be removed at 10-14 days following surgery.  The nurses will arrange this to be done at your local GP practice before you are discharged.

Physiotherapy

Physiotherapy is absolutely essential in ensuring that your shoulder fully recovers.  You will first need to allow the rotator cuff tear to heal before getting your muscles how to work properly again.  This whole process can take up to a year.  The first goal is to recover a good range of movement before starting to strengthen the rotator cuff.  The rotator cuff will not fully heal until 3 months and so heavy lifting should be avoided during this time.

The physiotherapist should see you before the operation to explain some simple exercises you can do after the operation.  They will also ensure a physiotherapy appointment is made for you within 3 weeks of the operation.  Physiotherapy can be arranged local to you.  

Driving

You should not drive for at least 4 weeks following your surgery.  After this stage you can return to driving as long as you feel safe to drive.  This means that you feel confident that you have full control of your car and are able to swerve out of the way of something in the road.  This will vary between patients but normally takes about 6 weeks.

Return to work

This depends on what your job is.  You should be able to return to a “desk job” within a few weeks of your surgery.  If you have a more manual job it can take up to 12 weeks before you feel ready to return to work.  Please discuss this further with your surgeon or physiotherapist if you feel unsure.  A sick note can be given to you at the time of your surgery if required.  Please ask the nurses on the ward if you need one.

What to expect

Recovery following surgery can be quite variable.  Most people will be able to get rid of the sling within 4-6 weeks and be using their arm comfortably below shoulder height at this stage.  Your symptoms should be improved/improving by 3 months with the majority fully recovered by 6 months.  It can, however, take up to a year for some patients to fully improve.