Revision Repair

Abstract

It is very common for patients to experience loss of structural integrity following a primary rotator cuff repair. Causes of failure after the primary repair can include biologic failure, technical error, traumatic failure, or a complication stemming from the primary injury. When evaluating a failed repair, it is critical to evaluate range of motion and obtain both magnetic reasonance imaging (MRI) and standard radiographs to have a successful preoperative diagnosis. It is essential to recognize the reason failure and to correctly evaluate the surgical indications compared to non-surgical management. When it comes to surgical treatment, the surgeon can opt to use open, mini-open, or arthroscopic techniques, but the senior author offers an arthroscopic approach in this chapter. Revision cuff repair presents unique challenges, and the outcomes are inferior to primary repair. However, a surgeon can consistently expect to see a satisfied patient with improved pain and functional scores.

Keywords: Rotator cuff; revision; arthroscopy; double-row; failure.

Introduction

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  Loss of structural integrity after primary rotator cuff repair is common.

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  Revision rotator cuff repair presents several challenges that are often not present at the time of primary rotator cuff repair.

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  Recognizing the reason for failure of the primary rotator cuff repair is essential for success in the revision setting.

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  Appropriate patient selection and preoperative planning cannot be overlooked in order to achieve success after revision rotator cuff repair.

Modes of Failure

Failure after rotator cuff repair in the appropriately indicated patient depends on a variety of factors but can often be broadly categorized as biologic failure, technical error, traumatic failure, or the result of a complication from the primary surgery ( ) ( Box 9A.1 ). Of these factors, biology continues to be the most influential force. Despite technical advances and multiple local and systemic augmentation strategies ( ), rotator cuff repair fails to replicate the native tendon to bone interface ( ). In the revision setting, poor tissue quality and atrophy or fatty infiltration of the muscles further limits the biologic potential ( ). Because of this, it is important to optimize the mechanical environment with a low-tension and high-surface-area repair. If this environment cannot be created because of local tissue loss or other factors, it may be necessary to consider options other than a standard revision rotator cuff repair.

The most common technical error is failure to accurately recognize the rotator cuff tear pattern. Most, but not all, rotator cuff tears can be categorized using descriptions popularized by Burkhart and include crescent, U-shaped, L-shaped, and reverse L-shaped tears ( ). Crescent tears are the most common and most easily repaired. If the torn rotator cuff tissue is not reduced anatomically and according to tear pattern, then undue tension is the likely result. For example, trying to repair the tissue at the apex of a U-shaped tear to the tuberosity, as would be done in the typical crescent-shaped tear, will almost certainly fail. Additionally, there has been much debate about the optimal insertion angle of suture anchors during rotator cuff repair, including Burkhart’s so-called deadman theory ( ), which has more recently been called into question with several biomechanical studies ( ). The current evidence cannot deem a particular angle of anchor insertion as an error because results and theories have been variable. However, anchor pullout or migration, which may be visualized with plain radiographs or advanced imaging depending on the material of the anchor, may be indicative of technical error and explain a rotator cuff repair failure. As more evidence becomes available, suture technique and location of the suture relative to the musculotendinous junction are likely to become important technical considerations ( ).

Traumatic failure after rotator cuff repair typically occurs within the first 3 to 6 months after surgery ( ). Failure is often secondary to repetitive microtrauma caused by noncompliance with postoperative rehabilitation or overzealous physical therapy. In the revision setting, it is important to understand the patient’s rehabilitative course after the initial surgery because this may provide clues to potential modes of failure. Additionally, any history of a fall or acute change in pain and function after a specific activity may suggest traumatic failure.

In general, complications after rotator cuff repair are rare, ranging from 5% to 10% ( ). The most frequent complications, not including early failure, are stiffness and infection. Any of these complications can lead to an unsatisfactory outcome for the patient. Deep infection after rotator cuff repair is particularly problematic because underlying infection limits the reparative process and puts the articular cartilage at risk. Although rare, it is important to consider any and all of these complications during the workup of a patient with failure of a previous rotator cuff repair because management options, including the surgical approach and plan, may have to be altered to adequately address the complication at hand.

Patient Evaluation