JBJS | Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Failed Repair of the Rotator Cuff. Evaluation and Treatment of Complications*†

The Journal of Bone & Joint Surgery, Volume 79, Issue 5

Instructional Course Lecture | May 01, 1997

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Failed Repair of the Rotator Cuff. Evaluation and Treatment of Complications*†

EVAN H. KARAS, M.D.‡; JOSEPH P. IANNOTTI, M.D., PH.D.‡, PHILADELPHIA, PENNSYLVANIA

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An Instructional Course Lecture. The American Academy of Orthopaedic Surgeons

The Journal of Bone & Joint Surgery. 1997; 79:784-93

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Introduction

Operative repair of a tear of the rotator cuff usually provides relief of pain^{8,21,22,36,41,48,54}. Restoration of strength is somewhat less predictable, but the rate of over-all patient satisfaction after primary repair of the rotator cuff has been reported to be as high as 91 per cent in a series of 340 shoulders^21,36. Improved operative techniques that have been developed over the last several decades have been largely responsible for this success. However, operative repairs do fail. These failures present diagnostic and therapeutic challenges, as they may be due to multiple reasons. Identification of the cause in a given patient requires a thorough evaluation that includes a complete history, physical examination, and review of the radiographs and the ancillary studies. Only then can an effective treatment plan be established. Although the results of repair of recurrent tears of the rotator cuff have not been as satisfactory as those of primary repair^{5,10,37,47,54}, proper diagnosis and treatment can greatly increase the chance for success.

The major reasons for failure of repair of the rotator cuff are an incomplete or incorrect diagnosis; postoperative complications; errors in operative technique; and errors in or poor performance of postoperative rehabilitation, or both. A combination of these factors may be responsible for a poor result in a given patient. The clinical evaluation of these parameters must be extremely thorough in order to avoid failure of treatment.

A careful history, including a review of the medical record, operative notes, and preoperative and postoperative imaging studies, must be obtained. This information should allow the preoperative diagnosis to be established on the basis of both the clinical data and the anatomical abnormalities. An inaccurate or incomplete diagnosis or an error in the execution of the operative procedure or the postoperative rehabilitation program may then be revealed. Accurate definition of all of the factors resulting in failure of the initial procedure is the first step in deciding on future treatment and improving the likelihood of a successful revision when such a procedure is indicated.

*Printed with permission of The American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 47, The American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1998.

†No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

‡Shoulder and Elbow Service, Department of Orthopaedic Surgery, PENN Musculoskeletal Institute, 39th and Market Street, Presbyterian Medical Center, Philadelphia, Pennsylvania 19104.

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Fig. 1-A and 1-B: Postoperative fractures of the acromion (arrows).

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Figs. 2-A and 2-B: Postoperative detachment of the deltoid. Fig. 2-A: Clinical photograph revealing a defect that is accentuated by attempted active elevation of the arm.

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Fig. 2-B: weighted magnetic resonance image demonstrating detachment and retraction of the origin of the deltoid (arrow).

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Fig. 3-A: Photograph showing insufficiency of the coracoacromial arch.

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Fig. 3-B: Photograph showing attempted elevation of the shoulder resulting in superior migration of the humeral head.

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Fig. 4-A and 4-B: Postoperative radiographs showing heterotopic ossification. Fig. 4-A: Axillary radiograph demonstrating heterotopic bone in the vicinity of an anterior acromioplasty.

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Fig. 4-B: Zanca (acromioclavicular joint) radiograph demonstrating heterotopic bone formation in the space created by resection of the lateral portion of the clavicle.

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Fig. 5: T2-weighted magnetic resonance image, made in the coronal plane, of a recurrent defect of the rotator cuff. There is a full-thickness, high-signal-intensity defect in the supraspinatus tendon (large arrow). Note the bone trough and the suture through the bone tunnel (small arrow).

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Figs. 6-A and 6-B: Photographs of a patient who had an excellent result two years after débridement of a massive tear of the rotator cuff. Fig. 6-A: The range of motion is excellent.

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Fig. 6-B: There is marked atrophy of the infraspinatus (arrow).

Errors in Diagnosis

Physical examination and injection tests help to define the patient's current problems. Care must be taken to specifically identify referred pain due to thoracic outlet syndrome and lesions of the cervical spine. Pain secondary to cervical lesions often presents in a dermatomal pattern over the posterior and lateral aspects of the shoulder; the pain may radiate to the occiput and the thoracic spine. Tenderness to palpation and a decreased range of motion of the neck are indicative of cervical disc disease. Provocative maneuvers, such as the Spurling test for discogenic disease and the Wright⁵⁵ and Adson¹ tests for thoracic-outlet syndrome^24,26, may be helpful if the results are positive. The Spurling test is performed by passive lateral bending and ipsilateral rotation of the neck. A positive test reproduces radicular symptoms. With the Adson test, the arm is positioned in extension with ipsilateral rotation of the neck. With the Wright test, the arm is placed in extension and abduction. The Adson and Wright tests are positive when they reproduce the symptoms of the upper extremity and the hand. If selective injection of lidocaine into the subacromial space or the acromioclavicular joint, or both, relieves pain, the cervical spine may be eliminated from consideration.

Neuropathies of the suprascapular and axillary nerves also may mimic disease of the rotator cuff and cause misdiagnoses. The suprascapular nerve, a branch of the superior trunk of the brachial plexus, may be compressed beneath the suprascapular ligament in the suprascapular notch⁴³ or by a ganglion in the spinoglenoid notch³⁸. In addition, if a superior capsular release was performed during the original procedure, it is possible that dissection more than two centimeters medial to the superior aspect of the glenoid rim may result in iatrogenic injury to the suprascapular nerve.

Clinical presentation of these neuropathies usually consists of pain in the posterior aspect of the shoulder with accompanying muscle weakness specific to the site of nerve compression. Proximal compression at the suprascapular notch or iatrogenic injury at this level denervates both the supraspinatus and the infraspinatus, while more distal compression at the spinoglenoid notch causes selective weakness of the infraspinatus. Similarly, weakness of the deltoid and the teres minor secondary to postoperative neuropathy of the axillary nerve may have a presentation very similar to that of a tear of the rotator cuff. Electromyographic analysis can help to confirm these diagnoses^12,14,43. Magnetic resonance imaging is the only useful imaging modality for defining neuropathy of the suprascapular nerve as a cause of failed operative treatment of a tear of the rotator cuff. It may reveal space-occupying lesions such as a ganglion cyst, or it may show severe muscle atrophy without a defect of the cuff.

Arthropathy of the acromioclavicular joint also may complicate the clinical presentation of disorders of the rotator cuff and may lead to failures in diagnosis and treatment. Careful clinical examination of the acromioclavicular joint, including direct palpation for tenderness and cross-arm adduction maneuvers, should be performed routinely for patients who have a possible lesion of the cuff. Imaging studies may be useful for diagnosing residual abnormalities of the acromioclavicular joint, a common cause of persistent pain after operations on the rotator cuff. A Zanca radiograph (an anteroposterior radiograph made with the x-ray beam centered on the acromioclavicular joint with 15 degrees of cephalic angulation) shows the full extent of the joint and may reveal lesions that were missed on routine anteroposterior radiographs. If the radiographs do not show conclusive findings and a lesion of the acromioclavicular joint is strongly suspected, a bone scan may confirm the diagnosis and lead to appropriate treatment.

An unrecognized os acromiale may lead to persistent pain after subacromial decompression and repair of the rotator cuff. This lesion is most readily identified on routine axillary radiographs of the shoulder or on axial magnetic resonance images of the acromion. If small fragments are mobile and painful, they can be excised with reattachment of the deltoid to the remaining edge of the acromion. Larger lesions may necessitate excision of the intervening synchondrosis and fixation with a tension-band wire with use of local bone graft obtained from a simultaneous acromioplasty.

Lesions of the biceps tendon and the superior aspect of the glenoid labrum often are found in patients who have impingement syndrome and a tear of the rotator cuff³⁵. Failure to recognize and treat these problems appropriately may lead to a poor operative result. An arthroscopic mini-open repair offers the advantage of improved visualization of the biceps tendon and its attachment to the superior aspect of the labrum. A finding of tenderness of the biceps tendon to palpation on physical examination, and a positive result on the Speed or the Yergason⁵⁶ test, are suggestive of but non-specific for biceps tendinitis. The Yergason test is performed by resisting supination and flexion of the forearm. The Speed test is performed by resisting flexion of the elbow and the shoulder with the elbow in 90 degrees of flexion and the shoulder in approximately 30 degrees of flexion. Both tests are performed to evaluate referred pain to the long head of the biceps tendon. Standard radiographs are not particularly helpful for assessing the status of the biceps tendon. An axial radiograph of the intertubercular sulcus may provide indirect evidence of a lesion of the biceps tendon⁹. Arthroscopy is the most useful tool for delineating severe lesions of the biceps tendon. Tendon-fraying and labral detachments can be both assessed accurately and treated arthroscopically. These intra-articular structures may be difficult to visualize and treat during routine open repair of defects of the cuff that are less than two centimeters long. Additionally, arthroscopy can be helpful for distinguishing internal impingement of the posterosuperior aspect of the glenoid or secondary subtle instability of the glenohumeral joint^27,52, especially in athletes who have pain during the late cocking phase (marked external rotation and abduction) of throwing.

Errors in Operative Technique

Errors in the operative technique of acromioplasty and repair of the rotator cuff can undermine the results of treatment of even the most accurately diagnosed lesions of the cuff. These errors include inadequate operations and intraoperative complications. Inadequate operations include those in which a lesion of the biceps tendon or the labrum, or both, is missed; those in which arthropathy of the acromioclavicular joint is missed, as discussed previously; and inadequate acromioplasty. Intraoperative complications include fracture of the acromion, detachment or denervation of the deltoid, and failure to preserve the coracoacromial arch in patients who have an irreparable tear of the cuff.

The principles of acromioplasty include removal of a sufficient amount of the bursa for adequate evaluation of the underlying rotator cuff and adequate removal of anteroinferior acromial bone without excessive shortening or narrowing of the acromion. Inadequate anterior acromioplasty has been reported by many investigators as a common source of failure necessitating a revision procedure^{4,5,10,17,20,40,45}.

In a study by Flugstad et al.¹⁷, fifteen of nineteen patients who had failure of operative treatment for impingement syndrome were found to have residual acromial spurs. Of 117 patients who had a failed acromioplasty in a study by Rockwood and Williams⁴⁵, all ninety who had recurrent symptoms of impingement had a residual anterior portion of the acromion at the time of the reoperation. DeOrio and Cofield¹⁰ also demonstrated the importance of dequate subacromial decompression in their study of failed repairs of the rotator cuff; more than 50 per cent of their twenty-seven patients had not had an acromioplasty during the first, unsuccessful operation.

Removal of an excessive amount of the anterior or lateral portion of the acromion may be associated with a fracture of the acromion or with detachment of the deltoid and a poor operative result²⁹. In the early development of techniques for repair of the rotator cuff, radical acromionectomy or subtotal lateral acromionectomy was advocated for subacromial decompression^2,51. More recently, however, it has become clear that the acromion serves a necessary function in providing a strong attachment point and fulcrum for the powerful deltoid muscle. In 1981, Neer and Marberry³⁴ reported on thirty patients who had had removal of 80 per cent of the acromion with resultant adhesions of the deltoid to the rotator cuff, retraction of the deltoid, and loss of the function of the acromion as a fulcrum. Attempted operative correction in twenty of these patients was unsuccessful. It is now accepted that acromionectomy is fraught with complications and should be abandoned^4,8,28,54.

Frank acromial fractures can occur either intraoperatively or postoperatively²⁹. Careful visualization and palpation of the thickness of the acromion is necessary to avoid this complication. Meticulous operative technique, with emphasis placed on the correct angle of progression of the osteotome and with great care taken not to lever on the acromion with a subacromial retractor, is mandatory. An intraoperative fracture should be identified readily at the time of the operation and should be corrected with open reduction and internal fixation to prevent a painful non-union and consequent weakness of the deltoid. Acromial fractures also have been reported after arthroscopic subacromial decompression²⁹ (Figs. 1-A and 1-B), emphasizing the need for excellent visualization of the undersurface of the acromion and careful control of removal of bone. Excessive use or trauma, or both, during the postoperative period also can cause an excessively thinned acromion to fracture.

The manner in which the deltoid is handled during an acromioplasty and a repair of the rotator cuff is critical to a successful result. Avoidance of lateral acromionectomy to prevent retraction of the deltoid and scarring of the rotator cuff has been discussed previously. However, detachment of the deltoid from an intact acromion can still occur. The technique for removing and repairing the origin of the deltoid from the acromion can help to minimize the occurrence of this complication. In 1972, Neer³³ reported a method of acromioplasty in which a limited portion of the origin of the deltoid is removed subperiosteally from the anterior portion of the acromion and the acromioclavicular joint. Blunt dissection between the anterior and lateral heads of the deltoid muscle then allows exposure of the rotator cuff without excessive destruction of the acromion or detachment of the deltoid³³. The technique of deltoid-splitting was modified by Bigliani and Rodosky³ to provide better access to the posterior tendons of the cuff without necessitating additional detachment of the origin of the deltoid.

Arthroscopic acromioplasty and mini-open repair of the rotator cuff theoretically should decrease the prevalence of detachment of the deltoid. To our knowledge, there have been no reported cases of detachment of the deltoid after mini-open or arthroscopic techniques. However, the senior one of us (J. P. I.) has seen such detachment after both arthroscopic mini-open repair of the cuff and arthroscopic acromioplasty alone. Therefore, it is possible for this complication to occur with both arthroscopic techniques.

Reattachment of the deltoid to the acromion after repair of a tear of the rotator cuff is crucial. If an inadequate soft-tissue cuff of fascia remains on the acromion, or if excessive detachment of the deltoid is necessary for repair of a massive tear, then the deltoid should be reattached to the osseous edge of the acromion and the clavicle (if necessary) through drill-holes. If the lateral portion of the clavicle has been resected, the deltoid must be repaired to the leading edge of the trapezius fascia. Improper reattachment may result in retraction of the deltoid and may substantially compromise the functional result. When poor-quality deltoid tissue is encountered, an extended period of protected mobilization of the shoulder may be necessary.

Examination of the shoulder of a patient who has detachment of the deltoid reveals a defect at the origin of the deltoid from the acromion and a prominence of the deltoid distal to the defect that is accentuated by active elevation of the arm (Fig. 2-A). A magnetic resonance image may be helpful for confirming this diagnosis (Fig. 2-B). Operative repair of a retracted deltoid should proceed as soon as possible. Prolonged retraction leads to scarring and subsequent stiffness, pain, and loss of shoulder function.

Sher et al.⁵⁰ reported on twenty-four patients who had had either repair of the deltoid (for an acute tear) or rotational deltoidplasty of the middle portion of the deltoid anteriorly (for a chronic tear) to reconstruct a postoperative disruption of the deltoid. At an average of thirty-nine months, sixteen patients (67 per cent) had an unsatisfactory clinical result. The poor results were associated with a previous lateral acromionectomy; involvement of the middle portion of the deltoid; a duration of symptoms of more than twelve months; and a concomitant, poorly compensated for, massive tear of the rotator cuff. Conversely, a satisfactory result was associated with an acute disruption isolated to the anterior portion of the deltoid, an intact acromion, and preserved function of the rotator cuff.

Iatrogenic denervation of the deltoid is a serious complication of repair of the rotator cuff. Knowledge of the anatomy of the terminal branches of the axillary nerve as they relate to the splitting of the deltoid muscle is critical. The axillary nerve arises from the posterior cord of the brachial plexus near the coracoid process and then courses through the quadrilateral space to reach the posterior aspect of the shoulder. While in the quadrilateral space, it divides into posterior and anterior terminal branches, which supply the posterior one-third and the anterior two-thirds of the deltoid muscle, respectively. The anterior branch travels approximately five centimeters inferior to the lateral and anterior margin of the acromion, perpendicular to the direction of the muscle fibers. The split in the deltoid therefore should not extend beyond this distance. A stay suture can be placed at the apex of this split to prevent its propagation from excessive retraction of the deltoid. Furthermore, Burkhead et al.⁶ showed that, in some smaller patients, the nerve may be located slightly closer than five centimeters from the acromial margin.

Neuropathy of the axillary nerve initially presents as weakness in abduction and forward elevation of the shoulder. Chronic disorders are accompanied by atrophy of the deltoid. Loss of sensation in the dermatome overlying the lateral aspect of the deltoid is variable, as the cutaneous nerves supplying this area often arise from the posterior terminal branches of the axillary nerve.

Electromyography should be used when denervation of the deltoid is suspected postoperatively, both to confirm the diagnosis and to establish the nature of the injury as either a neurapraxia or a neurotmesis. Neurapraxias can be managed expectantly, with institution of passive range-of-motion exercises to prevent stiffness of the shoulder. Transections of the nerve should be evaluated for recovery on a monthly basis; nerve repair can be considered if no improvement is evident by three to four months and if it is warranted by the degree of the functional impairment. However, these recommendations are based on results obtained after repair of injuries of the axillary nerve secondary to dislocation of the shoulder or operations for anterior stabilization in which the nerve was injured at its larger, main-branch region⁴². There is little information in the literature with regard to the treatment of lesions of the terminal branch after repair of the cuff. Leffert²⁵ described rotational deltoidplasty with excision of the denervated portion of the muscle as a valuable alternative to nerve repair for this problem.

The importance of the coracoacromial arch in providing anterosuperior stability for the humeral head has been the subject of several recent investigations^23,31. Lazarus et al.²³ demonstrated anterosuperior escape of the humeral head from beneath the coracoacromial arch in five of six cadaver shoulders after release of the coracoacromial ligament and anterior acromioplasty. In a more elaborate cadaver model, Flatow et al.¹⁶ demonstrated that this superior migration is most severe in the presence of large tears of the rotator cuff, especially when the edges of the tear approach the equator of the humeral head. Repair of the tears of the rotator cuff restored nearly normal glenohumeral kinematics in their patients. Failure to recognize the role of the coracoacromial arch in shoulders with a tear of the rotator cuff may lead to clinically evident anterosuperior instability (Figs. 3-A and 3-B). In an attempt to circumvent this problem, Flatow et al.¹⁵ recently described a technique of limited subacromial decompression and reattachment of the coracoacromial ligament in patients who had a massive irreparable tear of the rotator cuff.

Postoperative Complications

Complications of repair of the rotator cuff include infection, heterotopic ossification, frozen shoulder, and recurrent tearing. Since these complications can be related both to the operative technique and to the postoperative rehabilitation, they will be discussed separately in this section.

Postoperative infections may be difficult to diagnose, as they often present in a delayed and unimpressive fashion. Superficial wound infections are characterized by erythema with or without drainage, induration, warmth, and fever. These findings may be subtle initially and may be overlooked as normal postoperative inflammation. Laboratory and imaging studies are often unrevealing at this stage. If left to worsen, these infections eventually will manifest themselves as wound dehiscence, drainage, cellulitis, and lymphadenopathy. Treatment is most successful if begun early and based on positive cultures. A heightened awareness of this potential problem is critical, and aspiration of the joint or the wound should not be delayed in suspicious cases. Intravenous administration of antistaphylococcal and antistreptococcal antibiotics (first-generation cephalosporin) should be initiated after operative débridement and exploration of the extent of the infection. If the infection does not pass deep to an intact repair of the cuff, then the repair can be left intact if this allows for adequate débridement of necrotic tissue. If the infection extends into the shoulder joint, then it should be debrided arthroscopically. The subacromial space and the biceps tendon sheath should be debrided in an open fashion. Non-absorbable suture and any metallic suture anchors should be removed. Closed suction drains should be left in place, and antibiotics should be given intravenously as dictated by the results of gram stains and specimens of intraoperative cultures.

Heterotopic ossification is uncommon after acromioplasty and repair of the rotator cuff. It occurs in approximately 3 to 5 per cent of patients, in our experience, but not all of these patients are symptomatic. Copious irrigation to remove all bone fragments after acromioplasty reduces the chance of heterotopic bone formation. When ossification occurs in the subacromial space or in the space created by resection of the lateral portion of the clavicle, it can be a source of pain (Figs. 4-A and 4-B). The diagnosis is best made with use of routine radiographs. Lesions that cause severe pain or that limit motion can be treated with excision. Preoperative bone scans help to delineate mature lesions when they do not display markedly increased uptake of radioisotope. In our center, low-dose irradiation (700 centigray in a single dose) given within the first forty-eight hours after resection, or Indocin (indomethacin) given orally for six weeks, has been successful in preventing recurrence. This regimen is based on its effectiveness in patients who have had a total hip arthroplasty; we are unaware of any scientific data that support its use specifically for heterotopic ossification of the shoulder.

Postoperative stiffness after repair of the rotator cuff can lead to severe functional limitations. Bigliani et al.^4,5 reported on five patients who had frozen shoulder after the procedure. Those authors attributed the failures to inadequate rehabilitation in the postoperative period and they recommended gentle pendulum exercises and passive elevation in the scapular plane, beginning on the first or second postoperative day, as preventive measures. One must be careful to identify patients who have a severe loss of motion of the shoulder preoperatively, as they are at higher risk for frozen-shoulder syndrome during the postoperative period. Passive shoulder-stretching exercises should be initiated, and a nearly full range of motion should be achieved before the cuff is repaired. If rehabilitation is unsuccessful in restoring motion, then manipulation with the patient under anesthesia followed by arthroscopic capsular release for shoulders that are resistant to manipulation should be performed. The patient can be brought back to the operating room at a later date, after motion of the shoulder has been restored, for definitive operative treatment of the lesion of the cuff.

More recently, Mormino et al.³² reported on thirteen patients who had subdeltoid adhesions after repair of the rotator cuff. These patients had arthroscopic release of the adhesions, which was universally successful in alleviating pain. The average score according to the system of the University of California at Los Angeles increased from 14.8 to 30.1 points. These authors postulated that the adhesions acted as a functional tenodesis, thus altering the normal biomechanics of the shoulder by preventing rolling of the humeral head on the glenoid. This restriction of motion is distinct from that secondary to capsular contracture or to scarring in the classic frozen shoulder and has been termed the captured shoulder. Early mobilization of the shoulder postoperatively may reduce the prevalence of this complication. However, all of the patients in the series of Mormino et al. began therapy on the first postoperative day. These authors did not explore factors that may have been associated with the development of the adhesions.

Persistent Defects of the Rotator Cuff

Persistent defects of previously repaired rotator cuff tendons may be related to an inadequate initial repair of the cuff, poor-quality tendon or bone, persistent impingement, or improper physical therapy. The results of clinical evaluation and radiographs must be evaluated concomitantly in order to determine the presence of a persistent defect as well as its relative clinical importance.

Persistent impingement usually is related to inadequate acromioplasty. Inadequate repair of the original tear may be secondary to improper identification of thickened, hypertrophic subacromial bursal tissue as rotator cuff tendon or to inadequate mobilization of the torn tendons with consequent tension on the site of the repair. Bigliani et al.⁴ identified the cause of eleven of thirty-one failed repairs as secondary to inadequate mobilization. Observation of the ease with which the bursal tissue pulls away from the underlying rotator cuff, as well as the differential motion of the bursa as compared with that of the rotator cuff with rotation of the humeral head, should serve as guides with which to determine the proper tissue to repair.

Overly intensive physical therapy during the early postoperative period may lead to avulsion of the tendon before healing. This mechanism was associated with five of the thirty-one failures in the series of Bigliani et al.⁴. In addition, Neviaser and Neviaser³⁷ found that early use of weights was a factor leading to failure of repair of rotator cuff tears. Rehabilitation must be tailored individually to intraoperative observations of the repair in each patient. A small tear that is repaired without detachment of the deltoid will withstand more intensive therapy than will a large or massive tear necessitating takedown and repair of the deltoid origin. Intraoperative assessment of the quality of the tissue and the amount of tension on the site of the repair also will help to guide therapy.

The identification of persistent defects of the cuff with use of imaging modalities can be difficult. The most useful study in the postoperative setting is arthrography. Communication of contrast medium between the subacromial and glenohumeral joint spaces was reported to be 100 per cent sensitive and 96 per cent specific for the diagnosis of full-thickness tears of the rotator cuff in series ranging from twenty to 805 shoulders^7,30,53. Ultrasonography also has been used successfully to delineate full-thickness defects in the shoulder postoperatively. Accurate interpretation of sonographic images requires an extremely experienced sonographer who has the frequent opportunity to correlate the readings with the intraoperative findings. The sensitivity for the diagnosis of postoperative tears of the cuff approached 95 per cent over-all, and failure to visualize a supraspinatus musculotendinous unit was virtually 100 per cent predictive of a complete tear, in series of fifty¹³ and seventy-two³⁹ patients. Unlike preoperative magnetic resonance imaging scans, postoperative scans do not delineate partial tears of the rotator cuff accurately. Persistent full-thickness tears can be assessed accurately when there is a well defined defect in the tendon that displays high signal intensity on T2-weighted images (Fig. 5).

The clinical importance of a persistent full-thickness tear must be integrated within the context of the growing body of literature defining the presence of asymptomatic or minimally symptomatic tears. These data come from cadaver studies, imaging studies of shoulders after repair, clinical series of shoulders that have had subacromial decompression without repair of a massive tear, and imaging studies of asymptomatic individuals.

DePalma et al.¹¹, in their classic study of 108 cadavera, determined the prevalence of defects of the rotator cuff relative to aging. Although no specimens from individuals who had died before the fifth decade of life had a tear of the rotator cuff, 33 per cent from those who had died in the fifth decade and 100 per cent from those who had died in the seventh decade had a complete tear. Forty-four of these specimens were obtained during autopsies on patients for whom the history and the findings on physical examination had been negative for a lesion of the rotator cuff.

Calvert et al.⁷ used arthrography to study twenty shoulders after repair of the rotator cuff. They found that eighteen of the shoulders had a persistent defect and that seventeen of the eighteen had satisfactory relief of the preoperative pain. Harryman et al.¹⁹, in a larger, more detailed study, performed bilateral ultrasonography on 122 patients after repair of the cuff. Of 105 patients who had a postoperative defect of the cuff, ninety-four were satisfied with the decrease in pain. Persistent defects were related to a decreased range of motion of the shoulder and to an inability to perform activities of daily living. Additionally, the subjective results associated with intact repairs of recurrent tears were as successful as those associated with intact repairs of primary tears. The size of the tear was not related to the subjective assessment of function or pain relief at the latest follow-up evaluation if the repair had remained intact. However, a repair of a large defect is less likely to heal than is a small tear.

These results are not surprising, given the recent reports in the literature concerning the results of imaging of asymptomatic shoulders. With use of ultrasonography of the contralateral, asymptomatic shoulder of seventy-three patients who had a unilateral tear, Harryman et al.¹⁹ noted a defect of the rotator cuff in forty (55 per cent). Sher et al.⁴⁹ performed magnetic resonance imaging on ninety-six asymptomatic shoulders and found an over-all prevalence of full-thickness and partial-thickness tears of 15 and 20 per cent. All but one full-thickness defect was in a patient who was more than sixty years old.

Finally, the clinical importance of postoperative defects of the cuff must be interpreted in light of the evidence that acromioplasty and partial débridement or partial repair of a portion of the cuff is successful for the treatment of some large degenerative tears. Rockwood et al.^44,46 showed that this technique, coupled with intensive postoperative rehabilitation, can provide relief of pain and adequate function. Selection of the patients is critical, as the best results have been in patients who have had preoperative forward elevation of the shoulder above the horizontal plane, an intact long head of the biceps, and excellent function of the deltoid^44,46 (Figs. 6-A and 6-B). Less favorable results have been noted in patients who have had a previous operation, anterior deltoid dysfunction, or a tear of the biceps tendon^44,46. Although detachment of the cuff can provide favorable results in selected patients, we recommend repair of the cuff whenever possible.

To establish a treatment plan for patients in whom recurrent defects of the cuff are suspected, the results of imaging studies must be interpreted within the context of each patient's clinical presentation. Symptomatic patients who have subacromial crepitus, weakness of abduction and external rotation, and positive lag signs on external rotation as noted on physical examination are potential candidates for repeat repair. Findings at the time of the reoperation, including the size and location of the recurrent defect and the quality of the tendon and its degree of retraction and ability to be mobilized, will help to determine whether repeat repair of the torn edges of the tendon to bone is justified. A discussion of the patient's goals and expectations preoperatively is also important for guiding intraoperative decisions.

In conclusion, there are many potential causes of failure of rotator cuff repair. The categories of incomplete and incorrect diagnosis, errors of operative technique or postoperative rehabilitation, and postoperative complications are convenient for classification, but it must be remembered that there may be several causes of failure in any given patient. Clinical evaluation is most dependent on a careful history, a review of the medical record and the preoperative imaging studies, and a physical examination with use of injection tests as indicated. On the basis of this evaluation, a definitive diagnosis or a limited differential diagnosis often can be established. The selective use of additional imaging studies and diagnostic arthroscopy will define the anatomical abnormalities. These lesions must be correlated carefully with the clinical findings in order to determine their relative importance and to choose the appropriate treatment.

References

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Armstrong, J. R.: Excision of the acromion in treatment of the supraspinatus syndrome. Report of ninety-five excisions. J. Bone and Joint Surg.,31-B(3): 436-442, 1949.31-B(3)436 1949

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