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CURRENT CONCEPTS
Failed Rotator Cuff Repair Imaging Studies
The imaging studies are generally helpful in identifying a RC defect post repair, however there are limitations to the imaging modalities as they may potentially either under call or overcall the level of healing of the tendon. Imaging is also important in assessing the status of the residual RC (atrophy, retraction, and fatty infiltration), and also helps to identify alternate pathology (glenohumeral arthritis, os acromiale, AC joint arthrosis, and calcific tendinitis) (Figs. 1 and 2). Plain radiographs of the glenohumeral joint including the anteroposterior, axillary, and supraspinatus outlet views should be obtained to review degenerative changes, associated pathology and cysts or other postoperative issues. Advanced imaging studies are helpful in demonstrating a rotator cuff defect but whether this defect actually correlates with pain and loss of function requires clinical correlation. MRI arthrogram, CT arthrogram, and Ultrasonography are helpful and have their respective indications. MR arthrography is considered the imaging of choice for rotator cuff assessment in revision surgery. USG is cost beneficial but is highly user dependent. CT arthrogram is a valid option in patients who have a contraindication to an MRI. Presence of a rotator cuff defect on imaging studies after rotator cuff repair does not necessarily translate into clinical failure as many patients can have a painless functional shoulder despite having a rotator cuff defect.
Treatment options include both operative and non-operative strategies (Table 3). The patient should be informed about various treatment options, modifiable risk factors for poor healing of rotator cuff (smoking), the requirement for an extended postoperative rehabilitation and having realistic expectations from the revision surgery.
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Operative Principles of Revision Rotator Cuff Repair Surgery
The goal of revision rotator cuff repair is to perform a tension free rotator cuff repair. The integrity of the deltoid, presence of an external impingement, status of the biceps and AC joint, the quality of the residual RC tendons (atrophy, fatty infiltration, degree of cuff retraction, number of tendon involved), functional level of the patient, and hand dominance are important factors to be identified in preoperative planning. Prior operative notes, if available, can provide useful information regarding the type of rotator cuff repair performed during previous surgery (single row versus double row), the number and type of suture anchors used previously (absorbable versus metallic), status of the biceps tendon and quality of the residual rotator cuff.
Revision RCR can be performed via open or arthroscopic techniques based on the surgeon preference. We prefer arthroscopic revision RCR with provision to mini open if necessary. A beach chair position is used for arthroscopic revision RCR but a lateral approach can also be used based on the surgeon’s preference. Exam under anesthesia (EUA) provides valuable preoperative information regarding instability, restriction of range of motion, and also provides an opportunity for gentle manipulation of the shoulder.
Table 3. Treatment Options in Failed Rotator Cuff Repair
1. Non-operative
a. Physical Therapy-range of motion, scapular strengthening
b. Intraarticular steroid injections
c. Pain medications
d. Activity modifications
2. Operative intervention: provided there is no infection following operative options exist
a. Revision rotator cuff repair-arthroscopic or mini open
b. Arthroscopic debridement, subacromial decompression and biceps tenotomy/tenodesis
c. Tendon transfers
d. Prosthetic replacement
Treatment
Failed RCR continues to be a technically challenging scenario. The key problem, symptomatic retear or presence of significant weakness or stiffness, or alternate diagnosis should be identified during preoperative work up. If symptomatic retear of the rotator cuff is the predominant problem and the potential causative factors have been identified, the next question is whether the RC is reparable or not. Active infection, chronic massive cuff tears, severe cuff tear arthropathy, multiple tendon tears (>2 tendons) and advanced fatty infiltration of RC (Goutallier stage >2) are scenarios that are less likely to have a successful repair and alternative treatment options should be considered.
36 ISAKOS NEWSLETTER 2015: Volume I
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