"Rotator cuff repair" "You keep using that word. I do not think it means what you think it means."

One of my colleagues loves this quote of Inigo Montoya in the Princess Bride: "You keep using that word. I do not think it means what you think it means."

Inigo was referring to the word "Inconceivable", but this quote may also apply to arthroscopic rotator cuff repair.

According to a recent article, Characteristics of clinical shoulder research over the last decade: a review of shoulder articles in The Journal of Bone & Joint Surgery from 2004 to 2014, the most cited article on clinical shoulder research was "The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears"

The authors of this most cited article evaluated 18 patients who had complete arthroscopic repair of a tear measuring >2 cm in the transverse dimension at a minimum of twelve months after surgery and again at two years after surgery. The evaluation consisted of a standardized history and physical examination as well as calculation of the preoperative and postoperative shoulder scores according to the system of the American Shoulder and Elbow Surgeons. The strength of both shoulders was quantitated postoperatively with use of a portable dynamometer. Ultrasound studies were performed with use of an established and validated protocol at a minimum of twelve months after surgery.

Recurrent tears were seen in seventeen of the eighteen patients. Despite the absence of healing at twelve months after surgery, thirteen patients had an American Shoulder and Elbow Surgeons score of >/=90 points. Sixteen patients had an improvement in the functional outcome score, which increased from an average of 48.3 to 84.6 points. Sixteen patients had a decrease in pain, and twelve had no pain. Although eight patients had preoperative forward elevation to <95 degrees, all eighteen regained motion above shoulder level and had an average of 152 degrees of elevation. At the second evaluation, a minimum of twenty-four months after surgery, the average score, according to the system of the American Shoulder and Elbow Surgeons, had decreased to 79.9 points; only nine patients had a score of >/=90 points, and six patients had a score of </=79 points. The average forward elevation decreased to 142 degrees.

They concluded that arthroscopic repair of large and massive rotator cuff tears led to a high percentage of recurrent defects. The minimum twelve-month evaluation showed excellent pain relief and improvement in the ability to perform activities of daily living despite the high rate of recurrent defects; however, at a minimum follow-up of two years, the results deteriorated with only twelve patients who had an American Shoulder and Elbow Surgeons score of >/=80.

Comment: This sentinel article taught us that "repair" doesn't always mean what we think it does. Durable rotator cuff repair did not occur in many of these patients despite improvement in clinical outcome. Thus, improved clinical outcome cannot be used to judge the success of a surgical attempt to reattach the torn tendon to the tuberosity. This fact is echoed in many other articles, as shown in this post.

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Non-operative treatment of the failed shoulder joint arthroplasty

In that one of the principal manifestations of a failed arthroplasty is stiffness, gentle stretching exercises can often be helpful.
More about stretching
More about stretching
Stretching, manipulation

When the problem is weakness, gentle strengthening exercises may be helpful.
More about strengthening
The traction three

Here's a comprehensive exercise plan

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Resection arthroplasty

Resection arthroplasty for failed shoulder arthroplasty

The authors of this paper found 26 patients having had resection arthroplasty for failure of a primary arthroplasty. These patients demonstrated significant improvement in their pain score but not their function. What we found most interesting about this paper was that all but four of these resections were performed for intractable infection.
Patients having resection for reverse total shoulders had poorer function than those having resection for failed total shoulders or hemiarthroplasties.

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Resection arthroplasty

Resection arthroplasty for failed shoulder arthroplasty

This is a Level IV  review of 26 patients who underwent resection arthroplasty  at a mean follow-up of 41.8 months (range, 12-130 months) after a prior shoulder arthroplasty (total shoulder, hemiarthroplasty or reverse total shoulder). The procedures were performed at 5 different centers. The number of patients having resection arthroplasty at these centers but who were not available for follow-up is not known.

 At follow-up, the average VAS pain score was  3.2 ± 2.5 (0-10), the average Constant Score (for 21 of the shoulders) was  27.3 ± 12.5 (3-53), and the average forward elevation was 46.7 ±  29.1 degrees (0-100).

The most impressive aspect of this series was that 22 of the 26 resection arthroplasties were for arthroplasties that had become infected. The organisms responsible for the infections were not identified. Infection was not identified in the remaining four, however the protocol for culturing the shoulders was not explained. 

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Clinical results of revision shoulder arthroplasty using the reverse prosthesis. JSES

Clinical results of revision shoulder arthroplasty using the reverse prosthesis. JSES

Thirty shoulder arthroplasties in 28 patients were revised for rotator cuff deficiency , instability,  fracture, glenoid deficiency, and sepsis using a reverse total shoulder. Fifteen shoulders had complications of the revision of which seven required at least one additional surgery. The article illustrates methods for humeral component removal, humeral reconstruction with graft and glenoid reconstruction with graft. 

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Reverse total shoulder arthroplasty for failed shoulder arthroplasty. JSES

 reverse total shoulder,

Reverse total shoulder arthroplasty for failed shoulder arthroplasty. JSES

This report concerns 28 of 31 patients having revision of prior shoulder arthroplasty to a reverse total shoulder. These patients had extremely low SST scores before surgery (1.5) that improved to 7.6 at an average of 41 ± 17 months after surgery.

One of the cases shown demonstrates delayed cuff failure after a totals shoulder. Rotator cuff deficiency was the most common indication, followed by instability, infection, loosening and bony abnormalities. 

The authors remind us that reverse total shoulders have themselves a rather high complication rate, especially when performed for revision of a prior arthroplasty. 

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The reverse total shoulder for prior failed shoulder surgery

Recently we have had the chance to use the reverse total shoulder to manage some challenging shoulder problems. Some recent cases are illustrative.

The first is a patient who fell and sustained a fracture of the proximal humerus. Ten years ago the fracture was internally fixed, but the patient experienced ongoing severe pain and loss of function.

When she first met us, the shoulder looked like this.

After a detailed discussion of the alternatives we decided to offer her a reverse total shoulder. The key step in the procedure was transecting the head from the shaft before attempting to dislocate the proximal humerus - it turns out that the displaced humeral head was tightly scarred to the brachial plexus. The post operative x-rays look like this. We will eagerly await her functional outcome.

The second case was a shoulder that had had a standard arthroplasty a decade ago with an outstanding functional result. 

Recently, however the patient took a fall landing on the arm, losing the ability to actively elevate the arm due to a massive cuff tear.

We converted this to a reverse. The key step here was preserving the quality of the glenoid bone by cutting through the polyethylene pegs with an osteotome, rather than trying to dig the pegs and cement out of the glenoid bone. The base plate was then placed over the prepared glenoid surface.

Again, we eagerly await the result.

Stay tuned.

A third case presented with a rotationally unstable humeral component inserted for treatment of a four part fracture.

Because of concern about infection, this was revised to a spacer. Happily, there was no significant growth from the cultures taken at surgery.

Two years ago we revised the spacer to a reverse. Today she has a comfortable shoulder with 110 degrees of active elevation.

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Revision surgery for failed shoulder replacement arthroplasty due to glenoid component failure, Part 10

To continue with our discussion of the management of glenoid component failure, we've observed that attempts to reinsert a new glenoid component are accompanied by a high failure rate due to to the loss of supporting bone (two right hand figures below) in contrast to the situation when the first glenoid component was inserted (two left hand figures below).

Thus when we encounter a substantial glenoid defect, such as that shown below

rather than using a large amount of cement, bone graft, or a special component to fill the defect, we have been pleased with the result from removing all polyethylene, bone cement, and rough bone and then contouring the residual glenoid bone to support a new humeral head component (usually one with a diameter of 56 mm to achieve the maximal contact area.

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The smooth and move in the management of irreparable tears or failed rotator cuff repairs

While there is much current emphasis on restoring anatomic integrity of rotator cuff defects, this is not always in the best interest of the patient, particularly if a prior attempt at cuff repair has failed.

In patients with irreparable cuff tears or failed prior repairs that have preserved active elevation, the results of the 'smooth and move' can be excellent. This procedure enables immediate active use of the arm without the need to protect a tenuous repair. A full shoulder motion program can be started right away after surgery and progressed to gentle shoulder strengthening as rapidly as shoulder comfort permits.

Here is a followup note from a sixty year old rancher who had bilateral 'smooth and move' procedures without any attempt to repair his large supraspinatus or infraspinatus tendon defects. While some may have considered 'marginal convergence', a cuff graft, a tendon transfer, a superior capsular reconstruction or even a reverse total shoulder, none of these seemed appropriate for this active man who wanted to get back to roping cattle on his ranch.

From his operative note on the right side: "This rancher has pain and loss of function of his right shoulder. He has had a rotator cuff tear which was treated with a graft jacket. Unfortunately, this became infected and required debridement, leaving him with a stiff, painful shoulder.

There was extensive scar throughout the humeral scapular motion interface. The subscapularis was detached but was reconstructible. The supraspinatus was absent. The upper 2/3 of the infraspinatus was absent as well. There was minimal evidence of arthritis. The tuberosities were prominent. The undersurface of the coracoacromial arch was smooth. 

Under satisfactory anesthesia, the shoulder was carefully prepped and draped in the usual manner. The shoulder was approached through a superior "deltoid on" approach. The abundant scar in the humeral scapular motion interface was debrided. The previous sutures and graft jacket were excised. The bursa was removed. The prominent tuberosities were resected using a rongeur and a burr. The subscapularis was identified, freed from scar and reattached anteriorly. The wound was thoroughly irrigated. A manipulation under anesthesia was performed to assure a full range."

Two years later he had a similar procedure performed on left side for a failed prior repair.  His operative note states that there was "abundant scar in the humeroscapular motion interface. The supraspinatus was absent. The subscapularis was absent. The infraspinatus was absent in its upper 1/2. The biceps tendon was absent. The undersurface of the acromion was smooth.There was substantial scar and retained sutures. The deltoid was deficient in the area of the prior surgery.

The abundant scar in the humeroscapular motion interface was lysed.  The prior sutures were removed. The prominences on the humeral tuberosity were resected. The rough edges of the cuff were smoothed. The shoulder was gently manipulated for a full range of motion.The weakened area of deltoid was reinforced by imbrication of  the weakened area with six sutures of #2 Tevdek."

In a followup note he reported that both shoulders are dramatically improved and that he was back to roping and branding as shown in the photos below

Humeral component revision arthroplasty: outcomes of a split osteotomy technique. JSES

Humeral component revision arthroplasty: outcomes of a split osteotomy technique. - JSES

In this article our former fellow, Tony Romeo, recapitulates the split osteotomy technique described previously for the removal of a well-fixed humeral component.   This procedure is part of our comprehensive approach to the revision of failed shoulder arthroplasty.

Our only issue with this paper is that the authors recommend repairing the osteotomy with circumferential wires. The danger here is that the radial nerve comes to lie in a groove behind the humerus. While they had no nerve palsies, it is possible to circlage this nerve, so we prefer the 'bodice' repair.

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Revision for failed total shoulder arthroplasty because of glenoid loosening

As we've discussed in previous posts, glenoid component wear and loosening is one of the commonest causes of failure of total shoulder arthroplasty. While some surgeons recommend complex approaches to revision surgery, including glenoid bone grafting and special components, our approach is different.

Let me explain the reasons that we avoid bone grafting and avoid replacing the glenoid component:

(1) When a glenoid component has loosened, the bone beneath it is in the process of active resorption. While we clean out all the reactive tissue, we can't be sure that we've arrested this process and would not want to put a new component on deteriorating bone.

(2) When a glenoid component has loosened, there is a major structural defect, making the fixation of new glenoid component less secure that what was available at the original total shoulder replacement. Thus, it is logical to assume that the rate of failure for a reinsertion will be greater than that for primary total shoulder arthroplasty. We try to avoid building a house on an unstable foundation.

(3) When a glenoid component has loosened, the diagnosis of infection cannot be excluded at the time of surgery. Cultures for the most common organism found in this circumstance, P Acnes, are not final until several weeks after surgery. We avoid putting a new glenoid component or devitalized bone graft into a surgical field that may be contaminated.

(4) Revision to an uncemented humeral hemiarthroplasty with smoothing of the residual glenoid bone after thorough removal of all reactive tissue and scar offers the patient the opportunity for a permanent single stage revision on one hand while maintaing the option for a simple re-revision if that should become necessary down the line on the other hand. Furthermore, articulation of the soft glenoid bone with the metal humeral head gives the bone a chance to stabilize and mature with time, so that in the uncommon circumstance that glenoid reinsertion becomes desirable, this procedure can be performed with a more stable bony foundation and after any concern about infection has been resolved.


One of our first cases was a superior court judge known to be very tough on drunken drivers. He had a total shoulder that worked well for several years, but, perhaps related to his enjoying digging for geoducks, his glenoid component became loose. Over fifteen years ago we removed his loose glenoid, did no grafting or reimplantation. He continues to bang the gavel and to clam.

Here is a more recent case. A 50 year old coach from California came to see us because of bilateral painful total shoulders. It is obvious from the x-rays below that both of his glenoid components have failed. His SST scores were 5/12 on each side.

Three years ago we revised the left side. We withheld antibiotics until cultures could be obtained. There was a substantial amount of reactive tissue throughout the shoulder and abundant scar in the humeroscapular motion interface. The rotator cuff was intact. The glenoid component was loose. The humeral component was well fixed but proud superiorly. There was a substantial amount of osteolysis of the humerus and glenoid. Abundant samples of fluid and scar tissue were harvested from the area around the humerus. Some of this appeared to be chronic inflammatory, and some of the other elements appeared to be acute inflammatory reactions. These were sent for frozen section as well as for permanent sections, and finally specimens were sent for culture.

Both the humeral and glenoid components were removed; all reactive tissue was removed; the residual glenoid bone was smoothed with a 56 +2 "ream and run" reamer. A new humeral component was inserted using a press-fit with antibiotic-impregnated (vancomycin) allograft. Antibiotics were administered and continued for 6 weeks.

Two weeks after surgery, his cultures grew out P. Acnes.

Three months later we performed a revision of the right side. On this side there was no evidence of inflammation. The glenoid component and humeral head were removed. An extensive debridement was carried out. The humeral head was replaced with the appropriate eccentric inferior prosthesis after the glenoid bone was smoothed. No glenoid bone grafting was performed. Cultures were negative at one month.

His current x-rays (below) show healed, stable glenoid bone surfaces and secure humeral fixation. While both humeral heads are medialized, this has not been associated with loss of function: currently he answers "yes" to all 12 of the SST questions.

Here's another example of the many cases we've treated this way. This time it is an active lady, again from California with painful total shoulder replacements on each side.

Her preoperative films are shown here with loose glenoid compnents on the right and left sides. SST scores were 4/12 on the left and 5/12 on the right.

She had revisions on each side consisting of glenoid component removal, thorough removal of all reactive tissue, no bone grafting or reinsertion of glenoid components, and humeral head exchange.

Two years after her revision surgeries, she's regained the comfort and function in both shoulders with 10/12 SST scores on both sides. Here are her most recent films

We find this is a safe, straightforward approach to the relatively common problem of glenoid component failure.

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Reverse Total Shoulder for Combined Shoulder Arthritis and Massive Rotator Cuff Tear and for Failed Conventional Total Shoulder Replacement

The reverse total shoulder replacement can restore comfort and function to the arthritic shoulder combined with a massive rotator cuff tear and for failed conventional total shoulder replacement.  This combination of conditions can result in major loss of stability and active motion of the shoul­der. The reverse total shoulder provides stability of the shoulder joint so that the deltoid muscle can power the shoulder through a useful range of motion. In this procedure the arthritic ball is replaced by a socket fixed to the arm bone (humerus) by a stem that fits within it. A metal ball is fixed to the bone of the arthritic socket with screws. Success requires technical excellence of the surgery and a commitment to the rehabilitation program until the desired range of motion can be achieved comfortably. The figure below left shows the humeral stem, cup, and white polyethylene cup as well as the glenosphere (ball) and screws used for fixation into the scapula (shoulder blade). The figure below right is an x-ray of this prosthesis in place.

First, a review of some basics.

What Are The Key Parts Of The Normal Shoulder Joint?

The ball (humeral head) fits in the socket (glenoid) and is held there by the rotator cuff 

What Is Shoulder Arthritis?

Shoulder arthritis is a condition in which de­generation, injury, inflammation or previous surgery destroys the normally smooth carti­lage on the ball (humeral head-below left) and socket (glenoid-below right).

How Is Shoulder Arthritis Diagnosed?

Carefully standardized X-rays reveal the loss of the space between the hu­meral head and glenoid that is normally occupied by cartilage, leaving bone on bone contact.

What Is A Conventional Total Shoulder?

In a conventional total shoulder, the arthritic surface of the ball is replaced with a metal ball with a stem that is press fit in the inside of the arm bone (humerus-below left) and the socket (glenoid) is resurfaced with a high density polyethylene component (below right).

When Will A Conventional Shoulder Not Work?

When the rotator cuff is sufficiently torn that it no longer provides the necessary stability for the joint, the humeral head slides upwards. This results in slackening of the deltoid (below left) no longer able to raise the hand to carryout nor­mal activities. A conventional shoulder cannot restore the necessary stability in this situation (below right).

What Is A Reverse Total Shoulder?

In a reverse total shoulder the ball is located on the shoulder blade (glenoid) and the socket is located on the arm bone (humerus), exactly the opposite of the situation in a conventional total shoulder. This configuration provides sta­bility because the muscles around the shoul­der compress the ball and socket together. 

How Are The Parts Of A Reverse Total Shoulder Hooked To The Bones?

The ball (glenosphere) is screwed to the bone of the shoulder blade. The cup (humeral sock­et) is fixed to a stem that is cemented down the inside of the arm bone (humerus).

What Is The Incision Like?

After a general or regional anesthetic, this procedure is performed through an incision between the deltoid and the pectoralis major muscles on the front of the shoulder. It includes release of adhesions and con­tractures and removal of bone spurs that may block range of motion. Our team of surgeons, anesthesi­ologists, and surgical assistants usually perform this procedure in less than two hours.

Who Should Consider A Reverse Total Shoulder?

Surgery for shoulder arthritis and rotator cuff deficiency should only be considered when the condition of the shoulder is limiting the quality of the patient’s life and after a trial of physical therapy and mild analgesics to determine if non-operative management is helpful.  If severe disability persists, patients may consider the reverse total shoulder – no other surgical proce­dure has the ability to restore the stability needed in the absence of a functioning rotator cuff. The ideal patient is healthy, active, motivated and committed to complying with the rehabilita­tion program.

Who Should Probably Not Consider A Reverse Total Shoulder?

This procedure is less likely to be successful in individuals with depression or obesity. Pa­tients who use narcotic medication or who use tobacco may have increased difficult recover­ing from this procedure.

What Are The Keys To Success Of A Reverse Total Shoulder?

Success requires technical excellence of the surgery and a commitment by the patient to fol­low the rehabilitation program prescribed by the surgeon.

How Does A Patient Prepare For A Reverse Total Shoulder?

As for all elective surgical procedures, the patient should be in the best possible physical and mental health at the time of the procedure. Any heart, lung, kidney, bladder, tooth, or gum problems should be managed before surgery. Any infection may be a reason to delay the operation. Any skin problem (acne, scratches, rashes, blisters, burns, etc) on the shoulder or arm should be resolved before surgery. The shoulder surgeon needs to be aware of all health issues, including allergies as well as the non-prescription and prescription medications being taken. For instance, aspirin and anti-inflammatory medication may affect the way the blood clots. Some of these may need to be modified or stopped around the time of surgery.

What Happens After Surgery?

The reverse total shoulder is a major surgical procedure that involves cutting of skin, tendons and bone. The pain from this surgery is managed by the anesthetic and by pain medications. Immediately after surgery, strong medications (such as morphine or Demerol) are often given by injection. Within a day or so, oral pain medications (such as hydrocodone or Tylenol with codeine) are usually sufficient. The shoulder rehabilitation program is started on the day of surgery. The patient is encouraged to be up and out of bed soon after surgery and to pro­gressively reduce their use of pain medications. Hospital discharge usually takes place on the second or third day after surgery. The arm is kept in a sling for six weeks after the proce­dure to allow for healing, but the patient can use the hand for eating.  Driving is not recom­mended during this time. Thus the patient needs to be prepared to have less arm function for the six weeks after surgery than immediately before surgery. For this reason, patients usually require some assistance with self-care, activities of daily living, shopping and driving.  Man­agement of these limitations requires advance planning to accomplish the activities of daily living during the period of recovery.

What About Rehabilitation?

After the six weeks in a sling, progressive use of the shoulder for usual daily activities is en­couraged. Formal physical therapy is often not needed.

When Can Ordinary Daily Activities Be Resumed?

The reverse total shoulder is not a procedure that is designed for heavy use or sports.  It is designed to help the patient regard the gentle activities of daily living.  Every precaution should be taken to avoid falls on the operated shoulder.

What Problems Can Complicate A Reverse Total Shoulder And How Can They Be Avoided?

Like all surgeries, the reverse total shoulder can be complicated by infection, nerve or blood vessel injury, fracture, instability, component loosening, and anesthetic complications. Fur­thermore, this is a technically exacting procedure and requires an experienced surgeon to optimize the bony, prosthetic and soft tissue anatomy after the procedure.  The procedure can fail if the reconstruction is too tight, too loose, improperly aligned, insecurely fixed or if unwanted bone-to-bone contact occurs. 

Conclusion

Summary reverse total shoulder replacement for the arthritic shoulder combined with a massive rotator cuff tear. 

The reverse total shoulder is a a technically challenging surgical procedure that can restore comfort and function to shoulders with arthritis and mas­sive defects in the rotator cuff or in failed conventional total shoulder replacement. In the hands of an experienced surgeon, the reverse total shoulder can be an effective method for treating shoulders arthritis and severe rotator cuff deficiency. Pre-planning and persistent rehabilitation efforts will help assure the best possible result for the patient.

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