29 Revision Rotator Cuff Repair and Techniques for Mobilization

Joseph N. Liu, Anirudh K. Gowd, Brandon C. Cabarcas, Grant H. Garcia, and Nikhil N. Verma


Failed rotator cuff repairs are a challenging problem for the sports medicine surgeon. The initial approach involves identifying reasons for failure of the index repair such as diagnostic and/or technical errors, surgical complications, and patient intrinsic factors leading to nonhealing including advanced age and smoking. A systematic investigation of other causes of shoulder pain should also be exhausted before proceeding with revision repair. Imaging to assess the quality of the remaining tendon, presence of fatty infiltration or muscle atrophy, presence of underlying glenohumeral arthritis or humeral head migration should be obtained. Revision rotator cuff repair may be indicated particularly in the acute traumatic setting in the physiologically young, active patient. The preferred technique of the authors is an all-arthroscopic technique performed in the beach chair position. Complete visualization is of paramount importance to characterize the recurrent tear pattern to perform an optimal repair with the goal of restoring the length?tension relationship of the musculotendinous unit. Mobilization of the tendon can be facilitated with anterior and/or posterior slides as needed. Finally, biologic augmentation may be considered particularly in the presence of poor patient intrinsic factors.

Keywords: massive rotator cuff tear, revision rotator cuff repair, mobilization, shoulder arthroscopy

29.1 Patient Positioning

? Both beach chair and lateral positioning can be used; however, we prefer a beach chair position for rotator cuff repairs.

? Patient is brought to the edge of the bed and safely secured with the head and neck in a neutral position.

? An articulated arm-holding device can be used to facilitate arm position during the case (Spider2 Limb Positioner, Smith & Nephew, Andover, MA) (? Fig. 29.1).

29.2 Portal Placement

? Prior portals can be used if they are in the appropriate position.

? Standard posterior used for diagnostic arthroscopy.

? Anterior portal created in rotator interval just lateral to coracoid after spinal needle localization.

? Additional accessory lateral portals created during visualization of subacromial space can be used for suture anchor placement and suture management (? Fig. 29.2).

29.3 Surgical Technique (Step-by-Step Approach)

? Examination under anesthesia to determine range of motion and pattern of capsular contracture.


Fig. 29.1 Modified beach chair position.


Fig. 29.2 (a, b) Portal placement for Rotator Cuff Repair. A: Anterior portal, B: Accessory Anterolateral Portal, C: Direct Lateral Portal, D: Posterior Portal

? Diagnostic arthroscopy through the standard posterior portal with particular attention to the biceps tendon as it may be a source of pain if not previously treated at the index procedure.

? Low threshold to perform tenotomy or tenodesis if signs of tendonitis or tearing.

? Perform glenohumeral intraarticular work (e.g., biceps tenotomy, labral debridement, and/or chondroplasty, capsular release, subscapularis repair).

? Recreate space that is typically present above glenoid labrum between the undersurface of the rotator cuff to facilitate tendon mobilization.

? Enter subacromial space.

? Establish lateral/accessory lateral portals under direct visualization.

? Find plane between acromion and rotator cuff in adhesed tendons.

? Lateral viewing portal, posterior working portal.

? Bounce off scapular spine and push laterally through scar.

? Subacromial debridement including clearing up anterior, lateral, and posterior gutters to release adhesions between deltoid/acromion and rotator cuff.

? Thorough bursectomy to ensure appropriate visualization.

? Acromioplasty as needed (if not previously performed).

? Expose scapular spine down to the base, be careful of the suprascapular nerve when working close to fat.

? Spine excellent guide for identifying supraspinatus and infraspinatus, to lead toward anatomic repair.

? Rotator cuff repair.

? Tendon mobilization.

? Anterior Interval slide.

? Dissect plane between supraspinatus and subscapularis from the bursal then articular side, but leave lateral tissues intact.

? Palpate coracoid with radiofrequency wand, once you know where the bone is, can be liberal in fully exposing the base. You are safe as long as you stay lateral to coracoid.

? Posterior interval slide.

? Traction stitches placed in supraspinatus and infraspinatus.

? Use scapular spine as a guideline for plane between supraspinatus and infraspinatus.

? Thickened tissue is the plane of dissection.

? Use arthroscopic Metzenbaum tissue to cut in intervals.

? When you get to the adipose tissue, sign that you may be close to the nerve.

? As you get more medial, complete dissection bluntly to avoid damaging the nerve.

? Preparation of tendon footprint.

? Prepare entirety of footprint even if doing a medialized repair.

? Can medialize footprint 5?7 mm without changing biomechanics.

? Microfracture of lateral aspect of greater tuberosity to create better bony bleeding.

? Tendon repair.

? Infraspinatus repair.

? Begin repair by bringing infraspinatus above equator to lateral margin of tuberosity and place first anchor.

? Augmented suturing technique with triple-loaded anchor(Healicoil Suture Anchor, Smith & Nephew).

? Pass first stitch (ACCU-PASS, Smith & Nephew) in mattress suture (stay out of musculotendinous junction); around mattress stitch, place separate simple suture to create mason allen equivalent; finally, third suture is another simple suture at the lateral margin (tied first) to hold the tendon in reduced fashion.


Video 29.1 Surgical demonstration of revision rotator cuff repair and techniques for mobilization.

? Infraspinatus tied down first to give reference for repairing supraspinatus.

? Supraspinatus repair.

? Using more posterior suture anchor, pass mattress stitches (ACCU-PASS) through infra and supraspinatus to help close the defect between supraspinatus and infraspinatus (Healicoil Suture Anchor).

? Anterior suture anchor can be passed in the same augmented fashion as the infraspinatus repair.

? Augment reduction by holding tendon in place during knot tying to reduce tension on knot during tying (? Video 29.1).

29.4 Surgeon Tips and Tricks (Use of Specific Instrumentation)

? Can use same suture anchor sites if prior anchors were nonmetal.

? Stay out of musculotendinous junction when passing sutures through the rotator cuff.

? Prefer using penetrating device as these devices allow more precise passage of suture through the tendon.

29.5 Pitfalls/Complications

? Pitfalls.

? Avoid high-tension double-row repairs as they are at higher risk of failure. Prefer medialized single-row repair to get low-tension repair compared to high-tension double-row repair.

? Failure to recognize significant tears of the subscapularis tendon as a source of pain and/or dysfunction.

? Failure to adequately mobilize the rotator cuff tendons during surgery, which would lead to high-tension repair.

? Complications.

? Failure of the rotator cuff tear to heal.

? Hardware-related complications: greater tuberosity fracture, loose body, anchor or suture pull out or dislodgement, hypersensitivity reaction to suture anchors.

? Adhesive capsulitis.

? Infection (use of allograft patch).

? Deltoid insufficiency (open repairs).

29.6 Rehabilitation

? Sling for 6 weeks with no motion of shoulder.

? Passive, active assist until 8 weeks.

? Out of sling at 8 weeks.

? No strengthening until 14?16 weeks.

29.7 Rationale and/or Evidence for Approach

? Initial evaluation of a patient for revision rotator cuff repair first involves identification of patient- or surgeon-specific factors resulting in a symptomatic failed rotator cuff repair.

? Patient factors include smoking,1 diabetes,2,3 and osteoporosis.2

? A failed rotator cuff resulting in patient dissatisfaction can be from pain, weakness, stiffness, loss of function, or a combination.

? Patient should be carefully interviewed to delineate cause of failure.

? Shoulder pain persistent following surgery may be due to incorrect diagnosis, failure to address all pain generators at time of surgery (e.g., failure to recognize subscapularis tear or biceps tenosynovitis), postoperative synovitis/capsulitis, or perioperative rotator cuff failure.

? Shoulder pain following an interval of symptom improvement may be due to a traumatic acute retear.

? Insidious shoulder pain after surgery may be due to a chronic recurrent tear.

? Physical exam should help delineate cervical pathology, evaluate rotator cuff/deltoid atrophy, and/or scapular dyskinesia.

? Special tests for impingement (Neer?s, Hawkin?s), massive cuff tears (external rotation lag sign, horn blower sign), AC joint pathology (cross-arm adduction), biceps pathology (O?Briens, Speed?s, Yergason?s) should be performed to identify additional pathology that needs to be addressed at the time of surgery.

? Plain films should be repeated as they are the most reliable method for identifying prior metallic implants, proximal humeral migration, and assessment of glenohumeral arthritis.

? Advanced imaging includes repeat magnetic resonance imaging should be obtained to review the status of the remaining rotator cuff tendons, quality of tissue, presence of fatty infiltration, tendon retraction, presence of biceps subluxation, and/or subscapularis tendon tears if present.

? In low-demand older patients, a trial of nonoperative therapy with anti-inflammatories, injections, and physical therapy, may be sufficient for pain relief and regaining strength and function.

? Younger patients and those who fail nonoperative treatment may be indicated for surgery.

? Advanced age, fatty infiltration (Goutallier stage > 2),4 chronic massive rotator cuff tears, and severe arthropathy have a relative contraindication to revision rotator cuff repair.5,6,7,8

? Transosseous equivalent has superior contact pressure at cuff footprint and greater load to failure compared to double-row repair.9

? However, medialized single-row low-tension repair may be beneficial compared to double-row repairs10 when anatomic bone-to-tendon repair is difficult due to excessive tension of the repaired tendon or tendon unable to reach anatomic insertion.

? Microfracture of the lateral aspect of the greater tuberosity may be helpful in recreating healing environment at anatomic footprint to release marrow aspects.11

? Other biologics may be considered to augment repair particularly in the setting of poor patient intrinsic factors (advanced age, diabetes, osteoporosis).

? Platelet-rich plasma has controversial clinical results12; however, the majority of randomized trials are under powered.

? Animal studies using mesenchymal stem cells (e.g., bone marrow aspirate concentrate) have shown promise13,14,15; however, clinical studies are limited16 to demonstrate definitive benefit.

? Patch grafts have been used both as augmentation and bridging in the setting of massive rotator cuff tears.17

? May be used in larger tears and in patients with poor underlying healing potential such as those with brittle diabetes, poor tissue quality, with relatively high levels of success assuming low-tension repair.

? Adjunct procedures such as suprascapular nerve release, biceps tenodesis, and subacromial decompression may be of significant value in treatment of auxillary pain generators.


[1] Mallon WJ, Misamore G, Snead DS, Denton P. The impact of preoperative smoking habits on the results of rotator cuff repair. J Shoulder Elbow Surg. 2004; 13(2):129?132

[2] Chung SW, Oh JH, Gong HS, Kim JY, Kim SH. Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors. Am J Sports Med. 2011; 39(10):2099?2107

[3] Clement ND, Hallett A, MacDonald D, Howie C, McBirnie J. Does diabetes affect outcome after arthroscopic repair of the rotator cuff? J Bone Joint Surg Br. 2010; 92(8):1112?1117

[4] Goutallier D, Postel JM, Bernageau J, Lavau L, Voisin MC. Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan. Clin Orthop Relat Res. 1994(304):78?83

[5] Dwyer T, Razmjou H, Henry P, Gosselin-Fournier S, Holtby R. Association between pre-operative magnetic resonance imaging and reparability of large and massive rotator cuff tears. Knee Surg Sports Traumatol Arthrosc. 2015; 23(2):415?422

[6] Yoo JC, Ahn JH, Yang JH, Koh KH, Choi SH, Yoon YC. Correlation of arthroscopic repairability of large to massive rotator cuff tears with preoperative magnetic resonance imaging scans. Arthroscopy. 2009; 25(6): 573?582

[7] Goutallier D, Postel JM, Radier C, Bernageau J, Zilber S. Long-term functional and structural outcome in patients with intact repairs 1 year after open transosseous rotator cuff repair. J Shoulder Elbow Surg. 2009; 18(4):521?528

[8] Meyer DC, Wieser K, Farshad M, Gerber C. Retraction of supraspinatus muscle and tendon as predictors of success of rotator cuff repair. Am J Sports Med. 2012; 40(10):2242?2247

[9] Park MC, ElAttrache NS, Tibone JE, Ahmad CS, Jun BJ, Lee TQ. Part I: Footprint contact characteristics for a transosseous-equivalent rotator cuff repair technique compared with a double-row repair technique. J Shoulder Elbow Surg. 2007; 16(4):461?468

[10] Kim Y-K, Jung KH, Won JS, Cho SH. Medialized repair for retracted rotator cuff tears. J Shoulder Elbow Surg. 2017; 26(8):1432?1440

[11] Milano G, Saccomanno MF, Careri S, Taccardo G, De Vitis R, Fabbriciani C. Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study. Arthroscopy. 2013; 29(5): 802?810

[12] Greenspoon JA, Moulton SG, Millett PJ, Petri M. The role of platelet rich plasma (PRP) and other biologics for rotator cuff repair. Open Orthop J. 2016; 10:309?314

[13] Gulotta LV, Kovacevic D, Ehteshami JR, Dagher E, Packer JD, Rodeo SA. Application of bone marrow-derived mesenchymal stem cells in a rotator cuff repair model. Am J Sports Med. 2009; 37(11):2126?2133

[14] Kida Y, Morihara T, Matsuda K, et al. Bone marrow-derived cells from the footprint infiltrate into the repaired rotator cuff. J Shoulder Elbow Surg. 2013; 22(2):197?205

[15] Oh JH, Shin SJ, McGarry MH, Scott JH, Heckmann N, Lee TQ. Biomechanical effects of humeral neck-shaft angle and subscapularis integrity in reverse total shoulder arthroplasty. J Shoulder Elbow Surg. 2014; 23(8): 1091?1098

[16] Ellera Gomes JL, da Silva RC, Silla LM, Abreu MR, Pellanda R. Conventional rotator cuff repair complemented by the aid of mononuclear autologous stem cells. Knee Surg Sports Traumatol Arthrosc. 2012; 20(2):373?377

[17] Ono Y, D�valos Herrera DA, Woodmass JM, Boorman RS, Thornton GM, Lo IK. Graft augmentation versus bridging for large to massive rotator cuff tears: A systematic review. Arthroscopy. 2017; 33(3):673?680