Retears - what to do

Given the relatively high incidence of rotator cuff retear among patients of repair surgery, little seems to be written about how you might tell if you've retorn it and what to do. I have seen this article a number of times as it crops up on medical websites and has even been used here in the UK by our NHS as an advice leaflet; however, it seems to contain no information of any use - not to me at least. So, if I may, here are some of my experiences of dealing with retears. I have retorn my repaired rotator cuff more than once and now have an intact repair. Here's how I got there.

What is a Retear?

Simply put, a retear of the rotator cuff is where an attempted repair has failed. You have to have had a tear repaired before you can have a retear, so if you've not had a repair, you can't retear. Sorry if this sounds obvious, but this question has cropped up a couple of times!

Types of retear

Much is written about how the rotator cuff gets torn in the first place (trauma, wear and tear etc), however, much less is written about how tears fail. There are two points at which a repair can fail - pre-healing and post-healing.

Pre-healing: Usually in the first 6-8 weeks from surgery. The repair can fail during this time if the repair construct fails - this includes:
    - Tendon pulls through the suture (the most common cause)
    - Anchor pull-out from bone (rare, but happens)
    - Suture failure (rarer still)
   
Post-healing: Any failure or retear after the 8 week mark is almost definitely due to a failure of the bone-to-tendon healing - includes:
    - Mechanical failure of the healed bone/tendon interface
    - Failure of the bone to heal to the tendon (less common and more likely to result in a pre-healing failure anyway)
   
Causes:
- Using the joint too early
- Bone/tendon have not healed
- Further trauma - e.g. a fall or impact to the joint

Indications of retear:
- A sudden sound (pop/click) in the joint
- Sudden onset of pain
- Return of familiar pain
- Clunking or clicking that is easy to replicate with certain movements.
- Loss of movement

This is to say then, if you've had a rotator cuff repair and you're doing well at three months post-op, then you raise your arm and suddenly feel a click in your shoulder, followed by a return of familiar pain which is accompanied by a repeatable clunk and a loss of movement, then you have probably retorn your rotator cuff. The more of these indications that are present, the more likely a retear.

Red-herrings i.e. things that are very unlikely to indicate a retear on their own:
- Pop or click with no pain - probably just some adhesive scar tissue giving way.
- Sudden onset of pain that comes and goes for a while - probably part of the healing process

Coming to terms with a retear

If you've suffered an injury to your shoulder, undergone a rotator cuff repair and begun the rehab, then the prospect of repeating this experience can be nothing short of harrowing. We all respond differently in these situations: some are optimistic and hope for the best, some are pessimistic and fear the worst. If like me, you are a combination of both of these, you'll want to get answers so you can plan what to do next. The only way to do this is to get it rescanned, either by ultrasound or MRI.

Rescanning after surgery:
Because of the cost of scans, some surgeons don't like to authorise them until many months after surgery, which can be very frustrating if you're worried that you may've retorn your repair. Unfortunately, scans are less reliable after surgery due to residual swelling, fluid and scarring. It is fairly pointless to request a scan prior to three months after surgery as the scan really won't show much and no surgeon will take it seriously. This means, even if you think you retore your shoulder at two weeks post-op, you will have to wait until three-months before an MRI or ultrasound is viable -- sorry about that!

So if you're at 3 months post surgery and your surgeon won't authorise an MRI, what do you do? Well, in my case I got my Osteopath to refer me for an MRI that I paid for myself. In the UK an Osteopath, Chiropractor or your GP/Family Doctor can refer you for a private MRI - only your GP or surgeon can refer you for an MRI on the NHS and they may or may not be willing to do this.

Following your MRI Scan:
When you've had your scan done, my advice is to get hold of a CD of the images and the radiologist report. The images are useless without the report. If the scan was done privately, you should be given a CD of images and the report should be made available to you via the person that referred you for the scan. Get a copy of the report as soon as you can because, as you will see from the following story, you may have to take these to a different surgeon.

My story

Having retorn my repaired rotator cuff more than once, the most typical response I have got from my surgeon when I have first raised this is, no you haven't. Even with an MRI that shows a tear, many surgeons will claim that MRIs after surgery are misleading and you're probably fine. This has happened to me more than once and each time I was proved right and they were proved wrong. The only solution I have found is to go to someone else - no really; for some reason they don't want to accept that their excellent work has somehow failed.

Finding another surgeon:
There really is no straightforward guide to finding the next surgeon. All surgeons are not made equal and each one has their own special thing they do, their own set of preferred methods and their own particular attitude towards your case. This is based on the experience of seeing at least twenty UK shoulder surgeons - a few of whom have gone on to operate on me!

The truth about revision rotator cuff repair:
If you have retorn your cuff, the chances are it will be be harder to repair again. This is because:
    - Your cuff tissue is likely to be of poorer quality
    - The tear is likely to be bigger
    - The presence of anchors in the bone can make the positioning of new anchors more difficult - you can't reuse old anchors.
   
Having seen a number of surgeons and had my cuff repair re-done (revised) more than once, there is one piece of advice that drops out that I would share with anyone looking for a new surgeon and that is:

- If your rotator cuff repair has failed and the surgeon is proposing that they repair it using the same or similar technique as was tried before, then there is no reason to expect a better outcome.

I went through a stage of making sure the next surgeon was the 'best' guy and that his reputation was better so therefore he must be a better surgeon so his repairs must just be better etc. This turned out to be b*llsh*t every single time and I simply ended up suffering the arrogance of some of the UK's biggest rock-star shoulder surgeons; none of whom I'd recommend by the way. Reputation and ability are rarely proportional, in my experience.

Knowing I had limited options, I began researching repair techniques themselves and learning who was doing what. This led me to research the use of allograft patches, in particular a product called GraftJacket. I had a repair with this patch five weeks ago and so far so good. However, finding this surgeon was a long road and whilst I could find plenty of surgeons who had done GraftJacket repairs before, I couldn't find anyone who would do it on me. The reason, it turns out, was because most of these surgeons had done a handful of repairs on a few cases so were unsure if it would help me. I learned this when I went to see one of the first surgeons to do these repairs in the UK, who by this time had between 100 and 200 operations to reflect on. Fortunately for me, he agreed to surgery.