History

Similar to the evaluation of patients undergoing primary rotator cuff repair, the history is important to define the cause of pain and rule out non-shoulder pathology (e.g., cervical radiculopathy). Intermittent pain that is activity related is suggestive of symptoms related to the rotator cuff, whereas constant pain and/or systemic symptoms should raise suspicion for non-shoulder pathology or postoperative infection. For failed repairs, the patient’s previous postoperative rehabilitation protocol should also be reviewed to determine if early aggressive motion or strengthening contributed to structural failure.

Physical exam

Previous surgical incisions should be inspected for signs of inflammation that are suggestive of infection. It is important to determine the integrity of the deltoid attachment, particularly if the previous repair was performed with an open technique. Active and passive range of motion are compared to assess for postoperative stiffness. Patients with stiffness without a recurrent tear can benefit from an isolated capsular release alone. Pseudoparalysis is defined by most authors as active elevation of less than 90 degrees with full passive range of motion. Although recovery of pseudoparalysis following primary repair is approximately up to 90% in acute cases, the chance of recovery decreases with chronic pseudoparalysis and in the revision setting. ^,

In addition to standard strength testing, several physical exam tests can be used to define the pattern of tear and prognosis for recovery. The inability to maintain external rotation with the arm in 20 degrees of abduction and maximal external rotation is considered a positive external rotation lag sign and has been reported to have a sensitivity of 65% for detecting lesions extending into the infraspinatus tendon. Walch et al. reported that both the inability to maintain external rotation with the arm at the side (dropping sign) and the inability to externally rotate the arm from a position of 90 degrees abduction with the elbow flexed 90 degrees (hornblower’s sign) have a 100% sensitivity for detecting grade 3 or 4 fatty degeneration of the infraspinatus and teres minor. In our experience, a positive dropping arm sign or hornblower’s sign is a poor prognostic factor for revision repair and is best managed with tendon transfer or reverse shoulder arthroplasty (RSA) with tendon transfer based on age and extent of arthritis. The bear-hug test has been shown to have the highest sensitivity for detecting subscapularis tears. Given the inaccuracy of magnetic resonance imaging (MRI) at detecting subscapularis tendon tears, a positive bear-hug test should alert the surgeon to a previously missed subscapularis tear. Although commonly used, the lift-off test may not become positive until a tear is 75% or greater of the length of the subscapularis tendon.

Imaging

Plain radiographs are used to assess the glenohumeral joint space (i.e., >2 mm joint space remaining) for the presence of proximal migration and adaptive changes of the proximal humerus (i.e., femoralization) and undersurface of the acromion (i.e., acetabularization) ( Fig. 56.1 ). MRI should be evaluated for tendon retraction, tendon length, and fatty infiltration.

(A) Normal anteroposterior radiograph of a right shoulder. The glenohumeral joint is preserved, the humeral head is centered on the glenoid, and the contour of the greater tuberosity is maintained. (B) Right shoulder with adaptive changes. The greater tuberosity contour is less distinct and has changes of chronic enthesopathy, and there is sclerosis on the undersurface of the acromion.

Postoperative MRI is less accurate than MRI in the primary setting. In one study, there was a 91% sensitivity of MRI for detecting a recurrent rotator cuff tear, but the specificity was only 25%. In other words, MRI has the tendency to overdiagnose recurrent rotator cuff tears. In this study, MRI also demonstrated a poor ability to assess rotator cuff tear size. Compared with tear presence and size, MRI is likely more accurate in the postoperative setting for determining rotator cuff muscle quality. Another consideration is to evaluate for the amount of the greater tuberosity that is available for additional suture anchor placement. If large numbers of anchors are already present, or if cystic cavitation has occurred around the anchors, then the surgeon may have to remove some or all of the existing anchors and bone the graft defects.

Prognostic factors for healing

Negative patient factors for successful outcome following rotator cuff repair include advanced age, female sex, diabetes, osteoporosis, smoking, higher level of work, lower level of sports activity, and obesity (body mass index ≥30). Boileau et al. reported a 95% rate of tendon healing in patients younger than 55 years compared with only 43% at age 65 years or older. Similar results were reported by Harryman et al. following open rotator cuff repair, with a rate of healing of approximately 75% for patients 55 years of age or younger, 65% for patients 56 to 70 years of age, and 55% for patients older than 70 years. At the same time, age alone is not a contraindication to repair. Flurin et al. reported an 89% rate of tendon healing in patients older than 70 years when repairs were limited to small and medium tears. Radiographic factors associated with failure to achieve tendon healing include large tears, greater retraction, and increased fatty infiltration. Kwon et al. evaluated healing in 603 rotator cuff repairs at a minimum of 1 year postoperative and proposed a scoring system to predict healing. They proposed the following 15-point scoring system: 4 points for tendon retraction (≥3 cm = 4 points; 2 to <3 cm = 2 points; 1 to <2 cm = 1 point; <1 cm = 0 points); 3 points for infraspinatus fatty infiltration of 2 or greater; and 2 points each for anteroposterior tear size greater than 2.5 cm, age older than 70 years, bone mineral density of 2.5 or less, and high level of work. Patients with 4 points or fewer had a healing rate of 94%, compared with 45% for those with 5 points or more and 14% for those with 10 points or more. This scoring system provides a means of estimating the chance of healing and provides one method of looking at the overall scenario. However, it should be kept in mind that functional outcome can improve regardless of tendon healing. In a report of 108 arthroscopic repairs of massive tears, Chung et al. reported failure of healing in 60% of patients, with fatty infiltration of the infraspinatus being the most important factor for failure of healing in multivariate analysis. However, mean tear size was smaller in retears compared with initial size, and there was no difference in functional outcome between the healed and retear groups. The latter demonstrates that partial healing can still occur and lead to functional improvement. Likewise, Burkhart et al. reported that 100% of patients with grade 3 fatty degeneration obtained functional improvement following arthroscopic rotator cuff repair. However, for grade 4 degeneration, only 40% of patients demonstrated substantial functional improvement. Therefore, for individuals with grade 4 fatty degeneration (more fat than muscle), the decision to attempt revision rotator cuff repair should be carefully considered.

Reparability

As alluded to previously, assessing reparability is separate from assessing potential for complete healing. Much of the assessment relies upon preoperative imaging, although no one factor is predictive. Fatty degeneration has often been used as a cut-off for whether to attempt repair. Goutallier et al. originally classified fatty degeneration into five categories: grade 0, no fatty deposit; grade 1, some fatty streaks; grade 2, more muscle than fat; grade 3, muscle equals fat; and grade 4, less muscle than fat. They classified grade 2 as a turning point in prognosis for recovery. However, as noted previously, there is evidence that individuals with grade 3 and even grade 4 fatty degeneration can obtain improvement after arthroscopic rotator cuff repair. Furthermore, fatty degeneration by itself does not predict reparability, and this classification can be limited by the fact that it grades the entire muscle on only one MRI slice. Fukuta et al. demonstrated that Goutallier grading is influenced by tendon retraction. They suggested that more medial slices should be reviewed to evaluate overall remaining muscle quality ( Fig. 56.2 ).

Influence of retraction on Goutallier grading. (A) Coronal T2 magnetic resonance imaging (MRI) of a left shoulder shows a massive rotator cuff tear with retraction. (B) Sagittal T1 MRI demonstrates atrophy of the supraspinatus tendon which could be interpreted as grade 3 fatty infiltration. (C) Coronal T1 MRI evaluation shows that the location for the Goutallier grading (red arrow) in the case is misleading. There is good muscle quality more medial (green arrow), and in this case the grading is influenced by retraction.

Sheean et al. reported on radiographic factors associated with reparability in 86 arthroscopic repairs of massive rotator cuff. Complete repairs were achieved in 88% of cases overall, including 82% (9 of 11) with an acromiohumeral distance (AHD) less than 7 mm, 70% (14 of 20) with a positive tangent sign, and 57% (8 of 14) with grade 3 or 4 of the supraspinatus. In 62% of cases, advanced mobilization techniques (interval slides) were used and a mean of 5.3 anchors per case were required. Likewise, Kim et al. reported that individual signs alone, such as the tangent sign, were not completely predictive of an irreparable tear. In their experience the best predictor of an irreparable tear was infraspinatus fatty infiltration greater than grade 2 and retraction of the tendon to the level of glenoid (odds ratio, 127; sensitivity, 54%).

Technical factors

In addition to the aforementioned patient intrinsic factors, reparability and outcome are likely influenced by surgical technique and postoperative rehabilitation. Higher surgeon volume has been associated with lower complication rates following several surgical procedures, including rotator cuff repair and shoulder replacement. ^, In one study, the need for revision within 1 year of a primary rotator cuff repair was found to be higher for surgeons who performed fewer than three rotator cuff repairs per month. Tear pattern recognition, advanced mobilization techniques, repair constructs, and postoperative rehabilitation are all factors within the surgeon’s control that may influence the retear rate.

Tear pattern recognition is important to achieve complete repair. The surgeon must distinguish between tear patterns and avoid the mistake of simply pulling the tendon from medial to lateral (i.e., inadvertently repairing a U-shaped or L-L-shaped tear in a crescent manner). In the primary setting, MRI can be used to predict tear pattern; tears greater that 2 cm in only one dimension are likely longitudinal tears, whereas tears greater than 2 cm in both the sagittal and coronal plane are more likely to be massive contracted tears. Recognition of subscapularis tears is paramount in the repair of massive tears and requires identification of the comma tissue and often advanced releases. Repair of the subscapularis must be achieved not only from a functional standpoint but also because repair of the subscapularis decreases tension upon the subsequent posterosuperior rotator cuff repair ( Fig. 56.3 ). Finally, advanced mobilization techniques (interval slides) likely account for differences in reparability achieved by different authors.

Schematic of the relationship between subscapularis repair and supraspinatus repair. (A) Massive retracted and contracted tear of the subscapularis and supraspinatus tendons. (B) Repair of the subscapularis partially reduces the supraspinatus retraction. (C) Repair of the supraspinatus can then be accomplished with minimal tension.

(From Burkhart SS, Lo IK, Brady PC, et al. The Cowboy’s Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon. Philadelphia: Lippincott Williams & Wilkins; 2012.)

Biomechanically, the introduction of suture anchors in the early 1990s transferred the weak link in rotator cuff repair from the bone to the tendon. ^, One of the easiest ways to improve fixation of the tendon is to therefore increase the contact area (i.e., footprint restoration). From a biomechanical standpoint, double-row rotator cuff repairs have demonstrated improved fixation characteristics compared with single-row rotator cuff repairs. ^, When there is sufficient tendon mobility, double-row repairs are associated with a lower rate of structural failure compared with single-row repairs. In addition, complex suture constructs such as the load-sharing rip-stop repair can be used to optimize fixation in the setting of poor tendon quality.

Finally, given that the weak link in fixation of the rotator cuff is the suture-tendon interface, it is no surprise that early aggressive postoperative rehabilitation can lead to structural failure of a repair. In a histologic evaluation of rotator cuff healing in a primate model, Sonnabend et al. reported that maturation of the repaired rotator cuff requires 12 to 15 weeks. Historically, authors using open repair techniques advocated for early passive range of motion to prevent postoperative stiffness. However, more recent studies have shown that the risk of stiffness following arthroscopic rotator cuff repair is very low even with a conservative protocol of 6 weeks of immobilization. ^, Thus it is advisable to use a conservative rehabilitation protocol for massive tears to improve the chances of healing.

Concepts and indications

Historically, repair of the rotator cuff focused exclusively on the restoration of the tendinous insertion to the greater tuberosity. Recently, however, a growing interest has emerged in the role of the superior capsule in glenohumeral mechanics. The glenohumeral capsule is known to provide stability to the glenohumeral joint, particularly at end points of range of motion. The superior capsule of the glenohumeral joint is a relatively thin, fibrous structure that is attached to 30% to 61% of the greater tuberosity and has a surface area that is approximately double that of the humeral head ( Fig. 56.5 ). ^{, ,} Therefore the superior capsule attachment occupies as much or more of the greater tuberosity footprint than the supraspinatus. For this reason, some authors have argued that delaminated rotator cuff tears really represent separation of the superior capsule and rotator cuff and anatomic restoration during cuff repair should involve consideration of the superior capsule.

(A) Superior and (B) posterior views of the superior capsule and rotator cuff insertion. Note that the superior capsule (dashed outline) has a broad insertion on the greater tuberosity, occupying a larger area than either the supraspinatus (star) or the infraspinatus (circle) . Square denotes teres minor insertion. HH , Humeral head.

(From Nimura A, Kato A, Yamaguchi K, et al. The superior capsule of the shoulder joint complements the insertion of the rotator cuff. J Shoulder Elbow Surg. 2012;21:867–872.)

In 2012, SCR was initially described by Teruhisa Mihata, who developed his technique to treat irreparable rotator cuff tears because he did not have the availability of RSA. In his technique a tensor fascia graft was sutured from the glenoid to the tuberosity to replace the superior capsule. He first biomechanically demonstrated that SCR of a simulated massive rotator cuff tear could restore superior glenohumeral translation to normal levels, whereas simple patching grafting failed to reproduce normal mechanics. In his initial clinical report, 24 SCRs performed with tensor fascia autograft were reviewed at a mean of 34 months postoperatively. The AHD increased from 4.6 mm preoperatively to 8.7 mm postoperatively, the American Shoulder and Elbow Surgeons Shoulder (ASES) score improved from 24 to 93 points, and 83% were considered healed on MRI. In the United States the technique was adapted to use dermal allograft to avoid donor site morbidity. Denard et al. reported preliminary outcomes (minimum 1 year) in 59 patients who had an arthroscopic SCR using a dermal allograft. Overall, 68% of cases were considered successes clinically. However, only 45% of cases (9 of 20) had postoperative healing on MRI. It should be noted that 42% of their patients had undergone previous repair. Most importantly, they attempted to clarify indications for the use of SCR. Patients classified as Hamada 1 (normal joint) or Hamada 2 (normal tuberosity with decreased AHD) preoperatively had a 76% chance of success, whereas those with Hamada 3 (adaptive changes of the acromion and tuberosity) or Hamada 4 (glenohumeral arthritis) had only a 44% chance of success. In other words, SCR can be successful in earlier stages of rotator cuff tears prior to the development of adaptive changes or arthritis. However, chronic tears with adaptive changes or arthritis are difficult to overcome with an SCR. They also noted that postoperative healing was more common when the subscapularis had grade 0 or 1 atrophy, demonstrating that the procedure relies upon an intact subscapularis tendon or ability restore the anterior force couple. Patients with advanced subscapularis fatty infiltration (grade 3 or 4 changes) are not ideal candidates for SCR. Similarly, although not evaluated in their study, posterior force couple restoration is also likely important for SCR. We consider patients with less than 10 degrees of external rotation at the side to be poor candidates for SCR. Such patients require tendon transfer to restore external rotation either in isolation or in combination with SCR.

One question that has arisen is whether SCR functions as a spacer or truly restores glenohumeral mechanics. Time zero evaluation has shown that both a subacromial balloon spacer or an SCR are capable of decreasing superior translation. Superior translation can also be decreased by placing a dermal allograft on the inferior surface of the acromion. These studies demonstrate the spacer effect biomechanically but do not take into account dynamic forces or give information about graft healing. Mirzayan et al. reported no difference in postoperative functional outcome between grafts that healed or remained intact on the tuberosity but tore more medially, whereas grafts that tore and left the tuberosity uncovered had a poorer outcome. They suggested that an intact lateral graft may have a tuberoplasty effect, leading to reduction in pain and thus improvement in function. Lacheta et al. noted no difference in functional outcome between healed and unhealed grafts but reported that AHDs were decreased in grafts that did heal compared with those that healed, which implies that a healed graft is more functional. The functional role of SCR is also supported by case series reporting that SCR is capable of reversing pseudoparalysis. ^, In particular, Mihata et al. found that pseudoparalysis was not restored in patients with unhealed grafts. Thus, although the clinical effects of SCR are likely multifactorial and depend on graft healing, it appears that a healed graft provides a stabilizing effect to the glenohumeral joint.

Surgical technique

A diagnostic arthroscopy is performed through a posterior glenohumeral viewing portal. The subscapularis is visualized and repaired if torn. A biceps tenodesis is performed in most cases because there is often a tear of the subscapularis, tear or instability of the biceps tendon, and/or a compromised attachment of the biceps root.

Attention is turned to the subacromial space. Posterior viewing and lateral working portals are established. A 12-mm flexible cannula (Passport; Arthrex, Inc.) is placed in the lateral portal to aid with suture management and graft passage. A limited subacromial decompression is performed that preserves the coracoacromial arch. The rotator cuff is carefully dissected and freed from the internal deltoid fascia. The scapular spine is identified to visualize the raphe between the supraspinatus and infraspinatus. The infraspinatus is mobilized and repaired as much as possible.

The bone beds of the greater tuberosity and just medial to the superior glenoid labrum are prepared with a shaver and angle curette. We preserve the superior labrum, although some argue for debridement to increase the bony surface area for healing. Two anchors are placed in the superior glenoid neck at approximately the 10 o’clock and 2 o’clock positions approximately 5 mm medial to the superior labrum. Note: the placement medial to the labrum is chosen because this is the normal origin of the superior capsule, and because of the angle of approach these percutaneous portals are often more medial than typical portals use for placing anchors during superior labrum anterior and posterior repair. In most cases a third anchor is typically placed at the 12 o’clock position, slightly more medial, through a superior portal.

Next, two anchors are placed in the greater tuberosity along the articular margin. The distances between all anchors are carefully measured with a calibrated probe. The arm should be placed at 30 to 45 degrees of abduction during sizing and fixation. A 3-mm dermal allograft is used to reconstruct the superior capsule. The positions of the anchors are carefully marked on the dermal allograft. An additional 5 mm of tissue margins are left medial, anterior, and posterior to decrease the risk of suture cutout. An additional 10 mm of tissue is added laterally to cover the greater tuberosity. The final contoured graft is typically trapezoidal in shape.

The sutures from the anchors are then sequentially retrieved through the lateral cannula. It is important to ensure that the sutures are not tangled, which is confirmed by running back down the suture lines after all sutures are retrieved. The sutures from the greater tuberosity anchors are passed through their respective holes in the graft. Then the sutures from the glenoid anchors are passed through the graft. Knotless glenoid anchors may facilitate shuttling and also provide independent fixation. The graft is then pushed into the subacromial space with a grasper and fixation is completed ( Fig. 56.6 ).

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