Preoperative Issues With Rotator Cuff Surgery

Open Versus Arthroscopic

The overall complication rate for rotator cuff repair is roughly 1.3%, with higher rates consistently observed in open repair compared with arthroscopic. ^, Open repair is associated with increased risk of surgical infections, higher rates of return to the operating room within the 30 days, longer hospital stay, and greater stiffness. ^{, ,} Up to 20% of those undergoing open repair are likely to develop postoperative stiffness and are more likely to undergo intervention for stiffness within the first year. ^, Despite higher complication rates, an open approach to rotator cuff repair can be expeditious in the event of massive tears, poor bone or tendon quality, or for surgeons without an advanced arthroscopic skillset for complex tears. A number of efforts should be made in the preoperative setting to help avoid use of or conversion to an open approach, including thorough review of tear characteristics on magnetic resonance imaging (MRI), possible collaboration with a musculoskeletal radiologist, and knowledge of complex tear patterns (e.g., U-, L-, and reverse L–shaped tears) ( Fig. 29.1 ), and respective repair techniques. Arthroscopic approach now comprises the majority of repairs, demonstrating lower complication and adverse event rates than open repair, albeit with longer average operative times. ^{, ,}

Infection

Infections are one of the most common complications and can be devastating, at times necessitating readmission, intravenous antibiotics, and unplanned returns to the operating room, resulting in poorer outcomes because of soft tissue destruction and adhesions. Furthermore, management of infections contributes to increased healthcare costs. ^, The overall infection rate is between 0.3% and 2.45%. ^{, , , , ,} The most commonly identified pathogens following rotator cuff repair are Staphylococcus epidermidis, Propionibacterium acnes , and Staphylococcus aureus . Risk factors include open wounds, skin contamination, open approach, and/or systemic infections (urinary tract infection, upper respiratory tract infection, lower respiratory tract infection). Perioperative prophylactic antibiotics are an independent protective factor and are recommended in all-arthroscopic cuff repairs. Other potential mitigating measures include chlorhexadine or benzoyl peroxide pre-treatment and mupirocin nasal washes. However, recent studies suggest that administration of oral doxycycline (100 mg twice daily for 7 days) fails to significantly decrease P. acnes colonization of skin around the shoulder.

Advanced Chronological or Physiological Age

Increasing age in the setting of rotator cuff repair has been widely reported as a predictor of failure and increased complications. ^, Studies have demonstrated poor tissue quality and healing potential, often contributing to retear or failure in older patients. ^, Jung et al. found retears on MRI at 1 year in 26% of patients aged 75 years and older undergoing large or massive rotator cuff repair. Further, they reported no patient deaths or complications requiring extended hospitalization or intensive care needs. Despite elevated risk of retear, the authors concluded that elderly patients may still experience good functional outcomes without morbidity after rotator cuff repair, even in those with retears.

However, age should be appreciated as more than just a generic framework of “over versus under 65” years. Although young, competitive athletes tend to do very well with rotator cuff repair, surgeons should have a discussion with the athlete about sports and positions they play, as well as expectations/aspirations following surgery. Although 93% of those under 18 years of age return to the same or higher level of play following repair, nearly 60% have to change positions.

Tear Size and Fatty Infiltration

Although debated, general consensus is that more sizeable tears are associated with higher rates of retear; however, patient-reported function may vary. Increasing tear size and fatty infiltration of the supraspinatus have demonstrated a strong association with decreased tendon healing, subsequent failure, and a negative influence on long-term functional outcomes. ^, Muscle atrophy and fatty infiltration of the infraspinatus have been identified as independent predictors of American Shoulder and Elbow Surgeons Shoulder Scores and Constant scores, whereas tear size is an independent predictor of cuff integrity after repair and is associated with slower speed of recovery in forward elevation and external rotation. ^, The association of infraspinatus changes with poorer functional outcomes may be attributable to its role of force-coupling and balance with the subscapularis. In the event of tendon repair, fatty infiltration does not always improve, but tends to stabilize. With nonoperative management or failed repair, a significant increase in atrophy, tendon retraction, and tear size can often be expected. ^,

Tear shape should also be a consideration during the preoperative setting. For crescent-shaped tears, a conventional single- or double-row repair may be sufficient, whereas complex patterns such as U- or L-shaped tears may benefit from an alternative approach. More complex tear patterns often have an unrecognized mobile anterior and/or posterior component, and marginal convergence is often the initial maneuver to reduce the tear gap and tension, followed by an arthroscopic modified Mason–Allen suture to restore the rotator cuff footprint in a side-to-end repair technique. Having a proper understanding of tear pattern preoperatively can help mitigate potential for complications during the surgical procedure.