Surgery to repair the torn rotator cuff may be offered to patients who have significant shoulder pain symptoms severely affecting their quality of life and failing non-operative treatment options.

The surgery involves reattaching the torn tendons back to the bone. This is achieved arthroscopically (key-hole surgery). Following repair the tendon then, needs to heal to the bone.

During this surgery, other pain generators like the acromioclavicular joint, subacromial space and long head of biceps tendon may be addressed if found pathological.

Arthroscopic rotator cuff repair surgery is rarely an urgent surgery and results are generally better with proper preparation.

It is vital that you work with your physiotherapist to maximise the condition of your rotator cuffs as well as the deltoid and peri-scapular muscles to enhance your post-operative rehabilitation and recovery.

The MTP Health Shoulder Program is designed to help you with this.

It is important to consider the rehabilitation and recovery time from the surgery and what effect the timing of surgery will have on:
- Family events
- holidays
- Work trips or busy periods.

At MTP Health, we take your preparation for surgery very seriously. It is our policy to prepare you over a minimum period of 4-6 weeks in order to ensure that you get the best outcome through being psychologically prepared, physically strong and medically safe enough to undergo this procedure.

There are certain exceptions where your surgeon will need to reduce the pre-operative preparation time but this is not common and you will be informed of this if it applies to you.

Finally and importantly, we will help you to get strong: Our team of Physiotherapists and Exercise Physiologists will assess your level of function, you will be given a personal program in the lead up to your operation to make sure you are ready to start recovering as soon as you wake up from the anaesthetic.

We need to know about all your medications but especially those for diabetes, blood pressure or blood thinning as we may need you to stop some or all of them up to 1 week before surgery.

It is highly recommended that if you are a smoker, that you refrain from smoking for as long as possible prior to surgery to ensure the best outcomes.

You must ensure that your whole upper limb area, especially the shoulder, remains free from scratches in the weeks before surgeries - NO LAST MINUTE GARDENING.

If this occurs, please tell us as it increases your infection risk and your surgery may need to be delayed.

This can happen in the anaesthetic bay if we don't know about it beforehand. If not sure, send us a picture.

The hospital will contact you in the week of surgery and they will confirm with you on the day before your surgery, the time you need to arrive and when you need to start fasting.

For MTP Orthopaedics patients
MORNING LIST:
- You need to stop all food from midnight and stop clear fluids from 5:30am OR 2 hours before the planned start of the list, whichever comes first.

AFTERNOON LIST:
- You need to stop all food from midnight and stop clear fluids from 11:00am OR 2 hours before the planned start of the list, whichever comes first.

Acceptable clear fluids include water, ‘see through’ apple juice with no bits or ‘see through’ energy drink such as gatorade. It does not include milk or cloudy juice with bits.

You will arrive at the hospital between 1 and 2 hours before your surgery.

You will have your shoulder area prepared by a nurse who will shave the skin and paint on a coloured antiseptic solution.

You will then meet one of our anaesthetic team. They will make sure you are comfortable and safe during the procedure.

Before your anaesthetic, your surgeon will see you and ask you “What OPERATION, which JOINT and what SIDE?” This is critical as they will then check this matches your consent form and draw an arrow on the shoulder that you specify and point to. This is the most effective way of stopping ‘Wrong Side surgery.”

At the start of the procedure you are transferred from your nice warm bed to lie on your back on a hard and cold operating table - apologies in advance.

This operation will be done under general anaesthetic and if the anaesthetist deems you to be suitable for a regional block, and you are agreeable to it, you may get local anaesthetic injected into the nerves around the shoulder for better pain relief.

The Surgical team then performs the “Time-out” procedure to Double check that your name band, imaging and the arrow drawn on your shoulder all match with your signed consent form. The procedure is done under sterile conditions with you lying on your back before your back and head are raised to a semi-inclined position.

This is a key-hole surgery. There will be several small incisions used to insert a camera into the shoulder joint for visualisation on a screen as well as instruments for the purpose of debridement (cleaning up) and rotator cuff repair.

The small wounds will be closed with dissolvable sutures. Adhesive dressings will be applied.

A sling with an abduction pillow will also be applied. The surgery takes between 90 minutes to 2 hours on average with additional time before for anaesthetics and after for recovery.

For the waiting relatives or partners, it is usually between 3 and 5 hours from leaving the admissions area to getting back to the ward.

After the operation, you wake up in the recovery room, where you are monitored for approximately 1 hour. During this time, your surgeon will call your relative. It is important that they realise that this may be more than 4 hours from the time you were ‘taken into the operating theatres’ due to waiting and preparation times.

Once stable, you can be transferred to the ward to begin your post-surgical recovery.

DRESSINGS - The adhesive dressings are water-resistant but not perfectly water-proof. Please keep them dry, clean and intact until you have your first follow-up appointment in 2 weeks. It is normal to have ooze on the dressings. It the dressings fall off, please reapply new ones. It is recommended to avoid showering directly on the wounds or submerging the wounds under water.

GAME READY - If you have been supplied with a Game Ready machine, we advise that you use it on program 2 or 3 and for up to 2 hours at a time. You can use it as often as you like in a day as long as you manage to complete your rehabilitation exercises. If your pain and swelling are well controlled then you don’t need to use it.

When supplied by MTP Health you have the Game Ready for 2 weeks. At the end of this time it will be picked up by a courier unless you want to continue further rental.

LENGTH OF STAY - We call the day after surgery ‘Day 1 post surgery.’ Your aim on this first day is to pass all your discharge tests from the hospital physiotherapists and plan for going home. It is usually safe for some to go home on the next day after surgery. Some may require an additional night stay.

SURGEON FOLLOW UP
Your first post-operative visit will be with your surgeon at 2 weeks. This appointment is critical for checking your wound healing as well as to answer any questions you may have.

Further follow-ups with your surgeon are at:
- 6 weeks after surgery
- 3 months after surgery
- 6 months after surgery

Your recovery starts the minute you are awake from the anaesthetic. Your whole upper limb especially the fingers may feel numb and weak due to the local anaesthetic and regional block.

Once you regain movement of your limb, you need to start hand pumping exercises and wrist movement.

Your job is to get the Physiotherapists to sign you off as ‘READY FOR DISCHARGE HOME’ on DAY 1.

You need to show to them that you are able to walk safely and manage basic tasks safely in the sling.

PAIN MANAGEMENT - It is important to control your swelling, inflammation and pain in the initial post-operative period. Cold therapy using

GAME READY is useful. It is also important to take simple analgesia like paracetamol and anti-inflammatory agents like ibuprofen regularly for the first few days and stronger pain killers on an when needed basis. Wean off the medications as soon as you can.

RESTING AND SLEEPING - It may sound obvious but avoid lying or resting on your operated side for at least 3 months. It is recommended to rest and sleep in a reclined position for 3 months after surgery.

However, this may not be comfortable for everyone. A compromised position is lying on your back.

SLING - Please wear your sling at all times for 6 weeks after surgery even when you are resting or sleeping. The sling can only be removed for exercises a few times a day.

HYGIENE CARE - It will be challenging and annoying in the initial stage of recovery. The sling can be removed for hygiene routines but do not move your shoulder too much. You can lean forward and towards the operated side to get access to the armpit and chest. After that, wear a second sling (dedicated for shower) to continue the remaining of the hygiene routine.

REHABILITATION PROGRAM - It is important to understand that the surgery only brings the tendon back to where it is supposed to be.
The body still needs to do its own healing in order for the tendon to be able to withstand external stresses.

First 6 weeks: No shoulder exercises at all. Focus on finger, hand, wrist, forearm rotation and elbow range of motion exercises only. No lifting or loading at all. The focus is to prevent other joints from being stiff.

6-12 weeks: Continue the above and start shoulder range of motion exercises. Do not push through pain. The focus is to regain shoulder movement without damaging the tendon repair. No lifting, loading or strengthening yet. The sling can be weaned off.

12 weeks and beyond: Continue the above and commence strengthening exercises. The healing should be sufficient to withstand gradual increment in stresses.

Office based jobs: Can be restarted (writing and typing) as soon as you are comfortable and no longer taking strong pain killers (2 weeks).

No lifting or loading is allowed for 3 months (not even a cup of coffee). It takes longer to return to more physically demanding jobs for healing and safety reasons.

Sports and Physical Work: The limb can commence gradual strengthening and lifting after 3 months from surgery. This has to be gradually increased with time. It is important to discuss with your surgeon and therapist for a return to sports or work plan.

Driving: It is recommended that you do not recommence driving until you can safely control your vehicle in an “emergency" situation and are no longer taking strong pain killers.

Please discuss with your surgeon for a return to driving plan. You may also need to check with your car insurance provider.

This is a quality-of-life operation. The rotator cuff tear is not a life or limb threatening condition.

It is important to understand the risks before deciding on surgery.

Risks include scar, infection, damage to nerve, blood vessels, tendons, muscles, bone, and joint, bleeding, stiffness/frozen shoulder, blood clots, ongoing pain and weakness, unsuccessful repair (due to poor quality tendon or tendon retracting too far away), unsuccessful healing, swelling, anaesthetic risks and conversion from key-hole surgery (arthroscopy) to open surgery (bleeding, swelling, tear is too large).

The recovery period is long (minimum 6 months) and post-operative physiotherapy is essential to achieve a good outcome.

Other uncommon complications include:

• Anaesthetic risks
• Allergic reaction to medications
• Heart damage
• Stroke