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Revision Rotator Cuff Repair
Primary rotator cuff repair frequently leads to successful subjective results with decreased pain and increased function, but incomplete healing or retearing is known to commonly occur. Retear rates following repair of small to medium tears have been reported as high as 40%, and up to 94% following massive, chronic cuff tears. Despite retear, many patients can maintain pain relief and improved functional outcome. However, patients who do not heal, on average, tend to have worse satisfaction, clinical outcomes, and decreased function compared to those with an intact repair. Of those patients with retear who are unsatisfied and have continued symptoms, 6% to 8% will require revision rotator cuff repair. This chapter provides an approach to patient evaluation after unsatisfactory rotator cuff repair and details surgical options for this difficult problem.
History
A careful history is critical in understanding the etiology of rotator cuff repair failure and to understand the patient's expectations. Typically, patients with failed rotator cuff repairs present with shoulder pain and weakness. It is important to ascertain the onset, location, characterization, intensity of the pain, and the patient's physical demands for both work and recreation. Furthermore, it is important to elucidate whether any specific motions or activities elicit the pain. The surgeon should ask if there was a period of improvement after the primary surgery or if the symptoms continued to persist since the index procedure. The indication for most revision rotator cuff repairs is usually to manage persistent pain and weakness since the initial surgery. All previous surgeries should be discussed with the patient; obtaining previous medical records, operative reports, preoperative imaging, and arthroscopic pictures are helpful in assisting with treatment decisions.
When considering a revision procedure, the most important factor to ascertain from the history is the possible cause of failure—the exact cause of which is often multifactorial. Factors causing rotator cuff nonhealing or retear can be classified into three broad categories: biologic, technical, and traumatic. Injured tendons develop a fibrovascular scar at the tendon bone interface, which is altered from the native tissue with decreased vascularity and decreased healing potential. This biologically inferior milieu predisposes a repaired tendon to retearing.
Biologic
This category of risk factors includes both the biology and the nature of the cuff tear itself, as well as the patient as a whole. Patient factors, such as increased age, nicotine use, and diabetes, have all been consistently reported to lead to decreased healing rates and poor clinical outcomes. Preoperative factors related to the cuff tear itself, including tear size, degree of retraction, and muscle atrophy, have all been shown to correlate with increased failure rates. As the cuff ages, and the longer the tear has persisted, there is an increased level of fatty infiltration with decreased muscle in the cuff. Studies have shown that fatty infiltration and cuff atrophy can lead to increased tension on the repair and increased failure rates.
Infection is an uncommon cause of cuff repair failure; however, it must be ruled out. Patients who have persistent postoperative pain with no period of relief, who have compromised immune systems, a history of fevers, redness, or problems with their incision should undergo an infection work-up consistent with white blood cell count, erythrocyte sedimentation rate blood test, c-reactive protein test, joint aspiration for cell count, and culture.
Technical Factors
Identifying potential surgical errors as a cause of failure can be essential when planning a revision. These factors can include knot failure, inadequate recognition of tear size or pattern, poorly fixed or positioned anchors, and over-tensioning the repair. One of the most common modes of failure for rotator cuff repair is when sutures cutout through poor quality tendon Suture configurations, such as double row, single row, transosseous, and transosseous equivalent repairs, have been described to address this problem. Biomechanical data support double row fixation and/or transosseous equivalent repair, but clinical data have not consistently shown improved outcomes over a single row repair. Surgeon familiarity with the chosen technique is likely most essential, as low surgeon volume has been shown to be an independent risk factor for reoperation.
Failure to address other pain generators in the shoulder can also lead to persistent pain and decreased function, which can be incorrectly attributed to a failed repair. Failure to address biceps tendon pathology, prominent acromial spurs, or a symptomatic acromioclavicular joint at the index surgery can contribute to a persistently symptomatic shoulder after rotator cuff repair. Other noncuff tear etiologies of shoulder pain are shown in Table 49.1 .
TABLE 49.1
Noncuff Tear Etiologies of Residual Shoulder Pain
| Extrinsic Pain Generators |
|
| Intrinsic Pain Generators |
|
Traumatic
Traumatic tearing can be defined as early (before tendon healing has occur) or late (after healing has occurred). Early tears usually occur between 6 and 26 weeks postoperatively and can be a result of overly aggressive physical therapy in the acute recovery period. Late traumatic retears usually have a history of improved or return to normal shoulder function, followed by an identifiable trauma or injury that led to onset of new symptoms.
Physical Examination
The physical exam is paramount in identifying the cause of a failed rotator cuff repair and also the suitability of the patient for a second surgery. We start our evaluation with a cervical spine examination. Many patients with cervical spine disease have associated shoulder pain. They usually have limited cervical range of motion (ROM) particularly with hyperextension. It is important to note if there is any decreased sensation in a particular dermatome. A Spurling test should be performed to evaluate for radicular symptoms.
Examination of the shoulder begins with inspection of the shoulder by looking for evidence of supraspinatus or infraspinatus atrophy. Also assessing previous portals or incisions should be noted for healing, contracture, or signs of infection. The surgeon should palpate the glenohumeral joint, rotator cuff insertion, biceps groove, and acromioclavicular joint. Active and passive ROM of the shoulder should be evaluated and compared to the contralateral shoulder. Often passive ROM is greater than active ROM in the setting of a rotator cuff tear. Patients that have equal loss of passive and active ROM (true stiffness) without deficits in strength may have postoperative adhesions, glenohumeral arthritis, or capsular contracture. The strength of each rotator cuff tendon should be evaluated systematically. Having the patient internally rotate the arm and elevate it 90 degrees in the scapular plane against resistance tests the supraspinatus. The infraspinatus is tested with resisted external rotation with the arm at the side and elbow with 90 degrees of flexion. The lift-off test and belly press test are done to assess the strength of the subscapularis. The subscapularis also can be assessed with a bear hug test where the patient places the ipsilateral hand on the contralateral shoulder and the elbow positioned anterior to the body. The patient then actively resists the examiner's attempt externally rotate the forearm. If the patient is unable to keep his hand on his shoulder or weakness is detected, the test is positive.
Neer and Hawkins signs are used to evaluate for subacromial impingement. A hornblower sign is representative of significant deficit in the posterior rotator cuff (infraspinatus and teres minor). These patients commonly abduct the arm when trying to bring their hand to their face with their arm at the side. The cross-body adduction test is used to evaluate for AC joint pathology. Yergason and Speed test assess for biceps pathology.
When it is difficult to discern between cervical radiculopathy versus true shoulder pain, a diagnostic injection in the subacromial space can be helpful.
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