Rotator Cuff Treatment.

Last updated Wednesday, January 26, 2005

Figure 75

Failed cuff surgery

Causes of failure

Rotator cuff repair may fail to yield a satisfactory result for many reasons including failure to obtain preoperative expectations of strength and comfort, infection, deltoid denervation, deltoid detachment, loss of the acromial lever arm, adhesions in the humeroscapular motion interface, persisting subacromial roughness, denervation of the cuff, failure of the cuff repair, retear of abnormal tendon, failure of grafts to "take," failure of rehabilitation, and loss of superior stability. Effective treatment of these failures depends on the establishment of the proper diagnosis. Infectionrequires culture-specific antibiotics and irrigation and drainage if purulence is present. A prompt definitive approach may prevent joint surface destruction. Acute failure of the deltoid reattachment requires prompt repair before muscle retraction becomes fixed. Chronically painful and functionally limiting postoperative scarring often responds to gentle, frequent stretching at home. Shoulder manipulation in this situation is inadvisable because of the risk of cuff damage. However, in certain shoulders that are refractory to rehabilitation, substantial improvement in comfort and function can be achieved by an open lysis of adhesions and subacromial smoothing, followed by early assisted motion. Weakness of shoulder elevation often responds to gentle, progressive strengthening of the anterior deltoid and external rotators. Persistent weakness requires evaluation for possible neurological injury or cuff failure. Denervation of the deltoid is diagnosed by selective electromyography of the anterior muscle fibers. In selected cases, anterior deltoid denervation may be treated by anterior transfer of the origin of the middle deltoid with closure to the clavicular head of the pectoralis major, although consistently good results from this procedure have not been documented. Denervation of the supraspinatus and infraspinatus or subscapularis is diagnosed by selective electromyography and is difficult to manage. Postoperative cuff failure is suggested by failure of the patient to regain strength of external rotation or elevation of the shoulder, subacromial snapping, and upward instability of the humeral head. In this situation arthrography may not be reliable; false-negative results from scarring or false-positive results from inconsequential leaks reduce the diagnostic accuracy. In our experience, expert dynamic cuff ultrasonography provides the most specific data on cuff thickness and integrity. Repeat cuff exploration with smoothing or repair may be considered, although the patient is warned that the tissue may be of insufficient quantity and quality for a durable re repair. Loss of superior stability can result when the coracoacromial arch has been sacrificed without reestablishing stability with a durable cuff repair. The deltoid becomes stretched so that the humeral head seems to be just below the skin. Patients who lose stability and deltoid function are some of the most unhappy we encounter after previous repair attempts.

The results of surgery for failure of previous cuff repairs are inferior to those of primary repair. DeOrio and Cofield (DeOrio and Cofield, 1984) reviewed their experience with re repairs. At a minimum of two years' follow-up (average four years), 76 percent of patients had substantial diminution of pain; however, 63 percent still had moderate or severe pain. Only seven patients gained more than 30 degrees of abduction, and only four patients were felt to have a good result. The authors suggest that the main benefit of repeat cuff surgery is likely to be a reduction in discomfort.

Harryman et al (Harryman, Mack, 1991), however, showed that if cuff integrity is durably established at revision surgery, the results were comparable to those of primary repairs.

Arthrodesis

When a shoulder has been devastated by infection, deltoid detachment or denervation, intractable cuff failure or denervation, and/or acromionectomy, consideration is given to shoulder arthrodesis. Under these circumstances, a glenohumeral arthrodesis provides a salvage option: by securing the humeral head to the scapula, the scapular motors can be used to power the humerus through a very limited range of humerothoracic motion. 

The best candidates for this procedure are those patients with

1. permanent and severe weakness due to loss of cuff and deltoid function,
2. good bone stock,
3. a good understanding of the limitations and potential complications of a shoulder fusion,
4. intact scapular motors,
5. good motivation,
6. minimal complaints of pain, and
7. a functional contralateral shoulder.

To establish the limitations of shoulder fusions, we studied twelve patients who had glenohumeral arthrodeses at least two years prior to the time of study. (Matsen, Lippitt, 1994) In these patients, elevation in theplus 90 degrees (anterior sagittal) plane averaged 47 degrees. Elevation in the minus 90 degrees (posterior sagittal) plane averaged 22 degrees. External rotation averaged 9 degrees and internal rotation 46 degrees. These ranges of motion were similar to the scapulothoracic motion measured in normal subjects. Only one of the patients could reach his hair without bending his neck forward, only five could reach their perineum, six could reach the back pocket, seven the opposite axilla, and ten the side pocket.

We also studied normal in vivo shoulder kinematics to predict the functions which would be allowed by various positions of glenohumeral arthrodesis, assuming that the scapulothoracic motion would remain unchanged. Using the normal scapulothoracic motions we were able to model the functional effects of fusion positions. We found that activities of daily living could be best performed if the joint was fused in 15 degrees of flexion, 15 degrees of abduction, and 45 degrees plane and 45 degrees of internal rotation (see figure 75). This low angle of elevation and relatively high degree of internal rotation facilitated reaching the face, opposite axilla, and perineum.

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