I just got a failing grade in life. I had arthroscopic shoulder surgery to fix a broken rotator cuff and it didn't take. The physician's assistant I saw today explained to me that this is a case of "failed rotator cuff syndrome." I was told all about the next surgery I can have to fix the first one. The question is: if it didn't work the first time, why would another surgery be any more successful?
Sometimes patients don't get the expected results after arthroscopic rotator cuff repair. Instead of pain relief, increased shoulder motion, and restored function, they experience persistent pain and/or weakness. There are usually good reasons why this happens.
For example, older adults (65 years old and older) are at risk for failure to heal due to poor nutrition, poor general health, or the presence of other compromising conditions such as heart disease, diabetes, or smoking. If the tear was very large in size, there was significant muscle atrophy (wasting), or a lot of tendon retraction (tendon pulls way back from the bone), the risk of failure goes up dramatically.
A few other factors that hinder healing after rotator cuff tear repair include an unwillingness on the part of the patient to engage in the rehab program. Failure to follow the physician's or physical therapist's guidelines during recovery can also be some patient's downfall.
Treatment for failed rotator cuff syndrome varies depending on the reason(s) why the surgery wasn't successful in the first place. It doesn't have to be another surgery. A six to 12 week trial of physical therapy aided by a home exercise program may be all that's needed. But if this measure fails to restore motion and strength, then revision surgery is one possibility.
Revision surgery begins with release of any soft tissue restrictions (scarring, adhesions). If possible, the retracted tendon is brought back to the bone where it was originally attached (a place on the bone called the footprint).
If there isn't enough "give" in the tendon, then it is pulled as close as possible and sutured (stitched) to nearby soft tissue. The surgeon must maintain a balance between tendon tension and tendon mobility. Creating a balanced shoulder is important (meaning the muscles all around the joint pull equally, evenly, and in a coordinated fashion to create movement.
In young, active patients with massive tears, it may not be possible to repair the rotator cuff. In those cases, a tendon transfer can be used to restore motion and function. The tendon harvested for use depends on the location and severity of the rotator cuff tear. For example, with damage to the supraspinatus and subscapularis (front of the shoulder), the tendon to the pectoralis major muscle is used. If the cuff is damaged more toward the back of the shoulder, then the latissimus dorsi tendon is harvested.
Very large tears with poor tendon healing in older adults may just require a shoulder replacement instead of a revision procedure. There are several options to choose from: a hemiarthroplasty, reverse total shoulder arthroplasty, or traditional total shoulder replacement. The hemiarthroplasty is a partial replacement (only half of the shoulder is replaced). A reverse replacement places the round head needed for motion where the shoulder socket used to be and the shoulder socket where the round head of the humerus (upper arm) is normally located.
So you see there are reasons for the failure that may or may not be overcome. Treatment to improve symptoms is still possible so don't give up just yet. Give yourself some time to explore all your options and find a pathway that best suits you in this situtation. And good luck!
Eric J. Strauss, MD, et al. Management of Failed Arthroscopic Rotator Cuff Repair. In Journal of the American Academy of Orthopaedic Surgeons. May 2012. Vol. 20. No. 5. Pp. 301-309.
*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.