Outcomes After Open Revision Repair of Massive Rotator Cuff Tears With Biologic Patch Augmentation

Biologics in rotator cuff repair

Rotator cuff tears are common in middle-aged and elderly patients. Despite advances in the surgical repair of rotator cuff tears, the rates of recurrent tear remain high. This may be due to the complexity of the tendons of the rotator cuff, which contributes to an inherently hostile healing environment. During the past 20 years, there has been an increased interest in the use of biologics to complement the healing environment in the shoulder, in order to improve rotator cuff healing and reduce the rate of recurrent tears. The aim of this review is to provide a summary of the current evidence for the use of forms of biological augmentation when repairing rotator cuff tears.

Editorial Commentary: Bridging Graft Techniques Improve Short-Term Outcomes for Irreparable Rotator Cuff Tear Repair

There is a growing need for nonarthroplasty treatment options for irreparable rotator cuff tears. Options include superior capsular reconstruction (SCR), tendon transfers, subacromial balloon spacer, bridge grafting, biological tuberoplasty, and partial rotator cuff repair with or without augmentation. In our experience, repair with marginal convergence techniques is superior to SCR; if there is enough tissue, repair is the preferred strategy. In an effort to improve outcomes after repair, there has been increased interest in the use of interposition or bridging graft (BG) techniques, in which an allograft or autograft is secured on the humerus laterally and to the remnant tendon medially. Interposition or bridging grafts can be used to supplement partial repair in an effort to replace the patient's own missing tissues, and restore the biomechanical force couple of the rotator cuff and create a humeral head-depressing spacer effect in the subacromial space. These techniques show promising results compared to superior capsular reconstruction. Various graft options for BG are available, including human dermal allograft, fascia lata autograft, and tenotomized biceps autograft. Multiple animal studies have demonstrated that interposition grafts can improve the biomechanical properties of the repair construct, and histological studies in animal models have shown evidence of tissue in-growth into the BG, which could lead to increased repair strength over time. Finally, recent studies suggest that a bridging graft may improve short-term outcomes compared to partial repair alone. It remains to be seen whether this difference is clinically meaningful and durable.

Rotator Cuff Augmentation: Its Role and Best Practices

Rotator cuff tears are a common source of pain and impairment in the shoulder. Healing of the rotator cuff tendons following repair has been associated with improved patient outcomes. While there have been many technical improvements in surgical techniques for rotator cuff repair, failure rates are still surprisingly high. Augmentation of these repairs has been shown to help with fixation biomechanics as well as healing rates. The described types of augments include autograft, allograft, xenograft, and synthetic options. This report reviews the commonly available types of augments and some of the outcomes associated with their use.

Engineered Decellularized Tendon Matrix Putty Preserves Native Tendon Bioactivity to Promote Cell Proliferation and Enthesis Repair

Rotator cuff tears are a common soft tissue injury that can significantly decrease function of the shoulder and cause severe pain. Despite progress in surgical technique, rotator cuff repairs (RCRs) do not always heal efficiently. Many failures occur at the bone-tendon interface as a result of poor healing capacity of the tendon and failure to regenerate the native histological anatomy of the enthesis. While allografts are commercially available, clinical use is limited as they do not stimulate tissue regeneration and are associated with a structural failure of up to 40% in re-tear cases. Novel tissue engineering strategies are being developed with promise, but most involve addition of cells and/or growth factors which extends the timeline for clinical translation. Thus, there exists a significant unmet clinical need for easily translatable surgical augmentation approaches that can improve healing in RCR. Here we describe the development of a decellularized tendon matrix (DTM) putty that preserves native tendon bioactivity using a novel processing technique. In vitro, DTM promoted proliferation of tenocytes and adipose-derived stem cells with an increase in expression-specific transcription factors seen during enthesis development, Scleraxis and Sox9. When placed in a rabbit model of a chronic rotator cuff tear, DTM improved histological tissue repair by promoting calcification at the bone-tendon interface more similar to the normal fibrocartilaginous enthesis. Taken together, these data indicate that the engineered DTM putty retains a pro-regenerative bioactivity that presents a promising translational strategy for improving healing at the enthesis.

Poor evidence is used to support commercial payers' coverage policies for shoulder arthroplasty

BACKGROUND

The incidence of shoulder arthroplasty has continued to increase over the past decade. In response, commercial payers have implemented strategies to control the medical requirement of these surgeries in attempt to contain the growing costs. For example, most payers require a prolonged trial of conservative management prior to shoulder arthroplasty for patients who may otherwise be surgical candidates. However, little is known regarding the evidence used to support these indications. The purpose of this study was to analyze the references used by commercial payers to substantiate their coverage policies for shoulder arthroplasty.

METHODS

Ten of the leading commercial payers for total shoulder arthroplasty were identified. Publicly available coverage policies were searched on the internet or requested directly from the payer via email or telephone. Cited references were reviewed independently by two authors for type of document, level of evidence, and mention of the efficacy of conservative management.

RESULTS

A total of 5 coverage policies were obtained with 118 references. The most common reference type was primary journal article (n = 70; 59.3%) followed by review or expert opinion articles (n = 35; 29.7%). Most references were of level IV evidence (n = 60; 52.2%), with only 6 (5.2%) of level I or II evidence. Only 4 (3.5%) references mentioned the efficacy of conservative management in patients who may be candidates for shoulder arthroplasty.

CONCLUSION

The majority of references used to substantiate the coverage policies for shoulder arthroplasty among major commercial payers within the United States are of low scientific evidence and fail to demonstrate the success of required nonoperative intervention strategies. Our study underscores the need for high-quality, comparative trials that evaluate the outcomes of conservative management vs. shoulder arthroplasty in end-stage glenohumeral osteoarthritis patients in order to determine the most cost-effective treatment algorithm.

Superior Capsule Reconstruction Using Acellular Dermal Allograft Secured at 45° of Glenohumeral Abduction Improves the Superior Stability of the Glenohumeral Joint in Irreparable Massive Posterosuperior Rotator Cuff Tears

PURPOSE

The purpose of the current study was to create a dynamic cadaveric shoulder model to determine the effect of graft fixation angle on shoulder biomechanics following SCR and to assess which commonly used fixation angle (30° vs 45° of abduction) results in superior glenohumeral biomechanics.

METHODS

Twelve fresh-frozen cadaveric shoulders were evaluated using a dynamic shoulder testing system. Humeral head translation, subacromial and glenohumeral contact pressures were compared among 4 conditions: 1) Intact, 2) Irreparable supra- and infraspinatus tendon tear, 3) SCR using acellular dermal allograft (ADA) fixation at 30° of abduction, and 4) SCR with ADA fixation at 45° of abduction.

RESULTS

SCR at both 30° (0.287 mm, CI: -0.480 - 1.05 mm; P < .0001) and 45° (0.528 mm, CI: -0.239-1.305 mm; P = .0006) significantly decreased superior translation compared to the irreparably torn state. No significant changes in subacromial peak contact pressure were observed between any states. The average glenohumeral contact pressure increased significantly following creation of an irreparable RCT (373 kPa, CI: 304-443 vs 283 kPa, CI 214-352; P = .0147). The SCR performed at 45° (295 kPa, CI: 226-365, P = .0394) of abduction significantly decreased the average glenohumeral contact pressure compared to the RCT state. There was no statistically significant difference between the average glenohumeral contact pressure of the intact state and SCR at 30° and 45°.

CONCLUSION

SCR improved the superior stability of the glenohumeral joint when the graft was secured at 30° or 45° of glenohumeral abduction. Fixation at 45° of glenohumeral abduction provided more stability than did fixation at 30°.

CLINICAL RELEVANCE

Grafts attached at 45° of glenohumeral abduction biomechanically restore the glenohumeral stability after SCR using ADA better than fixation at 30° of glenohumeral abduction.

Human Dermal Allograft Patch Augmentation of Degenerate Rotator Cuff Tendon Using a Single Lateral-Row Technique

The role of biological augmentation in arthroscopic rotator cuff repair surgery has increased over the years. It has shown favorable healing rates and functional outcomes. Patch augmentation is commonly applied in repairs of massively retracted cuff tears, full-thickness tears, revision repair, or open cuff surgery. There is a paucity of literature on the use of patch augmentation when dealing with a chronic degenerate tendon associated with small-sized cuff tears. In recent years, the resorbable bioinductive bovine collagen implant has gained popularity for its application in partial-thickness tears via an isolated bioinductive repair fashion, without traditional rotator cuff repair. These bioinductive implants, albeit promising in their biological properties for tendon repair, lack structural strength and do not confer similar biomechanical advantages as human dermal allograft. We share our surgical technique for an arthroscopic patch augmentation involving human dermal allograft, using a single-lateral row surgical fixation, to address a degenerate cuff tendon with small-sized rotator cuff tear. We believe that our use of a human dermal patch augmentation conferred increased biomechanical advantage and reduced costs while delivering favorable outcomes for patients in our value-driven care.

The Number of Surgeons Using Superior Capsular Reconstruction for Rotator Cuff Repair Is Declining

Purpose

To investigate surgeon preferences for graft use, including biologic augmentation and superior capsular reconstruction (SCR) associated with surgical treatment of rotator cuff repair (RCR).

Methods

A 26-question survey was completed by arthroscopic shoulder surgeons. Surgeon demographics were evaluated. Surgeons were queried about shoulder arthroscopic graft use and rationale then responses were analyzed based on demographics.

Results

In total, 260 surgeons completed the survey. Fifty-one percent of surgeons reported a decrease in the volume of SCR use in the past 5 years. Less than 3% of surgeons used SCR in >90% of irreparable RCR cases, compared with 38% using SCR in <10% of irreparable cases (P < .05). Surgeons performing >100 RCR annually (42%; P < .05) and those employed in the hospital setting (44%; P < .05) reported an overall increase in the use of SCR. More international surgeons (67%) decreased their use of SCR compared with U.S. surgeons (44%; P < .05). In contrast, bioinductive graft use is generally on the rise, with 48% of surgeons reporting increased use since first use, although used in <10% of cases by 54% of surgeons. Sixty-eight percent of surgeons performing >100 RCRs annually used bioinductive grafts (P < .05). Fewer international surgeons (30%) performed biologic augmentation (P < .05). Suboptimal published outcomes (40%) and no perceived patient benefit (40%) were most cited for decreased SCR use. Surgeons reporting increased use cited improved personal patient outcomes (72%).

Conclusions

Arthroscopic surgeons report decrease in volume of SCR use in the past 5 years. Surgeon's personal experience of patient outcome and suboptimal published results were the strongest factors impacting decision-making. In contrast, bioinductive graft use is increasing. However, most surgeons use these grafts in a relatively small percentage of cases.

Clinical Relevance

Evaluation of scientific data, personal experience, and influences on surgical practice will give a comprehensive understanding of current RCR practices.

Loading Mesenchymal Stem Cell-Derived Exosomes Into a Traditionally Designed Rotator Cuff Patch: A Potential Strategy to Enhance the Repair of Chronic Rotator Cuff Tear Associated With Degenerative Changes

BACKGROUND

Retraction and degenerative changes of chronic rotator cuff tears limit the healing capacity after routine surgical repair.

PURPOSE

To fabricate a mesenchymal stem cell-derived exosome (MSC-Exos) loaded patch and evaluate the effect of this patch on the activity of rabbit tenocytes in vitro and on the repair of chronic rotator cuff tears associated with degenerative changes in vivo.

STUDY DESIGN

Controlled laboratory study.

METHODS

The MSC-Exos loaded patch was fabricated using a dynamic wet-spinning system. In the in vitro studies, the proliferation and migration activities of tenocytes were evaluated by culturing tenocytes with saline, a fiber-aligned patch, or an MSC-Exos loaded patch. In the in vivo studies, a rabbit model of chronic rotator cuff tear was established and directly repaired, repaired with fiber-aligned patch augmentation (RFPA group), and repaired with MSC-Exos loaded patch augmentation (REPA group). Histological and biomechanical analyses were performed at 4, 8, and 12 weeks after surgery.

RESULTS

An MSC-Exos loaded patch with inner aligned fibers, a loose microstructure, and reliable initial strength was fabricated using a dynamic wet-spinning system. The MSC-Exos loaded patch significantly promoted tenocyte proliferation and migration activities in vitro. In vivo, the REPA group exhibited significantly higher tendon maturing scores at 8 and 12 weeks after surgery compared with both the control and the RFPA groups. Fatty infiltration was significantly reduced in the REPA group at 4, 8, and 12 weeks compared with both the control and the RFPA groups. Biomechanical properties, including load to failure and stress, were also significantly improved at 12 weeks in the REPA group compared with both the control and the RFPA groups.

CONCLUSION

Results in the present study suggested that an MSC-Exos loaded patch was able to enhance the repair of a chronic rotator cuff tear by providing mechanical support and minimizing degeneration.

CLINICAL RELEVANCE

This work supported the idea that loading bioactive MSC-Exos into a traditionally designed rotator cuff patch might exert a better effect on the repair of chronic rotator cuff tears than augmented patch repair alone.

Clinical outcomes and structural integrity rate of arthroscopic augmented rotator cuff repairs using extracellular porcine matrix patch

Background

Structural failure rate in rotator cuff repairs is still high. The purpose of the study is to assess the structural integrity of a series of augmented rotator cuff repairs with porcine matrix patch and report the functional outcomes.

Methods

Between 2014 and 2017, 44 consecutive patients underwent arthroscopic double-row repair of medium to massive rotator cuff tears with extracellular porcine dermal matrix augmentation. At one-year follow-up, magnetic resonance imaging scan was performed to assess the integrity of the repair. Oxford Shoulder Score (OSS), Constant Score (CS) and Visual Analogue Scale pain score, together with range of motion were used to assess patients.

Results

Patients mean age was 68 (53-82); mean follow-up was 17.2 (12-24) months. On magnetic resonance imaging scans, seven rotator cuff repair failures (15.9%) were observed: tear size was an independent predictor of re-rupture at one-year follow-up. Clinical scores showed a statistically significant improvement at three months and until final follow-up (p< 0.001). No complications occurred.

Conclusion

Observed structural failure rate of 15.9% is lower than those reported in the literature for standard rotator cuff repair of medium to massive tears in similar cohorts to ours. Extracellular matrix augmentation for rotator cuff repair was shown to be a safe and reliable support to the repairs and patients recovered good shoulder function.Level of Evidence: Level IV.

Clinical and Anatomical Outcomes of Arthroscopic Repair of Large Rotator Cuff Tears with Allograft Patch Augmentation: A Prospective, Single-Blinded, Randomized Controlled Trial with a Long-term Follow-up

Background

Arthroscopic rotator cuff repair using human dermal matrix allograft augmentation has been widely used. We assessed the effect of acellular human dermal matrix augmentation after arthroscopic repair of large rotator cuff tears through a prospective, single-blinded, randomized controlled trial with a long-term follow-up.

Methods

Sixty patients with large-sized rotator cuff tears were randomly assigned to two groups. Patients in the control group underwent arthroscopic rotator cuff repair. Allograft patch augmentation was additionally performed in the allograft group. All patients were subdivided into a complete coverage (CC) group or an incomplete coverage (IC) group according to footprint coverage after cuff repair. Constant and American Shoulder and Elbow Surgeons (ASES) scores were assessed preoperatively and at final follow-up. Magnetic resonance imaging was also performed at the same time to evaluate the anatomical results.

Results

Forty-three patients were followed up for an average of 5.7 years. Clinical scores (Constant and ASES) increased significantly at the last follow-up in both groups. The increase in ASES score in the allograft group was statistically significantly greater than that in the control group. The degree of Constant score improvement did not differ significantly between the two groups. The retear rate was 9.1% in the allograft group, which was significantly lower than that in the control group (38.1%). In the control group, the CC subgroup had a statistically significantly lower retear rate (16.7%) than did the IC subgroup. There were no retear cases in the CC subgroup of the allograft group.

Conclusions

Long-term follow-up of arthroscopic repair of large rotator cuff tears with allograft patch augmentation showed better clinical and anatomical results. Footprint coverage after rotator cuff repair was an important factor affecting the retear rate. If the footprint was not completely covered after rotator cuff repair, allograft patch augmentation may reduce the retear rate.

The Evolution of Arthroscopic Rotator Cuff Repair

Over the past 30 years, arthroscopic rotator cuff repair (ARCR) has evolved to become the gold standard in treating rotator cuff pathology. As procedural concepts of ARCR continue to improve, it is also continually compared with the open rotator cuff repair as the historical standard of care. This review highlights the evolution of ARCR, including a historical perspective; the anatomic, clinical, and surgical implications of the development of an arthroscopic approach; how arthroscopy improved some of the problems of the open approach; adaptations in techniques and technologies associated with ARCR; future perspectives in orthobiologics as they pertain to ARCR; and lastly, the clinical improvements, or lack of improvements, with all of these adaptations.

[Research progress of indication and treatment of graft in shoulder superior capsular reconstruction for rotator cuff tear]

Objective

To review the research progress of indication and treatment of graft in shoulder superior capsular reconstruction (SCR) for rotator cuff tear (RCT).

Methods

The literature related to shoulder SCR in recent years was extensively reviewed, and the anatomy, biomechanics, surgical indications, and treatment of graft in SCR were summarized.

Results

Superior capsule plays a role as a functional complex with rotator cuff, ligament, and whole capsule. SCR can effectively restore the superior stability of the shoulder. The indications of SCR include the irreparable massive RCT, massive RCT combined with pseudoparalysis shoulder, medium/large RCT with severe degenerative rotator cuff tissue, and dual-layer RCT. In order to achieve a better healing of tendon-bone in graft and decrease the rate of long-term graft retearing, it is essential to select an appropriate thickness graft, fix the graft in right intensity, and get a better capsular continuity.

Conclusion

The technique of SCR advanced to SCR for reinforcement and it is indicated from substantial massive RCT to severe degeneration of rotator cuff tissue. Graft treatment is the key step for a successful SCR.

Patch augmentation surgery for rotator cuff repair: the PARCS mixed-methods feasibility study

BACKGROUND

A rotator cuff tear is a common, disabling shoulder problem. Symptoms may include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a need to improve the outcome of rotator cuff surgery, and the use of patch augmentation (on-lay or bridging) to provide support to the healing process and improve patient outcomes holds promise. Patches have been made using different materials (e.g. human/animal skin or tissue and synthetic materials) and processes (e.g. woven or mesh).

OBJECTIVES

The aim of the Patch Augmented Rotator Cuff Surgery (PARCS) feasibility study was to determine the design of a definitive randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible.

DESIGN

A mixed-methods feasibility study of a randomised controlled trial.

DATA SOURCES

MEDLINE, EMBASE and the Cochrane Library databases were searched between April 2006 and August 2018.

METHODS

The project involved six stages: a systematic review of clinical evidence, a survey of the British Elbow and Shoulder Society's surgical membership, a survey of surgeon triallists, focus groups and interviews with stakeholders, a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. The various stakeholders (including patients, surgeons and industry representatives) were involved in stages 2-6.

RESULTS

The systematic review comprised 52 studies; only 15 were comparative and, of these, 11 were observational (search conducted in August 2018). These studies were typically small (median number of participants 26, range 5-152 participants). There was some evidence to support the use of patches, although most comparative studies were at a serious risk of bias. Little to no published clinical evidence was available for a number of patches in clinical use. The membership survey of British Elbow and Shoulder surgeons [105 (21%) responses received] identified a variety of patches in use. Twenty-four surgeons (77%) completed the triallist survey relating to trial design. Four focus groups were conducted, involving 24 stakeholders. Differing views were held on a number of aspects of trial design, including the appropriate patient population (e.g. patient age) to participate. Agreement on the key research questions and the outline of two potential randomised controlled trials were achieved through the Delphi study [29 (67%)] and the consensus meeting that 22 participants attended.

LIMITATIONS

The main limitation was that the findings were influenced by the participants, who are not necessarily representative of the views of the relevant stakeholder groups.

CONCLUSION

The need for further clinical studies was clear, particularly given the range and number of different patches available.

FUTURE WORK

Randomised comparisons of on-lay patch use for completed rotator cuff repairs and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. These elements are included in the trial designs proposed in this study.

STUDY REGISTRATION

The systematic review is registered as PROSPERO CRD42017057908.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 13. See the NIHR Journals Library website for further project information.

Use of implantable meshes for augmented rotator cuff repair: a systematic review and meta-analysis

OBJECTIVE

To appraise studies reporting on clinical effectiveness and safety of surgical meshes used to augment rotator cuff repairs (RCRs).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase and Cochrane databases were searched between April 2006 and April 2020.

ELIGIBILITY CRITERIA

All studies evaluating adults (≥18 years) undergoing RCR were considered. There were no language restrictions.

DATA EXTRACTION AND SYNTHESIS

Screening, data extraction and quality appraisal were conducted by two independent reviewers. Meta-analysis was conducted using a random-effects models if ≥2 comparative studies reported the same outcome measure. Risk of bias assessment was undertaken for randomised (RoB2, Cochrane) and comparative studies (ROBINS-I, Cochrane).

RESULTS

We included 60 studies, consisting of 7 randomised controlled trials, 13 observational comparative studies and 40 observational case series. All comparative studies reported on shoulder-specific functional outcome scores, 18 on the radiographic occurrence of re-tear and 14 on pain score metrics. All studies contained some risk of bias.Compared with non-augmented repair, a small improvement in shoulder-specific function or pain scores was observed for synthetic patches with a mean improvement of 6.7 points on the University of California Los Angles (UCLA) shoulder score (95% CI 0.1 to 13.4) and 0.46 point reduction on the Visual Analogue Scale (95% CI -0.74 to -0.17), respectively. A reduced likelihood of radiologically observed re-tear was observed for synthetic (risk ratio (RR) 0.41, 95% CI 0.27 to 0.61) and allograft (RR 0.34, 95% CI 0.18 to 0.65) patches. A total of 49 studies reported on the occurrence of complications. Slightly higher crude complication rates were observed following patch-augmented repair (2.1%) than standard repair (1.6%).

CONCLUSIONS

While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented RCR, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations.

PROSPERO REGISTRATION NUMBER

CRD42017057908.

A case series of recurrent myotendinous rotator cuff tears repaired and augmented with dermal allograft: clinical outcomes at two years

When rotator cuff tears occur after a primary repair at the footprint, they often fail medially at the myotendinous junction, also called type II tears. These are difficult tears to treat, and little research has been published on how to address tears at the myotendinous junction and the clinical outcomes of the revised repairs. The purpose of this study is to evaluate the outcomes of type II rotator cuff tears repaired with a dermal allograft augmentation.

MATERIALS AND METHODS

We conducted a retrospective chart review of 9 patients with a type II rotator cuff tear medially at the myotendinous junction, arthroscopically repaired and augmented with acellular dermal allograft by a single surgeon. Two-year follow-up was obtained to evaluate pain, function, range of motion, and structural integrity of the repair via ultrasound.

RESULTS

Of all 9 patients, the mean visual analog scale preoperatively was 5.1 (standard error, ±2.1). With 9 patients having 2-year follow-up, the mean visual analog scale score continued to improve to 1.9 (standard error, ±2.4). At 2 years, the mean American Shoulder and Elbow Surgeons based on 8 patients was 76.1, and the mean Short Form 36 for all 9 patients was 78.7. All 9 patients with 2-year follow-up had an intact repair on ultrasound read by a musculoskeletal fellowship-trained radiologist.

DISCUSSION

Based on the early outcome data, patient satisfaction scores, and intact repairs visualized on ultrasound at 2 years postoperatively, the use of acellular human dermal matrix augmentation appears to be an efficacious and worthwhile treatment option for patients with recurrent rotator cuff tears at the medial myotendinous junction.

Biologics to Improve Healing in Large and Massive Rotator Cuff Tears: A Critical Review

Large and massive rotator cuff tears have the highest risk of retear. Common biologic modalities that can potentially reduce the retear rate and improve healing include platelet-rich plasma (PRP), scaffolds, and mesenchymal stem cells (MSCs). PRP has been studied for its role in improving rotator cuff healing and results of randomized controlled trials and meta-analyses show mixed results. Most studies in large and massivge tears show that PRP decreases the retear rate, but the connection between structural integrity and clinical outcomes is still unknown. Extracellular matrix (ECM) and synthetic scaffolds can increase healing in augmentation and bridging repair. Acellular dermal allografts have shown better healing rates and outcomes than xenografts in meta-analyses. Synthetic scaffolds augmented with bone marrow-derived stem cells have only been studied in vitro but are promising for the combination of mechanical stability and induction of a biological response. Superior capsule reconstruction is an exciting type of interposition graft reconstruction that has shown favorable early clinical outcomes for large and massive tears. Bone marrow-derived stem cells and adipose-derived stem cells improve the biomechanical characteristics of tendon repair and enhance the histological findings of the healing process in animal studies. However, evidence from human studies is lacking, especially in patients with large and massive tears. In summary, there are many biological options to augment rotator cuff repair in patients with large and massive tears. Due to mixed results and a lack of standardization in high-quality studies, we cannot recommend PRP at this time as an adjunct to rotator cuff repair. Both ECM and synthetic scaffolds, as well as SCR, can be used, especially in situations where native tendon is compromised, and additional mechanical augmentation is needed. Stem cells have been the least studied to date, so it is difficult to give recommendations for or against their use at this time.

Arthroscopic Knotless Rotator Cuff Repair With Decellularized Dermal Allograft Augmentation: The "Canopy" Technique

Repairability and clinical outcomes of full-thickness rotator cuff tears rely on tendon mobility, tissue quality, and subsequent tension on a repair. While repair of rotator cuff tears tend to yield excellent clinical results, poor tissue quality has been an important factor that has hampered successful outcomes. This Technical Note describes a double-row rotator cuff repair using a SpeedBridge configuration with dermal allograft "canopy" augmentation to bolster the repairable but thinned rotator cuff tissue. This technique employs a unique graft fixation strategy to simplify the procedure. This approach could provide surgeons with a great option when faced with mobile but thinned rotator cuff tissue.

Editorial Commentary: Biologically-Enhanced Patch Augmentation: The Perfect Marriage of Mechanical Stability and Biology for Rotator Cuff Healing? Unfortunately, Not Yet

Recurrent rotator cuff tears are a frequent cause of shoulder disability. To repair a rotator cuff, the surgeon faces both mechanical and biological challenges. Patch use as a scaffold for rotator cuff repair is well-described, as is biological augmentation, with clinical indications and efficacy being the subjects of ongoing study. However, a clinical report of dermal allograft patch augmentation combined with attempts at supercharging the biology is novel. This technique would benefit from controlled, prospective studies, with tight inclusion criteria.

Partial Rotator Cuff Repair With Superior Capsular Reconstruction Using the Biceps Tendon Is as Effective as Superior Capsular Reconstruction Using a Tensor Fasciae Latae Autograft in the Treatment of Irreparable Massive Rotator Cuff Tears

BACKGROUND

Several treatment options are available for stable massive rotator cuff tears, including partial repair with or without tissue augmentation, tendon transfer, superior capsular reconstruction (SCR), and reverse shoulder arthroplasty.

PURPOSE/HYPOTHESIS

The purpose of this study was to compare the outcomes and effectiveness of partial rotator cuff repair with SCR using the long head of the biceps tendon (PRCR-SCRB) and SCR with a tensor fasciae latae autograft (SCRTF) for the treatment of rotator cuff tears with severe fatty degeneration. The hypothesis of this study was that SCRTF would be superior to PRCR-SCRB in functional and anatomic outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 26 consecutive patients with massive and fatty degenerative rotator cuff tears were treated surgically. Patients were divided into either the PRCR-SCRB group (n = 14) or SCRTF group (n = 12). Functional outcomes were assessed at final follow-up, and the acromiohumeral distance (AHD) was measured.

RESULTS

All functional scores significantly improved in both groups at final follow-up. The PRCR-SCRB group showed better overall outcomes in terms of the visual analog scale for pain; American Shoulder and Elbow Surgeons score; and Quick Disabilities of the Arm, Shoulder and Hand, but these differences were not statistically significant. Better outcomes were found for only the AHD for the PRCR-SCRB group without statistical significance (P = .4). No statistical difference was found in terms of retear rate.

CONCLUSION

PRCR-SCRB had comparable outcomes and improvement in AHD compared with SCRTF without the need for additional graft harvesting.

Revision rotator cuff repair: a systematic review

BACKGROUND

The incidence of revision rotator cuff repair (RCR) has increased along with the incidence of primary RCR over the past 2 decades. The purpose of this study was to perform a systematic review to analyze the clinical outcomes of revision RCR and chiefly to identify prognostic factors that may influence postoperative outcomes.

METHODS

The PubMed, MEDLINE (Ovid), Embase (Elsevier), and Cochrane Library (Wiley) databases were searched from database inception through November 2018 for studies assessing revision RCR. All studies were screened in duplicate for eligibility. Pooled analysis correlations between mean preoperative range-of-motion measures, American Shoulder and Elbow Surgeons (ASES) scores, and visual analog scale (VAS) pain scores and mean postoperative outcomes with revision RCR were examined via linear regression and reported with the strength of the Spearman correlation coefficient (r_s).

RESULTS

A total of 22 studies met the inclusion criteria, including 3 level III and 19 level IV studies. Mean preoperative forward flexion had the greatest correlation with the mean postoperative ASES score (r_s = 0.98). A strong positive correlation was also found between mean preoperative forward flexion and mean postoperative forward flexion (r_s = 0.83). The mean preoperative VAS pain score was strongly correlated with the mean postoperative VAS pain score (r_s = 0.88) and demonstrated a moderate negative association with the mean postoperative ASES score (r_s = -0.48). Finally, the mean preoperative ASES score was moderately correlated with the mean postoperative ASES score (r_s = 0.56).

CONCLUSIONS

The results of this systematic review demonstrate favorable clinical outcomes following RCR revision performed both in an open manner and arthroscopically. Preoperative forward flexion was identified as a possible prognostic factor for improved outcomes.

Repair of Rotator Cuff Tendon Defects in Aged Rats Using a Growth Factor Injectable Gel Scaffold

PURPOSE

To determine if the tendon-specific crosslinking gelatin (Col-Tgel) impregnated with growth factors promotes tendon healing at the bone interface and in a tendon window model.

METHODS

Two different Col-Tgel formulations were first tested in vitro by evaluating cell morphology and tendogenic differentiation. After the optimum formulation was determined, the gel was mixed with either transforming growth factor-β3 (TGF-β3) or growth differentiation factor-7 (GDF-7) growth factor and prepared for injections. Window defects were induced in 12 animals, which were randomized into the following treatments: (1) sham, (2) empty Col-Tgel, (3) Col-Tgel containing TGF-β3, or (4) Col-Tgel containing GDF-7. Based on these results, the sham, empty Col-Tgel, and Col-Tgel containing TGF-β3 were applied to the supraspinatus repair interface. Tendons were analyzed biomechanically and histologically using hematoxylin and eosin and Masson's trichrome staining.

RESULTS

In the window defect model, histologic scores were the best in rats treated with TGF-β3 containing Col-Tgel, followed by the empty Col-Tgel scaffold, and finally the sham control. The GDF-7 Col-Tgel was not further tested because occasional ectopic cartilage and bone formation was found in the prior window defect model. In the supraspinatus repair model, there was no statistical difference (P > .05) in the biomechanical strength among the 3 treatment groups, but load-to-failure ratio improved when TGF-β3 was added to the scaffold, suggesting improved tendon healing.

CONCLUSIONS

This pilot study evaluated the performance of an injectable gel tendon graft in a population of retired breeder rats. The results suggest that Col-Tgel containing TGF-β3 may be a useful adjunctive treatment for surgical repair of full-thickness rotator cuff tears. Histologic and biomechanical scores suggest that Col-Tgel containing TGF-β3 promotes tendon healing.

CLINICAL RELEVANCE

The results of this study suggest that shoulders injected with Col-Tgel may be a useful adjunctive treatment for repair of rotator cuff tears.

Biomechanical Effects of Fiber Patch Augmentation on Rotator Cuff Repairs

Rotator cuff repairs are a common orthopedic procedure that have a relatively high failure rate when tendon quality is poor. New biotechnology exists that can make tendons with poor quality more amenable to repair. This study examined the biomechanical effects of augmenting a rotator cuff repair with an absorbable fiber patch. Six human cadaveric supraspinatus tendons were prepared into 1-cm wide strips and then repaired to the rotator cuff footprint using a titanium anchor and a single mattress suture. Each shoulder underwent repair with and without a fiber patch. The specimens were subjected to cyclic loading (100 cycles) and load-to-failure (LTF) testing. Gap formation after 100 cycles was measured along with LTF in surviving specimens. Gap formation after 100 cycles was 1.07 mm in the suture-only group and 0.50 mm in the fiber patch-augmented group (P=.002). Load-to-failure was 54.26 N in the suture-only group and 109.53 N in the patch-augmented group (P<.001). The use of a fiber patch to augment rotator cuff repair reduced gap formation and increased LTF. [Orthopedics. 2020; 43(1):42-45.].

Posterior Glenohumeral Capsular Reconstruction With Modified McLaughlin for Chronic Locked Posterior Dislocation

Posterior instability is relatively rare when compared with anterior instability but can comprise up to 40% of operatively treated instability cases. Posterior dislocations are much rarer and are classically due to trauma, seizure, or electric shock. Due to a lack of an obvious deformity and an internally rotated and adducted arm position, posterior shoulder dislocations often are missed on initial presentation. In the management of posterior dislocations, considerations need to be made in regard to bony and soft-tissue pathology. In the setting of soft-tissue deficiency, previous options included nonoperative management primarily consisting of bracing and activity modification as well as arthroplasty options that do not rely on the capsulolabral complex for stability. In this paper, we present a technique for treating a chronic posterior shoulder dislocation with an associated large reverse Hill-Sachs deformity. In this setting, a revision labral repair and capsulodesis is generally not possible due to insufficient capsulolabral tissues. Here, we present the technique for an arthroscopic posterior capsule reconstruction using an acellular dermal allograft as well as a McLaughlin procedure for the treatment of a reverse Hill-Sachs lesion.

Prospective randomized controlled trial for patch augmentation in rotator cuff repair: 24-month outcomes

BACKGROUND

To evaluate the anatomic integrity of rotator cuff repair performed by medialized single row and augmented by a porcine dermal patch, in comparison with a nonaugmented group.

METHODS

We conducted a single-center, prospective, double-blinded, randomized controlled trial. The sample size was predefined, and patients were divided into a study group and a control group, assessed preoperatively and at 1, 3, 6, 12, and 24 months. The EuroQol-visual analog scale; Constant-Murley questionnaire; Disabilities of the Arm, Shoulder and Hand Score; and Simple Shoulder Test were administered. The humeral-acromial distance was calculated on radiographs. Tendon thickness, tear extension, and tendon signal intensity were all measured on magnetic resonance images (MRIs) along with an evaluation of footprint extension and a classification into one of 4 healing grades-healed, thinned, partially healed, not healed.

RESULTS

The study population consisted of 92 patients who were equally randomized into 2 homogenous groups. Sixty-nine patients completed the 24-month follow-up. The study group showed a healing rate of 97.6% compared with 59.5% for the standard repair group. The study group showed better results in terms of repaired tendon thickness and footprint coverage, with a P value < .05, although the tendon density was comparable. The study group showed better strength recovery and functionality with the outcome scores submitted. During the entire study, only 2 patients reported complications, calling for a biopsy during revision surgery.

CONCLUSIONS

Rotator cuff repairs augmented with a porcine dermal patch resulted in excellent clinical outcomes with a higher healing rate and close-to-normal MRI findings. The technique is safe and effective; in addition, it is reproducible and allows for better outcomes compared with those of standard medialized single-row repairs.

Arthroscopic Superior Capsular Reconstruction With Biceps Autograft: Snake Technique

Many options have been developed to treat irreparable massive cuff tears. Superior capsular reconstruction has been reported as one of the treatment options for relatively young patients with irreparable massive cuff tear. However, this original technique has a disadvantage of requiring a tensor facia lata autograft. It requires another incision at the lateral thigh and can be a cause of thigh pain. This article describes our modified technique for arthroscopic superior capsule reconstruction using the biceps autograft to preserve the long head of the biceps tendon anchors to the glenoid labrum (the snake technique).

Editorial Commentary: New Kid on the Block: Rotator Cuff Patch Augmentation Requires Rigorous Scrutiny

There is still plenty of room for improvement in surgical rotator cuff repair healing as well as in nonsurgical cases. Adding an implant or patch to improve results has been a subject of much discussion for a couple of decades. The main problem has been that the surgical procedures are so difficult, with added time and its effect, and therefore are controversial. Many surgeons are reluctant to go the surgical route. As we have advanced technically, we are at a turning point, with newer implants that can be easily augmented. Therefore, recently many surgeons have been using implants, and preliminary reports seem promising. New implants must withstand vigorous challenges, and future extensive and long-term studies can enable improved implants using human tissue.

Use of a Novel, Reinforced, Low Immunogenic, Porcine Small Intestine Submucosa Patch to Repair a Supraspinatus Tendon Defect in a Rabbit Model

Background

Repairs of large to massive rotator cuff tears have a high failure rate. We investigated the efficacy of a novel, reinforced, low immunogenic, porcine small intestine submucosa (SIS) patch to repair a supraspinatus tendon defect in a rabbit model. We hypothesized that the histological and biomechanical results of SIS patch repair would be comparable with those of autologous fascia lata (FL) repair.

Methods

The study mainly comprised two parts. First, the characteristics of the SIS patch were evaluated, including its micromorphology, mechanical properties, and immunogenic properties. Second, a supraspinatus tendon defect model was created in 36 rabbits (72 shoulders). The bilateral shoulders were randomly chosen to undergo repair using either a SIS patch (SIS group) or autologous FL (FL group). At 4, 8, and 12 weeks, histological analysis was performed using four shoulders from each group, and biomechanical tests were performed using eight shoulders from each group.

Results

The SIS patch was a three-dimensional construct mainly composed of collagen fibers. The mean single and double suture retention loads of the SIS patch were 48.6 ± 5.8 N and 117.9 ± 2.7 N, respectively. The DNA content in the SIS patch was 53.9 ± 10.9 ng/mg dry weight. Both the histological score and ultimate load to failure increased in a time-dependent manner in both groups, with no significant differences between the SIS and FL groups at 12 weeks.

Conclusion

Repair of a large supraspinatus tendon defect using a reinforced, low immunogenic, SIS patch achieves similar effects as autologous FL in a rabbit model. This novel patch might be useful to be employed as a structural tissue replacement in medical activities.

Rotator Cuff Matrix Augmentation and Interposition: A Systematic Review and Meta-analysis

BACKGROUND

Surgical management of rotator cuff tears is controversial and complex, ranging from nonoperative management to reverse shoulder arthroplasty.

PURPOSE

To systematically review and evaluate the outcomes of graft augmentation or interposition versus rotator cuff repair (RCR) alone and evaluate via meta-analysis whether the use of a graft leads to superior outcomes versus RCR alone.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

An electronic literature search (Medline, Embase, CINAHL) was conducted. Studies with a minimum follow-up of 1 year and minimum sample size of 10 that provided clinical results of RCR or rotator cuff reconstruction using any type of augmentation tissue or matrix were included. Methodological quality was evaluated by assessment of the risk of bias in the included studies. Studies comparing outcomes of RCR with graft augmentation or interposition versus repair alone (control group) were subjected to meta-analysis.

RESULTS

The authors identified 774 articles and included 36 in the systematic review; 5 of the 36 studies underwent meta-analysis. Except for one outcome measure in a single study, all surgical interventions (RCR alone, RCR with augmentation, and RCR with interposition) improved clinical scores and outcome measures. Because of variability in study outcomes, no graft option was found to be superior. Compared with RCR alone, graft augmentation or interposition provided significantly lower retear rates ( P = .05) and higher American Shoulder and Elbow Surgeons (ASES) scores ( P = .005), but improvements in UCLA (University of California, Los Angeles) scores ( P = .29) and pain scores ( P = .1) did not reach statistical significance.

CONCLUSION

In the meta-analysis, graft augmentation or interposition appeared to provide a lower retear rate and improved ASES scores when compared with RCR alone. Future prospective, randomized, controlled, and appropriately powered trials are needed for more definitive recommendations.

Allograft Tissue Safety and Technology

Allograft tissues are commonly used by orthopedic surgeons and are processed using a variety of technologies to increase safety and clinical use. For safety, although disease transmission is a tangible risk, this possibility has been dramatically minimized through modern tissue-processing methods. These include steps to prevent processing tissues with unacceptable bioburden through rigorous screening using donor medical and social histories along with microbial testing of recovered tissue and viral testing of donor serum. Potential bioburden is also controlled through aseptic recovery and processing methods and then reduced through disinfection steps that can include antibiotics, detergents, mechanical process, chemical solutions, and terminal sterilization. Processing steps may also include decellularization methods to lower immunogenic potential of some tissues. To enhance fusion potential of bone void fillers, demineralization steps may be used, and the resultant demineralized bone matrices may be combined with a carrier to improve handling. Bone void fillers and osteochondral allografts may also be specially processed to retain a living cellular component. To preserve relevant biological, biochemical, and physical properties of allografts for clinical use and ease of handling, a number of methods may be used which include: (1) refrigeration in media, (2) freeze-drying, (3) cryopreservation, (4) freezing, and (5) media storage at room temperature. As academic and industry research continue to drive advances, the future direction of allograft tissue likely includes injectables, coatings, cellular therapies, and combinations with other materials. The technology approaches outlined here will be further described along with future directions.

Technologies to Augment Rotator Cuff Repair

Healing rates after rotator cuff repair vary widely. New technologies seek to improve tendon to bone healing with the addition of platelet-rich plasma, stem cells, and biological and synthetic grafts. Platelet-rich plasma and mesenchymal stem cells are used to help create a favorable environment for tendon to bone healing, and grafts and scaffolds provide structural support for repair. The efficacy of platelet-rich plasma and stem cell products seems to be variable, with different products offering different levels of cytokine and growth factors. Scaffold material is also variable with a wide range of synthetic and biological grafts.

Bridging Repair of Large Rotator Cuff Tears Using a Multilayer Decellularized Tendon Slices Graft in a Rabbit Model

PURPOSE

The purpose of this study was to evaluate the efficacy of an extracellular matrix scaffold with multilayer decellularized tendon slices (MDTSs) for reconstructing large rotator cuff tears in a rabbit model.

METHODS

Large defects in the infraspinatus tendons were created bilaterally in 36 rabbits. The graft group underwent bridging repair of the defects with the MDTSs grafts from Achilles tendons of adult beagle dogs, and the control group underwent repair with the autologous excised tendon. Specimens underwent histologic observation, biomechanical testing, and microcomputed tomography analysis at 2, 4, and 8 weeks after surgery.

RESULTS

Histologic analysis confirmed that the MDTSs graft promoted cell ingrowth and tissue integration, and fibrocartilage and Sharpey fibers formed at the enthesis at 8 weeks. Accordingly, the MDTSs graft generated a histologic appearance similar to that of the autogenous tendon graft. Mechanical testing revealed a significant increase of the regenerated tendons in ultimate load and stiffness from 4 to 8 weeks postoperatively, which was similar to autologous tendon repair. Microcomputed tomography analysis demonstrated that the MDTSs graft promoted bone formation at the tendon-bone insertion, thus improving the mechanical properties of the repair tendon.

CONCLUSIONS

The MDTSs graft used to bridge large rotator cuff defects in a rabbit model promoted host cell ingrowth, enhanced the remodeling of regenerated tendon, and promoted fibrocartilage formation, thus improving the biomechanical properties of the repaired tendon. This study thereby provides fundamental information for rotator cuff regeneration with the MDTSs graft.

CLINICAL RELEVANCE

Rotator cuff regeneration using MDTSs grafts is a promising procedure for large rotator cuff tears.

Allograft Use in Shoulder Surgery: Instability and Rotator Cuff

Shoulder instability and rotator cuff pathology can provide a challenging problem, especially in the revision setting. Allograft use in primary or revision surgical intervention for shoulder instability and rotator cuff tear may be a valuable resource. This paper reviews allograft tissue use in shoulder surgery for instability and rotator cuff tear.

Posterior Glenohumeral Capsular Reconstruction Using an Acellular Dermal Allograft

Posterior shoulder instability is an uncommon and challenging cause of shoulder pain and dysfunction. Surgical management has less reliable results and higher failure rates compared with techniques for anterior shoulder instability. The presence of generalized ligamentous laxity further complicates options for surgical management. If primary capsulolabral repair fails, controversy exists as to the optimal revision procedure. This technical description and video present an arthroscopic technique for reconstruction of the posterior glenohumeral capsule with an acellular dermal allograft to treat posterior instability in a patient with Ehlers-Danlos syndrome and a previously failed posterior capsular plication.

Outcomes of arthroscopic revision rotator cuff repair with acellular human dermal matrix allograft augmentation

BACKGROUND

The purpose was to assess the minimum 2-year patient-reported outcomes and failure rate of patients who underwent revision arthroscopic rotator cuff repair augmented with acellular human dermal matrix (AHDM) allograft for repairable retears.

METHODS

From 2008-2014, patients who underwent revision rotator cuff repair augmented with AHDM with greater than 2 years' follow-up by a single surgeon were retrospectively reviewed. Data regarding surgical history, demographic characteristics, and medical comorbidities were collected. Outcome data included American Shoulder and Elbow Surgeons (ASES) and Single Assessment Numeric Evaluation (SANE) scores, as well as rotator cuff healing on magnetic resonance imaging or ultrasound. Retears and subsequent surgical procedures were characterized.

RESULTS

A total of 28 patients met our inclusion criteria, and 23 (82%) were available for follow-up at 2 years. The mean age was 60.1 ± 9.3 years (range, 43-79 years), with a mean follow-up period of 48 ± 23 months. All patients had at least 1 prior rotator cuff repair. Of the 23 patients, 13 (56%) underwent postoperative imaging, and 4 of these 13 (31%) had a retear. A reoperation was performed in 3 of 23 patients (13%). Among the 6 patients with both preoperative and postoperative outcome scores, we saw improvement in the ASES score from 56 to 85 (P = .03) and in the SANE score from 42 to 76 (P = .03). The full cohort's mean postoperative ASES and SANE scores were 77 and 69, respectively.

CONCLUSION

AHDM allograft augmentation is a safe and effective treatment method for patients with full-thickness rotator cuff retears. Further research is needed with larger studies to confirm these findings from our small cohort of patients.

The Role of Biologic Therapy in Rotator Cuff Tears and Repairs

PURPOSE OF REVIEW

The purpose of this review was to establish the foundation of the major biologic adjuvants to rotator cuff repairs and review recent scientific findings.

RECENT FINDINGS

Platelet-rich plasma (PRP) overall has no significant impact on functional outcomes and repair integrity, but may be more advantageous in small to medium tears. Further studies should focus on leukocyte-rich versus poor preparations and the use of PRP in patients that are high risk for repair failure. Biologic and synthetic patches or augments provide mechanical stability for large and massive rotator cuff tears and decrease re-tear rates. Mesenchymal stem cells have demonstrated improved healing rates without an impact on outcomes. Cytokines and growth factors show promise in animal models, but require human trials to further evaluate. In massive or revision repairs, allograft or synthetic patch augmentation should be considered. Platelet-rich plasma may have benefit in smaller tears. Further studies are needed to evaluate the value of mesenchymal stem cells and various cytologic chemical signals.

Arthroscopic In Situ Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon

Large to massive rotator cuff tears are challenging to repair, although there are several options for dealing with them. Among them, superior capsular reconstruction was recently introduced as an effective procedure for retaining the static stability of the shoulder joint and preventing the progression to cuff tear arthropathy. The purpose of this technique-based article is to describe a surgical option, called arthroscopic in situ superior capsular reconstruction, for large to massive rotator cuff tears using the long head of the biceps tendon.

Management of Failed Rotator Cuff Repair in Young Patients

Management of failed rotator cuff repair may be difficult, especially in young patients. Various nonmodifiable and modifiable patient factors, including age, tendon quality, rotator cuff tear characteristics, acute or chronic rotator cuff tear, bone quality, tobacco use, and medications, affect rotator cuff repair healing. Surgical variables, such as the technique, timing, tension on the repair, the biomechanical construct, and fixation, as well as the postoperative rehabilitation strategy also affect rotator cuff repair healing. Variable outcomes have been reported in patients who undergo revision rotator cuff repair; however, a systematic surgical approach may increase the likelihood of a successful outcome. Numerous cellular and mechanical biologic augments, including platelet-rich plasma, platelet-rich fibrin matrix, mesenchymal stem cells, and acellular dermal matrix grafts, have been used in rotator cuff repair; however, conflicting or inconclusive outcomes have been reported in patients who undergo revision rotator cuff repair with the use of these augments. A variety of tendon transfer options, including latissimus dorsi, teres major, lower trapezius, pectoralis minor, pectoralis major, combined pectoralis major and latissimus dorsi, and combined latissimus dorsi and teres major, are available for the management of massive irreparable rotator cuff tears. Ultimately, the optimization of surgical techniques and the use of appropriate biologic/tendon transfer techniques, if indicated, is the best method for the management of failed rotator cuff repair.

Long Head of the Biceps as a Suitable Available Local Tissue Autograft for Superior Capsular Reconstruction: "The Chinese Way"

Massive irreparable rotator cuff tears remain a challenging condition during daily clinical practice. Irreversible fatty infiltration of muscles and excessive chronic retraction of tendons predispose to high failure rates of their surgical treatment. Superior capsular reconstruction with either fascia lata autograft or a dermal allograft patch is a newly described solution that could prevent superior humeral head migration and restore the anteroposterior shoulder muscle force couples. The purpose of this article is to propose a technical modification of superior capsular reconstruction using long head of the biceps tendon autograft. The tendon's insertion into the glenoid is left intact, whereas laterally, it is tenotomized, transferred, and sutured with anchors onto the footprint of the supraspinatus tendon acting as a superior static stabilizer of the shoulder joint. Although this surgical modification has theoretical biological advantages, could be performed with the least technical demands, and simplifies the original demanding procedure, further prospective studies with large cohort populations and long-term follow-up are necessary to establish its effectiveness.

Rotator Cuff Tears at the Musculotendinous Junction: Classification and Surgical Options for Repair and Reconstruction

Although uncommon, rotator cuff tears that occur medially at the musculotendinous junction can result from acute trauma, anatomic force imbalance, or medial row cuff failure following a previous rotator cuff repair. The quality of the torn muscle and tendon along with the length of the remnant tendon stump should be considered before deciding on the most appropriate repair technique. When muscle and tendon quality are sufficient, the tear can often be repaired directly to the remnant tendon stump and compressed onto the greater tuberosity. If the remnant tendon stump is degenerative, of insufficient length, or lacks tendon in which to place sutures, an allograft patch can be used to augment the repair. When the quality of the remaining muscle and tendon are poor or when the muscle is retracted too far medially and is nonmobile, a bridging technique such as superior capsule reconstruction is preferable. The purpose of this report is to (1) highlight that medial cuff failure can occur both primarily and after previous repair; (2) define and classify the 3 major tear patterns that are encountered, and (3) describe the authors' preferred techniques for medial cuff repair that specifically address each of the major tear patterns.

Anterior Capsular Reconstruction for Irreparable Subscapularis Tears

Chronic anterior shoulder instability due to structural failure of the subscapularis muscle and the anterior capsule is a rare and challenging diagnosis for surgeons to manage because poor-quality capsular, labral, and rotator cuff tissue often limits effective treatment options. If primary repair is not possible because of retraction and poor tissue quality, reconstruction with an allograft or autograft may be the only joint-preserving option. The purpose of this article is to describe a surgical technique for anterior capsular reconstruction using a human acellular dermal allograft for the treatment of irreparable subscapularis tears.

The "Pull-Over" Technique for All Arthroscopic Rotator Cuff Repair With Extracellular Matrix Augmentation

Despite the vast improvement in techniques for arthroscopic rotator cuff surgery, repairs of massive and large tears remain an issue as they are associated with significantly high failure rates, particularly in the elderly population. As a result, there has been a focus of attention to improve rotator cuff repair healing rates. One of the strategies is augmentation of the repair with a patch. Arthroscopic augmentation is, however, technically demanding with challenges in introduction and stabilization of the patch. The purpose of this Technical Note is to describe a technique for arthroscopic rotator cuff repair with augmentation, which offers additional advantages over previous techniques because it facilitates the passage of the patch as well as providing a more robust medial stabilization of the augment and therefore possibly a stronger construct.

Pectoralis Major Tear with Retracted Tendon: How to Fill the Gap? Reconstruction with Hamstring Autograft and Fixation with an Interference Screw

Rupture of the pectoralis major tendon is considered an uncommon injury and a significant number of ruptures are missed or diagnosed late, leading to a chronic tear. We report an open reconstruction technique and its outcomes in a case of chronic and retracted PM tear. At the last follow-up (12 months), the patient was pain-free, with a visual analogic scale at 0 all the time. He was very satisfied concerning the cosmetic and clinical results. The constant score was 93%, the SST value 95%, and the Quick DASH score 4.5. MRI performed one year postoperatively confirmed the continuity between PM tendon and graft, even if the aspect of the distal tendon seemed to be thinner than normal PM tendon. The excellent clinical outcomes at one-year follow-up suggest that PM tear with major tendon retraction can be reliably reconstructed with hamstring autograft, using a bioabsorbable screw to optimize the fixation device. This technique has proven its simplicity and efficiency to fill the gap.

Latissimus Dorsi Tendon Transfer with GraftJacket® Augmentation to Increase Tendon Length for an Irreparable Rotator Cuff Tear

Massive irreparable rotator cuff tears can be reconstructed with latissimus dorsi tendon transfers (LDTT). Although uncommon, the natural length of the latissimus dorsi tendon (LDT) could be insufficient for transfer even after adequate soft tissue releases. Descriptions of cases where grafts were needed to lengthen the LDT are therefore rare. We located only two reports of the use of an acellular dermal matrix to increase effective tendon length in tendon transfers about the shoulder: (1) GraftJacket patch for a pectoralis major tendon reconstruction and (2) ArthroFlex® patch for LDTT. Both of these brands of allograft patches are obtained from human cadavers. These products are usually used to cover soft tissue repairs and offer supplemental support rather than for increasing tendon length. Extending the LDTT with GraftJacket to achieve adequate length, to our knowledge, has not been reported in the literature. We report the case of a 50-year-old male who had a massive, irreparable left shoulder rotator cuff tear that was reconstructed with a LDTT. The natural length of his LDT was insufficient for transfer. This unexpected situation was rectified by sewing two patches of GraftJacket to the LDT. The patient had greatly improved shoulder function at two-year follow-up.

Season's Greetings: A Good Year for Arthroscopy

The Arthroscopy journal "Most Read" list evolves over time, and reflects the popularity of knee and shoulder and hip topics, original scientific articles, Letters to the Editor, and Level V Evidence (expert opinion). And, for the holiday season, we share a cruciverbalist challenge.