Rotator cuff repair after shoulder replacement

Rotator cuff repair after shoulder replacement Steven J. Hattrup, MD,a Robert H. Cofield, MD,b and Stephen S. Cha, MS,c Scottsdale, AZ, and Rochester, MN

Development of a rotator cuff tear after shoulder arthroplasty can adversely affect outcome. To assess the results of a subsequent procedure to repair the torn cuff, we reviewed all shoulder arthroplasties performed at our institution to identify patients who had a subsequent operation for cuff repair with or without component revision. We identified 19 patients and 20 involved shoulders. One patient was lost to follow-up, and one was excluded because the subsequent cuff repair could not be adequately accomplished. Patients were studied retrospectively a mean of 9.1 years after cuff repair by analysis of prospectively collected data supplemented by use of a questionnaire (10 shoulders). The presence of the tear was diagnosed preoperatively by physical examination or routine radiographs in 13 shoulders, an arthrogram in 3, and surgical exploration in 2. The tear involved the subscapularis in 7 shoulders, the supraspinatus in 15, and the infraspinatus in 8. Rotator cuff repair was successful in only 4 shoulders and was unsuccessful in the remaining 14. Pain was absent in 4 shoulders, slight in 6, occasionally moderate in 5, and moderate in 3. The mean visual analog pain score was 5.6. Range of motion was limited, with mean values for elevation of 78° and external rotation of 54°. Because results of subsequent cuff repair are poor, every attempt should be made to repair the cuff securely and carefully direct postoperative physical therapy. (J Shoulder Elbow Surg 2006;15:78-83.)

O ptimal outcome of total shoulder arthroplasty re-

quires proper balancing of soft tissue around a wellfixed implant accompanied by an intact rotator cuff. In a meta-analysis of 32 published series, Wirth and Rockwood27 reported that the third most common complication in more than 1600 replacements was tearing of the rotator cuff. Similarly, Cofield8 found

From the aDepartment of Orthopedics, Mayo Clinic, Scottsdale, and bDepartment of Orthopedic Surgery and cDivision of Biostatistics, Mayo Clinic, Rochester. Reprint requests: Steven J. Hattrup, MD, Mayo Clinic, 13400 E Shea Blvd, Scottsdale, AZ 85259. Copyright © 2006 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2006/$32.00 doi:10.1016/j.jse.2005.06.002

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rotator cuff disorders to be the second most frequent indication at the Mayo Clinic for revision of both total shoulder replacement and humeral head replacement. Cofield and Edgerton9 calculated an overall incidence of 2.2% to 2.7% for this complication. Yet, no published studies have specifically examined the outcome of repeat surgery for the complication of rotator cuff tearing after shoulder replacement. The indications for and benefits of operations for rotator cuff repair are unclear.27 To investigate the potential benefits of an additional operation to repair a rotator cuff tear after shoulder arthroplasty, we reviewed the experience at the Mayo Clinic. MATERIALS AND METHODS The Mayo Clinic Total Joint Registry was used to identify all cases of shoulder replacement performed at the institution between September 1976 and March 2001. Any patient who subsequently underwent rotator cuff surgery on the same shoulder was screened for inclusion in the study, which was approved by the Mayo Foundation Institutional Review Board. To ensure access to all operative reports for quality control of data, we considered only those patients who had both the arthroplasty and the subsequent cuff repair performed at the Mayo Clinic. The medical records of these patients were then reviewed for potential inclusion in the study. Because the purpose of the study was to assess the results of subsequent rotator cuff surgery, patients were excluded if they had a preexisting cuff tear or tearing in conjunction with posttraumatic tuberosity fracturing. Ultimately, 20 shoulders in 19 patients met the inclusion criteria of the study. Of the 19 patients who were included in the study, 2 had small preexisting rotator cuff tears that were clearly unrelated to the subsequent repair. These tears were a few millimeters in size, were considered incidental at the initial arthroplasty, and were not in the same anatomic location as the subsequent rotator cuff tear. They were, therefore, considered appropriate to include in the study. One patient with a single involved shoulder was lost to follow-up. An additional shoulder underwent an unsuccessful attempt at repair. At 6 months after routine arthroplasty complicated by a fall 3 months postoperatively, surgical exploration revealed a massive rotator cuff tear that could not be adequately repaired. The patient had a poor result and was not included in the analysis. This left 18 shoulders in the series. The medical records of these patients were abstracted for relevant demographic data; outcome data such as pain relief, range of motion, and strength; details of the rotator cuff tear; and need for further surgery. After arthroplasty,

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Table 1 Range of motion and strength assessment before and after arthroplasty and after rotator cuff repair

Before index shoulder arthroplasty

After index shoulder arthroplasty (complicated by rotator cuff tear)

After rotator cuff repair

Assessment

Mean

Range

Mean

Range

Mean

Range

Flexion (°) Abduction (°) External rotation (°) Abduction strength External rotation strength

109 108 25 4.6 4.7

45–180 50–165 0–70 4–5 4–5

85 83 51* 3.6* 4.0*

0–170 0–170 0–100 1–5 2–5

78 78 54 3.3 3.7

20–160 20–160 0–95 2–5 2–5

*These changes were statistically significant by the Wilcoxon signed rank test.

patients were strongly encouraged to return for periodic follow-up visits and were sent a questionnaire as a reminder. Prospectively gathered data were, therefore, typically available for this retrospective review. For a more contemporary assessment of outcome, these data were supplemented whenever possible with a current survey. Three patients with four involved shoulders were deceased, and four patients declined to participate in the most recent survey. Their follow-up was truncated at the most recent documented examination in the medical record. Patient characteristics were evaluated for their association with the surgical outcome, as determined by the clinical judgment of the operating surgeon. The Wilcoxon rank sum test was used to detect differences in range of motion, strength assessment, pain, delay to repair, and need for component revision among patients in the successful repair group compared with those in the failed repair group. All calculated P values were 2-sided, and P values of less than .05 were considered statistically significant.

RESULTS The information on these patients is best considered in 3 groups: (1) the status of the patient before the procedure complicated by the cuff tear, (2) the condition of the shoulder after the procedure followed by the rotator cuff tear (the index procedure), and (3) the most recent outcome after at least 1 attempt at repair. As might be anticipated, most procedures were in older individuals who, at presentation, had osteoarthritis. At the time of the index procedure, the mean age of the patients was 66 years (range, 45-81 years). The diagnoses were osteoarthritis in 10 shoulders, osteonecrosis in 2, failed arthroplasty in 3, traumatic arthritis in 2, and rheumatoid arthritis in 1. Patients all complained of moderate to severe pain and a limited range of motion (Table I). Fourteen procedures were total shoulder replacements, and four were humeral head replacements. The status of the rotator cuff was considered normal in 14 shoulders, somewhat thinned in 2, and torn in a small area in 2. As noted previously, repair was considered incidental to the

arthroplasty in these patients. No patients underwent associated acromioplasty. The results of the index procedure, which was, by definition, followed by a rotator cuff tear, were poor. Persistent pain was common; 6 shoulders were still severely painful, 9 had occasional to continuous moderate pain, 2 had mild discomfort, and 1 had no pain recorded. Postoperative range of motion and strength, except for active external rotation motion, were found to be inferior to preoperative range of motion and strength (Table I). Modern physical assessments of the integrity of the subscapularis, such as the liftoff or belly-press test, were not routinely recorded and, thus, were not studied. Other than the rotator cuff tear, complications associated with this procedure consisted of an element of instability in 10 shoulders; 2 cases each of nerve injury, glenoid arthrosis, or polyethylene disassociation from a metal-backed glenoid; and 1 case each of glenoid loosening or humeral loosening. The 2 instances of nerve injury were not viewed as clinically important to subsequent outcome. One patient had transient radial neuropathy that resolved before the patient was discharged, and one had a postoperative electromyogram and nerve conduction studies as part of the postoperative weakness workup. Although a patchy brachial plexopathy had been detected, the surgeon had judged it, at that time, as subclinical. The diagnosis of a rotator cuff tear in 12 shoulders was evident on the basis of a physical examination alone that identified persistent pain, loss of motion, and weakness. Superior subluxation of the humeral head with narrowing of the acromiohumeral distance found on plain radiographs provided the diagnosis in another patient and overall was found in 10 shoulders. Arthrography, performed for persistent pain, facilitated the diagnosis in 3 shoulders. In the final 2 shoulders, the tear was not suspected until surgical exploration. In addition, symptomatic instability was present in 10 shoulders. Five shoulders demonstrated an anterosuperior instability or an escape pattern on

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Table II Location of rotator cuff tearing Muscle

No. of patients

Subscapularis Infraspinatus Supraspinatus Subscapularis and supraspinatus Supraspinatus and infraspinatus Subscapularis, supraspinatus and infraspinatus

1 2 4 5 5 1

attempts at elevation, one had anterior instability, and four had posterior instability. The time from the index reconstruction to the rotator cuff repair was approximately 23 months. However, this interval varied widely (median, 15 months; range, 4-100 months). During surgical procedures, 5 of the tears were found to be of medium size, 12 were large, and 1 was massive. Only a single tear was limited to the subscapularis. The tears were distributed across the rotator cuff, involving the supraspinatus in 15 shoulders, the infraspinatus in 8, and the subscapularis in 7 (Table II). Repair was typically accomplished with the usual techniques, with tendon-to-tendon repair in 6 shoulders, direct advancement of tendon to bone in 4, and a combination of the two methods in 7. A single repair was accomplished with a superior subscapularis transfer. No patient underwent reconstruction of the coracoacromial ligament. In conjunction with the cuff repair, component removal was commonly necessary, because the original prosthesis was left intact in only 7 shoulders (Table III). The humeral component was exchanged in 10 shoulders. The new component was necessary to expose the glenoid because of a nonmodular component in 6 shoulders, to change the version because of instability in 2, because of a loose component in 1, and because of the preference of the surgeon for an alternate prosthetic system in 1. In a single case, the humeral head was revised alone to decrease tension on the cuff repair. Revision of the glenoid component was performed in 9 shoulders. In 4 cases, the revision consisted simply of a polyethylene insert exchange in a modular ingrowth glenoid component. In 3 shoulders, the polyethylene had dislocated from the metal backing, leading to revision with an all-polyethylene component. One glenoid component was revised to change the version because of instability, and 1 was removed because of loosening. The 2 patients with glenoid arthrosis had a glenoid component implanted during their revision surgery. Many patients required further surgery in addition to the procedure in which the cuff was repaired (Table III). Six shoulders underwent a second attempt at rotator

cuff repair. Glenoid complications were common, making glenoid revision necessary in 3 cases and removal of the glenoid component ultimately necessary in 1 shoulder. In addition, 1 humeral component was revised. If the cuff repair was found to have torn yet again, these shoulder repairs were treated as failures when the patients were evaluated at their most recent follow-up. The time of most recent follow-up was considered to be the last examination in the medical record or the date of the survey, whichever occurred later. The mean follow-up was 9.1 years (range, 1.8-22.1 years). Range of motion and strength were not found to have been improved by rotator cuff surgery (Table I). Pain was absent in 4 shoulders, slight in 6, occasionally moderate in 5, and moderate in 3. Only 4 rotator cuff repairs were identified as having healed satisfactorily clinically, whereas 14 were identified as having failed (Table III). In 7 shoulders, failure of the cuff repair was confirmed during an additional operation. The other 7 failures were diagnosed clinically by persisting symptoms of pain, weakness, and decreased range of motion. Seven shoulders with a presentation of instability continued to have clinically significant instability after an attempt at repair of the rotator cuff. Of the 4 repairs identified as having healed, 1 was later confirmed in a subsequent procedure for glenoid revision. There was no difference in pain reported by patients who had a clinically assessed intact rotator cuff compared with those who had repeat tearing (P ⫽ .378). Improvement was noted in active abduction (125° vs 65°, P ⫽ .0186) and flexion (125° vs 64°, P ⫽ .0218) for those shoulders identified as having an intact cuff compared with those that had cuff repair failure, respectively. There was no apparent relationship to timing of surgery and clinical success. The mean delay from arthroplasty to rotator cuff repair was 43 weeks in the 14 shoulders with an unsuccessful outcome and 121 weeks in the 4 shoulders with a successful outcome (P ⫽ .0168). In fact, all 12 repairs that were performed within 6 months were unsuccessful. These patients were also examined for any influence that the need for component revision surgery in conjunction with the rotator cuff repair had on their results. There were 10 shoulders in which component revision was performed and 8 in which this was not necessary. Three of the ten shoulders with revision surgery were judged to have a successful outcome versus one of the eight shoulders without concurrent component revision. This was not a significant difference (P ⫽ .3749). Active range of motion was also similar between the two groups, with mean active abduction of 73°, 73° flexion, and 58° external rotation in those patients with component revision

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Table III Patient demographics, surgical findings, and additional procedures Patient No.

Side of body

Age (y)

Delay to repair (mo)

Size of tear

Recurrent tear

Components revised at time of cuff repair

Additional surgery after cuff repair

1 2

Left Right

64 74

13 4

Large Medium

Yes Yes

None Cuff repaired and glenoid revised; glenoid removed

3

Left

59

80

Medium

Yes

4 5

Right Right

61 52

9 24

Large Large

Yes No

6 7

Right Right

63 61

16 98

Large Large

Yes No

8

Right

72

9

Large

Yes

9

Left

72

4

Medium

Yes

10

Left

63

15

Large

Yes

11 12

Right Left

59 81

6 26

Large Large

Yes Yes

13 14 15

Right Left Right

72 45 70

12 31 23

Medium Large Medium

Yes No No

16

Right

76

4

Massive

Yes

17 18

Right Left

62 81

9 17

Large Large

Yes Yes

None Humeral and glenoid components revised for instability Nonmodular humerus removed for exposure; glenoid polyethylene exchanged None Nonmodular humerus exchanged for exposure None Humerus and glenoid revised for loosening Nonmodular humerus removed for exposure; glenoid revised for polyethylene dislocation Nonmodular humerus removed for exposure; glenoid revised for polyethylene dislocation Nonmodular humerus removed for exposure, glenoid revised for polyethylene dislocation None Humerus revised because of instability; glenoid polyethylene exchanged Prosthetic system changed None Nonmodular humerus revised for exposure; glenoid implanted Glenoid polyethylene exchanged None Humeral head downsized; glenoid polyethylene exchanged

versus 85° abduction, 84° flexion, and 49° external rotation in those without revision surgery (P ⫽ .5140 for abduction, P ⫽ .5140 for flexion, and P ⫽ .5720 for external rotation). Likewise, no substantial difference in results was found for pain or strength between those shoulders with component revision versus those without. DISCUSSION The presence of an intact rotator cuff after shoulder arthroplasty is usually associated with improved function and outcome.11,22,24 Although the postoperative development of a rotator cuff tear may be asymptomatic in some patients,3,26 it has been related to ante-

Revision of humeral and glenoid components with cuff repair None Glenoid resurfacing None None None

None

Cuff repair and glenoid revision

Cuff repaired None

Cuff repaired None None

None None Cuff repaired with allograft; glenoid removed

rior and superior patterns of instability, increased pain, decreased range of motion, and weakness.4,6,7,10,19 –21,23,25,27 In a review of 139 unsatisfactory shoulder arthroplasties, Hasan et al13 reported that the finding of a rotator cuff tear or a tuberosity nonunion correlated highly with weakness on strength testing. Nevertheless, they reported that the symptoms of a rotator cuff tear after shoulder arthroplasty were usually minimal and reflected the natural progression of cuff disease. Several authors, therefore, recommend nonsurgical management of rotator cuff tears after arthroplasty, with the exception of acute traumatic tears accompanied by instability or profound dysfunction.7,15,20 Norris and Lipson20

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identified the most common cause of anterior instability as a rupture of the subscapularis and recommended exploring and repairing it early before the lesion became irreparable. Moeckel et al18 found that only 4 of 7 attempts to repair subscapularis ruptures because of anterior instability were successful. They emphasized the importance of early recognition and repair of torn tendons in the treatment of acute injuries. The indications for and the benefits of tendon repair for more chronic situations are less well established. Neer et al19 described outcomes in 5 cases of traumatic rotator cuff tears in a series of 273 arthroplasties. Two tears were repaired with undisclosed results. Of the 3 shoulders that were not repaired, all 3 patients were unable to raise their arms and 1 had a painful shoulder as well. More recently, Walch and Boileau25 indicated that 2 patients in a series of 101 replacements required reoperation for cuff tearing. Both injuries involved the subscapularis tendon. One repair, performed 4 years after the arthroplasty, resulted in a good range of motion but persistent weakness. The other surgical procedure, carried out 2 months postoperatively for instability, failed to help. Gartsman et al,12 Hawkins et al,14 and Kelly et al16 all described a single unsuccessful case of attempted repair of a postoperative rotator cuff tear. More positive results have been reported as well. Amstutz et al1 and Bigliani et al5 reported 1 case each of a successful cuff repair. Barrett et al,2 Levy and Copeland,17 and Worland and Arredondo28 all described the repair of cuff tears as a postoperative complication of patients without delineating the outcomes. Of 140 replacements for inflammatory arthritis, 3 late rotator cuff tears were diagnosed by Barrett et al3 based on the presence of superior subluxation on radiographs. No significant symptoms were found, and all patients were treated nonsurgically. In a review of complications of shoulder arthroplasty, Wirth and Rockwood27 suggested that the benefits of operative intervention were unclear because recurrent tearing of the cuff and persistent dysfunction of the shoulder were commonly reported. It was in this context that our study was undertaken. Although only a relatively small number of cases were identified for inclusion, this setting of strict criteria was a deliberate attempt to maintain quality control over data being analyzed for the study. By including shoulders with arthroplasty performed only at our institution, we were able to ensure the diagnosis and the absence of a substantive preexisting rotator cuff problem. Similarly, the inclusion of only those shoulders in which cuff repair was also carried out at this institution permitted a review of the subsequent presenting symptoms and the operative findings. Undoubtedly, these parameters were established at the cost of excluding some cases of rotator cuff repair. In addi-

J Shoulder Elbow Surg January/February 2006

tion, we did not evaluate the outcome of nonoperative treatment of rotator cuff complications of shoulder arthroplasty. Thus, this series cannot be construed as an accurate estimate of the incidence of rotator cuff tearing after shoulder arthroplasty or even of the need for surgical repair because of rotator cuff tearing. Given these limitations, we suggest that isolated cases of successful rotator cuff repair are possible but that failure is more common. Only 4 of 18 shoulders had sufficient restoration of function to indicate to the operating surgeon that the repair had held. Similarly, only 4 of 10 shoulders with clinically significant instability had improvement of that symptom. Although pain relief was commonly achieved, few patients had sufficient return of active range of motion for the operative surgeon to deem the cuff repair successful. One might argue that the clinical assessment of the success of repairs to the rotator cuff was inaccurate and that some of the repairs perceived to be successful were actually failures. However, the conclusion of the study would remain unchanged; clinically successful repair of the rotator cuff after shoulder arthroplasty is uncommon. Early repair of a tear in the rotator cuff has some theoretic advantages. The condition of the tendon tissue would be optimal before retraction and atrophy occurred. Mobilization of the tendon would be easier before scarring developed. Thus, immediate repair of a traumatic rupture, when the onset of the tear can be established, may offer the best chance for a successful repair. Early repair appears especially important for the subscapularis tendon, where Moeckel et al18 have shown that delayed repair may, in fact, not be possible. No relationship of timing of surgery and clinical success was found in this study. Isolated subscapularis tears were rare, though, and the least delay to cuff repair was still 4 months. Any benefits to an early surgical repair could have been lost by then. Outside this time span, the timing of a repair of the supraspinatus or infraspinatus tendon was not critical. With a larger number of subscapularis tears or with earlier operations, such an influence might have been found. In summary, we identified 18 shoulder arthroplasties with subsequent rotator cuff tearing for which a cuff repair was attempted. Although repair of the rotator cuff commonly produced relief of pain, the successful restoration of active motion was infrequent. Earlier surgical procedures were not beneficial in improving results. Thus, every attempt should be made at the time of the arthroplasty to balance the soft tissues and securely repair the rotator cuff and to direct appropriate postoperative physical therapy, because subsequent attempts to repair the rotator cuff are prone to failure.

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