Managing Complications of Rotator Cuff Repair: Revision Scope Repair
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1 Managing Complications of Rotator Cuff Repair: Revision Scope Repair Matthew T. Provencher, MD CDR MC USN Associate Professor of Surgery, Harvard University Chief of Sports Medicine and Surgery Boston, MA Rachel Frank, BS Resident, Northwestern University Introduction Ideal repair leads to biological healing of tendon to footprint Factors involved in optimal healing Footprint coverage Contact pressure Suture strength Loop and knot security Decreased motion at bone-tendon interface Maximization of the biological response Transosseous equivalent (TOE) repair is a double-row construct with lateral fixation laterally on the greater tuberosity to replicate transosseous tunnel fixation TOE better re-establishes the native footprint and provides a biomechanical advantage when compared to double-row fixation at time equals zero Early clinical results encouraging, some equivocal Need to define what is truly a double-row construct Not all DR (double row) repairs are the same. Single row (SR) constructs may be as robust as DR techniques, especially for certain tear configurations Classification A. Crescent: Tear between anterior and posterior attachments of supraspiantus tendon to greater tuberosity B. U-Shaped: Anterior and posterior supraspinatus attachments intact C. L- Shaped (Reverse L-Shaped): Either anterior (L-Shaped) or Posterior (Reverse L-Shaped). Tear will have apex that needs to be reapproximated Anatomy and Biomechanics Supraspinatus footprint Size- 12.7mm (medial to lateral) and 16.3mm (anterior to posterior) (Dugas 2002) 1
2 Coverage Observational studies 47% - single-row (Mazzocca 2005) 71% - transosseous suture (Meier 2006) 100% - double-row (Meier 2006) Contact film studies Significantly greater coverage with double-row versus single-row repair (Tuoheti 2005; Nelson 2008) 39.6% - double-row (Park, M. C. 2007) 77.6% - transosseous equivalent repair (Park, M. C. 2007) Repair strength at time equals zero Theoretical maximum contraction force of supraspinatus tendon 302N (Burkhart 2000) Load to failure 273N single-row (Gerber 1994) 336N double-row (Cummins 2005) 443N TOE (Park, M. C. 2007) Cycles to failure Double-row significantly greater than single-row fixation (Waltrip 2003) Gap Formation double-row significantly less then single row (Ahmad 2005; Kim 2006; Smith 2006; Milano 2008) Biological / Histological Long-term stability provided by biological healing Healing requires creation of thin fibrocartilaginous layer at bone-tendon junction. Optimizing biological healing requires adequate debridement of bony footprint and relative preservation of bursalll tissue (Uhthoff 2000) Motion at tendon-bone interfaces will impair healing (Rodeo 2006) A: Single Row B: Double Row, 4 anchors C: Double Row, Transosseous equivalent (TOE) The Failed Rotator Cuff Repair - Important factors to consider: - Biology (probably under-appreciated) - Technical (is the tear properly reduced? Is it over-tensioned? Etc) - Implants (failure load, placement, bioabsorbable or integration into bone? Suture type, configuration and suture-anchor interface considerations) - Tear quality (fatty infiltrate, retraction, tear pattern) - Intrinsic patient factors (smoking, medical conditions diabetes, collagen disorders, postop activity, etc) - Postoperative Factors (rehabilitation slow vs. accelerated, sling use, 2
3 postoperative medications NSAIDs) - Revision Rotator Cuff Literature - Failure of repair integrity - Stiffness - Postoperative pain (other pathology?) - DeOrio/Cofield (JBJS 1984) overall 17% good results with revision repair, remainder fair to poor overall. Recommended against doing revision repair (open tchniques) - Neviaser (JSES 1989) 92% improved pain, 50% improved motion. à Factors associated with success: Adequate decompression, closure of all RC defects, avoid weights and resistance for first 3 mos postoperatively. Tear size and age not predictive of success - Ellman (JBJS 1986) 84% of 50 pts satisfied after revision cuff surgery. Acromiohumeral distance of <7 mm = poorer outcome - Bigliani (JBJS 1992) 50% satisfied overall (out of 50 pts); but 81% with good pain relief. Not satisfied due to persistent weakness. - Lo (Arthroscopy 2004) Good results in 14 patients with revision scope RCR. UCLA 13 à 26. Selected Literature Keener: 21 patients, mean age of 55.6, 79% massive tears, postop ASES 74 Piasecke: 21 patients, mean age of 55.6, NA massive tears, postop ASES 68 Ladermann: 54 patients, mean age 54.9, 7% massive tears, postop ASES 77 Burkhart: 14 patients, mean age 57.6, postop UCLA 28, patient satisfaction 93% 3
4 References. Bigliani LU, Cordasco FA, McIlveen SJ, Musso ES. Operative treatment of failed repairs of the rotator cuff. J Bone Joint Surg Am. 1992;74: Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of full-thickness tears of the supraspinatus: Does the tendon really heal?. J Bone Joint Surg Am. 2005;87: Clement ND, Hallett A, MacDonald D, Howie C, McBirnie J. Does diabetes affect outcome after arthroscopic repair of the rotator cuff?. J Bone Joint Surg Br. 2010;92: Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures (Pre- and postoperative evaluation by CT scan). Clin Orthop Relat Res. 1994; Neer CS II. Reoperation for failed cuff repairs. Presented at the Closed Meeting of the American Shoulder and Elbow Surgeons, Orlando, FL, October 20, Neviaser RJ, Neviaser TJ. Reoperation for failed rotator cuff repair: Analysis of fifty cases. J Shoulder Elbow Surg. 1992;1: DeOrio JK, Cofield RH. Results of a second attempt at surgical repair of a failed initial rotator-cuff repair. J Bone Joint Surg Am. 1984;66: Abrams JS. Management of the failed rotator cuff surgery: Causation and management. Sports Med Arthrosc. 2010;18: Keener JD, Wei AS, Kim HM, et al. Revision arthroscopic rotator cuff repair: Repair integrity and clinical outcome. J Bone Joint Surg Am. 2010;92: Kowalsky MS, Keener JD. Revision arthroscopic rotator cuff repair: Repair integrity and clinical outcome: Surgical technique. J Bone Joint Surg Am. 2011;93(Suppl 1): Lädermann A, Denard PJ, Burkhart SS. Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears. Arthroscopy. 2011;27: Lo IK, Burkhart SS. Arthroscopic revision of failed rotator cuff repairs: Technique and results. Arthroscopy. 2004;20: Piasecki DP, Verma NN, Nho SJ, et al. Outcomes after arthroscopic revision rotator cuff repair. Am J Sports Med. 2010;38: Burkhart SS. Arthroscopic treatment of massive rotator cuff tears (Clinical results and biomechanical rationale). Clin Orthop Relat Res. 1991; Burkhart SS. Fluoroscopic comparison of kinematic patterns in massive rotator cuff tears (A suspension bridge model). Clin Orthop Relat Res. 1992; Burkhart SS. Reconciling the paradox of rotator cuff repair versus debridement: A unified biomechanical rationale for the treatment of rotator cuff tears. Arthroscopy. 1994;10:4 19. Cordasco FA, Bigliani LU. The rotator cuff. Large and massive tears. Technique of open repair. Orthop Clin North Am. 1997;28: Djurasovic M, Marra G, Arroyo JS, Pollock RG, Flatow EL, Bigliani LU. Revision rotator cuff repair: Factors influencing results. J Bone Joint Surg Am. 2001;83: Neviaser RJ. Evaluation and management of failed rotator cuff repairs. Orthop 4
5 Clin North Am. 1997;28: Packer NP, Calvert PT, Bayley JI, Kessel L. Operative treatment of chronic ruptures of the rotator cuff of the shoulder. J Bone Joint Surg Br. 1983;65: Post M, Silver R, Singh M. Rotator cuff tear (Diagnosis and treatment). Clin Orthop Relat Res. 1983; Cunningham G, Lädermann A. Tendon of the long head of the biceps brachii: Tenotomy versus tenodesis?. Leading Opin. 2011;2: Lo IK, Burkhart SS. The comma sign: An arthroscopic guide to the torn subscapularis tendon. Arthroscopy. 2003;19: Lo IK, Burkhart SS. Arthroscopic coracoplasty through the rotator interval. Arthroscopy. 2003;19: Burkhart SS, Lo IK. Arthroscopic rotator cuff repair. J Am Acad Orthop Surg. 2006;14: Denard PJ, Burkhart SS. Techniques for managing poor quality tissue and bone during arthroscopic rotator cuff repair. Arthroscopy. 2011;27:
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