Perioperative anaesthetic considerations for rotator cuff repair surgeries: A current concept review

Abstract

Surgeries for Rotator Cuff (RC) pathologies are required for either trauma or degenerative related aetiologies. Various surgical techniques from open to arthroscopic repair, are being undertaken by orthopaedic surgeons. Peri-operative anaesthetic management of the patients undergoing rotator cuff repair requires understanding the surgical procedure and patient status for optimal anaesthetic planning. Such management mandates a thorough pre-operative evaluation, including clinical history, examination, and relevant investigations. Patients with acute trauma associated Rotator Cuff (RC) tears should be assessed for visceral injuries using appropriate injury evaluation systems before such repairs. On the other hand, patients with degenerative tears tend to be older with associated comorbidities. Hence pre-operative optimisation is necessary according to risk stratification. Anaesthetic techniques for Rotator Cuff (RC) surgery include general anaesthesia or regional anaesthesia. These are individualised according to patient assessment and surgical procedure planned. Knowledge of relevant surgical anatomy is essential for intra-operative, and post-operative neural blockade techniques since optimal peri-operative analgesia improve overall patient recovery. The occurrence of a peri-operative complication should be recognised as timely management improves the patient-related surgical outcomes. We describe the relevance of surgical anatomy, the effect of patient positioning, irrigating fluids, various anaesthetic techniques and an overview of regional and medical interventions to manage pain in patients undergoing for Rotator Cuff (RC) surgery.

1. Introduction

Rotator Cuff (RC) tears and associated pathologies are common conditions seen in clinical practice, primarily due to trauma or degenerative aetiologies. Symptomatic patients may require surgical repair of RC tears and these are one of the frequently undertaken procedures in orthopaedic speciality worldwide. RC surgery can be performed either using a minimally invasive technique using arthroscopic intervention or with open approaches. Anaesthesia and anaesthetic techniques required to perform RC surgery form an integral part of the patient’s successful journey. Peri-operative care of patient scheduled for RC repairs or reconstruction requires an understanding of the surgical procedure itself and the patient. All patients require a thorough pre-operative evaluation, including surgical prioritisation category and risk assessment of associated comorbidities using methods such as the American Society of Anaesthesiologists Physical Status Classification System (ASA) grades for fitness for surgery. Various potential complications encompassing but not limited to nerve injury, intraoperative hemodynamic instability, cerebral hypoperfusion, airway oedema, complex regional pain syndrome can occur during the peri-operative period.^{1, 2, 3, 4, 5} Hence careful planning is needed. Although arthroscopic RC shoulder surgery is nowadays carried out as a day case procedure, these can be painful procedures since osseous stabilisation, decompression and or use of bone anchors may be required.⁶ Peri-operative pain management of these patients is challenging due to various patients and surgery-related factors. A thorough pre-operative assessment, strategic anaesthetic planning including monitoring, analgesia and timely identification of complications and its management is crucial.^5,7

This review provides an overview of various peri-operative anaesthetic management strategies of patients undergoing RC repair surgeries. We highlight the anaesthetic approach as well as various pharmacologic pain interventions to improve safety and surgical outcome.

2. Relevant anatomy

Planning and executing regional anaesthetic and analgesic techniques for rotator cuff repair (RCR) surgery needs familiarity with shoulder anatomy. The RC is an integral part of the shoulder complex and has four muscles and tendons. These include the supraspinatus, infraspinatus, subscapularis, and teres minor. RC maintains the stability of the humeral head during abduction and rotation at the shoulder joint. The shoulder area is supplied by branches of both cervical and brachial plexuses [Fig. 1 (a,b) and Fig. 2 (a,b)]. Knowledge of its relevant anatomy is necessary for consideration of peri-operative neural blockade and pain management. The brachial plexus supplies all motor and sensory functions of shoulder except skin above the clavicle, shoulder tip, and first two anterior intercostal spaces innervated by the superficial cervical plexus.^{8, 9, 10} Innervation of the shoulder’s deeper structures such as capsule and ligaments is via axillary, suprascapular, and lateral pectoral nerves. While performing interscalene brachial plexus block, one needs to be aware that suprascapular nerve emerges from the proximal part of a superior trunk. Thus supraclavicular nerve needs to be blocked for successful regional anaesthesia for an awake arthroscopic procedure and optimal analgesia. Similarly, the surgical approach to open surgery is also paramount because incision may also involve an area supplied by the median cutaneous and intercostobrachial nerve.

Fig. 1.

Nerve supply of shoulder joint (a) anterior view (b) posterior view.

Fig. 2.

Dermatomal supply for shoulder region related to Rotator Cuff Repair Surgeries (a) Anterior View (b) Posterior View.

3. Surgeries for rotator cuff tears

A wide variety of procedures and surgical techniques are undertaken for Rotator cuff repair (RCR).¹¹ These depend on RC tear’s nature- acute vs chronic, size of the tear, e.g. small or massive, partial or full-thickness tears, associated arthritis of the shoulder joint, and patient comorbidities.^{11, 12, 13, 14} The spectrum of surgery includes partial repair, complete arthroscopic repair, mini-open repair, debridement with acromioplasty with or without biceps tenotomy to the use of various auto and allografts. Some patients with massive rotator cuff tears may require tendon transfer, deltoid flap, hemiarthroplasty, and reverse shoulder arthroplasty.¹³ It has been acknowledged that RCR is more painful than other arthroscopic procedures such as subacromial decompression or shoulder stabilisation.¹⁵ Consequently, there is a great debate about peri-operative pain management pathways following RCR surgery.¹⁶ It is usually accepted that peri-operative anaesthetic and pain management requires a multi-modality approach with a combination of nerve blocks or peri-articular injections and associated techniques.¹⁷

4. Pre anaesthetic evaluation

Trauma associated RC tears may have associated trauma to various body organs of variable severity. Patients with injury-related RC tear need to be assessed for trauma-related effect on other body parts and organs. Mechanism of injury should be evaluated using systematic trauma protocols and appropriate Injury Severity Scoring systems. Life-threatening injuries are managed first.

Patients who have degenerative rotator cuff damage are usually elderly and have associated multiple comorbid conditions. Patients with these associated comorbidities need to be thoroughly assessed for systemic involvement and previous treatment. Apart from routine investigations (blood investigations and imaging), additional investigations need to be tailored individually.

Common peri-operative concerns which can affect the selection of anaesthesia technique and the patient’s outcome after RCR surgeries are highlighted in Table 1.

Table 1.

Peri-operative concerns associated with Rotator Cuff Repair Surgeries.

Period	Concerns	Factors
Intraoperative Concerns	Patient-related	•Age: Geriatric Vs. Young patients • Causes of Rotator cuff tear: o Traumatic o Degenerative diseases such as Rheumatoid Arthritis/osteoarthritis •Associated injuries: Spine or other musculoskeletal injuries etc. • Comorbid conditions (more common with geriatric patients): o Functional reserve: Poor Cardiorespiratory Reserve o Anticoagulation therapy Psychological preparation
	Surgery Related	•Open Vs. Arthroscopic repair •Minor Vs. Major surgery • Surgical Position: o Lateral Position (High incidence of airway oedema during/after arthroscopy) o Beach Chair Position (High incidence of hypotensive and or bradycardia) •Use of irrigation fluids
Post-Operative Concern	Patient-related	•Inadequate pain control (Acute/Chronic pain) •Complex Regional Pain Syndrome type 1 Need for the planned rehabilitation
	Surgery Related	• Consequences of Local and/Systemic absorption of irrigation fluids o Post-operative airway compromise o Haemodilution, Weight gain

5. Positioning

RCR surgery can be performed in either the beach-chair position (deck chair or modified sitting position)(Fig. 3) or lateral decubitus position (Fig. 4) depending on surgeon preference and anaesthetic prior risk assessment. The operating room team must know physiological changes and associated risks with either position. Teamwork and planning are essential for patient safety.^{1, 2, 3}

Fig. 3.

Diagrammatic representation of Beach-Chair Position (deck chair or modified sitting position).

Fig. 4.

Diagrammatic representation lateral decubitus position during shoulder surgery.

5.1. Beach chair position

Patients in the beach- chair position are prone to neurologic injury, cervical neuropraxia (lesser occipital nerve, greater auricular nerve, hypoglossal nerve), hemodynamic perturbations such as hypotension and bradycardia, reduced cerebral perfusion, and cerebral desaturation. Neurological injuries are due to excessive traction on the brachial plexus or nerve compression during the intraoperative period. Hypotensive episodes occur primarily because of blunting of compensatory mechanisms caused by anaesthesia, lack of stimulation with an effective block, and activation of Bezold–Jarisch reflex. Any fall in blood pressure should be prevented and treated rapidly. Extreme rotation of the head should be avoided, as it may compromise cerebral vessels. Cerebral oximetry may provide a non-invasive and continuous measurement of cerebral perfusion. However, the usefulness of cerebral oxygen saturation monitor has not been established.¹⁸

5.2. Lateral decubitus position

The lateral decubitus position is also associated with neurological injuries, airway obstruction, and pressure injury. The reported incidence of paresis/palsies ranges from 0.2% to 10%, though most of the injuries did recover.² Though debated, either of these patients’ positions has shown comparable clinical outcomes with low complication rates.^2,3

6. Effect of irrigating fluids

Arthroscopic procedures require the use of the high volume of irrigating fluid for improved visualisation and surgical intervention. Both local extravasation and systemic absorption of irrigation fluid during arthroscopic shoulder surgery could be devastating.^{4,19, 20, 21, 22} Extravasation of irrigation fluid can be lead to airway oedema and tracheal compression. Gravity plays a significant role in irrigation fluid-related airway compromise in lateral decubitus patients. Any healthy patients who can generate high negative intrathoracic pressure during inspiration against an obstructed airway may develop negative-pressure pulmonary oedema.²³ Long duration surgery, poor positioning, high irrigation pressure, and obesity are risk factors for airway obstruction both in the intraoperative and postoperative period.^19,21 Surabhi et al. found a significant positive correlation between the change in neck circumference and weight gain with the amount of irrigation and surgery duration. They also observed a drop in haemoglobin of 0.89 ± 1.23 g/dL with a positive correlation with surgery duration and the amount of irrigation. The amount of irrigation fluid used and collected should be monitored. Continuous monitoring of airway pressure and compliance during the intraoperative period, measurement of the neck circumference and cuff leak test before extubation should be done to reduce airway related adverse events.

7. Anaesthesia techniques

RCR surgeries have been performed using various anaesthetic techniques with variable outcomes. General anaesthesia, regional anaesthesia and a combination of both have been used for RCR surgeries. The choice of these anaesthetic techniques depends not only on patient status but also the proposed surgical intervention. Depending on the duration and complexity of RCR surgery, a balanced choice can be made for the anaesthetic technique. Significant tears of the rotator cuff usually require a longer duration of surgical intervention and thus combined general and regional anaesthetic techniques remains the preferred technique. Selection of anaesthesia technique is influenced by patient-related factors, surgical factors and anaesthesiologist preferences (Table 2).

Table 2.

Anaesthesia Techniques for Rotator Cuff Repair Surgeries and their advantages and disadvantages.

Type of Anaesthesia	Advantages	Disadvantages
General Anaesthesia	•Better intraoperative condition •Applicable to all type of procedure. •Provision for hypotensive anaesthesia if needed. •Secured airway	•Need for higher opioid analgesics in the intraoperative and post-operative period •High incidence of nausea/vomiting •Higher incidence of hypotension/bradycardia
Regional Anaesthesia with or without sedation	•Reasonable intraoperative and post-operative pain control	•Need cooperative patients •Not suitable for longer/complicated surgery •Not suitable for patients on anticoagulant therapy
Combined General Anaesthesia and Regional Anaesthesia	•Better intraoperative condition. •Secured airway •Reasonable intraoperative and post-operative pain control	•Higher incidence of hypotension and bradycardia •Longer induction time

7.1. General anaesthesia

General anaesthesia with an endotracheal tube is the preferred technique as it eliminates the risk associated with limited access to an unsecured airway during the intraoperative period. It also facilitates the provision for hypotensive anaesthesia to reduce the blood loss. It remains an option in patients who are anticoagulant therapy wherein regional techniques may not be feasible. Though general anaesthesia techniques are safe and provide intraoperative immobility, it has few limitations such as higher hypotensive and bradycardic events, postoperative nausea, vomiting, post-intubation sore throat, post-operative cognitive impairment, and inadequate postoperative analgesia.

7.2. Regional anaesthesia with or without sedation

On the other hand, sole regional anaesthesia techniques such as interscalene brachial plexus block demand psychological preparation of patients anaesthesiologist who is skilled in regional anaesthesia.^24,25 Though interscalene brachial plexus block is considered the gold standard regional technique for shoulder surgery, it has few adverse effects, such as hemidiaphragmatic palsy or paresis, respiratory distress, pneumothorax^26,27 Many nerve blocks strategies with diaphragm sparing effect have been studied for shoulder surgeries.^{27, 28, 29} Suprascapular nerve blocks and axillary nerve blocks have been used for postoperative analgesia after shoulder surgery. However, these blocks are not sufficient for sole anaesthesia for surgery.³⁰ The costoclavicular approach to brachial plexus has been shown to provide acceptable analgesia with an additional advantage of reducing hemidiaphragmatic palsy or paresis incidence.^31,32 Injection of local anaesthetics around the superior trunk (formed by the fusion of C5 and C6 nerve roots) provided equivalent postoperative analgesia of the interscalene brachial plexus block with a significantly lower incidence of complete or partial hemidiaphragmatic paresis (76.3% vs 97.5%).²⁹ Recently the erector spinae plane (ESP) block, a modification of the paravertebral block, has been tried as a viable alternate nerve block for shoulder surgeries. Direct cervical ESP block has been recently performed successfully for postoperative pain after shoulder surgeries.³³ The cadaveric study by Elshakawy et al. has supported the opinion that cervical erector spinae block could be useful nerve block for shoulder surgeries.³⁴ The local anaesthetic drugs that have been used for these blocks include bupivacaine or ropivacaine. Specific adjuvants to increase anaesthesia’s duration and quality have also been added to the local anaesthetic agents. These include agents like fentanyl, dexamethasone, and more recently, dexmedetomidine.

7.3. Combination of general anaesthesia with regional

A combination of general anaesthesia with regional block have shown stable intraoperative hemodynamic and enhanced post-operative analgesia. It reduced opioid consumption and pain score.^35,36 A recent meta-analysis has shown the type of anaesthesia, and intra-operative pharmacological agents like β-agonists or opioids are not linked with adverse heart rate variation during shoulder surgeries in the beach chair position.³⁷

8. Analgesia

Optimal analgesia is an essential aspect of preventing pain associated with adverse events like cardiovascular events and improving the overall patient outcomes.³¹

8.1. Intraoperative analgesia

A multimodal regimen remains the standard care of analgesic management intraoperatively. Though the regional anaesthetic technique remains an acceptable method using a local anaesthetic and adjuvant, other pharmacological agents may also be used simultaneously. The intravenous opioids like morphine and fentanyl provide acceptable analgesia. Short-acting agents like fentanyl are used because of the beneficial effects of its shorter duration and can be titrated easily for optimal pain relief. The use of acetaminophen and Non-steroidal anti-inflammatory drugs (NSAIDs) like diclofenac and ketorolac provides analgesia with an opioid-sparing effect.

8.2. Post-operative analgesia

Post-operative pain associated with RCR surgery may cause prolonged in-hospital stay or re-admission and affect rehabilitation.^7,38 The PROSPECT (PROcedure-SPECific post-operative pain managemenT) guideline (under European Society of Regional Anaesthesia and Pain therapy)provides evidence-based practical recommendations for perioperative pain management for potentially painful operations, including Rotator cuff repair surgeries.³⁹ They guidelines evaluated a total of 59 randomised controlled trials and one systematic review to evaluate the effects of analgesic and surgical interventions on postoperative pain after RCR surgery, and the following recommendation was made. (Table 3).

Table 3.

Recommended perioperative AnalgesiaTechnique for rotator cuff repair surgeries.

Period	Techniques
Intraoperative Analgesic technique	Systemic Analgesics •Paracetamol •NSAID or Cyclo-oxygenase-2 Inhibitor •Intravenous Dexamethasone (Increase duration of regional blocks) Regional Analgesia •Interscalene Brachial Plexus Block (1st choice), Continuous/Single shot •Suprascapular nerve blocks ± Axillary nerve block as an alternate analgesic technique. •The role of adjuncts such as opioid, α-2 agonist, steroids for regional nerve blocks is not recommended.
Postoperative Analgesic technique	•Paracetamol •NSAID or Cyclo-oxygenase-2 Inhibitor •Opioids (as rescue analgesia)

8.2.1. Systemic medications

Paracetamol and NSAID or a cyclo-oxygenase-2 inhibitor are recommended, during the peri-operative period, unless contraindicated. Intravenous dexamethasone is recommended for its ability to increase the analgesic effect of interscalene block, decrease analgesic demand, and antiemetic effects.

8.2.2. Regional analgesia

Regional analgesic techniques should be included as a part of multimodal analgesia during RC surgery. Interscalene brachial plexus blockade (continuous or single-shot) is recommended as the first-choice regional analgesic technique. A suprascapular nerve block with or without axillary nerve block is the second commonly used technique. Perineural adjuvant drugs to a local anaesthetic agent such as buprenorphine, tramadol, dexamethasone, magnesium sulphate have a limited role. Intravenous dexamethasone is recommended over perineural administration.

9. Post-operative management

Planning of adequate analgesia and evidence-based rehabilitation is critical for optimal patient recovery after RCR surgery.

9.1. Post-operative monitoring

Patients should be monitored postoperatively for analgesia and any associated intraoperative events with appropriate clinical parameters including Early Warning Scoring (EWS) systems which record vital signs such as pain, temperature, blood pressure and heart rate. The level of monitoring depends on the patient’s status and nature of intraoperative events. Patients with associated comorbidities or intraoperative complications like excessive bleeding should be observed in an intensive care setup or a high dependency unit.

9.2. Complications

After rotator cuff repair surgeries, various complications related to fingers and hand have been reported, such as carpal tunnel syndrome, flexor tenosynovitis, and complex regional pain syndrome type-1 (CRPS).^{40, 41, 42} Taneuse et al. reported that the incidence of CRPS after arthroscopic RCR surgeries were 0.5–24.2%. They also demonstrated that low abduction strength was significantly associated with the development of CRPS after RCR surgery.⁴¹ Open surgery, hypothyroidism, and pre-operative high level of daily physical activity were also identified as a risk for CRPS.⁴² patients with CRPS present with the clinical features of intense pain, hypersensitivity, oedema skin/hair changes, abnormal sweating, movement restriction, and the temperature difference. The management of CRPS requires a multidisciplinary approach which includes physical/occupational therapy, patient counselling and medications including NSAIDs, steroid, gabapentin, amitriptyline and carbamazepine. This approach also includes sympathetic nerve blocks like the stellate ganglion block. The benefit of neuromodulation techniques such as dorsal root ganglion stimulation for CRPS is still under debate.^43,44

10. Conclusion

As with all surgical procedures, RC surgery requires the peri-operative team, including orthopaedic surgeon and anaesthesiologists, to communicate effectively in formulating a safe plan to provide optimal anaesthesia and analgesia with attempts at minimising complications. While evaluating a patient, detailed history, clinical examination, and specific investigations are vital. All patients must be well informed about the options of the available anaesthetic techniques and associated implications. The anaesthetic technique for RCR surgeries should be individualised for every patient considering the type of procedure, intraoperative positioning, associated comorbidities, and plan for perioperative analgesia.

Statement of funding

None.

Declaration of competing interest

None.