Review Article

Arthroscopic Revision Rotator

Cuff Repair
Abstract
Patrick J. Denard, MD
Stephen S. Burkhart, MD

Rotator cuff repair leads to good and excellent outcomes in most

patients. However, structural failure of the repair occurs in a
substantial number of cases and can lead to an unsatisfactory
result. Several factors have been implicated, including patientrelated factors (eg, patient age, tear size) and extrinsic factors (eg,
surgeon surgical volume, biomechanical failure). Structural failure
requires a detailed patient evaluation to elucidate the cause of
persistent symptoms. Function can be maintained despite a
recurrent tear; therefore, a recurrent tear alone is not an indication
for revision repair. The major indication for revision rotator cuff
repair is the persistence of clinical symptoms, despite nonsurgical
management, in the absence of substantial risk factors for failure.
Although the outcome is poorer than after primary repair,
satisfactory results have been reported following revision repair of
recurrent rotator cuff tears, particularly with arthroscopic
techniques.

From The San Antonio Orthopaedic

Group, San Antonio, TX.
Dr. Burkhart or an immediate family
member has received royalties from,
serves as a paid consultant to, and
has received research or institutional
support from Arthrex, and serves as
a board member, owner, officer, or
committee member of Arthroscopy
Association of North America.
Neither Dr. Denard nor any
immediate family member has
received anything of value from or
owns stock in a commercial
company or institution related
directly or indirectly to the subject of
this article.
J Am Acad Orthop Surg 2011;19:
657-666
Copyright 2011 by the American
Academy of Orthopaedic Surgeons.

November 2011, Vol 19, No 11

he number of rotator cuff repairs performed annually is

steadily rising,1 and these repairs result in good and excellent outcomes
in most cases.2 However, structural
failure of repair remains common because of a variety of factors.3 Thus,
the number of revision repairs for recurrent rotator cuff tears will likely
increase. Although functional outcome has been correlated with postoperative rotator cuff integrity,2,4
many patients maintain a satisfactory outcome despite structural failure.5,6 In patients with persistent
symptoms and structural failure of
the repair, a careful evaluation is required to determine whether further
treatment is appropriate. Historically, mixed results were reported
following open revision repair of recurrent rotator cuff tears.7,8 Recently,
however, several authors have reported encouraging results following

arthroscopic revision repair of recurrent rotator cuff tears.9-11

Causes of Failure
The causes of failure after rotator
cuff repair are multifactorial. Broad
classification of causes of clinical
failure include improper or missed
diagnosis, improper management,
technically inadequate surgery or rehabilitation, postoperative stiffness,
and structural failure of repair. Here,
we review structural failure of repair.
Structural failure of repair can be
the result of intrinsic and extrinsic
factors (Table 1). Factors intrinsic to
the patient include patient age,2,4,12
tear size,12,13 and biologic failure despite strong fixation.12,14 Boileau
et al4 examined the relationship between increasing age and structural
integrity of the rotator cuff following

657

Arthroscopic Revision Rotator Cuff Repair

Table 1
Factors Associated With Re-tear
Following Rotator Cuff Repair
Intrinsic
Advancing patient age
Increasing tear size
Biologic failure despite strong fixation
Tendon and muscle quality
Systemic disease (eg, rheumatoid
arthritis, diabetes mellitus)
Smoking history
Extrinsic
Surgeon volume
Inadequate biomechanical construct or
improper repair configuration
Overaggressive postoperative rehabilitation

an arthroscopic repair. The rate of

healing assessed by MRI or CT arthrography was 95% for patients
<55 year of age; the rate decreased to
75% for patients 55 to 64 years of
age and to 43% for patients >65
years of age. Similar results were reported by Harryman et al2 following
open rotator cuff repair, with a rate
of healing of approximately 75% for
patients 55 years of age, 65% for
patients 56 to 70 years of age, and
55% for patients >70 years of age.
Increasing tear size is the greatest
risk factor for structural failure of repair. In a prospective analysis of arthroscopic rotator cuff repair, Nho
et al12 reported that for every centimeter of increase in rotator cuff size,
the odds of a postoperative tendon
defect increases more than two
times. These authors also reported
that for multiple-tendon tears, the
likelihood of failure was nearly nine
times greater than that for singletendon tears. In their series of open
rotator cuff repairs, Harryman et al2
reported 80% healing for singletendon full-thickness tears, which
decreased to 57% for two-tendon
tears and to 32% for three-tendon
tears.

658

Biologic failure despite strong fixation is more difficult to quantify than

are tear size and age, but it also plays
a role in the rate of rotator cuff healing. In 1994, Goutallier et al15 reported that grade 2 fatty degeneration (ie, more muscle than fat) of the
infraspinatus muscle following open
rotator cuff repair with suture to
bone was associated with a poorer
functional outcome and higher tear
recurrence. (These authors classified
fatty degeneration into five categories: grade 0, no fatty deposit; grade
1, some fatty streaks; grade 2, more
muscle than fat; grade 3, muscle
equals fat; and grade 4, less muscle
than fat.) In their series, the re-tear
rate was 50% with grade 2 fatty degeneration compared with 10% with
fatty degeneration of grade 1 or 0.15
In contrast, Burkhart et al16 reported
that, with arthroscopic suture anchor fixation of the rotator cuff,
86% of massive tears with Goutallier
preoperative grade 3 or higher fatty
degeneration achieved functional improvement.
Recent efforts to augment biologic
healing have led to the development
of platelet-rich plasma (PRP) and rotator cuff patches and to several
preclinical investigations of other biologic enhancements. To date, however, the effect of these enhancements
is unproven. Moreover, although patient age and tear size are inherently
related, multivariate analysis has
suggested that these factors may be
more important than biologic factors
in rotator cuff healing.12
In contrast to intrinsic factors, factors
extrinsic to the patient are within the
surgeons control. Extrinsic factors associated with revision rotator cuff repair include surgeon surgical volume,
biomechanical failure resulting from inadequate strength of the repair construct or improper repair configuration
for a given tear pattern (eg, repairing
a U- or L-shaped tear as though it were
a crescent tear), and aggressive postop-

erative rehabilitation leading to failure

of the repair construct.
Higher surgeon volume has been
associated with lower complication
rates following several surgical procedures, including rotator cuff repair
and shoulder replacement. In a recent study, the need for revision
within 1 year of a primary rotator
cuff repair was found to be higher
for surgeons who performed fewer
than three rotator cuff repairs per
month.1
Biomechanically, the introduction
of suture anchors in the early 1990s
transferred the weak link in rotator
cuff repair from the bone to the tendon.17,18 One of the easiest ways to
improve fixation of the tendon,
therefore, is to increase the contact
area (ie, footprint restoration). From
a biomechanical standpoint, doublerow rotator cuff repairs have demonstrated improved fixation characteristics compared with single-row
repairs.19 Most early clinical studies
of nonsuture-bridging double-row
repairs have not yet demonstrated a
better functional outcome.20,21 Although concern has been raised
about over-tensioning resulting in
medial failure following double-row
repair,22 overall, double-row repairs
are associated with a lower rate of
structural failure compared with
single-row repairs. In a systematic review of 23 articles with a total of
1,252 rotator cuff repairs, the recurrence rate for tears 3 cm was 19%
following single-row repair compared with 7% following doublerow repair.3 For tears >3 cm, the retear rate increased to 45% following
single-row repair compared with
26% following double-row repair.
Given the long-term association between decreased functional outcome
and structural failure of the rotator
cuff, it is possible that, with longerterm studies, these differences in
healing will result in improved functional outcome following double-

Journal of the American Academy of Orthopaedic Surgeons

Patrick J. Denard, MD, and Stephen S. Burkhart, MD

mobilization. In a recent systematic

review of arthroscopic rotator cuff
repair, the rate of postoperative stiffness that was permanent or required
capsular release was 3%.29

Figure 1

Evaluation

Comparison of traditional double-row repair and suture-bridging double-row

repair. A, With the original double-row rotator cuff repair, two medial anchors
were placed, sutures were individually passed and tied as mattress stitches,
and then the suture limbs were cut. Two lateral anchors were also placed,
sutures were passed and tied as simple stitches, and the suture limbs were
cut. B, In a suture-bridging double-row repair, the medial and lateral rows are
linked. Two medial suture anchors are placed, and sutures from these
anchors are individually passed and tied as mattress stitches. Rather than
cutting the suture limbs, however, the sutures are crisscrossed and secured
laterally to two knotless anchors. This repair mechanically links the two rows
and provides enhanced footprint compression to encourage rotator cuff
healing. (Reproduced with permission from Burkhart SS, Lo IK, Brady PC,
Denard PJ: The Cowboys Companion: A Trail Guide for the Arthroscopic
Shoulder Surgeon. Philadelphia, PA, Lippincott Williams and Wilkins, in
press.)

row compared with single-row repairs.

Moreover, in the early clinical
studies, a traditional or triangular
double-row repair was performed,
which consists of two independent
rows of fixation (Figure 1, A). Current double-row repairs are suturebridging, in which the medial and
lateral rows are linked (Figure 1, B).
These suture-bridging constructs exhibit even greater load-to-failure23
and footprint restoration24 compared
with the traditional double-row repair; early clinical results are very encouraging.25 Also, similar to the
improvements
demonstrated
in
double-row repair, single-row repair
may be enhanced. The number of
fixation points can be increased with
triple-loaded anchors, and stitch
configuration can be altered to limit
cutout (eg, anchor-based ripstop).26
November 2011, Vol 19, No 11

At this time, however, no clinical

studies have compared double-row
repairs and single-row repairs with
triple-loaded anchors or complex
stitch configurations.
Given that the weak link in fixation of the rotator cuff is the suturetendon interface, early, aggressive
postoperative rehabilitation can lead
to structural failure of a repair.27 In a
histologic evaluation of rotator cuff
healing in a primate model, Sonnabend et al28 reported that maturation of the repaired rotator cuff requires 12 to 15 weeks. Historically,
authors using open repair techniques
advocated for early passive range of
motion to prevent postoperative
stiffness. However, recent studies
have shown that the risk of stiffness
following arthroscopic rotator cuff
repair is very low, even with a conservative protocol of 6 weeks of im-

When structural failure occurs, the

surgeon must decide whether further
surgery is indicated. Structural failure does not always result in clinical
failure. Many patients with partial
healing of the cuff and a residual defect will be much improved after surgery; surgical intervention is not indicated in these patients. In general,
patients with disabling pain and
weakness at 9 to 12 months after
surgery should be evaluated for possible revision repair. A detailed history, physical examination, and evaluation of imaging are necessary.
Additionally, consideration should
be given to further diagnostic testing
when infection or neurologic injury
is suspected.

History
As with the evaluation done of patients undergoing primary rotator
cuff repair, the history of patients undergoing revision rotator cuff repair
is important to define the cause of
pain and rule out nonshoulder pathology (eg, cervical radiculopathy).
Intermittent pain that is activity related is suggestive of symptoms related to the rotator cuff, whereas
constant pain and/or systemic symptoms should raise suspicion of postoperative infection. The patients
previous postoperative rehabilitation
protocol should also be reviewed to
determine whether early aggressive
motion or strengthening contributed
to structural failure.

Physical Examination
Previous surgical incisions should be
inspected for signs of inflammation

659

Arthroscopic Revision Rotator Cuff Repair

bow flexed 90 (ie, hornblowers

sign) have a 100% sensitivity for detecting grade 3 or 4 fatty degeneration of the infraspinatus and teres
minor respectively. In one study, the
bear-hug test had the highest sensitivity for detecting subscapularis tendon tears33 (Figure 2). Given the
inaccuracy of MRI at detecting subscapularis tendon tears,34,35 a positive
bear-hug, belly-press, or lift-off test
should alert the surgeon to a previously missed subscapularis tear.33

Figure 2

Imaging

The bear-hug test. The hand on the affected side is placed on the opposite
shoulder with the fingers extended and the elbow flexed forward. The patient
resists as the examiner tries to pull the hand off the shoulder in a direction
that is perpendicular to the plane of the forearm (arrow). If the examiner is
able to lift the hand off the shoulder, the patient likely has a torn (either
partial or complete) upper subscapularis tendon. (Reproduced with
permission from Burkhart SS, Lo IK, Brady PC: Burkharts View of the
Shoulder: A Cowboys Guide to Advanced Shoulder Arthroscopy.
Philadelphia, PA, Lippincott Williams and Williams, 2006, p 118.)

suggestive of infection. It is important to determine the integrity of the

deltoid attachment, particularly if
the previous repair was performed
with an open technique. Djurasovic
et al8 reported that 78% of patients
with an intact deltoid had a satisfactory result following revision open
repair, compared with 57% for patients with compromised deltoid integrity.
Active and passive ranges of motion are compared to assess for postoperative stiffness. Patients with
stiffness without a recurrent tear can
benefit from an isolated capsular release and subacromial lysis of adhesions. Pseudoparalysis is defined by
active elevation of <90 (because of
an unstable glenohumeral fulcrum
rather than pain) with full passive
range of motion. Although recovery
of pseudoparalysis following pri-

660

mary arthroscopic repair is approximately 75%,30 to our knowledge,

there are no published data regarding recovery of pseudoparalysis following revision rotator cuff repair.
In addition to standard strength
testing, several physical examination
tests can be used to define the pattern of tear and establish a prognosis
for recovery. The inability to maintain external rotation with the arm
in 20 of abduction and maximal external rotation is considered a positive external rotation lag sign; it has
been reported to have a sensitivity of
65% for detecting lesions extending
into the infraspinatus tendon.31
Walch et al32 reported that both the
inability to maintain external rotation with the arm at the side (ie,
dropping sign) and the inability to
externally rotate the arm from a position of 90 abduction with the el-

Plain radiographs are obtained to assess the glenohumeral joint space

and to evaluate for the presence of
proximal migration and adaptive
changes of the proximal humerus (ie,
femoralization) and the undersurface
of the acromion (ie, acetabularization). Proximal migration alone is
not a contraindication to repair and
can be reversed following arthroscopic rotator cuff repair.36
However, advanced adaptive rotator
cuff arthropathy changes are a contraindication to repair. Radiographs
should also be evaluated for other
causes of pain (eg, chondrolysis,
loose anchors, acromial fracture).
Advanced imaging is used to assess
tear pattern and rotator cuff muscle
quality. Ultrasonography is cost effective and has less postoperative
hardware artifact than does MRI.
However, ultrasonography is operator dependent, is unfamiliar to most
orthopaedic surgeons, and does not
provide a thorough evaluation of the
glenohumeral joint. Postoperative
MRI is less accurate than is MRI in
the primary setting. In one study,
91% sensitivity was reported for
MRI for detecting a recurrent rotator
cuff tear, but the specificity was
25%.37 MRI thus has the tendency to
overdiagnose recurrent rotator cuff
tears. In the same study, MRI also
demonstrated a poor ability to assess

Journal of the American Academy of Orthopaedic Surgeons

Patrick J. Denard, MD, and Stephen S. Burkhart, MD

rotator cuff tear size.37 Compared

with the results demonstrated for
tear presence and size, MRI is likely
more accurate in the postoperative
setting for determining rotator cuff
muscle quality. T1-weighted parasagittal images should be inspected for
the presence and severity of fatty degeneration, which correlates with
prognosis.38 Another consideration
in performing preoperative imaging
studies is to evaluate for the amount
of the greater tuberosity that is available for additional suture anchor
placement. When large numbers of
anchors are already present, or when
cystic cavitation has occurred
around the anchors, then the surgeon
may have to remove some or all of
the existing anchors and bone-graft
the defects.

Diagnostic Tests
Electrodiagnostic testing should be
considered if there is the possibility
of neurologic injury (eg, axillary
nerve palsy) or cervical radiculopathy. The erythrocyte sedimentation
rate (ESR) and C-reactive protein
levels are commonly used to evaluate
for postoperative infection. However, the sensitivity of these tests is
60% and 50%, respectively, in the
setting of postoperative rotator cuff
infection.39 If there is strong suspicion for postoperative infection, then
consideration should be given to a
joint aspiration for cell count, Gram
stain, and culture. Because most of
these infections are caused by Propionibacterium acnes, cultures should
be retained for a minimum of 7
days.39

Management
Nonsurgical
Several studies have shown that most
patients obtain functional improvement despite re-tear following rotator cuff repair.2,5,6 Most such re-tears
November 2011, Vol 19, No 11

are smaller than the original tear,

suggesting that partial healing can
improve function. Jost et al5 reported
on the long-term outcome of 20 retears following an open repair. At an
average follow-up of 7.6 years, Constant scores did not demonstrate notable deterioration compared with
values at 3.2 years, and 95% of the
patients remained satisfied with the
result of surgery. However, negative
prognostic factors included a decrease in the acromiohumeral interval and progression of glenohumeral
arthritis and fatty degeneration. Notably, the six patients with extension
of the re-tear into the infraspinatus
tendon had an age-adjusted Constant score of 75%, compared with
94% for the patients with an intact
infraspinatus tendon.

Indications for Revision

Repair
Revision repair is considered for patients with persistent symptoms (ie, of
9 to 12 months), despite nonsurgical
management, in whom a comprehensive evaluation has ruled out infection
or nonshoulder diagnoses and in whom
radiographs do not demonstrate advanced adaptive changes. Although
Goutallier et al15 classified grade 2 as
a turning point in prognosis for recovery, evidence from the primary
repair literature indicates that patients with grade 3 and even grade 4
fatty degeneration can obtain improvement after arthroscopic rotator
cuff repair with suture anchor fixation. Burkhart et al16 reported that
100% of patients with grade 3 fatty
degeneration obtained functional improvement following arthroscopic
rotator cuff repair. For grade 4 degeneration, however, only 40% of
patients demonstrated substantial
functional improvement. Therefore,
in patients with grade 4 fatty degeneration, the decision to attempt revision rotator cuff repair should be

carefully considered. In a young patient without adaptive changes of the

proximal humerus, a revision repair
may be reasonable, following proper
counseling of the prognosis. Alternatively, latissimus dorsi transfer is a
consideration for a young patient
with an irreparable posterosuperior
tear. For patients >70 years of age
with grade 4 fatty degeneration and
severe dysfunction, a reverse total
shoulder arthroplasty may provide a
more predictable functional outcome.38

Arthroscopic Technique
Both open and arthroscopic techniques have been reported for revision rotator cuff repair. Additionally,
a mini-open repair may be an option,
but at this time, there are no published reports on this technique for
revision rotator cuff repair. Our preference is an arthroscopic technique.
Compared with an open or miniopen approach, an arthroscopic
technique creates minimal trauma to
the deltoid insertion, allows a complete evaluation and treatment of the
frequent concomitant pathology (eg,
biceps tenodesis, capsular release)
within the glenohumeral joint, and
provides a better evaluation of the
tear pattern and its mobility. The
major limitation of an arthroscopic
approach is the high technical demand of the procedure. However,
with any technique, revision rotator
cuff repair is more difficult and time
consuming than primary repair: the
rotator cuff is often retracted and adhesed to the glenoid, coracoid process, and undersurface of the acromion. As previously alluded, the
emphasis for large and massive tears
is to restore balanced force couples,
which means that repair of the subscapularis and infraspinatus tendons
is of paramount importance.
In most revision rotator cuff repair
cases, we perform an arthroscopic

661

Arthroscopic Revision Rotator Cuff Repair

Figure 3

A, Posterior arthroscopic view of a right shoulder demonstrating the comma

sign (blue comma symbol) in a patient with a massive retracted rotator cuff
tear. The comma sign leads to the superolateral border of the subscapularis
tendon (SSc) (outlined by dashed black lines). B, Posterior arthroscopic view
of the same patient as in panel A demonstrating how the comma tissue
connects the subscapularis and supraspinatus (SS) tendons. Subscapularis
tendon repair will therefore facilitate supraspinatus tendon repair.
G = glenoid, H = humerus. (Panel B reproduced with permission from
Burkhart SS, Lo IK, Brady PC, Denard PJ: The Cowboys Companion: A Trail
Guide for the Arthroscopic Shoulder Surgeon. Philadelphia, PA, Lippincott
Williams and Wilkins, in press.)

biceps tenodesis or tenotomy. We address the biceps for two reasons.

First, the biceps tendon has been
shown to be an important source of
pain in patients with primary rotator
cuff tears;40 thus, we have a lower
threshold to address the biceps in the
revision setting. Second, many revision repairs involve the subscapularis
tendon, and poorer outcomes have
been associated with attempts to retain the biceps tendon in the setting
of subscapularis repair.41 The choice
between tenotomy and tenodesis is
based on functional demands and
cosmetic concern.
It is important to closely evaluate
for a tear of the subscapularis tendon
and to perform a repair when the
tendon is torn. Three unique aspects
of the subscapularis make it more
challenging to repair than posterosuperior rotator cuff tears. First, the
chronic subscapularis tear tends to
retract much more than does the rest
of the rotator cuff, causing mobilization to be more difficult. Second,

662

mobilization of the retracted subscapularis can be intimidating because it scars against the coracoid
process, in close proximity to important neurovascular structures. Third,
visualization, arthroscopic instrument manipulation, and knot tying
in the limited subcoracoid space are
more challenging compared with
working in the subacromial space.
However, with a systematic approach, reliable fixation can be
achieved.
If the subscapularis tendon is not
immediately visible at the front of
the joint, it is probably retracted medially to the level of the glenoid margin. When the upper subscapularis
tears away from its bone attachment,
the medial sling (which is directly adjacent to it) also tears away from the
bone. The torn medial sling forms a
distinctive comma-shaped arc of soft
tissue (ie, comma sign) at the superolateral corner of the subscapularis
(Figure 3). This tissue not only helps
identify the subscapularis tendon,

but it also connects the superolateral

subscapularis tendon to the anterolateral supraspinatus tendon. As
such, subscapularis repair facilitates
repair of the supraspinatus and, in
fact, is critical because failure to repair the subscapularis places the anterior supraspinatus tendon under
greater tension, potentially leading
to repair failure (Figure 4).
In rare circumstances, the subscapularis is not immediately identifiable
because of significant scarring. In
this scenario, a window is created
just anterior to the glenoid above the
mid-glenoid notch, and dissection is
carried medially to the base of the
coracoid process, where the subscapularis can be reliably identified (Figure 5).
For a retracted subscapularis tear,
a three-sided release of the subscapularis is required. An anterior release
is achieved by skeletonizing the posterolateral aspect of the coracoid
process. Release of the superior border of the subscapularis from the
coracoid base is bluntly achieved
with a 30 arthroscopic elevator. The
posterior release is achieved by freeing adhesions between the anterior
glenoid neck and the posterior surface of the subscapularis tendon. Following mobilization, the subscapularis is repaired to bone. Attention is
then turned to the posterosuperior
rotator cuff.
A systematic dissection of the bony
landmarks and excavation of the rotator cuff is required to identify the
posterosuperior tear margins. Identifying the scapular spine helps the
surgeon delineate the supraspinatus
from the infraspinatus. The surgeon
delineates the rotator cuff while
viewing through the lateral portal.
For tears adhesed to the undersurface of the acromion, a technique for
excavating the cuff is to place a
4.5-mm shaver through the posterior
portal, in a plane just below the
acromion, aiming just lateral to the

Journal of the American Academy of Orthopaedic Surgeons

Patrick J. Denard, MD, and Stephen S. Burkhart, MD

Figure 4

Schematic of the relationship between subscapularis repair and supraspinatus repair. A, Massive retracted and
contracted tear of the subscapularis and supraspinatus tendons. B, Repair of the subscapularis partially reduces the
supraspinatus retraction. C, Repair of the supraspinatus can then be accomplished with minimal tension. (Courtesy of
David Baker, San Antonio, TX.)

Figure 5

Posterior arthroscopic view of a left

shoulder demonstrating retracted
adhesed subscapularis tendon tear
in which the comma sign is not
readily visible. A window is created
anterior to the glenoid (G) above
the mid-glenoid notch, and
dissection proceeds medially to
identify the subscapularis tendon
passing inferior to the coracoid
neck on its way to intersect the
glenoid rim at the level of the midglenoid notch. H = humerus.
(Reproduced with permission from
Burkhart SS, Lo IK, Brady PC,
Denard PJ: The Cowboys
Companion: A Trail Guide for the
Arthroscopic Shoulder Surgeon.
Philadelphia, PA, Lippincott
Williams and Wilkins, in press.)
November 2011, Vol 19, No 11

scapular spine. When the scapular

spine is palpated with the tip of the
shaver, it is swept laterally, maintaining its plane just below the acromion, until the tip of the shaver
blade penetrates the fibrous tissue as
it thins out laterally (Figure 6). This
maneuver preserves whatever rotator
cuff might have been encased within
the scar tissue that had become adhesed to the acromion. The shaver
blade then completes the dissection
of the lateral edge of this soft-tissue
envelope from the acromion. After
the bony landmarks have been skeletonized, residual bursal leaders,
which represent a false cuff, must be
dbrided back to tendon (Figure 7).
Following identification of the rotator cuff margins, the bone bed is
prepared for repair. At this stage,
previous remaining sutures or anchors are removed as needed. Often
previous anchors can be retained,
and new anchors can be placed adjacently. However, anchor removal
sometimes can be necessary either to
remove a prominent anchor or to
provide sufficient biologic surface
for tendon-to-bone healing. If the in-

side of the anchor is visible and the

type of implant is known, the inserter from that implant can be used
to remove the anchor. Otherwise, an
Osteochondral Autologous Transfer
System (OATS) harvester (Arthrex,
Naples, FL) larger than the diameter
of the anchor can be used. The harvester is impacted around the anchor,
then turned counterclockwise to remove the anchor. This technique removes some additional bone surrounding the anchor, which can be
retained and replaced into the defect.
Additionally, any remaining defect
can be filled with an allograft compaction grafting technique using the
same OATS harvester.
Next, an assessment is made of
tear pattern and mobility. If there is
insufficient mobility of the tendon to
reach the bone bed, then a slight
amount of mobility can be gained
with a capsular release beneath the
supraspinatus and infraspinatus tendons. If the capsular release fails to
provide sufficient additional excursion, then interval slides are required
to obtain tendon-to-bone repair.8,42-44
In most cases, single-row suture an-

663

Arthroscopic Revision Rotator Cuff Repair

Figure 6

Figure 7

A, Lateral subacromial arthroscopic view of a right shoulder demonstrating a

massive contracted rotator cuff tear that is adhesed to the undersurface of
the acromion. B, A shaver (black arrow) is inserted through a posterior portal
and used to bounce off the scapular spine, just lateral to the bone, and it is
then swept laterally to penetrate the fibrous tissue laterally as it defines the
plane about the rotator cuff (RC). G = glenoid, H = humerus. (Reproduced
with permission from Burkhart SS, Lo IK, Brady PC, Denard PJ: The
Cowboys Companion: A Trail Guide for the Arthroscopic Shoulder Surgeon.
Philadelphia, PA, Lippincott Williams and Wilkins, in press.)

chor repair is possible following interval slides, and in some cases, the
additional excursion is great enough
to allow double-row repair. However, when only partial repair is possible, then as much of the tendon as
possible is repaired to bone, with
emphasis on the infraspinatus. Additionally, a side-to-side repair of supraspinatus to infraspinatus may
help to reestablish a crescent-shaped
cable that can transmit a distributed
load to the anterior and posterior anchor points of the partial repair.

Results
The results of open surgical management of failed rotator cuff repairs
have been mixed in the few series reported in the literature. In 1984, DeOrio and Cofield7 reported on 27 revision repairs, 8 of which were
massive tears. Overall, only 17% of
patients obtained a good result, and
among the massive tears, only
12.5% of patients achieved a good
result. The results led to the authors

664

to recommend an immediate glenohumeral arthrodesis when the recurrent tear is massive. More recently, Djurasovic et al8 reported
more encouraging results in 80 revision rotator cuff repairs, 51 of which
were classified as large or massive
tears. Overall, active elevation improved from 105 preoperatively to
130 postoperatively, and 69% of
patients achieved a satisfactory result. In large or massive tears, a satisfactory (ie, excellent, good, fair)
functional outcome was obtained in
67% of patients. A satisfactory result
was associated with an intact deltoid
origin, good-quality rotator cuff tissue (defined subjectively), preoperative active elevation of the arm above
90, and only one prior procedure.
The results following arthroscopic
revision rotator cuff repair have been
encouraging. Lo and Burkhart9 reported on 14 cases, 11 involving massive tears, at a mean follow-up of 23.4
months. The mean postoperative University of California Los Angeles
(UCLA) score was 29, good or excel-

Lateral subacromial arthroscopic

view of a right shoulder
demonstrating a bursal leader (BL),
which is excised with a shaver to
delineate the true rotator cuff (RC)
margins. H = humerus.
(Reproduced with permission from
Burkhart SS, Lo IK, Brady PC,
Denard PJ: The Cowboys
Companion: A Trail Guide for the
Arthroscopic Shoulder Surgeon.
Philadelphia, PA, Lippincott
Williams and Wilkins, in press.)

lent results were achieved in 64% of

patients, and 93% of patients were satisfied with the procedure.
Keener et al11 reported on 12 arthroscopic revision rotator cuff repairs with a mean follow-up of 33
months. Nine of 21 patients had a
single-tendon tear, 11 had a twotendon tear, and 1 had a threetendon tear. However, it was not
noted whether the tears were complete, making classification between
nonmassive and massive impossible.
Following revision, American Shoulder and Elbow Surgeons (ASES)
scores had improved from 40 to 73,
and forward elevation had improved
from 130 to 147. Postoperative ultrasound was also performed on all
of the patients. Overall, 48% percent
of shoulders had an intact repair.
Seventy percent of the single-tendon
repairs were intact, compared with
27% of the two-tendon tears (P =
0.05). The average age of the 10 patients with an intact repair was 52
years, compared with 59 years for

Journal of the American Academy of Orthopaedic Surgeons

Patrick J. Denard, MD, and Stephen S. Burkhart, MD

the 11 patients with a recurrent tear.

Postoperative healing was associated
with an improved functional outcome according to age-adjusted Constant scores (84 for healed versus 69
for recurrent tears).
Piasecki et al10 reported the results of
54 arthroscopic revision rotator cuff repairs. Only four patients (7.4%) presented with a massive rotator cuff tear.
At a mean follow-up of 31 months,
ASES scores had improved from 44 to
68, and forward elevation had improved from 121 to 136. The authors
described an association between poor
outcome and female sex or active preoperative forward elevation <120 before revision.
Although tear size has been associated with the risk of recurrence following primary repair, size of tear is
not a contraindication to revision repair. Recently Ldermann et al45 reported on a cohort of 21 nonmassive
tears and 53 massive tears with a
mean follow-up of 63 months. Overall, the mean ASES score improved
from 47 to 75, the mean UCLA score
improved from 17 to 26, and 78%
of patients were satisfied with the
surgery. No statistical difference was
observed in the functional outcome
between massive and nonmassive repairs. Only 6 of the 74 patients (8%)
required additional surgery within
the follow-up period of >5 years. Interestingly, functional improvement
was noted by ASES scores between
the 1-year postoperative visit and final follow-up. This finding is important for several reasons. From a
rehabilitation standpoint, revision
repairs appear to take a longer time
to reach full functional improvement
than do most primary repairs. This
information is useful for the surgeon
monitoring postoperative progress,
as well as for counseling patients regarding the timeline for recovery.
More importantly, this sustained improvement suggests that revision arthroscopic repair of recurrent tears is
November 2011, Vol 19, No 11

durable in the long term. Similar to

the findings of Piasecki et al,10 female
sex and preoperative forward elevation <135 were associated with a
poorer result.

Summary
Structural failure is not uncommon
following rotator cuff repair. Intrinsic and extrinsic factors contribute to
failure of a repair. A careful evaluation is required to determine which
patients will benefit from a revision
repair because many patients maintain functional improvement despite
recurrence. Revision repair is technically challenging. Encouraging results have recently been reported for
revision repair with arthroscopic
techniques.

outcome and repair integrity of

completely arthroscopically repaired
large and massive rotator cuff tears.
J Bone Joint Surg Am 2004;86(2):219224.
7.

DeOrio JK, Cofield RH: Results of a

second attempt at surgical repair of a
failed initial rotator-cuff repair. J Bone
Joint Surg Am 1984;66(4):563-567.

8.

Djurasovic M, Marra G, Arroyo JS,

Pollock RG, Flatow EL, Bigliani LU:
Revision rotator cuff repair: Factors
influencing results. J Bone Joint Surg Am
2001;83(12):1849-1855.

9.

Lo IK, Burkhart SS: Arthroscopic

revision of failed rotator cuff repairs:
Technique and results. Arthroscopy
2004;20(3):250-267.

10.

Piasecki DP, Verma NN, Nho SJ, et al:

Outcomes after arthroscopic revision
rotator cuff repair. Am J Sports Med
2010;38(1):40-46.

11.

Keener JD, Wei AS, Kim HM, et al:

Revision arthroscopic rotator cuff repair:
Repair integrity and clinical outcome.
J Bone Joint Surg Am 2010;92(3):590598.

12.

Nho SJ, Brown BS, Lyman S, Adler RS,

Altchek DW, MacGillivray JD:
Prospective analysis of arthroscopic
rotator cuff repair: Prognostic factors
affecting clinical and ultrasound
outcome. J Shoulder Elbow Surg 2009;
18(1):13-20.

13.

Bishop J, Klepps S, Lo IK, Bird J,

Gladstone JN, Flatow EL: Cuff integrity
after arthroscopic versus open rotator
cuff repair: A prospective study.
J Shoulder Elbow Surg 2006;15(3):290299.

References
References printed in bold type are
those published within the past 5
years.
1.

Sherman SL, Lyman S, Koulouvaris P,

Willis A, Marx RG: Risk factors for
readmission and revision surgery
following rotator cuff repair. Clin
Orthop Relat Res 2008;466(3):608-613.

14.

2.

Harryman DT II, Mack LA, Wang KY,

Jackins SE, Richardson ML, Matsen FA
III: Repairs of the rotator cuff:
Correlation of functional results with
integrity of the cuff. J Bone Joint Surg
Am 1991;73(7):982-989.

Mallon WJ, Misamore G, Snead DS,

Denton P: The impact of preoperative
smoking habits on the results of rotator
cuff repair. J Shoulder Elbow Surg 2004;
13(2):129-132.

15.

Duquin TR, Buyea C, Bisson LJ: Which

method of rotator cuff repair leads to the
highest rate of structural healing? A
systematic review. Am J Sports Med
2010;38(4):835-841.

Goutallier D, Postel JM, Bernageau J,

Lavau L, Voisin MC: Fatty muscle
degeneration in cuff ruptures: Pre- and
postoperative evaluation by CT scan.
Clin Orthop Relat Res 1994;304:78-83.

16.

Burkhart SS, Barth JR, Richards DP,

Zlatkin MB, Larsen M: Arthroscopic
repair of massive rotator cuff tears with
stage 3 and 4 fatty degeneration.
Arthroscopy 2007;23(4):347-354.

17.

Burkhart SS, Diaz Pagn JL, Wirth MA,

Athanasiou KA: Cyclic loading of
anchor-based rotator cuff repairs:
Confirmation of the tension overload
phenomenon and comparison of suture
anchor fixation with transosseous
fixation. Arthroscopy 1997;13(6):720724.

18.

Cummins CA, Murrell GA: Mode of

failure for rotator cuff repair with suture

3.

4.

Boileau P, Brassart N, Watkinson DJ,

Carles M, Hatzidakis AM, Krishnan SG:
Arthroscopic repair of full-thickness
tears of the supraspinatus: Does the
tendon really heal? J Bone Joint Surg Am
2005;87(6):1229-1240.

5.

Jost B, Zumstein M, Pfirrmann CW,

Gerber C: Long-term outcome after
structural failure of rotator cuff repairs.
J Bone Joint Surg Am 2006;88(3):472479.

6.

Galatz LM, Ball CM, Teefey SA,

Middleton WD, Yamaguchi K: The

665

Arthroscopic Revision Rotator Cuff Repair

anchors identified at revision surgery.
J Shoulder Elbow Surg 2003;12(2):128133.
19.

20.

21.

Ma CB, Comerford L, Wilson J, Puttlitz

CM: Biomechanical evaluation of
arthroscopic rotator cuff repairs:
Double-row compared with single-row
fixation. J Bone Joint Surg Am 2006;
88(2):403-410.
Burks RT, Crim J, Brown N, Fink B,
Greis PE: A prospective randomized
clinical trial comparing arthroscopic
single- and double-row rotator cuff
repair: Magnetic resonance imaging and
early clinical evaluation. Am J Sports
Med 2009;37(4):674-682.

Allen technique (Alex stitch).

Arthroscopy 2007;23(4):440, e1-e4.
27.

Neviaser RJ: Evaluation and

management of failed rotator cuff
repairs. Orthop Clin North Am 1997;
28(2):215-224.

28.

Sonnabend DH, Howlett CR, Young AA:

Histological evaluation of repair of the
rotator cuff in a primate model. J Bone
Joint Surg Br 2010;92(4):586-594.

29.

Franceschi F, Ruzzini L, Longo UG,

et al: Equivalent clinical results of
arthroscopic single-row and double-row
suture anchor repair for rotator cuff
tears: A randomized controlled trial. Am
J Sports Med 2007;35(8):1254-1260.

30.

22.

Trantalis JN, Boorman RS, Pletsch K, Lo

IK: Medial rotator cuff failure after
arthroscopic double-row rotator cuff
repair. Arthroscopy 2008;24(6):727-731.

31.

23.

Park MC, Tibone JE, ElAttrache NS,

Ahmad CS, Jun BJ, Lee TQ: Part II:
Biomechanical assessment for a
footprint-restoring transosseousequivalent rotator cuff repair technique
compared with a double-row repair
technique. J Shoulder Elbow Surg 2007;
16(4):469-476.

24.

25.

26.

666

Park MC, ElAttrache NS, Tibone JE,

Ahmad CS, Jun BJ, Lee TQ: Part I:
Footprint contact characteristics for a
transosseous-equivalent rotator cuff
repair technique compared with a
double-row repair technique. J Shoulder
Elbow Surg 2007;16(4):461-468.
Toussaint B, Schnaser E, Bosley J,
Lefebvre Y, Gobezie R: Early structural
and functional outcomes for
arthroscopic double-row transosseousequivalent rotator cuff repair. Am J
Sports Med 2011;39(6):1217-1225.
Castagna A, Garofalo R, Conti M,
Borroni M, Snyder SJ: Arthroscopic
rotator cuff repair using a triple-loaded
suture anchor and a modified Mason-

32.

Denard PJ, Ldermann A, Burkhart SS:

Prevention and management of stiffness
after arthroscopic rotator cuff repair:
Systematic review and implications for
rotator cuff healing. Arthroscopy 2011;
27(6):842-848.
Oh JH, Kim SH, Shin SH, et al:
Outcome of rotator cuff repair in largeto-massive tear with pseudoparalysis: A
comparative study with propensity score
matching. Am J Sports Med 2011;39(7):
1413-1420.
Castoldi F, Blonna D, Hertel R: External
rotation lag sign revisited: Accuracy for
diagnosis of full thickness supraspinatus
tear. J Shoulder Elbow Surg 2009;18(4):
529-534.
Walch G, Boulahia A, Calderone S,
Robinson AH: The dropping and
hornblowers signs in evaluation of
rotator-cuff tears. J Bone Joint Surg Br
1998;80(4):624-628.

33.

Barth JR, Burkhart SS, De Beer JF: The

bear-hug test: A new and sensitive test
for diagnosing a subscapularis tear.
Arthroscopy 2006;22(10):1076-1084.

34.

Adams CR, Schoolfield JD, Burkhart SS:

Accuracy of preoperative magnetic
resonance imaging in predicting a
subscapularis tendon tear based on
arthroscopy. Arthroscopy 2010;26(11):
1427-1433.

35.

36.

Tung GA, Yoo DC, Levine SM, Brody

JM, Green A: Subscapularis tendon tear:
Primary and associated signs on MRI.
J Comput Assist Tomogr 2001;25(3):
417-424.
Burkhart SS, Tehrany AM: Arthroscopic
subscapularis tendon repair: Technique
and preliminary results. Arthroscopy

2002;18(5):454-463.
37.

Motamedi AR, Urrea LH, Hancock RE,

Hawkins RJ, Ho C: Accuracy of
magnetic resonance imaging in
determining the presence and size of
recurrent rotator cuff tears. J Shoulder
Elbow Surg 2002;11(1):6-10.

38.

Werner CM, Steinmann PA, Gilbart M,

Gerber C: Treatment of painful
pseudoparesis due to irreparable rotator
cuff dysfunction with the Delta III
reverse-ball-and-socket total shoulder
prosthesis. J Bone Joint Surg Am 2005;
87(7):1476-1486.

39.

Athwal GS, Sperling JW, Rispoli DM,

Cofield RH: Deep infection after rotator
cuff repair. J Shoulder Elbow Surg 2007;
16(3):306-311.

40.

Walch G, Edwards TB, Boulahia A,

Nov-Josserand L, Neyton L, Szabo I:
Arthroscopic tenotomy of the long head
of the biceps in the treatment of rotator
cuff tears: Clinical and radiographic
results of 307 cases. J Shoulder Elbow
Surg 2005;14(3):238-246.

41.

Edwards TB, Walch G, Sirveaux F, et al:

Repair of tears of the subscapularis.
J Bone Joint Surg Am 2005;87(4):725730.

42.

Lo IK, Burkhart SS: Arthroscopic repair

of massive, contracted, immobile rotator
cuff tears using single and double
interval slides: Technique and
preliminary results. Arthroscopy 2004;
20(1):22-33.

43.

Lo IK, Burkhart SS: The interval slide in

continuity: A method of mobilizing the
anterosuperior rotator cuff without
disrupting the tear margins. Arthroscopy
2004;20(4):435-441.

44.

Tauro JC: Arthroscopic repair of large

rotator cuff tears using the interval slide
technique. Arthroscopy 2004;20(1):1321.

45.

Ldermann A, Denard PJ, Burkhart SS:

Mid-term outcome of arthroscopic
revision repair of massive and nonmassive rotator cuff. Arthroscopy, in
press.

Journal of the American Academy of Orthopaedic Surgeons