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Commentary & Perspective | ||||||||
"Revision Rotator Cuff Repair: Factors Influencing Results" Functional failure of primary rotator cuff repair is seen in approximately 10% to 15% of cases1-9. Anatomic failure, incomplete healing of the rotator cuff, can occur in up to 60% of large or massive rotator cuff tears10-12. It is important not to overlook the difference between functional and anatomic failure of rotator cuff repair because many patients with large or massive rotator cuff tears will have a persistent anatomic rotator-cuff defect following surgery, yet have functionally satisfactory results13-14. Therefore, when we evaluate a patient who has persistent pain and unsatisfactory function following rotator cuff repair, we should consider other causes besides a persistent rotator-cuff defect. The causes of clinical failure of rotator cuff repair in any particular case are often multifactorial8,15-19, but failure of tendon-healing is frequently a factor. The most common causes of failure of tendon-healing include the size of the tear (which is determined by both its anterior-posterior dimension and the degree of retraction), the quality of the tissue, the chronicity of the tear, and the degree of muscle atrophy. These specific factors may be interrelated as they often occur concomitantly in many patients with failed primary rotator cuff repairs. Surgically related reasons for the clinical failure of primary rotator cuff repair include inadequate subacromial decompression, severe subacromial scarring, and untreated symptomatic acromioclavicular arthritis. Postoperative complications commonly associated with the symptoms and signs of persistent pain and weakness include deltoid detachment and stiffness (frozen shoulder). The prevalence of deltoid detachment increases when there is extensive resection of the distal end of the acromion (partial acromionectomy), and/or overly aggressive and premature initiation of active range-of-motion or resistive exercises in the rehabilitation process. Frozen shoulder is often related to delayed initiation of postoperative passive range-of-motion exercises. It is important to identify the causes of failure of a primary rotator cuff repair because they are, in many instances, the same factors that are associated with a less favorable prognosis for revision surgery. In the study on revision rotator cuff repair that appears in this issue of The Journal, Djurasovic et al. demonstrate that detachment of the deltoid origin, the size of the tear at the time of primary repair, the quality of the rotator cuff tissue, the number of prior surgical procedures, and the degree of active forward elevation prior to revision each contributed, as independent variables, to a suboptimal clinical outcome of revision rotator cuff repair. In many cases, a careful physical examination, measurement of rotator cuff strength and of active elevation, assessment of deltoid function, and a review of the operative report from the primary rotator cuff repair can identify factors that may contribute to a less favorable prognosis for revision surgery. The primary goal of revision rotator cuff repair is pain relief, and the secondary goal is functional improvement (often described by the patient as weakness or inability to perform activities of daily living). Pain or the inability to perform certain functions of daily living are comorbid factors that are interrelated. As the patient's pain is relieved, function improves, as does the patient's ability to perform exercises for rehabilitation of the shoulder. The occurrence or severity of postoperative stiffness (frozen shoulder) can be minimized when a patient does not have shoulder pain. A satisfactory passive range of motion is also an important factor associated with functional improvement. Preoperative physical examination, plain radiographs, and the use of selective injection of local anesthetic to the acromioclavicular joint are useful in evaluating the persistence of subacromial impingement and symptomatic acromioclavicular arthritis. In the current study, the indications for revision acromioplasty were determined by intraoperative findings. Although the authors surgically treated many of their patients with revision acromioplasty and distal clavicular resection, they did not define how these additional components of the revision surgery played a role in the overall improvement in shoulder function and pain relief. In addition, the occurrence of shoulder stiffness either before or after the revision surgery was not discussed. The current study highlights the importance of deltoid function, the size of the rotator cuff tear, the number of prior procedures, and the range of active forward flexion in patients who have a functional failure of rotator cuff repair. All of these factors can and should be defined preoperatively in order to assess the likelihood of successful revision surgery. *The author did not receive grants or outside funding in support of the research for or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated. References 1. Adamson GJ, Tibone JE. Ten year assessment of primary rotator cuff repairs. J Shoulder Elbow Surg. 1993;2:57-65. | ||||||||
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