We provide medical and surgical care certified to the highest national standards, locally-delivered here in Indiana.
Recognized by his peers, Dr. Agrawal is honored to be included among the “10 Shoulder Specialists to Know in America. ”
We specialize in providing innovative treatments for regular and complex problems; including helping patients that have not had satisfactory results from other types of surgeries.
We have performed thousands of arthroscopic repairs and are also experts in surgical reconstruction. Along with other innovations and cutting edge procedures, we introduced all arthroscopic grafting for complex rotator cuff repairs, arthroscopic global labrum reconstruction for complex instability, arthroscopic suprascapular nerve decompression, and the Reverse Total procedure to Indiana.
The resources on this web site and our blog will inform you about some of the standard and innovative treatments we offer.. Each patient is unique, and the content of this web site is general in nature, so please do not consider the information herein as medical advice for your personal condition.
If you have questions or would like an appointment contact us.
- 1 Services
- 1.1 The Makeup Of the Shoulder
- 1.2 Shoulder Fractures
- 1.3 Symptoms of a Broken Shoulder and Treatment Options
- 1.4 Symptoms of a Fractured Clavicle and Treatment Options
- 1.5 Signs Of An Upper Arm Break
- 1.6 Shoulder Blade Fracture Symptoms
- 1.7 Recovery From A Shoulder Fracture
- 1.8 Understanding the Causes, Symptoms, and Treatments
- 1.9 Who is at Risk?
- 1.10 What Types of Symptoms Develop?
- 1.11 How Can Frozen Shoulder Be Treated?
- 1.12 What about Surgery?
- 1.13 How are the two surgeries different?
- 1.14 Are there risks associated with a reverse total shoulder replacement?
- 1.15 Is a reverse total shoulder replacement worth considering?
- 1.16 Causes Symptoms and Treatment
- 1.17 What Can Cause the Separation?
- 1.18 Symptoms of a Shoulder Separation
- 1.19 What Can Be Done?
- 1.20 Before, During and After
- 1.21 Preoperative Examination
- 1.22 Suprascapular Nerve Procedure
- 1.23 After Care
- 1.24 Conclusion
- 1.25 Defining a Failed Shoulder Surgery
- 1.26 Patient Satisfaction despite Technical Failure
- 1.27 Causes of Failed Shoulder Surgeries
- 1.28 Factors Linked to Success or Failure of Repair of the Rotator Cuff
- 1.29 Improving the Outcome Following Shoulder Surgery
- 1.30 Why Conventional Techniques Fail
- 1.31 Revision Arthroscopic Rotator Cuff Repair
- 1.32 Superior Capsular Reconstruction
- 1.33 Reverse Total Shoulder Replacement
- 1.34 Final Thoughts
Located in Carmel IN, we are dedicated exclusively to providing the most advanced care available in 2015. Our practice concentrates on providing innovative treatments for routine and complicated problems including failed surgeries and second medical opinions. Combining targeted examination techniques with the latest diagnostic modalities, our first priority is to help provide you with honest and accurate information regarding your problem. We provide surgical and non-surgical care for all shoulder troubles.
Failed shoulder surgery unfortunately occurs commonly. It’s important to take a deep breath and find a specialist with significant experience in evaluating and treating patients with the most complex problems to give yourself the best chance at an excellent outcome. We hear too often of patients having multiple failed operations resulting in permanent limitations in both work and play. Whether it is a failed rotator cuff repair, failed labrum repair , failed unstable shoulder repair, failed separation repair, failed shoulder replacement, or methods to deal with arthritis, take the time to give the depth of consideration required and seek out a surgeon with extensive experience in evaluating and treating these complex issues. Most failed surgeries although very frustrating don’t represent a true emergency, so you have the option to take the time needed to weigh your options and determine where and when to have any additional procedures if indicated for the best outcome for you personally. Many cutting edge minimally invasive techniques like reinforcement grafting and superior capsule reconstruction for failed and complex rotator cuff tears are only available at a few highly specialized shoulder centers around the world. The same is true for the best treatment options available for unstable shoulders including, global labrum reconstruction, Remplissage, and arthroscopic bone grafting. Failed shoulder replacement can often be the result of choosing the wrong type of replacement procedure and many patients aren’t aware that there are many different types of replacement options. Many shoulder problems have hundreds of different surgical procedures described and performed sometimes varying only because of surgeon experience and training or geographic availability. Patients are increasingly traveling across the country – and around the world – to seek out the best solutions for their surgery. The solution to your failed shoulder surgery is no longer limited by your location. Contact us for a second opinion.
The shoulder remains an oft injured part of the body, and injuries range from mild to severe. Separated shoulders often occur as a result of a fall, and car accidents at high speeds may lead to the collarbone or shoulder blade being fractured. In fact, this part of the body continues to be one of the most frequently injured, with most individuals injuring one or more parts of the shoulder during their lifetime.
The Makeup Of the Shoulder
The shoulder consists of three separate bones: the scapula or shoulder blade, the clavicle or collarbone and the humerus or arm bone. Most people only associate the shoulder blade with the shoulder, yet all three parts work together to ensure proper functioning, and the shoulder also contains tissues to ensure the joint works as intended. This includes muscles, tendons, ligaments and the joint capsule.
A fracture occurs when a bone in the shoulder is broken. Some fractures involve the collarbone, and others occur in the shoulder blade. When the top of the humerus or upper arm bone is fractured, this is also considered a broken shoulder.
Symptoms of a Broken Shoulder and Treatment Options
Pain is often the first sign something is wrong with the shoulder, and the individual may find he or she can no longer move the joint normally. If the shoulder can be moved, it may be accompanied by a grinding sensation, and some report they notice something is wrong when the shoulder doesn’t appear as it should. Bruising and swelling are other signs the shoulder needs to be examined by a medical professional.
Symptoms of a Fractured Clavicle and Treatment Options
When a clavicle or collarbone is fractured, a person may notice the middle of the bone appears to be swelling. The shoulder’s range of motion may be diminished with this type of fracture and the collarbone may appear to have a bump. This is an indication the two ends of the broken bone are protruding.
In most cases, surgery isn’t needed to repair a fractured clavicle. In the event of a compound fracture which broke through the skin, however, or when the bone has moved considerably out of place, surgery may be called for. When it is, rods are placed inside the bone or plates and screws are used to hold the pieces of the bone together.
Signs Of An Upper Arm Break
When the upper portion of the humerus is fractured, the shoulder tends to swell significantly. The person is typically unable to move the shoulder very much, and he or she will be in severe pain. Prompt medical attention is called for to have the bone set, so the healing process may begin.
When determining a treatment plan for a break in the upper arm or proximal humerus, medical professionals look at the placement of the bone fragments. When they have not shifted, no surgery will be needed. If they have, however, pins or plates and screws will be used to move them back to the proper position and, in severe cases, a shoulder replacement may be required.
Shoulder Blade Fracture Symptoms
When the shoulder blade sustains a fracture, pain and swelling are commonly reported. Another sign of a fracture in this area is severe bruising. Individuals cannot assume the bruising means the shoulder is simply injured. It must be checked to determine if there is an actual break.
For the majority of shoulder blade or scapula fractures, the shoulder heals with nothing more than immobilization using a shoulder immobilizer or sling, the application of ice and the dispensing of pain medications. Nevertheless, 10 to 20 percent of patients do require surgery, and this typically happens when the shoulder joint is affected or the shoulder blade and collarbone are both broken. The fracture fragments are then fixed using screws and plates.
Recovery From A Shoulder Fracture
Individuals need to allow the shoulder time to heal, as this isn’t an overnight process. In fact, recovery can take weeks or months, depending on the treatment plan needed, and most plans involve both immobilization and rehabilitation. For less severe injuries, full function of the shoulder typically returns in four to six weeks. Exercises need to be completed, however, as they help to build muscle strength lost during the recovery process, improve the range of motion of the shoulder and decrease any stiffness. Patients need to follow their doctor’s orders exactly to restore the shoulder to normal levels of function in the shortest time possible and to prevent any complications that may arise from not following these instructions.
Understanding the Causes, Symptoms, and Treatments
Frozen shoulder is a term that refers to stiffness in the shoulder that makes it impossible to move without experiencing a great deal of pain. In the worst case scenario, moving the shoulder at all is not possible. Fortunately, there are medical treatments that can help to alleviate the pain and restore a greater range of motion.
Who is at Risk?
Unlike some ailments, people of any age or gender can experience a frozen shoulder. The trigger for developing a frozen shoulder can vary widely, an injury or trauma to the shoulder girdle, nerve pain such as a herniated disc or pinched nerve, a stroke, heart or lung disease, and hyperlipidemia are just a few of the many causes.
Other people develop this condition after surgery, especially when the procedure was performed in the general vicinity of the shoulder. If an individual undergoes a mastectomy or lymph node dissection, the connective tissue surrounding the tendons, muscles, and bones of the shoulder may become inflamed triggering the process for development of a frozen shoulder.
Individuals with chronic conditions like diabetes and thyroid disorders are also at a greater risk of developing frozen shoulder. The exact sequence of events for the development of a frozen shoulder is as yet unknown, but the development of vascular inflammation and stiffness are the final common pathway for many different and varied initiating causes. For many patients no clear contributing factor is apparent and these cases are called idiopathic frozen shoulder (meaning no clear cause).
What Types of Symptoms Develop?
A frozen shoulder has so many initiating causes that there is not one clear pathway and timeline to the development of symptoms. Many patients experience a very slow incremental and insidious onset of pain with a seemingly sudden development of severe stiffness and pain. Often, the initial pain is felt in the lateral arm rather than the shoulder itself and only with sudden movements or at the end ranges of movements.
An advanced case will involve an inability to move the shoulder at all. At this juncture, the tissue surrounding the main components of the joint are so inflamed that the muscles surrounding the shoulder become very guarded and movement will not take place, even if the individual tries to ignore the pain. It is at this stage people begin to realize how often shoulder movement is involved in completing the simplest of tasks.
How Can Frozen Shoulder Be Treated?
One of the first lines of defense is to do something that helps to reduce the inflammation. After a doctor confirms that what the patient is experiencing is frozen shoulder, starting medication designed to ease pain and swelling may provide symptomatic relief.
Depending on the severity of the situation, the doctor may recommend the patient use an over the counter anti-inflammatory medication. For patients with more severe or persistent symptoms oral or injectable steroids may be recommended.
Many types of supportive therapy such as massage, chiropractic, and physical therapy are designed to help support joint mobility while minimizing further inflammation and trauma. This is why any aggressive manipulation or therapy should be avoided for frozen shoulder. Depending on the root cause for frozen shoulder, reaching the thawing phase of the disease process and resolution may take two years or longer.
What about Surgery?
Surgical procedures are only considered when non-invasive methods do not restore the frozen shoulder to an acceptable range of motion. If tests reveal the presence of scar tissue or adhesions in and around the shoulder, surgery may be recommended to remove some of that tissue damage. Once the removal is done, a combination of medication and physical therapy is used during the recuperative period. There are many different types of surgical procedures reported including open surgery, manipulation under anesthesia, and arthroscopic capsulotomy. The decision for surgery and the best surgical option for an individual patient involve complex decision making combined with the skill and experience of the surgeon.
Remember there can be many different causes for a frozen shoulder, and a qualified medical specialist can help you establish a comprehensive diagnosis, including other contributing factors and get you back on the road to recovery in the shortest time possible.
Joint replacement has become so commonplace that some patients simply assume surgery options available will correct virtually any type of joint pain or injury. Patients, however, are all different, and the joint replacement surgery that corrects one issue for one person may not offer the same benefits for another patient. In addition, there are now more options available for some joints that create confusion. The difference between total shoulder replacement surgery and reverse total shoulder replacement surgery is an excellent example. When discussing shoulder surgery options with an orthopedic surgeon, it’s important to understand the basic differences.
How are the two surgeries different?
First, it’s important to understand the shoulder includes a ball and socket joint. The socket, called the glenoid, forms the upper portion of the joint while the ball portion, the humerus, is the lower portion of the joint. The rotator cuff assists the functioning of the joint, allowing the patient to raise and lower the arm while stabilizing the joint.
If the rotator cuff is injured, some patients are no longer able to comfortably move the arm, and raising the arm above shoulder height can become quite difficult. Rotator cuff tears are quite common and often standard surgical procedures may not succeed. Some patients with rotator cuff tears do not recover full function with or without surgery.
In other cases, the shoulder joint can be injured. Accidents can cause irreparable injuries to the joint. In those types of cases, the surgeon may recommend a complete shoulder replacement, but there is one important stipulation—a total shoulder replacement will only work if the shoulder joint is stable. Patients with severe bone loss, rotator cuff tears or other severe joint damage may be much better served with a reverse total shoulder replacement.
Older individuals are prone to developing joint damage due to arthritis. When arthritis invades the joint, range of motion generally deteriorates, and that loss of motion may be accompanied by significant pain. In addition to the joint deterioration, many older patients also experience loss of rotator cuff function. That means, for the majority of sufferers, replacing the shoulder joint using the traditional total shoulder replacement may not be the best option.
A total shoulder replacement involves replacing both the glenoid and the humerus. With the original total shoulder replacement, the two elements are both replaced with mechanical substitutes, leaving the actual shoulder design much the same as it was originally.
In a reverse total shoulder replacement, the joint’s design is actually reversed, hence the surgery’s name. Where the ball, or humerus, was originally the lower portion of the joint, after a reverse total shoulder replacement, the ball becomes the upper portion of the joint. The socket portion, or glenoid, would then form the lower portion of the joint. The reversal of the components changes the dynamics of the joint, allowing it to function more efficiently when the rotator cuff is compromised.
Again, a reverse total shoulder replacement is generally indicated when there is damage to the rotator cuff and when arthritis has significantly impacted the joint’s ability to function properly. The procedure may also be recommended when a prior rotator cuff or shoulder replacement surgery has failed to achieve the desire results. As a rule, a reverse total shoulder replacement dramatically reduces pain levels and enhances function for patients.
Are there risks associated with a reverse total shoulder replacement?
As with any surgical procedure, there are always risks involved. Obviously, infection is always a risk, as is the risk of damage to nerves in the area. Every surgical procedure involves some level of risk associated with the use of anesthetics. It is always a good idea to review any general risks or risks associated with any condition specific to the patient with the surgeon prior to any procedure. However, the benefits of a reverse total shoulder replacement can be life changing for many patients.
Of course, every patient undergoing a reverse total shoulder replacement will be required to follow a specific rehabilitation protocol after the surgery to allow appropriate healing and to enhance the results of the procedure. As the healing progresses, both passive and active motion exercises will be assigned, followed by exercises to help restore function.
Is a reverse total shoulder replacement worth considering?
Reverse total shoulder replacement is a relatively new procedure (available in Europe since approximately 1990 and in the United States since 2004), but is recognized as an option that, as a rule, dramatically improves the quality of life for patients. Range of motion is noticeably improved, and patients routinely report significant reductions in pain after undergoing the procedure. While surgery is not a panacea, it is certainly an option worth discussing with a shoulder surgeon when pain or loss of motion in the shoulders becomes debilitating.
Causes Symptoms and Treatment
Anyone who has ever experienced a separated shoulder knows that the condition is less than pleasant. Once the injury takes place, prompt attention is the best way to keep the pain to a minimum and promote the process of healing. By learning more about shoulder separation, it is easier to understand how such a condition could develop, what sort of symptoms will appear, and the options for dealing with the problem.
What Can Cause the Separation?
It takes a great deal of force to cause this type of damage. With a shoulder separation, the shoulder girdle absorbs a lot of force in a very short time. When this happens, the connecting tissue is strained and will often become inflamed. If the amount of force transmitted to the shoulder girdle is relatively minor, only a minor grade of separation results.
Because so much force is needed to cause the separation, there are only a few situations that will result in this type of issue. One of the more common causes is participation in contact sports. Participating in sports like football, soccer, or hockey are prime examples. Even other sports where contact is less frequently, such as baseball can lead to situations where the shoulder is separated, sometimes also called an AC (acromioclavicular joint) separation or dislocation. For example, if two players collide while attempting to catch the baseball, the impact may be sufficient to cause injury to one or both of them.
Auto accidents may also result in this type of injury. Anything that causes the driver or a passenger to be thrown forward has the force needed. Seat belts, while designed to minimize the potential of a fatal injury, could add to the force of the impact and cause the collarbone and the shoulder bone to separate.
Falling is another cause of this type of shoulder injury and the level of force and trauma absorbed determines the degree of shoulder separation. While stepping off a curb and losing the footing may most often result in a lower grade of separation, a construction worker who falls off scaffolding that is one or two floors from the ground is at a greater risk for a more severe grade of shoulder separation. Even if the individual lands on a grassy area, the impact could still be sufficient.
Symptoms of a Shoulder Separation
The signs that a separation has taken place will develop immediately. Pain that is somewhat like the sensation of knives being stuck into the flesh is often the first indication. Expect the area around the shoulder and up to the neck to begin swelling. It is not unusual for a bump under the skin to develop along the point where the shoulder normally meets the collarbone.
Moving the arm, if it is possible at all, will trigger more waves of pain. In some instances, the arm will seem so weak that movement is out of the question. The injured party can also expect bruises to develop around the site of the separation.
What Can Be Done?
Prompt medical attention is the most efficient and prudent way to get on the road to healing. One of the first things the medical professional will want to do is examine the shoulder and determine how severe the separation happens to be. Along with the physical examination, the physician will order X-rays as a way of identifying what sort of swelling is present and what it will take to move the shoulder back into a proper alignment.
With less severe cases, the application of cold will help to reduce the swelling. If the pain is minor, the physician may recommend specific dosages of over the counter medications. If necessary, a prescription pain killer will be provided. Expect the physician to place the arm in a sling once the shoulder is moved back into position. While many other types of braces and bandages have been used historically, most studies find a simple arm sling does the best job at supporting the weight of the shoulder girdle. It will take a few weeks for the healing process to allow the pain to resolve and then a few more months to more likely than not be able to return to normal.
When the separation is severe, surgery is a possibility. This is especially likely if the shoulder girdle muscles aren’t able to restore and maintain control and stability and the patient continues to have persistent debility. The decision for surgery is a complex one and it is always best to seek several opinions and find a highly qualified shoulder surgeon.
Surgery is designed to reconstruct the torn ligaments supporting the shoulder girdle and an allograft (donated tissue tendon) is most often used for this purpose. As it takes approximately 18-24 months for the new ligaments to fully mature, it is often recommended that the amount of load applied to the shoulder girdle be gradually increased to better promote the healing process. The duration of the healing period varies with each patient and the type of activity involved.
The thing to remember is that a shoulder separation should not be taken lightly. Seek medical help as soon as possible. Doing so increases the odds of avoiding complications and being back to normal sooner rather than later.
Before, During and After
The human body is comprised of a number of distinct systems, all of which are designed to work together in perfect harmony. Among these is the nervous system, which acts as the body’s mediator. Nerves send signals from other systems to the brain and relay messages from the brain back to other areas of the body. When a nerve is damaged or obstructed, the part of the body it controls may not function as it should.
One example of this type of scenario is suprascapular nerve compression. This occurs when the nerve running from between the fifth and sixth vertebrae branches off the brachial plexus very early and travels through two anatomic tunnels and then travels down along the back side of the shoulder is over-extended or pinched. Since this nerve corresponds to voluntary movements of the shoulder joint, or rotator cuff symptoms of this type of injury include pain and weakness in the affected area. Though suprascapular neuropathy can often be treated with therapy, prescription pain medications, anti-inflammatory agents and steroids, surgery is sometimes the most effective course of action.
Because the symptoms of suprascapular nerve compression are similar to those of a number of other conditions, testing is needed to confirm this particular issue is responsible for the pain and weakness being experienced. Among the most helpful of these tests is electromyographic analysis. Electrodes are inserted into the skin, and small electrical shocks are administered to measure muscle and nerve response. Different types and grades of nerve pathology provide different responses.
A combination of MRI, x-ray imaging and ultrasound or a remote consultation may also be used to determine the root cause and extent of the injury. Should the pathology be severe and not respond to conservative measures, an arthroscopy may be chosen. During this procedure, a small incision is made, and an endoscope is inserted for more thorough examination of the shoulder joint. This technique can also be used for freeing the nerve once suprascapular nerve compression is confirmed.
Suprascapular Nerve Procedure
Patients need to be fully unconscious during this procedure, so a general anesthesia will be administered. Two small incisions will be made on the front of the shoulder from near the middle point of the acromion, the ridge along the top of the shoulder. The arthroscope will be inserted into one incision, and actual surgical repairs will be made via the other.
After cutting through the skin and fatty tissue underneath, the trapezius muscle will be exposed. From that point, the fibers of this muscle will be separated to reveal the next layer of muscle, the Supraspinatus. This muscle will be moved aside, as will the suprascapular artery and the superior transverse scapular ligament connecting to two different areas of the suprascapular notch. This is where the Suprascapular nerve typically becomes compressed.
The surgeon will now be able to free the nerve from its restriction. If necessary, the bone tissue of the Suprascapular notch may be trimmed away to allow more room for the nerve. Should a cyst or tumor be the cause of compression, it will be removed. In the event the superior transverse scapular ligament is responsible for nerve entrapment, it can also be safely removed without negatively impacting the patient’s range of motion.
After decompressing the nerve, the incisions will be closed in reverse order from the inside out with no need for drainage tubes to be inserted. Use of arthroscopy in the procedure creates minimal visible scarring and usually generates a speedier recovery than other techniques. Since this is an outpatient surgery, the patient should be able to return home shortly after the procedure is completed.
Applying ice packs to the surgery site in various intervals throughout the days to follow will help relieve pain and pressure associated with swelling. Patients are advised to wear an abductor pillow for the purpose of comfort and to help support the weight of the shoulder to prevent muscle tension and pain. Pillows should be placed under the affected arm while sleeping for additional support. Pain medications will also be prescribed.
Rehabilitation efforts will come into play following surgery. Some patients may be given a regimen of light stretching exercises to be done at home, and some patients benefit by working with a physical therapist. Specific therapy programs are different for each patient and may include stretching and strengthening as well as mobility-increasing measures.
Shoulder girdle pain can result from many different sources. Pain because of suprascapular nerve pathology can be difficult to diagnose and result in significant pain and weakness. While surgery is typically a last resort, it is often necessary to prevent more extensive nerve damage and muscle loss.
Neither the patient nor the surgeon wants to discover that the shoulder surgery has failed, but it happens more often than anyone would like. Studies revealed that rotator cuff tears will happen to approximately 13% of those over 50 and to half of those over 80 years old. Obviously, this means that there is the potential for a substantial number of failed shoulder surgeries.
Defining a Failed Shoulder Surgery
The only practical definition of a failed shoulder surgery is when the expectations of both the surgeon and the patient are not met. If a strictly technical definition of failure is desired, studies have shown that three out of four rotator cuff repairs could be said to have failed surgically since the cuff is not intact following the surgery. A more practical failure rate was reported in the Journal of Orthopaedic & Sports Physical Therapy. They reviewed ten research reports and found that the failure rate ranged between 18% and 40%.
Patient Satisfaction despite Technical Failure
Further studies find that there is still a very high level of patient satisfaction following surgery. The conclusion was that rehabilitation is critically important. Even if the surgery did not achieve 100% of the goal, if patients experienced substantial pain relief and were better able to use their arm and shoulder, they were generally pleased with the surgery.
Causes of Failed Shoulder Surgeries
There is a risk of failure with any surgery. Every case is unique, with multiple variables. Some of the causes of surgical failure are associated with:
• Injuries to the nerves;
• Complications from infection;
• Weakness or instability;
• Chronic pain;
• Failure of the patient to follow post-op instructions;
• Failure to heal.
Factors Linked to Success or Failure of Repair of the Rotator Cuff
The Journal of Orthopaedic & Sports Physical Therapy review identified various factors affecting the outcome of surgery to repair the rotator cuff. They divided these factors into four categories: demographic, clinical, rotator cuff integrity and the surgical procedure.
As would be expected, the older the patient, the higher the likelihood that the tendon would not heal as it should. For those people younger than 55, there was an 88-95% probability that the tendon would heal. On the other hand, the likelihood that the tendon would heal was reduced to 43-65% for people over 60.
Early treatment improves outcomes. Unfortunately, many people delay seeking help, sometimes for years, while the damage gradually worsens. By the time they go for treatment, the damage is significant and the surgery more complex.
There were a number of clinical factors associated with poor healing following the surgery.
• Low bone mineral density;
• Obesity – associated with a 12% reduction in a successful outcome;
• Low activity level prior to surgery; the best outcomes were for those who regularly swam, golfed or ran;
• Final post-op strength was linked to strength prior to the surgery;
• Stiffness before surgery delayed recovery.
Integrity of the Rotator Cuff
Poor outcomes were related to four factors:
• The size of the tear;
• How many rotator cuff muscles were involved;
• How much tendon retraction there was;
• The degree of fatty infiltration.
As would be expected, the more the tissue had degenerated, the less likely that there would be a good outcome.
Delaying treatment after an initial tear can cause the tear in the cuff to become bigger, retract from the bone and weaken. There is almost a 97% chance that a small tear repair will heal, while a repair to a large tear has only a 58% chance of healing properly.
One study found that poorer outcomes were linked to additional surgical procedures performed on the acromioclavicular joint or biceps.
Improving the Outcome Following Shoulder Surgery
• Seek early treatment, as delay reduces the chance of a successful outcome;
• Become active prior to surgery; a sedentary lifestyle is linked to poorer outcomes;
• Lose weight prior to surgery;
• Before surgery, begin regular physical therapy; if the shoulder is stronger before surgery, it will be stronger after surgery;
• Ensure that diabetes or other medical conditions are being controlled.
The evidence indicates that shoulder surgical failures can be reduced if the patient becomes a full partner in the procedure and takes the proper actions both before and after the surgery. Some factors linked to failure are controllable, while others are not. Patient expectations need to be realistic. An active and fit 40 year old is much more likely to have an excellent recovery than a sedentary 70 year old diabetic, even if both have a similar problem and surgery. Regardless of the technological advances and skill of the surgeon, some of the factors affecting the ultimate success or failure of the surgery are entirely controlled by the patient.
Shoulders have a greater range of motion than any other joint in the human body with an entire group of nerves, muscles and tendons working in conjunction to keep them functioning properly. Unfortunately, this fluidity comes with its fair share of potential problems. Among the most common of these are rotator cuff injuries (video 1, video 2, video 3, video4.)
Though plenty of options, ranging from combinations of medications and physical therapy to various types of surgery, are available to help remedy this type of damage, a number of patients experience little or no relief through conventional means. Some even go through the full range of traditional repair techniques to no avail. While this could, understandably, leave a patient discouraged and resigned to a life of pain and limited mobility, all hope is not lost.
Why Conventional Techniques Fail
Lack of skill and experience on the part of surgeons performing these procedures can be a factor behind failed rotator cuff repairs; as such, finding one with considerable experience and expertise is crucial to success. Age of the patient and his or her level of health going into the surgery are also directly related to the outcome. Extent of damage is likewise to blame.
Patients actually bear a great burden of responsibility in some failed attempts at repairing rotator cuff tears as repairs require an extended time to heal. Smoking inevitably slows the healing process following injuries as well as surgical procedures regardless of how non-invasive they may be. Many simply fail to properly follow after-care instructions as they should. Either way, several alternatives could provide a solution to previously unsuccessful strategies.
Revision Arthroscopic Rotator Cuff Repair
In the event that despite a failed rotator cuff repair, there is still ample rotator cuff muscle and tendon available, a revision arthroscopic rotator cuff procedure with a reinforcement graft may be the answer. A small incision will be made for the arthroscope, which is a camera used to determine damage extent. Once the physician decides how to proceed, additional incisions/portals will be made for insertion of surgical instruments and to allow necessary access to tendons and muscles.
Multiple sutures are routinely used to return the tendons and muscles to their proper positions and also to apply a load sharing graft. This is the least invasive failed rotator cuff repair and may be implemented regardless of the type of surgery previously performed. Though this is beneficial in causing as little further damage to tendons, muscles and nerves as possible, this option may not be appropriate in all cases.
Superior Capsular Reconstruction
Also performed arthroscopically, this procedure uses a dermal patch to replace irreparably damaged rotator cuff tissues. The artificial patch will act just as the natural muscles and tendons of a healthy rotator cuff to hold the humerus in place within the shoulder joint. As is the case with traditional rotator cuff repair surgery, sutures will be inserted in the bones of the shoulder. Sutures will be drawn through the tendons and patch and tied in place to support the patch and, by extension, the joint itself.
While this type of repair may not fully restore strength and mobility to pre-surgery status, it often aids in reducing pain and weakness. It will keep the humerus in place and help prevent it from impinging nerves or tendons in the future. This procedure has been found most effective in patients with issues stemming from tendons in the back side of the shoulder, but it can be helpful in many scenarios where other techniques have failed.
Reverse Total Shoulder Replacement
For patients who have developed arthritis in the affected shoulder because of, or in addition to, a rotator cuff tear, reverse total shoulder replacement may be the best solution. With this strategy, a plastic cradle is attached to the top of the humerus, and a metal ball is affixed in the shoulder socket. Because this technique is essentially the reverse setup of a normal shoulder joint, it allows alternate muscles to take over for no longer functioning ones.
Rotator cuff repairs commonly fail due to a number of reasons. Finding a capable surgeon is key to regaining strength and mobility following a rotator cuff injury or unsuccessful previous techniques. Though not everyone is a suitable candidate for every alternative, many are able to experience pain relief and greater functionality through these options.