Rotator cuff repair with smaller incisions and sturdier stitches

Less invasive technique could speed healing

When we hear about rotator cuff injuries, we tend to hear mostly about high profile athletes, but shoulder injuries can affect anyone. Each year, an estimated four million people in the United States seek medical attention for shoulder injuries. Nearly 300,000 of those require surgery to repair the rotator cuff.

Strong stitches attach the rotator cuff directly to the shoulder bone.
Strong stitches attach the rotator cuff directly to the shoulder bone.

Rotator cuff surgery used to mean a substantial incision, a long recovery and lots of pain, but that’s changing as more surgeons begin using minimally invasive repair techniques. At Washington University School of Medicine in St. Louis, orthopaedic surgeon George Paletta, M.D., is one of a growing number of surgeons now using a system designed to limit post-surgical pain and promote faster healing.

The rotator cuff is a series of four muscles in the shoulder that are critical in helping elevate and rotate the arm. That’s why rotator cuff injuries can be so devastating for pitchers. But the injuries actually are most common in the older population — 55 and above — because injury to the rotator cuff is, in part, a degenerative process that gets worse with age.

Paletta, on staff at Barnes-Jewish Hospital and chief of the Sports Medicine Service at Washington University, also serves as head team physician for the St. Louis Cardinals. In that position, he’s dealt with lots of sore shoulders over the years. But he says the rotator cuff is involved with much more than throwing fastballs.

“It’s important in helping us raise the arm overhead and to generate any force or strength with rotational movements of the arm.” Paletta says. “Rotator cuff problems clearly can affect a person’s day-to-day life, even performing normal activities from sweeping the floor to putting away groceries.”

The most common symptoms of a rotator cuff injury are shoulder pain, weakness, inability to raise the arm overhead and problems or pain trying to rotate the arm. But the degree of symptoms varies from person to person.

George Paletta
George Paletta

Most have at least mild pain. Some can be treated with physical therapy that strengthens the intact portion of the rotator cuff to help compensate for what’s torn. But Paletta says many patients have so much pain and dysfunction that surgery is their only alternative. Those are the patients who may be able to benefit most from a minimally invasive technique developed by Opus Medical Inc. that Paletta and other surgeons are using to treat rotator cuff tears. (Click here to view a short animation of the new technique.)

“This system has eliminated a lot of the barriers and technical issues that concerned surgeons about the reliability and reproducibility of minimally invasive rotator cuff repair,” Paletta says.

One improvement in this system, he says, is something called a SmartStitch™ suturing device that allows the surgeon to place stitches within the rotator cuff tissue that are as strong as the stitches that are used in the more invasive, “open” surgical technique. The system allows the surgeon to cinch the stitches directly to the shoulder bone.

“In other minimally invasive procedures, the surgeon attached an eyelet to the bone and then ran the sutures through that eyelet and tied a knot,” Paletta explains. “Your repair was only as good as the knots you tied. This system eliminates those knots and eyelets and gives us a much more reproducible technique.”

Cinching the stitches directly to the bone might promote better healing, Paletta says.

“You have a much broader contact point between the rotator cuff tissue and the bone you’re trying to repair it to,” he says. “A broader contact point, at least theoretically, provides the potential for a better, broader healing surface, and, hopefully, a better repair.”

Paletta says it’s too early to tell whether patients treated with the AutoCuff™ system really will have better outcomes, but there is preliminary evidence that patients treated with this approach have less stiffness or loss of motion after surgery. It also appears that many have less pain in the first few weeks after an operation. Those anecdotal reports will require more study before they can be verified, but Paletta already knows that the system shortens time spent in the operating room. Because it eliminates problems like knot tying, the system means operations can be completed more quickly.

The minimally invasive technique also limits the damage to the healthy part of the shoulder. Traditional, open techniques often caused damage to other muscles even as they repaired damage to the rotator cuff. Limiting that collateral damage seems to contribute to a faster return to normal activity following surgery. And although none of those factors really influence who should or should not have rotator cuff surgery, Paletta thinks patients are more likely to agree to surgery if they think they’ll heal faster and have less pain.

What doesn’t change, however, is the biology of the healing of the rotator cuff.

“It still takes a long time for the rotator cuff repair to heal to the bone,” Paletta says. “This system doesn’t alter the biology of the healing — which still takes almost a year — but it certainly minimizes any additional insult to the shoulder, and that’s what patients really struggle with in the first few weeks after surgery.”

The full-time and volunteer faculty of Washington University School of Medicine are the physicians and surgeons of Barnes-Jewish and St. Louis Children’s hospitals. The School of Medicine is one of the leading medical research, teaching and patient-care institutions in the nation. Through its affiliations with Barnes-Jewish and St. Louis Children’s hospitals, the School of Medicine is linked to BJC HealthCare.