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 • Ossur – Consultant – Institutional Support – Research Support • Smith Nephew – Institutional Support – Consultant • Arthrex – Institutional Support – Consultant • Mimedx – Institutional Support – Consultant – Research Support • Conmed Linvatec – Consultant – Institutional Support

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 e mo ryhe a lthc a re .o rg / o rtho

Why Rotator Cuffs Fail to Heal? • Inability of tendon to withstand load prior to healing • Inadequate tissue healing at the repair e mo ryhe a lthc a re .o rg / o rtho

L ä dermann A, et al. JISAKOS 2016 Patterns of Anatomic Deficiency Failure of tendon healing Poor tendon quality Fatty infiltration/atrophy Bone defects in the Bony and tendinous Retear medial to the medial row of fixation greater tuberosity insufficiency e mo ryhe a lthc a re .o rg / o rtho

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 e mo ryhe a lthc a re .o rg / o rtho

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” e mo ryhe a lthc a re .o rg / o rtho

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

Tuberosity • Osteoporosis • Prior anchors • Cystic greater tuberosity • Bone grafting? • “Reverse SAD” Levy DM, et al. Am J Orthop. 2012 e mo ryhe a lthc a re .o rg / o rtho

Others • Infection – relatively rare after arthroscopic rotator cuff repair, 0.27- 1.94% – P. Acnes & Staph • Patient factors: – Smoking – Diabetes e mo ryhe a lthc a re .o rg / o rtho

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

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 e mo ryhe a lthc a re .o rg / o rtho

Contraindications • Active infection • Advanced radiographic signs of arthritis • Fixed proximal humeral migration with contact of the humeral head against the acromion • Proximal humeral escape • Pseudoparalysis • Deltoid insufficiency or axillary nerve palsy Kowalsky, MS, Keener JD. JBJS 2011 e mo ryhe a lthc a re .o rg / o rtho

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. e mo ryhe a lthc a re .o rg / o rtho

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 e mo ryhe a lthc a re .o rg / o rtho

Subacromial Space • Bursectomy especially posteriorly and laterally • Subacromial decompression decreases re- operation 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 e mo ryhe a lthc a re .o rg / o rtho

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 e mo ryhe a lthc a re .o rg / o rtho

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 e mo ryhe a lthc a re .o rg / o rtho

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

Case e mo ryhe a lthc a re .o rg / o rtho

e mo ryhe a lthc a re .o rg / o rtho

Bone Grafting Burkhart SS, et al. Arthroscopy 2005 e mo ryhe a lthc a re .o rg / o rtho

Anchor Stacking Danard PJ, et al. Arthroscopy 2011 e mo ryhe a lthc a re .o rg / o rtho

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

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 e mo ryhe a lthc a re .o rg / o rtho

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 e mo ryhe a lthc a re .o rg / o rtho

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 e mo ryhe a lthc a re .o rg / o rtho

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

THANK YOU Spero G Karas, MD e mo ryhe a lthc a re .o rg / o rtho