Abstract
Background:
As a degenerative condition, symptomatic rotator cuff disease is frequently seen in the aging population, often requiring arthroscopic repair to eliminate pain and restore function. Repair integrity remains a concern in both short- and long-term postoperative periods due to high rates of primary repair failures, leading to increased interest in biologic patch augmentation to improve healing.
Indications:
Patch augmentation during rotator cuff repair is indicated in patients at high risk for repair failure or incomplete healing, including patients with poor quality, degenerative tendon tissue, those undergoing revision repair, and patients with large or massive rotator cuff tears.
Technique Description:
Standard arthroscopic portals are established and following diagnostic arthroscopy, the rotator cuff tear is identified, mobilized, and the humeral head gently debrided to a bleeding surface. Medial row suture anchors are placed, and following suture passage through the rotator cuff, the medial row sutures are tied. A bioinductive augmentation patch is introduced and provisionally secured medial to the enthesis utilizing spinal needles. Sutures are shuttled over the patch and incorporated into the lateral row repair utilizing 2 knotless suture anchors, effectively securing the patch over the bone-tendon interface.
Results:
Utilization of the described patch augmentation technique may improve repair healing by stimulating collagen formation and tissue vascularity, while providing structural support during the immediate postoperative period, effectively facilitating new tissue formation.
Discussion/Conclusion:
Incorporation of the bioinductive patch into the lateral row suture repair, directly over the tendon-bone interface, may assist in repair healing and decrease issues related to patch migration, while minimizing operative time and materials cost.
This is a visual representation of the abstract.
Video Transcript
This is a video presentation of our surgical technique using a bioinductive augmentation patch, utilizing an anchorless, cost-effective technique for the repair of a massive rotator cuff tear.
The authors’ full disclosures are available online, while 4 of our authors are Smith and Nephew consultants.
Rotator cuff tearing is a degenerative condition frequently seen in the aging population. Arthroscopic repair is generally recommended and performed to eliminate pain and restore patient function. The integrity of the rotator cuff repair, as well as long-term durability, remain a concern in some patients leading to increased investigations in recent years into the use of patch augmentation. Biologic patch augmentation is generally indicated in patients at high risk for repair failures, namely, patients with poor quality or degenerative tissue, those undergoing revision repairs, and those patients with large to massive rotator cuff tears. Our technique describes the utilization of a bioinductive patch during a standard rotator cuff repair, which is incorporated into our lateral row repair.
Our patient is a 65-year-old man with a history of bilateral rotator cuff tears, who presented for evaluation and management of right chronic shoulder pain. The patient reports having sustained a fall in which he landed directly on the right shoulder. He currently endorses increasing discomfort within the right shoulder that is poorly controlled with anti-inflammatory medication. He rates his pain as an 8 out of 10, associated with weakness and limited range of motion, and states that the shoulder feels approximately 40% of normal.
On physical examination, he demonstrates limited range of motion and active scaption to 90,° with external rotation limited to 30° and internal rotation to L5. He demonstrates 1+ tenderness to palpation over the greater tuberosity and the bicipital groove, and 4+/5 strength when testing the supraspinatus and infraspinatus. He is otherwise neurovascularly intact.
Magnetic resonance imaging (MRI) demonstrates a full thickness tear of the supraspinatus and infraspinatus rotator cuff tendons with tendon retraction medial to the glenoid.
Indications for operative management include the presence of a symptomatic full thickness rotator cuff tear following failure of conservative management. Biologic patch augmentation is indicated in the setting of a reconstructible rotator cuff failure in the presence of poor-quality tendon tissue with increased risk for repair failure. Contraindications to surgery include patients with an active infection, those with significant medical comorbidities, or those with rotator cuff tearing with concurrent stiffness secondary to adhesive capsulitis.
Patients are positioned in the standard beach chair position with all bony prominences well padded.
The procedure begins by establishing standard posterior and anterior arthroscopic portals and performing a diagnostic arthroscopy. The arthroscope is then placed in the subacromial space and a mid-lateral working portal, established 5 to 6 cm lateral from the acromion and is created to allow for rotator cuff repair and graft passage, with accessory anterolateral or posterolateral portals created as needed for visualization. Bursal tissue is then debrided utilizing a combination of a shaver and radiofrequency device. An acromioplasty is performed, if necessary.
The footprint of the rotator cuff on the humeral head is then decorticated to a bleeding surface utilizing a burr. The torn edge of the rotator cuff is then identified and mobilized by releasing superficial and deep adhesions to the bursa and/or synovial tissue bluntly or with a radiofrequency device, with a rotator interval release or interval slide performed, as necessary, to ensure repair to the humeral surface. A standard arthroscopic punch is then utilized to establish the medial row.
Following anchor placement, sutures are then passed through the rotator cuff in a horizontal mattress fashion. A second anchor is then inserted into the medial row, and sutures are again passed through the rotator cuff. Sutures are then tied utilizing an arthroscopic knot-tying device to secure the medial row. The augmentation patch is then introduced through the lateral portal and deployed. The patch may then be provisionally secured utilizing percutaneously placed spinal needles.
Once secure, the inserter device may then be removed. The location of the lateral anchors are then identified and subsequently prepared utilizing electrocautery device. A punch and tap are then utilized to prepare for the lateral row. Sutures are then appropriately shuttled and then loaded within the knotless anchor and inserted into the cortical bone for the lateral row. It is critical during this step to avoid bunching up the patch. An arthroscopic grasper maybe utilized to mobilize the sutures appropriately, so they are evenly placed over the graft.
Once appropriate suture placement is achieved, the anchor may then be inserted into the bone. The suture strands are then cut, and then the process is repeated to create another lateral row anchor. Once secured laterally, the spinal needles may then be removed, the remaining sutures appropriately shuttled, followed by anchor placement. It is again critical to ensure that the full bioinductive properties of the graft are utilized by ensuring that no part of the graft is bunched up. The arm is then placed through a range of motion to ensure that the graft is secure without any evidence of loosening.
Technical pearls and pitfalls of this surgical technique include the importance of achieving excellent visualization of the subacromial space. As such, it is important to pay particular attention to debriding the bursal tissue, anteriorly, laterally, as well as posteriorly. And, if there is limited working space, one can consider debridement of the deltoid fascia, as there is little morbidity in doing so and it typically reconstitutes in a matter of weeks.
Generally, we utilize 3 spinal needles to provisionally fixate our graft or patch medially before withdrawing the insertion device. Before withdrawing the device, it is best to locate the patch in its final location with provisional fixation provided by these spinal needles. And when placing the lateral anchors, visualization of the course of the sutures from the medial to the lateral row is essential to ensure that all corners of the patch are covered. If inadequate coverage is present, consider relocating the lateral row anchor. Therefore, it is important to simulate placement of the lateral row anchor with the suture before punching the lateral row. Utilizing a blunt probe or blunt grasping device to subtly shift the location of the patch beneath the sutures can ensure that the sutures successfully cover the patch. Do not use sharp instruments and place the patch as close to the medial row as possible to achieve a seal of the tuberosity and repair, optimizing retention of marrow elements, fibrin, and growth factors.
It is also imperative to perform a thorough preparation of the greater tuberosity footprint, ideally creating a bleeding cortical surface while not completely decorticating this area, which could decrease anchor pullout strength. And adequate bioinductive patch and rotator cuff repair will benefit significantly from the access to these underlying vascular channels. While there is a risk for developing stiffness following patch augmentation, the use of early range of motion through a standardized rehabilitation protocol minimizes this complication. While the failure rates following patch augmentation in massive rotator cuff tears are largely unknown, the use of the bioinductive patch should ideally decrease failure rates by enhancing tendon regeneration while protecting repair integrity.
Following surgery, patients are enrolled in a 6-phase rehabilitation program that spans approximately 5 months. During the first phase, over the course of the first 2 weeks following surgery, the patient is restricted to strict immobilization in a sling with an abduction pillow. Physical therapy generally begins 1 to 2 weeks after the procedure. During the second phase, from weeks 2 to 5, passive range of motion exercises are performed as tolerated, progressing to active-assisted and eventually active range of motion exercises. At 6 weeks, the sling is discontinued, and the patient is encouraged to perform all passive, active-assisted, and active range of motion exercises. Range of motion and strengthening are then initiated as tolerated. Patients are expected to possess full passive and active range of motion by 2 to 3 months with progression to strengthening. Additional isotonic exercises and strengthening are continued after 4 months, including a total body conditioning program while patients begin to engage in task or sport-specific exercises by 5 months.
A prospective cohort study demonstrated that when looking at return to work, patients treated with rotator cuff repair with patch augmentation returned to work in an average of 48.4 days following surgery compared with 8 weeks in patients undergoing rotator cuff repair without patch augmentation. Moreover, patients undergoing repair with patch augmentation have been reported to return to sport at an average of 105 days, which compares favorably with the average of 6.9 months in patients undergoing rotator cuff repair without patch augmentation, as reported previously in the literature.
When analyzing patient outcomes, a prospective multicenter registry-based study examined 1-year outcomes in 192 patients undergoing rotator cuff repair for full thickness tears, augmented with a bioinductive implant. The authors reported statistically significant improvements in single-assessment numeric evaluation (SANE), Veterans RAND 12-item physical components (VR-12 PCS), American Shoulder and Elbow Surgeons (ASES), and Western Ontario Rotator Cuff (WORC) scores during the 1-year study period. In addition, the minimally clinically important difference was achieved at 1 year for SANE in 84% of patients, VR-12 MCS (Veterans RAND 12-item mental components) in 40% of patients, VR-12 PCS in 78.5% of patients, ASES in 90.5% of patients, and WORC in 87% of patients.
Our references can be seen here, and we thank you for watching our video.
Footnotes
Submitted December 29, 2021; accepted March 18, 2022.
One or more of the authors has declared the following potential conflict of interest or source of funding: B.F. is an American Orthopaedic Society for Sports Medicine (AOSSM) board or committee member; received research support from Arthrex, Smith & Nephew, and Stryker; received royalties, financial, or material support from Elsevier; is on the editorial or governing board of the Video Journal of Sports Medicine; received stock or stock options from iBrainTech, Jace Medical, and Sparta Biopharma; and is a paid consultant for Smith & Nephew and Stryker. D.M.K. received research support from Arthrex; is a paid presenter or speaker for DJ Orthopaedics; and received other financial or material support from Encore Medical and Smith & Nephew. E.J.B. received stock or stock options from Amgen Co. and Johnson & Johnson. J.C. is a board or committee member of AOSSM, the Arthroscopy Association of North America, and International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine, and is a paid consultant for CONMED Linvatec, Ossur, and Smith & Nephew. M.T.F. is a board or committee member for American Academy of Orthopaedic Surgeons (AAOS), AOSSM, American Shoulder and Elbow Surgeons, Arthroscopy Association of North America, and International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine; received research support from Major League Baseball, National Institutes of Health National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) & National Institute of Child Health and Human Development (NICHD), and Regeneration Technologies; is a paid consultant, presenter, or speaker; received research support from Smith & Nephew; and is a paid consultant for Tornier and an unpaid consultant for Sparta. J.R. received stock or stock options from Restor3d and is a paid consultant for Smith & Nephew and Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
