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Management of failed rotator cuff repair: a systematic review

      Importance

      Recurrent tear after rotator cuff repair (RCR) is common. Conservative, and open and arthroscopic revisions, have been advocated to treat these failures.

      Aim or objective

      The purpose of this systematic review was to evaluate the different options for managing recurrent rotator cuff tears.

      Evidence review

      A search was conducted of level I through 4 studies from January 2000 to October 2015, to identify studies reporting on failed RCR. 10 articles were identified. The overall quality of evidence was very low.

      Findings

      Mid-term to long-term follow-up of patients treated conservatively revealed acceptable results; a persistent defect is a well-tolerated condition that only occasionally requires subsequent surgery. Conservative treatment might be indicated in most patients, particularly in case of posterosuperior involvement and poor preoperative range of motion. Revision surgery might be indicated in a young patient with a repairable lesion, a 3 tendon tear, and in those with involvement of the subscapularis.

      Conclusions and relevance

      The current review indicates that arthroscopic revision RCR can lead to improvement in functional outcome despite a high retear rate. Further studies are needed to develop specific rehabilitation in the case of primary rotator cuff failure, to better understand the place of each treatment option, and, in case of repair, to optimise tendon healing.
      What is already known
      • Recurrent tear after rotator cuff repair (RCR) is common. Structural failure does not always result in clinical failure. The efficacy of various treatment options has still to be determined. Arthroscopic revision RCR can lead to improvement in functional outcome; however, the retear rate may be high.
      • Level of evidence: systematic review of level I-IV prognostic studies, level IV.

      Introduction

      Failure of tendon healing after rotator cuff repair (RCR) is common, reported in approximately 20% of cases, depending on tear size.
      • Collin P
      • Abdullah A
      • Kherad O
      • et al.
      Prospective evaluation of clinical and radiologic factors predicting return to activity within 6 months after arthroscopic rotator cuff repair.
      Tear recurrence can be related to various factors such as: (1) inadequate strength of the initial repair construct, (2) biological failure to heal despite strong initial fixation and (3) inappropriate postoperative rehabilitation causing structural failure of the repair.
      • Bigliani LU
      • Cordasco FA
      • McIlveen SJ
      • et al.
      Operative treatment of failed repairs of the rotator cuff.
      ,
      • Boileau P
      • Brassart N
      • Watkinson DJ
      • et al.
      Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?.
      ,
      • Cho NS
      • Moon SC
      • Jeon JW
      • et al.
      The influence of diabetes mellitus on clinical and structural outcomes after arthroscopic rotator cuff repair.
      ,
      • Chung SW
      • Oh JH
      • Gong HS
      • et al.
      Factors affecting rotator cuff healing after arthroscopic repair: osteoporosis as one of the independent risk factors.
      ,
      • Clement ND
      • Hallett A
      • MacDonald D
      • et al.
      Does diabetes affect outcome after arthroscopic repair of the rotator cuff?.
      ,
      • Goutallier D
      • Postel JM
      • Bernageau J
      • et al.
      Fatty muscle degeneration in cuff ruptures. Pre- and postoperative evaluation by CT scan.
      ,

      Neer CS II SC. Reoperation for failed cuff repairs. Presented at the Closed Meeting of the American Shoulder and Elbow Surgeons; Orlando, FL, October, 1987.

      ,
      • Neviaser RJ
      • Neviaser TJ
      Reoperation for failed rotator cuff repair: analysis of fifty cases.
      While functional outcome has been correlated with postoperative rotator cuff integrity,
      • Boileau P
      • Brassart N
      • Watkinson DJ
      • et al.
      Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?.
      many patients maintain a satisfactory outcome despite structural failure.
      • Jost B
      • Zumstein M
      • Pfirrmann CW
      • et al.
      Long-term outcome after structural failure of rotator cuff repairs.
      The ideal treatment for a recurrent tear is thus not completely defined.
      Our aim was to perform a systematic review of the literature regarding recurrent rotator cuff. The purpose was to (1) analyse postoperative techniques of evaluation of repaired rotator cuffs, (2) review the natural history of failed RCR, (3) evaluate the different treatment options, (4) determine if revision leads to better clinical and functional outcome compared with non-operative treatment and (5) identify prognostic factors associated with outcome following revision. The hypothesis of the study was that arthroscopic revision RCR can lead to substantial improvement in functional outcome.

      Methods

      Literature search

      A systematic review was performed on PubMed articles from January 2000 to October 2015. To avoid overlooking appropriate studies, no filters were applied to the search strategies. Two authors (AL and PJD) independently identified published studies addressing treatment of failed RCR. Search terms included “open and arthroscopic rotator cuff repair”, “failure”, “revision surgery”, “physiotherapy”, “non-operative”, “conservative treatment” and “postoperative imaging”. In addition, we reviewed the references of the initially identified articles. Inclusion criteria included (1) functional outcome data on treatment of failed RCR, (2) level I-IV evidence relevant to the search terms, (3) English, French or German language and (4) a minimum of 12-month follow-up. Studies that did not specifically focus on treatment of failed RCR, but that provided useful information about diagnosis and treatment outcome, were also included. Expert opinions were excluded.
      Information collected included year of publication, number of shoulders included, age of participants, surgical approach (open or arthroscopic), duration of follow-up, postoperative imaging, functional outcome measures and associated prognostic factors.

      Statistical analysis

      Continuous data were described by mean or median value, SD, percentage and range.

      Results

      Literature search

      The MEDLINE search identified 33 studies that focused on revision RCR.
      • Abrams JS
      Management of the failed rotator cuff surgery: causation and management.
      ,
      • Agrawal V
      Healing rates for challenging rotator cuff tears utilizing an acellular human dermal reinforcement graft.
      ,
      • Bell JE
      Repair of symptomatic rotator cuff tears after failed nonoperative treatment is cost-effective: commentary on an article by Richard C. Mather III, MD, et al.: “the societal and economic value of rotator cuff repair.”.
      ,
      • Burkhead Jr, WZ
      • Moen TC
      • Rudolph GH
      General surgical principles of open rotator cuff repair in the management of failed arthroscopic cuff repairs.
      ,
      • Chuang MJ
      • Jancosko J
      • Nottage WM
      Clinical outcomes of single-row arthroscopic revision rotator cuff repair.
      ,
      • Cordasco FA
      • Bigliani LU
      The treatment of failed rotator cuff repairs.
      ,
      • Denard PJ
      • Burkhart SS
      Arthroscopic revision rotator cuff repair.
      ,
      • Djurasovic M
      • Marra G
      • Arroyo JS
      • et al.
      Revision rotator cuff repair: factors influencing results.
      ,
      • Gee S
      • Dunn J
      • Waterman B
      • et al.
      Orthobiological augmentation of consecutive rotator cuff repair failure and deltoid dehiscence.
      ,
      • George MS
      • Khazzam M
      Current concepts review: revision rotator cuff repair.
      ,
      • Godinho GG
      • Franca Fde O
      • Freitas JM
      • et al.
      Result from arthroscopic surgical treatment of renewed tearing of the rotator cuff of the shoulder.
      ,
      • Hartzler RU
      • Sperling JW
      • Schleck CD
      • et al.
      Clinical and radiographic factors influencing the results of revision rotator cuff repair.
      ,
      • Karas EH
      • Iannotti JP
      Failed repair of the rotator cuff: evaluation and treatment of complications.
      ,
      • Keener JD
      • Wei AS
      • Kim HM
      • et al.
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.
      ,
      • Keener JD
      Revision rotator cuff repair.
      ,
      • Kowalsky MS
      • Keener JD
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome: surgical technique.
      ,
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Revision arthroscopic rotator cuff repair: systematic review and authors' preferred surgical technique.
      ,
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      ,
      • Lenart BA
      • Martens KA
      • Kearns KA
      • et al.
      Treatment of massive and recurrent rotator cuff tears augmented with a poly-l-lactide graft, a preliminary study.
      ,
      • Lo IK
      • Burkhart SS
      Arthroscopic revision of failed rotator cuff repairs: technique and results.
      ,
      • Ma HL
      • Hung SC
      • Wang ST
      • et al.
      The reoperation of failed rotator cuff repairs.
      ,
      • Montgomery SR
      • Petrigliano FA
      • Gamradt SC
      Failed rotator cuff surgery, evaluation and decision making.
      ,
      • Parnes N
      • DeFranco M
      • Wells JH
      • et al.
      Complications after arthroscopic revision rotator cuff repair.
      ,
      • Piasecki DP
      • Verma NN
      • Nho SJ
      • et al.
      Outcomes after arthroscopic revision rotator cuff repair.
      ,
      • Postacchini F
      • Gumina S
      Results of surgery after failed attempt at repair of irreparable rotator cuff tear.
      ,
      • Scheibel M
      [Recurrent defects of the rotary cuff: causes and therapeutic strategies].
      ,
      • Sears BW
      • Choo A
      • Yu A
      • et al.
      Clinical outcomes in patients undergoing revision rotator cuff repair with extracellular matrix augmentation.
      ,
      • Shamsudin A
      • Lam PH
      • Peters K
      • et al.
      Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients.
      ,
      • Sherman SL
      • Lyman S
      • Koulouvaris P
      • et al.
      Risk factors for readmission and revision surgery following rotator cuff repair.
      ,
      • Skoff HD
      Revision rotator cuff reconstruction for large tears with retraction: a novel technique using autogenous tendon and autologous marrow.
      ,
      • Strauss EJ
      • McCormack RA
      • Onyekwelu I
      • et al.
      Management of failed arthroscopic rotator cuff repair.
      ,
      • Tashjian R
      Turning failure into success: not always when it comes to the rotator cuff: commentary on articles by Surena Namdari, MD, MSc, et al., “Factors affecting outcome after structural failure of repaired rotator cuff tears,” and H. Mike Kim, MD, et al., “Factors affecting satisfaction and shoulder function in patients with a recurrent rotator cuff tear.”.
      ,
      • Tonino PM
      • Gerber C
      • Itoi E
      • et al.
      Complex shoulder disorders: evaluation and treatment.
      Fifteen studies were excluded because they were reviews,
      • Abrams JS
      Management of the failed rotator cuff surgery: causation and management.
      • Burkhead Jr, WZ
      • Moen TC
      • Rudolph GH
      General surgical principles of open rotator cuff repair in the management of failed arthroscopic cuff repairs.
      • Cordasco FA
      • Bigliani LU
      The treatment of failed rotator cuff repairs.
      • Denard PJ
      • Burkhart SS
      Arthroscopic revision rotator cuff repair.
      • George MS
      • Khazzam M
      Current concepts review: revision rotator cuff repair.
      • Karas EH
      • Iannotti JP
      Failed repair of the rotator cuff: evaluation and treatment of complications.
      • Keener JD
      Revision rotator cuff repair.
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Revision arthroscopic rotator cuff repair: systematic review and authors' preferred surgical technique.
      • Montgomery SR
      • Petrigliano FA
      • Gamradt SC
      Failed rotator cuff surgery, evaluation and decision making.
      • Scheibel M
      [Recurrent defects of the rotary cuff: causes and therapeutic strategies].
      • Strauss EJ
      • McCormack RA
      • Onyekwelu I
      • et al.
      Management of failed arthroscopic rotator cuff repair.
      • Tonino PM
      • Gerber C
      • Itoi E
      • et al.
      Complex shoulder disorders: evaluation and treatment.
      case reports
      • Gee S
      • Dunn J
      • Waterman B
      • et al.
      Orthobiological augmentation of consecutive rotator cuff repair failure and deltoid dehiscence.
      and commentary on studies.
      • Bell JE
      Repair of symptomatic rotator cuff tears after failed nonoperative treatment is cost-effective: commentary on an article by Richard C. Mather III, MD, et al.: “the societal and economic value of rotator cuff repair.”.
      • Tashjian R
      Turning failure into success: not always when it comes to the rotator cuff: commentary on articles by Surena Namdari, MD, MSc, et al., “Factors affecting outcome after structural failure of repaired rotator cuff tears,” and H. Mike Kim, MD, et al., “Factors affecting satisfaction and shoulder function in patients with a recurrent rotator cuff tear.”.
      One study dealt with results of surgery after failed attempt at repair of irreparable rotator cuff tear
      • Postacchini F
      • Gumina S
      Results of surgery after failed attempt at repair of irreparable rotator cuff tear.
      and six had insufficient data (ie, no distinction in the results between primary and revision cases).
      • Agrawal V
      Healing rates for challenging rotator cuff tears utilizing an acellular human dermal reinforcement graft.
      • Godinho GG
      • Franca Fde O
      • Freitas JM
      • et al.
      Result from arthroscopic surgical treatment of renewed tearing of the rotator cuff of the shoulder.
      • Lenart BA
      • Martens KA
      • Kearns KA
      • et al.
      Treatment of massive and recurrent rotator cuff tears augmented with a poly-l-lactide graft, a preliminary study.
      • Ma HL
      • Hung SC
      • Wang ST
      • et al.
      The reoperation of failed rotator cuff repairs.
      • Sears BW
      • Choo A
      • Yu A
      • et al.
      Clinical outcomes in patients undergoing revision rotator cuff repair with extracellular matrix augmentation.
      • Sherman SL
      • Lyman S
      • Koulouvaris P
      • et al.
      Risk factors for readmission and revision surgery following rotator cuff repair.
      Two studies described the results
      • Keener JD
      • Wei AS
      • Kim HM
      • et al.
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.
      and the operative technique
      • Kowalsky MS
      • Keener JD
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome: surgical technique.
      of the same population. Finally, 10 met our inclusion criteria and were included in this study (table 1). All studies that met the study inclusion criteria were level IV evidence except for one (table 1).
      • Shamsudin A
      • Lam PH
      • Peters K
      • et al.
      Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients.
      Table 1Summary of key articles used in systematic review
      StudyYear of publicationTechniqueShouldersAge in years, mean (range)Massive tears (% of total)Follow-up in month, mean (range)DesignLevel of evidence
      Djurasovic et al
      • Djurasovic M
      • Marra G
      • Arroyo JS
      • et al.
      Revision rotator cuff repair: factors influencing results.
      2001Open8059.030%49 (25–110)Retrospective case seriesIV
      Lo and Burkhart
      • Lo IK
      • Burkhart SS
      Arthroscopic revision of failed rotator cuff repairs: technique and results.
      2004Arthroscopic1457.679%23.4 (12 to NA)Retrospective case seriesIV
      Keener et al
      • Keener JD
      • Wei AS
      • Kim HM
      • et al.
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.
      2010Arthroscopic2155.6NA36 (24–50)Retrospective case seriesIV
      Piasecki et al
      • Piasecki DP
      • Verma NN
      • Nho SJ
      • et al.
      Outcomes after arthroscopic revision rotator cuff repair.
      2010Arthroscopic5454.97%31.1 (12–78)Retrospective case seriesIV
      Lädermann et al
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      2011Arthroscopic7460.872%59 (24–120)Retrospective case seriesIV
      Hartzler et al
      • Hartzler RU
      • Sperling JW
      • Schleck CD
      • et al.
      Clinical and radiographic factors influencing the results of revision rotator cuff repair.
      2013Open3758 (41–80)16%7.0 (1–14.9)Retrospective case seriesIV
      Parnes et al
      • Parnes N
      • DeFranco M
      • Wells JH
      • et al.
      Complications after arthroscopic revision rotator cuff repair.
      2013Arthroscopic9452 (44–72)54%NA (NA to 12)Retrospective case seriesIV
      Chuang et al
      • Chuang MJ
      • Jancosko J
      • Nottage WM
      Clinical outcomes of single-row arthroscopic revision rotator cuff repair.
      2014Arthroscopic3269.359%70.3 (13–165)Retrospective case seriesIV
      Shamsudin et al
      • Shamsudin A
      • Lam PH
      • Peters K
      • et al.
      Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients.
      2015Arthroscopic5063 (43–80)NA35 (19–45)Cohort studyIII
      Skoff
      • Skoff HD
      Revision rotator cuff reconstruction for large tears with retraction: a novel technique using autogenous tendon and autologous marrow.
      2015Open1058 (47–65)0%24 (12–44)Retrospective case seriesIV
      NA, not available.
      We also identified 9 studies that described the natural history and outcome after structural failure of RCR
      • Boileau P
      • Brassart N
      • Watkinson DJ
      • et al.
      Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?.
      • Jost B
      • Zumstein M
      • Pfirrmann CW
      • et al.
      Long-term outcome after structural failure of rotator cuff repairs.
      • Anderson K
      • Boothby M
      • Aschenbrener D
      • et al.
      Outcome and structural integrity after arthroscopic rotator cuff repair using 2 rows of fixation: minimum 2-year follow-up.
      ,
      • Cole BJ
      • McCarty III, LP
      • Kang RW
      • et al.
      Arthroscopic rotator cuff repair: prospective functional outcome and repair integrity at minimum 2-year follow-up.
      ,
      • Lafosse L
      • Jost B
      • Reiland Y
      • et al.
      Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears.
      ,
      • Galatz LM
      • Ball CM
      • Teefey SA
      • et al.
      The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears.
      ,
      • Jost B
      • Pfirrmann CW
      • Gerber C
      Clinical outcome after structural failure of rotator cuff repairs.
      ,
      • Namdari S
      • Donegan RP
      • Chamberlain AM
      • et al.
      Factors affecting outcome after structural failure of repaired rotator cuff tears.
      ,
      • Paxton ES
      • Teefey SA
      • Dahiya N
      • et al.
      Clinical and radiographic outcomes of failed repairs of large or massive rotator cuff tears: minimum ten-year follow-up.
      and 29 studies that presented initial imaging findings. Two studies presented the outcome of the same patients at different points of follow-up.
      • Jost B
      • Zumstein M
      • Pfirrmann CW
      • et al.
      Long-term outcome after structural failure of rotator cuff repairs.
      • Jost B
      • Pfirrmann CW
      • Gerber C
      Clinical outcome after structural failure of rotator cuff repairs.
      Postoperative scores were reported in every study, but tendon healing was only reported in four studies.
      • Agrawal V
      Healing rates for challenging rotator cuff tears utilizing an acellular human dermal reinforcement graft.
      • Keener JD
      • Wei AS
      • Kim HM
      • et al.
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.
      • Lenart BA
      • Martens KA
      • Kearns KA
      • et al.
      Treatment of massive and recurrent rotator cuff tears augmented with a poly-l-lactide graft, a preliminary study.
      • Shamsudin A
      • Lam PH
      • Peters K
      • et al.
      Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients.
      Patient demographic characteristics and results for all included studies are shown in table 2.
      Table 2Clinical results of revision RCR
      Djurasovic et alLo and BurkhartKeener et alPiasecki et alLädermann et alHartzler et alParnes et alChuang et alShamsudin et alSkoff
      Active postoperative forward elevation, mean±SD (gain)130°±NA (25)153°±33° (32)146°±29° (NA)136°±11.8° (15)152°±42° (16)Median 110° (−20)NA156°±17° (9)NA (2)NA
      Postoperative ASES, mean±SD (gain)NANA74±24 (NA)68±7 (24)77±25 (26)NANA87±13 (NA)NA75 (57)
      Postoperative UCLA, mean±SD (gain)NA28±7 (15)NANA27±7 (9)NANA30±5 (14)NA28 (24)
      SST, mean±SD (gain)NANA8.9±3.2 (3.5)7.5±1.1 (4)NANANANANA
      Postoperative VAS pain score, mean±SD (gain)3 (4.4)NA2.7±2.6 (NA)2.7±0.8 (2.4)2.0±2.3 (3.0)median 5.0 (3)NA0.9 (3.7)NANA
      Patient satisfaction (%)7093NANA78NANANANANA
      SANE score, mean±SDNANANA68.1±8.374.7±20.9NANANANANA
      Non-healing or retear (%)NANA52NANANA10.6NA400
      Complications/revision (%)NA0011.18.12.79.6NA120
      ASES, American Shoulder and Elbow Surgeons; NA, not available; RCR, rotator cuff repair; SANE, Single Assessment Numeric Evaluation; SST, Simple Shoulder Test; UCLA, University of California Los Angeles; VAS, visual analogue scale.

      Initial radiological findings

      The goal of imaging studies is to confirm the site of the recurrent tear. Trantalis et al
      • Trantalis JN
      • Boorman RS
      • Pletsch K
      • et al.
      Medial rotator cuff failure after arthroscopic double-row rotator cuff repair.
      were the first to report five patients with retearing of the cuff after double-row RCR. All five patients had retearing medial to the medial row as sutures were placed near the musculotendinous junction of the supraspinatus.
      • Trantalis JN
      • Boorman RS
      • Pletsch K
      • et al.
      Medial rotator cuff failure after arthroscopic double-row rotator cuff repair.
      Hayashida et al
      • Hayashida K
      • Tanaka M
      • Koizumi K
      • et al.
      Characteristic retear patterns assessed by magnetic resonance imaging after arthroscopic double-row rotator cuff repair.
      observed that the prevalence of complete retearing of the tendon after a double-row RCR is similar around the medial anchors, with a well-preserved footprint. Another point of interest is the quality of the tendon.
      • Denard PJ
      • Burkhart SS
      Techniques for managing poor quality tissue and bone during arthroscopic rotator cuff repair.
      A significant and growing number of RCRs are performed in individuals with poor rotator cuff tissue quality. Djurasovic et al
      • Djurasovic M
      • Marra G
      • Arroyo JS
      • et al.
      Revision rotator cuff repair: factors influencing results.
      reported an incidence of 30% (24 on 80) of poor rotator cuff tissue quality (graded subjectively at the time of surgery). At the same time, the muscle undergoes intrinsic degeneration. After a retear, Deniz et al
      • Deniz G
      • Kose O
      • Tugay A
      • et al.
      Fatty degeneration and atrophy of the rotator cuff muscles after arthroscopic repair: does it improve, halt or deteriorate?.
      found that fatty infiltration and atrophy continued to worsen significantly. However, fatty infiltration of the supraspinatus does not seem to be a determinant factor in tendon healing. Park et al
      • Park JS
      • Park HJ
      • Kim SH
      • et al.
      Prognostic factors affecting rotator cuff healing after arthroscopic repair in small to medium-sized tears.
      did not find significant relationship between preoperative supraspinatus fatty infiltration and postoperative tendon healing. Contrarily, it seems that fatty infiltration of the infraspinatus and subscapularis is a highly significant factor (p<0.001).
      • Park JS
      • Park HJ
      • Kim SH
      • et al.
      Prognostic factors affecting rotator cuff healing after arthroscopic repair in small to medium-sized tears.
      Another point is the bone quality. Oh and colleagues demonstrated that bone mineral density within the greater tuberosity decreases in patients with rotator cuff tears. In another retrospective study that investigated the relationship between greater tuberosity osteopaenia and chronicity of rotator cuff tears, Cadet et al
      • Cadet ER
      • Hsu JW
      • Levine WN
      • et al.
      The relationship between greater tuberosity osteopenia and the chronicity of rotator cuff tears.
      found that there were significantly greater osteopaenic changes in the greater tuberosity in patients with chronic retracted rotator cuff tears. However, this localised osteoporosis may not influence tendon healing. In a recent study, Park et al
      • Park JS
      • Park HJ
      • Kim SH
      • et al.
      Prognostic factors affecting rotator cuff healing after arthroscopic repair in small to medium-sized tears.
      did not, after primary repair, observe that bone mineral density influenced final results. Nevertheless, the greater tuberosity in revision cases can also be deficient due to anchor removal or perianchor cyst formation. Kim et al, in a retrospective case series of 209 patients, observed bone cyst formation in 97 instances (46.4%), and these authors questioned the utility of bioabsorbable anchors because of possible interference with revision surgery. Consequent bone lysis can be noticed after trauma. Lädermann et al
      • Lädermann A
      • Denard PJ
      • Collin P
      Massive rotator cuff tears: definition and treatment.
      reported massive bone resorption after osteosynthesis of the greater tuberosity, leading to combined tendon and bony insufficiency, and pseudoparalysis.
      Postoperative MRI are difficult to interpret.
      • Khazzam M
      • Kuhn JE
      • Mulligan E
      • et al.
      Magnetic resonance imaging identification of rotator cuff retears after repair: interobserver and intraobserver agreement.
      Recent prospective studies have confirmed that ultrasound has a high sensitivity and specificity for detecting a recurrent rotator cuff tear compared with MRI.
      • Codsi MJ
      • Rodeo SA
      • Scalise JJ
      • et al.
      Assessment of rotator cuff repair integrity using ultrasound and magnetic resonance imaging in a multicenter study.
      ,
      • Collin P
      • Yoshida M
      • Delarue A
      • et al.
      Evaluating postoperative rotator cuff healing: prospective comparison of MRI and ultrasound.
      ,
      • de Jesus JO
      • Parker L
      • Frangos AJ
      • et al.
      Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis.
      ,
      • Lee KW
      • Yang DS
      • Chun TJ
      • et al.
      A comparison of conventional ultrasonography and arthrosonography in the assessment of cuff integrity after rotator cuff repair.
      In a study comparing MRI and ultrasound after RCR, Codsi et al
      • Codsi MJ
      • Rodeo SA
      • Scalise JJ
      • et al.
      Assessment of rotator cuff repair integrity using ultrasound and magnetic resonance imaging in a multicenter study.
      found 92% agreement with a coefficient of 0.70. Similarly, Collin et al
      • Collin P
      • Yoshida M
      • Delarue A
      • et al.
      Evaluating postoperative rotator cuff healing: prospective comparison of MRI and ultrasound.
      reported that ultrasound had 80% sensitivity and 98% specificity compared with MRI.

      Conservative treatment of failed RCR

      Jost et al
      • Jost B
      • Zumstein M
      • Pfirrmann CW
      • et al.
      Long-term outcome after structural failure of rotator cuff repairs.
      evaluated 20 patients with a failed RCR at a mean follow-up of 38 months and reported that the adjusted Constant score and Subjective Shoulder Value (SSV) averaged 83% and 75%, respectively. Namdari et al demonstrated a successful outcome in 54% of patients (defined by an American Shoulder and Elbow Surgeons (ASES) score of >80 points) and a mean 15 point improvement in the ASES score at a mean of 52 months postoperatively. Finally, the same group compared the 2-year and 10-year results for patients with known structural failures of RCR. The average long-term ASES score was 79 points (range 50–95 points) and the average visual analogue scale (VAS) pain score was 2.2 points (range 1–4 points); both scores were unchanged from those at 2 years. The average Simple Shoulder Test (SST) score was 9.2 points (range 6–12 points), and the average age-adjusted Constant score was 73 points (range 59–90 points).
      • Paxton ES
      • Teefey SA
      • Dahiya N
      • et al.
      Clinical and radiographic outcomes of failed repairs of large or massive rotator cuff tears: minimum ten-year follow-up.

      Clinical and radiological results after revision RCR

      The clinical results of the 10 studies are summarised in table 2. Seven studies used an arthroscopic technique and three studies used an open technique for revision. Overall, range of motion improved, except in one series of open RCR.
      • Hartzler RU
      • Sperling JW
      • Schleck CD
      • et al.
      Clinical and radiographic factors influencing the results of revision rotator cuff repair.
      Functional outcome improved in all series and 70% or more of patients were satisfied or very satisfied.
      The short-term to intermediate-term incidence of complications—including subsequent revision surgery—after revision RCR, is relatively low, around 10% in this review (table 2). However, the studies in this review primarily considered reoperation a complication and did not examine complications such as haematoma, hardware failure and postoperative stiffness. The prevalence of postoperative complications is therefore probably higher than reported. The prevalence of non-healing or retear was around 40% (range 0–62%) in the four studies with postoperative imaging.
      • Agrawal V
      Healing rates for challenging rotator cuff tears utilizing an acellular human dermal reinforcement graft.
      • Keener JD
      • Wei AS
      • Kim HM
      • et al.
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.
      • Lenart BA
      • Martens KA
      • Kearns KA
      • et al.
      Treatment of massive and recurrent rotator cuff tears augmented with a poly-l-lactide graft, a preliminary study.
      • Shamsudin A
      • Lam PH
      • Peters K
      • et al.
      Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients.
      Furthermore, these tears may progress with time; Shamsudin et al reported a prevalence of defect of 28% at 6 months and of 40% at 2 years.

      Risk factors for poorer postoperative results

      Several patient-related factors appear to be associated with poorer results. Female sex
      • Chuang MJ
      • Jancosko J
      • Nottage WM
      Clinical outcomes of single-row arthroscopic revision rotator cuff repair.
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      • Piasecki DP
      • Verma NN
      • Nho SJ
      • et al.
      Outcomes after arthroscopic revision rotator cuff repair.
      and, in one study, if the surgery was performed on the dominant arm, were negatively associated with postoperative outcome.
      • Chuang MJ
      • Jancosko J
      • Nottage WM
      Clinical outcomes of single-row arthroscopic revision rotator cuff repair.
      There is still controversy about certain risk factors such as age of patients.
      • Chuang MJ
      • Jancosko J
      • Nottage WM
      Clinical outcomes of single-row arthroscopic revision rotator cuff repair.
      • Keener JD
      • Wei AS
      • Kim HM
      • et al.
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      Disease-related factors included patients with a recurrent tear after the revision repair,
      • Keener JD
      • Wei AS
      • Kim HM
      • et al.
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.
      preoperative VAS pain score greater than five
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      and poor preoperative range of motion.
      • Chuang MJ
      • Jancosko J
      • Nottage WM
      Clinical outcomes of single-row arthroscopic revision rotator cuff repair.
      • Djurasovic M
      • Marra G
      • Arroyo JS
      • et al.
      Revision rotator cuff repair: factors influencing results.
      • Hartzler RU
      • Sperling JW
      • Schleck CD
      • et al.
      Clinical and radiographic factors influencing the results of revision rotator cuff repair.
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      • Piasecki DP
      • Verma NN
      • Nho SJ
      • et al.
      Outcomes after arthroscopic revision rotator cuff repair.
      • Denard PJ
      • Lädermann A
      • Jiwani AZ
      • et al.
      Functional outcome after arthroscopic repair of massive rotator cuff tears in individuals with pseudoparalysis.
      The ranges vary from less than 90° in the studies from Piasecki et al
      • Piasecki DP
      • Verma NN
      • Nho SJ
      • et al.
      Outcomes after arthroscopic revision rotator cuff repair.
      and Denard et al
      • Denard PJ
      • Lädermann A
      • Jiwani AZ
      • et al.
      Functional outcome after arthroscopic repair of massive rotator cuff tears in individuals with pseudoparalysis.
      to 140° in the study of Chuang et al.
      • Chuang MJ
      • Jancosko J
      • Nottage WM
      Clinical outcomes of single-row arthroscopic revision rotator cuff repair.
      The latter factor has been reported in almost all series and is probably the most important preoperative indicator. In addition, acromiohumeral distance (<7 mm) can be associated with a satisfactory outcome.
      • Hartzler RU
      • Sperling JW
      • Schleck CD
      • et al.
      Clinical and radiographic factors influencing the results of revision rotator cuff repair.
      There is controversy about patients with more than one prior surgery, with one study reporting that this negatively impacted results and another study reporting that it did not.
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      • Piasecki DP
      • Verma NN
      • Nho SJ
      • et al.
      Outcomes after arthroscopic revision rotator cuff repair.
      Operative-related factors, such as poor tendon quality,
      • Djurasovic M
      • Marra G
      • Arroyo JS
      • et al.
      Revision rotator cuff repair: factors influencing results.
      • Lo IK
      • Burkhart SS
      Arthroscopic revision of failed rotator cuff repairs: technique and results.
      are associated with poorer results. One study compared outcomes between massive and non-massive tears and did not find any significant difference in terms of postoperative anterior elevation, pain, or functional outcome.
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.

      Postrevision rehabilitation

      In all studies, participants took part in standardised rehabilitation protocols. Most studies did not allow immediate overhead passive motion.
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      • Lo IK
      • Burkhart SS
      Arthroscopic revision of failed rotator cuff repairs: technique and results.
      • Piasecki DP
      • Verma NN
      • Nho SJ
      • et al.
      Outcomes after arthroscopic revision rotator cuff repair.
      In all studies except one,
      • Skoff HD
      Revision rotator cuff reconstruction for large tears with retraction: a novel technique using autogenous tendon and autologous marrow.
      the sling was discontinued after 6 weeks. Strengthening was delayed until 6,
      • Shamsudin A
      • Lam PH
      • Peters K
      • et al.
      Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients.
      12
      • Chuang MJ
      • Jancosko J
      • Nottage WM
      Clinical outcomes of single-row arthroscopic revision rotator cuff repair.
      • Djurasovic M
      • Marra G
      • Arroyo JS
      • et al.
      Revision rotator cuff repair: factors influencing results.
      • Hartzler RU
      • Sperling JW
      • Schleck CD
      • et al.
      Clinical and radiographic factors influencing the results of revision rotator cuff repair.
      • Lo IK
      • Burkhart SS
      Arthroscopic revision of failed rotator cuff repairs: technique and results.
      • Parnes N
      • DeFranco M
      • Wells JH
      • et al.
      Complications after arthroscopic revision rotator cuff repair.
      • Piasecki DP
      • Verma NN
      • Nho SJ
      • et al.
      Outcomes after arthroscopic revision rotator cuff repair.
      • Skoff HD
      Revision rotator cuff reconstruction for large tears with retraction: a novel technique using autogenous tendon and autologous marrow.
      to 16 weeks
      • Keener JD
      • Wei AS
      • Kim HM
      • et al.
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      postoperatively. Full return to activity was not allowed until 4,
      • Keener JD
      • Wei AS
      • Kim HM
      • et al.
      Revision arthroscopic rotator cuff repair: repair integrity and clinical outcome.
      6,
      • Shamsudin A
      • Lam PH
      • Peters K
      • et al.
      Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients.
      or even 12 months.
      • Chuang MJ
      • Jancosko J
      • Nottage WM
      Clinical outcomes of single-row arthroscopic revision rotator cuff repair.
      • Lädermann A
      • Denard PJ
      • Burkhart SS
      Midterm outcome of arthroscopic revision repair of massive and nonmassive rotator cuff tears.
      • Lo IK
      • Burkhart SS
      Arthroscopic revision of failed rotator cuff repairs: technique and results.

      Discussion

      This systematic review summarises the current literature regarding failed RCR and confirms the hypothesis of the study that arthroscopic revision surgery can lead to substantial improvement in functional outcome. However, due to the relative small number of studies, it was not possible to reach any definitive conclusion regarding appropriate management of failed RCR. Moreover, the low methodological quality of the included studies and, subsequently, the low quality of evidence, seriously affected the strength of recommendation of the present review. Any proposed assessment and treatment algorithm therefore also includes personal experience and extrapolated scientific data that are offered for consideration.
      One aim of the study was to evaluate postoperative imaging. When milestones of typical postoperative recovery are not met, analysis of RCR should be considered, and a multimodal evaluation is required. The goal of imaging studies is to confirm the site of the recurrent tear (figure 1),
      • Hayashida K
      • Tanaka M
      • Koizumi K
      • et al.
      Characteristic retear patterns assessed by magnetic resonance imaging after arthroscopic double-row rotator cuff repair.
      • Mellado JM
      • Calmet J
      • Olona M
      • et al.
      MR assessment of the repaired rotator cuff: prevalence, size, location, and clinical relevance of tendon rerupture.
      the type of failure (eg, in continuity)
      • McCarron JA
      • Derwin KA
      • Bey MJ
      • et al.
      Failure with continuity in rotator cuff repair “healing.”.
      and, if possible, its cause. Other points of interest are the quality of the bone (tuberosity deficiency),
      • Lädermann A
      • Denard PJ
      • Collin P
      Massive rotator cuff tears: definition and treatment.
      tendon and muscle,
      • Deniz G
      • Kose O
      • Tugay A
      • et al.
      Fatty degeneration and atrophy of the rotator cuff muscles after arthroscopic repair: does it improve, halt or deteriorate?.
      and whether further surgery is feasible. Standard shoulder radiographs, including anteroposterior, axillary lateral and scapular Y (outlet) views, may demonstrate decreased acromiohumeral distance, glenohumeral arthritis, subacromial spurs, acetabularisation of the acromion, femoralisation of the humeral head and implant or anchor migration.
      • Hartzler RU
      • Sperling JW
      • Schleck CD
      • et al.
      Clinical and radiographic factors influencing the results of revision rotator cuff repair.
      • Nove-Josserand L
      • Edwards TB
      • O'Connor DP
      • et al.
      The acromiohumeral and coracohumeral intervals are abnormal in rotator cuff tears with muscular fatty degeneration.
      It can also be used to rule out chondrolysis, anchor migration or prominence, and acromial fracture. Among evaluation techniques, the most widely accepted reference standard is MRI, which allows visualisation of the tendons and does not involve radiation exposure. Intra-articular contrast may be used in association with MRI to increase the sensitivity for detecting a recurrent tear.
      • de Jesus JO
      • Parker L
      • Frangos AJ
      • et al.
      Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: a meta-analysis.
      Postoperative MRI are difficult to interpret
      • Khazzam M
      • Kuhn JE
      • Mulligan E
      • et al.
      Magnetic resonance imaging identification of rotator cuff retears after repair: interobserver and intraobserver agreement.
      • Saccomanno MF
      • Cazzato G
      • Fodale M
      • et al.
      Magnetic resonance imaging criteria for the assessment of the rotator cuff after repair: a systematic review.
      ; inadequate coverage of the greater or lesser tuberosity may indicate partial healing and not a recurrent full-thickness tear.
      • Motamedi AR
      • Urrea LH
      • Hancock RE
      • et al.
      Accuracy of magnetic resonance imaging in determining the presence and size of recurrent rotator cuff tears.
      • Spielmann AL
      • Forster BB
      • Kokan P
      • et al.
      Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals—initial experience.
      Furthermore, only 10% of reattached tendons generate a normal MRI signal. Thus, a common finding is the presence of an intermediate signal within the tendon, indicating granulation tissue, or of a low-intensity signal produced by fibrous tissue.
      • Khazzam M
      • Kuhn JE
      • Mulligan E
      • et al.
      Magnetic resonance imaging identification of rotator cuff retears after repair: interobserver and intraobserver agreement.
      • Spielmann AL
      • Forster BB
      • Kokan P
      • et al.
      Shoulder after rotator cuff repair: MR imaging findings in asymptomatic individuals—initial experience.
      ,
      • Mohana-Borges AV
      • Chung CB
      • Resnick D
      MR imaging and MR arthrography of the postoperative shoulder: spectrum of normal and abnormal findings.
      ,
      • Ruzek KA
      • Bancroft LW
      • Peterson JJ
      Postoperative imaging of the shoulder.
      ,
      • Zanetti M
      • Hodler J
      MR imaging of the shoulder after surgery.
      ,
      • Zanetti M
      • Hodler J
      MR imaging of the shoulder after surgery.
      These signal changes may persist for longer than 6 months, due to tissue remodelling, and seem to have no clinical implications.
      • Gerber C
      • Schneeberger AG
      • Perren SM
      • et al.
      Experimental rotator cuff repair. A preliminary study.
      • Tudisco C
      • Bisicchia S
      • Savarese E
      • et al.
      Single-row vs. double-row arthroscopic rotator cuff repair: clinical and 3 Tesla MR arthrography results.
      Finally, the evaluation of MRI scans is made difficult by the normal leakage of fluid into the subacromial space after the opening of the rotator interval and passage of instruments through the tendon, which may contain artefacts generated, for instance, by metal anchors or high-strength sutures. These factors, together with the high cost of MRI, lend considerable appeal to ultrasound as a method for evaluating RCR, even if its effectiveness is operator dependent.
      • Ok JH
      • Kim YS
      • Kim JM
      • et al.
      Learning curve of office-based ultrasonography for rotator cuff tendons tears.
      • Prickett WD
      • Teefey SA
      • Galatz LM
      • et al.
      Accuracy of ultrasound imaging of the rotator cuff in shoulders that are painful postoperatively.
      CT arthrogram can also be used to aid in the identification of recurrent rotator cuff tears when neither ultrasound nor MRI are options.
      • Nazarian LN
      • Jacobson JA
      • Benson CB
      • et al.
      Imaging algorithms for evaluating suspected rotator cuff disease: Society of Radiologists in Ultrasound consensus conference statement.
      Failure after RCR was previously believed to occur during the first 3 months.
      • Kluger R
      • Bock P
      • Mittlbock M
      • et al.
      Long-term survivorship of rotator cuff repairs using ultrasound and magnetic resonance imaging analysis.
      • Miller BS
      • Downie BK
      • Kohen RB
      • et al.
      When do rotator cuff repairs fail? Serial ultrasound examination after arthroscopic repair of large and massive rotator cuff tears.
      While the majority of retears do occur within the first 3 months, it has now been demonstrated that retears can occur up to 6 months after repair.
      • Iannotti JP
      • Deutsch A
      • Green A
      • et al.
      Time to failure after rotator cuff repair: a prospective imaging study.
      • Kim JH
      • Hong IT
      • Ryu KJ
      • et al.
      Retear rate in the late postoperative period after arthroscopic rotator cuff repair.
      Figure thumbnail gr1
      Figure 1Six patterns of anatomic deficiency associated with failed rotator cuff repair. (A) Failure of tendon healing; (B) poor tendon quality; (C) fatty infiltration/atrophy; (D) retear medial to the medial row of fixation; (E) bone defects in the greater tuberosity after anchor removal, or perianchor cyst formation and (F) bony and tendinous insufficiency.
      Another goal of the present article was to analyse the natural history of failed RCR. 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. Characteristics associated with successful and unsuccessful results after structural failure of RCR are poorly understood. Retear or non-healing of tendons is rather frequent and surgery is rarely proposed because this condition is often well tolerated with marked clinical improvement in comparison with the preoperative state.
      • Boileau P
      • Brassart N
      • Watkinson DJ
      • et al.
      Arthroscopic repair of full-thickness tears of the supraspinatus: does the tendon really heal?.
      • Jost B
      • Zumstein M
      • Pfirrmann CW
      • et al.
      Long-term outcome after structural failure of rotator cuff repairs.
      • Anderson K
      • Boothby M
      • Aschenbrener D
      • et al.
      Outcome and structural integrity after arthroscopic rotator cuff repair using 2 rows of fixation: minimum 2-year follow-up.
      ,
      • Cole BJ
      • McCarty III, LP
      • Kang RW
      • et al.
      Arthroscopic rotator cuff repair: prospective functional outcome and repair integrity at minimum 2-year follow-up.
      ,
      • Lafosse L
      • Jost B
      • Reiland Y
      • et al.
      Structural integrity and clinical outcomes after arthroscopic repair of isolated subscapularis tears.
      ,
      • Galatz LM
      • Ball CM
      • Teefey SA
      • et al.
      The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears.
      ,
      • Jost B
      • Pfirrmann CW
      • Gerber C
      Clinical outcome after structural failure of rotator cuff repairs.
      ,
      • Namdari S
      • Donegan RP
      • Chamberlain AM
      • et al.
      Factors affecting outcome after structural failure of repaired rotator cuff tears.
      ,
      • Paxton ES
      • Teefey SA
      • Dahiya N
      • et al.
      Clinical and radiographic outcomes of failed repairs of large or massive rotator cuff tears: minimum ten-year follow-up.
      One reason for clinical failure is probably the non-restoration of balanced force couples and the suspension bridge system of force transmission in the shoulder.
      • Denard PJ
      • Koo SS
      • Murena L
      • et al.
      Pseudoparalysis: the importance of rotator cable integrity.
      The location (involvement of the subscapularis on which the rotator cable is attached) along with the size (more than 2 tendons) is the primary determinant of rotator cuff function.
      • Collin P
      • Matsumura N
      • Lädermann A
      • et al.
      Relationship between massive chronic rotator cuff tear pattern and loss of active shoulder range of motion.
      It has long been recognised that revision RCR is challenging, as there are frequently multiple components to the pathoanatomy and multiple reasons for the failure of the initial repair. We consequently aimed to evaluate the different surgical treatment options and the prognostic factors associated with the outcomes of the procedure. The most important factor related to poor results seems to be poor preoperative range of motion. If revision is planned, patients have to be aware of the high prevalence of persistent structural defect. Moreover, retear rate after reoperation continues to deteriorate with time.
      • Shamsudin A
      • Lam PH
      • Peters K
      • et al.
      Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients.
      • Vastamaki M
      • Lohman M
      • Borgmastars N
      Rotator cuff integrity correlates with clinical and functional results at a minimum 16 years after open repair.
      The alarming retear rate revealed by this review indicates that several surgical options can be considered that must be individualised to the patient. For example, in the setting of an acute traumatic retear in a physiologically young, healthy, active and non-pseudoparalytic patient, arthroscopic revision surgery is generally recommended. Techniques to enhance mechanical fixation, such as linked load-sharing rip-stop constructs, should be considered.
      • Burkhart SS
      • Denard PJ
      • Konicek J
      • et al.
      Biomechanical validation of load-sharing rip-stop fixation for the repair of tissue-deficient rotator cuff tears.
      Augmented repairs using scaffold devices derived from autografts,
      • Skoff HD
      Revision rotator cuff reconstruction for large tears with retraction: a novel technique using autogenous tendon and autologous marrow.
      • Lädermann A
      • Denard PJ
      • Collin P
      Massive rotator cuff tears: definition and treatment.
      • Mori D
      • Funakoshi N
      • Yamashita F
      Arthroscopic surgery of irreparable large or massive rotator cuff tears with low-grade fatty degeneration of the infraspinatus: patch autograft procedure versus partial repair procedure.
      allograft,
      • Agrawal V
      Healing rates for challenging rotator cuff tears utilizing an acellular human dermal reinforcement graft.
      xenograft extracellular matrix
      • Sears BW
      • Choo A
      • Yu A
      • et al.
      Clinical outcomes in patients undergoing revision rotator cuff repair with extracellular matrix augmentation.
      or synthetic matrices such as poly-l-lactide grafts,
      • Lenart BA
      • Martens KA
      • Kearns KA
      • et al.
      Treatment of massive and recurrent rotator cuff tears augmented with a poly-l-lactide graft, a preliminary study.
      have been used to offer a structural support to the repair during the crucial healing period and to improve healing rates. The scientific literature does not contain enough data to justify any systematic-associated augmentation techniques. Tendon transfers may be used in patients without advanced glenohumeral arthritis who have significant loss of external rotation strength and maintain anterior active elevation.
      • Gerber C
      • Rahm SA
      • Catanzaro S
      • et al.
      Latissimus dorsi tendon transfer for treatment of irreparable posterosuperior rotator cuff tears: long-term results at a minimum follow-up of ten years.
      • Pearsall IV, AW
      • Madanagopal SG
      • Karas SG
      Transfer of the latissimus dorsi as a salvage procedure for failed debridement and attempted repair of massive rotator cuff tears.
      If the patient is young, pseudoparalytic, and suffers from a combined bony and tendinous rotator cuff insufficiency, a calcaneum and Achilles tendon allograft could be considered.

      Lädermann A, Denard P, Abrassart S, et al. Achilles tendon allograft for an irreparable massive rotator cuff tear with bony deficiency of the greater tuberosity: a case report. Knee Surg Sports Traumatol Arthrosc In Press.

      Finally, whereas primary pseudoparalysis responds well to arthroscopic RCR, persistent pseudoparalysis after a previous attempt at RCR may be more predictably managed with reverse shoulder arthroplasty (RSA). We reported in a previous study that pseudoparalysis was reversed in the revision setting in only 43% of patients, with a low rate (54%) of satisfaction.
      • Denard PJ
      • Lädermann A
      • Jiwani AZ
      • et al.
      Functional outcome after arthroscopic repair of massive rotator cuff tears in individuals with pseudoparalysis.
      In contrast, Boileau et al
      • Boileau P
      • Gonzalez JF
      • Chuinard C
      • et al.
      Reverse total shoulder arthroplasty after failed rotator cuff surgery.
      found that anterior elevation was reliably restored with RSA after failed RCR and 73% of patients were satisfied.

      Limitations

      This study has several limitations. First, we were inherently limited to a review of primarily level III and IV studies, and the low quality of evidence seriously affected the strength of recommendation. We also excluded studies from journals that had insufficient data available; this lowered our sample sizes and could have introduced a selection bias. Second, no attempt was made to contact the authors of each study, to obtain individual patient data for the purposes of a meta-analysis. Third and lastly, many outcomes such as Constant score
      • Constant CR
      • Murley AH
      A clinical method of functional assessment of the shoulder.
      were not considered due to the paucity of studies. This lack of data or heterogeneity of the studies did not allow statistical analysis.

      Conclusion

      The current review indicates that arthroscopic revision RCR can lead to improvement in functional outcome despite a high retear rate. A clear deficiency exists in the literature concerning this topic; more research should be performed in the future to develop specific rehabilitation in cases of failure, to better understand the place of each treatment option with comparative studies and, in cases of repair, to optimise tendon healing.

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