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A New Look at Shoulder Revision Surgery for Rotator Cuff Tears

With the development of arthroscopic surgery, surgeons have been able to repair rotator cuff tears (RCTs) in the shoulder with minimal trauma to the rest of the shoulder. But sometimes the repair doesn't hold and the patient retears the tissues. When that happens, is it okay to do the revision (second) surgery arthroscopically? Or should the surgeon perform an open incision for that second surgery?

That's what this group of surgeons set out to investigate with 54 of their own patients. The patients ranged in ages from 22 to 82. The surgeons saw them over a period of two years for arthroscopic revision repair of the rotator cuff. Everyone was followed for at least one full year. Some patients came back for additional testing for almost three years.

The patients were tested before and after the second surgery comparing strength, range-of-motion, function, and pain levels. All kinds of data was collected about each patient. The authors were hoping to find some way to predict who might have a positive result and who was at risk for a failed second surgery. For example, age, gender, hand dominance, past medical and surgical histories, occupation and work levels (light, medium, heavy), use of tobacco and/or alcohol, and number of previous shoulder surgeries were all recorded and analyzed with the results.

Besides looking at the social and medical histories, the surgeons also made note of the number and type of fixation (anchors and sutures) used during the revision procedure. Sometimes only a single-row of fixation was needed. Tissue quality and tension placed on the repair determines whether a single versus double-row of sutures/anchors is needed.

Any repairs made to other damage in the shoulder were also taken into consideration. Before and after imaging studies were done using X-rays and MRIs. The presence of bone spurs and other signs of osteoarthritis were revealed by these additional imaging studies.

After surgery, every patient participated in a six-month long rehab program. The program was directed and supervised by physical therapists. There were three phases: passive motion while the shoulder was immobilized in a sling, active motion after the sling was discontinued, and strengthening and conditioning.

Every detail of time in rehab, cooperation and compliance, and final functional capacity was observed and reported. The researchers left no stone unturned when it comes to looking for any factor that might possibly tip the surgeon off as to the final result (success versus failure). They even had outside experts evaluate and test the patients to avoid any potential bias.

Patients were carefully selected for this study. Focusing on a subgroup of similar patients makes it possible to reduce the effects of too many variables (factors) thrown in together. In this study, they excluded anyone who had a partial-thickness tear or tears that couldn't be repaired. Only patients with full-thickness tears (ruptures) that could be operated on were included. Patients were taken out of the study any time the surgeon started with an arthroscopic procedure but had to switch over to an open repair.

Most of the studies already published about revision surgery for rotator cuff repairs focus on the results of open surgery. An open incision gives the surgeon easier access to the area but it is more invasive than arthroscopic surgery. Arthroscopy makes it possible to see inside the joint and clearly identify the type of tear and extent of damage. With a tiny TV camera on the end of the scope, the surgeon can probe the area and look for any other soft tissue disruptions or joint lesions that can't be seen otherwise.

When it was all said and done and the patients had been analyzed in many different ways, they found that the results weren't optimal using arthroscopy to do the revision. There was some pain relief and improved shoulder function but 10 per cent had a failed response. These patients faced yet another operation, including shoulder replacement.

Patients most likely to have a failed revision surgery were those who had already had more than one previous surgery on the same shoulder. Anyone who couldn't lift the arm overhead seemed to have the worst outcomes.

And it turned out that gender was also an important factor. Women were more likely to have a poor result compared with men. Patients most likely to get back to work were those with the smallest tears who didn't smoke and whose job did not require heavy lifting or manual labor.

The authors concluded that revision of rotator cuff repairs that retear can be done arthroscopically. If the surgeon suspects there's a complex tear pattern and/or other damage present, then arthroscopy over open incision is still the better choice. The open incision technique might be better for patients with negative predictive risk factors (e.g., women, smokers, those who have had previous shoulder surgeries).

Either way, patients should be warned that the results usually aren't as good as if the shoulder were being repaired for the first time. The goal of revision surgery is to improve patient comfort and function with the least amount of scarring and complications. If there is some way to reduce the risk of failure, surgeons want to know that. The results of this study may help surgeons when evaluating which surgical approach to take when repairing a torn rotator cuff for the second time.

References: Dana P. Piasecki, MD, et al. Outcomes After Arthroscopic Revision Rotator Cuff Repair. In The American Journal of Sports Medicine. January 2010. Vol. 38. No. 1. Pp. 40-46.

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