Management of Screw Backout After Rotator Cuff Repair
Screw backout after rotator cuff repair requires revision surgery when symptomatic, with arthroscopic revision being the preferred approach for patients experiencing persistent pain or functional impairment despite conservative management.
Clinical Assessment and Decision-Making
The primary consideration is whether the patient has persistent clinical symptoms that warrant intervention, as structural failure alone is not an indication for revision surgery 1. Key factors to evaluate include:
- Pain severity and functional limitation - The major indication for revision is persistence of clinical symptoms despite nonsurgical management 1
- Maintained function despite hardware failure - Some patients maintain adequate function even with screw backout, and these cases do not require revision 1
- Patient age and gender - Female patients and those with preoperative abduction less than 90° have poorer outcomes with revision surgery 2
- Number of prior surgeries - More than one prior ipsilateral shoulder surgery is associated with cases requiring additional surgery 2
Initial Conservative Management
Before proceeding to revision surgery, attempt nonsurgical management 1:
- Supervised physical therapy is preferred over unsupervised home exercise programs 3
- Single corticosteroid injection with local anesthetic may provide short-term pain and functional improvement 3
- Avoid multiple steroid injections as they may compromise rotator cuff integrity and affect subsequent repair attempts 3
- Multimodal pain management using non-opioid modalities 3
Surgical Intervention: Revision Repair
When conservative management fails and symptoms persist, arthroscopic revision rotator cuff repair is the recommended approach 1, 2:
Expected Outcomes
- Arthroscopic revision provides significant improvement in shoulder function and pain relief 2
- American Shoulder and Elbow Surgeons scores improve from approximately 44 preoperatively to 68 postoperatively 2
- Visual analog pain scores improve from 5.2 to 2.8 2
- Forward elevation increases from 121° to 136° 2
Prognostic Factors for Success
Favorable candidates for revision repair include 4:
- Male gender
- Age younger than 70 years
- Not seeking workers' compensation
- Forward elevation greater than 90°
- Small retear with good-quality muscles and tendons
- No glenohumeral osteoarthritis
- Acromiohumeral distance greater than 6mm 5
- Goutallier fatty degeneration grade less than 2 5
Technical Considerations
The revision repair should adhere to established principles 5:
- Decorticate the bony reattachment site - healing proceeds largely from bone
- Release the cuff to enable reattachment without tension
- Ensure permanent bone-to-tendon contact until healing is complete
- Gentle, passive rehabilitation postoperatively
Common Pitfalls to Avoid
- Operating on asymptomatic hardware failure - structural failure without symptoms does not require intervention 1
- Inadequate patient selection - patients with multiple prior surgeries, female gender, or limited preoperative range of motion have higher failure rates 2
- Aggressive rehabilitation - can lead to early trauma and repair failure 4
- Ignoring tissue quality - poor muscle and tendon quality significantly impacts outcomes 4
Alternative Options for Unfavorable Cases
When revision repair is not feasible due to poor tissue quality or other unfavorable factors 4:
- Material implantation (autograft, allograft, or substitute)
- Muscle transfer procedures
- Reverse shoulder arthroplasty for massive, unrepairable tears with pseudoparalysis 3
Note that outcomes with these salvage procedures are poorer than when used as primary procedures 4.
Prevention Strategies
Prevention is the best treatment for hardware failure 4:
- Careful patient selection initially
- Smoking cessation strongly encouraged
- Control of metabolic disorders associated with repair failure
- Consider biceps tenotomy on a case-by-case basis