Failure to Heal After Rotator Cuff SurgeryAustrian surgeons lend their expertise to the question of why there is such a high failure rate after rotator cuff surgery. In an analysis of 95 patients over an 11 year period of time, they found an overall failure rate of 33 per cent. Most of those weren't really retears but rather a failure to heal. Their observations as reported in this article are very similar to what other surgeons are finding in other locations.
Each one of the patients in this study was treated with a mini-open arthroscopic repair. The torn tendon was cleaned up if the edges were ragged. Any other damage to the soft tissues around the shoulder were repaired. The tendon was then reattached using a transosseous technique. This method requires drilling holes (tunnels) through the bone and sutures attached to the torn tendon threaded through the tunnels to secure the tendon to the bone.
They were also followed closely with physician examinations and ultrasound images taken every three months for the first year. Pain, range-of-motion, strength, and function were also evaluated. They used the American Shoulder and Elbow Surgeons (ASES) and Constant scores to assess these results. They also took a look at recreational and sports activity levels.
Continued follow-up was done in the same way every year. In this way, the surgeons were able to see at what point a prognosis or prediction could be made about the final results. One MRI was done about five years after the surgery.
MRI results were compared with ultrasound images to confirm ultrasound findings. These imaging studies showed the presence of a tear, size, depth (partial- or full-thickness, and location). The authors report that ultrasound for evaluating rotator cuff repairs and tears is a very reliable tool.
Other than the reruptures, the only other complications or problems reported were a few cases of shoulder stiffness and impingement. One patient had a stroke affecting the involved arm but the stroke was not related to the shoulder surgery.
In addition to the high failure rate, the surgeons could see that patients with the larger tears were more likely to be in the rerupture group. And as expected, there was a direct relationship between retears and scores on the functional tests.
The question is raised: with continued high rates of retears, should rotator cuff repairs be done? The authors conclude Yes because the majority (two-thirds) of all patients have a successful repair. They get significant pain relief and return of motion, strength, and function.
For those patients who had a failed result, this study supports the idea that it's because the repair didn't heal. And those reruptures don't heal on their own. Small tears have a chance of self-healing but most retears tend to get larger over time. For patients who have a successful healing in the first six months, the long-term results are excellent.
In cases of retears that are asymptomatic (no pain or other symptoms), patients eventually start to lose strength. If the tears that develop in the first six months are less than two centimeters in size, the shoulder still functions fairly well. These patients report pain from time-to-time and loss of strength with shoulder abduction (moving the arm out to the side away from the body).
Patients with large tears (more than two centimeters in size) can expect persistent pain and loss of motion, strength, and function. Thus, the authors conclude the timing (early) and size of tear do predict final clinical outcomes. The task remains to find ways to perform the surgery so that everyone has an excellent result and retears are eliminated (or at least decreased considerably).
Rainer Kluger, MD,et al. Long-Term Survivorship of Rotator Cuff Repairs Using Ultrasound and Magnetic Resonance Imaging Analysis. In The American Journal of Sports Medicine. October 2011. Vol. 39. No. 10. Pp. 2071-2081.
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