Surgery - Acromioplasty
8. We suggest that routine acromioplasty is not required at the time of rotator cuff repair.
Strength of Recommendation: Moderate
MMT: agree. However, if there is a large spur, or if it is clear that the tear was the result of "Impingement", then I recommend release of the CA ligament and an acromioplasty.
Surgery – Partial Rotator Cuff Repair, Debridement, or muscle transfers for patients with
irreparable rotator cuff tears when surgery is indicated.
9. It is an option to perform partial rotator cuff repair, debridement, or muscle transfers
for patients with irreparable rotator cuff tears when surgery is indicated.
Strength of recommendation: Weak
MMT: Partial cuff repairs are of benefit. Muscle transfers can be helpful, but patient selection is critical. In my experience, a latissimus transfer is best suited for a patient with an irreparable tear who does not have pseudoparalysis. Now that the Reverse shoulder is such a good option, I would lean towards that option in patients older that 60 who desire improved pain relief and overhead function.
Surgery – Tendon to Bone Healing
10. a. It is an option for surgeons to attempt to achieve tendon to bone healing of the cuff
in all patients undergoing rotator cuff repair.
Strength of Recommendation: Weak
MMT: I am not sure what the point is here; anytime one elects to repair a torn cuff tendon, the goal is tendon to bone healing if the tendon can be brought back to its normal footprint without tension. Although it is known that in some cases of "good outcome" the cuff has not actually healed to bone---which may raise the question of whether tendon to bone healing is critical--it is certainly the goal to achieve this.
Surgery - Suture Anchors and Bone Tunnels
10. b. We cannot recommend for or against the preferential use of suture anchors versus
bone tunnels for repair of full thickness rotator cuff tears.
Strength of Recommendation: Inconclusive
MMT Agree. The fundamental tenet is secure fixation--and both are options. It is certainly more common to use anchors when a repair is performed arthroscopically. The theoretical advantage of bone tunnels is the avoidance of foreign material were an infectious complication to develop, or to avoid interfering with a postoperative MRI (if a metal anchor were to be used, for example.)
Surgery – Arthroscopic, Open, Mini-Open
10. c. We cannot recommend for or against a specific technique (arthroscopic, mini-open
or open repair) when surgery is indicated for full thickness rotator cuff tears.
Strength of Recommendation: Inconclusive
MMT: Agree. We do know that all are effective. However, the overwhelming majority of shoulder experts perform repairs arthroscopically in most cases because the minimally invasive nature of this technique diminishes soft tissue trauma and may result in a bit less pain after surgery. The "biology" of repair, and the necessity of being in a sling for 6 weeks is the same regardless of technique.
Surgery - Non-Crosslinked, Porcine Small Intestine Submucosal Xenografts
11. a. We suggest surgeons not use a non-crosslinked, porcine small intestine submucosal xenograft patch to treat patients with rotator cuff tears.
Strength of Recommendation: Moderate
MMT: Agree I have had to remove these and do not recommend use to augment thin tendon or to bridge defects
Surgery - Allografts and Xenografts
11. b. We cannot recommend for or against the use of soft tissue allografts or other
xenografts to treat patients with rotator cuff tears.
Strength of Recommendation: Inconclusive
MMT: I have no experience using these over the course of 17 years---in light of inconclusive evidence, I see no reason to start.
Post-Operative Treatment - Cold Therapy
12. In the absence of reliable evidence, it is the opinion of the work group that local cold
therapy is beneficial to relieve pain after rotator cuff surgery.
Strength of Recommendation: Consensus
MMT Agree. However, I have stoppped using expensive, commercially available devices due to cost, and have found that ice packs (filling a bag with ice) is equally efficiacious.
Post-Operative – sling, shoulder immobilizer, abduction pillow, or abduction brace
13. a. We cannot recommend for or against the preferential use of an abduction pillow
versus a standard sling after rotator cuff repair.
Strength of Recommendation: Inconclusive
MMT: Though a wedge/abduction pillow are not critical, there is evidence that shows that the strain on the repaired tendon is eased by the wedge. For that reason, there may be a beneficial, though unproven, impact on healing. It's for that reason that I routinely advise the use of this type of sling for 6 weeks after repair.
Post-Operative Rehabilitation – Range of Motion Exercises
13. b. We cannot recommend for or against a specific time frame of shoulder
immobilization without range of motion exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive
MMT Agree. However, there is some new evidence to support "No Motion" for 6 weeks as opposed to Passive motion. See this link:
http://www.rearmyourself.com/article...%20Cuff-Repair
Post-Operative Rehabilitation – Active Resistance Exercises
13. c. We cannot recommend for or against a specific time interval prior to initiation of
active resistance exercises after rotator cuff repair.
Strength of Recommendation: Inconclusive
MMT: The initiation of such exercises will "load" the repair. This may stimulate healing, but it may also cause gapping at the repair site. For that reason I start isometrics at 8-10 weeks but defer resistance exercises until 3 months.
Post-Operative Rehabilitation – Home Based Exercise and Facility Based Rehabilitation
13. d. We cannot recommend for or against home-based exercise programs versus
facility-based rehabilitation after rotator cuff surgery.
Strength of Recommendation: Inconclusive
MMT:Agree --compliance with whatever program is selected is the key.
Post-Operative - Infusion Catheters
14. We cannot recommend for or against the use of an indwelling subacromial infusion
catheter for pain management after rotator cuff repair.
Strength of Recommendation: Inconclusive
MMT: in light of the risk of Chondrolysis when these catheters are used inside the glenohumeral joint, and because a cuff repair may not be "watertight", I do not use these catheters any more. I have found that a good regional block will provide 8-10 hours of pain relief, and my patients did not seem to complain more after I stopped using these devices.