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CURRENT CONCEPTS
Failed Rotator Cuff Repair
Options for managing rotator cuff defects include reinforcement by local autograft (long head of the biceps), and use of allograft tissue and synthetic scaffolds. Allograft patch (synthetic or biologic) augmentation is used for reinforcement of the tendon defects. The allograft can be biologically augmented with autologous platelet rich plasma (harvested from peripheral blood) and autologous bone marrow aspirate (harvested from the proximal humerus) (Fig. 11). Mini open arthroscopic assisted revision rotator cuff repair is an attractive option especially when dealing with a large rotator cuff tear and rotator cuff defect. Unlike the open technique the deltoid attachment on the acromion is maintained but still provides the ease of using Mason-Allen type grasping stitches through the tendon and extensive soft tissue releases. The use of suture anchors or transosseous repair seems more convenient with the mini open technique. Furthermore, this technique is especially helpful when using the allograft tissue or synthetic scaffolds to bridge or augment the rotator cuff defects.
Tendon transfers and arthroplasty are alternative treatment options for an irreparable revision rotator cuff. Pectoralis major transfer is indicated for an irreparable, painful subscapularis tendon tear. Latissimus dorsi transfer is principally a pain relieving operation, which is performed for an irreparable posterosuperior rotator cuff in a highly functional patient (usually younger patient) who does not have pseudoparalysis or advanced glenohumeral arthritis (preferably intact subscapularis). The gain in external rotation with a Latissimus dorsi transfer is variable. The reverse shoulder prosthesis is preferred in the older patients with chronic pseudoparalysis or severe rotator cuff tear arthropathy.
Post-operative rehabilitation is a critical part of the RCR management. We prefer a protective rehabilitation protocol allowing sufficient time to maximize healing and utilize delay muscle strengthening protocols.
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Postoperative Shoulder Stiffness
Literature metanalysis demonstrates that the shoulder stiffness after arthroscopic RCR is less common than open RCR. The majority of mild and moderate stiffness responds to non-operative treatment (structured rehabilitative protocol). Persistent significant shoulder stiffness is an indication for arthroscopic surgical capsular release (Fig.10). EUA provides useful information regarding the true pattern of stiffness. After performing diagnostic arthroscopy, we proceed with the rotator interval release and superior glenohumeral ligament release. Anterior or inferior or posterior capsular releases are performed depending on the predominant pattern of capsular stiffness. Subacromial adhesiolysis is performed after the intracapsular releases have been completed. The response to capsular releases and restoration of range of motion is checked intra-operatively to verify adequacy of capsular release.
In conclusion, failed rotator cuff repair is a challenging clinical situation. Symptomatic retear, stiffness and presence of significant weakness can result in dissatisfaction after rotator cuff repair. Identification of factors that led to failure of the index procedure, and systematic approach to the management of failed rotator cuff repair is essential for a successful outcome.
01 Fig 1
02 Fig 2
03 Fig 3
04 Fig 4
05 Fig 5
06 Fig 6
07 Fig 7
08 Fig 8
09 Fig 9
10 Fig 10
11 Fig 11
11
Axillary view of right shoulder following rotator cuff repair with continued pain in the acromion demonstrating os acromiale Axial view of a magnetic resonance image demonstrates artifact from previous hardware, which can interfere with assessment of rotator cuff healing.
Arthroscopic view from the posterior portal demonstrating fraying, delamination and partial tear of long head of the biceps tendon
Arthroscopic view from the posterior portal showing LHB
tenotomy
Arthroscopic view from the posterior portal showing
a subscapularis tear
Arthroscopic view from posterior portal showing subscapularis repair
Arthroscopic view from the posterolateral portal showing revision acromioplasty
Arthroscopic view from the lateral portal showing transosseous equivalent double row rotator cuff (speed bridge technique) Arthroscopic view from lateral portal showing suture passage for margin convergence and single row rotator cuff repair Arthroscopic view from posterior portal showing distal
clavicle excision
Injection of allograft dermal matrix with autologous PRP
and bone marrow concentrate on back table (a) prior to implantation via miniopen incision to augment rotator
cuff defect (b)
38 ISAKOS NEWSLETTER 2015: Volume I