Posterior Cuff
- Kyle R. Duchman, MD
- Brian R. Wolf, MD, MS
Abstract
It is very common for patients to experience loss of structural integrity following a primary rotator cuff repair. Causes of failure after the primary repair can include biologic failure, technical error, traumatic failure, or a complication stemming from the primary injury. When evaluating a failed repair, it is critical to evaluate range of motion and obtain both magnetic reasonance imaging (MRI) and standard radiographs to have a successful preoperative diagnosis. It is essential to recognize the reason failure and to correctly evaluate the surgical indications compared to non-surgical management. When it comes to surgical treatment, the surgeon can opt to use open, mini-open, or arthroscopic techniques, but the senior author offers an arthroscopic approach in this chapter. Revision cuff repair presents unique challenges, and the outcomes are inferior to primary repair. However, a surgeon can consistently expect to see a satisfied patient with improved pain and functional scores.
Keywords: Rotator cuff; revision; arthroscopy; double-row; failure.
Introduction
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Loss of structural integrity after primary rotator cuff repair is common.
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Revision rotator cuff repair presents several challenges that are often not present at the time of primary rotator cuff repair.
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Recognizing the reason for failure of the primary rotator cuff repair is essential for success in the revision setting.
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Appropriate patient selection and preoperative planning cannot be overlooked in order to achieve success after revision rotator cuff repair.
Modes of Failure
Failure after rotator cuff repair in the appropriately indicated patient depends on a variety of factors but can often be broadly categorized as biologic failure, technical error, traumatic failure, or the result of a complication from the primary surgery ( ) ( Box 9A.1 ). Of these factors, biology continues to be the most influential force. Despite technical advances and multiple local and systemic augmentation strategies ( ), rotator cuff repair fails to replicate the native tendon to bone interface ( ). In the revision setting, poor tissue quality and atrophy or fatty infiltration of the muscles further limits the biologic potential ( ). Because of this, it is important to optimize the mechanical environment with a low-tension and high-surface-area repair. If this environment cannot be created because of local tissue loss or other factors, it may be necessary to consider options other than a standard revision rotator cuff repair.
Biology
Poor tendon quality
Muscle atrophy and fatty infiltration
Decreased bone mineral density at the greater tuberosity
Technical Errors
Inadequate tissue mobilization
Excessive tension on the repair
Inadequate “time zero” strength of the repair construct
Traumatic Failure
Early, active range of motion
Noncompliance with activity restrictions
Falls or other specific injuries
Complications
Infection
Loss of deltoid origin
The most common technical error is failure to accurately recognize the rotator cuff tear pattern. Most, but not all, rotator cuff tears can be categorized using descriptions popularized by Burkhart and include crescent, U-shaped, L-shaped, and reverse L-shaped tears ( ). Crescent tears are the most common and most easily repaired. If the torn rotator cuff tissue is not reduced anatomically and according to tear pattern, then undue tension is the likely result. For example, trying to repair the tissue at the apex of a U-shaped tear to the tuberosity, as would be done in the typical crescent-shaped tear, will almost certainly fail. Additionally, there has been much debate about the optimal insertion angle of suture anchors during rotator cuff repair, including Burkhart’s so-called deadman theory ( ), which has more recently been called into question with several biomechanical studies ( ). The current evidence cannot deem a particular angle of anchor insertion as an error because results and theories have been variable. However, anchor pullout or migration, which may be visualized with plain radiographs or advanced imaging depending on the material of the anchor, may be indicative of technical error and explain a rotator cuff repair failure. As more evidence becomes available, suture technique and location of the suture relative to the musculotendinous junction are likely to become important technical considerations ( ).
Traumatic failure after rotator cuff repair typically occurs within the first 3 to 6 months after surgery ( ). Failure is often secondary to repetitive microtrauma caused by noncompliance with postoperative rehabilitation or overzealous physical therapy. In the revision setting, it is important to understand the patient’s rehabilitative course after the initial surgery because this may provide clues to potential modes of failure. Additionally, any history of a fall or acute change in pain and function after a specific activity may suggest traumatic failure.
In general, complications after rotator cuff repair are rare, ranging from 5% to 10% ( ). The most frequent complications, not including early failure, are stiffness and infection. Any of these complications can lead to an unsatisfactory outcome for the patient. Deep infection after rotator cuff repair is particularly problematic because underlying infection limits the reparative process and puts the articular cartilage at risk. Although rare, it is important to consider any and all of these complications during the workup of a patient with failure of a previous rotator cuff repair because management options, including the surgical approach and plan, may have to be altered to adequately address the complication at hand.
Patient Evaluation
History
An adequate history is essential when evaluating a patient with a suspected rotator cuff repair failure. Patients with failure of posterior rotator cuff repairs most frequently present with persistent anterolateral shoulder pain and functional deficits. When obtaining the history, it is important to consider the clinical picture before the primary rotator cuff repair, including physical therapy and diagnostic or therapeutic injections, and how they affected symptomatology. If available, imaging that was obtained before previous surgeries, procedure notes, and arthroscopic images can provide valuable information about the type(s) of procedure(s) performed as well as the size of the tear and quality of the tendon at the time of the primary procedure. These details will not only help delineate possible causes of failure that may ultimately guide treatment but also serve to expose any concomitant pathology that may or may not have been addressed.
Physical Examination
Physical examination of the patient with suspected rotator cuff repair failure should include general inspection of the shoulder, taking care to note the location and type(s) of incision(s) used for the primary repair. In the revision setting, it is particularly important to note the contour and appearance of the deltoid because loss or insufficiency of the deltoid origin at the acromion can occur, particularly in the setting of a prior open or mini-open rotator cuff repair ( ) ( Fig. 9A.1 ). Inspection of both the supra- and infraspinatus fossae should also be performed because atrophy may indicate suprascapular nerve pathology. Active and passive range of motion should be assessed in all planes. When evaluating a patient with a failed rotator cuff repair, active range of motion assessment provides crucial information. In the senior author’s experience, patients with preserved active motion are more apt to benefit from revision repair than a patient with pseudoparalysis, which is supported by the literature ( ). A variety of special tests have been described to assess the function of the posterior rotator cuff with variable diagnostic accuracy ( ). Concomitant shoulder pathology, including acromioclavicular joint, biceps, and labral pathology, should be evaluated with provocative testing maneuvers because these areas may serve as the source of ongoing pain after rotator cuff repair. Last, because cervical spine pathology can result in shoulder pain, a thorough examination of the cervical spine is warranted.
Diagnostic Imaging
Standard radiographs, including anteroposterior, axillary, and scapular outlet (Y scapular) views, should be obtained. Superior humeral head migration may be indicative of a large or massive rotator cuff tear. An acromiohumeral distance less than 6 mm, which is measured off plain radiographs, may call into question the feasibility of rotator cuff repair ( ) ( Fig. 9A.2 ). Additionally, evaluation of the glenohumeral and acromioclavicular joint for degenerative changes may shed light on concomitant pathology. Close inspection of the axillary shoulder radiograph should be performed to rule out an os acromiale and further assessment of glenohumeral joint space. Advanced imaging modalities, including magnetic resonance imaging (MRI) and ultrasonography, are now easily accessible and routinely obtained. However, postsurgical changes often limit the ability of MRI to detect the presence of recurrent tears in the revision setting ( ), with limited additional benefit with the use of intraarticular contrast ( ). In the revision setting, ultrasound evaluation of the rotator cuff repair may provide improved diagnostic accuracy ( ), although operator dependence may limit its applicability. Despite its limitations in detecting tears compared with ultrasonography, MRI can provide additional information, including fatty infiltration and atrophy of the supraspinatus and infraspinatus muscle bellies ( ), that can help guide treatment and prognosticate outcomes ( ).
Additional Diagnostic Tests
Additional diagnostic tests are not routine and should be used to help corroborate any unusual or concerning findings. If there is any concern for infection, the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) should be obtained. However, because of the relatively indolent nature of the most common infectious pathogens, Staphylococcus epidermidis and Propionibacterium acnes ( ), ESR and CRP levels may be normal ( ). If clinical concern for infection remains, a glenohumeral aspirate with cell count and culture is warranted. Other diagnostic considerations include electrodiagnostic testing if there is any concern for axillary nerve injury, suprascapular neuropathy, or cervical radiculopathy.
Management
Nonoperative Management
It is important to distinguish between the asymptomatic and symptomatic patient with concern for recurrent tear on advanced imaging. Several studies have reported generally favorable long-term improvement in patient-reported outcomes despite advanced imaging evidence of recurrent tears ( ), although results for patients with labor-intensive jobs are less satisfying ( ). Additionally, increasing atrophy and fatty infiltration of the rotator cuff musculature in patients with recurrent tears raises some concern as to the stability of these long-term results ( ). Based on the current evidence and limited ability to predict clinical deterioration of recurrent rotator cuff tears, close surveillance of minimally symptomatic patients remains a viable option.
Surgical Indications
Identifying the appropriate surgical candidate for revision rotator cuff repair is arguably the most important step in management. Previous literature has provided insight into several patient and tear characteristics that portend a low likelihood of success with revision rotator cuff repair. These factors include age older than 65 years ( ), Goutallier grade 3 or 4 fatty infiltration ( ), tear retraction at or medial to the glenoid rim, a deficient deltoid origin ( ), and an inability to comply with postoperative rehabilitation and restrictions. Additionally, advanced glenohumeral arthritis and rotator cuff arthropathy are generally a contraindication to revision rotator cuff repair because other surgical procedures may provide more consistent outcomes ( ). Although the term irreparable is frequently used throughout the literature, the definition of an irreparable tear varies among surgeons and is not defined by concrete parameters. Instead, factors that influence the success of the repair should be considered and ultimately guide the surgical indication.
Outcomes
Revision rotator cuff repair may be performed using open, mini-open, or arthroscopic techniques. Although no comparative studies evaluating open and arthroscopic techniques for revision rotator cuff repair exist in the literature, proponents of the arthroscopic technique cite a less invasive approach that allows better visualization of the pathology and more precise dissection. However, this argument is only weakly supported by level IV evidence from systematic reviews with significant historical bias ( ). What has been better defined within the literature are consistently poorer outcomes, including increased retear rates, pain, inferior strength, and poorer shoulder function when comparing revision rotator cuff repair with primary repair ( ).
The number of studies reporting outcomes on revision rotator cuff repair pales in comparison to the amount of outcome data available on primary rotator cuff repair. In one of the largest single series of revision rotator cuff repairs, reported that 70% of patients were satisfied with their revision procedure. Although pain relief was reliably achieved, superior functional outcomes were more commonly reported in patients with an intact deltoid origin, preoperative forward elevation above 90 degrees, and only one prior surgical procedure. reported on the results of 54 patients who underwent arthroscopic revision rotator cuff repair, noting that arthroscopic revision was feasible even after previous open surgery. At a mean follow-up of nearly 3 years, 11% of patients had failure of the repair requiring further surgery. However, pain and function were generally improved. In their study, females and patients who had undergone more than one previous shoulder surgery were more likely to have poor outcomes. reported the 5-year results of 74 rotator cuff tears, noting consistent improvement in pain and function. Female sex and limited preoperative forward elevation resulted in inferior outcomes. reported the functional and structural outcomes of 21 revision rotator cuff repairs using ultrasonography. At minimum 1-year follow-up, only 48% of revision repairs were intact. Both increased patient age and increasing number of tendons involved were associated with a decreased likelihood of an intact repair. Additionally, a repair with loss of structural integrity resulted in inferior shoulder abduction strength and patient-reported outcomes. Despite the improvement in pain relief and potential improvement in function with revision rotator cuff repair ( ), complications after revision repair exceeded 20%, nearly twice the rate of reported complications in primary repair ( ).
More recently, biologic augmentation of revision rotator cuff repair with dermal allograft has been described. Several techniques have been described, including the use of the dermal allograft as a reinforcing scaffold placed on top of the repaired tendon in the subacromial space ( ) and techniques that describe using the dermal allograft as a bridge between a medialized tendon that cannot be adequately mobilized to reach the footprint ( ). Both of these techniques should be distinguished from superior capsular reconstruction, which has just recently emerged as an option for young patients with posterosuperior rotator cuff deficiency ( ). Although all of these options have been shown to be safe and modestly effective in limited short-term studies, the durability of the results for these techniques is largely unknown. Further research is needed in this area to determine the most suitable candidates as well as the long-term results of these procedures. Last, in some cases, the rotator cuff tear cannot be completely reduced and repaired to the tuberosity. In these cases, a partial repair of the rotator cuff is an option with reasonable results reported in the literature ( ).
Surgical Management: Authors’ Preferred Technique
Revision rotator cuff repair is generally performed using an arthroscopic approach because we believe that this optimizes visualization and allows precise dissection and mobilization of the rotator cuff. It also provides opportunity for a thorough diagnostic examination and evaluation of concomitant pathology.
We prefer to perform rotator cuff repair surgery in the beach-chair position with the patient under general anesthesia. Care is taken to appropriately pad all bony prominences before sterile draping. Blood pressures are maintained throughout the procedure to limit cerebral hypoperfusion. After sterile draping, a standard posterior viewing portal is established in the posterior soft spot, approximately 2 cm inferior and 2 cm medial to the posterolateral corner of the acromion. The trocar and arthroscope are initially placed in the glenohumeral joint, and a thorough diagnostic arthroscopic examination is performed. If necessary, an anterior portal is created in the rotator interval using an 18-gauge spinal needle for localization, serving as a working portal for intraarticular pathology. In the revision setting, we maintain a relatively low threshold to perform a biceps tenotomy or tenodesis, with tenodesis typically reserved for younger patients with cosmetic or supination strength concerns ( ). When indicated, biceps tenodesis is performed after revision rotator cuff repair through an open subpectoral approach ( ), although we have moved toward suspensory fixation on the anterior cortex of the humerus as opposed to biotenodesis screw fixation.
After completing a diagnostic arthroscopy, the arthroscope is directed into the subacromial space. A standard anterolateral portal is established using needle localization at approximately 30% to 40% of the anteroposterior length of the acromion and 2 to 3 cm from the lateral edge of the acromion. A posterolateral portal is also created half the distance between the anterolateral and posterior portals. This is the typical viewing portal for the repair. We typically place cannulas in all portals directed into the subacromial space to aid with eventual suture management and knot tying.
It is the authors’ preference to complete the bursectomy and release of adhesions while visualizing through the posterolateral portal and working through the other three portals as needed. In revision cases, adhesions are not uncommon and need to be released and resected. If the prior rotator cuff repair was done in an open or mini-open fashion, there are usually adhesions between the deltoid fascia and the rotator cuff and greater tuberosity. It is important to identify the undersurface of the acromion and using a combination of a 4.5-mm shaver and radiofrequency wand to develop a plane and then work medially and laterally. Occasionally, the torn rotator cuff will be adhered to the undersurface of the acromion. This can often be identified on the preoperative imaging. Care must be taken to mobilize the rotator cuff tissue in this setting without destroying its integrity. We continue with our bursectomy until we identify the anterior and posterior margins of the tear. We extensively release adhesions while taking care not to violate the deltoid origin or muscle. It is crucial to work carefully yet efficiently while performing the subacromial bursectomy and identification of the tear margins because excessive swelling in the subacromial space can make visualization, anchor placement, and suture management more difficult.
Next, we assess the mobility of the rotator cuff tissue using a grasper through the anterolateral portal. Often traction on the retracted tendon reveals further adhesions that need to be released. After complete release of adhesions, it is extremely important to take time to analyze the shape and characteristics of the tear because a variety of classic tear types exist that each need to be handled differently to cover the footprint with minimal tension ( ). If excessive tension is noted with attempted mobilization to the footprint, an anterior interval release can be performed. Specifically, the coracohumeral ligament should be identified and released using the radiofrequency wand. Additionally, the capsule beneath the torn and retracted rotator cuff can be released and mobilized under the tear and around the glenoid as needed. A posterior interval release, between the posterior border of the supraspinatus and infraspinatus, has been described and can be performed if necessary, although the senior author does not routinely use this release. These techniques typically allow adequate mobilization to the footprint on the greater tuberosity.
After mobilization of the tendon, the footprint itself is debrided of all soft tissue and previous suture material ( Fig. 9A.3 ). Placing the shoulder into an adducted position assists in instrument access to the tuberosity. The footprint is then finally prepared with a bone-cutting shaver or arthroscopic bur. Bone quality should be accounted for and the cortex left intact, especially in osteoporotic female patients or when anchor fixation is of concern. Prior anchors are assessed. If prior anchors are loose, they can be removed. If the anchors are not loose, then it is preferred to leave them in place and work around or over prior implants. If metal anchors were used previously and are prominent, a bur can be used to remove prominent anchor material taking care to suction away all metal debris.
