Introduction
Approximately 18 million Americans report shoulder pain each year, of which a large percentage are attributable to rotator cuff pathology. Tears of the rotator cuff tendon are common in the general population, and are associated with shoulder pain, dysfunction, and a detrimental effect on patient quality of life. Rotator cuff tears occur in up to 50% of individual older than 65 years of age, and may arise from either traumatic, degenerative, or overuse etiologies. , Whether partial- or full-thickness, both tear subsets may improve with a trial of nonoperative management. However, if these efforts fail to provide adequate pain relief and return of function, surgical intervention is often considered. , Rotator cuff repair is among one of the most commonly performed surgical procedures in orthopedic surgery and is reliably effective at restoring function and alleviating pain. However, complications are not uncommon and can be devastating when they do occur. , A multitude of patient-specific and surgical factors contribute to or are associated with complications of rotator cuff repair. In this chapter, we will review these complications and discuss potential factors and pitfalls that contribute to their development. Additionally, we will itemize preventative strategies and specific considerations in the preoperative setting that may assist the surgeon in avoiding complications.
Common Complications
Surgeons should have a thorough understanding of the common complications and risk factors during rotator cuff repair and review these with the patient during the preoperative consultation. Complications of rotator cuff repair have been well described, and the most frequent include: surgical site infections, unplanned return to operating room, readmissions within 30 days, deep venous thrombosis and thromboembolism, failure to heal/retear, stiffness or arthrofibrosis, and missed concomitant pathology. , Audigé and colleagues recently published a Delphi international consensus report of local core events associated with arthroscopic rotator cuff repair, dividing complications into two categories: intraoperative and postoperative. This report is quite thorough, and although these are mainly issues encountered either during or after surgical intervention, the surgeon should be familiar with the information provided in this report for both patient education and surgical planning.
Predictors or Factors Associated With Complications
Among the most common associated factors or predictors of complications are: tear size, open repair (vs. arthroscopic), longer operative time (>90 minutes), male gender, increasing age or age over 60 to 65 years, advanced tear morphology or severity, American Society of Anaesthesiologists classification greater than 2, and selected medical comorbidities, such as chronic obstructive pulmonary disease, hypertension, and steroid use. , Low surgeon volume (<12 rotator cuff repairs/year) has been associated with increased complication rates, length of stay, surgical time, and surgical costs.
Open Versus Arthroscopic
The overall complication rate for rotator cuff repair is roughly 1.3%, with higher rates consistently observed in open repair compared with arthroscopic. , Open repair is associated with increased risk of surgical infections, higher rates of return to the operating room within the 30 days, longer hospital stay, and greater stiffness. , , Up to 20% of those undergoing open repair are likely to develop postoperative stiffness and are more likely to undergo intervention for stiffness within the first year. , Despite higher complication rates, an open approach to rotator cuff repair can be expeditious in the event of massive tears, poor bone or tendon quality, or for surgeons without an advanced arthroscopic skillset for complex tears. A number of efforts should be made in the preoperative setting to help avoid use of or conversion to an open approach, including thorough review of tear characteristics on magnetic resonance imaging (MRI), possible collaboration with a musculoskeletal radiologist, and knowledge of complex tear patterns (e.g., U-, L-, and reverse L–shaped tears) ( Fig. 29.1 ), and respective repair techniques. Arthroscopic approach now comprises the majority of repairs, demonstrating lower complication and adverse event rates than open repair, albeit with longer average operative times. , ,
Infection
Infections are one of the most common complications and can be devastating, at times necessitating readmission, intravenous antibiotics, and unplanned returns to the operating room, resulting in poorer outcomes because of soft tissue destruction and adhesions. Furthermore, management of infections contributes to increased healthcare costs. , The overall infection rate is between 0.3% and 2.45%. , , , , , The most commonly identified pathogens following rotator cuff repair are Staphylococcus epidermidis, Propionibacterium acnes , and Staphylococcus aureus . Risk factors include open wounds, skin contamination, open approach, and/or systemic infections (urinary tract infection, upper respiratory tract infection, lower respiratory tract infection). Perioperative prophylactic antibiotics are an independent protective factor and are recommended in all-arthroscopic cuff repairs. Other potential mitigating measures include chlorhexadine or benzoyl peroxide pre-treatment and mupirocin nasal washes. However, recent studies suggest that administration of oral doxycycline (100 mg twice daily for 7 days) fails to significantly decrease P. acnes colonization of skin around the shoulder.
Advanced Chronological or Physiological Age
Increasing age in the setting of rotator cuff repair has been widely reported as a predictor of failure and increased complications. , Studies have demonstrated poor tissue quality and healing potential, often contributing to retear or failure in older patients. , Jung et al. found retears on MRI at 1 year in 26% of patients aged 75 years and older undergoing large or massive rotator cuff repair. Further, they reported no patient deaths or complications requiring extended hospitalization or intensive care needs. Despite elevated risk of retear, the authors concluded that elderly patients may still experience good functional outcomes without morbidity after rotator cuff repair, even in those with retears.
However, age should be appreciated as more than just a generic framework of “over versus under 65” years. Although young, competitive athletes tend to do very well with rotator cuff repair, surgeons should have a discussion with the athlete about sports and positions they play, as well as expectations/aspirations following surgery. Although 93% of those under 18 years of age return to the same or higher level of play following repair, nearly 60% have to change positions.
Anatomic and Tear-Related Factors
Tear Size and Fatty Infiltration
Although debated, general consensus is that more sizeable tears are associated with higher rates of retear; however, patient-reported function may vary. Increasing tear size and fatty infiltration of the supraspinatus have demonstrated a strong association with decreased tendon healing, subsequent failure, and a negative influence on long-term functional outcomes. , Muscle atrophy and fatty infiltration of the infraspinatus have been identified as independent predictors of American Shoulder and Elbow Surgeons Shoulder Scores and Constant scores, whereas tear size is an independent predictor of cuff integrity after repair and is associated with slower speed of recovery in forward elevation and external rotation. , The association of infraspinatus changes with poorer functional outcomes may be attributable to its role of force-coupling and balance with the subscapularis. In the event of tendon repair, fatty infiltration does not always improve, but tends to stabilize. With nonoperative management or failed repair, a significant increase in atrophy, tendon retraction, and tear size can often be expected. ,
Tear shape should also be a consideration during the preoperative setting. For crescent-shaped tears, a conventional single- or double-row repair may be sufficient, whereas complex patterns such as U- or L-shaped tears may benefit from an alternative approach. More complex tear patterns often have an unrecognized mobile anterior and/or posterior component, and marginal convergence is often the initial maneuver to reduce the tear gap and tension, followed by an arthroscopic modified Mason–Allen suture to restore the rotator cuff footprint in a side-to-end repair technique. Having a proper understanding of tear pattern preoperatively can help mitigate potential for complications during the surgical procedure.
Residual Tendon and Imaging
The surgeon should also use MRI to appreciate the quality and substance of the remaining tendon. Not only is adequate tendon length necessary for repair, but the tendon must also be of adequate quality to hold suture and withstand anatomic retensioning. Tendon quality on MRI tends to correlate well with intraoperative findings and may reflect corresponding degenerative changes in tissue mobility and tendon microstructure. As tear size increases, remnant tendon available for repair tends to decrease. In chronic tears, both the muscle fibers and tendon itself may be truncated, contributing to retraction seen on MRI. As length of the residual tendon decreases, there is increasing likelihood that the tendon will require overtensioning to completely reduce the tendon to the lateral aspect of the footprint. This overtensioning is a risk factor for failure and should be avoided, at times necessitating interval slide releases, anatomic single row repair, alternative self-reinforcing suture configurations (e.g., modified “rip stop” construct), footprint medialization, and/or patch augmentation to ensure likelihood for successful repair.
Critical Shoulder Angle
Critical shoulder angle (CSA) has become a recent topic of research, and its impact in the setting of rotator cuff pathology and revision repair is becoming increasingly appreciated. In a 2017 retrospective cohort, Garcia et al. reported significantly higher risk of full-thickness retear of the rotator cuff for those with a CSA greater than 38 degrees (odds ratio 14.8, P <.01). In 2018, Gerber et al. reported similar findings with higher retear rates in those with postoperative CSA over 34 degrees. Furthermore, patients undergoing arthroscopic lateral acromioplasty with a CSA correction to 33 degrees or less had 25% more abduction strength than counterparts with a CSA of 35 degrees or greater. Further, those with less than 5 mm of lateral resection demonstrated no compromise of the deltoid origin or function. Katthagen and colleagues investigated the effectiveness of two arthroscopic techniques for reducing CSA: anterolateral acromioplasty and lateral acromion resection. Both techniques significantly reduced CSA, with anterolateral acromioplasty decreasing CSA by 1.4 degrees, and, when combined with 5-mm lateral acromion resection, by 2.8 degrees. They found no disruption of the deltoid origin.
Presence of Preoperative Cuff Tear Arthropathy
Initially described by Neer and further stratified intro grades 1 to 5 by Hamada ( Fig. 29.2 ), cuff tear arthropathy (CTA) may develop in patients with chronic untreated large or massive rotator cuff tears. , Advanced CTA stages (4 and 5) are characterized by arthritic changes of the glenohumeral joint. Historically, attempted rotator cuff repair in the presence of advanced CTA has failed to provide satisfactory improvement in pain and function, and is now considered an indication for reverse shoulder arthroplasty. In patients with acromiohumeral remodeling without glenohumeral arthritis, repair of large and massive tears may still be possible, but the surgeon should preoperatively consider the merits of partial repair, complete repair, or augmentation. With anatomically or functionally irreparable tears, superior capsular reconstruction may also be an option, although higher rates of failure are associated with Hamada grades 3 and 4. Management of large rotator cuff tears in the absence of glenohumeral arthritis is challenging, and decision making should include consideration of the patient’s age, demands, current function, tear size, shape, chronicity, and tendon characteristics such as retraction and quality of remaining cuff because these will affect both the ability to reduce the tendon to its insertion, gain adequate fixation, and appropriately tension the repair, and the ability of the repair to heal. , , ,
Concomitant Pathology and Procedures Performed
Stiffness
Classically, the approach to concomitant rotator cuff tears and stiffness demands staged treatment of the problem: first addressing range of motion (ROM) and subsequently undertaking cuff repair. More recent studies demonstrate good outcomes with single-stage intervention for combined cuff tear with adhesive capsulitis. In a recent review of the literature, Sabzevari et al. compared those undergoing rotator cuff repair with and without stiffness in a single-stage procedure, where those with stiffness underwent concomitant rotator cuff repair and manipulation under anesthesia with or without capsular release. They found no statistical difference in ROM for all planes between the two groups, concluding that preoperative physical therapy to address stiffness may not be necessary and that single-stage intervention may have comparable results to those without stiffness undergoing rotator cuff repair. These results are supported by data presented by McGrath et al., who also reported similar conclusions and suggested that stiffness was protective against retear.
Instability
Although more rare, rotator cuff tears can occur in setting of shoulder instability, most often associated with persistent pain or dysfunction after a traumatic dislocation. In a recent systematic review, Gomberawalla et al. concluded that surgical repair of rotator cuff tears after dislocation results in improved pain relief and patient satisfaction compared with nonoperative management. They also note that concomitant repair of the rotator cuff along with capsulolabral lesions effectively restores shoulder stability. Parnes and colleagues echoed these results in the young military population, demonstrating excellent comparable clinical outcomes in those with concomitant rotator cuff and labral repair. They report a high rate of return to preoperative recreational and military activity. Although there is no consensus, concomitant rotator cuff repair and arthroscopic stabilization must be addressed with earlier initial ROM to prevent stiffness-related complications.
Long Head of Biceps Tendon and Concomitant Pathology
Schmidt et al. note that, in the event that a supraspinatus or infraspinatus tear proves to be irreparable, the surgeon may be able to improve pain and reverse pseudoparalysis by performing partial repairs and addressing concomitant issues, such as biceps pathology. When rotator cuff tears involve the subscapularis tendon, the surgeon must also carefully evaluate the stability of the long head of the biceps tendon (LHBT). The integrity of the biceps pulley system is sustained by the superior glenohumeral ligament (SGHL), coracohumeral ligament (CHL) complex, and subscapularis tendon. Godeneche and colleagues reported disruption of the SGHL/CHL complex in 75% of subscapularis tears, with 39% undergoing plastic deformation and completely absent in 35% of cases. Further, they found that the medial wall of the LHBT sheath in the biceps groove was normal in only 25% of cases, with partial and complete tearing present in 39% and 35%, respectively. They concluded that the subscapularis tendon is important for LHBT stability and that, in cases with a pathological SGHL/CHL complex, the LHBT is nearly always unstable and concomitantly pathological ( Fig. 29.3, 29.4 ).
Concurrent Procedures
A number of recent studies have investigated the effects of concurrent procedures performed at the time of rotator cuff repair. Subacromial decompression is often reported as the most common concomitant procedure performed in addition to rotator cuff repair, despite evidence suggesting a lack of efficacy with routine use. , Performing concomitant arthroscopic subacromial decompression or release of the coracoacromial ligament during rotator cuff repair has failed to demonstrate significant differences in outcomes and may lead to anterosuperior escape of the humeral head and worsening of symptoms. However, higher reoperation rates have been reported for those not undergoing concurrent subacromial decompression. Overall, no benefits in patient outcome measures have been reproducibly demonstrated for routine subacromial decompression during repair of rotator cuff tears, and this approach is not supported by the American Academy of Orthopaedic Surgeons. , These reports should highlight the importance of the preoperative physical examination. Concomitant procedures should be performed when indicated by patient symptoms and should not be performed as routine protocol for rotator cuff repairs. When necessary, further testing such as site-specific injections, which may be both therapeutic and diagnostic, may be undertaken to rule in or out concomitant pathology for possible intervention at the time of surgery.
Nerve Injury
With increasing cuff tear size and severity comes increased risk for concomitant suprascapular neuropathy. However, debate exists whether suprascapular neuropathy can be effectively treated with rotator cuff repair alone, or whether nerve decompression and/or release of the superior transverse scapular ligament is necessary. Given the low overall incidence of suprascapular neuropathy, routine suprascapular nerve release during rotator cuff repair is not currently supported, although this may be selectively considered with advanced fatty infiltration and/or tear retraction. , Diagnostic lidocaine challenge and preoperative bilateral electromyography (EMG) may provide insights regarding the utility of suprascapular nerve release, although most decisions are based on preoperative physical examination ( Fig. 29.5A,B ), review of advanced radiographic studies, and intraoperative findings.
Although rare, peripheral nerve injuries do occur in the setting of rotator cuff tears, and are often the result of traumatic etiology. The axillary nerve can be involved, and is most often injured via a dislocation event and warrants careful evaluation during physical examination ( Fig. 29.6 ). Data suggest that rotator cuff repair in the setting of concurrent nerve injury is less favorable than in isolated repairs. Timing of electrodiagnostic testing will vary circumstantially. When the aim is to localize a lesion and separate conduction blocks from axonotmesis, studies performed around 7 to 10 days following the injury may be helpful. However, studies performed 3 to 4 weeks postinjury will yield better diagnostic information on EMG, whereas studies collected 3 months postinjury and beyond will provide insight into recovery status of the nerve.
