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CURRENT CONCEPTS
Failed Rotator Cuff Repair
Mandeep S. Virk1
Additional Authors:
Petar Golijanin2
Matthew T. Provencher, MD2
Corresponding Author:
Augustus D. Mazzocca, MS, MD1
1 Department of Orthopaedic Surgery, New England
Musculoskeletal Institute, University of Connecticut School of
Medicine, Farmington, CT, USA
2 Department of Orthopaedic Surgery, MGH Sports Medicine
Surgery, Harvard Medical School, Boston, MA, USA
Conflict of interest
Mandeep S. Virk–No conflict of interest
Augustus D. Mazzocca–Consulting and research support from Arthrex
Matthew T. Provencher–Consulting Arthrex and JRF/Royalties Arthrex
Petar Golijanin–No conflict of interest
Introduction
Rotator cuff repair (RCR) results in a predictable pain relief and variable return of function (motion and strength) in the majority of patients. The symptomatic failed rotator cuff repair continues to be a challenge. However, not all rotator cuff structural failures have clinical deficiencies, and many patients who don’t fully heal their rotator cuff may continue to enjoy a high level of function and pain relief. The term “failure” needs to be well defined-in that RCR may fail for pain, stiffness, or weakness, or a combination of some or all three of these factors.
For any revision surgery and in failed RCR there are three very important questions that the orthopaedic surgeon should ask oneself before proceeding with the revision surgery:
a. Why did the first surgery fail?
b. How does one go around fixing the problem this time (preoperative planning)?
c. Are there any preoperative risk factors that are predictive of the high rate of failure of revision RCR and in that case what are the alternative treatment options?
Provided that the index surgery was appropriately indicated and performed for a correct diagnosis and other concomitant diagnoses or sources of pain were addressed in prior surgeries, there are multiple factors that can lead to failure of RCR (Table 1). A systematic approach should be utilized to investigate other causes (besides rotator cuff failure) that can result in shoulder pain and loss of function after rotator cuff repair (Table 2). These could be related to the cervical spine, biceps tendon, acromioclavicular (AC) joint, adhesive capsulitis and infection (Table 1).
Loss of motion and stiffness is less common with arthroscopic rotator cuff repair compared to the open repair. Numerous predisposing risk factors have been proposed for development of adhesive capsulitis and include prolonged immobilization, presence of preoperative stiffness or concomitant labral pathology, smaller tear size and articular sided tears, and systemic illness (diabetes, hypothyroidism).
Clinical studies measuring isokinetic strength testing of shoulder after rotator cuff repair have demonstrated that it takes up to a year to achieve peak recovery of shoulder strength. The recovery of strength in the shoulder is slower and inconsistent in large and massive tears compared to small and medium tears. Suprascapular nerve injury is an uncommon cause of postoperative worsening of rotator cuff strength and function.
Table 1. Associated with Failed Rotator Cuff
A. Biologic failure (inability of the cuff to heal at the bone tendon interface)
1. Poor quality tissue for healing-poor blood supply, tendon atrophy, fatty infiltration, chronic tear with degenerative changes
2. Infection
3. Smoking
4. Physiologic older age
5. Diabetes
6. NSAIDS use
B. Mechanical failure: (structural failure of rotator cuff fixation to the bone)
1. Failure of fixation at the tendon suture interface (poor structural integrity of the cuff, repair under significant tension, tendon gap despite tendon tissue after mobilization)
2. Failure of fixation at the bone-anchor interface (greater tuberosity fracture, poor pull out strength in osteoporotic bone at the greater tuberosity)
3. Early aggressive rehabilitation
4. Infection
5. Non compliance with post-operative rehabilitation plan
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ISAKOS NEWSLETTER 2015: Volume I