Arthroscopic Rotator-cuff Repair - Patient Information.
Rotator-cuff is a cuff of muscle-tendon tissue that envelops the shoulder joint, to aid its stability and movement. Patients may suffer from a tear for a variety of reasons, it may be partial or complete. Patients with pain and weakness from a complete tear inspite of non-surgical treatment, are usually recommended this procedure. Some partial tears, will also benefit from the procedure.
Patients presenting with such symptoms for the first time to our clinic, are ususally given a thorough clinical assesment and appropriate investigations like x-rays or MRI scans may be requested. After diagnosis, a physiotherapy protocol is initially recommended for most patients. Patient's who fail the above protocol are recommended for surgery.
Pre-Operative assesment
This involves being assesed by a Physician / Anaesthetist to decide on fitness for surgery and the type of anaesthesia. Appropriate blood tests, X-rays and Scans may be requested. This is usually a General Anaesthesia with a nerve block for post-operative pain releif, if necessary.
Admission
This maybe done as a day-care or an over-night(s) admission procedure, depending on other co-morbidities (illnesses) and insurance provisions.
Procedure
Inside the operating theatre, our Anaesthetisit will give the General Anaesthesia, and a block sometimes, for post-operative pain relief.
Position
This is usually done with the patient in the lateral position (lying-by-the-side) or sometimes by the beach-chair position (semi-sitting). With the former position, the arm is suspended by a simple pulley traction system. to facilitate the procedure. If a beach-chair position is used, mechanical compression stockings may be used, to facilitate blood flow from the legs.
Arthroscopic Procedure
After Anaesthesia, the area is prepared by cleaning thoroughly with anti-septics (e.g. Chlorhexidine), and draped with sterile sheets to maintain sterility during the procedure. Antibiotics also may be administered.
A small (less than a cm) stab incision called a portal (key-hole size), is made at the back of the shoulder to facilitate entry into the joint. A cannula (conduit) is inserted to keep the portal open. A tiny camera (Arthroscope), with a light source and water inflow are used to visualise the joint. The landmarks inside the shoulder joint are duly noted, and the integrity of structures may be probed with a tiny probe through another portal made from the front of the joint.
In a patient with a Rotator-cuff tear, the tear may be noted from inside the joint. Some times there may be an associated wear of the biceps tendon too, which maybe probed and assesed. Then the scope is directed slightly upward into the space above the shoulder joint, called the sub-acromial space. From here you can actually look down upon the Rotator cuff. But there is a thick bursa, which is cleared with the help of a thin mechanised shaver. Part of the Acromion process (shoulder tip) is also shaved to decrease impingement on the cuff. Once a clear view of the tear is obtained, it is probed to asses its type and extent. Types like U or L have been described depending on the shape of the tear. This helps in the design of the repair too. Now two additional portals are made to help in the repair. The bed of bone, on the head of the Humerus bone, where the cuff has to be attached is prepared. Anchors are inserted. The sutures are threaded into the Rotator-cuff, using specialised instruments, and the cuff is tied down securely onto the bone. The number of anchors used depends on the type of the tear. Thus attempting to re-create a pre-tear anatomical environment for the shoulder. The whole procedure is completed with the aid of special tiny instruments through tiny skin incisions called portals. These incisions are closed with sutures, at the end of the procedure, and dressings applied on top.
After the Procedure, the patient may find himself or herself, in the Recovery Room, which is a specially equipped and staffed room for recovering patients from Anaesthesia. They may notice that their arm is supported in a sling, to protect them from moving their operated shoulder. And after recovery, they will be shifted to the ward. Usually, if it was a planned day-case procedure they may be discharged on the same evening, if not the following day.
After discharge, the patient is asked to return to the clinic for regular dressing changes till, sutures are removed.
Re-habilitation involves six weeks of immobilisation in the sling, followed by gradual mobilisation to obtain a good range of motion. The special Re-habilitation protocol is individualised according to patient's needs. It is often a fine balance between delaying it just enough to let it heal un-disturbed and starting it early enough, to minimise stiffness. After due re-habilitation, sports specific exercises are instituted, for sportspersons who are intending to get back to play.
