Revision Rotator Cuff Repair Research Articles

True Transosseous Hybrid Rotator Cuff Repair

Transosseous repair has been used safely and effectively for primary and revision rotator cuff repair for decades; as a result, it is considered by many the historical gold standard of open repair techniques. Transosseous repair offers the advantage of excellent biology, double-row anatomic footprint reconstruction, and the ability to create multiple low-cost fixation points per surface area of tendon with high-strength suture, while avoiding anchor pullout, cyst formation, and imaging artifact. More recently, in arthroscopic applications, transosseous-equivalent anchor-based repairs have been introduced that have shown satisfactory clinical and biomechanical results; however, these attributes have been coupled with increased cost, nonbiologic burden to the healing interface of the tendon, and new catastrophic failure modes including tendon transection, anchor pullout, and bone voids. This article delineates a technique for arthroscopic true transosseous hybrid cuff repair that combines the use of anchors and transosseous techniques to maximize the benefits and minimize the detriments of both techniques. Level 1 (shoulder); level 2 (rotator cuff).

Revision rotator cuff repair: a systematic review

The incidence of revision rotator cuff repair(RCR) has increased along with the incidence of primary RCR over the past 2 decades. The purpose of this study was to perform a systematic review to analyze the clinical outcomes of revision RCR and chiefly to identify prognostic factors that may influence postoperative outcomes. The PubMed, MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library (Wiley) databases were searched from database inception through November 2018 for studies assessing revision RCR. All studies were screened in duplicate for eligibility. Pooled analysis correlations between mean preoperative range-of-motion measures, American Shoulder and Elbow Surgeons (ASES) scores, and visual analog scale (VAS) pain scores and mean postoperative outcomes with revision RCR were examined via linear regression and reported with the strength of the Spearman correlation coefficient (rs). A total of 22 studies met the inclusion criteria, including 3 level III and 19 level IV studies. Mean preoperative forward flexion had the greatest correlation with the mean postoperative ASES score (rs = 0.98). A strong positive correlation was also found between mean preoperative forward flexion and mean postoperative forward flexion (rs = 0.83). The mean preoperative VAS pain score was strongly correlated with the mean postoperative VAS pain score (rs = 0.88) and demonstrated a moderate negative association with the mean postoperative ASES score (rs = -0.48). Finally, the mean preoperative ASES score was moderately correlated with the mean postoperative ASES score (rs = 0.56). The results of this systematic review demonstrate favorable clinical outcomes following RCR revision performed both in an open manner and arthroscopically. Preoperative forward flexion was identified as a possible prognostic factor for improved outcomes.

Preoperative Vitamin D Deficiency Is Associated With Higher Postoperative Complications in Arthroscopic Rotator Cuff Repair.

Introduction:Rotator cuff tears are one of the most common injuries worldwide, yet it is difficult to predict which patients will have poor outcomes after arthroscopic rotator cuff repair (RCR). The purpose of this study was to identify an association between preoperative vitamin D (25D) levels and postoperative complications in arthroscopic RCR.Methods:From a national claims database, patients undergoing arthroscopic RCR with preoperative 25D levels were reviewed. Patients were stratified into 25D-sufficient (≥20 ng/dL) or 25D-deficient (<20 ng/dL) categories and examined for development of postoperative complications. Multivariate logistic regression was performed using age, sex, and Charlson Comorbidity Index (CCI) as covariates. From this, risk-adjusted odds ratios (ORs) were calculated comparing complications between the two groups.Results:One thousand eight hundred eighty-one patients with measured preoperative 25D levels were identified; 229 patients were 25D deficient (12.2%). After adjusting for age, sex, and Charlson Comorbidity Index, 25D-deficient patients had increased odds of revision RCR (OR 1.54, 95% confidence interval 1.21 to 1.97, P < 0.001) and stiffness requiring manipulation under anesthesia (OR 1.16, 95% confidence interval 1.03 to 2.03, P = 0.035).Conclusions:Vitamin D deficiency is associated with a greater risk of postoperative surgical complications after arthroscopic RCR and may be a modifiable risk factor. Further investigation on preoperative vitamin D repletion is warranted.

Injections Prior to Rotator Cuff Repair Are Associated With Increased Rotator Cuff Revision Rates

To determine whether shoulder injections prior to rotator cuff repair (RCR) are associated with deleterious surgical outcomes. Two large national insurance databases were used to identify a total of 22,156 patients who received ipsilateral shoulder injections prior to RCR. They were age, sex, obesity, smoking status, and comorbidity matched to a control group of patients who underwent RCR without prior injections. The 2 groups were compared regarding RCR revision rates. Patients who received injections prior to RCR were more likely to undergo RCR revision than matched controls (odds ratio [OR], 1.52; 95% confidence interval [CI], 1.38-1.68; P < .0001). Patients who received injections closer to the time of index RCR were more likely to undergo revision (P < .0001). Patients who received a single injection prior to RCR had a higher likelihood of revision (OR, 1.25; 95% CI, 1.10-1.43; P= .001). Patients who received 2 or more injections prior to RCR had a greater than 2-fold odds of revision (combined OR, 2.12; 95% CI, 1.82-2.47; P < .0001) versus the control group. This study strongly suggests a correlation between preoperative shoulder injections and revision RCR. There is also a frequency dependence and time dependence to this finding, with more frequent injections and with administration of injections closer to the time of surgery both independently associated with higher revision RCR rates. Presently, on the basis of this retrospective database study, orthopaedic surgeons should exercise due caution regarding shoulder injections in patients whom they are considering to be surgical candidates for RCR. Level III, therapeutic study.

Preoperative Shoulder Injections Are Associated With Increased Risk of Revision Rotator Cuff Repair

The goal of this study was to determine whether the timing of preoperative shoulder injections is associated with an increased risk of revision rotator cuff repair following primary rotator cuff repair (RCR). A retrospective analysis of claims data of privately insured subjects from the MarketScan database for the years 2010 to 2014 was conducted. Multivariable logistic regression models were used to compare the odds of reoperation between groups. Laterality for the injection, index procedure, and subsequent surgery were verified for all subjects. A total of 4,959 subjects with an arthroscopic RCR were identified, 392 of whom required revision RCR within the following 3years. Patients who had an injection within 6months preceding the index surgery were at a much higher risk of undergoing reoperation for revision RCR: 0 to 3months prior, adjusted odds ratio (AOR) 1.375 (95% confidence interval [CI], 1.027-1.840); 3 to 6months prior, AOR 1.822 (95% CI, 1.290-2.573); and 6 to 12months prior, AOR 1.237 (95% CI, 0.787-1.943). Patients who had received an injection within 6months prior to RCR were much more likely to undergo a revision cuff repair within the following 3years. The risk of reoperation significantly declines if there is more than 6months between injection and RCR. Consideration should be given to minimizing preoperative injections in patients requiring RCR or delaying primary RCR for 6months following injection. Level III, therapeutic study.

Preoperative Injections May Be an Iatrogenic Cause of Reoperation After Arthroscopic Rotator Cuff Repair

To determine whether an association exists between preoperative shoulder injections and reoperations in patients undergoing arthroscopic rotator cuff repair (aRCR). The PearlDiver Patient Records Database was reviewed for Humana-insured patients undergoing aRCR after a shoulder injection. Two matched groups were created: aRCR within 1year of injection (n= 12,054) and aRCR without prior injection within 1year of surgery (n= 12,054). Reoperation rates within 3months, at 3 to 6months, and at 6 to 12months postoperatively were assessed. Statistical analysis was performed with the χ-square test. The rate of reoperation within 3months of the index procedure was higher in the control group (3.7% vs 3.1%, P= .01); however, 3 to 6months after the index procedure, the rate of reoperation was higher in patients who received an injection within 1year of the index procedure (1.8% vs 1.4%, P=.03). During the same intervals, the rate of revision rotator cuff repair (RCR) within 3months of the index procedure was higher in the control group (2.9% vs 2.6%) and the rate of revision RCR 3 to 6months after the index procedure was higher in patients who received an injection within 1year of the index procedure (1.1% vs 0.9%); however, these results were not statistically significant (P= .3 and P= .8, respectively). The incidence of revision RCR (1.6% vs 1.1%; odds ratio, 1.4; P= .003) and incidence of subacromial decompression (1.5% vs 1.1%; odds ratio, 1.3; P= .01) 6 to 12months afterthe index procedure were significantly higher in patients receiving an injection within 1year before surgery. Preoperative shoulder injections may increase the risk of revision RCR and subacromial decompression by up to 150% in patients 6 to 12months after index surgery compared with patients who did not receive a preoperative injection. However, the absolute increase in these revision procedures is only 0.5%. Level III, comparative study.

Shoulder Injection Prior to Rotator Cuff Repair is Associated with Increased Risk of Subsequent Surgery

Objectives:Corticosteroid injections (CSI) are frequently utilized in the nonoperative management of rotator cuff tears. However, recent literature suggests that injections may reduce biomechanical strength of tendons and ligaments in animal models and increase the risk of postoperative infections following surgery. The goal of this study was to determine if the timing of CSI is associated with an increased risk of reoperation following primary rotator cuff repair (RCR).Methods:A retrospective analysis of claims data of privately-insured subjects from the MarketScan® database for the years 2010-2014 was conducted. A cohort of subjects aged 18-64 who were diagnosed with a rotator cuff tear and underwent repair in 2011 was identified. Multivariable logistic regression models were used to compare the odds of reoperation between groups.Results:A total of 4,959 subjects with an arthroscopic RCR were identified. Of this, 550 subjects required reoperation within the following 3 years. Patients who had a CSI within 6 months preceding the RCR were at a much higher risk of undergoing reoperation: 0-3 months prior, AOR 1.536 (95% CI: 1.201 -1.965); 3-6 months, AOR 1.843 (95% CI: 1.362-2.494); and 6-12 months AOR 1.339 (95% CI: 0.914 -1.962). Of those patients that underwent a reoperation, the most common surgery performed was revision rotator cuff repair followed by arthroscopic debridement (48.5% versus 38.9%, respectively).Conclusion:Patients who had received a CSI within 6 months prior to RCR were much more likely to undergo a subsequent reoperation within the following 3 years. These odds diminished as more time passed between CSI and primary repair. Consideration should therefore be given to delaying primary rotator cuff repair for 6 months following injection.Table 1.Unadjusted rate of reoperation, with and without previous CSI.Group# of Failures# in GroupFailure RateAny reoperation, no CSI35636499.76%Any reoperation, with CSI197131015.04%Revision cuff repair, no CSI25436497.0%Revision cuff repair, with CSI138134010.3%Figure 1Odds of reoperation following primary rotator cuff repair (RCR) among those who received a corticosteriod injection (CSI) in the 12-months prior to surgery.

Minimum Five-Year Outcomes and Clinical Survivorship Following Arthroscopic Double-Row Repair for Full-thickness Supraspinatus Tears

Objectives:Rotator cuff tears lead to significant morbidity due to pain and decreased function. Despite the prevalence of cuff repairs, mid-term outcomes have been scarcely reported. The purpose of this study is to report minimum 5-year outcomes and clinical survivorship after double-row rotator cuff repair for full-thickness supraspinatus tendon tears.Methods:Patients at least five years out from arthroscopic double-row repair for a full-thickness cuff tear involving the supraspinatus tendon were included. Pre- and postoperative ASES, SF-12 PCS, QuickDASH, SANE, and satisfaction scores were collected. The relationship between outcomes and (1) tear chronicity, (2) number of tendons involved, (3) type of repair, and (4) primary versus revision procedure, was also evaluated. Kaplan-Meier survivorship analysis was conducted defining failures as progression to revision rotator cuff surgery.Results:From November 2005 to February 2012, a total of 189 shoulders were eligible for inclusion. Fifteen shoulders (7.9%) underwent revision rotator cuff repair and were considered failures. Outcomes data were reported at a mean follow-up of 6.6 (range, 5.0-11.0) years. All outcome scores significantly improved from pre- to postoperative time point, including mean ASES (57.9 to 92.9, P < 0.001), SF-12 PCS (43.4 to 52.0, P < 0.001), QuickDASH (35.2 to 10.5, P < 0.001), and SANE scores (61.5 to 86.5, P < 0.001). Acute tears demonstrated significantly better ASES and SANE scores than chronic tears (ASES 95.1 ± 8.9 versus 91.7 ± 11.2, P = 0.025; SANE 89.6 ± 19.9 versus 85.7 ± 21.3, P = 0.042). No other analyzed variable had a significant association with outcomes scores (P > 0.05). Survivorship analysis demonstrated a postoperative clinical survivorship of the repair of 96.5% at two years and 93.8% at five years (Figure 1).Conclusion:Patients can expect excellent clinical outcomes and a low failure rate following arthroscopic double-row repair of full-thickness supraspinatus tears at mid-term follow-up. The repair of acute tears and primary repairs were associated with better postoperative outcomes.

Effectiveness of ASA for VTE Prophylaxis in Arthroscopic Rotator Cuff Repair

Objectives:Venous thromboembolic disease (VTED) is a rare complication following arthroscopic rotator cuff repair (RCR). Historical rates of symptomatic VTED after arthroscopic shoulder surgery, DVT and PE, are 0.26%, and 0.01-0.21%, respectively. At present, the American Academy of Orthopaedic Surgeons (AAOS) and American College of Chest Physicians (ACCP) have no prophylaxis guidelines specific to shoulder arthroscopy. Despite this, many surgeons prescribe Aspirin (ASA) for chemical prophylaxis following RCR. The efficacy of ASA as a thromboprophylaxis after shoulder arthroscopy is unknown, but there are risks associated with its’ use. The purpose of this study is to evaluate the effectiveness of chemical prophylaxis (ASA) and mechanical prophylaxis vs. mechanical prophylaxis alone in preventing VTED following RCR.Methods:A total of 914 patients underwent RCR between the months of January 2010 and January 2015. A retrospective case control study was performed. The control group (n=484) consisted of patients treated with perioperative mechanical VTED prophylaxis (compression boots) and early mobilization. The study group (n=430) also utilized perioperative mechanical prophylaxis and early mobilization, and added chemical prophylaxis (ASA 81 mg daily) for four weeks after surgery. The primary outcome was symptomatic VTED (DVT/PE). Chart records were collected and evaluated for six months after surgery. Patient demographics and other surgical complications were also analyzed.Results:A total of 7 VTED events occurred during the study period, 6 DVTs and 1 PE. The total rate of VTED was 0.88%, DVT was 0.77%, and PE was 0.11%. There was no significant different between DVT (p=0.88, 95% CI= -1.36% - 1.65%) or PE (p=0.45, 95% CI = -0.77% - 1.50%) between the control and study groups. The control group (no ASA) recorded an incidence of 0.62% DVT and 0.00% PE. As compared to the study group (ASA), which recorded an incidence of 0.47% DVT and 0.23% PE. The control group had significantly greater number of documented current smokers (8.68% vs 3.72%, p= 0.0003). The study group had a statistically significant higher mean age of subject (59.1 vs 57.7, p=0.0055), as well as more subjects undergoing revision RCR surgery (4.67% vs 1.86%, p= 0.021).Conclusion:Based on our study of 914 patients, ASA does not provide a clinically significant reduction in VTED rates in patients undergoing RCR. We conclude that the use of mechanical prophylaxis and early mobilization is a sufficient method of VTED prophylaxis in this low risk population.

Preoperative Shoulder Injections are Associated with Increased Risk of Subsequent Revision Rotator Cuff Repair

Objectives:Corticosteroid injections (CSI) are frequently utilized in the nonoperative management of rotator cuff tears. However, recent literature suggests that injections may reduce biomechanical strength of tendons and ligaments in animal models and increase the risk of postoperative infections following surgery. The goal of this study was to determine if the timing of CSI is associated with an increased risk of reoperation following primary rotator cuff repair (RCR).Methods:A retrospective analysis of claims data of privately-insured subjects from the MarketScan® database for the years 2010-2014 was conducted. A cohort of subjects aged 18-64 who were diagnosed with a rotator cuff tear and underwent repair in 2011 was identified. Multivariable logistic regression models were used to compare the odds of reoperation between groups.Results:A total of 4,959 subjects with an arthroscopic RCR were identified. Of this, 553 subjects required reoperation within the following 3 years (Table 1). Patients who had a CSI within 6 months preceding the RCR were at a much higher risk of undergoing reoperation (Figure 1): 0-3 months prior, AOR 1.536 (95% CI: 1.201 -1.965); 3-6 months, AOR 1.843 (95% CI: 1.362-2.494); and 6-12 months AOR 1.339 (95% CI: 0.914 -1.962). Of those patients that underwent a reoperation, the most common surgery performed was revision rotator cuff repair followed by arthroscopic debridement (48.5% versus 38.9% respectively).Conclusion:Patients who had received a CSI within 6 months prior to RCR were much more likely to undergo a subsequent reoperation within the following 3 years. These odds diminished as more time passed between CSI and primary repair. Consideration should therefore be given to delaying primary rotator cuff repair for 6 months following injection.Table 1.Listing of reoperations, by timing of last CSI prior to primary RCRReoperation (CPT)No CSI0-3 Months3-6 Months6-12 Months12+ MonthsTOTAL (%)Arthroplasty23470. Hemiarthroplasty310004(0.7)23472. Arthroplasty11642124(4.4)Arthroscopy29805. Diagnostic300003(0.5)29820. Synovectomy (Partial)300003(0.5)29821. Synovectomy (Complete)301004(0.7)29822. Debridement (Limited)509108077(13.9)29823. Debridement (Extensive)87301560138(25.0)29825. With lysis and resection of adhesions20714032(5.8)29827, With Rotator Cuff Repair1784430142268(48.5) 358 97 61 34 3 553 Figure 1.Odds of reoperation following primary rotator cuff repair (RCR) among those who received a corticosteroid injection (CSI) in the 12-months prior to surgery. Odds ratios are relative to the patients who did not receive a CSI in the 12-months prior to surgery.

Outcomes of arthroscopic revision rotator cuff repair with acellular human dermal matrix allograft augmentation

The purpose was to assess the minimum 2-year patient-reported outcomes and failure rate of patients who underwent revision arthroscopic rotator cuff repair augmented with acellular human dermal matrix (AHDM) allograft for repairable retears. From 2008-2014, patients who underwent revision rotator cuff repair augmented with AHDM with greater than 2 years' follow-up by a single surgeon were retrospectively reviewed. Data regarding surgical history, demographic characteristics, and medical comorbidities were collected. Outcome data included American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, as well as rotator cuff healing on magnetic resonance imaging or ultrasound. Retears and subsequent surgical procedures were characterized. A total of 28 patients met our inclusion criteria, and 23 (82%) were available for follow-up at 2 years. The mean age was 60.1 ± 9.3 years (range, 43-79 years), with a mean follow-up period of 48 ± 23 months. All patients had at least 1 prior rotator cuff repair. Of the 23 patients, 13 (56%) underwent postoperative imaging, and 4 of these 13 (31%) had a retear. A reoperation was performed in 3 of 23 patients (13%). Among the 6 patients with both preoperative and postoperative outcome scores, we saw improvement in the ASES score from 56 to 85 (P = .03) and in the SANE score from 42 to 76 (P = .03). The full cohort's mean postoperative ASES and SANE scores were 77 and 69, respectively. AHDM allograft augmentation is a safe and effective treatment method for patients with full-thickness rotator cuff retears. Further research is needed with larger studies to confirm these findings from our small cohort of patients.

Five-Year Outcomes After Arthroscopic Repair of Partial-Thickness Supraspinatus Tears

To investigate clinical outcomes in patients who underwent arthroscopic repair of isolated partial-thickness rotator cuff tears (PTRCTs) of the supraspinatus tendon with a minimum follow-up period of 5years. All patients who had undergone arthroscopic repair of isolated PTRCTs at least 5years earlier were included. Preoperatively and postoperatively, the American Shoulder and Elbow Surgeons, QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire), and Short Form 12 Physical Component Summary scores were collected, along with postoperative satisfaction (10-point scale) and return to activity. The associations between (1) patient age and outcome scores and (2) location of partial-thickness tear (articular vs bursal sided) and outcome scores were evaluated. Failure was defined as revision surgery of the rotator cuff repair. The study included 24 shoulders (24 patients comprising 9 women and 15 men). Follow-up data were available on 20 shoulders (7 women and 13 men, 83% follow-up) at a mean of 6 ± 1years postoperatively. The mean age at index surgery was 55 ± 11years; 6 bursal- and 14 articular-sided tears were repaired. No patient required revision surgery. All scores significantly improved from preoperatively to postoperatively (P < .05); the median satisfaction rating (1, not satisfied; 10, completely satisfied) was 10 (range, 1-10). Neither patient age nor tear location correlated with outcome scores (P > .05). Seventeen patients indicated that they participated in previous recreational activity. Of these patients, 13 (76%) returned to the original level or a similar level of activity, 3 (18%) returned to activity at a lower level, and only 1 (6%) indicated an inability to return to activity. Patients undergoing arthroscopic repair of PTRCTs can expect excellent clinical outcomes with low failure rates at midterm follow-up given that no patient progressed to revision rotator cuff repair during follow-up. The return-to-activity rate was very high after repair of isolated PTRCTs. Neither patient age nor tear location was associated with outcome scores. Level IV, retrospective case series.

Management of Failed Rotator Cuff Repair in Young Patients.

Management of failed rotator cuff repair may be difficult, especially in young patients. Various nonmodifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing. Variable outcomes have been reported in patients who undergo revision rotator cuff repair; however, a systematic surgical approach may increase the likelihood of a successful outcome. Numerous cellular and mechanical biologic augments, including platelet-rich plasma, platelet-rich fibrin matrix, mesenchymal stem cells, and acellular dermal matrix grafts, have been used in rotator cuff repair; however, conflicting or inconclusive outcomes have been reported in patients who undergo revision rotator cuff repair with the use of these augments. A variety of tendon transfer options, including latissimus dorsi, teres major, lower trapezius, pectoralis minor, pectoralis major, combined pectoralis major and latissimus dorsi, and combined latissimus dorsi and teres major, are available for the management of massive irreparable rotator cuff tears. Ultimately, the optimization of surgical techniques and the use of appropriate biologic/tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair.

Revision of Failed Rotator Cuff Reconstruction With a Large Humeral Head Cyst

A revision rotator cuff repair is a technically challenging surgical procedure. This can be further complicated by the presence of poor quality of the cuff tissue, as well as a large greater tuberosity cyst, typically located at the rotator cuff footprint. This Technical Note discusses the surgical approach to deal with a revision rotator cuff tear with a large humeral head cyst. This described arthroscopic technique is performed in a single-stage procedure using a human dermal allograft (GraftJacket) for augmentation. This technique was specifically designed to (1) address the limited area for anchor placement, (2) use a bone graft, demineralized bone matrix, for repairing the bone cyst, and (3) optimize the biology for healing by augmenting the reconstruction with GraftJacket.

Perioperative Serum Lipid Status and Statin Use Affect the Revision Surgery Rate After Arthroscopic Rotator Cuff Repair

Background: Recent animal studies have demonstrated that hyperlipidemia is associated with poor tendon-bone healing after rotator cuff repair; however, these findings have not been substantiated in human studies. Purpose: To examine any association between hyperlipidemia and the failure of arthroscopic rotator cuff repair requiring revision surgery and to investigate whether the use of statin lipid-lowering agents had any influence on observed associations. Study Design: Cohort study; Level of evidence, 3. Methods: From a national insurance database, patients who underwent arthroscopic rotator cuff repair with perioperative lipid levels (total cholesterol, low-density lipoprotein [LDL], and triglycerides) recorded were reviewed. For each lipid test, patients were stratified into normal, moderate, and high groups based on published standards. For the total cholesterol and LDL cohorts, a subgroup analysis of patients stratified by statin use was performed. The primary outcome measure was ipsilateral revision rotator cuff surgery, including revision repair or debridement. A logistic regression analysis controlling for patient demographics and comorbidities was utilized for comparison. Results: There were 30,638 patients included in the study. The rate of revision rotator cuff surgery was significantly increased in patients with moderate (odds ratio [OR], 1.20; 95% CI, 1.03-1.40; P = .022) and high total cholesterol levels (OR, 1.36; 95% CI, 1.10-1.55; P = .006) compared with patients with normal total cholesterol levels perioperatively. Within each of these groups, patients without statin use had significantly higher rates of revision surgery, while those with statin prescriptions did not. The absolute risk reduction for statin use ranged from 0.24% to 1.87% when stratified by the total cholesterol level, yielding a number needed to treat from 54 to 408 patients. The rate of revision surgery was significantly increased in patients with moderate (OR, 1.24; 95% CI, 1.10-1.41; P = .001) and high LDL levels (OR, 1.46; 95% CI, 1.08-1.99; P = .014) compared with patients with normal LDL levels perioperatively. Again, patients without statin prescriptions had significantly increased rates of revision surgery, whereas patients with statin use did not. The absolute risk reduction for statin use ranged from 0.26% to 1.89% when stratified by the LDL level, yielding a number needed to treat from 53 to 387 patients. There were no significant differences in the rates of revision rotator cuff surgery between patients with moderate and high triglyceride levels compared with patients with normal triglyceride levels. Conclusion: The present study found a significant association between moderate and high perioperative total cholesterol and LDL levels and the rate of revision surgery after primary arthroscopic rotator cuff repair. Furthermore, the use of statin agents appeared to mitigate the need for revision rotator cuff repair. Further prospective studies are necessary to validate these preliminary findings and determine if better perioperative lipid control can improve clinical outcomes after arthroscopic rotator cuff repair.

The Effect of Concomitant Biceps Tenodesis on Reoperation Rates After Rotator Cuff Repair: A Review of a Large Private-Payer Database From 2007 to 2014

To determine if reoperation rates are higher for patients who underwent isolated rotator cuff repair (RCR) than those who underwent RCR with concomitant biceps tenodesis using a large private-payer database. A national insurance database was queried for patients who underwent arthroscopic RCR between the years 2007 and 2014 (PearlDiver, Warsaw, IN). The Current Procedural Terminology (CPT) 29,827 (arthroscopy, shoulder, surgical; with RCR) identified RCR patients who were subdivided into 3 groups-group 1: RCR without biceps tenodesis; group 2: RCR with concomitant arthroscopic biceps tenodesis (CPT 29827 and 29,828); group 3: RCR with concomitant open biceps tenodesis (CPT 29827 and 23,430). Reoperation rates (revision RCR, subsequent biceps surgeries) and complications at 30days, 90days, 6months, and 1year were analyzed. Multivariate logistic regression was used to compare reoperations and complications between groups. Rotator cuff tear size, whether the biceps was ruptured and whether a biceps tenotomy was performed, was not available. Group 1: 27,178 patients. Group 2: 4,810 patients. Group 3: 1,493 patients. More patients underwent concomitant arthroscopic than concomitant open tenodesis (P < .001). A total of 2,509 patients underwent a reoperation for RCR or biceps tenodesis within 1year after RCR. When adjusted for age, sex, and comorbidities, no significant differences in reoperation rates at 30days or 90days among the 3 groups, but significantly more patients who had a tenodesis, required a reoperation compared with those who did not have a tenodesis at 6months and 1year (both P < .001). Urinary tract infections were more common in patients who did not have a tenodesis, whereas dislocation, nerve injury, and surgical site infection were more common in tenodesis patients. Higher reoperation rates at 1year were seen in patients who had concomitant biceps tenodesis. Level III, case-control database review study.

Clinical outcome and prognostic factors of revision arthroscopic rotator cuff tear repair.

The aim of this study was to evaluate the clinical outcome of arthroscopic rotator cuff revision surgery in a cohort of patients and to identify prognostic factors for this procedure. Fifty-one consecutive patients undergoing revision arthroscopic rotator cuff repair were prospectively followed over a minimum period of one year. Radiologic findings and clinical data regarding primary and revision surgery were collected. Clinical evaluation was performed pre- and post-operatively by means of Constant Score and Simple Shoulder Test. Median age at the time of revision surgery was 60years (range 36-77years). Median follow-up was 25months (range 12-58months). There were 17 men (33.3%) and 34 women (66.7%). The majority of the tears affected the supraspinatus tendon alone (51%) or both the supra- and infraspinatus tendons (35.3%). Significant improvements were seen in terms of active forward elevation, active external rotation, pain, Simple Shoulder Test score, Constant Score, and post-operative satisfaction-age, gender, and time to revision surgery did not show significant predictive value. A smaller tear size and pre-operative elevation greater than 90° were demonstrated to be independent prognostic factors for better outcome. However, the mean increase in Constant Score was not related to the size of the tear, range of motion, or age. The results of this study indicate that arthroscopic revision rotator cuff repair results in reliable improvement in shoulder function, pain, and satisfaction. Pre-operative active range of motion and tear size seem to determine final outcome. A similar increase in mean Constant Score can be achieved even in large tears in patients aged over 65years. IV.

Revision Rotator Cuff Repair: Tips and Tricks to Get it Repaired and to Get it to Heal

Revision rotator cuff repair is a complex and increasingly common problem. Failure of initial tendon healing is caused by a variety of factors, most prominently biological, but technical factors of the primary surgery and post-operative trauma also contribute. Identifying a failed rotator cuff surgery is based on a combination of imaging and physical exam. However, the decision to proceed with a revision rotator cuff repair is more complex and based on predicted success of the revision procedure as well as an extensive discussion with the patient that revision cuff surgery is more complex procedure with higher failure rates than the initial cuff repair. Despite the complexity of a revision surgery, patient outcomes are significantly improved if cuff healing can be obtained. In this paper we discuss our methods for identifying patients who are good candidates for revision rotator cuff surgery as well as discussing in detail surgical “tips and tricks” for getting the cuff back down to the footprint and getting it to heal in a revision setting.

Arthroscopic Patch Augmentation for Rotator Cuff Repair

Revision rotator cuff repair and surgical repair of massive rotator cuff tears present a significant technical challenge to orthopedic surgeons with unacceptably high failure rates. Rotator cuff repair augmentation using biological or synthetic patches has been proposed as a potential method to improve repair integrity, particularly in those patients with poor tendon quality. The purpose of this review is to discuss the available patch or scaffold options and review the surgical technique and technical pearls.

Early postoperative fluoroquinolone use is associated with an increased revision rate after arthroscopic rotator cuff repair.

To evaluate the association of postoperative fluoroquinolone use following arthroscopic primary rotator cuff repair with failure requiring revision rotator cuff repair. An insurance database was queried for patients undergoing rotator cuff repair from 2007 to 2015. These patients were divided into three groups: (1) patients prescribed fluoroquinolones within 6months postoperatively (divided into 0-2, 2-4, and 4-6 months), (2) a matched negative control cohort of patients not prescribed fluoroquinolones, and (3) a matched positive control cohort of patients prescribed fluoroquinolones between 6 and 18months following rotator cuff repair. Rates of failure requiring revision rotator cuff repair were compared within 2years. A total of 1292 patients were prescribed fluoroquinolones within 6months after rotator cuff repair, including 442 within 2months, 433 within 2 to 4months, and 417 within 4 to 6months, and were compared to 5225 matched negative controls and 1597 matched positive controls. The rate of revision rotator cuff repair was significantly higher in patients prescribed fluoroquinolones within 2months (6.1%) compared to matched negative (2.2%, P=0.0009) and positive controls (2.4%, P=0.0026). There were no significant differences in the rate of revision rotator cuff repair when fluoroquinolones were prescribed >2months after rotator cuff repair. Early use of fluoroquinolones following rotator cuff repair was independently associated with significantly increased rates of failure requiring revision rotator cuff repair. This is the first clinical study examining the association of postoperative fluoroquinolone use with failure following arthroscopic rotator cuff repair. III.