Treatment options for Failed Rotator Cuff Surgery
Ross A. Hauser, MD; Danielle R. Steilen-Matias, MMS, PA-C
Treatment options for Failed Rotator Cuff Surgery
There are many people who have had very successful rotator cuff repair surgeries. These are typically not the people that we see in our office. We see the people after surgery who have been diagnosed or classified as a “failed rotator cuff surgery patient.” In this article, we will explore non-surgical options for the problems of continued pain and loss of function following rotator cuff surgery.
We will often hear stories like this, maybe it is like yours:
I was told before surgery that there was a chance the surgery would not help.
I had the surgery. I had a very long rehab. I went back to my surgeon because the pain in my surgical shoulder was getting much worse. My shoulder clicks, pops, and sometimes it gets stuck mid-motion. I was told before surgery that there was a chance the surgery would not help. I had the surgery anyway. It did not help. My shoulder is now worse. My surgeon wants to send me to get an MRI so we can decide if a second rotator cuff repair surgery may help or if I should get a shoulder replacement. I have decided against any surgery, too much pain, too much rehab, too much everything. If you can help me with your treatments I would be interested but I can also just live with this.
None of them could explain why my surgeries had failed.
I have had two surgeries, both failed. I had a team of surgeons. None of them could explain why my surgeries had failed. My options now are the occasional cortisone injection and more physical therapy. My surgeons want to take a wait and see approach before making any further recommendations. Can you help me?
I have had three rotator cuff surgeries on my left shoulder and two on my right shoulder. Despite these repairs both shoulders have progressed to full thickness tears. Now I am told my only option is total reverse shoulder replacement.
Why did the surgery fail and how do you treat it?
Let’s point out again that many people have successful rotator cuff surgeries. Many people have success after a second or third surgery goes in and adjusts or fixes the first surgery. Surgery can also cause more harm than good. Recovery time is often long and presents its own complications.
In this section, we will highlight two recent studies. The learning points are:
- There is no high-level, conclusive surgical evidence that one rotator cuff repair surgery is superior to the other.
- All the surgeries carry the risk of high retear rates.
Is there a good time to have a revision rotator cuff surgery? Soon after surgery, wait for a while?
An October 2020 study (1) examined when was the best time for a patient to get a revision rotator cuff surgery.
- Sixty patients who underwent revision surgery due to symptomatic failed rotator cuff repair after arthroscopic repair were included.
- Patients were divided into two groups: patients who underwent revision surgeries within 1 year postoperatively (21 patients, group I) and patients who underwent revision surgeries more than 1 year postoperatively (39 patients, group II).
- Patients who had early revision surgeries had significantly worse clinical outcomes after primary surgery than patients who had late revision surgeries. Healing failure at the tendon-bone interface on the greater tuberosity and re-tear combined with full-thickness tear of subscapularis tendon were related to early revision. Conversely, patients of the late revision group had muscle weakness that considerably impacted daily activities, even with improved pain and shoulder function.
It can be said, neither group had the best of outcomes. However, for some people the revision surgery was very successful for them.
The Rotator Cuff Bridge Collapse
If you are reading this article it is unlikely that you need a long description of the rotator cuff “bridge” technique. This surgery is appealing to the younger, more active person or those who do physically demanding work because it has demonstrated superior clinical results and lower failure rates compared to other rotator cuff surgical techniques. There is a knottless version and a knot-tying suture-bridge technique. Numerous ongoing studies compare the two.(2) In the bridge technique, cadaver tissue is used to repair complete ruptures or rotator cuff tears where the tissue cannot be repaired.
In February 2019, surgeons at the University of Cincinnati Medical Center and the University of Alexandria Medical Center in Egypt, combined their observations in examining Type 2 retears after arthroscopic single-row, double-row and suture bridge rotator cuff repair. The research appears in the European Journal of Orthopaedic Surgery & Traumatology.(3)
In this study, the researchers examined data from 14 published studies and 260 rotator cuff re-tears. Re-tears were classified into type 1 (failure at the tendon-bone interface) and type 2 (medial cuff failure).
- Repair technique had a significant impact on the estimated incidence rate of type 2 retear.
- The estimated incidence rate of type 2 retear was
- 24% with single-row technique surgery
- 43% with double-row
- 62% with suture bridge.
Conclusion: “this study suggests that double-row and suture bridge techniques increase the risk of medial cuff failure. Modifications in surgical techniques in both double-row and suture bridge repairs can help decrease that risk.”
So in agreement with the idea that the “bridge repair” is better is the above study.
Bridge surgery is the most effective?
Here is a 2019 study in the journal Scientific Reports.(4) It examined 1815 shoulders that had a rotator cuff repair surgery. What the researchers were looking for was retear rate and range of motion scores (forward flexion and external rotation). Here are the findings:
- Single-row repair resulted in a higher retear rate than suture bridge and double-row repairs.
- Moreover, the single-row repair and double-row repairs resulted in higher incidences of retear than suture bridge repair.
- The ranking of the treatments based on the constant score and external rotation was suture bridge repair, single-row repair, and double-row repairs, whereas the treatment ranking according to forward flexion was suture bridge repair, double-row repairs, and single-row repair.
- In summary, this network meta-analysis provides evidence that suture bridge repairs might be the best choice to improve the postoperative recovery of function and decrease the retear rate.
In this third study, there is an agreement that one surgery is not vastly superior to the other. Bridge repair is just one of many options.
“Although numerous biomechanical and clinical studies comparing different rotator cuff repair techniques have been published in the past decade, none has achieved universal acceptance.”
In this September 2019 study in the Orthopaedic Journal of Sports Medicine (5) and from the Hospital Italiano de Buenos Aires, Hospital for Special Surgery, New York, and Rush University Medical Center, Chicago, the following points are made:
- “There is substantial evidence indicating that double-row repair restores more of the anatomic rotator cuff footprint and is biomechanically superior to single-row repair. Transosseous-equivalent (TOE) techniques have shown biomechanical advantages when compared with traditional DR, including increased contact at the rotator cuff footprint, higher pressure at the tendon-bone interface, and increased failure strength.
- Several meta-analyses of evidence level 1 and 2 studies have shown a lower rate of failed/incomplete healing when double-row repair was compared with single-row repair types. There is some limited evidence that TOE techniques improve healing rates in large and massive tears as compared with single-row repair and double-row repair.
- Overall, most level 1 and 2 studies have failed to prove a significant difference between single-row repair and double-row repair repairs in terms of clinical outcomes. However, most studies include only short-term follow-up, minimizing the impact that the higher rate of retears/failed healing seen with single-row repair repairs can have in the long term.
- There are no high-quality clinical studies comparing different double-row repair configurations, and there are currently not enough clinical data to determine the functional advantages of various double-row repair technique modifications over one another.
- Although numerous biomechanical and clinical studies comparing different rotator cuff repair techniques have been published in the past decade, none has achieved universal acceptance. It is essential for the orthopaedic surgeon to know in detail the available literature to be able to apply the most appropriate and cost-effective technique in terms of healing and functional outcomes.”
Simply, depending on the surgeon, you can get many different types of surgery because there is no conclusive evidence that one surgery is vastly superior to another.
In this illustration we show typical sites injected during a Prolotherapy treatment. The point is not to isolate on a single problem but to stabilize the shoulder surgery as a whole.
Prolotherapy as a treatment option for failed rotator cuff surgery
Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on extensive research and clinical results, Prolotherapy is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle. For extensive medical citations and research please see our comprehensive Prolotherapy information page.
In our more than 27 years experience in helping people post-surgery, we have seen many rotator cuff failures. To be fair, failures can be described in many different ways. Most commonly, failure is seen when the shoulder was worse off after the surgery or the surgery did not achieve all the patient’s goals but still provided some pain relief and some function. We have seen many patients respond positively.
In February 2019, (6) Sports specialist and orthopedic surgeons in Turkey published their findings on the effectiveness of Prolotherapy in helping the patient with failed rotator cuff repair surgery. This research was published in the Turkish journal of physical medicine and rehabilitation.
- A total of 15 patients (5 males, 10 females; average age 50; youngest patient 33, oldest patient 71 years old) with failed rotator cuff repair surgery who had at least six months of complaints and were did not respond to at least of three months of conservative methods were included.
- Ultrasound-guided prolotherapy injections were performed and the patients were instructed to carry out a home-based exercise program. Clinical assessment of shoulder function was performed using a visual analog scale (VAS) for pain, Shoulder Pain and Disability Index (SPADI), Western Ontario Rotator Cuff (WORC) Index, patient satisfaction and shoulder range of motion. All patients were examined at baseline, at Week 3, 6, and 12 and at the final follow-up visit.
The intra-group comparison showed that the patients achieved significant improvements at all time points, compared to baseline as measured by VAS, SPADI, WORC index, and shoulder range of motion. Twelve patients (80%) reported excellent or good outcomes.
CONCLUSION: “Our study results show that prolotherapy is effective in the treatment of patients with failed rotator cuff repair surgery with significant improvements in the shoulder functions and pain relief.”
These results are in general agreement with what we have seen in our clinic.
Bone Marrow Stem Cell Therapy and Platelet Rich Plasma Injections after surgery
In the video below Prolotherapy and Platelet Rich Plasma injections are explained. In combination, we call this PRP Prolotherapy. In Platelet Rich Plasma injections your blood is used, by way of its platelets, to create concentrated platelet solutions rich in healing and regenerative factors.
Stem cell therapy is reserved for more advanced degenerative changes in the shoulder. Treatment utilizing stem cells for rotator cuff as a first-line treatment is something that we usually do not offer because of expense and the ability of Prolotherapy and PRP to do a good job of healing. We do discuss this with all patients prior to treatment.
Our ultimate goal with all forms of Prolotherapy is to get the patients back to doing the things that they want to do without pain and without surgery.
In this video, a general demonstration of Prolotherapy and PRP treatment is given for a patient with repeated shoulder dislocations
Danielle R. Steilen-Matias, MMS, PA-C narrates the video and is the practitioner giving the treatment:
- PRP or Platelet Rich Plasma treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets and growth and healing factors from your blood into the shoulder. The treatment is explained further below.
- In the shoulder treatment, I treat all aspects of the shoulder including the ligament and tendon injections to cover the whole shoulder.
- The patient in this video is not sedated in any way. Most patients tolerate the injections very well. The treatment goes quickly. However, we do make all patients comfortable including sedation if needed.
- This patient, in particular, came to us for a history of repeated shoulder dislocations. His MRI findings showed multiple labral tears and rotator cuff problems.
- The patient complained of shoulder instability typical of the ligament and tendon damage multiple dislocations can do.
- Treatment continues to the front of the shoulder. The rotator cuff insertions, the anterior joint capsule, and the glenohumeral ligaments are treated.
- PRP is introduced into the treatment and injected into the front of the shoulder. PRP is a form of Prolotherapy where we take concentrated cells and platelets from the patient’s blood and inject that back into the joint. It is a more aggressive form of Prolotherapy and we typically use it for someone that has had a labral tear, shoulder osteoarthritis, and cartilage lesions.
- PRP is injected into the shoulder joint and the remaining solution is injected into the surrounding ligaments, in this case, it was in his anterior shoulder attachments to address the chronic dislocations.
The problem of post-surgical nerve pain
In this video, Danielle R. Steilen-Matias, MMS, PA-C discusses treating a patient with nerve pain following shoulder surgery.
- It is not uncommon for us to see patients after shoulder surgery who continue to have shoulder instability issues and continued pain. It may be the same pain that they had before surgery or it may be a different type of pain.
- What we find in many of these people is that even though healing is occurring and the shoulder looks well, the pain they are having is related to the nerves that may have been impacted during the surgery. We treat these patients with Nerve release injection therapy or more commonly hydrodissection.
We have seen many people with many problems following their rotator cuff surgeries. If you have questions about your Rotator Cuff problems You can get help and information from our Caring Medical staff.
1 Lee S, Park I, Kim MS, Shin SJ. Clinical differences between patients with early and late revision surgery for symptomatic failed arthroscopic rotator cuff repair. Knee Surg Sports Traumatol Arthrosc. 2020 Oct 23. doi: 10.1007/s00167-020-06333-6. Epub ahead of print. PMID: 33095333. [Google Scholar]
2 Comparison of Repair Integrity and Functional Outcomes Between Knot-tying and Knotless Suture-bridge Arthroscopic Rotator Cuff Repair: a Prospective Randomized Clinical Trial. ClinicalTrials.gov Identifier: NCT03982108
3 Bedeir YH, Schumaier AP, Abu-Sheasha G, Grawe BM. Type 2 retear after arthroscopic single-row, double-row and suture bridge rotator cuff repair: a systematic review. European Journal of Orthopaedic Surgery & Traumatology. 2019 Feb 4;29(2):373-82. [Google Scholar]
4 Xu B, Chen L, Zou J, Gu Y, Hao L, Peng K. The clinical effect of arthroscopic rotator cuff repair techniques: A network meta-analysis and systematic review. Scientific reports. 2019 Mar 11;9(1):1-1. [Google Scholar]
5 Rossi LA, Rodeo SA, Chahla J, Ranalletta M. Current Concepts in Rotator Cuff Repair Techniques: Biomechanical, Functional, and Structural Outcomes. Orthopaedic journal of sports medicine. 2019 Sep 20;7(9):2325967119868674. [Google Scholar]
6 Akpancar S, Örsçelik A, Seven MM, Koca K. The effectiveness of prolotherapy on failed rotator cuff repair surgery. Turkish Journal of Physical Medicine and Rehabilitation. 2019 Jun;65(4):394. [Google Scholar]