Abstract
Aims
Multiple studies have shown excellent clinical results in primary rotator cuff repairs; however, not much evidence is available in the literature on the outcomes of arthroscopic revision rotator cuff repairs. The purpose of this study was to report a cohort of patients who underwent revision arthroscopic rotator cuff repair and identify factors that may influence its outcomes.
Methods
We examined a cohort of 62 patients which underwent revision arthroscopic rotator cuff repair in a single UK institution with a minimum of 24 months follow-up. Active shoulder movements including forward flexion, abduction and external rotation were evaluated, as well as Oxford Shoulder Score (OSS). Further subgroup analysis was performed looking of the effects of age, size of tear, obesity and diabetes mellitus had on clinical outcomes.
Results
59 patients were available for final review. 39 male and 23 were female. The mean age was 64 years. Overall, significant improvements were seen in terms of OSS (p < 0.05), active forward flexion (p < 0.05), active abduction (p < 0.05) and active external rotation (p < 0.05). Our study showed that a significant proportion of patients undergoing arthroscopic revision rotator cuff repair achieve good outcomes. Repairing small- and medium-size tears was successful, diabetics had no post-operative improvements, obese patients achieved significant improvement in range of movement and age was not a predictor of surgical success.
Conclusion
Overall, arthroscopic revision surgery is a successful option; however, appropriate patient selection and counselling is paramount.
Keywords: Revision, Arthroscopic, Rotator cuff, Diabetes, Obesity
Introduction
Multiple studies have shown excellent clinical results in primary rotator cuff repairs, though poor tendon healing and re-tear is not an uncommon complication that may lead to need for revision surgery. Recurrent tear or absence of healing has been associated with decreased function and strength of shoulder when compared to intact repairs [1–10]. Several factors can make revision cuff repair difficult. These include advanced tendon damage or degeneration, progressive rotator cuff muscle atrophy and fatty infiltration, capsular contracture and stiffness. Literature on the outcomes of arthroscopic revision cuff repair is very limited [11–16]. In addition, to our knowledge there has not been any studies evaluating the effect of diabetes and obesity on the outcome of this group. We aim to evaluate the clinical outcomes of a cohort of patients following revision surgery and identify possible factors that might compromise success of arthroscopic revision rotator cuff repair.
Materials and Methods
We conducted a retrospective analysis of a cohort of patients following revision arthroscopic rotator cuff repair. Institutional approval was obtained prior to the review of surgical logs at Royal Derby Hospital Trauma and Orthopaedics Department. Included subjects were those that underwent arthroscopic revision of rotator cuff tear with documented failure of healing or re-tear (as determined on the basis of ultrasound scan). All recurrent tears involved the posterior-superior part of the cuff (supraspinatus and infraspinatus tendon) with or without involvement of subscapularis. The primary indication for surgery was persistent shoulder pain and/or weakness despite a minimum of 6-month rehab following surgery.
Inclusion criteria were revision surgery done arthroscopically alone with minimum duration of follow-up of 24 months and pre-operative MRI confirming the quality of the rotator cuff muscles. Exclusion criteria were any non-arthroscopic repair, any graft augmentation, irreparable tears and those with significant rotator cuff muscle atrophy (Goutallier 3 and 4).
From January 2011 to May 2015, a total of 86 patients who underwent revision arthroscopic cuff repair were identified and 62 met all of the inclusion criteria, 59 patients were available for final review. The medical notes of all patients were reviewed to collect relevant information related to previous treatment and clinical presentation.
The cohort consisted of 23 females and 39 males with a mean age of 64 (SD 8.1) (range, 48–83). 51 patients had one previous rotator cuff repair in the same shoulder, 6 had two previous repairs and 2 had three previous repairs.
The previous operations included repairs isolated to the supraspinatus and infraspinatus or subscapularis tendon.
54 patients had undergone previous primary rotator cuff repair. 6 patients had 2 previous rotator cuff repairs and finally 2 patients had 3 previous rotator cuff repairs.
Clinical presentation of the patients was variable. Subjects experienced persistent or increasing shoulder pain and limited function following surgery. The median duration of time from the most recent previous failed rotator cuff repair to revision was 26.8 months (SD 26.3) (range, 3–52). 5 early failures (< 6 months) were identified with age ranging 62–76. One was a traumatic re-tear, one due to suture pullout and 3 were the result of cuff failure.
Recurrent tears were classified according to which tendons were involved (under USS confirmation and intra-operative findings). 54 patients had an isolated supraspinatus tendon tear, 3 had a combined supraspinatus and infraspinatus tendon tear, and 2 patients had a combined supraspinatus and subscapularis tendon tear. Quality of the rotator cuff muscles was assessed with MRI scan prior to further surgical intervention.
Clinical Evaluation
All patients completed a questionnaire that included the Oxford Shoulder Score (OSS) at the time of presentation, prior to operation and postoperatively. Preoperatively and postoperatively the patients were clinically evaluated, examination included measurement of active range of movement of the shoulder including active forward flexion (FF), abduction (Abd) and external rotation (ER). Internal rotation was not included in the study due to the variability of the assessment method.
Surgical Technique
The tears were repaired arthroscopically using either direct tendon-to-bone double row approach or single row margin convergence technique and performed by one of 4 consultant orthopaedic surgeons. The treating surgeon selected the repair technique based to the cuff tear shape and quality of tissue.
All procedures were performed using a local anaesthetic block with the patient in a beach chair position. The following surgical information was recorded: size of rotator cuff tear and number of anchors needed for repair. Acromioclavicular joint (ACJ) excision during the procedure was also noted. This intervention is indicated in patients that exhibit ACJ arthritis, which may be an additional source of shoulder pain.
Postoperative Rehabilitation
In all patients, the rehabilitation protocol consisted of—from day one all shoulders were immobilised in a polysling (without waistband) ± abduction wedge to be worn day and night. The sling could be removed for self-care and for exercising. Exercises included pendular shoulder exercises; elbow, wrist and hand active exercises; passive shoulder abduction and flexion. All shoulders were immobilized in a sling for a period of 4–6 weeks. At 4–6 weeks, patients were weaned off the sling/wedge and progressed to assisted, then full active movement within pain limits. At 6 weeks isometric exercises for all muscle groups could be started. At 8 weeks resisted exercises through range was commenced within limits of pain. Return to work varied depending on job—office jobs approximately 4–6 weeks, manual/physical jobs approximately 3 months. Return to sport at 3 months (non-contact) or 6 months (contact).
Statistical Analysis
Statistical analysis was performed using SPSS 22 for windows (IBM Corp). Pre- and postoperative score and range of movements were analysed as paired data. The datasets were tested for normality using the Shapiro–Wilk test confirming they were not normally distributed and were therefore analysed using non-parametric tests (i.e. Wilcoxon signed-rank test) using a significance level of p < 0.05.
Results
59 out of the 62 patients had complete postoperative clinical follow-up at a minimum of 24 months after surgery. The average duration of follow-up was 28 months (range, 12–36). The median duration of time from the most recent previous failed rotator cuff repair to revision was 26.8 months (range, 3–52 months).
| The cohort consisted of: | ||||||
| DM | 8 | Non-DM | 51 | |||
| BMI > 30 | 25 | BMI < 30 | 34 | |||
| Mean BMI | 29.8 | (Range, 23–50) | ||||
| Tear size | Small and medium | 26 | Large | 29 | Massive | 4 |
| Mean tear size | 2.5 cm | (Range, 0.9–5 cm) | ||||
| Location of tear |
54 3 2 |
Supraspinatus Supraspinatus and infraspinatus Supraspinatus and subscapularis |
||||
| At 24 months follow-up | 25 | Discharged | ||||
| 37 |
15 open revision—FAILED REPAIR 5 reverse shoulder arthroplasty—FAILED REPAIR |
|||||
| 14 | 14 with residual pain requiring further physiotherapy—No re-tear on USS | |||||
| 3 | 3 lost to follow-up | |||||
Functional Results
Comparison was made between preoperative and postoperative functional outcomes for the 59 subjects. Significant improvement following revision rotator cuff repair were noted in terms of Oxford Shoulder Score (p < 0.033), active abduction (p < 0.016). Active forward flexion (p = 0.115) and active external rotation (p = 0.935) did not show statistically significant improvements. Complete preoperative and postoperative functional data are provided on Table 1.
Table 1.
Preoperative and postoperative Oxford Shoulder Score (OSS) and clinical evaluation
| All patients (59) | Preoperative | Postoperative |
|---|---|---|
| OSS | 38.5 ± 8.3 |
30.8 ± 11.9 (p = 0.033) |
| FF | 104.3 ± 45.1 |
122 ± 50.1 (p = 0.115) |
| Abd | 94.6 ± 46.6 |
118.3 ± 50.1 (p = 0.016) |
| ER | 44.2 ± 16.3 |
48 ± 20.8 (p = 0.935) |
Final functional results for the 59 subjects with complete preoperative and postoperative clinical data were compared between shoulders with small, medium, large and massive tears (Table 2).
Table 2.
Preoperative and postoperative OSS and clinical evaluation of small and medium, large and massive size tears
| Small and medium tears (n = 26) | Large tears (n = 29) | Massive tears (n = 4) | ||||
|---|---|---|---|---|---|---|
| Preop | Postop | Preop | Postop | Preop | Postop | |
| OSS | 38.7 ± 7.26 |
32.5 ± 12.42 (p = 0.238) |
38.8 +—9.95 |
30 ± 11.6 (p = 0.161) |
37.5 | 27.6 |
| FF | 99.2 ± 40.9 |
128.6 ± 41.9 (p = 0.056) |
118.2 ± 46.8 |
117.5 ± 52.2 (p = 0.912) |
110 | 110 |
| Abd | 95.6 ± 45.2 |
122.4 ± 40.9 (p = 0.05) |
104.2 ± 49.45 |
117 ± 53.9 (p = 0.284) |
88.3 | 110 |
| ER | 42.2 ± 12.6 |
53.8 ± 17.6 (p = 0.075) |
46.9 ± 21.8 |
45.9 ± 22.4 (p = 0.696) |
47.5 | 45 |
Final functional results were compared between patients with BMI > 30 and those with BMI < 30 (Table 3).
Table 3.
Preoperative and postoperative OSS and clinical evaluation of obese and non-obese patients
| Non-obese (n = 34) | Obese (n = 25) | |||
|---|---|---|---|---|
| Preop | Postop | Preop | Postop | |
| OSS | 36.47 ± 7.5 |
29.87 ± 13.5 (p = 0.690) |
37.47 ± 8.7 |
34.79 ± 12.6 (p = 0.134) |
| FF | 118.1 ± 44.2 |
116.9 ± 45.8 (p = 0.939) |
85.3 ± 40.2 |
116.8 ± 56.5 (p = 0.021) |
| Abd | 108.9 ± 44.6 |
115 ± 47.9 (p = 0.383) |
79.5 ± 42.9 |
113.2 ± 55.1 (p = 0.014) |
| ER | 45.6 ± 19.6 |
46.5 ± 23.3 (p = 0.690) |
41.5 ± 7.5 |
49.6 ± 18.6 (p = 0.394) |
Final functional results were compared between patients with diabetes and non-diabetic (Table 4).
Table 4.
Preoperative and postoperative OSS and clinical evaluation of non-diabetics and non-diabetics
| Non-diabetic (n = 51) | Diabetic (n = 8) | |||
|---|---|---|---|---|
| Preop | Postop | Preop | Postop | |
| OSS | 38.3 ± 8.1 |
31.4 ± 13.6 (p = 0.019) |
38.2 ± 6.6 |
34.6 ± 14.8 (p = 0.753) |
| FF | 106.7 ± 44.2 |
129.2 ± 48 (p = 0.022) |
81.4 ± 35.3 |
78.5 ± 45.98 (p = 0.038) |
| Abd | 98.7 ± 44.3 |
126.7 ± 47.9 (p = 0.041) |
86.4 ± 44.6 |
78.6 ± 45.9 (p = 0.462) |
| ER | 45.8 ± 16.5 |
51.3 ± 22.1 (p = 0.056) |
38 ± 19.2 |
30 ± 21.2 (p = 0.432) |
Final functional results were compared between patients under 65 and over 65 years of age (Table 5).
Table 5.
Preoperative and postoperative OSS and clinical evaluation of under and above 65 years
| Under 65 (n = 29) | Over 65 (n = 30) | |||
|---|---|---|---|---|
| Pre | Post | Pre | Post | |
| OSS | 38.6 ± 6.8 |
33.0 ± 13.9 (p = 0.05) |
36.5 ± 8.8 |
33.1 ± 11.1 (p = 0.52) |
| FF | 90.9 ± 47.2 |
115.6 ± 50.6 (p = 0.176) |
117.1 ± 30.7 |
126.5 ± 51.5 (p = 0.110) |
| Abd | 85.9 ± 51.5 |
112.8 ± 47.7 (p = 0.116) |
104.3 ± 39.9 |
121.9 ± 48.7 (p = 0.052) |
| ER | 40 ± 11.5 |
48.6 ± 22.5 (p = 0.2) |
48.8 ± 16.6 |
47.6 ± 19.7 (p = 0.753) |
Final functional results were compared between patients having one, two or three previous repairs (Table 6).
Table 6.
Preoperative and postoperative OSS and clinical evaluation of one, two and three repairs
| One repair (n = 51) | Two repairs (n = 6) | Three repairs (n = 2) | ||||
|---|---|---|---|---|---|---|
| Preop | Postop | Preop | Postop | Preop | Postop | |
| OSS | 38.7 ± 8.51 |
31 ± 10.01 (p = 0.0001) |
33 | 33.2 | 37.5 | 19.5 |
| FF | 102.4 ± 43.57 |
120.3 ± 45.26 (p = 0.006) |
140 | 122.5 | 90 | 160 |
| Abd | 91.9 ± 43.5 |
115.9 ± 46.8 (p = 0.0085) |
140 | 125 | 80 | 160 |
| ER | 45.2 ± 15.8 |
47.9 ± 20.59 (p = 0.163) |
45 | 48.3 | 27.5 | 50 |
Two patients who underwent multiple attempts at repair (i.e. three attempts) showed good clinical improvement in terms of OSS (37.5–19.5), FF (90–160), Abd (80–160) and ER (27.5–50) (Table 6). This, however, was not statistically significant due to the small number of patients in this group. Both patients were young (28 and 46), one had a 2 cm tear and the other had a 3.5 cm tear, respectively. None were diabetic and with both had good quality cuff tissue found intraoperatively.
Discussion
Limited information regarding outcome of arthroscopic revision rotator cuff repairs exists, most literature focuses primarily on the outcome of open repairs. These studies demonstrate good pain relief but less improvement in the function of the shoulder [11–13]. Very little has described on the influence that co-morbidities (i.e. diabetes mellitus, obesity), age, size of tear, number of tendons torn and the number of previous repairs have on clinical outcome of revision surgery. Djurasovic et al. reported reliable pain relief following open surgery, this is to date the largest series of revision surgery report. In this study 69% of the 80 subjects had satisfactory outcome according to the modified Neer score. Authors identified several factors that had significant impact on the clinical results, this included an intact deltoid origin, good-quality rotator cuff tissue, pre-surgical active elevation of at least 90, and no more than one previous attempted rotator cuff repair [11].
Lo and Burkhart reported the clinical results of arthroscopic revision rotator cuff repair in a study of 14 patients, twelve of whom had large or massive tears. 9 patients had a good or excellent outcome according to the modified University of California at Los Angeles scale, and improvements were noted in terms of pain and shoulder range of motion. Interestingly, clinical failures in those previous studies were largely attributed to pre-existing deltoid injury or poor-quality rotator cuff tissue rather than to suspicion of a recurrent rotator cuff tear [14]. Our study shows that overall revision arthroscopic cuff repair can provide good improvement in terms of shoulder pain and function in selected cases, diabetics and those with large and massive tears show poor clinical outcomes following revision rotator cuff repair. Difficulties arise when attempting to compare results to other previous studies due to the differences in patient selection and the measured outcomes used.
Overall, 40% of the surgical repairs at a minimum of 2 years after revision were asymptomatic and with good function. Given the fact that these shoulders already had a failure of at least one previous attempted rotator cuff repair, it seems intuitive that postoperative outcome would be less positive than that following a primary repair.
In our study, factors that correlated with good outcome included the absence of diabetes and the size of the tendon tear. It is well recognised that rotator cuff size has a strong influence on the rate of tendon healing following surgical repair [2, 6, 7, 10, 16–19].
Age and number of tendons torn have consistently been shown to have a strong association with tendon healing in studies of primary cuff repair [1, 2, 4]. In the present study, age and number of tendons torn did not seem to be a predictor of surgical success. Repair of small and medium size tears had positive outcomes and repair of large and massive size tears showed improvements in OSS.
The strengths of the present study include the use of standardised and validated outcome tools for the assessment of shoulder movement and function. The study group was novel and represents an important cohort of patients to whom minimal research has been directed.
In conclusion, a significant proportion of patients undergoing revision rotator cuff repair with an arthroscopic technique achieve good clinical outcomes. Age was not a predictor of surgical success. Obese patients achieved significant improvements in range of movement but not in OSS, while diabetic patients did not experience any significant post-surgical clinical improvement. Repairing small and medium sized recurrent tears was a successful option; even repairs of large and massive tears improved OSS. Finally, multiple previous surgeries do not preclude successful arthroscopic revision.
Funding
There is no funding source.
Declarations
Conflict of interest
The authors declare that they have no conflict of interest.
Ethical standard statement
This article does not contain any studies with human participants or animals performed by any of the authors.
Informed consent
For this type of study, informed consent is not required.
Footnotes
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