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?

5 surgeries

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.

Post-op infection

I had a rotator cuff repair then developed post op infection. After four months of fighting the infection my surgeon told me that at this point I would need a reverse shoulder replacement. Is there anything that may help? Post-op infections are very difficult to treat. For many people replacement surgery is the only option.

I am not having surgery on the other shoulder

Rotator cuff surgery on left shoulder. I had surgery on my right shoulder which left me with frozen shoulder. A subsequent manipulation under anesthesia (MUA) was unsuccessful and made my situation worse. My shoulder was dislocated in the procedure and damaged a blood vessel causing the need for a stent. I have limited motion in my shoulder (unable to shake hands or give hugs). I don’t want surgery on my remaining working (but painful) shoulder.

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.

A December 2022 study from European researchers and published in the Journal of shoulder and elbow surgery (11) investigated how well tendons held up after a surgery to repair a previously failed rotator cuff surgery.

Sixty-nine consecutive patients (average age, 55 years old)
38% had primary failed open (38%) or arthroscopic (62%) cuff repairs. All patients underwent arthroscopic revision rotator cuff repair.
Patients with massive cuff tears and upward humeral migration (superior subluxation) or glenohumeral osteoarthritis were excluded.

Results: The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. At risk were:

Patients over 55 years old.
Patients with tendon retraction (tendon rupture) of stage 2 or higher
No differences in retear rates were found between single-row and double-row surgical techniques.
In 36 shoulders, tissue samples were tested for infection; 13 (36%) showed positive findings for infection and associated antibiotic treatment was given.

Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied.

Why did my rotator cuff surgery fail?

In an editorial in the July 2021 journal Arthroscopy (7) from doctors at the University of Oxford and University of Calgary suggest: “Causes of failure after arthroscopic rotator cuff repair include patient factors, tear factors, and surgical factors. Failure may occur at the suture-tendon interface, the bone-tendon interface, or the bone-anchor interface. Low bone mineral density (BMD) in the greater tuberosity has been reported as a prognostic factor for recurrent tears following rotator cuff repair, and although most studies suggest the tendon-to-suture interface as the “weakest link,” patients with low bone mineral density may have lower suture anchor pull-out strength. A potential alternative cause of failure is the suture cutting through the greater tuberosity bone in patients with low bone mineral density.”

A February 2022 paper in the Journal of clinical orthopaedics and trauma (8) wrote that many rotator cuff tears are asymptomatic, however some tears will continue to grow even without pain. The spectrum of cuff tear ranges from partial rotator cuff tear, full thickness cuff tear with or without retraction. The mainstay of treatment for partial thickness cuff tear is systematic rehabilitation (physical therapy) and for the full thickness cuff tear an initial (period of physical therapy) is an accepted management.

After three months if the physical therapy has failed to demonstrate improvements in the full thickness cuff tear, or in situations of acute traumatic tear, younger age, intractable pain, good quality muscle, this is when surgical repair of a full thickness cuff tear should be considered. However, the study authors suggest there can be confusion in offering surgery to the right patient. They write: “Though there are defined indications for surgical intervention in the full thickness rotator cuff tear, differentiating an asymptomatic tear that would not progress or identifying a tear that would become better with rehabilitation is an undeniable challenge for even the most experienced surgeon.” They also note that the success rate for these surgeries approximates around 60-80%. Finally, and as well discuss further below, augmenting cuff repair to enhance biological healing is a recent advance in rotator cuff repair surgery. The augmentation factors can be growth factors like Platelet Rich Plasma, scaffolds both auto and allografts. The outcome of these procedures from literature has been variable. As there are no major harmful effects, it can be viewed as another future step in bringing better outcomes to patients having rotator cuff tear surgery.

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 a 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.

At 5 year follow up – revision rotator cuff surgery has its successes

A July 2020 study published in the Journal of shoulder and elbow surgery (10) examined the medium-term outcomes of patients who had revision rotator cuff repairs. The researchers collected pain, function (Flex-SF – Flexilevel Scale of Shoulder Function), and postoperative self-assessment scoring data from patients at baseline; 6, 12, and 24 months; and 5 years. A total of 125 revision rotator cuff repairs were included in this study.

Average improvement in Flex-SF (function) and pain from baseline to 5 years was 8.5 and 2.1 points, respectively.
The improvement was not as pronounced as those who underwent primary repair.
Significantly lower pain scores were seen in nonsmokers and in those who underwent tenotomy rather than tenodesis for a damaged long head of biceps.
Significantly higher function scores were seen in those with only 1 tendon involved.
The patient-reported retear rate was 32.6%, and the reoperation rate was 34.7%.

Conclusion: “Revision rotator cuff repair provides significant improvement in both pain and function at 5 years postoperation, though not as good as primary repair. Superior clinical outcomes are seen in nonsmokers, those with only 1 tendon affected, and those who undergo tenotomy instead of tenodesis for a damaged long head of biceps tendon.”

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 knotless 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).

The 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 a 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 a single problem but to stabilize the shoulder surgery as a whole.

Here we see the areas including the transverse humeral ligament, the coracoid process, the subscapularis muscle and tendon insertion, the brachial plexus, the coracobrachialis, the biceps bracii muscle, the axillary artery, the pectoralis minor muscle.

Revision rotator cuff tear and a discuss of the enthesis

A July 2022 study published in The American journal of sports medicine (10) analyzed the medium-term pain and functional outcomes of revision rotator cuff repairs in 100 patients. During a 40-month period, 100 patients who underwent arthroscopic revision rotator cuff repair were enrolled in this multicenter study. Outcomes were evaluated preoperatively, at 6 months, and at 24 months.

All clinical scores improved significantly during the study period
At two years, a retear rate of 51.8% (43/83) and a surgical revision rate of 12.6% (11/87) were observed.
“Although arthroscopic revision rotator cuff repair improved shoulder function, retears were frequent but usually smaller. Patients with retears, however, did not necessarily have poorer shoulder function.”
“Patient satisfaction at 2 years was lower when primary open rotator cuff repair was performed (as opposed to arthroscopic), when a subscapularis tear or osteoarthritis was present, and when the rotator cuff retear was located at the musculotendinous junction (where the tendon attaches to the bone).”

Of interest is the lower patient satisfaction when the retear occurred at the the musculotendinous junction. First let’s look at this image. Here we see the sites of the tendon origins and insertions, where the tendons attach the muscles to the bones. Let’s focus here on the shoulder and the muscles of the rotator cuff. The caption reads: Clinically significant enthesopathies (when the enthesis has damaged by previous surgery, overuse, acute injury or infection) with small fiber neuropathies (nerve injury causing pain) are common at the locations noted by the black dots. Look how many black dots there are in the shoulder. Treatments that we describe here, Prolotherapy and Platelet Rich Plasma therapy are injection treatments specifically designed to heal, rebuild and strengthen the enthesis.

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 of 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.

Prolotherapy research

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 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.

PRP maybe helpful in preventing re-tear rates

Dr. Eric Hoffman, MBBS, FRCS, PhD, MD wrote an editorial in the journal Arthroscopy (9) where he outlines the problems of offering definitive evidence that PRP can make shoulder surgeries more successful. “Studies investigating the effect of PRP on shoulder rotator cuff healing, clinical outcomes, and retear rates suggest that PRP has no effect on outcome and healing but potentially reduces re-tear rates. However, study quality is compromised by low samples sizes, inadequate randomization protocols, and heterogeneity. . . PRP preparation varies among studies, and a variety of patient factors such as smoking; comorbidity; rotator cuff tear size, configuration, and grade; and functional demands are difficult to control even if a randomized study protocol is undertaken. Until there are reliable and valid data available, the use of PRP in rotator cuff repair is not strongly supported and is at the discretion of the treating surgeon. The current evidence shows the superiority of PRP over hyaluronic acid and corticosteroids, and there is promise that PRP could be a useful adjunct promoting rotator cuff healing following surgical repair.”

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:

Prolotherapy is an injection technique utilizing simple sugar or dextrose.

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.

Video blurbs:

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.

Caring Medical Research

Ross Hauser, MD discusses the Prolotherapy treatment results that were published a few years ago on part of our article series on the use of Hackett-Hemwall dextrose Prolotherapy, as well as shows a treatment demonstration from a Prolotherapy symposium he taught in 2021

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.

References

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]
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