A Patient s Guide to Rotator Cuff Repair Surgery

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1 NewYork-Presbyterian Columbia ORTHOPAEDICS A Patient s Guide to Rotator Cuff Repair Surgery

2 NewYork-Presbyterian Columbia ORTHOPAEDICS

The Rotator Cuff At Columbia Orthopaedics, patients find nationally recognized specialists with years of experience in the diagnosis and treatment of diseases and injuries to the rotator cuff a group

3 The Rotator Cuff At Columbia Orthopaedics, patients find nationally recognized specialists with years of experience in the diagnosis and treatment of diseases and injuries to the rotator cuff a group A Patient s Guide to Rotator Cuff Repair Surgery of four tendons that form a cuff over the upper end of the arm. The rotator cuff provides stability to the shoulder joint and enables a person to lift and rotate their arm. A common cause of pain and disability in adults, rotator cuff problems include full or partial tears, tendonitis, inflammation, bursitis, and impingement syndrome. Today, with advances in minimally invasive approaches, rotator cuff conditions, in nearly all cases, can be managed arthroscopically, allowing patients to recover from surgery faster and with outstanding results.

Rotator cuff problems may begin as mild to moderate weakness in the shoulder due to degeneration of the tendon.

A tear can also occur when lifting a heavy object or by acute trauma.

MRI of tendon tear The First Steps of Treatment NSAIDs (non-steroidal anti-inflammatory drugs), physical therapy referral and a home exercise program are typically recommended as the initial

4 Rotator cuff problems may begin as mild to moderate weakness in the shoulder due to degeneration of the tendon. This degeneration can progressively worsen into a partial or complete tear causing pain, increasing weakness in the arm, and loss of motion. A tear can also occur when lifting a heavy object or by acute trauma. Irritation of the rotator cuff often develops in swimmers, baseball pitchers, and other throwing athletes or those who do repetitive lifting or overhead movements. MRI of tendon tear The First Steps of Treatment NSAIDs (non-steroidal anti-inflammatory drugs), physical therapy referral and a home exercise program are typically recommended as the initial non-operative program for treatment of rotator cuff problems. In some patients, a cortisone injection may be necessary as well. Cortisone is a strong antiinflammatory medication that can be injected directly into the inflamed bursa and lead to longlasting pain relief in patients. Multiple cortisone injections are not usually recommended (usually no more than three to four per year). Indications for Surgery Surgery may be indicated for a rotator cuff tear when nonoperative treatment can no longer address the pain, weakness, loss of function, and limited motion associated with this condition. Immediate surgical intervention may be recommended if a patient experiences profound weakness and cannot raise the arm after an acute injury, for example. An imaging study such as an MRI is indicated to assess the size of the tear. Rotator Cuff Surgery Repair of a major tear of the rotator cuff can be performed in three ways arthroscopically, miniopen, or open. Partial tears are usually repaired arthroscopically; small to medium tears are generally repaired with either an arthroscopic or mini-open approach; and large and massive tears are typically repaired with either an arthroscopic or open approach. Each option will be explored in discussion between you and your surgeon. The goal of surgery for a torn rotator cuff is to reattach the tendon to the ball of the joint (humeral head) and promote healing of the tendon to the bone. Regardless of the surgical approach, patients will achieve similar levels of pain relief and improvement in strength with healing of the torn tendon to the bone. Rotator cuff repair typically takes one to two hours, followed by several hours in the recovery room.

Understanding Shoulder Anatomy Patients are usually discharged the same day. Some rotator cuff repair patients may stay overnight following open repair or tendon transfer procedures.

This minimally invasive surgical technique uses a small fiberoptic camera (arthroscope) to view the inside of the joint for diagnostic and treatment purposes.

After the arthroscope is inserted, fluid is injected to inflate the joint to allow for visualization of the internal structures.

During the procedure, your surgeon will also insert surgical instruments through other small incisions in the shoulder to first perform a bursectomy (removal of the inflamed bursal sac) and an

5 Understanding Shoulder Anatomy Patients are usually discharged the same day. Some rotator cuff repair patients may stay overnight following open repair or tendon transfer procedures. Arthroscopic Repair Arthroscopic rotator cuff repair can be performed through several incisions. Arthroscopy is one of the most common orthopaedic procedures performed in the United States. This minimally invasive surgical technique uses a small fiberoptic camera (arthroscope) to view the inside of the joint for diagnostic and treatment purposes. Approximately four millimeters in diameter, the arthroscope can be inserted through incisions as small as 1/8 of an inch. After the arthroscope is inserted, fluid is injected to inflate the joint to allow for visualization of the internal structures. The scope transmits a highresolution image of the inside of the shoulder to a nearby monitor that is viewed by your surgeon. During the procedure, your surgeon will also insert surgical instruments through other small incisions in the shoulder to first perform a bursectomy (removal of the inflamed bursal sac) and an acromioplasty a procedure that removes bone spurs from the acromion the projection of the scapula (shoulder blade) that forms the point of the shoulder. Then your surgeon will repair the torn rotator cuff. The shoulder is one of the most flexible joints in the body; however, it is also an unstable joint because of the range of motion it provides. It is comprised of three bones the upper arm bone (humerus), the shoulder blade (scapula), and the collarbone (clavicle). Two joints are responsible for shoulder movement the scapulothoracic and the glenohumeral joint, which is the familiar ball-and-socket structure that allows complete range of motion. The bones of the shoulder are held in place by muscles, tendons, and ligaments. Tendons are tough cords of tissue that attach the shoulder muscles to bone and assist the muscles in moving the shoulder. Ligaments attach shoulder bones to each other, providing stability. The head of the upper arm bone (humeral head) rests in a shallow socket in the shoulder blade called the glenoid. A firm cartilage rim (labrum) surrounds the socket to help stabilize the joint and serves as an attachment site for several ligaments. The deltoid muscle is a thick triangular muscle covering the shoulder joint and is used to raise the arm from the side. The rotator cuff is composed of four tendons that attach to the top of the humerus and provide mobility and strength to the shoulder. The glenoid socket and humeral head are both cushioned by articular cartilage (surface cartilage). A bursal sac is on top of the rotator cuff and assists to allow smooth movement of the joint. When this bursal sac gets inflamed, it is referred to as bursitis. Arthroscopy minimizes trauma to the muscles, ligaments, and tissues and results in a more rapid recovery and less scarring. Front Back Anatomy of the Rotator Cuff

Mini-Open Repair A less-invasive version of open surgery, the mini-open repair is performed in combination with arthroscopy and can be accomplished through an incision of between three and five

An arthroscope is first used to visualize the tear, assess the damage, and perform a bursectomy (removal of the inflamed bursal sac) and an acromioplasty a procedure that removes bone spurs from

Your surgeon then proceeds to the mini-open incision to repair the rotator cuff.

6 Mini-Open Repair A less-invasive version of open surgery, the mini-open repair is performed in combination with arthroscopy and can be accomplished through an incision of between three and five centimeters. An arthroscope is first used to visualize the tear, assess the damage, and perform a bursectomy (removal of the inflamed bursal sac) and an acromioplasty a procedure that removes bone spurs from the acromion the projection of the scapula (shoulder blade) that forms Arthroscopic view of rotator cuff tear the point of the shoulder. Your surgeon then proceeds to the mini-open incision to repair the rotator cuff. Open Repair Open repair is a major surgical procedure and may require the surgeon to partially detach the deltoid muscle at the top of the shoulder in order to reach the torn rotator cuff. At the same time, the surgeon can address any impingement of the acromion (by spurs), by creating additional space for the rotator cuff this is referred to as an acromioplasty. The open technique was the first approach used to repair a torn rotator cuff and continues to achieve the Arthroscopic view of rotator cuff repair desired result of restoring function and reducing pain.

Role of Anesthesiology The surgeons of Columbia Orthopaedics work closely with a highly skilled anesthesiology team that has a great deal of experience in managing patients having shoulder/upper

7 Role of Anesthesiology The surgeons of Columbia Orthopaedics work closely with a highly skilled anesthesiology team that has a great deal of experience in managing patients having shoulder/upper extremity surgery using an interscalene block a procedure that selectively anesthesizes the extremity. General anesthesia may be necessary in some cases as well. The regional block will provide pain relief up to eighteen hours following surgery. When the block begins to wear off, pain relief can be achieved through a combination of oral medications (narcotics and analgesics). It is important for patients to take their medications at the appropriate intervals in order to stay ahead of the pain curve. At about four days post-op, many patients have already stopped taking oral narcotics and are managing any discomfort with over-the-counter analgesics (for example, Tylenol, Advil or Aleve). The Road to Recovery Following rotator cuff surgery, your therapy progresses in stages. Initially, the repair needs to be protected until adequate healing of the tendon to bone occurs. Therefore, patients undergoing arthroscopic rotator cuff repair generally do not begin active therapy for up to six weeks depending on the size of the tear. Icing is important and should be done frequently throughout the day. A sling is worn for the first week, including during sleep with the operative arm elevated on a pillow. During this first week, patients may come out of the sling three times a day to move their elbow, wrist and fingers. The sling should be worn four to six weeks, especially when you are in a setting that may make your arm vulnerable to jostling (sleep and in public). Patients will have their first post-operative visit within two weeks after surgery but should call the office with questions or concerns at any time. If you experience any signs of infection (increased swelling, redness, drainage from the incisions (not clear fluid from the arthroscopy but yellowish, thick fluid like pus), warmth, fever >101.8, chills, or severe pain unrelieved by prescribed medications), you should contact our office immediately. During weeks two through six, patients can begin some passive range of motion exercises (depending on the size of the tear and your surgeon s directions). The goals for this phase of recovery include allowing the rotator cuff to heal, reestablishing shoulder stability, and decreasing pain and inflammation. Patients should continue to avoid lifting any heavy objects. In weeks six to twelve, active range of motion exercises can begin as directed by your surgeon and physical therapist. At this time, patients will be able to begin progressing towards sports and other activity-specific tasks. Your surgeon will provide guidance on continued activity restrictions. Patients will continue with advanced strengthening exercises in the subsequent weeks, with a return to complete functioning by four to six months after surgery.

If you have a complete rotator cuff tear and are experiencing weakness and pain, you will likely be advised to have surgery to repair the tear as soon as possible.

8 Q&A There are many questions on the minds of our patients who are candidates for rotator cuff repair surgery. This Q & A addresses some of the issues you will want to discuss with your orthopaedic surgeon as you prepare for your procedure and recovery. Why do I need surgery on my rotator cuff? If you have a complete rotator cuff tear and are experiencing weakness and pain, you will likely be advised to have surgery to repair the tear as soon as possible. Surgery is usually indicated if your rotator cuff problem has not been helped with nonsurgical treatment and if you experience increasing weakness, loss of function, and limited motion in your shoulder. If you have symptoms for more than six to twelve months and find that you are unable to manage your normal level of activities, you may also be a candidate for surgical intervention. Can cortisone injections help? A cortisone injection can reduce inflammation and accompanying pain in conjunction with physical therapy and a home exercise program. One benefit of a corticosteroid injection is that it is injected directly into the area causing pain (the inflamed bursa) and is more rapid and powerful than traditional NSAIDs (non-steroidal antiinflammatory drugs) taken by mouth. Typically, no more than three to four injections are given per year. How do you repair a rotator cuff tear? Your orthopaedic surgeon will discuss with you the three surgical approaches all of which achieve similar success in terms of pain relief and improvement in shoulder strength. Arthroscopic repair is the least invasive method performed through several small incisions (portals) with the aid of a camera to view the inside of the shoulder. Your surgeon may recommend a mini-open procedure which combines arthroscopy and a slightly larger incision through which the repair can be performed. In some cases, large or massive tears may be repaired through a more major open surgical approach. What type of anesthesia is used? Regional anesthesia (interscalene block) is used for most rotator cuff repair procedures. General anesthesia is sometimes used in conjunction with the regional block. Your anesthesiologist will speak with you before the procedure and address any of your questions or concerns. How will my pain be managed? You will often have been given your prescription for post-operative oral narcotics PRIOR to your surgery. If not, you will be given a prescription upon

For more information, please visit our website www.nyp.org/columbiaortho discharge from the hospital. As your pain level decreases, you will be able to taper the doses. How long will my recovery take?

You should be able to drive once you are out of the sling and no longer need oral narcotics for pain relief (~three weeks). First you must check with your surgeon. When can I remove the sling?

9 For more information, please visit our website discharge from the hospital. As your pain level decreases, you will be able to taper the doses. How long will my recovery take? With regular physical therapy, range of motion, strength and function of your shoulder should be dramatically improved in four to six months. When can I drive? You should be able to drive once you are out of the sling and no longer need oral narcotics for pain relief (~three weeks). First you must check with your surgeon. When can I remove the sling? You can take the sling off for showering and to do your elbow, wrist and finger exercises on post-op day 1. However, you must wear your sling in public and at night for sleeping for the first four to six weeks (your physician will specifically discuss duration dependent on the size of the tear and other factors). When can I return to work? This really depends on the individual patient specifically with respect to job demands (labor vs. desk job). Some patients return to work as soon as four to seven days post-operatively and others require extensive time away from work if limited duty is not available. How long will I have physical therapy after the surgery? A typical therapy program may be a minimum of three months. The first phase of therapy will be designed to safely regain your range of motion while the second phase of therapy will be directed at regaining function, strength, and endurance. How much pain will I have? This is variable of course but we provide you with an appropriate amount of narcotic pills to keep you comfortable until your 1st post-operative visit. Remember that your anesthetic block provided for surgery may last up to 24 hours, so it is not unusual for you to have a dead arm the next day after surgery. Why is my shoulder leaking? Remember that arthroscopy is performed by pumping in a lot of fluid into the shoulder and this fluid then escapes through the small incisions (portals) this is entirely normal to occur after surgery. When should I call the office with concerns? If you experience any signs of infection (increased swelling, redness, drainage from the incisions (not clear fluid from the arthroscopy but yellowish, thick fluid like pus), warmth, fever >101.8, chills, or severe pain unrelieved by prescribed medications), you should contact our office immediately.

Why should I choose NewYork-Presbyterian Columbia ORTHOPAEDICS NewYork-Presbyterian Hospital/Columbia University Medical Center in conjunction with its academic partner Columbia University College of

10 Why should I choose NewYork-Presbyterian Columbia ORTHOPAEDICS NewYork-Presbyterian Hospital/Columbia University Medical Center in conjunction with its academic partner Columbia University College of Physicians and Surgeons comprise one of the leading academic medical centers in the nation. NewYork-Presbyterian/ Columbia provides state-of-the-art inpatient, ambulatory and preventive care in all areas of medicine, and is committed to educating and training future generations of health care professionals, as well as conducting basic research with the goal of translating discoveries into new therapies for fighting disease and Outstanding Care for Orthopaedic Conditions NewYork-Presbyterian Columbia Orthopaedics provides care through services focused on the following specialty areas: Foot and Ankle Hand and Microvascular Hip and Knee Pediatric Orthopaedics Shoulder, Elbow and Sports Medicine Spine Sports Therapy Trauma Tumor and Bone Disease At the Forefront of Research The department s Center for Orthopaedic Research investigates novel therapeutic concepts through translational studies that bridge basic science and clinical practice. Current and prior research activities include research on the molecular pathophysiology of shoulder rotator cuff disorders, molecular mechanism of osteolysis, osteoblast biology, sarcoma research, molecular mechanism of bone regeneration, normal function of diarthrodial joints, osteochondral healing, and growth plate abnormalities. improving health. NewYork- Presbyterian Hospital is rated one of the top hospitals in America by U.S. News and World Report. Decades of Distinction The origins of NewYork-Presbyterian Columbia Orthopaedics date back to the founding of the New York Orthopaedic Hospital, which opened in the mid-1800 s to treat needy children afflicted by diseases of the musculoskeletal system. In 1950, New York Orthopaedic Hospital which is also home to one of the nation s oldest orthopaedic training programs joined Columbia Presbyterian Medical Center, now NewYork-Presbyterian/Columbia, in upper Manhattan. Over the years, our surgeons have advanced the discipline through pioneering work and groundbreaking research in the diagnosis and treatment of orthopaedic conditions. Their achievements have profoundly influenced the techniques that are today helping to restore mobility and function to patients of all ages. Affiliated with Columbia University College of Physicians and Surgeons, one of the most prestigious medical schools in the country, NewYork-Presbyterian Columbia Orthopaedics remains dedicated to providing the highest quality musculoskeletal care, pursuing innovative research, and training top orthopaedic surgeons of the future.

Anatomy Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle).

Anatomy Your shoulder is made up of three bones: your upper arm bone (humerus), your shoulder blade (scapula), and your collarbone (clavicle). Shoulder Impingement/Rotator Cuff Tendinitis One of the most common physical complaints is shoulder pain. Your shoulder is made up of several joints combined with tendons and muscles that allow a great