rotator cuff situations such as revision or failed rotator cuff tears and what do we do now my disclosures are available through the Academy's online disclosure program. So our history today is a 47 year old right-hand male he's a dentist he had chronic low-lying shoulder pain but then fell walking his dog immediate onset of functional loss and decreased range of motion his MRI showed a full thickness tear of the rotator cuff leading into the infraspinatus with biceps tendonitis and he got the standard procedure for me which is a rotator cuff repair followed by a arthroscopic biceps tenodesis we'll skip his MRIs just for time. He underwent an index surgery in October of 2020 with the procedures as you see before we did use BMAC at the time of the index procedure based on his request he came back at four months was progressing with PT but was still having vague anterior superior shoulder pain with some weakness on forward flexion at that point we tried some injections and based on his failure to continue to progress a new MRI scan was obtained. So this is what the new MRI scan looked like you can see that he's got a recurrent defect of his rotator cuff he's got some tendon atrophy you can see the anchors that were placed from the prior surgery maybe some leading-edge muscle fatty infiltration but generally overall well-preserved muscle. Here's his axial MRI scan and his subscap still continues to look fairly healthy maybe a small upper border tear articular cartilage is well maintained. So we have a 47 year old male he's failed his primary rotator cuff repair which was done with a standard trans osseous equivalent technique he complains of pain and loss of strength and the question is what do we do different the next time. So I think when we're managing these patients with complex rotator cuff problems the first things we need to assess is what are their real primary symptoms and these can be either pain functional loss or a combination of both and we also want to know what was the progression of the history was this somebody was doing well for a long period of time and then had an acute re-injury or is this been like in this case just a chronic simmering failure to thrive so to speak. When we decide what to do for these procedures part of the problem is we have a very poor understanding of why are these causing pain right we've all seen in post-operative MRI studies where you see the same patient who's doing extremely well clinically but we get the MRI for whatever purpose and they've got a recurrent defect or a failure to heal on their rotator cuff. We know that there are a number of different pathologies that may exist within the shoulder that are all pain drivers and so we need to think about which of these may not have been addressed at the index procedure. In addition why do some patients come in with massive tears and they do this and other patients come in with small tears and they do this and so this functional decompensation is somewhat hard to understand in many cases it's limited by pain we also know that there's some compensatory muscle strength I believe that it's a sequence of active activation or some neuromuscular component that allows some people to compensate and others not can be the location of the tear involvement of the subscapularis and loss of the anterior posterior force couple. We need to ask them what is their priority a younger patient may prioritize strength and accept a little bit of residual pain for many of our older patients they just want to be able to sleep at night and do their functional activities of daily living and that may change the procedure that we decide to do and how aggressive we need to be about actually achieving structural integrity of the rotator cuff itself because I think in orthopedics and shoulder surgery we often think what we got to fix the cuff but the truth is in many cases we can probably achieve a satisfactory outcome even if the cuff is not structurally intact. We want to look closely at their examinations specifically with regard to lag signs I think if we have a patient that has poor active elevation that's a much more challenging problem than a patient that has good functional elevation but complains of pain as their primary variable. We want to evaluate for alternate sources of pain things like the AC joint the biceps stiffness or loss of range of motion these can all be addressed at the time of surgery and may be as important as the actual repair of the rotator cuff in terms of resulting in a positive benefit for our patients. We can probably discuss this at our table but the problem with pseudoparalysis is how do we define it? The literature would define it as elevation of less than 90 degrees but we all know that we can see lots of patients that come in with small tears and can't elevate because they're painful yet we don't define those as pseudoparalysis. I think it's and I know it when I see it and I'll tell you my definition which is chronic tears so these have to be present over a period of six months to a year they're massive generally involving the subscapularis most of these patients are actually painless they just have a functional loss they've got full passive range of motion so they're not stiff and they've got complete loss of glenohumeral active elevation which means when you tell them to elevate they do this with the scapular thoracic joint they have no initiation of active forward elevation. We've looked at this in a video study where we sent surgeons videos of patients that had elevation less than 90 we asked them if they thought it was pseudoparalysis we asked them for the definition of pseudoparalysis we then went back and sent them the MRIs of those patients and said now do you think it's pseudoparalysis and as you would expect very poor reliability or consistency with regard to how each of us is defining this complex problem. We do know that as we see these predictable muscle changes that occur over a period of 12 to 18 months that they do have some effect on the outcomes following surgery and they're definitely predictive of patients that may have a higher risk of failure of healing following a surgical procedure particularly when we see grade two or more fatty infiltration of the supraspinatus and then progressive to the infraspinatus. The treatment algorithms unfortunately are fairly complex and look like this and we have a number of different procedures which are available to us which include primary repair with either augmentation or interposition grafting, tendon transfers, reverse shoulder arthroplasty. In the last 10 years we've heard about superior capsular reconstruction and now of course the balloon procedure which is available for older patients in a lower demand setting. I think from a decision-making standpoint the x-rays for me are extremely helpful and the Hamada classification is very important to understand. If you've got a head that's centered or you've and you've got the absence of arthritis then you've got a good chance of making a soft tissue procedure work but as soon as you see these Hamada threes and beyond which means contact between the humeral head and the acromion or the presence of osteoarthritis in the glenohumeral joint you probably should start thinking about a reverse arthroplasty because your results are going to be no better than 50-50 even with some of the more complicated procedures. So does healing matter? The reality is that it does and it doesn't. It probably doesn't when it comes to pain relief but it probably does when it comes to structural improvement and strength recovery. So I think this goes back to looking at what does your patient want? Is it a younger high-demand patients that's looking for functional recovery overhead or is it an older patient that's looking to sleep at night? And that influences me in terms of how aggressive I am about trying to get the rotator cuff to heal. In massive tears I think Brian already spoke on this but the releases are significantly important. We need to manage all types of pathology. We need to evaluate the configuration of the tear and how we can reduce these tears to take stress off and to restore the normal anatomy and of course we want to take any of the confounding factors out of the equation so biceps tenonomy or tenodesis, decompression, distal clavicle, all of those things are important. The mobilization of massive tears, again Brian talked about this, but we want to be very liberal about releasing on the undersurface of the rotator cuff as well as in the anterior interval and the techniques for doing this have been presented by Dr. Burkhardt and Dr. Lowe and others and so we'll skip ahead to try to save time here. This is what the medial release looks like after you've done it. So we've released the undersurface of the capsule. We've exposed the coracohumeral ligament insertion on the coracoid. We've released that insertion but I think as Brian said it's very important to maintain that comma tissue laterally because that's essentially the connection of the force couple between the leading edge of the supraspinatus and the subscapularis. I think it's important functionally. It's an important landmark for you in identifying how to repair these and I think once you reduce the subscapularis, if there's a tear that will set you up for a nice reduction of the supraspinatus as well. The posterior inferior release you see here it's basically a capsule release staying directly off the glenoid margin will come up superiorly and you can see how as we release this capsule the muscle comes into view underneath and then we can be confirmed that we'll be able to mobilize the tendon appropriately. Do we do double rows or single rows? I think both are appropriate. My algorithm is a low tension double row repair when possible. If the repair is under tension then I go medializing the footprint up to five to ten millimeters using triple loaded anchors and that has resulted in good results. SCR I think is starting to fall a bit out of favor. It still has a role in my practice but we have to understand what it does and what it doesn't do. It improves range of motion. It can reduce pain. It can improve function. It does not treat these patients with advanced rotator cuff arthropathy or stiffness or patients that have significant strength complaints in the absence of pain. That's probably the hardest patient to treat in my office is the younger patient who comes in and says I can do everything I want I just can't lift a hundred pounds like I used to. Doc can you help me to do that again because I don't have an operation that's going to normalize their strength reproducibly in this situation. The outcomes I think have been mixed but in my experience when you choose patients appropriately and you at least educate them about the goals of the procedure you can achieve good results with about 75 to 90 percent patient satisfaction. Biologics of course we're still learning about this. I think the patient selection is critical. There's a lot of questions that we need to answer in terms of when we use these what is appropriate and how to deploy them. These are just a couple of the options that are in the market now. A patch augmentation device and a new DBM implant that I've been working on that tries to flip the script to maybe working on enthesis and thesis reconstruction rather than putting collagen patches over the top. So I think this will be the next great step in rotator cuff repair is how do we actually harness and control biology going forward. What about the balloon? Well I think it's an important adjuvant. You'll hear about this in the main session in about 45 minutes but it's older patients they prioritize pain over function. They've got preserved active elevation in the absence of glenohumeral arthritis with an intact subscapularis and when you see that and they say doc I just want to sleep at night this is a very good option for an accelerated recovery and has worked very well in my hands as well as represented in the literature. Finally we have to accept to sports surgeons that reverse is not a dirty word right. It's not that procedure that carries a 15 or 20 percent complication rate anymore. If you look at large series of primary reverse arthroplasty now the complication rates are one to two percent. Very quick recovery and very reproducible. So if you have the right patient instead of stretching the indications and accepting a 50 percent failure rate just put a reverse in and they'll come back to you in eight weeks and tell you thank you so much for helping me with my problem. So what do we do? Again this is the 47 year old male failed primary rotator cuff surgery. This is what it looks like and I think this is our typical problem with the type 2 trans-osseous equivalent re-tear after surgery. You can see this is not a mechanical failure. My sutures are still in place. My suture bridge is still in place. My knots are tied. What happened? This tear feed failed medial to my repair due to the biologic quality that causes a 47 year old tear to occur in the first place. You can see there's some fairly significant adhesions that are present but we do have some tissue to work with which gives me hope that we've got a solution here to help this patient. What we did in this situation was to repair using a medialized construct. So we use triple loaded anchors. This is really a reverse L configuration. So I first repaired the infraspinatus. I then put an anchor up front to the supraspinatus and then I bridged the defect or the linear progression of the tear between the supraspinatus and the infraspinatus. And in doing that I think you can really anatomically reduce the tear where it needs to be. Because this is a type 2 failure this tissue doesn't want to go all the way to the lateral aspect of the tuberosity. So I put it medially. But in an effort to try to restore some of the collagen that was potentially missing we then used a patch over the top. There are a number of different patches available. We have xenografts, we have allografts, we have all sorts of deployment mechanisms. I think we're still learning about where this is applicable and the Rohy score. For those of you who haven't looked at that it's a publication in 2019 that tries to strategize about which tears are at higher failure risk. But this is just one of the techniques that's available to try to deploy a patch in a very reproducible and quick manner. Thanks for much for your attention.

rotator cuff repair

shoulder pain

full thickness tear

range of motion

complex rotator cuff problems