INDICATIONS

The primary goal of surgical management of rotator cuff tears is pain relief and
this is accomplished with predictable results.
Improvement of function is a secondary but important consideration.
Functional improvement is not as predictable as pain relief and depends on the a
ge of the patient, the age and size of the tear (which suggests the quality of t
he tissue and the condition of the muscle), and the postoperative rehabilitation
program.
In elderly patients or those with low activity demands, attempt a short course o
f conservative treatment (approximately 6 weeks).
If there is no improvement, we proceed to surgery to minimize the atrophy of the
rotator cuff musculature.
Surgery is appropriate for an acute rotator cuff injury in a young patient or in
an older patient (60 to 70 years of age) with a defined injury who suddenly is
unable to rotate the arm externally against resistance.
The approach chosen depends on the type of tear and the quality of the residual
tissue.
For small and moderate-sized tears (up to 3 cm) without significant retraction,
a standard anterior incision for acromioplasty is used.
Large tears (3 to 5 cm) are more challenging and usually require mobilization of
tissues.
Acromioplasty should be performed along with repair.
The results of repair without decompression are not as good as those using the c
ombined procedure.
The following principles described by Neer should be adhered to during acromiopl
asty:
Release (but not resection) of the coracoacromial ligament
Removal of the anterior lip of the acromion
Removal of part of the acromion anterior to the anterior border of the clavicle
Removal of the distal 1 to 1.5 cm of clavicle if significant degenerative change
s are found
CONTRAINDICATIONS
Any significant preoperative stiffness must be corrected before rotator cuff rep
air to avoid severe postoperative stiffness.
EQUIPMENT
Oscillating saw
Drill
Burr osteotome
Hohmann retractors
Malleable retractors
ANATOMY
The rotator cuff is composed of four muscles:
Supraspinatus
Arises from supraspinatus fossa of scapula
Inserts into superior portion of greater tuberosity
Innervated by suprascapular nerve (C5)
Supplied by suprascapular artery
The suprascapular artery is a branch of the thyrocervical artery, which arises f
rom the subclavian artery.
Infraspinatus
Arises from infraspinatus fossa of scapula
Inserts into middle portion of greater tuberosity
Innervated by suprascapular nerve (C5)
Supplied by suprascapular artery and circumflex scapular artery
The circumflex scapular artery is a branch of the subscapular artery.
Teres minor
Arises from lateral scapula
Inserts into inferior portion of greater tuberosity
Innervated by axillary nerve

Supplied by circumflex scapular artery and posterior circumflex humeral artery

The posterior circumflex humeral artery is a branch of the axillary artery.
Subscapularis
Arises from subscapular fossa of scapula
Inserts into lesser tuberosity of humerus
Innervated by upper and lower subscapular nerve
Supplied by the circumflex scapular artery, the dorsal scapular artery, the supr
ascapular artery, and the lateral thoracic artery
The rotator cuff has three functions:
Rotating the humerus with respect to the scapula
Compressing the humeral head into the glenoid fossa
Providing muscular balance
The concavity-compression effect and mechanical depression of the humeral head c
ounteract the superiorly directed force produced by the deltoid.
In essence, the rotator cuff serves to center the humeral head within the glenoi
d, to allow the deltoid to function without causing subluxation or dislocation.
Layers of the shoulder
The shoulder can be divided into four supporting layers:
I
Deltoid muscle
Pectoralis major muscle
II
Clavipectoral fascia
Conjoined tendon, short head of the biceps muscle, and coracobrachialis muscle
Coracoacromial ligament, posterior scapular fascia, and superficial bursal tissu
e
III
Deep layer of the subdeltoid bursa
Subscapularis, supraspinatus, infraspinatus, and teres minor muscles
IV
Glenohumeral joint capsule and synovium
Coracohumeral ligament
Axillary nerve anatomy
The axillary nerve is an important structure at risk during the anterolateral su
rgical approach.
It is derived from the posterior cord of the brachial plexus, C5-C6.
It innervates the deltoid and teres minor muscles.
It runs posterior under the glenohumeral joint.
It courses through the quadrangular space with the posterior circumflex humeral
artery.
It is then runs transversely across the deep surface of the deltoid, approximate
ly 7 cm below the tip of the acromion.
Dissection of the deltoid below 7 cm puts the axillary nerve at risk.
Clinical Pearls: Some surgeons advocate placing a stay suture at the apex of the
deltoid split to prevent overdissection.
Axillary nerve palsy can result in significant weakness of the deltoid muscle an
d restriction of forward elevation.
PROCEDURE
Sample excerpt does not include step-by-step text instructions for performing th
is procedure
The full content of this section includes:
Step-by-step text instructions for performing the procedure
Clinical pearls providing practical clinical tips from medical experts
Patient safety guidelines consistent with Joint Commission and OHSA standards
Links to medical evidence and related procedures
POST-PROCEDURE

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CARE
An abduction pillow, low-profile pillow sling, or a shoulder immobilizer is worn
up to 6 weeks.
This is then removed for assisted exercises in flexion and external rotation to
avoid adhesions, disuse atrophy, and disruption of the repairs.
Somewhat empirically we advance to isometric exercises of external rotation at 6
weeks, and at 12 weeks active motion is permitted.
Patients are cautioned that overaggressive use of the extremity can lead to disr
uption of the repair for 6 to 12 months.
COMPLICATIONS
Acromioplasty complications
The worst common complication is loss of anterior deltoid function.
This is caused by either axillary nerve injury or detachment of the deltoid from
the acromion.
Other complications include infection, seroma formation, hematoma, synovial fist
ula, biceps rupture, pulmonary embolus, acromial fracture, and reflex sympatheti
c dystrophy.
Rotator cuff repair complications
Complications of rotator cuff repair occur with tears of all sizes, but especial
ly with large and massive tears.
Large amounts of retracted friable tissue are difficult to repair, and repair ca
n be quite tenuous.
Because the suprascapular nerve lies only 1.8 cm from the posterosuperior glenoi
d rim, cuff mobilization should not exceed this.
Clinical Pearls: If more mobilization is necessary, capsular stripping, as repor
ted by Warren, can be done.
Transposition of the upper portion of the subscapularis tendon can result in ant
erior instability and weakness of internal rotation.
Transposition of the teres minor and infraspinatus muscles can result in externa
l rotator weakness.
Free grafts have been used with very little success and are not recommended.
Despite an excellent technical result, some patients do not return to previous a
ctivity levels. Some develop postoperative stiffness from immobilization and som
e have persistent night pain.
RESULT ANALYSIS
The clinical results of rotator cuff repair in symptomatic patients who have bee
n followed for as long as 10 years are good to excellent in a high percentage of
cases, even though rerupture of the cuff is known to occur in 20% to 65% of pat
ients.