Revision Shoulder Surgery

A shoulder that still hurts after surgery is not the same problem as a shoulder that has never been operated on. It is a harder one, and it needs to be approached differently.

It is one of the areas other surgeons refer patients here for.

Why a second operation is a different operation

After any shoulder surgery, three things have changed inside the joint.

Scar tissue has formed. It obscures the normal planes a surgeon works along, and it can itself be a source of stiffness and pain independent of whatever the original problem was.

The anatomy has been altered. Tissue has been moved, tensioned, and anchored. Bone may have been removed. What you find on going back in is not the anatomy described in a textbook.

Hardware may be present. Anchors, sutures, and implants from the first operation constrain what is possible in the second. Sometimes they have to come out, which is its own procedure.

Together these mean revision surgery requires more planning before the operation and more judgment during it. A great deal of the work happens before you reach the operating room.

Why shoulder repairs fail

Understanding why the first operation did not work is the whole of the assessment, because the answer determines whether another operation would help.

The repair did not heal. Rotator cuff repairs depend on tendon healing back to bone, and that healing is not guaranteed. Large tears, poor tissue quality, older age, smoking, and diabetes all reduce the chance of it happening. The repair can be technically excellent and still not heal.

The tear was larger or older than expected. Retracted, chronically torn tendons with atrophied muscle behave differently from acute tears, and are considerably harder to repair durably.

The original diagnosis was incomplete. Shoulder pain has multiple sources, and it is possible to correctly repair one problem while a second one, unaddressed, continues to cause the symptoms. Stiffness, arthritis, nerve problems, and instability can all coexist with a cuff tear.

Rehabilitation went wrong. Too much too early can disrupt a repair. Too little can leave a shoulder stiff enough that the repair no longer matters. Both are common, and both are avoidable.

It re-tore. Sometimes a repair heals and then fails later, through another injury or through gradual attrition.

Note that most of these are biology rather than error. Patients often arrive assuming the first surgeon made a mistake, and that is usually not what happened.

What the assessment involves

Your history matters more than usual. What the shoulder was like before the first operation, what changed immediately after, and what has changed since. A shoulder that was never better after surgery is telling a different story from one that improved for a year and then deteriorated.

We want the operative report. What was found, what was repaired, and what was used. This is the single most useful document you can bring, and it is worth requesting from the previous surgeon’s office before your appointment.

We want the actual imaging. Not only the radiologist’s report. Prior films establish what the shoulder looked like before and immediately after, and comparing them across time reveals things a single study cannot.

A full examination. Range of motion, strength, stability, and the specific tests that separate a failed repair from stiffness, arthritis, or a problem elsewhere. Pain referred from the neck presents as shoulder pain more often than people expect.

Further imaging is often needed. An MRI in a shoulder that already has metal in it is harder to interpret, and sometimes a CT arthrogram gives a clearer answer.

What revision surgery can involve

The right operation depends entirely on what is found, and there is no single revision procedure:

• Repeat repair, where the tissue is good enough to hold and the tear pattern allows it
• Removal or revision of previous hardware, where anchors have loosened or are causing problems
• Release of scar tissue and capsular release, where stiffness rather than a failed repair is the main problem
• Tendon transfer, where the original tendon is beyond repair but function can be restored another way
• Shoulder replacement, including reverse replacement, where the joint surface and cuff have both failed
• Superior capsular reconstruction and graft techniques, in selected irreparable tears

Which of these applies is a decision made from the examination and imaging, and sometimes only confirmed at the time of the operation. That uncertainty is normal in revision work, and you should expect it to be discussed with you honestly before you consent to anything.

When another operation is not the answer

Some failed repairs should not be revised.

Where a tendon has retracted badly and the muscle has atrophied and turned to fat, a repair will not hold, and operating again puts you through a recovery for no benefit. Where the joint surface has worn out, repairing the cuff does not address the reason it hurts. And where pain is being generated somewhere other than the shoulder, shoulder surgery will not help it.

In those cases the honest answer is a different plan: injection, targeted rehabilitation, activity modification, or a different operation entirely. Being told that clearly is more useful than being offered another operation that will not work.

Recovery

Recovery after revision surgery is generally slower than after a first operation. Tissue that has been operated on before heals less predictably, and rehabilitation is usually staged more cautiously as a result.

The rehabilitation plan is set out with the surgical plan rather than handed off afterwards, because in shoulder surgery the two together determine the outcome. What happens in the twelve weeks after the operation matters at least as much as what happens during it.

Getting a second opinion

If you have had shoulder surgery and it has not worked, having it reviewed is reasonable, and you do not need your original surgeon’s permission.

Bring the operative report and the imaging. A useful second opinion means someone looking at the actual images and examining the actual shoulder, not reading somebody else’s conclusion and agreeing with it.