Abstract
Background:
Nearly half a million rotator cuff repairs are performed annually in the United States. Rotator cuff healing occurs at the interface between the tendon and greater tuberosity, known as the enthesis. Given that a significant number of rotator cuff tears do not heal following surgical repair, multiple adjunctive strategies have been devised to improve the structural integrity of the repaired construct. Recently, a biphasic, demineralized allograft bone implant has been developed to improve enthesis healing.
Indications:
Relative indications for use of tissue augmentation include greater tuberosity osteopenia, revision rotator cuff surgery, attenuated rotator cuff tissue quality, and massive rotator cuff tears. Relative contraindications include a history of infection and recent immunosuppression.
Technique Description:
Following preparation of the footprint with an arthroscopic burr, two triple-loaded PEEK suture anchors were placed along the medial aspect of the greater tuberosity. Sutures were then passed through the rotator cuff tendon in a horizontal mattress configuration, and each pair of suture limbs were tied along the medial row. To aid in arthroscopic passage, the biphasic graft is folded longitudinally and clamped with a curved hemostat. The graft is loaded into an arthroscopic cannula and both are delivered simultaneously through a lateral arthroscopic portal. Two 18-gauge spinal needles are placed percutaneously to fix the allograft in the desired position. Subsequently, double-row transosseous-equivalent rotator cuff repair with standard techniques is done, which provides sufficient stability to the graft.
Discussion:
In a series of 192 patients who underwent arthroscopic rotator cuff repair augmented with a similar bioinductive collagen implant, patients demonstrated significant improvement in patient-reported outcomes at 1 year postoperatively. Moreover, a meta analysis published in 2022 demonstrated a significantly reduced retear rate among patch-augmented rotator cuff repairs as compared to isolated rotator cuff repairs.
Conclusion:
Tissue augmentation can be performed efficiently and reproducibly to promote biologic healing of arthroscopic rotator cuff repairs. The specific biphasic cancellous allograft presented in this video may be a viable treatment adjunct in the setting of deficient greater tuberosity bone stock, revision cases, or impaired native enthesis healing; however, further research is needed to assess clinical outcomes associated with its use.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
The following is a video presentation describing an arthroscopic rotator cuff repair augmented with a novel, biphasic interpositional cancellous allograft.
We have no relevant disclosures.
In this video, we will provide a brief overview of an augmentation technique for rotator cuff repair, discuss a case presentation along with surgical pearls, describe our postoperative management, and review patient-reported outcomes.
Nearly half a million rotator cuff repairs are performed annually in the United States. 1 Rotator cuff healing occurs at the interface between the tendon and greater tuberosity, known as the enthesis.2,5 Given that a significant number of rotator cuff tears do not heal following surgical repair, multiple adjunctive strategies have been devised to improve the structural integrity of the repaired construct. Recently, a biphasic, demineralized allograft bone implant has been developed to improve healing at the enthesis. The allograft is comprised of a highly porous bony matrix with a layer of mineralized cancellous bone that promotes osteointegration with the underlying bone at the repair site.3,8,9
In this case presentation, a 77-year-old right hand-dominant man presented with persistent right shoulder pain 3 months following a mechanical, ground-level fall. The patient endorsed mild pain and partially relieved with over-the-counter pain medications; however, he rated his shoulder function as 20% of normal.
Physical examination of the right shoulder was notable for 165° of active scaption, 30° of external rotation with the arm at his side, and internal rotation to L1. The patient had weakness of both his supraspinatus and infraspinatus with positive impingement signs. He had tenderness to palpation of the bicipital groove and acromioclavicular joint.
Standard shoulder radiographs were relatively unremarkable and demonstrate maintenance of the glenohumeral joint space and centered humeral head.
Magnetic resonance imaging (MRI) of the right shoulder was obtained to evaluate the integrity of the rotator cuff. Coronal MRI demonstrated a full-thickness supraspinatus tear with preserved muscle bulk and minimal fatty infiltration.
Given the patient’s symptoms and clinical findings, the patient was indicated for arthroscopic rotator cuff repair with subacromial decompression, distal clavicle excision, and biceps tenodesis. Given his history of osteopenia, the patient was indicated for potential greater tuberosity enthesis augmentation.
Across clinical practices, the indications for tissue augmentation of rotator cuff repairs continue to be defined. In our practice, relative indications for use of tissue augmentation include greater tuberosity osteopenia; revision rotator cuff surgery, attenuated rotator cuff tissue quality, and massive rotator cuff tears. Relative contraindications include a history of infection and recent immunosuppression.
In the operating room, the patient was placed in the beachchair position. 6 Following standard diagnostic arthroscopy within the glenohumeral joint, the arthroscope was introduced into the subacromial space. Following a thorough subacromial bursectomy, a full-thickness supraspinatus tear was identified and measured to be approximately 3 cm by 3 cm with a crescent morphology. After preparation of the footprint with a 4.0 mm arthroscopic burr, two 5.5 mm triple-loaded PEEK suture anchors were placed along the medial aspect of the greater tuberosity. Sutures were then passed through the rotator cuff tendon in a horizontal mattress configuration and each pair of suture limbs were tied along the medial row.
At the time of surgery, the patient’s osteopenic bone at the greater tuberosity was confirmed and use of a biphasic allograft implant was indicated.
The biphasic interpositional allograft was placed onto the surgical field. To aid in arthroscopic passage, the graft is folded longitudinally and clamped with a curved hemostat. The graft is loaded into an arthroscopic cannula and both are delivered simultaneously through a lateral arthroscopic portal. It is important to preload the graft. Note two clamps are used to pass the canula and graft, respectively. Doing so facilitates introduction of the graft into the subacromial space.
Two 18-gauge spinal needles are placed percutaneously to fix the allograft in the desired position at the greater tuberosity footprint. Note, the superficial side of the graft marked for identification. To complete the rotator cuff repair, suture limbs from the two medial row suture anchors were then passed into two lateral row suture anchors positioned 8 mm lateral to the greater tuberosity, such that the rotator cuff tendon interfaced directly with the allograft implant.
Note that this double-row transosseous-equivalent rotator cuff repair employs standard techniques that provide sufficient stability to the graft and repair construct.
Postoperatively, patients are immobilized in a sling for 6 weeks with physical therapy beginning 1 week postoperatively. Passive range of motion is initiated 10 to 14 days postoperatively, followed by active-assisted range of motion exercises at 3 to 4 weeks postoperatively. Active range of motion commences at 6 weeks. Strengthening exercises are initiated at approximately 3 months postoperatively. Return to sports or full recreational activities generally occurs at 6 months.
At 6 months postoperatively, our patient had complete resolution of pain, restoration of shoulder range of motion, and near full strength, as well as a self-reported Single Assessment Numeric Evaluation (SANE) score of 100%.
Four technical pearls will facilitate successful and efficient performance of the procedure. First, a thorough subacromial bursectomy is necessary to ensure adequate visualization. Second, while not shown, the biphasic graft should be hydrated with sterile saline prior to increase graft flexibility. Third, preload the graft into a flexible cannula prior to placing the cannula into the lateral portal. Finally, fixation of the graft to the greater tuberosity footprint with multiple 18-gauge spinal needles secures the graft in the desired position.
Owing to its recent development and clinical application, outcomes data following rotator cuff repair with a biphasic interpositional allograft augmentation is extremely limited. In a series of 192 patients who underwent arthroscopic rotator cuff repair augmented with a similar bionductive bovine collagen implant, patients demonstrated significant improvement in multiple patient-reported outcomes at 1 year postoperatively.3,7 A meta-analysis published in 2022 comprised of seven controlled trials demonstrated a significantly reduced re-tear rate among patch-augmented rotator cuff repairs as compared to isolated rotator cuff repairs. The relative efficacy of various patch options, including allografts, xenografts, synthetic polymers, and autografts, remains unproven. 4 Clinical outcomes assessment of the biphasic interpositional allograft is ongoing.
In conclusion, tissue augmentation can be performed efficiently and reproducibly to promote biologic healing of arthroscopic rotator cuff repairs. The specific biphasic cancellous allograft presented in this video may be a viable treatment adjunct in the setting of deficient greater tuberosity bone stock, revision cases, or impaired native enthesis healing; however, further research is needed to assess clinical outcomes associated with its use.
Here are our references.
Thank you for your attention.
Footnotes
Submitted December 9, 2022; accepted February 6, 2023.
The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. 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.
