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Revision Rotator Cuff Repair

Feb 21, 2022
so the first thing to remember is that

rotator

cuff

is a tendon disease so you are not taking a normal healthy tendon with the exception of perhaps an acute traumatic tear you have a collagen disorder you have a messy arrangement , you have a type 3 increasing type 1 decreasing vascularity and tinocyte abnormality so you are fighting biology and if we talk about how good our cup

repair

s are and how good our patients are I mean the retail sales happen and maybe it's not just the relative degree of hyperbole when ken yamaguchi and lisa gallis posted a retail rate of 94 but honestly it's probably closer to 20 percent when you consider all comers, um and that's not that huh that should be better we should be able to get better at that and a twenty percent retail rate should be alarming we don't have a vei complication rate nte percent in any surgery that we're going to recommend to patients so we talked about this a little bit in the last panel but there are a couple of F points I want to bring up and I think they set the table for why or how I look at surgery

rotator

cuff

revision

First, Bruce Miller looked at this and the important findings he found was that most retail terrors were within the first three months 78 percent and in this study had a relatively 40 41 retail rate alta joe annotti looked at this in a similar way and found that their median retail rate was about 20 weeks or 19.2 weeks again these two studies combined let us know that when they are going to get in trouble it will be from The beginning, the next thing you should think of is George World, and if you don't know him, you should read his studies. one on tennis elbow was able to do sham surgery in australia he goes on to publish amazing research but what he showed us is what we already know it's almost like gospel that the failure, the mechanism of the failure, is really the tendon. suture interface much less than anchors Dr.
revision rotator cuff repair
Burkhart figured out how to make good anchors that last work but now it's the biological tissue we have to address and the weak link here is the tendon suture interface so when do they happen retail sales? I know it's not really early failure and maybe it's a failure to heal not necessarily an acute traumatic fall absent in the perioperative period and rotator cuff healing we know to be slow is six months late so our

repair

s aren't always they are good enough to hold out long enough for the tendon to re-attach to the bone so with that preface I guess my talk would be how do I manage your unhappy patient after rotator cuff repair and focus on arthroscopic solutions not the tendon transfers and reverse shoulder arthroplasty that Dr.
revision rotator cuff repair

More Interesting Facts About,

revision rotator cuff repair...

Hearthstone is going to talk about and what are, I think, good things, the first question I want to ask myself is why are they here, you know? What is it about this patient that brings him back to my office because we know we can discuss a lot? We know that many patients, in fact, most patients who have uh MRIs or retail ultrasounds or failure to heal are not back in their office. We also know that curation gives better results, but the retailers do it. What is it that makes them unhappy? Is it pain that makes them unhappy?
revision rotator cuff repair
Is the weakness because healing is not necessarily necessary? over and over expecting different results is crazy i don't necessarily want to go in there and do the exact same thing one more time if they ever get better they are infected they are stiff stiff is a common reason for pain and you can release or treat the stiffness and improve them if they missed some pathology if they missed the biceps the ac joint the right subscapularis selective injection to try to see where this pain generator is part of the problem so I'm just going to go through a couple of modifications, a couple of ideas on how to do this the first one is kiss the mods keep it really simple exactly and if they did well for a while and they come back and if you are forced to mate with your subscapularis and your rehab infra intact and the data shows us that 54 of patients can have a lasting success rate of two years or more when they come in a couple of years later and have a new tear. don't go straight to the operating room and that's something to remember so if i keep it really simple it doesn't work then i go to option two and this guy walks in and he's he's unhappy he's got some arthritis he's got anchoring granulomas um so I start to prepare.
revision rotator cuff repair
I'm like okay, well what am I going to do? He's a pretty functional guy. You know. 69 years. I can't have reverse mania. They will shout at me on the podium. I like it okay I repeat the last one I did and I'm going to stack my anchors that Peter told us about stacking anchors and I'm going to graft my holes with bones with bone sync and then I'm going to get alice ink because they really know that the The interface between the bone and the tendon is going to be very important in these

revision

cases and somehow reconstituting something more like a sharpies fiber instead of a fibrovascular scar is going to be important so I got really excited and got ready to go in. in this case um and uh and i decided to keep it really simple i tenonized the biceps tendon and kind of uh do we have audio?
Can I get it and then don't worry? The guy tells me you know I'm ecstatic. it's so now look keeping it simple rehab keeping it super simple looking simple miss pathology now you have to go back to fix it so you're going back to the operating room I'm going to I'm going to what I call a goofy or pe maybe a goofy repair something a little simpler so you guys already know these repairs i'm exactly sympathetic to everyone in the burkhart group this is this is what i want to do i want a front and rear luggage tag to rebuild my cable but this is not what i'm going to get on rotator cuff revision surgery if you're going in there and the tendon is so mobile there's been a serious mistake in the first surgery and that's the case it's not often so the indications I got green lights yellow lights and lights red, you know, the pain I want to treat is age, age is going to be very important. years once you get over 56 is where we see most patients have a significant decrease in healing hopefully it's smaller than when i first went in there i want to have a chance before it's too much atrophy i start to get nervous with the upper migration I mean there is something well tolerated but as it goes up and up I get very nervous I will tolerate a little bit of arthritis too but you know it's not like that if the deltoid is insufficient or if their axillary nerves are insufficient or if they had any too aggressive type of acromioplasty two or three times, so I'm not really going to go for this cuff.
I think it is a problem and again I want to see my untreated pathology. i want to hope that you can find a biceps ac or super or subscapularis i want to hope that your superscapularis nerve may be a candidate for release and i'm going to look at stiffness and stiffness here post-op stiffness is not just capsule release there is a lot of subdeltoid stiffness that you also need to address so you need to be up and down to get an effective result there so what should i do on this repair? need to speed up the healing somehow and i have to address this trifecta of what i think will determine the healing, anatomy, biomechanics and biology so the first step is to get to the o and trust your gut because you know you're going to look at this tissue you've done 15 years of practice 10 years of practice you know what you're looking at so in this study i looked correlated i said i'm going to look at this i'm going to create a rotator cuff score i'm going to look at the tendon i'm going to tell you if it's thick thin elastic inelastic I'm going to take a biopsy of that tendon right then and score the tendon and then I'm going to do ultrasounds afterwards so I'm going to put all this together and predict who and who can't heal because I know how they are see a tendon and i know what disease the tendon will look like the multivariate analysis i passed i am age gender state of repair we have i spoke shamelessly i spoke about thickness fraying stiffness of the tendon and then I can't say this out loud but the way you rate the tendons is the erection score that's really true so that's the tenocytes the ground substance collagen the vascularity you add it up and it's a total of 12.
So look what we did is we put all this together and this is what I found, you don't know what you're looking at, the degree of tendinopathy, we had three different surges, we looked at what the disease was or wasn't this tendon and what i said it looked like it had has nothing to do with what it looked like histologically so your interpretation of elasticity delamination doesn't mean the tendon is diseased at all so seeing is believing it isn't , not really the same study done looking at open fractures of the tibia and the degree of muscle uh muscle necrosis the surgeons rated the muscle necrosis they said oh god this is bad we have to carve it bad so don't trust your o jos so don't trust your gut is what I'm saying when you're looking at muscle tendon disease on your MRI you may not be able to move When the tendinopathy gets over you may so don't trust your guts.
Here are some other options. Our panel talked about this. Maximize your biology. We talked about articular surface medialization for a little more real estate. use use the ring correctly create the vents you want create a crimson quilt you want to try and get a healing path from the bone up the next thing you want to do for an option for a failed rotator cuff is to look for a partial recovery a partial recovery the cuff repair pulling on your infrastructure and removing the biceps can be a very effective cuff derrick here in florida looked at this and had 75 of their patients lastingly satisfied there is some argument that they are and their group looked at this and they said : look, you know what, it may not be that durable, they deteriorated after two years, so debridement alone may not be the answer, but partial repair may be a reasonable answer even at revision.
The next option I'm going to consider is a medialized repair, so once again I'm going to medialize the articular cartilage by five millimeters. I'm going to place my anchors relatively medially and I'm going to use a suture setup where I take a mattress and then two simple bites, so I'm going to use a triple-loaded anchor recognizing that three stitches are 50 stronger than two stitches, so whenever I can I'm going to use a triple load anchor and I'm going to set this up we use the word low stress repair but what we're really thinking about at least in the lab is a low stress repair and your stress is your change in length of its original length and when you see When you look at tinocytes in cell cultures, when you apply tension to the tenocytes, they don't react well, so when you have a low-tension repair, you're going to do better and that's going to touch on the idea of ‚Äč‚Äčaugmentation . and how do i want to de-stress on this option three i am totally on your team on this one dr burkhart i want to go burkhart on that the idea here is to use his rip stop technique and i really think of this as a cable reconstructive technique uh and when i do i did it for the first time i i was so amazed by what happened and you really know the way i've done it is run the fiber tape from the front to the back um and then i'm going to run my stitch my tear stop sutures around I like to use the lasso because it helps me see and place it exactly where I want to be, but what am I interested in after this? acromioplasty but right here is my posterior cable reconstruction.
I'm going all the way across and here's my previous cable rebuild and that's going to be. to link down and I'm going to maybe if I maybe have a residual weakness or a residual tear in the core aspect of that but a lot of people will do very very well if you can restore your front and back cable so I think it's an important tool and it's going to be an important tool even as we get into other things and I just want to play what the results are so let's be a little bit data driven in everything I talk about what are the results of the revision rotator cuff repair well imagine they're not as good as your main retail rate unlike we talked about 20's your retail rate will be around 40 your complication rate your stiffness infection everything will increase at a rate of 20 and that is extremely high so this is not a surgery to say oh my god don dont worry about it you better think carefully why alex and patrick and dr burkhart looked at this and n the meta-analysis and at the end of the day they also found a retail rate of 40 but 70satisfied so that's a pretty good number without having to take out the metal and plastic rise i think this is something we started talking about and i'm not talking about interposition so steve snyder talked about interposition and that has really been a good thing bad and other than steve and allison toth i dont know if a lot of people have posted good on it but what can you do what can you do now or you can use dermal augmentation i use the a flex three you can use amniotic patches and the amniotic as we mentioned earlier may not be doing the same in structural terms but it's probably an mmp inhibitor and we know that mmps will be concentrated in his bursa and in his rotator cuff afterwards so here just a couple points on my raise is not just a single no I just take this thing and put a bridge on top of it and hope it works it's very important to me to take the strain off so I want to unload my rotator cuff so my medial sutures go est ar through uh through ugh the graft my repair is done and then i'm going to tie this right away then regardless i want to carry that graft and i want that graft to sit on top of it and protect me and protect my repair and carry me through that six month window so that will be my tip and what are the results again based on data with primary augmentation revision sleeve repair is very exciting you can see a lot of really good results and I would send you that in a lot of patients you want see that but your retail rates are going to be somewhere between 40 and 60 percent once again with about 70 percent of your patients satisfied what's next what about additional biologics okay we can we can special sauce we can call an angel or we can now start to think about the graft net and the trombonator as a combination if you want to be a little more uh cost consideration and you can see I don't have much hot in coming in late but i have a chart l help downstairs i left the corner stitch before i put it in and you'll see what i'll do now is take the bone marrow aspirate i'll take a spinal needle i'll slide it under my sandwich let the water seep through and i'll fill it with bone marrow it's completely crazy no we just talked about the hernia seeing this and we talked about the peter mills evaluation with uh with prp so is there some role for this uh and me again in the review setting what are some of the best actors? rob uh rob hearthstone actually wrote an article on this and said look rad3 infraspinatus the infraspinatus is a bad actor infraspinatus atrophy intraspinal necrosis osteopenia smoking opioid dependency uh active range of motion these are bad, bad actors for setting up revision repair of the rotator cuff so look at the end of the day there are fewer and fewer revisions for rotator cuff repair we have scr we have sdr sandwich i think tendon transfers and for me it goes to b e a lower trapezius is a very effective operation and we have reversals that are going to be indications for it so thank you don't miss the pathology reduce tension rebuild your wire think about the uh think about dermal augmentation

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