Surgical treatment options for massive, retracted tears or failed repairs of the rotator cuff tendons

Failed rotator cuff surgery is usually a combination of several factors. Occasionally, it is a result of technical error, which in my experience is attributed to "weak repair" or repair under significant tendon tension which leads to progressive failure of the integrity of the repair. Ernest Codman established the principles of successful treatment of rotator cuff tears in the popular monograph "Rupture of the supraspinatus tendon and other lesions in or about the subacromial bursa " that he distributed to the members of American College of Surgeons at the beginning of the 20th century. In his monograph Codman talks about rotator cuff repair surgery in carefully "selected patients". Codman practiced the art of surgery with unparalleled leadership and established several principles for the successful treatment of rotator cuff disease. Today, "patient selection" remains the cornerstone of successful surgery in almost every field of orthopaedic surgery. But what did he mean when he talked about "patient selection" in rotator cuff surgery?

What makes the practice of medicine an art and not a science is the following:

The ability of the surgeon to see the problem within the patient's living environment, function and health status. The ability to understand the needs of the patient, the activity level, the reliability and willingness of the patient to get better and follow the postoperative instructions is a lifelong learning process for the practicing physician.  Any underlying health or personality factors that may affect the outcome need to taken into account before offering complex or even simple reconstructive rotator cuff surgery.

The following cases are examples of fitting a treatment plan or surgery to the profile and problem of a particular patient with a complex rotator cuff tear. A torn rotator cuff should never be approached with the only dilemma in mind "to fix or not to fix the torn tendons". This is illustrated below with two case examples.

Case 1: 

The following case represents a patient in his 70s who had 2 prior failed rotator cuff repairs. There were "heroic attempts" at repair of the rotator cuff which is indicated in the x-rays below. The number of the metallic anchors indicate the efforts to make the tendon repair successful. A repair is successful if the following factors can be justified as reported by one of the pioneers in shoulder surgery of our era:

1. Good tendon biology (smoking, diabetes or any other nutrition factors may affect healing)
2. Good tendon quality and quantity ( good elasticity and thickness of the tendon, and tension free repair)
3. Absence of glenohumeral arthritis (in the presence of arthritis the repaired rotator cuff will lead to increased contact pressures within the glenohumeral joint and make the pain worse!)
4. Reliable patient who will follow the rehab protocol and protect the repair for at least 3-6 months.

These x-rays above indicate that the blood flow to the footprint of the rotator cuff is compromised, due to the high number of anchors. In addition, the Grashey view indicates a slight superior migration of the humeral head which is a sign of rotator cuff failure. We elected not obtain a preoperative MRI as on exam the abduction and external rotation strength of the shoulder was 4/5 indicative of involvement of the supraspinatus and infraspinatus. The diagnosis of massive rotator cuff tear was clear.

There was no anterosuperior escape and active forward elevation was to 100 degrees without signs of pseudoparalysis. Although there is mild arthritis and the pain level was 9/10 on the VAS scale, it seems that prior to a reverse total shoulder replacement an attempt to improve motion and pain by removing the anchors shoulder be made. Any prominent anchors should be removed and by performing of what Frederick Matsen calls "the smooth and move" procedure there is good chance of establishing a smooth articulation of the humerus to the coracoacromial (CA) arch. 

The smoothness of the CA arch is imperative in allowing painless elevation of the shoulder.

Indeed, in this case loose sutures and prominent anchors were seen and removed. The retracted rotator cuff tendon was debrided to stable margins as seen in the pictures below.

Loose sutures at the footprint of the rotator cuff

Humeral head arthritis does not permit rotator cuff repair as such operation increases contact forces in the GH joint and makes the pain worse!

Prominent anchors were removed

Loose or prominent sutures were removed as well.

VIDEO

VIDEO  Massive irreparable rotator cuff tear with tendon of poor quality and quantity 

The above operation resulted in decrease of the pain from 9/10 to 2/10 and improved the active forward elevation from 100 degrees to 170 degrees. After this surgery there is no need for dedicated rehab, for protection any tendon repair and no retained hardware that can complicate future reconstructive surgery. 

Case 2:

The following case represents the same scenario as in Case 1, however the patient is in his 40s, had two previous failed rotator cuff repairs, there is no glenohumeral joint arthritis, there is slight high riding humeral head and there is some tendon left of good thickness that may permit a repair as indicated on the MRI. However, there is shortening of the tendon and a double or single row rotator  cuff repair with anchors is not feasible as there will be significant tension in the repair. The two prior failed repairs highlight the need for a tension free repair. 

As seen in the pictures below there is no arthritis on xray and the MRI arthrogram shows supraspinatus tendon tear with retraction of 4 cm from the footprint 

The arrow indicates the retracted edge of the supraspinatus.

During arthroscopy there was a prominent bioabsorable anchor as seen below. This anchor along with loose suture was removed.

Loose sutures at the fooprint are seen above, viewing from posterior portal with a spinal needle in place

Prominent anchor is seen at the fooprint just anterior to the infraspinatus. Viewing from posterior portal.

A decision was made due to the size and the shape of the tear to proceed with margin convergence which decreased the size of the tear as shown in the drawing below. There was a tendon split at the infraspinatus supraspinatus margin which was incorporated into the margin convergence (video) :

This technique limits superior migration of the humerus during active forward elevation and provides "coverage" of the humeral head with healthy tendon. Biomechanically, when such a tendon to tendon repair heals - which is easier to heal compared to a tendon to bone repair - the forces responsible for humeral head rotation and depression applied by the rotator cuff are partially restored in a suspension bridge configuration as seen below:

Video 1: Size and configuration of the U type tear with an associated substance tear at the infraspinatus supraspinatus margin. The probe is inserted from the anterior portal and the arthroscope from the posterior portal - right shoulder. The area of the prominent anchor that was removed is indicated at the footprint. There is a hole in the rotator cuff footprint of the humerus.

Video 2: Viewing from posterior portal, cannula in the anterior portal, subacromial space, right shoulder. Traction sutures placed in the infraspinatus. Notice the elasticity of the tendon when traction is applied to it. This large size tear cannot be repaired to the footprint by repairing the edges of the tendons back to the fooprint in a "classic" double or single row configuration. In addition, notice the bone loss at the fooprint after the removal of the failed/prominent anchor from prior failed rotator cuff repair.

Video 3: Viewing posterior portal, cannula in the anterior portal, subacromial space, right shoulder. The margin convergence is completed with three non absorbable sutures and nearly 90% of the footprint of the rotator cuff is covered without the need of anchors, tendon transfer or patch.

Reverse total shoulder replacement for medial glenoid erosion and retroversion in cuff tear arthropathy

This case illustrates a successful treatment of a complex shoulder problem. Prior to the introduction of the reverse total shoulder replacement, the operative treatment would have been impossible or very challenging

Rotator cuff arthropathy with glenoid medial erosion and retroversion.

Reverse TSA

Dislocation of reverse shoulder replacement. Can we always identify the reason?

This case illustrates an early dislocation of a reverse total shoulder replacement (rTSA). The procedure was done for severe rotator cuff arthropathy with very limited preoperative active motion. In fact the active forward elevation was 10 to 20 degrees. During surgery an insitu humeral cut was required to achieve shoulder dislocation due to significant stiffness and difficulty in dislocating the shoulder for the humeral cut. After a successful rTSA and at 3 weeks postoperatively, the patient was found to have an anterior dislocation but reported no pain. Interestingly, he had no idea that the shoulder was dislocated. It was found dislocated at a routine follow up visit. Closed reduction was unsuccessful, and for that reason the patient was taken to the operating room for revision. A revision was performed to a thicker polyethylene which made the prosthesis stable intra-operatively at the extremes of ROM. In addition, no impingement was seen intra-operatively. Two weeks later he dislocated again in an anterior direction and again the patient was pain FREE.

Preoperative images are seen above

First dislocation is seen above 3 weeks after index procedure

Revision to thicker polyethylene provided stability for a short period of time (2 weeks)

At two weeks after the revision to a thicker polyethylene the shoulder was dislocated anteriorly and interestingly the patient

1. was not aware of when or how this happened
2. had NO PAIN.

During the past 7 years of my shoulder practice I have used the reverse TSA to solve complex problems of failed prior shoulder operations and never had a dislocation. I am not sure I understand the exact reason of this failure. An attempt is made below to identify the cause.


Identifiable reasons for dislocations are:

1. Male gender
2. Infection
3. Non compliance with restrictions in activity
4. Trauma
5. Prior shoulder surgery with an unstable prior arthroplasty - greatest risk
6. Soft tissue imbalance
7. Implant design
8. Scapular notching
9. Subscapularis release and choice of no repair back to humerus
10. Impingement to bony structures or soft tissue
11. High BMI
12. Component malpositioning
13. Abutment of the medial aspect of the humeral cup against the scapular neck causing the humeral component lever away from glenosphere.
14. Loose soft tissue tensioning.

From those factors only number 1, 3, 7  can be considered in this case as the revision surgery and evaluation of the shoulder intra-operatively eliminated the other factors.

In the Australian registry 2016 (Data Period 1 September 1999 – 31 December 2015) the proportion of rTSA has increased from 43.7% in 2010 to 64.1% in 2015. In the same registry the majority of revisions of reverse total shoulder replacements were done for dislocation or instability. However, it is not mentioned how many of those remained stable. In general the rate of revision after rTSA is 3-10% for instability or dislocation and it is the most common complication in the majority of published series of rTSA. In the Australian registry instability or dislocation accounts for 38% of all revisions.

Some implant designs are prone to high chances of impingement as seen below, as the humerus or polyethylene is in close proximity with the glenoid.

Bottomline is we are still learning about the reverse total shoulder prosthesis and there is a lot of space for improvement in the design and patient selection process.

While initially the patient elected to avoid a 3rd operation, later on during the course of his treatment he decided to proceed with conversion to a hemi-arthoplasty. Pictures below show that his scapula is superiorly tilted. This scapula position, is different compared to superior glenoid wear which is seen in rotator cuff arthropathy. Correction of this scapula alignment with over-reaming inferiorly could have been a possible solution, however the eccentric glenoid reaming and removal of glenoid bone  inferiorly would be have extensive and thus weakening the fixation and of glenosphere to the glenoid .

The films after the conversion to hemi-arthroplasty are seen below:

Is it time for hybrid polyethylene and metallic cage pegged glenoid components?

There are implant companies that promote hybrid - "metallic cage" pegged polyethylene glenoid components. This is not a new concept. Several companies have introduced glenoid components in the past that have metal pegs in an attempt to solve the problem of radiolucent lines around the glenoid peg holes which in some series can reach a frequency of 70% on initial radiographs. The concern with the cage or metallic cage pegs, is that the junction of the polyethylene to the metallic peg will see extensive stress during the edge loading of the glenoid rim from the humerus. The plastic deformation of the polyethylene is advantageous for the shoulder joint. In this new design the concern is that these "new" hybrid polyethylene components may fail the same way that the metal back glenoid components fail. Dissociation is a true concern. We need to have 5 year data to decide whether this is the case. In the meantime, I continue to use all poly cemented pegged glenoid components such as the one seen on X-rays below:

Neer Award 2017: A rapid method for detecting Propionibacterium acnes in surgical biopsy specimens from the shoulder

Background: Propionibacterium (P) acnes infection of the shoulder after arthroplasty is a common and serious complication. Current detection methods for P acnes involve anaerobic cultures that require pro- longed incubation periods (typically 7-14 days). We have developed a polymerase chain reaction (PCR)- restriction fragment length polymorphism (RFLP) approach that sensitively and specifically identifies P acnes in tissue specimens within a 24-hour period.
Methods: Primers were designed to amplify a unique region of the 16S rRNA gene in P acnes that con- tained a unique HaeIII restriction enzyme site. PCR and RFLP analyses were optimized to detect P acnes DNA in in vitro cultures and in arthroscopic surgical biopsy specimens from patients with P acnes infections. 
Results: A564base-pairPCRampliconwasderivedfromalloftheknownPacnesstrains.HaeIIIdigests of the amplicon yielded a restriction fragment pattern that was unique to P acnes. P acnes-specific amplicons were detected in as few as 10 bacterial cells and in clinical biopsy specimens of infected shoulder tissues. 
Conclusion: This PCR-RFLP assay combines the sensitivity of PCR with the specificity of RFLP mapping to identify P acnes in surgical isolates. The assay is robust and rapid, and a P acnes-positive tissue specimen can be confirmed within 24 hours of sampling, facilitating treatment decision making, targeted antibiotic therapy, and monitoring to minimize implant failure and revision surgery.
Level of evidence: Basic Science Study; Microbiologic Laboratory Study
© 2016 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Comment: this is a significant contribution, the sample costs 5 dollars and it simplifies the process of diagnosis a low grade infection which most of the time is in "stealth mode" and it is difficult to diagnose. The protocol I follow when I suspect a p acnes infection is that I do a one stage exchange of the components, i do not remove well fixed components, I do extensive debridement and I prescribe oral Augmentin 875 mg BID for 14 days until the cultures are finalized. This window of antibiotic treatment with Augmentin can be eliminated with the use of this test. Below is an example of a different application for the diagnosis of pseudomonas.



The authors of the p acnes paper state:

"A major strength of PCR-RFLP assay described in this report is its specificity for P acnes. This specificity is predicted to be greater than routine culture-based approaches and previously published PCR approaches, because it has 2 levels of verification. The first level is PCR amplification with P acnes-specific primers, and the second is a P acnes-specific RFLP pattern. Previous reports had the first (albeit less specific than ours), but not the second. The strength of this extremely sensitive technology is the ability to detect fewer than 10 P acnes cells in the sample. The weakness is that this level of sensitivity makes aseptic sample collection very important. PCR and RFLP mapping are techniques that are routinely performed in many clinical microbiology and pathology laboratories, and so this approach is not restricted to highly specialized research laboratories."

Revision of failed cemented hemiarthroplasty to a reverse total shoulder replacement

Failure of healing of the tuberosities is considered a frequent cause of poor outcome after hemi-arthroplasty for proximal humerus fracture. Cemented hemi-arthroplasties that have failed to provide adequate pain relief or function to the shoulder are very challenging problems. Most of the time the patient is an elderly person, there might be associated osteopenia, and the active shoulder range of motion is limited. The following case is an example of the challenges that a surgeon is facing in the treatment of this complex problem.

This patient underwent 3 shoulder surgeries prior to referral to us.  The primary press fit hemi-arthroplasty for the proximal humerus fracture was the first surgery which was revised to a cemented hemi-arthroplasty due to loss of the version of the press fit prosthesis. The 3rd operation was done as an attempt to revise to a reverse shoulder replacement and a vascular injury resulted in abandoning the surgery. Subsequently the patient was referred to us for treatment. She had constant pain and very limited active forward flexion of the shoulder.

Below are the preoperative Grashey X-ray of the shoulder which demonstrates a high riding humeral head and prosthesis, failure of healing of the tuberosities, no signs of loosening of the implant, and thin cortices at the metaphyseal area of the proximal humerus. A CT scan shows good bone stock and no cavitation of the glenoid.

Revision to a reverse shoulder replacement was considered in this case as there was enough glenoid bone stock and the patient was older than 70 years of age. The main challenges of this surgery are outlined below:

1. Prior axillary artery repair, increase risk of repeat vascular injury as there is an altered surgical field from 3 prior surgeries

2. Although there is modularity of shoulder implants with the option to preserve the humeral stem and convert to a reverse total shoulder replacement, a high riding humeral prosthesis in combination with scar tissue from prior surgeries does not permit enough lengthening of the arm for conversion to a reverse.  

3. Preservation of the humeral stem seems impossible in this case as it is necessary to displace the humeral head distally enough to accommodate an inferior placed glenosphere on the glenoid

4. Removal of a well fixed cemented humeral stem in the setting of osteopenia with thin bone cortices  is one of the most challenging problems in shoulder revision surgery. There is a high risk for fracture.

Taking into consideration those challenges and being prepared for those complications we elected to proceed with conversion to a reverse total shoulder replacement. The steps for a conversion to a reverse are outlined below:

1. Careful approach to the shoulder using the previous deltopectoral approach

2. Removal of the prosthetic humeral head from the stem

3. Prior multiple cultures showed no signs of infection, however multiple cultures were obtained again

4. Osteotomes were used on the proximal collar to "debond" the prosthesis and avoid fracture of the tuberosities during the removal of the stem. 

 5. A vertical humeral uni-cortical osteotomy was performed with an oscillating saw. With a set of osteotomes that are placed vertically in the osteotomy site - within the osteotomy - gentle twisting opened the humeral envelope and increased the diameter of the canal by a few millimeters. Gentle repetition of this twisting created a visible gap between the cement mantle and the prosthesis. It is important to avoid distal extension of the osteotomy pass the tip of the humeral prosthesis as this creates a stress riser. 

6. A bone impactor is placed on the collar of the prosthesis proximally and the stem was gently tapped which resulted in extraction of the prosthesis.

7. Cables were passed around the shaft of the humerus and a new press fit implant was selected by assessing the diameter of the cemented humeral canal with a straight reamer. A "tight fit" is enough for fixation as later closure of the osteotomy site with the cables will create a stable construct. Cement can be used at this stage if desired.

The remaining part of the case was a typical implantation of a reverse prosthesis. 

Postoperative xray is shown below:

6 weeks after surgery there is healing of the osteotomy and no dislocation

Arthroscopic glenoid fracture fixation

Intra-articular fractures of the glenoid associated with fractures of the body of the scapula can be treated non operatively most of the time. Intra-articular glenoid step off and gapping of more than 5 mm may require operative fixation in selected patients. Fixation can be completed arthroscopically eliminating the need for excessive soft tissue surgical trauma. In the following video the technique for fixation of such fractures is demonstrated.