I'm going to speak about revision rotator cuff repair, bone and soft tissue considerations. These are my disclosures. A failed rotator cuff repair can be challenging to treat, not only for your patient, but for the patient referred to you. Failed repair can mean many things and what defines a failed repair and how do we best help the patient? Failure can be defined in categories, diagnostic errors, technical errors, complications related to the surgical intervention, or failure to heal. And failure is actually often multifactorial. Failure can result from an incorrect diagnosis, such as cervical radiculopathy, adhesive capsulitis, or even suprascapular neuropathy, or an incomplete diagnosis, concurrent biceps pathology, glenohumeral joint arthritis, or symptomatic AC joint, for example. Technical errors are certainly also a possibility, inadequate mobilization of the rotator cuff tissue, repairing the tendon tear in a high-tension environment, or poor fixation, either through the use of improper suture anchor placement or inadequate suture passage and tying. Complications can also result from postoperative infection, deltoid detachment, stiffness, or even neurologic injury, although thankfully it's uncommon. Failure to heal, however, is usually an intrinsic problem due to poor vascularity, quality of the rotator cuff tissue, or bone quality. Advanced age, larger tears that are more than two tendons, and fatty degeneration, along with diabetes and smoking, have all been statistically associated with decreased healing rates in rotator cuff repair. Revision of these failed rotator cuff tears requires a number of important keys, including proper indications, thorough evaluation required to identify the proper candidates. That includes review of medical records, a detailed history and physical examination, and the liberal use of advanced imaging. Also, these revision surgeries can be arthroscopically challenging to perform. The literature for revision rotator cuff repair includes a number of studies, such as Kienert et al.'s JBJS study in 2010 that reviewed 21 patients after an arthroscopic revision rotator cuff repair, and at 33 months follow-up, significant improvements were seen in a variety of parameters. Likewise, in the same year, Piasecki et al. reported on 54 patients after arthroscopic revision rotator cuff repair, and again, significantly improved outcomes postoperatively. They also found that if the patient had had more than one prior shoulder surgery, they had an increased chance of failure postoperatively. In this study from 2018, in 31 patients with a follow-up of 50 months, revision rotator cuff repair, again, significantly improved clinical outcomes. The MRI retear rate was 55%, but again, there was very little difference in outcomes, whether or not the rotator cuff healed in this revision setting. So here are seven things that I try to do in revision rotator cuff repair. First is correct motion loss, to breathe the shoulder thoroughly, identify rotator cuff tissue and mobilize it as necessary, medialize the footprint as helpful and utilize the biceps as a graft when indicated, also use supplemental patches and grafts as necessary, and address concomitant pathology in this revision setting. First, correct the motion loss. Stiffness is very common in revision rotator cuff repair. Encapsular releases improve rotator cuff mobility and can lower the humeral head in certain situations. Motion loss can be caused by cuff scarring to the acromion and coracoid, and notice the significant adhesions in this failed revision rotator cuff repair procedure. Dense adhesions must sometimes be removed, and even finding the margin between the rotator cuff tissue and the bony structures is sometimes necessary, as shown here. Second, to breathe the shoulder thoroughly, adequate visualization is required so we can assess the rotator cuff, establish tear pattern constructs, and identify all of the cuff tissue, which can sometimes be a challenge. Excessive debridement also involves removal of residual sutures and additional adhesions. Number three, revision rotator cuff repair tissue can be retracted with poor quality and vascularity, and a low tension repair is critical. Notice here that this cuff appears to be absent, but we realize that the cuff is actually adhesed to the undersurface of the acromion. Identification of this cuff tissue is critical to helping us establish a repairable construct. Also, extensive mobilization allows us to maximize the footprint coverage of the tendon to the bone. Increased fixation security and medialization of the rotator cuff footprint as necessary can also be very valuable in an effort to achieve a successful outcome post-operatively. Notice here that significant mobilization and adhesion removal have allowed us to repair this cuff to a medialized footprint. More specifically, medialization of the footprint maximizes our footprint for healing and reduces tissue tension after repair. It can be commonly utilized in both index and revision repairs, and I personally use it as necessary to achieve a low tension repair. One can see here that approximately a centimeter of superior humeral head articular surface has been removed, allowing us to get a good re-approximation in a relatively low tension state of this tendon to a braided bone. Several articles, including this article from 2018, have demonstrated that medialization of the footprint is a valuable and effective technique. In their study of chronic retracted rotator cuff tears, 24 of their patients had medialization of the footprint versus 36 that did not. The healing per MRI post-operatively in these two groups showed significant differences with significantly increased healing in the medialized footprint group compared to the group that was not medialized. The biceps can sometimes be utilized as a graft as well, especially when there's inadequate or retracted tissue that's challenged to repair. Can the biceps tendon even be used to supplement or even serve as a superior capsule? Two biomechanical studies recently published have suggested this is a possibility. Both studies biomechanically restored shoulder stability after transfer or transposition of the biceps tendon, and they found that it was a biomechanical equivalent to a tensor fascia lata autograft in the prevention of superior humeral head migration. In this arthroscopy techniques article from 2018, the biceps was transferred to serve as a superior capsule reconstruction, and there are a number of techniques prescribed. In this example, we can even see that the humeral head was lowered in patients that have undergone this procedure. This is an example of how the biceps might be used. The biceps has been mobilized from the bicipital groove and can be transferred to serve in the role as a potential superior capsule. After mobilization of this very retracted rotator cuff tendon tear, one can see that suture has been passed around the biceps, and then the biceps can be transposed to this more superior position on the humeral head. Rotator cuff repair can be performed as per usual, but the biceps can also serve as a post for re-approximation repair of the rotator cuff and can help support and help improve stability of the rotator cuff repair construct as shown here. Patches and grafts can likewise be used, and bioinductive type patches may improve healing. They're used more commonly in revision rotator cuff repairs, but indications seem to be expanding. Some early evidence suggests that it may improve healing, but no long-term data is present. They're very easy to apply, but they are expensive. In this study, utilizing bioinductive collagen patches and 16 large and massive revision rotator cuff repairs, 15 of 16 were noted to be healed by either MRI or ultrasound, and there were no adverse events or implant complications related to its implementation. These patches or grafts can be used to prepare for superior capsule reconstructed and selected revision rotator cuff repair cases. Usually an ASAIL or dermal allograft or other graft can be used using techniques that we're familiar with. Indications may be expanding, though in this case, bottom right, we can see that the rotator cuff in revision setting is still repairable and is placed over a superior capsule reconstruction graft and incorporated and tied to that graft on top. Lastly, we want to make sure we address all pain generators in this revision setting. The biceps is a common cause of pain, and one should have a low threshold for release of the biceps, either through tenodesis or tenotomy. Likewise, if the distal clavicle had not been resected at the index operation, one should consider removing it in case it serves as a pain generator as well. In summary, rotator cuff failure is due to a number of causes, and often multiple factors contribute to failure. In revision rotator cuff repair, appropriate indications are the key to success, and that requires thorough preoperative assessment and intraoperative evaluation. The technique can be challenging, including the necessity often for capsule release, extensive rotator cuff debridement immobilization, and occasionally medialization or even the use of supplemental grafts, including the biceps, to achieve a secure repair. But given these criteria of being met, successful revision rotator cuff repair is likely. Thank you very much.

revision rotator cuff repair

diagnostic errors

technical errors

healing complications

surgical techniques