Evaluation and Management of Failed Rotator Cuff Surgery

CHAPTER 18 Evaluation and Management of Failed Rotator Cuff Surgery

Rotator cuff tears are a common cause of shoulder pain and disability. Surgical repair can provide successful clinical results.^1,² However, complications leading to poor outcomes do occur. Mansat and colleagues published a review of 40 articles evaluating outcomes of open rotator cuff repairs and found a complication rate of 10.5%.³

Both intrinsic and extrinsic pathologic processes were implicated as causes, including failed tendon repair, infection, deltoid avulsion, postoperative stiffness, and reflex sympathetic dystrophy. A study by Brislin and coworkers showed that the complication rate after arthroscopic rotator cuff repair (10.6%) is similar to the rate associated with open repairs; however, the types of complications typically encountered are different.⁴ Arthroscopic rotator cuff repair allows improved glenohumeral joint assessment and avoidance of deltoid attachment, which makes missed intra-articular pathology (e.g., labral tears, biceps tendinitis) or deltoid avulsions much less likely as causes of pain after surgery. Despite the advancement to all-arthroscopic rotator cuff surgery, open or mini-open surgeries can still be useful if one is contemplating concomitant removal of hardware or internal fixation of a fracture.

We define failure after rotator cuff surgery as a lack of improvement relative to the preoperative condition secondary to decreased function, persistent pain, or both. As both of the above-mentioned studies imply, retear of the rotator cuff is only one of the many factors that can lead to failed rotator cuff surgery. Intrinsic and extrinsic pathologic processes have both been implicated as causes of failure (Box 18-1).⁵ A detailed knowledge of the possible complications is necessary to thoroughly evaluate patients with persistent pain or dysfunction after rotator cuff surgery. Treatment options are then individualized based on patient characteristics and the type of complication suffered. Typically, the results of revision surgery are inferior to the expected outcomes of primary rotator cuff surgeries.^1,⁶^–⁹ However, when the source of failure is correctly identified and treated appropriately, functional and symptomatic improvement can be expected. This chapter details the more common causes of failed rotator cuff surgery, with particular attention given to revision repairs. Chapter 23 focuses on anterosuperior escape and the use of the reverse shoulder prosthesis.

DIAGNOSIS

In many cases, a detailed history, physical examination, and standard shoulder radiographs enable the physician to narrow the extensive differential diagnosis associated with pain after rotator cuff repair. In general, failed surgery can be classified as weakness, stiffness, instability, arthritis, surgical complication, or pain without apparent cause. In terms of establishing a diagnosis, we find it useful to group pathologies into one of two etiologies: intrinsic causes and extrinsic causes (see Box 18-1).⁵ In certain cases, extrinsic and intrinsic factors both contribute to persistent disability. Successful treatment of patients requires identifying all contributing pathologic entities.

The patient history should document preoperative symptoms, previous steroid injections, details of the initial surgery (when, where, technique used, associated procedures), medical comorbidities, and nicotine use. A copy of the initial operative report should be obtained, as should postoperative physical therapy notes. It is important to distinguish between patients who did well until a specific acute event and those who never did well after surgery. Documenting the amount of force and mechanism of an acute event, when possible, can be helpful. New symptoms, including pain, weakness, night pain, stiffness, fevers, chills, and wound problems, must be documented.

Physical examination includes strength and range-of-motion testing of both upper extremities. Tests for stability and impingement should be performed. Atrophy of the infraspinatus and supraspinatus or of the infraspinatus alone can indicate suprascapular neuropathy. Though scapular winging is a rare cause of persistent pain after rotator cuff surgery, scapulothoracic and scapulohumeral motion should be observed in all patients.⁵ In patients with severe dysfunction and winging, electromyography (EMG) can confirm long thoracic or spinal accessory nerve lesions. Examination of the cervical spine and a detailed neurovascular examination of the entire extremity are essential components of the work-up. Cervical radiculopathy involving the fifth or sixth cervical root is one of the most common extrinsic causes of persistent shoulder pain.⁵ When indicated, magnetic resonance imaging (MRI) and EMG can confirm the diagnosis.

Adjunctive studies can help make or confirm diagnoses. Standard radiographs should be used in all cases, because they can reveal entities such as glenohumeral arthritis, acromial stress fractures, heterotopic ossification, and supraspinatus outlet narrowing. Previous studies have confirmed the utility of MRI for evaluation of patients who have pain and loss of function after surgery for rotator cuff disease.^10,¹¹ Gaenslen and colleagues found MRI to be 84% sensitive and 91% specific for diagnosing full-thickness rotator cuff tears in this patient population and 83% sensitive and specific for diagnosing partial-thickness rotator cuff tears.¹¹ Diagnostic arthroscopy can also be a useful tool for evaluating intrinsic causes of persistent pain after rotator cuff repair.

Recurrent or persistent rotator cuff tears have been reported to occur in 12% to 90% of cases.¹²^–¹⁹ Advances in surgical instrumentation and repair biomechanics have improved healing rates, but the most significant factor determining the success of healing continues to be the size of the tear.^14,^16,^17,²⁰ Massive tears have a much higher retear rate than single tendon tears, and posterosuperior massive tears have the worst prognosis.^14,^21,²² Other associated risk factors include advanced age, chronic tears with poor tendon quality and muscle atrophy, diabetes, smoking, steroid injections, inappropriate rehabilitation, increased tension on the repair, and insufficient subacromial decompression.^6,^15,²³^–²⁵

In general, rotator cuff repair is associated with satisfactory pain relief; however, the success rates do not correlate well with tendon healing.^12,^14,^16,²⁴ Harryman and coauthors used ultrasound to document the integrity of rotator cuff repairs in 105 shoulders.¹⁶ The tendon was intact in 80% of isolated supraspinatus tears. If more than one tendon was involved, healing rates went down to less than 50%. Patients who had an intact repair had better function, motion, and pain relief than those with recurrent tears. Despite this, overall, more than 90% of the patients were satisfied with the surgery, and this result did not correlate with repair integrity. Other studies have corroborated these findings.

Galatz and colleagues studied large and massive rotator cuff tears treated with arthroscopic repair.¹⁴ Seventeen of 18 patients showed evidence of a recurrent tear via ultrasound. Patient satisfaction, however, remained high: 16 of 18 reported decreased pain and increased function at 1 year after surgery. By 2 years after surgery, there was a decrease in functional outcomes, but all patients were satisfied with the result.

Jost and colleagues found a similar lack of correlation between rotator cuff integrity and patient satisfaction.^26,²⁷ They assessed 20 patients with documented reruptures of the rotator cuff after surgical repair at an average of 3.2 years and again at 7.6 years. In the short-term study, they found that despite progression of atrophy, fatty degeneration, and glenohumeral arthritis in all patients, 17 of the 20 were satisfied with the procedure. At longer term follow-up, satisfaction increased, and 19 of 20 patients were satisfied or very satisfied with the outcome.²⁷ They found that reruptures present at 3.2 years did not increase in size, and supraspinatus reruptures smaller than 400 mm² had the potential to heal.

These studies elucidate the paradox between repair integrity and clinical success. They also illustrate the point that not every recurrent tear requires revision surgery. Determining which patients would benefit from revision surgery requires an understanding of the etiology of the retear, as well as an assessment of the patients’ goals. Certain risk factors impair rotator cuff healing. In cases where these risk factors can be addressed, revision repair may be warranted. Poor surgical technique, including inadequate subacromial decompression, poor tendon mobilization with subsequent undue tension on the repair, and subpar suturing, can be improved upon during revision surgery. Additionally, poor patient compliance or improper physical therapy are potentially correctable factors that might have caused failed repairs.

In Bigliani’s large series of failed rotator cuff repairs, persistent impingement, based on radiographs and operative visualization, was the most common identifiable factor.¹ Inadequate decompression was associated with a retear of the tendon in 90% of the cases. Additionally, they found that 15 of 31 patients had inadequate tissue mobilization at the time of initial repair. In addition to eliminating a source of external impingement, acromioplasty and subacromial decompression can improve visualization in the subacromial space, making the technical aspects of the repair easier.

Rotator cuff tendon repair technique is an important factor in tendon healing. The most common mode of failure involves suture pulling through the tendon.²⁸ Gerber and coworkers showed that a modified Mason–Allen stitch provides superior pullout strength, and possibly a more secure repair, than simple or mattress sutures.²⁹ Arthroscopically, the massive cuff stitch acts in a similar fashion.^30,³¹ Strength of fixation is also related to the pullout strength of anchoring devices, number of anchors, and quality of both the bone and tendon tissue. Many studies have elucidated the biomechanical benefits of double-row suture anchor repairs.³²^–³⁷ Theoretically, these repairs better re-create the three-dimensional anatomic footprint of the rotator cuff insertion over the tuberosity while providing increased pullout strength and ultimate load to failure.³⁷^–³⁹ Clinically, the results are promising as well.²⁰ If repair site biomechanics, knot stability, quality of repair tissue, and repair tension were not optimized at the time of initial surgery, then revision surgery, in which these issues are addressed, can provide patients with improved outcomes. Despite meticulous surgical technique, healing can be compromised by poor patient compliance with postoperative activity restrictions and physical therapy.

Evaluation

The index of suspicion for a recurrent tear should be high when evaluating patients with any risk factors for poor healing. Elderly smokers who have large chronic tears and who complain of pain should be thoroughly evaluated for the possibility of a recurrent tear. These patients often have complaints similar to those of patients with rotator cuff tears who have never had a repair. It is critical to exclude other causes of pain after rotator cuff surgery, most of which are discussed later, such as stiffness, heterotopic ossification, persistent impingement, and infection. The importance of excluding other pathology is highlighted by the literature that documents patients’ satisfaction despite lack of tendon healing.

Physical findings vary based upon size and location of the tear. Concomitant soft tissue contracture makes the findings on rotator cuff examination less reliable. The physical examination of the rotator cuff complex is discussed in detail in Chapter 17. Briefly, weakness with the arm abducted in the scapular plane with the elbow extended and the humerus internally rotated can indicate a recurrent tear in the supraspinatus. Recurrent defects in the supraspinatus and upper infraspinatus tendons may manifest by weakness of arm abduction and weakness of external rotation with the arm at the side.⁴⁰ In these tears, the weakness resolves as the arm is elevated to 90 degrees in the scapular plane. This is in contradistinction to tears that involve the inferior infraspinatus and teres minor tendons, which demonstrate weakness in external rotation with the arm at the side as well as in 90 degrees of elevation. A positive external rotation lag sign is present when the arm cannot be actively held after maximum passive external rotation. This indicates a substantial tear involving the infraspinatus tendon.⁴¹ Weakness of terminal internal rotation and increased passive external rotation indicate subscapularis insufficiency. The lift-off test is sensitive for detecting subscapularis dysfunction, as well.⁴² Suspected recurrent rotator cuff tears are confirmed by imaging studies.

Standard radiographs, including an anteroposterior, an axillary lateral, and an outlet view should be obtained to assess for joint space narrowing, subacromial spurs, acromial fracture, and implant positioning. Displaced suture anchors may be seen in cases of recurrent rotator cuff tears (Fig. 18-1). Superior migration of the humeral head is associated with chronic large and massive tendon tears. Some postulate that when the acromial–humeral distance is less than 7 mm, the tear is irreparable or, at best, has a low chance to heal.

FIGURE 18-1 A, Anteroposterior radiograph of the shoulder showing a loose suture anchor after rotator cuff repair. B, Outlet view showing the same loose anchor.

Ultrasound has been used to effectively evaluate the rotator cuff. Specificity has been reported to range from 86% to 100%.^43,⁴⁴

MRI scans are very useful in the postoperative setting to evaluate both the cuff and other intra-articular structures (Fig. 18-2).¹¹ In Gaenslen’s study,¹¹ they diagnosed articular cartilage damage as well as a ganglion cyst in the supraspinatus muscle. Neither of these findings would have been evident on ultrasound. Muscle atrophy and tendon retraction, as visualized on MRI, can give a surgeon a good idea of the type of tissue quality that can be expected at the time of surgery.

FIGURE 18-2 A, T1-weighted coronal MRI showing a supraspinatus tendon tear with retraction after a previous repair. B, Sagittal image showing the retracted tear after a previous reconstruction.

Treatment and Outcomes

Physical therapy and activity modification, débridement, anatomic repair, partial repair, augmentation with biological materials, and tendon transfer have all been used with varying degrees of success to treat recurrent rotator cuff repairs.^6,^21,⁴⁵^–⁴⁹ Patient factors such as age, medical condition, activity level, and degree of functional impairment influence specific treatment recommendations. In general, however, given the relatively inferior outcomes of revision acromioplasty and rotator cuff repair, a trial of nonoperative treatment is warranted.^1,^6,^7,⁹ Physical therapy is the hallmark of nonsurgical treatment, but attention should be given to activity modification. If the patient fails this course of conservative management and has realistic expectations regarding function after surgery, revision rotator cuff surgery is indicated.

Even when open or mini-open re-repair are planned, arthroscopy should be the initial step in the revision case. This allows identification and possible treatment of concomitant pathology. Additionally, it allows an assessment of the tendon quality and mobility. Based on these findings and each surgeon’s comfort and skill level with arthroscopic techniques, the decision is made to proceed or to convert to an open or mini-open repair. The principles of revision surgery remain the same no matter how the surgery is performed.

A systematic release of subacromial, subdeltoid, rotator interval, and extracapsular adhesions is carried out. It is imperative to define the torn tendon edge so as not mistake it for thick subacromial bursa. Once the tendon edge is identified, it is mobilized laterally. If contracture of the coracohumeral ligament is preventing lateralization of the tendon, the ligament should be released. Interval slides may also help to improve tendon excursion. The tendon is then repaired to its insertion on the greater tuberosity or slightly medial to it if excursion is limited.

When the entire defect is not reparable, partial repair has been shown to decrease strain at the free margins, resulting in improved function.⁵⁰ Additionally, if necessary, tendon transfer can be used to treat the residual defect. Latissimus dorsi transfer is used for patients with posterosuperior tears with weak external rotation (Fig. 18-3).^21,^22,^51,⁵² When done in conjunction with primary repair of a massive cuff tear, the transfer is effective in stabilizing external rotation function to the degree necessary to allow active elevation to 90 degrees.⁵³ In revision cases, even in the hands of experienced shoulder surgeons, the results of this salvage procedure have been variable. Pectoralis major transfers can be considered in cases of anterior cuff insufficiency or for loss of the subscapularis tendon.^54,⁵⁵ Tendon transfers should be viewed as salvage procedures. These are technically demanding procedures that provide mixed outcomes, at best.⁵⁶

FIGURE 18-3 Latissimus dorsi tendon transfer technique. A, Tagged latissimus dorsi tendon is prepared for fixation. B, The tendon is then used to cover the posterosuperior defect.

(From Dines DM, Moynihan DP, Dines J, McCann P: Irreparable rotator cuff tears: What to do and when to do it; the surgeon’s dilemma. J Bone Joint Surg Am 88:2294-2302, 2006.)

Much work has focused on the use of biologicals to enhance or augment rotator cuff healing. Theoretically, augmentation devices, such as small intestine submucosa patches, provide an absorbable scaffold to reinforce the repair and to stimulate healing.^48,^57,⁵⁸ Recent literature does not support their use, however, given the significant inflammatory reactions that can occur combined with the lack of clinical benefit.^47,⁵⁹ Walton and colleagues compared a group of patients undergoing standard rotator cuff repair to a group undergoing repair augmented by xenograft (Restore Orthobiologic Implant).⁴⁷ At 2 years after surgical repair, patients with xenograft had no recognizable benefit compared to the control group, and 4 of 10 patients treated with the xenograft had severe inflammatory reactions requiring second surgeries. At this point, there is not enough supporting evidence to recommend use of these products in revision rotator cuff repair cases. Ongoing research using growth factors to enhance the tendon healing process might prove valuable in the revision setting; however, clinical trials are necessary before their potential roles can be delineated.⁶⁰^–⁶²

After revision rotator cuff repair, patients should be placed in a sling with an abduction pillow that places the arm in about 15 degrees of abduction, for 6 weeks. During this time, stiffness is avoided by allowing passive motion, including nonprovocative pendulums and circles and saws. After the initial period of limited mobilization, the patient may begin active assisted range of motion and isometric exercises. Weights and resistive exercises should be avoided for the first 3 months.¹⁸ After this period, light elastic band–resisted exercises may be performed at below shoulder level. Patients are progressed slowly, realizing that adequate rehabilitation after revision rotator cuff repair usually takes about 9 months.

Appropriate diagnosis, surgical technique, and postoperative rehabilitation are all critical to give patients the best chance for a successful outcome; however, the results of revision rotator cuff repair are less predictable than primary repair outcomes. DeOrio and Cofield were the first to publish results on revision rotator cuff repairs.⁶ They followed up patients at a minimum of 2 years after surgery. Only 4 of 27 patients were considered to have a good result. Seven required a second revision rotator cuff repair, and 3 of these 7 eventually required a glenohumeral arthrodesis. They did find that 76% of the patients had reduced pain. Bigliani and associates reported better results in their series. Nineteen percent of patients had excellent results, 32% had good results, 23% reported fair outcomes, and 26% had poor results.¹ Worse results were associated with previous lateral acromionectomy, detachment of the deltoid origin, and poor tendon quality at the time of re-repair.

Neviaser and colleagues performed revision rotator cuff repairs in 50 patients.⁹ They critically evaluated range of motion and found that more than 50% of patients gained motion and had decreased pain after revision surgery. Djurasovic and coworkers reported on the largest series of revision rotator cuff repairs.⁷ Of the 80 patients with retears, initial tear size was classified as massive in 22, large in 28, medium in 10, and small in 13. At the time of revision, 45% of the cases required interval slides, and 24 patients required deltoid repair to the acromion. Overall results of revision repairs were excellent in 33%, good in 25%, fair in 9%, and poor in 31%. An intact deltoid origin was a good prognostic indicator, because 78% of the patients with such a finding had a satisfactory outcome compared to only 57% satisfaction in patients with a deltoid injury. Djurasovic and colleagues also found that poor tendon quality, decreased preoperative active range of motion, and an increased number of prior procedures were all associated with poor outcomes.

Lo and Burkhart were the first to report on the results of arthroscopic revision rotator cuff repairs.⁸ They revised 11 massive tears, 1 large tear, and 2 medium-sized tears. It was a small mixed series of patients, including 7 involved in workers’ compensation claims and 5 with superior migration of the humeral head. Five of the patients had concomitant pathology, including persistent acromial spurs, SLAP (superior labrum anterior and posterior) lesions, and biceps tendinopathies. Overall, there were 4 excellent, 5 good, 4 fair, and 1 poor result. They concluded that arthroscopic revision is a viable method for treating these complex problems.

Authors’ Preferred Treatment

We prefer to carry out revision rotator cuff repairs arthroscopically and revert to a mini-open repair in few cases where significant bone or soft tissue deficiency is present. Our surgical approach in all patients for whom revision rotator cuff repair is indicated is the same. We use the beach chair position to give us complete access to the front and back of the shoulder and to allow us to carry out diagnostic, therapeutic, and rotator cuff surgical procedures arthroscopically, while affording the ability to convert to an open procedure if necessary without changing the patient’s position on the operating table. Before operating, we perform an examination under anesthesia to identify contracture and the need for releases. Standard operating portals are then used for observation. Previous arthroscopy and open incisions are marked and incorporated and, if appropriate, are used during the revision arthroscopy. It is important to have preoperative x-rays and all imaging studies in the operating room for access during the procedure, especially to identify anchors or loose bodies that might be found.

We start with diagnostic glenohumeral and subacromial and subdeltoid arthroscopy to comprehensively evaluate the tear, tendon quality, and mobility as well as any comorbid pathologic factors that might affect the shoulder. These include glenohumeral arthritis, lesions of the long head of the biceps and labrum, loose bodies, capsular contractures, subscapularis tears, recurrent anterior impingement, subcoracoid impingement, and acromioclavicular joint arthrosis. Each of these pathologic entities can be identified and treated arthroscopically at the time of revision rotator cuff surgery. For example, débridement, microfracture, or chondroplasty (or some combination) can be used to address chondral damage on either the glenoid or humeral head. It is extremely important to identify and treat any tears of the subscapularis tendon. These can be occult partial undersurface tears or large detachments. These lesions are often overlooked and can lead to poor outcome in the revision rotator cuff procedure.

The recurrent rotator cuff tear is evaluated from the glenohumeral joint and the subacromial space for size, configuration, tissue quality, and mobility. This requires extensive débridement of scar tissue and excision of loose sutures and hypertrophic scar and bursa. The scarred tendon ends must also be débrided of atrophic tissue prior to repair. This step can be quite difficult because the tendon edge can be caught in this scar tissue and confused with scarred bursa. It is helpful to identify more normal tendon anteriorly or posteriorly and follow it to the scarred areas to help identify the appropriate tissue planes for débridement.

At this point, the size and configuration of the recurrent rotator cuff tear can now be well delineated, and the mobility of the rotator cuff tendon can be evaluated. If, at this point, it is determined that there is insufficient tendon quality or quantity to effect a satisfactory repair, débridement or partial repair should be considered. In the ideal case, the tendon edge can be mobilized back to the footprint or base of the greater tuberosity as in a primary repair. In most cases mobilization is limited and will require some releases to enable proper positioning for repair. This surgical mobilization includes arthroscopic release from bursal adhesions and the spine of the scapula superiorly. It also requires inferior release from the underlying capsule lateral to the labrum and the rotator interval, if necessary. This is one of the advantages of arthroscopic surgery: Visualization is easier with the arthroscopy and bleeding can be controlled by electrocautery.

We then attempt to reduce the tear to the native insertion site or at least the medial edge of that insertion site, if it cannot be completely reduced. Once mobility has been restored, fixation techniques are planned including the number of anchors, double- versus single-row fixation, and the amount of medialization of repair that is necessary to fix the tendon to the bone solidly and durably with the arm at the side.

In cases where tear configuration precludes direct repair to the tuberosity, the tear shape must be recognized, and appropriate interval repairs or margin conversions must be carried out using heavy nonabsorbable suture. This is achieved with any of the available arthroscopic suture-passing instruments and appropriate knot-tying techniques. Arthroscopic techniques facilitate this type of closure. Even in cases where the surgeon wishes to use a mini-open technique, this part of the procedure is facilitated by the arthroscopic observation and techniques that can be used. In some cases, this is all that can be done. However, if after the side-to-side repair is performed, the tendon can be advanced to the footprint, we then proceed with suture anchor repair (Fig. 18-4).

FIGURE 18-4 Arthroscopic pictures of a 67-year-old man who presented with a symptomatic failed rotator cuff tear. A, Retear of rotator cuff with torn sutures from a previous repair. B, It is critical to remove previous sutures and scar tissue to allow better visualization of the tendon tear. C, Picture after completed revision rotator cuff repair.

In most revision cases, when possible, we use a double-row technique. Arthroscopic advances using transosseousequivalent repairs provide a nice tool to re-establish the rotator cuff footprint.³⁷ Double-row repairs are particularly useful in cases when the index procedure was fixed with one row of anchors. In the revision setting, we commonly put a row of anchors medial to the previous fixation site and a row lateral to the site. This creates a strong construct that spans the previous site of fixation, enabling us to avoid putting more anchors in what is most likely poor-tuberosity bone stock.

In cases of significant osteoporosis or osteopenic bone or in patients whose bone will not support anchors, the mini-open procedure with possible deltoid release is carried out to facilitate the use of bone tunnels. If necessary, the universal exposure, which releases the deltoid from the anterior and lateral aspects of the acromion, can help with exposure of the tuberosity. In severely osteoporotic bone we sometimes repair the tendon over an augmented bone bridge with buttons or a buttress plate. Another option would be to insert the sutures more distally.

Postoperative care involves immobilization and appropriate rehabilitation. The principles are the same as those used for primary repair; however, we tend to progress these patients more slowly to increase the chance of tendon healing. Patients are treated with analgesic medication to prevent too much pain and to decrease the risk of stiffness. We immobilize all patients for 6 weeks in a sling with an abduction pillow. During the first 6 weeks, only passive, nonprovocative range-of-motion exercises, including pendulums and circles and saws, are allowed and encouraged to prevent stiffness; rotation is avoided. Hand, elbow, and wrist motion is encouraged as well. After 6 weeks, the patient is removed from the sling and started on active assisted range-of-motion exercises and isometrics for internal and external rotation, deltoid muscle function, and scapular rotation. Scapular shrugs are started at this time. At 3 months, elastic resistance–band exercises are started. Free weights are avoided in this revision population until complete active range of motion and activities of daily living have been achieved. Patients are counseled that rehabilitation will continue to show improvement for up to 1 year or more.

PERSISTENT SUBACROMIAL IMPINGEMENT

Etiology

In several studies, inadequate supraspinatus outlet decompression has been implicated as a cause of failed rotator cuff repairs.^1,^7,⁶³^–⁶⁶ It can be the result of residual anterior acromial spurring, regrowth or persistence of the coracoacromial ligament, subacromial calcification, or inferiorly projecting acromioclavicular osteophytes.^63,⁶⁵^–⁷⁰ Persistent impingement syndrome as a cause of pain after rotator cuff surgery has been reported in 18% to 79% of patients with failed acromioplasty.⁶³^–⁶⁶ The true incidence of inadequate decompression or persistent impingement, however, is unknown.

There is still debate surrounding the surgical indications, technique, and optimal amount of acromioplasty to relieve supraspinatus outlet narrowing.^71,⁷² Gartsman and colleagues performed a randomized study on the efficacy of concomitant subacromial decompression during rotator cuff repair.⁷² The study was limited to patients with full-thickness supraspinatus tears and type II acromial morphology. At an average of 2 years after surgery, there was no statistically significant difference in mean American Shoulder and Elbow Surgeons (ASES) scores of the decompression group compared to the repair group without decompression. Other studies support the association between type III acromial morphology and rotator cuff tear size.⁷³

Despite the differing opinions, a couple of studies on failed rotator cuff repairs have implicated inadequate acromioplasties as at least part of the reason for the failures.^1,⁷ Bigliani noted that 5 of the 31 patients in his series did not undergo acromioplasty during the initial rotator cuff repair, and the remaining patients needed revision acromioplasty during their subsequent rotator cuff surgery.¹ Another study reported on the results of revision rotator cuff repair in 80 patients.⁷ Of this group, 53 patients (66%) required acromioplasty at the time of revision, either because of inadequate bone resection during the index procedure or because of failure to address the acromial morphology during the initial repair.

Those who doubt the role of acromioplasty in the treatment of rotator cuff disease most likely doubt the role that persistent impingement plays as a cause of pain following rotator cuff surgery. That being said, in patients who are worked up appropriately to rule out other causes of pain after rotator cuff surgery and in whom a subacromial injection relieves their pain, subacromial decompression is a reasonable treatment option.

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