Sunday, December 29, 2013
Failed cuff surgery: What can be done if rotator cuff surgery fails to give the desired result?
In our practice we see many patients referred or self-referred because the results of a previous attempt at a rotator cuff repair were not satisfactory. Common problems include, in addition to pain, (1) stiffness, (2) crepitance (popping and snapping), (3) weakness, (4) instability, (5) infection, and (6) detachment or denervation of the deltoid.
In addition to a good history and physical examination, high quality plain x-rays are important in the evaluation, seeking evidence of glenohumeral arthritis, upward displacement of the humeral head in relation to the glenoid, prominent suture anchors, and unwanted bone.
Unless there is some obvious contraindication (such as a prominent suture anchor), it is usually worthwhile giving the shoulder the benefit of a gentle exercise program.
If the shoulder does not respond to non-operative management, and if the primary mechanical problems include some combination of crepitance or stiffness, a smooth and move procedure is usually helpful. In many cases we've found loose suture and prominent anchors or prominent tuberosities as the cause of the stiffness and crepitance. These can be removed and trimmed back to leave a smooth upper surface to the proximal humeral convexity. Again, we preserve the acromion and coracoacromial ligament as important stabilizers of the shoulder. It is rare that a failed repair offers a good opportunity for a re-repair in that the quality and quantity of cuff tendon are usually compromised.
Infection is managed by a good smooth and move after cultures are obtained followed by copious irrigation and appropriate antibiotic management. It is now recognized that Propionibacterium can not infrequently be recovered from failed cuff repairs.
Failed cuff repairs leaving the shoulder unstable or with less than 90 degrees of active elevation may be candidates for a reverse total shoulder.
In addition to a good history and physical examination, high quality plain x-rays are important in the evaluation, seeking evidence of glenohumeral arthritis, upward displacement of the humeral head in relation to the glenoid, prominent suture anchors, and unwanted bone.
Unless there is some obvious contraindication (such as a prominent suture anchor), it is usually worthwhile giving the shoulder the benefit of a gentle exercise program.
If the shoulder does not respond to non-operative management, and if the primary mechanical problems include some combination of crepitance or stiffness, a smooth and move procedure is usually helpful. In many cases we've found loose suture and prominent anchors or prominent tuberosities as the cause of the stiffness and crepitance. These can be removed and trimmed back to leave a smooth upper surface to the proximal humeral convexity. Again, we preserve the acromion and coracoacromial ligament as important stabilizers of the shoulder. It is rare that a failed repair offers a good opportunity for a re-repair in that the quality and quantity of cuff tendon are usually compromised.
Infection is managed by a good smooth and move after cultures are obtained followed by copious irrigation and appropriate antibiotic management. It is now recognized that Propionibacterium can not infrequently be recovered from failed cuff repairs.
Failed cuff repairs leaving the shoulder unstable or with less than 90 degrees of active elevation may be candidates for a reverse total shoulder.
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