Clinical and Imaging Outcomes After Revision Open Rotator Cuff Repair: A Retrospective Review of a Midterm Follow-Up Study

Abstract

Background

Revision open rotator cuff repair (ORCR) has been associated with unpredictable functional outcome with concerns of deltoid detachment. The aim of this study was to evaluate the clinical and imaging outcomes of revision ORCR.

Materials and Methods

The study retrospectively reviewed 30 consecutive patients (mean age 60.4 ± 7.2 years) who underwent revision ORCR after failed rotator cuff repair. Pain visual analog scale (VAS), Constant and American Shoulder Elbow Surgeon (ASES) score were assessed preoperatively and at mean 58-month follow-up (range 24–120 months). The acromio-humeral distance (AHD) was measured on pre- and postoperative radiograph. Tear size and fatty infiltration of rotator cuff were evaluated by preoperative magnetic resonance imaging (MRI) study. The retear rate, change of fatty infiltration and deltoid origin integrity were evaluated by postoperative MRI.

Results

There was significant improvement of pain VAS and functional outcome scores (all p < 0.001). AHD showed no significant change after surgery. On postoperative MRI, the retear rate was 43% (13/30). However, the size of the tendon defect was smaller than that of pre-revision tear (p = 0.006). The patients who had intact tendon had significantly better functional outcomes than those with retear. The intact group had significantly higher AHD both pre- and postoperatively than the retear group. There was no change of fatty infiltration after surgery. Four patients (13%, 4/30) showed thinning of deltoid origin on postoperative MRI, but showed no weakness on clinical examination.

Conclusion

Revision ORCR resulted in improved outcomes in pain relief and shoulder function, with low rate of subclinical deltoid thinning.

Introduction

Rotator cuff tear is one of the most common causes of shoulder pain. The advent of arthroscopy has made the all-arthroscopic rotator cuff repair (RCR) the standard surgical procedure. With the exponential increase of arthroscopic rotator cuff surgeries [1, 2], failures of tendon healing are more frequently encountered. Previous studies have shown that revision surgery has inferior outcome than the primary repair [3–5]. The poor tissue quality, adhesion and contracture related to the previous surgery, and deltoid injury can complicate the revision surgery [6]. Recently, the approach to the revision surgery has shifted from open revision surgery to arthroscopic surgery. Revision open surgery was associated with unpredictable functional outcome with great concerns about deltoid injury [3, 4]. There have been only few reports on revision ORCR [3, 4, 7, 8], and no recent literature has described the clinical outcome of revision ORCR of failed arthroscopic rotator cuff repair along with MRI findings.

The main objective of the current study was to report the clinical and imaging outcomes of revision ORCR. The secondary purpose was to investigate factors related to the clinical outcomes and complications especially regarding the deltoid integrity after revision surgery. We hypothesized that revision ORCR would provide reliable functional improvement and achieve tendon healing comparable to the historical results of revision arthroscopic RCR with minimal complications.

Materials and Methods

Ethics Approval

The study was approved by the ethics committee at our institution.

Patient Selection

This retrospective study was conducted in a tertiary university hospital after acquiring approval from institutional review board. All patients who underwent revision ORCR from 2007 to 2016 were identified from prospectively collected surgical database. The medical records were retrieved to collect information about prior surgery and clinical presentation. The indication for revision surgery was patients who had failure of tendon healing as proven by MRI study, with considerable pain and disability after a trial of conservative management. Any patients who had moderate to severe degenerative arthritis (Samilson–Prieto grade II and III), less than follow-up period of 2 years or no follow-up MRI study were excluded.

Surgical Techniques and Postoperative Rehabilitation

All surgeries were performed by a single senior surgeon in the beach-chair position under general anesthesia. The shoulder was approached through a standard anterosuperior skin incision that paralleled 1/3 lateral border of the acromion in the Langer skin lines. The incision starts from the mid-point of the acromion to the coracoid process (Fig. 1). After splitting the anterior and middle deltoid about 3–4 cm longitudinally, a small portion of anterior deltoid was taken down. Coracoacromial (CA) ligament was peeled off from the undersurface of acromion and preserved for reattachment. Acromioplasty was performed if the subacromial spur was identified.[9]. Any suture materials from the previous surgery were thoroughly removed. Multiple non-absorbable traction sutures were placed in the torn rotator cuff for mobilization. It was frequent to encounter severe adhesion under the CA ligament, subdeltoid and subacromial space. Meticulous adhesiolysis was carried out using Mayo scissor and blunt dissection. If the cuff could not be reduced to the original footprint after adhesiolysis, rotator interval release between the subscapularis and the supraspinatus was performed. Once adequately mobilized, the margin was converged with multiple tendon-to-tendon sutures when necessary and the torn edge of the tendon was reattached to the greater tuberosity using No. 2 Ethibond (Ethicon, Cincinnati, Ohio, USA) in trans-osseous double mattress fashion. A tendon-grasping mattress thread is first made, and then tied to each end of the trans-osseous mattress thread. Additional trans-osseous sutures are tied to reattach the torn cuff to the tuberosity (Fig. 2). Deltoid was repaired along with CA ligament to the acromion.

Fig. 1.

a The skin incision in left shoulder, made in Langer skin lines, paralleling the lateral-third margin of the acromion. b After splitting the anterior and middle deltoid, torn rotator cuff tendons are exposed

Fig. 2.

Double mattress suture technique. A tendon-grasping mattress thread (red) are tied to trans-osseous thread (blue). Additional trans-osseous sutures (green) are tied to reattach the torn cuff to the tuberosity

An abduction brace was maintained for 8 weeks postoperatively to ease the tension and protect the repair. The patients were allowed to mobilize their hand and elbow immediately after surgery. Gentle pendulum exercise was added at 1 week after surgery. The formal protected passive range of motion exercise were initiated on the 4th postoperative week. Strengthening of the rotator cuff and peri-scapular muscle using Theraband (Hygenic Corporation, Akron, Ohio, USA) and wall push-ups were commenced at 12 weeks postoperatively. Posterior capsular stretching exercises and internal rotation stretching were initiated at 6 months postoperatively.

Clinical Evaluation

After revision RCR, patients were regularly followed up in the outpatient clinic at 1, 3, 6, and 12 months. After 12 months, an annual checkup visit was recommended. An independent nurse practitioner examined the patient to document clinical outcomes before undergoing the revision surgery and at a mean of 58 months postoperatively (range 24–120 months). The range of motion (forward elevation, external rotation) was measured using a hand-held goniometer. Abduction, supraspinatus and external rotator muscle strength was measured using the Nottingham Mecmesin Myometer (Mecmesin Co., Nottingham, UK). Pain visual analog scale (VAS) score, American Shoulder and Elbow Surgeons (ASES) score, and age-adjusted Constant score [10] were documented.

Imaging Study

Standard shoulder anteroposterior (AP) X-ray was analyzed to assess the presence of glenohumeral joint arthritic change and acromio-humeral distance (AHD). AHD was measured as the distance between the undersurface of the acromion and superior margin of the humeral head. Preoperative MRI was reviewed to assess AP size of tears, involved tendons and fatty infiltration of subscapularis, supraspinatus, and infraspinatus tendons according to Goutallier’s classification [11]. The patients underwent 3.0-T MRI (Achieva, Philips Medical System, Amsterdam, The Netherland) at 12 months postoperatively. Sugaya classification of repair integrity [12] was used to define the failure of healing. The AP size of retear, if present, and fatty infiltration of tendons was measured on sagittal plane of MRI. The integrity of deltoid origin was evaluated for any tear or thinning. All imaging studies were analyzed by a fellowship-trained shoulder specialist who was blinded to the information of the patients.

Statistics

Paired t test and Wilcoxon signed-rank test were used to compare pre- and postoperative clinical and imaging parameters. To compare the differences between the two subgroups according to the postoperative MRI (intact cuff repair vs retear), Fisher’s exact test was used to for the categorical data and Mann–Whitney test was used for the numerical data. Statistical analyses were performed using the SPSS software (version 21; IBM, Armonk, NY, USA). The significance level was set at a p value of 0.05.

Results

From 2007 to 2016, 43 consecutive patients underwent revision ORCR. Nine patients had less than 24 months follow-up period. Four patients had no follow-up postoperative MRI. Thus, a total of 30 patients were enrolled as the final study group. The study group included 13 men and 17 women with an average age of 60.4 ± 7.2 years at the time of surgery. The surgery was performed the most frequently on the dominant side (26 dominants, 4 non-dominants). The mean AP size of cuff tear was 28.2 ± 9.0 mm on MRI. Twenty-eight patients had undergone one previous rotator cuff repair (all-arthroscopic in 19, arthroscopic mini-open in 2, open repair in 7) and two patients underwent two previous surgeries (two arthroscopic repairs in one patient, arthroscopic repair followed by open revision in another patient).

Clinical Outcomes

Pain VAS score, ASES score, Constant score, forward elevation ROM, muscle strength significantly improved following surgery at final follow-up (Table 1). Four patients had pseudoparalysis (active forward elevation less than 90°) before the surgery, which resolved after revision surgery. The two patients who had two failed surgeries (a 60-year-old female and a 43-year-old male) showed relief of pain (pain VAS 6 decreased to 3) and improvement of functional scores (ASES score of 55 and 58 preoperatively to 68 and 72 postoperatively for each patient; Constant score of 51 and 58 preoperatively to 70 and 64 postoperatively for each patient). There were no reports of postoperative complications. At the time of final follow-up, no patient had additional shoulder operation of the involved arm.

Table 1.

Clinical outcomes after revision ORCR (n = 30)

	Preoperative	Postoperative	p valuea
VAS pain	6.2 ± 1.6	1.7 ± 1.6	< 0.001*
ASES	52.8 ± 14.4	82.9 ± 15.2	< 0.001*
Constant	55.9 ± 14.4	80.6 ± 14.5	< 0.001*
ROM, FE (°)	134 ± 34	151 ± 13	0.01*
ROM, ER (°)	36 ± 14	37 ± 10	0.641
SST power (kg)	2.1 ± 1.0	3.1 ± 1.6	< 0.001*
ER power (kg)	2.7 ± 1.0	3.8 ± 1.7	< 0.001*
Abd power (kg)	2.6 ± 1.5	3.5 ± 1.9	0.009*

The values are reported as mean and standard deviation

VAS Visual Analog Scale, ASES American Shoulder and Elbow Surgeons score, ROM range of motion, FE forward elevation, ER external rotation, SST supraspinatus, ER external rotator, Abd abduction

*significant level = p < 0.05

^aTest used = paired t test

Imaging Outcomes

There was no development of glenohumeral arthritis on the follow-up X-ray. On evaluating the repair integrity of postoperative MRI, 13 of 30 patients (43%) had radiological signs of retear. For the patients with two-time failures, one of the patients (a 43-year-old male) showed healing of repaired rotator cuff, but the other showed retear. The average size of tears in these patients decreased significantly from 27.9 ± 7.2 to 17.9 ± 7.1 mm (p = 0.006). The mean fatty infiltration grade of rotator cuff and mean AHD did not show significant change after revision surgery (Table 2).

Table 2.

Preoperative (preop) and postoperative (postop) imaging parameters in revision ORCR patients (n = 30)

Parameter	Preop	Postop	p valuea
Fatty infiltration
Subscapularis	0.7 ± 0.7	0.8 ± 0.7	0.083
Supraspinatus	2.6 ± 0.6	2.5 ± 0.7	0.103
Infraspinatus	2.1 ± 0.9	2.1 ± 0.9	1.000
AHD (mm)	6.5 ± 2.6	6.8 ± 2.2	0.139

The values are reported as mean and standard deviation

Fatty infiltration Goutallier grading, AHD acromio-humeral distance

^aTest used = paired t test

Subgroup Analysis

Subgroup analysis between the retear group (n = 13) and intact group (n = 17) showed no significant difference with regard to age, sex, hand dominance, and preoperative tear size (Table 3). Preoperatively, a significantly higher ASES score was observed in the intact group than in the retear group (p = 0.018). Postoperatively, the intact group showed better ASES score, Constant score than the retear group (p = 0.003 and p = 0.001, respectively). Despite the failure of cuff healing, pain VAS score, ASES score, Constant score, forward elevation ROM and muscle power significantly improved in the retear group (Table 4). When the imaging studies were analyzed, we found no difference between the two groups with respect to the pre- and postoperative fatty infiltration of the rotator cuff tendons (all p > 0.05). However, a significantly higher mean AHD was observed in the intact group than in the retear group pre- and postoperatively (all p < 0.001) (Table 5).

Table 3.

Comparison between retear group vs intact group

	Retear (n = 13)	Intact (n = 17)	p valuea
Age	62 ± 6.1	59.2 ± 7.8	0.245
Tear size (mm)	27.9 ± 7.2	28.5 ± 10.4	0.934
Gender (M:F)	5:8	7:10	0.897
Involved side (D:ND)	11:2	15:2	0.565

The values are reported as mean and standard deviation

D dominant, ND nondominant

^aTest used = Mann–Whitney test for age and tear size, Fisher’s exact test for the rest

Table 4.

Functional outcomes after surgery: Comparison between retear group (n = 13) and intact group (n = 17)

	Preoperative			Postoperative			p valueb
	Retear	Intact	p valuea	Retear	Intact	p valuea	Retear	Intact
VAS pain	6.5 ± 2.0	6.0 ± 1.2	0.651	2.3 ± 1.8	1.2 ± 1.2	0.094	0.003*	< 0.001*
ASES	47.5 ± 15.7	56.8 ± 12.2	0.018*	74.5 ± 18.8	89.2 ± 7.3	0.003*	0.009*	< 0.001*
Constant	52.8 ± 17.5	58.4 ± 11.5	0.281	71.4 ± 15.3	87.5 ± 9.3	0.001*	0.019*	< 0.001*
ROM, FE (°)	125 ± 34	140 ± 33	0.079	148 ± 15	154 ± 6	0.621	0.05*	0.028*
ROM, ER (°)	35 ± 15	37 ± 14	0.651	35 ± 11	39 ± 9	0.483	0.752	0.949
SST power (kg)	1.9 ± 0.9	2.3 ± 1.0	0.363	2.9 ± 1.1	3.3 ± 1.9	0.902	0.007*	0.03*
ER power (kg)	2.4 ± 1.0	2.9 ± 1.0	0.157	3.4 ± 1.4	4.0 ± 1.9	0.727	0.016*	0.001*
Abd power (kg)	2.4 ± 1.5	2.8 ± 1.5	0.229	3.3 ± 1.2	3.7 ± 2.3	0.582	0.011*	0.109

The values are reported as mean and standard deviation

VAS Visual Analog Scale, ASES American Shoulder and Elbow Surgeons score, ROM range of motion, FE forward elevation, ER external rotation, SST supraspinatus, ER external rotator, Abd abduction

*Significant level = p < 0.05

^aTest used = Mann–Whitney test

^bTest used = Wilcoxon signed-rank, compares the pre/postoperative value within each group

Table 5.

Preoperative and postoperative imaging parameters of retear group (n = 13) and of intact group (n = 17)

	Preoperative			Postoperative			p valueb
	Retear	Intact	p valuea	Retear	Intact	p valuea	Retear	Intact
Fatty infiltration
Subscapularis	0.8 ± 0.7	0.7 ± 0.7	0.837	1.0 ± 0.7	0.7 ± 0.7	0.373	0.083	1.000
Supraspinatus	2.6 ± 0.7	2.6 ± 0.6	0.934	2.6 ± 0.7	2.4 ± 0.7	0.467	1.000	0.329
Infraspinatus	2.1 ± 0.9	2.1 ± 0.9	0.967	2.2 ± 1.0	2.0 ± 0.8	0.809	0.655	0.579
AHD (mm)	4.6 ± 2.1	7.9 ± 2.0	< 0.001*	5.2 ± 1.6	8.1 ± 1.7	< 0.001*	0.116	0.381

The values are reported as mean and standard deviation

Fatty infiltration Goutallier grading, AHD acromio-humeral distance

*Significant level = p < 0.05

^aTest used = Mann–Whitney test

^bTest used = Wilcoxon signed-rank, compares the pre/postoperative value within each group

Deltoid tear/change of deltoid

One 54-year-old female presented with shoulder weakness two months after undergoing arthroscopic rotator cuff repair at outside hospital. MRI study revealed large-size (33 mm in AP dimension) retear of rotator cuff with detachment of deltoid. After revision repair of rotator cuff and deltoid, the patient recovered full active range of motion. Although the patient showed failure of rotator cuff healing on postoperative MRI, the size of defect decreased (19 mm in AP dimension) and origin of deltoid was intact (Fig. 3). Four patients with retear of rotator cuff showed less than 50% thinning of deltoid origin on postoperative MRI (Fig. 4). These patients all had full range of forward elevation, and had no deltoid weakness.

Fig. 3.

A 54-year-old female who presented with retear of rotator cuff and deltoid dehiscence. a Prior to the revision surgery. b 1 year after revision ORCR and deltoid repair. Rotator cuff failed to heal, but deltoid healed

Fig. 4.

Deltoid thinning as seen on MRI in a 63-year-old female patient. a Before revision. b 1 year after revision ORCR. Note the thinning of deltoid, but origin still attached to the acromion

Discussion

The most important finding of the current study is that after revision ORCR, the patients had improvement of functional outcome regardless of the cuff healing, although those who had intact repair fared better. The postoperative MRI showed retear rate of 43% and decrease in tendon defect size. Contrary to the general concerns about the deltoid injury, only 13% of patients (4/30) who had retear showed thinning of deltoid, which had no effect on deltoid strength. AHD was higher for the intact group in both pre- and post-operative measurements.

Despite the remarkable advances in rotator cuff surgery, failed rotator cuff repairs are inevitable and expected to increase following the rising incidence of surgeries. These group of patients are obviously difficult to manage. First, the tissue condition is poor and fragile, and the severe contracture and adhesion between capsule, acromion and deltoid fascia with rotator cuff make it difficult to understand the anatomy [6]. The previous suture anchors may hinder the ideal reattachment of the tendon to the tuberosity. The bone may be porotic, increasing the risk of anchor pull-out. These difficult situations complicate the repair and thus make outcome of revision surgery inferior to that of the primary surgery. Therefore, the treating surgeon should understand the expected outcome of revision surgery before making the decision.

In the earlier studies on attempt to repair the failed tendons in open approach, the results were unfavorable. In 1984, DeOrio and Cofield [3] reported on 27 patients who underwent a revision open repair of failed rotator cuff repair. At a mean follow-up time of 46 months, 63% of patients continued to complain of moderate to severe pain, and 58% of patients had a poor result. Djurasovic et al. [4] reported on 80 patients who underwent a revision ORCR. Although improvement in pain was seen in 86% of patients, 31% of patients continued to have significant deficits in strength and function, leading to a poor result. Since the first report of all-arthroscopic revision rotator cuff repair [13], recent literatures have shown the favorable outcome of all-arthroscopic technique, making it popular choice for many surgeons [14–17].

We have used open approach for all patients who presented with failed cuff surgery, and the results suggest that revision ORCR can provide reliable outcome in terms of both shoulder pain relief and functional improvement. Open repair still has an important role in revision surgeries from our experience. Using multiple tagging sutures and the tactile feedback of which arthroscopic surgery cannot fully replicate can help release the adhesion and understand the tear configuration better. Also, trans-osseous suture technique can be particularly useful when suture anchor insertion is limited due to crowding of the anchors from previous surgery and porosity of tuberosity bone bed is present. Its cost-effectiveness compared to using multiple anchors is another advantage of this technique [18].

Although legitimate concerns exist over the deltoid injury caused by open approach, our series showed that all patients showed reliable healing of deltoid with good muscle power when following a standardized technique. When there is dehiscence or tear of deltoid from previous surgery, open approach is the only way to address the issue. Arthroscopic rotator cuff surgery in complicated cases may not be innocuous regarding the preservation of deltoid. Cho et al. compared alterations of deltoid muscle after open and arthroscopic RCR in large to massive tears [19]. ARCR cohort showed similar rate of partial detachment, attenuation or atrophy of deltoid muscle as ORCR cohort.

There are only a few studies that evaluated the rotator cuff repair integrity after revision surgery. Keener et al. showed that eleven patients out of nineteen patients (52%) had defect of revision arthroscopic rotator cuff repair as assessed by ultrasonography [14]. Shamsudin et al. reported that revision arthroscopic RCR cohort had retear rate of 40% at 2 years follow-up [5]. To the best of our knowledge, the current study is the first study that described the postoperative MRI evaluation of revision ORCR, showing similar rate of healing failure (43%).

The patients with retear after revision ORCR in our series showed inferior clinical outcomes when compared to the intact repair group. The reason why the retear group still had clinical improvement even after healing failure is unclear. The retear group showed decrease in the mean defect size after revision surgery, which may explain the clinical improvement. Also, adhesiolysis and subacromial decompression along with postoperative rehabilitation could be the contributing factor.

One remarkable factor that the intact group had was significantly higher AHD both pre- and postoperatively when compared with the retear group. Increased preoperative AHD (7 mm or more) has been reported as positive predictive factor in revision ORCR [20]. One possible explanation is that patients who had higher AHD before revision surgery had better humeral head compression of remaining cuff, and that could have affected the tendon healing.

The current study is not without limitations. First, there are possible bias inherent to the retrospective design of the study. Second, the number of study population was small, preventing it from having a powerful subgroup analysis. Third, we did not have a control group with revision arthroscopic RCR, although it is beyond the scope of this study to compare the outcome of two different procedures. Lastly, the study includes wide range of follow-up period which may affect the outcome analysis. We are presently following up on the cohort and would present the long term follow-up results in the future.

The strength of this study includes the advanced imaging of revision ORCR previously unavailable in the literature that revealed a healing rate comparable to the historical revision ARCR and a small portion of deltoid alteration that may have been overly suspected. Also, clinical assessment of patient’s muscle strength was available to corroborate that deltoid function was intact after surgery. Preoperative AHD may be a predictive factor for success of healing after revision ORCR.

Conclusion

In our series, revision ORCR was safe and effective treatment for failed rotator cuff surgery at a minimum 2-year follow-up. After revision ORCR, there was a significant improvement of pain VAS and functional scores regardless of tendon healing. Contrary to previous concerns about the vulnerability of tendon healing and deltoid integrity after revision ORCR, postoperative MRI study showed the comparable tendon healing rate to that of historical arthroscopic studies and small rate of thinning of deltoid which had no effect in deltoid function.

Funding

None.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

IRB/Ethical committee approval

AMC IRB 2017-1097.

Informed consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.