earlier. So these are my conflicts. So you know most most of my practice is actually revision surgery. I don't get to do primaries anymore so this is some of it is just flat-out experience and different things we do. So if we're looking at a failed cuff and Nick showed you some incredible data that we really haven't gotten a whole lot better at getting these things to heal. I think we're doing better in terms of function. And so what's the most common cause of failure? So there's there's immediate failures that occur from trauma in the first early phase when the cuffs not healed. But it takes about 10 months for that supraspinatus to completely heal. So you're at risk for a long period of time. That being said the first 12 weeks are your most critical time. So you can have acute trauma, repetitive trauma, but most of the time it just doesn't heal. You're in a barren landscape for the most part with poor blood supply and that's all the elegant work that Gus is doing is trying to change those enthesiopathic changes and then figure out what to do. So when we're looking at it and trying to figure out why did this completely fail and what can we do about it, knee-jerk response is well we got to do something else. We have to do a reverse shoulder, we have to do a lower trap, we have to do an SCR, all these things. But pretty much maybe maybe we can still fix it if we think about some other things and this is this is what we're talking about. So so here you can see if this comes up this is a cluster of anchors. Now you might think well I don't do that but yet here's the edge of the articular surface. So if you put anchors here and then you put anchors here then you have with this big cystic area as they start to dissolve and they're going to move around on you. So then that's going to jeopardize your fixation. So when you're thinking about your primaries then that's one of the things you want to talk about. Exam wise you just want to make sure they're not stiff and you want to loosen it up. We like to do a lot of different testing really look at their scapula position. These folks are used to hiking their shoulders so you're starting behind the eight ball with abnormal movement and you want to check everything. And as Nick alluded to we don't really we can't talk the same language pseudo pseudo paralysis pseudo paresis. And so how do you make these decisions about what to do? Well we do imaging right so if there's residual tendon like you see here on the bottom one here and it's a type 2 failure that's a bit more difficult than a type 1 failure where it comes across. To me muscle atrophy is my big thing that we want to look at and then look at your bone framework. Did they not take out the distal clavicle? Did they leave a spur? Is there pressure on the suprascapular nerve down here? You can look at this thing's just flat as a pancake so there's a lot of different things that you want to look at if you have a fail cuff and you're thinking about going back in and trying to fix it. So preoperative decision-making first thing I look at is is there anything to repair? Did they have eight anchors in and it's all sutures and there's no tendon left or did the tendon just pop off the stitches and you still have residual slump of tendon? So sometimes the transfers are better one unless let's look at atrophy where you look at the supraspinatus with some fat inside of it the infraspinatus is almost all gone you've got teres minor hypertrophy but you got a great subscap. And so when you look at Guttier's classification for zero to four it's really not that helpful. It's really not. That was based on intramuscular fat in a French patient population where the tendon loss where the muscle lost all of its elasticity and ability to contract. That's not what we see in the US. It's not what most people see around the world. We see stuff more like this where you have the supraspinatus is atrophied you have some some fat in it a little bit in the subscap and so what we decided to do is we changed our Guttier classification because zero to four if it's 50-50 you can fix that all day long. Put it back and the patient's gonna do really well. So we added a five six and seven right so make it more complicated so five is up to 75% atrophy that would be this infraspinatus. So you have a little bit of muscle left here this is mostly fat it's atrophied and you got to make sure you go as far medial as possible because when you're looking at the muscle and you look at it more laterally of course it's retracted far away and you have a problem and then six seventy seventy-five to ninety percent atrophy you got to start thinking about that muscles not going to function. Can you still fix it? Yes you can. Will it get rid of pain down low? Yes it will but they're not going to use their arm up overhead. They're not going to do that and if they say I need to reach overhead and I want some strength sometimes you got to say not possible and sometimes you say well I can get this for you but you're not going to get that. So if it's an electrician and they want to go back to work and they're gonna have to get their arm up all the time and they've got 75 or 80 percent atrophy we can't get that back especially if it's a super smash we can't get back at all nothing's gonna give them that back and then 90 to 100 percent atrophy you're looking at replacements almost no matter what or maybe a parachute procedure or some other things so predictably this really helps me because if you walk in and I look at the MRI scan and the cuts are medial enough no matter what their exam is I'm still thinking I want to fix it. Can I fix it and if I fix it can I give that patient back what they want out of life and I don't know the answer that we'll talk about some other things so initial steps are releases releases releases I'll harp on this as much as possible I do a huge release inside these shoulders and I'll start inside because I know where the labrum is I release right outside the labrum I use the hook cautery because I like to be very precise but as you saw in some of the previous talks this cuff will scar back medially it's gonna scar to the acromion it'll scar to the scapular spine and the coracoid and so we'll take this and we'll go circumferentially 360 degrees and a word of caution when you look in there most of us look in and we see all this labral fraying and it's debris and you think I'm gonna clean all this up first that's a waste of your time that's the degenerative labrum it's going to generate by the time they get back to recovery room you've done nothing you just spent 15 minutes of really good operative time playing with something that's completely irrelevant so ignore it and get to the capsule release because that's what you want to do the bursal debridement you're gonna release under and over we usually take out most of the old stitches because the tendon pulls off the stitches but if there's some that are across it and still there we'll leave them and use them as a ripstop stitch but we're gonna release all of this and really try to to make sure that we can move tendon around and pull on it and do different things and just see that because you know you want to release the cortical ligament and so I'm going to play these both at the same time focus a little bit more on the right so here's a big tear not huge I wouldn't classify this massive I would put it as a large and if you look at the one on the right that's the base of the coracoid we've released all of that cortical ligament and what that does with our capsule release is lets the head come down if you don't release the infer capsule and you don't release the cortical ligament from outside the heads not coming down it's going to stay up and as soon as you start to move the arm guess what happens your whole cuff comes apart because the head is supposed to move down as you go into overhead movement and if it can't go down then it's not going to work out so you got to do this and check your mobility so all of the prep work takes forever and then Gus this is for you I do margin convergence all the time so you have a tear like this we'd all say that's a pretty big tear so attracted to the glenoid we've done our releases we've saved the biceps I know in France that's a heresy I do it all the time here and and I like to keep it and I'm gonna cross this and I use retrograde retrieving because I think that's a good way to do it a soft stitch that won't cut through the tendon because this especially the poster part of the cuff and we're gonna use the subscap Nick showed you an upper subscap tear if you do convergence this way you can go through an advisor portal superspace to subscap and put them together and then as we tie this this massive retracted tear that looked horrible on MRI scan with severe atrophy with one stitch is now back in place now you look at this one at the bottom we can all fix that that's a two centimeter tear that's right there at the edge of the articular cartilage so with one suture in an oblique fashion poster medial to enter lateral we've now made this huge tear that people are gonna look at and go it's irreparable into something that's really a chip shot to fix it's nice and easy and this takes tension off your repair so it's easy and if you want to do it with tape and then put it in a lateral row anchor I will submit to you that when we looked at our anchors for my massive tears I use 1.8 anchors 1.8 and these are all revisions these are all people that have we've taken out six anchors when we're doing it so the other thing to remember is that you can use the biceps so back with an advisor's taught us uses as a graft and so if you have it and you have a tear like this one way big tear around we'll just leave it attached to the glenoid take it out of the groove put it right on top and then so everything back to it it's an auto graft so it's more like me Otto's fascia you put it back together gives you a nice graphic covers everything it's an easy cheap way to do it you save the patient $10,000 that's not terrible and so it works out pretty well so if it's there you should use it and there's there's a lot of different ways to use it maybe we can talk about that in the discussion but putting it back together gives you better tissue so we have a lot of things the good Lord gave us around the shoulder to put back what about patches well I think the patch was a miracle Steve Arnosky came up with it does Bakker did it when they brought it over they were using it for partial tears I do not use it for partial tears I use it for my big tears work because to me this is a non structural patch cannot use it if you don't have tendon so if you can use this particular patch then you using it to improve circulation to the tendon and so if we put it on and we were very nice this meeting gave us an award a few years ago because we did we actually did 25 large massive almost all of them were revision cases and it added about a 10% success rate prior to this my healing with these were about 80 to 85 percent and it kicked it up 10 to the 95 percent range we ultrasound every one of our rotator cuffs for a year to see what's going on because it takes it that long to look normal but overall 10% increase in healing I'll take that all day long so if it's a little something that it can make things better then we do that and then Nick showed the spacer this is what it looks like I put it in from the back and I only use it and this is completely off-label I use it when I do a repair so I have a mod of four and five really superiorly migrated they're hitting on the head I find cuff I can fix I put it all back that's what you're seeing below it and then we expand the balloon word of caution if you have a surgery center and you do these at your surgery center you got to make sure the insurance is going to pay for it ahead of time this thing is very very expensive and so pre cert ahead make sure it's going to get paid for it because whether you own the surgery center or not you're not going to make enough money to pay for this thing now if it's a hospital I don't care I mean to be honest with you because they do all this billing stuff and they charge too much anyway so I don't care if they have to pay for it doesn't make any difference to me but remember that you want to put this back together the problem with the spacer is that it was originally designed for an isolated supraspinatus tear with intact anterior and posterior force couples with superior migration right that patient doesn't exist so the original indication doesn't happen you would put in one every four or five years I do 500 cuffs a year and I would never have an indication to use it by itself now on top of a repair with superior migration it pushes it down and it actually looks pretty good you have to have the CA arch intact so you cannot do a decompression if you're going to put the spacer in and you certainly cannot detach the CA ligament it's very very bad if that happens I won't tell you how I know that but I will tell you that if the balloon happens to come out to where you took the arch down and it's sitting on top you can puncture it with a needle and deflate it and get rid of that big bump that might happen this is what it looks like it's pretty incredible so this is we measure this as three millimeters and then we measure this one as 12 and that's with the spacer but that's with the repair and the capsule release and I was talking with Joe Boone about a year ago and he said sometimes these get really tight and I said once you release in for a capsule because you're pushing it down it's not tight if you release in for capsule because the head comes down anyway so remember you do this in combination not by itself and then Gus talked about the lower trap transfer I think Basim's a genius I've known him since he was in med school and I think this is an incredible thing the other part of it is that using Achilles allograft that Achilles is about a centimeter thick where it sits on top of the greater tuberosity so not only are you getting a little muscle pull from the from the lower trap you're also putting a giant spacer on top the greater tuberosity so probably better than a dermal allograft is an Achilles allograft on top is actually stuff that belongs there and then reverse shoulder of course and I'm not an anti reverse person I think it's a miracle for a true pseudo paralytic shoulder and an older patient that wants to function pretty well so our indication for reverses is always pain never function you get more function back if you can fix the cuff and if you can do a transfer but reverses get rid of pain they do wonderfully day-to-day activities they do great some of my unhappiest patients are folks that come in that had a reverse shoulder put in at age 48 or 50 because they supposedly had an irreparable tear especially if they're a gym rat and I like to go work out all the time and they go there and they find they cannot do a bench press because when they extend back it wants to subluxate on them and then they want to they want to change it and a reverse is actually an irreversible step that's that's a lifetime commitment to that operation and I don't I do probably one reverse shoulder revision a week now and mostly for instability infection some other things and I never walk out of a revision reverse shoulder thinking oh I did a great job I go I talked to the family I go well I think the hands still on and we'll see how they do because this is a miserable operation and it took too long and I don't know how they're gonna do so it's a tough thing you don't want to be in that position so a couple comments post-op rehab I like to use an abduction pillow I go as slow as possible you heard Nick say that these are mostly older patients they have poor quality tissue poor quality bone about 30 degrees of abduction is the best position to get blood flow into there sometimes we don't even let them take it off for the first week they get home exercises if they have access to a pool and I live in a place where it's pretty much you can get in the water six months of the year easy outside so we just tell them nothing with waves but get in there and just kind of float your arm around a little bit it's a nice easy way to do it and that sometimes they do the whole rehab program in the water supplements we use these are a couple of things that we add in and I've got a couple of patients who are real world famous nutritionists that email me about each of them at least once a month with something we should put our patients on about 1 in 12 actually have good evidence that we should use it and since I ultrasound everybody I'll change it now look at now add something to it and then see how they do following it with ultrasound if it looks better on ultrasound we'll keep using it so a couple things for your revisions doxycycline 100 milligrams twice a day three to six weeks okay not only is it an mmp3 inhibitors one of the best medicines to kill c-acne's and I think a fair number of these failed cuffs have a little subtle c-acne's infection so you do both of those by doing that we put them on amend or juven HMB the womb guys use this all the time I talked to a general surgery colleague of mine I said have you ever heard this he went we use it all the time for wounds it helps healing I said how come I don't know that he said well you're dumb orthopod you're not supposed to know this it's like okay fine thank you so we put him on it because I was fixing his cuff and and then I use vitamin C because I read Linus Pauling's work when I was a kid probably not necessary so if they have to drop one we drop that one we do put them on vitamin D and we test vitamin D and I'll bet you half of the people that have failed cuffs have vitamin D deficiency or insufficiency it's mind-boggling how common that is and then I restrict insets for the first four weeks I think that's I'm not sure that that's crazy problem but they've already failed an operation that's a miserable operation to begin with rotator cuff repair is a terrible thing to do to anyone but we do it all the time we try to get them better so I tell them look give me a month of hurting all over your body and then we'll let you start taking it five common errors number one is settling for an inferior surgical repair if you're in there give them your best operation especially if it's a revision use everything available if you don't know how to do a convergent stitch let me know we can go play in the cadaver lab I'll show you how to do it it's the simplest thing in the world know how to do the releases but don't settle don't say why I did part of the repair because it wouldn't work that kind of stuff do your best repair come with everything that you need and do that second is early active motion George Murrell did a great study and he found in 1200 cuffs if they had stiffness and some loss of motion at three months at the end of a year on an MRI scan 100% of those people healed if they had full range of motion before three months nice easy this looks great it's so wonderful 40% of those failed 40% don't do it don't succumb to it don't let your therapist tell you I need to see him early and get all their motion backs all baloney right they're just trying to rip your repair part make you look bad no not really but and then pendulums and pulleys everybody likes to start those early because they're supposed to be good those are actually active exercises don't do them ignore them you can do pulleys later but not at the beginning fourth is a real thing try to do active abduction before your rotator cuff starts to recover if they try to abduct and the cuff is not ready to hold the head down then the first thing that's gonna happen is the deltoid is gonna pull it up right through the repair not tell folks all the time the weakest part of your body right now is my repair so if it comes apart it's my fault don't do this it's really bad because they're gonna do this and then lastly they'll want to do standing resistance exercises you go to therapy they're gonna tell you let's get this five-pound weight and raise it up over your head oh hell no don't do that that is terrible right so lay them down on their back and let them start doing this on their back back and forth while they're supine or in the water do something to take gravity out of the picture and let them work up here and then as they get better you can kind of ratchet it up on the tilt table or something I'll put a pillow behind their back and work it up that way so gravity is not trying to pull it apart so in conclusion I think there are a lot of options for failed prior surgical intervention revision repair is one of them hopefully this gives you some guidelines on when to do it I think basically we want to try to correlate our surgical ability and pick the best option maybe not the easiest option but the one that gives the patient back the activity that they desire to do and just take your time start off with the fact that it's going to be a 12 to 18 month recovery to get back to normal very long very slow they have to commit we have to commit the family has to commit and then I think you can get a good result so thanks very much

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rotator cuff repair

causes of failure

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