Rotator cuff is a tendon-muscle envelope comprised of four muscles: subscapularis, supraspinatus, infraspinatus and teres minor. All four muscles have their start points in the shoulder blade and grasp onto bone bulges of the humerus (Fig. 1). Rotator cuff is the key shoulder structure. The primary function of the rotator cuff is dynamic stabilization of the head of the humerus. Damage to one of the said four muscles significantly decreases shoulder, i.e. arm function.
Due to its position and function, the most common is injury to the supraspinatus tendon (about 90%), isolated or in combination with infraspinatus. The subscapularis tendon is subject to injury a lot less, especially to cases of isolated tear. Injury of rotator cuff tendons include inflammation of tendons (tendonitis, tendinosis), partial or complete tendon rupture (Fig. 2). Inflamation of tendons calls for a conservative treatment, while a tear in most cases requires surgical repair.
Ruptures occur as a consequence of injuries and wearing away and degeneration of tissues in older people. In sportsmen or people active in sports, especially if involving overhead activites (tennis, hand-ball, sports including throwing some object etc.), ruptures of tendons are found in an earlier life stage, even in one’s twenties. Most frequently these are partial ruptures which in time turn into total ruptures. The reason why ruptures appear at an earlier age is overwork. In an already injured tendon, the slightest injury can bring to a total rupture. A frest rotator tendon rupture should be operated on immediately. Why? The tendon will become shorter and retracted so later repair will often become impossible.
Patients complain about shoulder pain, often on the outer side of the upper arm, especially when performing some actions which are above shoulder level, and they complain about weakness of the arm. Any activities below shoulder level are performed without significant difficulties. Very often they say that even the sheets at night seem heavy. The pain appears at night and does not allow the patient to lie and sleep on that shoulder. In acute injuries, the patient cannot lift the arm away from the body.
Ultrasound of the shoulder completes the clinical features of the patient. Ultrasound gives a high probability of finding the ruptured tendon and establishing the size of the rupture. Total cuff rupture is easily determinded by ultrasound. Difficulties lie in partial ruptures when only one side of the tendon is injured and it is usually the joint side. Partial rupture means that one part of the thickness of the tendon is injured, ruptured. Size of the rupture determines the treatment method.
Magnetic resonance imaging enables the display of the whole tendon and muscle showing the position and size of the rupture and the condition of the muscle. MRI enables an insight into the retraction size of the tendon and changes on the ruptured muscle aka fatty degeneration whereby muscle is replaced by fatty tissue. .
Senior patients who do not have significant difficulties, need no surgery. They are advised to avoid intense activities during the day and to take non-steroidal anti-inflammatory medications. In all other patients, surgery is recommended. The type of surgery depends on the size and type of the rupture.
In Akromion Hospital, arthroscopic rotator cuff repairs are performed routinely.
In partial rupture, most commonly this is supraspinatus tendon rupture, cleaning is performed, debridement of the ruptured part of the tendon – if the defect is up to 10-20% of the thickness of the tendon; if the defect is larger and covers a larger surface, fixation of the tendon to the bone is necessary (Fig. 3). In case of a total rupture, the tendon is fixed in the position it occupied prior to the rupture.
Surgical techniques available to operaters can be divided into two groups; open and arthroscopic. Open surgery techniques are technically less demanding, but give a lesser view and approach to the rotator cuff tissue, and cause somewhat longer rehabilitation since tissue through which tendon rupture is approached needs to heal. Stitching the ruptured tendon and fixation to the bone with sutures introduced through tunnels drilled in the greater tubercle are standard; or, suture anchors can be used. Arthroscopic procedure for the repair of ruptured rotator cuff tendon requires a better technological equipment of the surgical team and operator experience. Arthroscopic method gives a better visualization of the injured tissue, a better possibility of mobilizing the ends of injured tendons, plus a faster rehabilitation course and recovery of the patient.
Prof Nikola Čičak and his team published and introduced a routine clinical practice of arthroscopic transosseous fixation of the rotator cuff which imitates the open technique of the rotator cuff repair with a combination of suture anchor technique and forming a transosseous tunnel through which a suture for tendon fixation is passed (Fig. 4). This method enables an optimum contact of the tendon and bone whereby creating the conditions for a firm fixation and faster healing of the repaired tendon.
Fig. 4 Arthroscopic transosseous fixation of the supraspinatus tendon
Open methods are used when we are dealing with a massive rupture of the rotator cuff, when open or arthroscopic repair is impossible. In these cases, a transposition of the surrounding muscles is done; transposition of latisimus dorzi muscle in supraspinatus and infraspinatus ruptures, and transposition of the large pectoral muscle in isolated subscapularis tendon rupture. In advanced cases, in patients where shoulder arthropathy has developed as consequence of massive rotator cuff rupture, reverse shoulder endoprosthesis is implanted. Indication for this type of prosthesis is patient’s age, above 70 years of age, and pseudoparalysis of the arm (lack of possibility to move the arm away from the body).
After the surgery, after the arthroscopic cuff repair, the patient has a shoulder sling for 3-4 weeks. The day after the surgery the patient starts physical therapy, light arm motions are performed with the help of the other arm or a physical therapist. During the first 6 weeks, the arm is not to be actively moved away from the body. During this time, full passive arm mobility is targeted. Rotator cuff muscles start to gain strenght some 8 weeks after the surgery. Usually, patients start to use the hand 2-3 weeks after the surgery is performed. Full burdening of the arm is allowed after 4 months following the surgery.