Rotator cuff surgery, once a subspecialty with a low public profile, has become the subject of frequent headlines for sports fans. And a new generation of technology is improving surgical outcomes as well as the recovery process. The increased visibility of rotator cuff surgery results from several factors according to Kenneth Bramlett, MD of the Orthopaedic Sports Medicine Clinic of Alabama.
"There is a combination of factors that make the surgery more identifiable," Bramlett says. "In the information age people have more access to sports news, and commentators are revealing injuries on a more frequent basis than they have in the past, so people's engagement at an emotional level is higher than it was before.
"And with the advent of arthroscopy and the ability to make repairs and to be proactive before rotator problems turn into a major injury, there is more being done on the front end - phase one of the injury as opposed to phase three - in the nature of preventing accelerated or extended injury."
Chronic rotator cuff tears develop slowly over time with the natural aging process, as well as with professions that require extended lifting and overhead motions, such as carpenters, painters, servers, custodians, orchestral and choral conductors, drummers, and others. The tears are also common for athletes in a wide range of sports: baseball, softball, football (mainly pitchers and quarterbacks), swimming, boxing, martial arts, tennis, bowling, and others.
The mechanical structure of a rotator cuff can be compared to a baseball being held in a glove. "The glove has four fingers and a web, and there are four muscles in the shoulder that encase that ball, which is the humerus," Bramlett says. "The muscles raise and lower to rotate the arm and they can develop a weak spot, where it's most likely to tear, between the subscapularis and the supraspinatus.
"Chronic wear and tear can thin down that muscle, so that when you do the repair it's helpful if you have something to supplement it with, to enhance the healing process, and that's where the bovine rotational medical patch comes in."
The patch is a bio-inductive implant obtained from the Achilles tendon of a cow. "You can compare the injury to blue jeans that thin out in the knees and are repaired with a patch. It's the same concept. It measures about an inch by an inch and a quarter, and the reason it's so effective is that it's completely endoscopic and can be deployed through a small opening."
The patch is attached over the torn area with proprietary staples. "It's stapled onto the repair," Bramlett says. "Once it's stapled down around the lower edges and sticking to the bone, it stays there and initiates osteointegration for a quick recovery.
"When we do a surgery we clean out the undersurface of the acromion bone, the bone above the shoulder. It's the equivalent of cleaning out underneath a car fender that's been down a tarry road and has tar and gravel stuck under it. We rake it out so that the wheel, i.e. the shoulder, has more room to move.
"The acromion after resection is a very vascular space and a small hematoma occurs in the immediate post-op phase. By putting the patch on the rotator cuff and the sclerotic, less than optimal, vascular tissue we save that tissue. The bovine graft appears to attract reparative cells. Fibroblast and vascularization over the shoulder give a nice smooth surface. We've been following the results closely, and our experience is that it decreases the pain response.
"The procedure is not for everybody, because some people have good tissue already so there's no need putting a patch on it."
Bramlett has used the new procedure for the past year and a half, performing nearly a hundred surgeries after participating in a clinical study. "It's been so successful that other surgeons around the country are using it with more than 4,000 cases in the last year alone," he says.