Procedure
Rotator cuff repair
Arthroscopic re-attachment of torn rotator cuff tendons to the humeral head with suture anchors. Restores the lifting and rotating mechanics of the shoulder when the cuff has torn off the bone.
Indications
When rotator cuff repair is the right operation
Not every rotator cuff tear needs surgery. Many partial tears and some smaller full-thickness tears settle with non-operative treatment. Surgery is considered when:
- An acute traumatic tear in a younger patient. Earlier repair gives the best chance of tendon healing and a good long-term result.
- A full-thickness tear with weakness or significant pain. Particularly when the tear is interfering with sleep, work, or daily function.
- A partial tear that has not responded to physiotherapy. After three to six months of conservative treatment.
- Progressive tears. Some tears get bigger over time. Repair before the tear becomes massive or irreparable can preserve options later.
- Active patients with high functional demands. Manual workers, sportspeople, and patients who need full overhead function for their occupation or activities.
The decision is individual. Tears in older patients with low functional demand and degenerative tears that have been present for years may not benefit from repair, even if they are full-thickness. In those cases, non-operative treatment, or in advanced cases a reverse shoulder replacement, may be the better option.
How it works
How the repair holds the tendon to the bone
The rotator cuff tendons normally insert into a footprint of bone on the humeral head. When the tendon tears off, the goal of repair is to bring the tendon back to that footprint and hold it there while it heals.
The fixation is done with suture anchors. Each anchor is a small screw-in or push-in device with sutures threaded through it. The anchor is placed into the bone of the humeral head, and the sutures are passed through the torn tendon and tied to bring the tendon down onto the footprint.
For most tears, two rows of anchors are used (a double-row repair). This recreates a broader contact area between the tendon and the bone, which improves the chance of healing.
The procedure
What happens in the operating theatre
The procedure is performed under general anaesthetic, usually with a regional nerve block to help with post-operative pain control. The patient is positioned in a beach-chair position, and the operative arm is prepped and draped free.
Two or more small skin incisions are made around the shoulder. A camera (the arthroscope) is placed through one of the portals, and instruments through the others. The shoulder joint is examined first, then the bursa above the cuff is cleared so the tear can be assessed.
The torn edge of the tendon is freed up so it can be brought back to the bone without tension. The bone footprint is prepared. The anchors are placed into the bone, and the sutures are passed through the tendon. The sutures are tied to bring the tendon down onto the footprint.
Other associated problems are addressed at the same time. Common examples include trimming the undersurface of the acromion if there is impingement, treating biceps tendon damage with a tenotomy or tenodesis, and treating AC joint arthritis if symptomatic.
The skin incisions are closed with absorbable sutures. A sling is applied at the end of the procedure. Most patients stay one night.
Recovery
What recovery looks like
The sling is worn for six weeks to protect the repair while the tendon heals back to the bone. Passive exercises (movement of the shoulder without using the shoulder muscles) start within the first week or two under physiotherapy guidance. The aim is to maintain range of motion without putting load through the repair.
Active movement out of the sling progresses through weeks six to twelve. Strengthening is introduced from around three months, starting with very light resistance and building up gradually.
Most patients can drive at six weeks once out of the sling and with safe two-handed control of the steering wheel. Office work is usually possible within two to four weeks. Manual or overhead work is later, depending on the demands of the job and the size of the tear, often three to six months.
Strength and range of motion continue to improve for six to twelve months after surgery. The repair is at its weakest in the first three months and gets stronger as the tendon heals to the bone.
Complications and risks
What can go wrong
Arthroscopic rotator cuff repair is a well-established procedure with generally good outcomes. The specific risks include (but are not limited to):
- Re-tear of the repair. A repaired tendon is never as strong as a healthy tendon. Re-tear rates depend on the size of the original tear, the quality of the tendon and muscle, and the patient's compliance with the rehabilitation. Re-tear rates can be significant in larger tears.
- Stiffness. A period of stiffness after sling removal is normal and improves with physiotherapy. A small number of patients develop significant stiffness that needs further treatment.
- Frozen shoulder. A specific condition that causes pain and stiffness in the shoulder. The condition is self-limited (gets better by itself) but recovery from frozen shoulder can take 12 to 18 months or more.
- Persistent pain. Some patients have ongoing pain after surgery, particularly if there are other associated shoulder problems that were not fully addressed.
- Infection. Very rare with arthroscopic shoulder surgery.
- Nerve injury. Rare. Stretch injuries to the brachial plexus from positioning are uncommon and usually recover.
- Complex regional pain syndrome (CRPS). A rare condition that causes pain and stiffness in the hand.
- Anaesthetic complications. Discussed separately with the anaesthetist before surgery.
- DVT. Very rare with surgery of the upper limb.
FAQ
Frequently asked questions
- How long is recovery from a rotator cuff repair?
- A sling is worn for six weeks to protect the repair while the tendon heals back to the bone. Passive exercises start within the first week or two. Active movement progresses through weeks six to twelve. Strengthening starts around three months. Most patients can drive at six weeks once out of the sling and with safe two-handed control of the steering wheel, and return to office work within two to four weeks. Strength continues to improve for six to twelve months.
- When is rotator cuff surgery indicated rather than physiotherapy?
- Surgery is considered for acute traumatic tears in younger patients (earlier repair improves healing), full-thickness tears with significant weakness or pain, partial tears that have not responded to three to six months of physiotherapy, progressive tears, and active patients with high functional demand. Many small partial tears settle with non-operative treatment alone.
- What is a re-tear, and how common is it?
- A re-tear is when the repaired tendon detaches from the bone after surgery. A repaired tendon is never as strong as a healthy tendon. Re-tear rates depend on the size of the original tear and the quality of the tendon and muscle. For larger tears, re-tear rates can be significant. Smoking also increases the risk of re-tears. Compliance with the rehabilitation protocol matters.
- Will I get full strength back after rotator cuff repair?
- Most patients regain most or all of their strength, but the timeline is slow. Strength continues to improve for six to twelve months after surgery. Some patients with massive or chronic tears retain mild residual weakness even after a successful repair. The closer the tendon and muscle quality at the time of repair, the better the long-term strength.
- Is the repair done arthroscopically?
- Yes. Dr Piper performs rotator cuff repair arthroscopically, through two or more small skin incisions, using a camera and instruments inside the shoulder joint. The torn tendon is freed up, the bone footprint is prepared, and suture anchors are placed in the bone with sutures passed through the tendon to bring it back to the footprint.
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