The treatment of failed rotator cuff repairs

Results following surgical management of failed rotator cuff tears are clearly inferior to those obtained in the treatment of primary repairs. Conservative management may be the treatment of choice in selected patients with failed rotator cuff repairs. The primary goal for revision rotator cuff surgery should be relief of pain, not improvement in function. If the level of pain is manageable, and the patient is functioning with respect to activities of daily living, additional surgery may not be helpful. As there are multiple etiologies associated with failure of the initial repair, each patient should be carefully evaluated on an individual basis to determine if a subsequent procedure would be appropriate. Repeat repair is more likely to succeed in patients with an intact and functioning deltoid, an intact lateral portion of the acromion, and good quality of rotator cuff tissue. Conversely, patients who have had a lateral or radical acromionectomy, a detached or nonfunctioning deltoid, or poor quality of remaining rotator cuff tissue are less likely to have a successful result after repeat repair. It is evident that some of the factors associated with failure are avoidable. As the best chance for a successful result is at the time of the primary repair, the following points will briefly review these factors. The skin incision should be made in the flexion creases which are perpendicular to the deltoid fibers. The deltoid origin should be meticulously protected during the repair and lateral or radical acromionectomy should not be performed. Adequate anterior acromioplasty is essential for removal of the impingement lesion and to prevent subsequent wear on the repaired cuff tendon. The acromioclavicular joint should be evaluated preoperatively and treated as indicated at the time of the surgery. Adequate release of adhesions and mobilization of rotator cuff tissue should be performed using the coracohumeral ligament release and interval slide when necessary. The rotator cuff should be repaired to bone using tendon to bone sutures and/or secure suture anchors. In large and massive tears, there appears to be a role for the reattachment of the coracohumeral ligament. Early phase I range of motion should be initiated following rotator cuff repair and early resistance exercise with weights should be avoided.