Rotator cuff surgery is a medical procedure that has as main purpose the repair of a torn tendon in the shoulder. There are two main approaches for this procedure, meaning the open surgery in which a large incision is made in the shoulder or the arthroscopic surgery, in which several small incisions are made. The surgeon will decide on the approach that is best used for your own particular condition; however, it is common knowledge that large tears or chronic problems are better repaired through open surgery. Arthroscopic surgery is more recommended for smaller tears and acute conditions.
The rotator cuff is comprised of muscles and tendons that actually form the a cuff over the joint over the shoulder. The main purpose of the rotator cuff is to maintain the arm in the joint and also to allow for different movements in the said joint. The tendons of these muscles are often affected in various injuries but a torn can also result from over-using that particular joint (for example, in a sport or as occupational hazard). Rotator cuff surgery is recommended when the tear is severe or when the other non-surgical treatments have failed to provide the desired results. Often times, physical therapy is recommended before and after the procedure.
Procedure of Rotator Cuff Surgery
The open rotator cuff surgery involves making a large incision in the shoulder. After the incision has been made, the surgeon will detach the shoulder muscle (deltoid) in order to better visualize the site of the tear and have complete access to the tendon. Bone spurs can also be removed during this procedure and complex reconstruction or tendon transfer might be performed for large tears. The incision is closed with stitches or staples and a dressing is applied to the wound.
The arthroscopic rotator cuff surgery involves making several smaller incisions in the affected area. The surgeon will then insert an arthroscope through one of the incision and visualize the operation area with the help of the camera that this cable also presents. The area of operation will be displayed at an enhanced resolution on a video monitor and all the necessary instruments for the operation will be introduced through these small incisions. The surgeon will use small surgical tools in order to remove damaged tissue and fragments of bone, using suture anchors to attach the tendon to the bone. These suture anchors are made from special materials and they are in time absorbed by the body, so there is no need for removal.
The cost of the rotator cuff surgery depends on the geographical location, the facility in which the surgery is performed and also on the surgeon performing the actual surgery. Also, depending on the type of procedure that is recommended, you will have to pay a different price. It is common knowledge that the arthroscopic approach is more expensive than the open approach, especially if robotic or hand assisted devices are used during the procedure. It is for the best that you check your insurance policy before you go through with the procedure, so that you make sure you are covered.
When thinking about the cost of the rotator cuff surgery, you will also have to take into consideration the physician fees, the facility fees and anesthesia costs. Plus, if there are any complications during or after the procedure, the costs for the additional medical care will add to the bill. The average cost for the rotator cuff surgery with all the included fees can reach $50.000. Once again, it is recommended that you check your insurance policy and see whether you are partially or completely covered.
These are the most common risks associated with rotator cuff surgery:
- Risks related to anesthesia – allergic reactions can range from mild to severe. This why you need to speak to your doctor and mention whether you have allergies to certain medications or not. Difficult breathing or vascular collapse will require emergency medical treatment.
- Blood loss
- Blood clots – these can travel to the lungs or legs, causing deep vein thrombosis
- Shoulder weakness
- Stiffness in the shoulder, resulting in limited mobility
- Infection at the site of the operation
- Muscle or tendon damage (during the intervention either the deltoid muscle or its tendon might be damaged; in some cases, a second surgery might be necessary to repair the damage)
- Risk of repeating the surgery because the primary surgery did not provide the expected results, either in terms of symptoms or functionality (tears that are too large)
- Nerve or artery injury (rare)
- Complex pain regional syndrome (rare)
- Re-rupturing of the rotator cuff
- Excessive scarring at the site of the incision
These are the most common complications that can occur with rotator cuff surgery:
- Post-operative frozen shoulder – this is primarily characterized by stiffness in the shoulder and it most commonly occurs in older people who have suffered surgery for tendon repairs. Physical therapy, injections with corticosteroids and additional surgery (capsular release) are recommended for the alleviation of symptoms.
- Recurrent dislocation of shoulder instability
- Stiffness is considered a complication only it has persisted for three months or more following the surgery
- Deep vein thrombosis is both a risk and a complication
- Persistent pain
- Disruption of deltoid origin
- Foreign body reactions (bioabsorbable materials)
- Neurological injury (nerve injury, stretch neuropraxia, reflex sympathetic dystrophy
- Post-operative infection with Propionibacterium Acnes
- Death (rare cases)
The best recovery is guaranteed if the rotator cuff surgery takes places shortly after an injury has occurred. However, in elder patients, the condition might develop over a long course of time, without exhibiting too many symptoms. Large tears will require a complex surgical repair and the recovery period is going to be considerably longer. During the recovery period, physical therapy is essential so as to guarantee the success of the surgery. You have to understand that surgery performed on a tendon that is aged, frayed or thinned is not going to be as successful as the surgery performed on a healthy tendon. The same goes for the recovery period, it being longer in the first case.
Immediately after the surgery, the patient will be instructed to wear a sling and a shoulder immobilizer. This will prevent the shoulder from moving and it will guarantee a faster healing of the recently operated area. The recommended time to wear a sling depends on the type of procedure (open or arthroscopic) but on average the patients are recommended to wear the sling somewhere between four and six weeks after the surgery. The recovery period can range somewhere from three to six months, depending on the type of procedure, the size of the tear and other factors. Pain medication might be prescribed to deal with the symptoms.
Physical therapy is essential during the recovery period. The physical therapist will make a post-operative assessment, so as to decide what kind of mobility and strength you have in the shoulder after the surgery. After the initial assessment, you will be given a set of exercises that you will have to perform on a daily basis. In the initial period, the physical therapist will aid the movements you make in the shoulder joint and will even perform some of the movements himself. As the area heals and you regain your mobility, you will start to make some active movements yourself. The initial objective of the physical therapy program will be to increase the mobility in the shoulder joint and to allow, gradually, for movements in all possible plans. The last movements to be rehabilitated are going to be the rotations and horizontal flexion and extension.
The second part of the physical therapy program will be to strengthen the muscles of the rotator cuff. Here, you will be given once more sets of exercises that are meant to put those muscles to work, without excessive physical activity being involved. You will also be recommended to do some water physical therapy, as this is highly indicated for this kind of problem (in the water, you do not have to defeat the gravitation and the movements are more easily made). Progressively, you can start to swim and do other sports. The last part of the physical therapy program will concentrate on involving that particular shoulder joint in the daily living activities.
Watch the Rotator Cuff Surgery video: