Which Patients Need Rotator Cuff Surgery?
Indications for surgery to repair a torn rotator cuff should ultimately be individualized based on patient assessment and physician evaluation.
Leesa M. Galatz, MD
Rotator cuff repair is one of the most common procedures performed in the shoulder. Recent advances in techniques and instrumentation have made the procedure technically easier in many ways, yet no clear clinical differences result from any single repair configuration or device. [1-3] Choices in this regard depend entirely on surgeon preference.
The controversy, more often, is in regards to surgical indications. Who and when to operate is as important as how to operate. The prevalence of rotator cuff tears is high, especially in the older population. However, not all these tears are symptomatic, and not all result in functional disability.
Factors Contributing to Treatment Guidelines
Examining the natural history of rotator cuff disease demonstrates the increasing prevalence and incidence of rotator cuff tears with age. In a study of individuals with unilateral shoulder pain, the presence of rotator cuff disease highly correlated with increasing age, such that the presence of a rotator cuff tear and the presence of bilateral cuff tears were seen in the sixth and seventh decade, respectively. 
Another study found that of 924 patients screened with ultrasound, 99 had a tear.  The average age of the tear group was a decade older than the non-tear group: 60 versus 70 years old. Although many patients were asymptomatic, the patients with the tears had less shoulder function and more pain.
Understanding the natural history of rotator cuff tears helps form treatment guidelines.
- Asymptomatic degenerative tears in older people should be treated non-operatively.
- Patients who present with tears sooner than might be expected, such as in their 40s and early 50s, are at risk for tear size progression and concomitant development of degenerative muscle changes.
- Given that smaller tears and tears in younger individuals heal more predictably, [6,7] early intervention may be indicated.
- At the minimum, surveillance of known tears helps prevent progression to an irreparable state.
Functional and Structural Outcome
Studies reporting the functional and structural outcome after rotator cuff repair also contribute to treatment guidelines. [8-10] The literature clearly shows that rotator cuff tendon healing is less predictable after age 60 to 65 years. Tear size also has an impact on results. 
Therefore, factors to consider include:
- Patient age
- Tear size and reparability
- Pain level
- Functional disability
- Extent of non-operative treatment
Potential patient outcome should also be considered. Pain relief can occur in many in spite of poor healing after a rotator cuff repair. [8,12] The pain relief alone is a benefit, aside from structural restoration of tendon continuity.
Rotator Cuff Surgery
Indications for surgery to repair a torn rotator cuff should ultimately be individualized based on patient assessment and physician evaluation. In general, indications for cuff repair include:
- Symptomatic tears in younger patients (less than 60 years)
- Symptomatic tears in patients that have failed nonoperative treatment for at least 3-6 months
- Acute, traumatic tears in younger patients
- Any acute tear that results in a sudden loss of overhead elevation
The author prefers arthroscopic double-row repair (suture bridge configuration): [13,14]
- Position the patient and administer preoperative antibiotics.
- Drape the patient, allowing adequate exposure of both anterior and posterior aspects of the shoulder (Figure 1).
- Establish the posterior portal, approximately 1 cm medial and 1 cm inferior to the posterolateral corner of the acromion (Figure 2).
- Examine the shoulder joint, including the biceps anchor, biceps tendon, rotator cuff, cartilaginous surfaces of the glenoid and humeral head, inferior pouch, and subscapularis.
- Establish the rotator interval portal.
- Probe the biceps and labral tissues for any defect or tear.
- Debride the tear and perform any other intra-articular surgical procedures needed.
- Place the scope in the subacromial space.
- Establish the anterolateral portal, approximately two finger breadths distal to the lateral edge of the acromion. Localize under direct visualization to optimally place the portal in the anterior-posterior plane. Performing a bursectomy will allow adequate visualization.
- Gently debride the edge of the tear and greater tuberosity with a shaver.
- Place medial row anchors through the superior accessory portal lateral to the acromion. They should be close to the articular margin, but lateral to the cartilage
- Retrieve suture limbs, one at a time, through the anterolateral portal.
- Pass sutures sequentially through the tendon using a suture passing device (anterior to posterior).
- Tie the sutures, posterior to anterior.
- Anchor the limbs of the suture over the lateral edge of the tuberosity in a crossing fashion to create a lateral row.
- Perform subacromial decompression and/or distal clavicle resection if indicated.
Note: The technique may vary depending on the type of anchor used, the size of the tear, and use of single versus double row repair.
Figure 1. The patient is draped to provide exposure of the anterior and posterior aspects of the shoulder.
Figure 2. The posterior portal is established approximately 1 cm medial and 1 cm inferior to the posterolateral corner of the acromion.
Pearls and Pitfalls
- Proper positioning allows for adequate exposure of the anterior and posterior shoulder for unimpeded placement of scope and cannulas.
- Perform subacromial decompression after the cuff repair. The intact soft tissue sleeve that encompasses the coracoacromial ligament and deltoid fascia keeps fluid from extravasating into the deltoid as quickly, and may help with swelling.
- Use the superior accessory portal for anchor placement. Anchors enter the bone at the correct (deadman’s) angle, which prevents misplacement.
- Suture management is critical for successful arthroscopic cuff repair. Develop a management strategy preoperatively. Various anchors may require different management strategy depending on whether knots are tied along the medial row versus function as a tension band.
- Use accessory portals or rotator interval portals for suture storage to keep them out of the way while placing subsequent sutures.
- A posterlateral portal is helpful with larger tears.
- Place sutures through the tendon from anterior to posterior and store them in the rotator interval cannula.
- Do not over reduce the cuff.
- Tie sutures from posterior to anterior to avoid crossing the sutures.
- If double-row repair is used, avoid over-tensioning the lateral row. Medial rupture along the suture line has been reported and is a very challenging problem to solve given the loss of tendon tissue.
- Be aware of time: Fluid will extravasate into the deltoid and bursa and make surgery more difficult as time goes on.
- Medial row anchors placed too medially, which can cause cartilage injury
- Improper knot-tying technique, which may cause loss of fixation
- Twisted sutures
- Poor preoperative planning
- Poor familiarity with instruments
- Over-tension lateral row; can injure tendon, may impede vascularity
- Excessive soft tissue swelling
- Poor surgical indication
Rehabilitation protocols differ somewhat. However, most orthopaedic surgeons agree that passive range of motion (ROM) or immobilization is appropriate for the first 4 to 6 weeks after surgery.
If immobilized, patients are then progressed to passive ROM for 2 weeks, and then active and active assisted ROM over the next 2 weeks. Resistance exercises are begun at 10 to 12 weeks after surgery.
Leesa M. Galatz, MD, is Associate Professor, Shoulder and Elbow Service, Washington University Orthopedics, Barnes- Jewish Hospital, St. Louis, Missouri.
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