Revision Rotator Cuff Repair Spero G. Karas MD Head Team Physician- - - PowerPoint PPT Presentation

Revision Rotator Cuff Repair

Spero G. Karas MD

Head Team Physician- Atlanta Falcons Director- Sports Medicine Fellowship Associate Professor of Orthopedics Emory Healthcare Sports Medicine

Pramote Malasitt, MD

Emory Sports Medicine Center

Team Physicians

Disclosures

• DJO Surgical

– Consultant – Research Support – Institutional Support

• Arthrex

– Consultant – Institutional Support – Research Support

• Conmed Linvatec

– Consultant – Institutional Support

• Ossur

– Institutional Support

• Smith Nephew

– Consultant – Institutional Support

• Mimedx

– Consultant

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Causes of Failure of Rotator Cuff Repair

Biologic

• a. Patient age
• b. Size of tear
• c. Fatty infiltration/Muscle atrophy
• d. Diabetes
• e. Smoking
• f. Stiffness

Technical

• a. Inadequate fixation
• b. Inadequate visualization
• c. Inadequate mobilization of tear
• d. Improper or aggressive rehabilitation

Traumatic

• a. Early: Before complete cuff healing
• b. Late: Failure of a previously well-functioning repair

Montgomery SR, et al. Clin Sports Med 2012

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Why Rotator Cuffs Fail to Heal?

• Inability of tendon to withstand load prior to

healing

• Inadequate tissue healing at the repair

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Patterns of Anatomic Deficiency

Failure of tendon healing Poor tendon quality Fatty infiltration/atrophy Retear medial to the medial row of fixation Bone defects in the greater tuberosity Bony and tendinous insufficiency

Lädermann A, et al. JISAKOS 2016

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Evaluation

• Careful History & Physical Exam
• Operative reports, preoperative imaging, and

arthroscopic photos, prior rehabilitation process should be reviewed

• Infection is uncommon but must be

considered in revision. P. acnes - the most commonly identified bacteria after rotator cuff repair, present in 50-86% of postoperative infections

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Things to consider

• Recognize and treat other pathology: biceps,

AC, glenohumeral arthritis

• Muscle atrophy/Fatty infiltration
• Familiarity with advanced arthroscopic

surgical techniques

• Set the patient’s expectations: Goal - primary

to reduce pain, whereas added function is an additional benefit and the shoulder will not likely return to “normal”

Tendon

• Age
• Atrophy/Fatty infiltration
• Tear size, tendon loss
• Tendon quality/vascularity

to tendon

• Ability to repair the tendon

defect adequately cannot be fully determined until the time of surgery

• Goal of tension-free repair

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Tuberosity

• Osteoporosis
• Prior anchors
• Cystic greater tuberosity
• Bone grafting?
• “Reverse SAD”

Levy DM, et al. Am J Orthop. 2012

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Others

• Infection

– relatively rare after arthroscopic rotator cuff repair, 0.27- 1.94% – P. Acnes & Staph

• Patient factors:

– Smoking – Diabetes

Factors Influencing Results

• Results are inferior to

those of primary repair

• Intact deltoid origin
• Good-quality rotator cuff

tissue

• Preoperative active

elevation of the arm above the horizontal

• Only one prior procedure

Djurasovic, et al. JBJS 2001

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Indications

• Persistent PAIN and limited shoulder function
• Should have intact or repairable subscapularis
• Good deltoid function
• At least 90 degree forward elevation, no ER lag

sign

• Ideal candidates have no more than Goutallier

stage-2 fatty infiltration

• Important to have a frank discussion with

patients who are not good revision candidates

Kowalsky, MS, Keener JD. JBJS 2011

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Contraindications

• Active infection
• Advanced radiographic signs of arthritis
• Fixed proximal humeral migration with contact
• f the humeral head against the acromion
• Proximal humeral escape
• Pseudoparalysis
• Deltoid insufficiency or axillary nerve palsy

Kowalsky, MS, Keener JD. JBJS 2011

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Steps

• Intra-articular assessment
• Evaluate the biceps ( tenotomy vs tenodesis)
• Inspected to determine the extent of the tear,

degree of retraction, quality of the tissue, and presence of delamination

• Prominent suture material or anchors are

sought and are removed

• Tissue biopsy if suspicion for infection.

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Release

• Releasing adhesions between the glenoid

labrum and the under-surface of the rotator cuff with use of an electrocautery wand or a shaver Avoid the

• use of the electrocautery or the

shaver >15 mm medial to the glenoid rim to prevent injury to the suprascapular nerve

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Subacromial Space

• Bursectomy especially posteriorly and laterally
• Subacromial decompression decreases re-
• peration rates
• Undersurface of the scapular spine is exposed to

ensure mobility of the tendon

• Release the adhesions between the rotator cuff

and the undersurface of the acromion

• Maintaining CA ligament (if present) may prevent

future/further shoulder escape

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Evaluation

• Determine the extent of

the tear

• Determine tear pattern
• Degree of retraction
• Quality of the tissue
• Presence of delamination
• Reduction without

excessive tension to ensure successful healing

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Releases

• Anterior or posterior interval slides can be

performed if needed

• Anterior interval release separating the

supraspinatus from capsule, medially to the coracoid base, full release of the coracohumeral ligament

• Avoid posterior interval slide unless the

infraspinatus cannot be mobilized because of its attachment to a severely retracted supraspinatus

Greater Tuberosity

Residual

• soft-tissue and

suture material are removed Previously placed anchors

• are removed when they are

prominent or when crowding of the greater tuberosity is seen Prepare the tuberosity with

• burr to enhance healing

Microfracture

• Crimson

duvet

Levy DM, et al. Am J Orthop. 2012

Suture Anchors

• Suture anchor stacking
• Replacement with the

use of larger suture anchors

• Transosseous drilling

nonanchor fixation

• Bone grafting
• Far lateral suture

anchor fixation

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Case

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Bone Grafting

Burkhart SS, et al. Arthroscopy 2005

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Anchor Stacking

Danard PJ, et al. Arthroscopy 2011

Repair

• Prefer dual-row or TOE repair

if possible

• If limited tendon excursion

despite releases, or tissue loss, then medialize the footprint and perform a single-row repair

• Margin convergence if

necessary

• Incorporate all layers of the

torn tendons when delamination is encountered

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Revision RCR- Results

• 21 patients – average age 56
• Retear rate > 50%
• Retear rate > 70% for 2 tendon tears
• Significant improvements were seen in VAS pain score,

SST score, ASES score, active elevation, and external rotation

• Tendon healing had no effect on outcomes measures

with the exception of the Constant score

• Age and the number of torn tendons are related to

postoperative tendon integrity

Keener JD, et al. JBJS 2010

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Revision RCR- Results

• 72 revision arthroscopic rotator cuff repairs
• Mean age 60, 63 months follow up
• 78% were satisfied
• Significant improvements in pain, range of

motion, and function with no difference between massive and small tears

• Repeat surgery was needed in ~10%
• Female gender, limitation of forward elevation,

and a preop VAS pain score of > 5 correlated with a poorer clinical result

Ladermann A, et al. Arthroscopy 2011

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Complications

• 20% within 1 year
• Twice the rate of primary surgery
• Direct correlation between the complication

rate and the number of revision surgeries

• Failure to heal, stiffness, infection, nerve

injury

Parnes N, et al. Arthroscopy 2013

If Irreparable

Partial repair

• the rotator

cuff force couple can be reestablished Patch/Graft

• tendon quality

is poor or a persistent

• defect. Offer a structural

support and improve healing rates

• Tendon transfer

Superior Capsular

• Reconstruction

Reverse

• total shoulder

arthroplasty

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THANK YOU

Spero G Karas, MD