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Question: I am a 60-year-old female. I have had two rotator cuff shoulder surgeries, both failed. I was told it couldn’t be repaired again because there’s not enough tissue to hold the joint in place. But is it possible to take muscle and tendons from another area to help rebuild the cuff? And what about the theory of keeping the joint immobilized for up to six weeks post surgery?
The day after my last surgery, I was put on an active therapy machine. I also developed a very severe infection in my spine two to three weeks after the operation. And I have been on very strong immune-suppresser drugs. Could any of these things have played a significant role in why my cuff surgery failed? In the past year-and-a-half, the immune-suppressing drugs have been discontinued. So, could I be considered a candidate for one more surgery? I know this is a complicated case, but I love being active with my grandkids, gardening and painting. I need my shoulder.
Answer: Shoulder problems can, indeed, be complicated. So I raised your case with a very experienced shoulder expert, Dr. Richard Holtby, a surgeon at the Holland Orthopaedic & Arthritic Centre of Sunnybrook Health Sciences Centre.
Before delving into the details of your situation, it’s worthwhile reviewing the role of the rotator cuff. It’s essentially a group of muscles and tendons that surround the shoulder joint. It holds the ball of the upper arm bone (or humerus) in the shoulder socket, while also enabling the arm to move in almost any direction. So it performs several critical functions. With repetitive use, or injuries, the rotator cuff can become worn, or damaged, and weaken over time. Some people, like you, may require an operation to repair it.
Dr. Holtby says you are correct – some of the factors you mentioned may have contributed to your surgery failures.
“If she had a severe infection and the bacteria in her blood settled into her shoulder, that could have certainly compromised her rotator cuff repair,” he says.
Immune-suppressor drugs can also interfere with recovery. “It’s possible, if she was taking those at the time of the surgery, that may have been a factor in why it didn’t heal properly.”
Furthermore, overly aggressive movements soon after surgery may be counter-productive. “Normally we would immobilize the shoulder to give it a chance to begin healing before we start moving it.”
Although the infection is presumably gone and the immune-suppressing drugs have been stopped, I’m sorry to say that you still wouldn’t be considered a good candidate for yet another operation.
That’s partly because your chances of having a successful operation drop with each subsequent surgery.
“Almost never would we do it a third time – unless there were extenuating circumstances,” says Dr. Holtby.
Judging from how you’ve described your condition, your main problem is that there’s very little good tissue left. The surgeon simply doesn’t have much to work with. Could tissues from elsewhere be used to rebuild the cuff? Dr. Holtby doesn’t think that’s possible in cases like yours.
“There are operations in which we try to move another muscle into the shoulder or perhaps use some synthetic materials,” he explains. “Perhaps we would consider them for a younger person as a salvage procedure. I don’t think we would do them in a 60-year-old woman.” The existing evidence suggests these procedures don’t produce reliable results in a person of your age.
Still, it’s likely worthwhile getting a second opinion if the same surgeon performed both your previous operations. Another doctor may conclude there is enough good tissue left to try one more time. Your family doctor or the surgeon who performed your earlier operations could make the referral.
Dr. Holtby suggests you should ask to be sent to a surgeon who specializes in shoulders. “A lot of general orthopaedic surgeons do shoulder surgery,” he notes. In your rather complicated case, “it’s better to see a shoulder specialist who is doing this work all the time.” (Keep in mind it can take a long time to see a specialist.)
But what do you do if the second opinion backs up the original assessment – and another rotator cuff operation can’t be justified? What options do you have left?
Dr. Holtby says what happens next will partly depend on how your shoulder problem interferes with your daily life – and how much pain you’re experiencing.
“If it’s painful, then we have to look at the reason for the pain.” A certain amount of pain can be expected with routine movement. But it can also be excessive. “If she has constant pain, can’t sleep at night, or gets severe pain just sitting quietly, then she may be developing a chronic or abnormal pain problem.” If faced with that amount of discomfort, you should be referred to a pain specialist.
Dr. Holtby points out that some patients with rotator cuff problems can develop arthritis in the shoulder.
Some of them eventually need a shoulder replacement operation – and that could be your situation.
Because your rotator cuff is worn out and can’t be relied upon to perform its normal functions, you could require a special type of shoulder replacement – called a reverse-prosthesis arthroplasty.
In a conventional shoulder replacement, the old ball and socket are surgically removed and the bones are fitted with artificial parts.
With a reverse-prosthesis arthroplasty, the location of the ball and socket are actually switched around with the new parts that are installed. (The ball is attached to the shoulder and the socket to the humerus.)
“This configuration keeps the centre of rotation of the joint in its normal place… and you regain some of the ability to lift your arm,” explains Dr. Holtby.
However, he warns, changing the mechanics of how the arm works puts a lot of stress on the replacement parts and they tend to wear out in about a decade.
You’re 60 now and could live well into your 80s or longer. That means the prosthesis would have to last an unusually long time. You don’t want it giving out while you still need a functioning arm.
“Once it does fall apart, and becomes loose, it’s very hard to fix,” he says. “We would probably just take it out,” leaving only fibrous tissue connecting the arm to the body.
So it’s best to postpone this type of shoulder replacement until it’s really needed.
As Dr. Holtby puts it: “It maybe appropriate when you are older, but not when you are younger.”
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog Personal Health Navigator is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca and follow Paul on Twitter @epaultaylor