There are numerous conundra that the surgeon faces when dealing with a recurrent rotator cuff tear. The very first question that comes to mind is whether or not the patient is an operative candidate. Although some patients may clinically do well in the short term with nonoperative treatment, there are serious implications with the nonoperative treatment of a recurrent rotator cuff tear, including, but not limited to, increased pain, decreased strength, decreased function, increased tear size, shortening of the tendon stump, proximal humeral migration, and a high prevalence of glenohumeral joint arthritis.¹,²,³,⁴ Furthermore, the patient’s rotator cuff tear may advance to the point that a safer, less-complicated procedure, (like an arthroscopic revision repair), may not be possible. For all of these reasons, unless it is medically contraindicated, we prefer operative treatment of symptomatic recurrent rotator cuff tears in most cases.

Once it is determined that the patient is an operative candidate, the next question is which procedure is best for the patient. There are several surgical options for treating a recurrent rotator cuff tear, including complete arthroscopic repair, partial repair, debridement, superior capsular reconstruction (SCR), tendon transfers, and reverse shoulder arthroplasty. Our general approach is to attempt a complete rotator cuff repair. If a complete repair is not possible, then we consider a partial repair and/or SCR. In those rare cases of complete loss of active external rotation, we will consider a tendon transfer. And finally, in cases of advanced glenohumeral joint arthritis with a massive rotator cuff tear, we will perform a reverse shoulder replacement.

Historically, the results of most revision rotator cuff repairs have been fair to poor; however, most of these repairs were done by open surgery with inferior technology and techniques.⁵ The senior author has been reporting encouraging results with arthroscopic treatment with modern technology and techniques since 2004.⁶ Several authors have recently reported favorable arthroscopic results, lending support to arthroscopic revision repair of recurrent rotator cuff tears.⁷,⁸,⁹,¹⁰

There are several factors that we consider to determine if a complete repair of the rotator cuff is possible. Our routine starts with a thorough history to include the number of attempted rotator cuff repairs, the duration of time between repair and retear, the impact of the recurrent rotator cuff tear on the patient’s pain and functional activities, and the details of the previous operative report(s).

A special emphasis is placed on testing the function of the rotator cuff during the physical examination. The three tests commonly used to evaluate the integrity of the subscapularis include the bear-hug, belly-press, and lift-off tests. It has been shown that the bear-hug test is the most sensitive of all the physical examination tests for diagnosing a subscapularis tendon tear, and if the test is positive, at least 30% of the upper tendon is usually torn.¹¹ Although the lift-off test is the least sensitive of the three, if it is positive, then at least 75% of the
subscapularis tendon is usually torn. Although classically the supraspinatus empty can test and resisted shoulder abduction in the first 30° have been described to assess the supraspinatus, we have found that patients with supraspinatus tears typically also have pain and weakness with resisted external rotation. The infraspinatus and teres minor are also tested with resisted external rotation. However, we test the infraspinatus in 0° of shoulder abduction and the teres minor in 90° of shoulder abduction (Hornblower test). We have found that lack of preoperative active external rotation past neutral (0°) is a poor prognostic finding for recovery of function after a revision rotator cuff repair.

There are several findings on plain films, in addition to the presence or absence of glenohumeral arthritis, that can provide diagnostic and prognostic information in regard to a rotator cuff tear and the best treatment option for the patient. The relationships between the humeral head, glenoid, and acromion are carefully evaluated. Patients with massive rotator cuff tears will often present with proximal humeral migration with a narrowed acromiohumeral distance. It has been previously determined that the threshold for proximal migration of the humerus occurs when at least the entire supraspinatus tendon is retracted at least 1 cm, which anatomically represents the threshold for concomitant tearing of the infraspinatus and/or subscapularis tendons.¹² However, rotation of the arm must be carefully noted when measuring the acromiohumeral distance. For instance, in a patient with a massive posterosuperior rotator cuff tear and intact subscapularis, a normal acromiohumeral distance may be seen with external rotation (Fig. 2-1A) and a narrowed acromiohumeral distance with internal rotation of the arm (Fig. 2-1B). The explanation for this phenomenon lies in the tensioning of the subscapularis. With the arm in external rotation, the subscapularis is tensioned, and the humeral head is held down in position. Whereas in internal rotation, the subscapularis is relatively slack, and there is no rotator cuff to oppose the superior pull of the deltoid so the humeral head elevates. Another radiographic finding that may be seen is anterior subluxation of the humeral head on the axillary plain film in a patient with a complete tear of the subscapularis tendon (Fig. 2-2).

We routinely obtain an MRI scan in a patient with a suspected retear of the rotator cuff. A thorough evaluation of the MRI is done to rule out any other pathological lesions (e.g., labral tear, biceps tear). The coronal images are very helpful for evaluating the attachments of the posterosuperior (supraspinatus and infraspinatus) rotator cuff tendons, whereas the axillary images are most useful for the anterior (subscapularis) and posterior (infraspinatus and teres minor) rotator cuff tendons. The sagittal oblique
images, medial to the glenoid, give the best view of the size and quality of the rotator cuff muscles. However, keep in mind that a retracted rotator cuff tear may give the false impression that more atrophy of the muscle is present than in reality exists.

Some authors have suggested that patients with fatty degeneration of the rotator cuff muscles ≥50% (Goutallier stage 3 or 4) should not undergo a repair of the rotator cuff because these patients do not improve after surgery.¹³,¹⁴ However, this has not been our experience. In fact, the senior author published his results of arthroscopic rotator cuff repair in patients with >50% fatty degeneration of the infraspinatus muscle, which some would consider irreparable, and he reported that most of these patients had significant improvement of their symptoms after surgery.¹⁵ Patients with up to 75% fatty infiltration were routinely reparable. Furthermore, in some cases, what appears to be atrophy of the rotator cuff muscle is in fact the retracted tendon seen in the prior location of the muscle, which gives the appearance of muscle atrophy. Therefore, it has not been our practice to solely rely on the appearance of the muscle to determine if the patient is a candidate for an arthroscopic rotator cuff repair.

At the beginning of every arthroscopic shoulder surgery, we perform a thorough evaluation of the shoulder. After a comprehensive diagnostic arthroscopy, we create a game plan. The game plan not only consists of what structures can and will be repaired but also the priority of the steps. Our standard order of steps is as follows:

1. Diagnostic arthroscopy

2. Biceps tenotomy or tenotomy plus whipstitch in preparation for tenodesis

3. Mobilization and repair of the subscapularis

4. Completion of biceps tenodesis

5. Mobilization of the supraspinatus and infraspinatus tendons (± interval slides)

6. Complete repair of the supraspinatus and infraspinatus tendons (if possible)

7. Superior capsular reconstruction (SCR) if complete repair is not possible

We also pay close attention to the efficiency of the steps and the amount and quality of “anatomical real estate” available to perform the rotator cuff repair. For instance, if a patient has a tear of the long head of the biceps tendon that requires repair with a concomitant subscapularis tear, we will often incorporate the sutures from the biceps tenodesis into the repair of the subscapularis tendon (Fig. 2-3).

Another example of using a single implant for repair of two structures would be a tear of the long head of the biceps tendon in conjunction with a complete supraspinatus tear. In this situation, we will often place the biceps tenodesis anchor in the anteromedial position of the greater tuberosity footprint and use the sutures from this anchor to incorporate into the supraspinatus repair (Fig. 2-4).

In addressing revision rotator cuff repair, we first repair the subscapularis tendon if it is torn. In our experience, most subscapularis tendon tears can be repaired arthroscopically, even in the revision setting. Please refer to our previous two books as well as to Chapter 1 of this book for full details on the techniques, tips, and pearls for repairing a subscapularis tendon tear. However, there are several important points that should be mentioned specifically in reference to revision subscapularis tears.

Video 2-2 It cannot be overemphasized that the surgeon must first be able to recognize the tear before he or she can fix it. It has been reported that subscapularis tendon tears are only identified by preoperative MRI scans in about one third of all arthroscopically confirmed tears.¹⁶ Therefore, in most cases, a subscapularis tear is first identified at the time of arthroscopy. We have found that most smaller tears that involve less than the upper one third of the subscapularis attachment can be seen with a 30° arthroscope. However, larger tears usually require a 70° arthroscope to adequately visualize the extent of the tear. It should also be mentioned that certain occult tears can only be seen with either probing the subscapularis tendon or having the surgical assistant apply flexion and internal rotation or the posterior lever push to identify the tear (Fig. 2-5). Furthermore, occult subscapularis tears are often obscured by an intact medial sling of the biceps and present arthroscopically as a rent in the medial sidewall of the bicipital groove. Such tears can only be seen by looking down the bicipital groove with a 70° arthroscope (Fig. 2-6).

It is common to see retraction and scarring of the subscapularis tendon in the revision setting of a complete tear. In this case, the surgeon must remember four key points. First, the subscapularis is always caudal to the coracoid process and anterior to the glenoid. Second, the upper lateral edge of the subscapularis tendon can be identified with
most retracted tears at the level of the mid-glenoid notch. Third, the comma tissue always leads you to the superolateral border of the subscapularis tendon. Fourth, the subscapularis can be freely mobilized in most cases with a standard three-sided release (Fig. 2-7).

Video 2-4 However, if the subscapularis cannot be mobilized completely to the lesser tuberosity without significant tension, the bone bed may be medialized up to 5 to 7 mm with no clinical detriment to the subscapularis function.¹⁷ It should also be noted that in revision cases, we will use a motorized drill or manual punch for additional bone bed preparation to create biologic channels for the bone marrow to escape to the healing surface (Fig. 2-8).

Video 2-5 It is always our preference to perform an anatomical tension-free double-row repair of the subscapularis when possible (Fig. 2-9). However, in many revision cases, we have found that a single-row repair is all that can be achieved (Fig. 2-10A). In this setting, we will place one anchor for tears involving <50% of the upper subscapularis tendon and at least two anchors for tears involving more than 50% of the tendon length from caudal to cephalad (Fig. 2-10B).

Once the subscapularis tendon is repaired, we address any posterosuperior tears of the rotator cuff. If the rotator cuff tendon is able to be mobilized over to the greater tuberosity footprint, the tear pattern is analyzed by determining the mobility of the cuff tissue in various directions with a tissue grasper (Fig. 2-12).

In revision cases, the supraspinatus and infraspinatus tendons are frequently scarred against the undersurface of the acromion (Fig. 2-13A). In such cases, we “excavate” the tendons in a stepwise manner. We insert a 30° arthroscope through a lateral viewing portal, while a motorized shaver is placed through a posterior working portal. We aim the shaver anteromedially toward the scapular spine. Once we feel the shaver blade strike the scapular spine, we sweep the blade laterally while maintaining contact with the undersurface of the acromion (Fig. 2-13B). Once the shaver blade emerges laterally in the plane between the rotator cuff and the acromion, the surgeon has a clear view of the plane that must be developed (Fig. 2-13C).

There is usually scar tissue and bursal leaders extending from the rotator cuff to the internal deltoid fascia. One helpful pearl that can aid in distinguishing tissue that needs to be resected from tissue that should be preserved is to identify the glenoid labrum and then the overlying rotator cuff (Fig. 2-14A). Tissue superficial to those two structures but deep to the internal deltoid fascia is often scar tissue that should be resected (Fig. 2-14B). Another helpful pearl
is by maximally internally rotating the arm, the intact posterior cuff attachments, which insert directly into bone, can easily be seen and can be distinguished from the overlying bursal leaders, which insert into the internal deltoid fascia (Fig. 2-14C). These bursal leaders are then debrided back to intact rotator cuff tendon, and the plane of the posterior gutter is developed. We will also carefully expose the scapular spine to distinguish the raphe between the supraspinatus and infraspinatus (Fig. 2-14D, E). Once the supraspinatus and infraspinatus have been fully dissected and the tear pattern is determined, interval slides may be performed if necessary, and the rest of the repair is completed (Fig. 2-14F).