The Failed Rotator Cuff Repair: Evaluation and Surgical Management


Chapter 33

The Failed Rotator Cuff Repair


Evaluation and Surgical Management



Rolando Izquierdo Jr , Marie Rivers, Scott W. Trenhaile, and Geoffrey S. Van Thiel

Introduction


Failed rotator cuff repair includes patients with recurrent tears; however, it also includes those patients who have not achieved adequate pain control or improved functional outcomes following the index procedure. There are intrinsic and extrinsic factors that contribute to persistent symptoms. The intrinsic factors are specific to the rotator cuff itself and a recurrent tear. The extrinsic factors include persistent biceps symptoms, symptomatic acromioclavicular (AC) joint arthritis, glenohumeral arthritis, unrecognized instability, and persistent subcoracoid impingement.

Procedure


Arthroscopic or open rotator cuff repair involves the reattachment of the tendinous rotator cuff complex to the appropriate tuberosity insertion. However, it also includes managing any other additional pathology (i.e., AC joint arthritis, any causes of impingement, biceps pathology, adhesive capsulitis, glenohumeral arthritis, implant complications, poor bone quality, and so forth) not addressed at the index procedure.

Patient History



Patient Examination



Imaging



Treatment Options: Nonoperative and Operative





  1. • Living with the symptoms.
  2. • Nonsteroidal antiinflammatory drugs (NSAIDs).





  3. • Corticosteroid injection.
  4. • Formal physical therapy/home exercise program.
  5. • Revision rotator cuff repair: technique based on surgeon preference.


    1. – Single- versus double-row: greater tuberosity surface area availability, bone loss, cuff mobility, and necessity of removal of old implants must all be considered.

  6. • With or without biceps tenodesis or tenotomy.
  7. • Decompression, anterior acromioplasty (if indicated): look at the coracoacromial ligament. In our practice if it looks normal, we leave it alone. If the coracoacromial ligament is frayed or abnormal, we release it and perform an anterior acromioplasty. ALWAYS check an axillary image for an os acromiale before releasing the coracoacromial ligament, because this may lead to instability of the os.
  8. • AC joint resection/revision if symptomatic.



Radiographic Anomalies



Surgical Anatomy



Surgical Indications



Surgical Technique Setup


Positioning





  1. • Beach chair (our preference for rotator cuff pathology) or lateral decubitus (our preference for instability) position.
  2. • Beach chair advantages: easy conversion to open or extensile incisions; easier to rotate the arm to visualize the rotator cuff.
  3. • Patient is sitting up 50–70 degrees.
  4. • Rotate the table 45 degrees in the room.
  5. • Position lights if needed for open procedure.
  6. • Use an arm holder whenever possible to maintain a steady position of the arm.
  7. • Make sure the legs are not in a dependent position.
  8. • Padding/pillows underneath the knees/ankles.
  9. • For beach chair position, use a positioner that maintains a neutral cervical alignment.


  10. • Opposite extremity should be in a neutral position on a well-padded arm holder. Protect the ulnar nerve of the opposite extremity.
  11. • Pad all bony prominences.
  12. • For patients with deep vein thrombosis risk, use TED hose (thromboembolic deterrent hose). Consider sequential compression devices or plexipulses if indicated.

Possible Pearls



Possible Pitfalls



Equipment



Surgical Exposure/Portals





  1. • Try to use old portals if possible. Do not sacrifice appropriate portal positioning. Do not be afraid to make as many accessory percutaneous portals/incisions as needed.
  2. • Posterior portal: 2 cm distal and 1 cm medial to the posterolateral acromion. (Find the soft spot in the back of the shoulder with your thumb.)
  3. • Anterior portal: use the spinal needle for localization. Stay lateral to the coracoid process to avoid neurovascular structures. This tends to be more distal and lateral than you expect, which is helpful because the shoulder swells with fluid extravasation.
  4. • If planning an AC joint resection, the posterior portal tends to be more medial: 2–2.5 cm medial to the posterolateral acromion (more in line with the AC joint). Also, the anterior portal would be slightly more medial.


  5. • Lateral portal can be adjusted based on the tear (typically midclavicular line). In a far anterior supraspinatus tear, the lateral portal can be more anterior.
  6. • REMEMBER: axillary nerve position.
  7. • Establish percutaneous portals for anchor placement and suture management. These are normally positioned using the spinal needle.
  8. • Percutaneous portals for anchors should be placed with the arm in full adduction in order to allow adequate clearance of the acromion and appropriate angle to the greater tuberosity (Fig. 33.18).

Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on The Failed Rotator Cuff Repair: Evaluation and Surgical Management
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