Hardy, Eva A. MSN, RN, ANP-BC; Hardy, Eric BS, PA-C
The growth of the older American population is rapidly accelerating due to aging baby boomers.1 As of 2008, approximately 39 million people were age 65 and older (or roughly 13% of the population).1 This same segment of the population is expected to reach 72 million (or 20% of the total U.S. population) by 2030.1 Therefore, it's expected that older adults will become the largest consumers of surgical care in the coming years (see Population projections and estimates). Osteoarthritis (with its associated soft tissue degeneration) is among the most common chronic diseases in this population. This article will focus specifically on the procedure of rotator cuff arthroscopy in adults age 60 and over.
Of all the joints in the body, the shoulder is the most mobile and has the greatest range of motion (ROM). The scapula and clavicle comprise the bony aspect of the shoulder girdle.2 The clavicle is an S-shaped bone that connects the axial skeleton and the upper extremity.2 The glenohumeral joint is formed by the glenoid cavity (on the lateral angle of the scapula) and the humeral head, allowing the shoulder joint full ROM (see Anatomy of the shoulder). The scapula is freely moveable and is an origin attachment for the rotator cuff. The cuff is comprised of four muscles (the supraspinatus, infraspinatus, teres minor, and subscapularis) as well as the glenohumeral ligaments and the long head of the biceps tendon.2 These soft tissues form a sleeve around all aspects of the humeral head and glenoid cavity and compress the glenohumeral joint, providing strength and mobility.2 The four muscles making up the rotator cuff allow for three types of movement: abduction, internal rotation, and external rotation.3 The bursa lubricates the acromion and rotator cuff, allowing the tendons to move smoothly with arm motion.3 Tendon damage is typically accompanied by an inflamed and painful bursa, commonly known as bursitis.3
While younger patients typically require rotator cuff repair due to sports or work-related injuries, older adults are more likely to be treated surgically for degenerative damage that's occurred over time. Degeneration of bony and soft tissue structures of the shoulder (resulting from aging, disease, or injury) can increase the incidence of instability and risk for other injuries.3 Instability can occur because the humeral head is larger than the glenoid cavity that holds it, which results in various injuries, including torn rotator cuffs.3
While it's unclear exactly how rotator cuff degeneration occurs, the literature broadly divides the mechanisms into intrinsic and extrinsic factors.4 Codman's “intrinsic” theory suggested that age-related tendon damage and chronic microtrauma results in partial-thickness tears, which then progresses to full-thickness tears. In more recent years, an “extrinsic” theory espouses that the majority of rotator cuff tears result from degenerative changes secondary to impingement, the incidence of which increases with age.5 Since age is a main factor in progressive rotator cuff degeneration, it should be considered the most important factor in the pathogenesis of tears.6 (See Rotator cuff tear.)
Arthroscopic surgical techniques have been advancing over the last decade. There is ample literature to suggest that shoulder arthroscopy is safe and effective in treating rotator cuff damage. Arthroscopic procedures allow for decreased postoperative pain (compared to open procedures), maintenance of the deltoid muscle, improved treatment of intraarticular lesions, and improved mobilization and release of the rotator cuff.7
Colvin and colleagues examined rates of open and arthroscopic rotator cuff repairs from 1996 and 2006 and found that, while the rate of all repairs performed increased by 141%, the rate of arthroscopic repairs increased by 600% in that same time period.7 Improvements in arthroscopic technique and surgical instrumentation have facilitated this increase in rotator cuff repairs.7 In addition to the shift to more arthroscopic repairs, the number of outpatient surgeries in ambulatory settings has increased, correlating these findings.7 While the number of arthroscopic rotator cuff repairs increased among all age groups, those 65 or older increased from 20 to 99/100,000 capita.7 Many studies in the literature have demonstrated that older age and larger tear size are associated with higher failure rates; as a result, surgeons have become more aggressive with early arthroscopic repair.7 In addition, patient age difference has increased over time. Female patients undergoing rotator cuff repair are seven years older (on average) than their male counterparts, and the difference between the number of male or female patients having these procedures narrowed dramatically from 1996 to 2006.7 In regard to surgical time, arthroscopic repair requires a high level of technical skill.7 Because of this, Colvin and colleagues observed a longer average surgical time with arthroscopy (84 minutes) compared with open technique (66 minutes); however, there was no noticeable difference in postanesthesia care unit time for either.7 In terms of anesthesia, researchers noted that there were “significant increases in the use of combined general anesthesia and regional nerve block” (3.79% to 15.42%) over that 10-year span.7 Interscalene blocks have been shown to be more cost-effective and safer for pain management when compared to general anesthesia.7
Even though shoulder X-ray is usually normal in rotator cuff tears, it remains the first-line of imaging in order to rule out fracture or dislocation as a source of the patient's pain.4 Ultrasound has also been shown to have accuracy when performed by experienced musculoskeletal radiologists.4 On an ultrasound, chronic tears may appear subtle and may not demonstrate a significant amount of fluid.4 More acute tears will reveal a tendon interruption with fluid in the gap.4 In general, ultrasound is more accurate for diagnosing full-thickness tears than partial-thickness tears.4
Magnetic resonance imaging (MRI) is the study of choice for evaluating rotator cuff pathology because of its ability to visualize tear size and shape, amount of tendon retraction and muscle atrophy, and quality of remaining tendon.4 Even though older studies demonstrated better sensitivity and specificity to diagnosing full-thickness tears, newer MRI machines and techniques show improvement at revealing partial thickness supraspinatus tears.4 High signal intensity on a T2 image extending from the superior to inferior borders of the tendon is the most reliable indicator of a full-thickness tear.4
Conservative therapy. The American Academy of Orthopedic Surgeons states that in 2008, approximately 2 million people in the United States went to their primary care provider because of a rotator cuff problem.8 Approximately 50% of patients with rotator cuff tears respond to nonsurgical treatment and do not require repair.8 Conservative treatments can include rest and activity modification; nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen; physical therapy with strengthening exercises to improve flexibility and ROM; and a corticosteroid injection with a local anesthetic and cortisone preparation.8 The benefits of conservative treatment would be to avoid the risks associated with surgery, such as infection, stiffness, lengthy recovery, and complications from anesthesia.8 However, the disadvantages would include continued weakness, permanent activity limitations, and increased tear size over time.8 Standard indications for surgical repair include persistent symptoms for 6 to 12 months, a tear of greater than 3 cm, acute injury, and significant loss of upper extremity function.8
Assessment of the older adult
Prior to any surgical procedure in an older adult patient, it's important for the interdisciplinary team to thoroughly evaluate the patient to ensure optimal outcomes. The Comprehensive Geriatric Assessment is defined as a multidimensional, interdisciplinary diagnostic process to determine the medical, psychological, and functional capabilities of an older adult.9 The clinical goals are to recognize those functional problems and disabilities with the aim of providing appropriate care, assembling long-term follow-up, improving care outcomes, and containing care costs.10
The medical assessment should minimally include a review of the cardiovascular, respiratory, renal, musculoskeletal, and endocrine systems assessing for diabetes, if applicable.11 The medication review should include prescription medications, supplements, vitamins, topical ointments, over-the-counter drugs, herbal preparations, recreational drugs, and alcohol use (alcohol is commonly abused in older adults). Assessing nutritional status is important because poor dietary practice can lead to dehydration, impaired wound healing, and increased risk of infection.12 In regards to a rotator cuff repair, it's especially important that during the assessment of functioning, the nurse should discourage family members from answering on the patients' behalf so that the patients may answer candidly and raise any concerns they may have.12 A thorough psychosocial assessment may also identify those at risk of inadequate social support,12 which will be vital during the rehabilitation phase of the rotator cuff repair.
Older adults commonly suffer from multiple comorbid conditions, and the risk of surgical complications (especially cardiovascular and respiratory) is high. Betelli stated that, “Three factors contribute to increased perioperative risk in elderly patients: progressive functional decline and reduced compensational capacity; associated illness with limited baseline function and altered response to stress; and increased incidence of unexpected reactions to medications, anesthesia, and surgery.” Therefore, preoperative evaluation should take place several days prior to the surgical procedure to allow for further assessment of riskier patients.13
Pharmacokinetic and pharmacodynamic changes significantly interfere with the final action of general anesthetics and increase a patient's adverse reactions.14 The older adult will be more susceptible to variations in BP and volume, body temperature, and oxygenation.12 Reduced baroreceptor reflexes and stiffened vascularity can interfere with compensatory tachycardia and result in sharp drops in BP.12,14 Medications should be titrated and administered slowly (at least over 30 seconds) in order to compensate for this. The transition to ventilatory respiration can lead to reduced cardiac output.12 In addition, since the older adult patient has diminished alveolar exchange, the potential for overdosing of inhaled anesthetics increases.14
More rotator cuff repairs are being performed on an outpatient basis, and multiple studies have shown this to be safe and cost-effective. This can be successfully done with a combination of general anesthesia and regional nerve block, such as an interscalene block. These types of blocks provide better pain control, less general anesthetic requirement with fewer adverse reactions, and earlier discharge home.15 Although a regional nerve block can be used alone, many surgeons prefer to use it in conjunction with light general anesthesia.16 In a study by Sultan and colleagues, it was noted there were more unplanned admissions from day of surgery in patients who didn't receive interscalene blocks in conjunction with general anesthesia or who received them from less-experienced anesthesia providers, particularly in patients over 65.15 Interscalene block anesthetizes the roots of the brachial plexus between the middle and anterior scalene muscles in the neck.16 It's commonly used for surgeries of the upper extremity to provide better postoperative pain control. Preparations of ropivacaine or bupivacaine with added epinephrine are most commonly used and can provide 12 to 24 hours of postoperative pain relief.16 Prior to administration, the patient should be positioned slightly elevated with the head turned contralaterally.16 Ultrasound guidance may be used, and, if so, a pillow should be placed under the operative shoulder for added elevation.16 Even though ultrasound allows for more accurate injection of the solution, there are still potential complications that occur in relation to the location of the anesthetic. In addition to the typical adverse reactions associated with local injection (such as hematoma, infection, or allergy), there can be more serious adverse effects. These include postoperative paresthesia or nerve deficit, local anesthetic systemic toxicity, diaphragmatic paralysis, hoarseness, Horner syndrome, pneumothorax, and epidural or intrathecal tracking.16 There has also been a case report of spinal cord injury from the nerve stimulation technique when the block was administered under general anesthesia.16 For this reason, it's best if the patient is conscious and awake while the block is administered.16
Techniques for rotator cuff repair include open, mini-open, and arthroscopic. The open repair requires a standard incision that's several centimeters long and may be required for massive or complicated tears. In the past, it was considered the “gold standard” in rotator cuff surgical treatment; however, this is no longer the case. An incision is made at the anterior shoulder, and the deltoid is detached for better access to the tendon. An acromioplasty is also usually performed in which osteophytes (bone spurs) are removed from under the acromion. Occasionally, reconstruction in the form of a tendon transfer may be needed for complex tears.
In the mini-open repair, the surgeon makes a smaller incision, usually 3 to 5 centimeters long. This technique uses arthroscopy to perform acromioplasty and makes other repairs within the joint while leaving the deltoid intact. Repairs to the rotator cuff are then made and viewed through the incision instead of the video monitor (see Arthroscopic acromioplasty and mini-open rotator cuff repair).
In an arthroscopic repair, an arthroscope with a camera is inserted into the shoulder joint, and pictures are then displayed onto a video monitor. No incision is necessary (only small puncture openings), and the deltoid is completely preserved. This allows the surgeon to avoid iatrogenic injury to the muscle, provides less postoperative pain, and quicker rehabilitation. In this method, arthroscopic repair is the least-invasive technique and is almost always performed in an outpatient setting.
Once the patient is in the OR and under anesthesia for the arthroscopic repair, the patient's positioning can either be done in a beach chair or lateral position, based on surgeon preference. If placed laterally, the patient's affected extremity might be distracted overhead to 45 degrees with a 10 lb (4.5 kg) weight to facilitate a posterior portal. An intraarticular evaluation can then be conducted with the scope and debridement performed on the affected tissue. If damage to the biceps tendon is noted, it will be repaired at this point along with acromioplasty if necessary. Depending on the amount of inflammation, the subdeltoid bursa might also be resected. Preparation of a cancellous surface of the humeral head is then performed, and the rotator cuff is pulled back over it. Either single- or double-row anchors can be used to secure the rotator cuff in position. Double-row repair uses a medial and lateral row to fixate the tendon to the humeral head. Although this double-row technique has shown significantly higher rates of tendon healing and greater external rotation, studies haven't shown it to significantly improve function, strength, forward flexion, internal rotation, or patient satisfaction.3 (See Arthroscopic views of a rotator cuff repair.) While rates of tendon healing have been shown to decrease with increasing age, studies have shown that even without complete tendon healing, older adult patients still have functional improvement, decreased pain, and increased ROM with rotator cuff repair. For this reason, cost may be contained by using the single-row technique.
Patient response to pain management needs to be closely monitored, since older adult patients are more sensitive to drug effects and more likely to experience adverse reactions, including delirium. Renal and hepatic function can be decreased, so there is altered drug clearance. Titration of pain medications should start at the minimum dose and increased carefully. I.V. patient-controlled analgesia (PCA) tends to have a higher incidence of delirium than epidural PCA, which can effectively decrease pain and has been linked to a shorter duration of delirium.17
Effective pain management after rotator cuff arthroscopy can be challenging, especially within the first 48 hours post-op.18 Common postoperative analgesia after rotator cuff repair includes local analgesic injection, regional nerve block, and PCA.18 Because postoperative pain has become a more scrutinized issue in recent years, multimodal analgesia using drug combinations has been gaining more interest. These combinations can include opioids, NSAIDs, and local anesthetics that act by different mechanisms of action, producing synergistic analgesia and decreased adverse reactions.18 In a study by Cho and colleagues, the multimodal approach to pain management provided for better pain relief than I.V. analgesia alone and didn't increase the risk of adverse effects.18 This multimodal analgesia included NSAIDs and local analgesic techniques, including nerve blocks and intraarticular or subacromial injections, as well as written and oral preoperative patient education.18
However, NSAIDs are well known to cause potentially serious adverse reactions, such as increased postoperative bleeding, diminished tissue healing, and decreased renal function. As a result, one study suggests the use of gabapentin (off-label use) as a potential multimodal perioperative drug to be given prior to the surgical procedure.19 It's been widely used for years as a treatment for neuropathic pain and also has anxiolytic properties.19 In this study, the researchers used a low oral dose prophylactically and found that visual analog scores were reduced without increasing adverse drug adverse reactions, such as nausea, vomiting, and respiratory distress.19
It's been well established that there's a high incidence of recurrent defects in all age groups after rotator cuff repair,5 with an average structural failure rate of approximately 22%.20 Rotator cuff repair can most typically fail because of recurrent instability, continued pain, and postoperative stiffness.21 Even though rotator cuff repair has been shown to provide better results in older adults than debridement alone, there are definite challenges to the procedure.5 Patients over the age of 65 tend to have larger tear sizes and a higher level of fatty infiltration of skeletal muscle, which can increase the difficulty of repair.5,20 Because older adults have a high incidence of multiple chronic diseases (such as diabetes, renal disease, and rheumatoid arthritis), healing may be weakened and surgical management complicated.5 Tendon cellularity and vascularity is markedly diminished at 70 years compared with corresponding tissue at 50 years.5
Bone quality is also diminished, particularly in women—due to osteoporosis—and can complicate suture fixation, and thus, structural healing.5 Although more studies are needed in regard to the effect of osteoporosis on rotator cuff repair, it's logical to believe that anchor loosening and impairment of healing can occur in the presence of this condition.20 Chung and colleagues performed a study demonstrating that “in addition to the amount of retraction and fatty infiltration of the infraspinatus, bone mineral density (BMD) is also a key independent prognostic factor affecting cuff integrity after arthroscopic rotator cuff repair.”20 Positive clinical outcomes regarding functional improvement are consistently reported, which may be due to the effect of partial healing.20
Postoperative shoulder stiffness is a common complication after arthroscopic repair of the rotator cuff. Francheschi and colleagues demonstrated in a study that plasma concentration levels of substance P (SP) were higher after arthroscopic rotator cuff repair in patients with post-op stiffness than levels in patient with a good postoperative outcome.22 SP is secreted in the nervous system and in inflammatory cells and is transported centrally and peripherally with most of its release into the peripheral tissues.22 Inflammatory effects are apparent in diseases of the respiratory, gastrointestinal, and musculoskeletal systems.22 In the shoulder, the biceps tendon is innervated by sensory fibers, including SP, and that may play a part in shoulder pain.22 As a result, optimal pain management should be monitored in these patients in order to facilitate rehab and improve functional outcomes.
Even though older adult patients have unique variables in operative outcomes, they can still benefit substantially from rotator cuff repair if indicated by preoperative work-up. Despite the possibility of complications, there's still a high probability based on current evidence that they'll improve functionally and in terms of overall pain level. It's important for the perioperative nurse to be aware of the unique challenges of this age group in order to improve outcomes and provide the highest quality of care.
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