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The Question: My wife had arthroscopic surgery for a rotator cuff injury more than two years ago. Unfortunately, the surgery did not help because my wife is still experiencing severe pain intermittently. She did physiotherapy and lately she did shock wave therapy. Basically, we did everything. We want to get another opinion. Please help us on how to start.
The Answer: I sense you are exasperated and justifiably so – it is difficult to know where to turn, especially when you feel you have gone through every available avenue to address your wife’s medical issue. According to Robin Richards, Sunnybrook’s surgeon-in-chief emeritus, in about 15 to 20 per cent of cases, symptoms persist after rotator cuff surgery. “Nothing we do is 100 per cent successful,” notes Dr. Richards, an orthopedic surgeon who specializes in shoulders. “There is a significant percentage who don’t get better.”
The rotator cuff is a thick tendon that surrounds the upper end of your arm bone, medically referred to as the humerus. Its job is to initiate movements of the shoulder and to hold the ball in the socket of your shoulder, allowing you to use the big muscles in your arms. It can be damaged through repetitive use, age-related changes and in rare cases, trauma. When damaged, patients feel pain from the swollen, inflamed tendon, which can be particularly intense at night or when lifting overhead.
The most common need for surgery is to decompress painful chronic rotator cuff tendonopathy, a wear and tear process or to repair a tear of the cuff. “The tendon can become thin and develop a tear,” said Dr. Richards. “When a patient doesn’t get better after surgery you have to ask: ‘Did the repair fall apart?’”
When surgery is unsuccessful, the surgeon will look first for complications such as infection and then try to determine if the surgery was done for the correct diagnosis, if the decompression of the cuff was adequate and if the cuff repair healed. The surgeon will do a physical examination, take a medical history and order investigational procedures such as an MRI and X-rays. From there, the surgeon will form a diagnosis and determine whether a revision surgery is likely to work.
“If the MRI shows a re-tear, the repair had failed, then we would think about surgery again,” according to Richard Holtby, an orthopedic and shoulder surgeon at Holland Orthopaedic & Arthritic Centre. “Usually the MRI accurately diagnoses a retear but it is not perfect and sometimes the only way to know if a repair failed is to look at it again surgically.”
Typically, surgeons will do a revision if it is medically indicated.
“If it was a small rotator cuff tear, and the surgeon felt he had a good repair and expected a good result but the patient did not get a good result, we would think about doing another surgery,” said Dr. Holtby.
If it’s a big tear, however, and the surgeon knew it was never going to be perfect but did the best job possible, due to the limited amount of tissue, a second surgery is unlikely to be more successful, said Dr. Holtby.
Something to be mindful of: in revision surgery for rotator cuff problems, 70 to 75 per cent of patients will rate the operation as good or excellent, compared to 80 to 85 per cent who undergo a primary rotator cuff decompression and/or repair. Complication rates also increase with revisions, with 5 per cent of patients experiencing at least one, such as an infection, bleeding, nerve damage or stiffness. That compares to the 2 per cent of cases that typically experience one of those complications the first time around.
The good news is that the rotator cuff doesn’t have to be perfect to have a good result. It’s rare that surgeons can’t find a way to fix it. If the repair didn’t work the first time, the surgeon might reinforce the cuff with other biological material, transfer a muscle from nearby to replace the damaged cuff muscle or replace the shoulder.
Dr. Holtby suggests you ask for a second opinion. “No one should hesitate to ask their surgeon for a second opinion,” said Dr. Holtby.
If your wife is still experiencing pain, she should go to the surgeon. She might want to say that she knows the doctor did her or his best and she knows that shoulder surgery is complicated. She could also say that she’s not sure why she’s having the symptoms but would like to find out. She should then ask if she could get a second opinion or if there is someone else she could talk to. She should thank the surgeon for the care.
Once you have that appointment, she needs to get all the reports together, preferably on a CD. She needs MRI scans, X-rays, copies of the operation record and consultation reports. She should physically carry these with her to the appointment with the new surgeon – she should not rely on her surgeon to send these reports because it may not get there in time.
“Whenever there is failed surgery,” said Dr. Holtby, “It is probably reasonable to get a second opinion.”
Lisa Priest is Sunnybrook’s Manager of Community Engagement & Patient Navigation. Her blog Personal Health Navigator provides advice and answers questions from patients and their families, relying heavily on medical and health experts. Her blog is reprinted on healthydebate.ca with the kind permission of Sunnybrook Health Sciences Centre. Send questions to AskLisa@sunnybrook.ca.