Revision Rotator Cuff Surgery

1. Biological issues: The biology of the patient plays a crucial role in the healing process. Poor tissue quality, inadequate blood supply, and age-related degeneration can impede healing. Young and active patients with good tissue quality and no muscle atrophy have a much higher repair success rate when compared to elderly patient with poorer tissue quality. Additionally, systemic factors like diabetes or smoking can negatively affect tissue repair and healing.
2. Mechanical factors: Improper surgical technique or failure of the surgical repair, such as suture breakage or anchor pullout, or retained hardware are mechanical reasons for failure. Overuse or trauma post-surgery can also disrupt the repair.
3. The complexity of the tear: Larger and more complex tears have a higher failure rate. These tears are more challenging to repair and have a higher tendency to re-tear.
4. Muscle atrophy and fatty infiltration: Chronic rotator cuff tears can lead to muscle atrophy and fatty infiltration, reducing the muscle’s ability to function and heal properly.
5. Other complications: Other complications such as stiffness or scar tissue formation can also contribute to suboptimal outcomes.

Revision surgery is considered in a variety of scenarios:

• Persistent Pain and Dysfunction: If pain, weakness, or limited range of motion persists despite adequate post-operative rehabilitation, it may indicate a failure of the initial repair.
• Re-tear of the Rotator Cuff: Identified through imaging studies like MRI or ultrasound, a re-tear of the repaired tendon is a direct indication for revision surgery.
• Inadequate Improvement: If the patient’s shoulder function does not improve as expected, it may warrant a re-evaluation and possibly a revision surgery.
• New Injury or Trauma: If the shoulder experiences new trauma or injury post-surgery, it can lead to the failure of the initial repair.

Before opting for revision surgery, a thorough evaluation is essential. This will include taking a detailed medical history, a physical exam to understand the patient’s symptoms and limitations, and evaluation of previous surgical interventions. MRI or ultrasound can assess the status of the rotator cuff repair, muscle quality, and any other shoulder pathology. It’s also important to align the surgical goals with patient expectations.

The surgical technique used for revision rotator cuff surgery depends on the unique features of the tear and the surgeon’s preference. Revision surgery is more challenging than the initial repair due to factors such as scar tissue, changes in anatomy, and poorer tissue quality.

Tissue grafts may be necessary when the tendon tissue is poor. Often, other shoulder pathologies like biceps tendonitis or shoulder impingement are addressed during the revision surgery. Further, several surgical aides such as bone marrow stimulation (microfracture) and bioinductive implants can help the healing process by inducing the growth of new tendon tissue.

Revision rotator cuff repairs may be performed minimally invasively. Arthroscopic revision repair offers many advantages over open repair including smaller incisions, less tissue trauma and faster healing.  It allows the surgeon to evaluate the joint more thoroughly and if additional problems are discovered, those can be addressed before repairing the rotator cuff.