indications for and expectations after revision arthroscopic surgery

There are a number reasons why you may still have pain after rotator cuff surgery. In most cases it may bother mainly at the extremes of motion--ie overhead---and you may elect to live with it. If, however, you cannot live with the pain, or have weakness, you may be a candidate for another procedure.

I generally feel that there are few contraindications to taking a look inside again--especially if you have been compliant with therapy, and do not wish to live with the pain so long as you understand that --it is difficult to guarantee success, and that it is unlikely that a second attempt at improving things with arthroscopic techniques will make you worse.

If you did not originally need a repair of a torn cuff tendon, scar tissue may have built up, which may cause impingement. This can be removed. A partial tear of the cuff may be causing pain and require conversion to a full thickness tear with repair. A small full thickness tear that was only debrided may require repair. A repaired tendon may not have healed, or you may have sustained a retear. Your long head biceps tendon may be the cause of pain, and require tentomy or tenodesis. Your AC joint might be causing the pain, in which case a distal clavicle resection can be performed. Bottom line, you may have everything to gain, and nothing to lose--understanding, ofcourse, that we do not want to be cavalier about a second operation.

In the March 2010 issue of the Journal of Bone and Joint Surgery (JBJS 2010; 92:590-598), Ken Yamaguchi and his co-authors from Washington University address this very question. I have attached the article below. They found that re-repair results in reliable pain relief and improvement in function in selected cases. Only half of the revision repairs were intact at 1 year follow-up, and patient age and the number of torn tendons were related to postoperative tendon integrity. Seventy percent of single tendon tears healed; results declined when both the supraspinatus and infraspinatus tendons were torn. They also noted that postoperative abduction strength and functional scores were better when tendon healing actually occurred--which is not surprising. The study was not designed to identify a particular age after which tendon healing is less likely, but it is well known that advanced age is a risk factor for poorer healing---probably more due to the status of the tendon that anything else.

Other factors that may impact on re-repair success include what your x-ray looks like ( is your humeral head [the ball] centered on the glenoid [socket] or superiorly translated? Is there arthritis?), the health of your rotator cuff muscle (is there fatty infiltration or atrophy on MRI?). A retracted tendon may not be fixable, or there may be too much tension on the repair. When the muscle has atrophied, the functional results following repair decline. And if the ball has migrated superiorly, the kinematics of the shoulder may not be restorable enough to "protect" a repair.


Obviously what one wants to avoid is a revision cuff repair that is not going to work. By the same token, if a revision repair is likely to be successful---that is far better than living with pain or having a salvage procedure like a joint replacement--since the latter will require activity limitation down the road, in comparison. The most appropriate treatment strategy will depend, in summary, on a number of factors including age, activity expectations, range of motion and strength, the x-ray, and the status of your cuff muscle.


At the very least, revision surgery will bring closure to things if we do everything possible and help, or find little to explain your discomfort and let you know that you may need to live with it the way it is. If you would like to have me evaluate your painful shoulder, please try to bring copies of your previous operative reports with you when you come for your appointment.

 

1 comment

mtomaino    4/10/11 at 12:38 pm

This past week I performed a revision arthroscopy on a patient who had undergone 2 previous surgeries--the 1st was an arthroscopic repair a partial tear, and the 2nd, because of ongoing pain, was a mini-open "side to side" repair of the supraspinatus tendon. He had ongoing pain, however, and because he had good pain relief after I injected some lidocaine into his subacromial space, I thought that there may still be unaddressed pathology. This patient ended up having a high grade tear and tendinopathic tendon which I debrided to a full thickness defect and then repaired securely to bone. I have attached the intraoperative videos.

This patient provides a great example of the potential value in electing to have a revision arthroscopy in the event that a thorough assessment of the previous operative records and current physical exam indicate that sosmething more can be done to help, as opposed to telling someone that they need to live with th pain.

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