What should I consider for a failed rotator cuff repair?

Q: I had a rotator cuff repair surgery six months ago that failed. The surgeon wants to redo it.  What sorts of things should I consider?

A: Surgeons everywhere are grappling with the fact that rotator cuff repairs aren't always successful. There are many different reasons why this may happen. Let's take a look at causes of failure from both the patient and surgeon side of the equation. That might help you review your own case, ask appropriate questions, and make an informed decision.

The two top factors that put patients at increased risk of rotator cuff repair failure are age and tear size. Increasing age starting at age 55 has been shown to be a key factor in repair re-tears. Studies show that the rate of healing in patients younger than 55 years of age is around 95 per cent. This declines to 75 per cent for patients between the ages of 55 and 64. The rate of healing takes another nose dive down to 43 per cent in patients 65 and older.

Tear size can also be matched with risk of retear centimeter by centimeter. For example, for every one centimeter increase in tear size, the risk of rotator cuff failure goes up more than two times. With more than one tendon involved, the risk of retear increases nine times.

Other patient-related factors include poor quality of tendon or muscle, smoking, and the patient's overall health. Patients with chronic systemic conditions like rheumatoid arthritis, heart disease, or diabetes are more likely to experience re-tear after rotator cuff repair.

The role of the surgeon in rotator cuff success is important, too. Low volume (i.e., the surgeon doesn't do very many of these procedures) has been linked with a higher failure rate. Studies place the number performed to qualify for low volume as fewer than three rotator cuff repairs per months. High volume (the surgeon performs more than three rotator cuff tear repairs each month) increases the likelihood of a good result.

Surgical technique is also important. The surgeon must accurately assess each patient for the best repair approach. The technique selected depends on whether the repair is for a single tendon (versus multiple tendons), full-thickness versus partial-thickness tears, and tear pattern. Tear pattern refers to the shape of the tear (U-shaped or L-shaped).

Revision surgery is only needed when the patient continues to have chronic pain months to years after the original surgery and the problem has been diagnosed as rotator cuff repair failure. All efforts to treat the problem conservatively (without surgery) have failed to change the picture for the patient. And (very importantly), the patient does not have multiple risk factors for failure.

The presence of pain and loss of motion doesn't always signal a failed surgery. There could be some other complication such as infection or systemic disease referring pain to the shoulder. A careful evaluation is needed to sort out the cause of shoulder pain and need for further surgery. The surgeon performs various clinical tests, orders imaging studies, and considers the need for electrodiagnostic testing.

If you are certain the problem is a failed primary (first) surgery and you have gone through a conservative program of rehabilitation under the direction of a physiotherapist and you still have pain, loss of motion, and decreased function, then surgery to revise the failed repair is likely indicated.

The information here should help you consult with your surgeon before making a final decision. You are also free to seek a second opinion if you think that might help.

Reference: Patrick J. Denard, MD, and Stephen S. Burkhart, MD. Arthroscopic Revision Rotator Cuff Repair. In Journal of the American Academy of Orthopaedic Surgeons. November 2011. Vol. 19. No. 11. Pp. 657-666.