Revision Rotator Cuff Repair: A Comprehensive Approach and Stepwise Technique

The bioinductive collagen implant yields positive histological, clinical and MRI outcomes in the management of rotator cuff tears: A systematic review

PURPOSE

The aim of this study is to report and discuss the outcomes of clinical, histological and animal studies exploring the application of bio-inductive collagen implants (BCIs) to partial and full-thickness rotator cuff tears (PT- and FT-RCTs) in addition to reporting on cost-related factors.

METHODS

Review of literature was performed using the PRISMA guidelines. A systematic electronic literature search was conducted using the CENTRAL, CINAHL, Cochrane Library, EBSCOhost, EMBASE and Google Scholar bibliographic databases. Microsoft Excel was used to create tables onto which extracted data were recorded. Tables were organized based on the research statement formulated using the PICO approach. No statistical analysis was performed.

RESULTS

Nine studies evaluated clinical and MRI outcomes of BCI augmentation for FT-RCTs, seven evaluated similar outcomes when applied to PT-RCTs, two additional studies were case reports and three studies assessed application to FT- and PT-RCTs without stratification of results, one of which also reported on histological data. Two studies reported on histological data alone, and finally, two reported on healthcare costs. BCI augmentation, alone and combined with rotator cuff repair (RCR), displays generally good histological, postoperative clinical and MRI outcomes for PT- and FT-RCT treatment. Recent economic analyses seem to be in favour of the use of this procedure, when selected and applied for appropriate patient populations.

CONCLUSION

Several studies have shown promising results of BCI application to PT- and FT-RCTs, both concomitantly and independently from RCR. Investigations report promising histological characteristics, improved clinical outcomes, increased tendon thickness, reduced defect size and lower re-tear rates.

LEVEL OF EVIDENCE

Level IV.

Rotator Cuff Injury: Pathogenesis, Biomechanics, and Repair

Anterior Rotator cuff tears are one of the most common surgically addressed disorders, as the tears in the tendon can affect anyone regardless of risk factors or activity level. The rotator cuff is responsible for most of the shoulder motion, hence the tendon-bone interface experiences immense stress making it incredibly prone to failure. Rotator cuff tendon tears can either occur due to trauma or natural degeneration of the rotator cuff. To help mitigate effects of high stress on the rotator cuff tendon-bone interface, the rotator cuff is intrinsically designed to redistribute stress through protective mechanisms, such as the rotator crescent or coronal-transverse force. But when the tear goes through the intrinsic protective mechanisms, the glenohumeral joint is left unstable and thus is no longer capable of its normal range of motion. Location, size, and type of rotator cuff tendon tears are the strongest indicators for interventional therapy. Surgical therapies demonstrate low success rates, as seen by the significantly high recurrence rate of rotator cuff reinjury following initial repair. This is due to extrinsically healing of rotator cuff tendons, instead of the more intrinsic healing, which causes rotator cuff tendons to not undergo the necessary biomechanical remodeling to prevent reinjury leading to a mechanically and functionally inferior healed tendon. In this article, we thoroughly discussed the underlying pathophysiology of rotator cuff tears from onset to repair to healing, demonstrating that rotator cuff tendon healing is an intrinsically flawed process, irrespective of the risk factors, occurrence of rotator cuff tears, or surgical treatment. Rotator cuff healing can only be successful if rotator cuff tendon repair surgery is augmented with biologics to promote a successful intrinsic healing environment.

A Systematic Review and Meta-analysis of Risk Factors for the Increased Incidence of Revision Surgery After Arthroscopic Rotator Cuff Repair

BACKGROUND

Approximately 90% of patients who undergo arthroscopic rotator cuff repair (RCR) are satisfied with their pain levels and function after surgery. However, a subset of patients experience continued symptoms that warrant revision surgery. Preoperative risk factors for RCR failure requiring revision surgery have not been clearly defined.

PURPOSE

To (1) determine the rate of RCR failure requiring revision surgery and (2) identify risk factors for revision surgery, which will help surgeons to determine patients who are at the greatest risk for RCR failure.

STUDY DESIGN

Systematic review and meta-analysis; Level of evidence, 4.

METHODS

A systematic review and meta-analysis in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were performed. The initial search resulted in 3158 titles, and 533 full-text articles were assessed for eligibility. A total of 10 studies met the following inclusion criteria: (1) human clinical studies, (2) arthroscopic RCR, (3) original clinical research, and (4) evaluation of preoperative risk factors for revision.

RESULTS

After a full-text review, a total of 16 risk factors were recorded and analyzed across 10 studies. Corticosteroid injection was the most consistent risk factor for revision surgery, reaching statistical significance in 4 of 4 studies, followed by workers' compensation status (2/3 studies). Patients with corticosteroid injections had a pooled increased risk of revision surgery by 47% (odds ratio, 1.44 [95% CI, 1.36-1.52]). Patients with workers' compensation had a pooled increased risk of revision surgery by 133% (odds ratio, 2.33 [95% CI, 2.09-2.60]). Age, smoking status, diabetes, and obesity were found to be risk factors in half of the analyzed studies.

CONCLUSION

Corticosteroid injections, regardless of the frequency of injections, and workers' compensation status were found to be significant risk factors across the literature based on qualitative analysis and pooled analysis. Surgeons should determine ideal candidates for arthroscopic RCR by accounting for corticosteroid injection history, regardless of the frequency, and insurance status of the patient.

"Double Row Rip-Stop" Arthroscopic Repair Technique for Acute, Retracted Rotator Cuff Tears

Acute, retracted rotator cuff tendon tears are important to recognize and can present unique technical challenges to repair. Various arthroscopic techniques and suture configurations have been proposed for repair of acute tears with aims to maximize the repair footprint and optimize tendon fixation. The double row rip-stop configuration was designed and has been used for rotator cuff repair due to its potential advantages related to suture pullout, footprint reapproximation and load sharing. The purpose of this article is to present the author's arthroscopic technique for repair of acute, retracted rotator cuff tendon tears using a double-row, rip-stop suture configuration. The indications and authors' preferred arthroscopic technique for biceps tenodesis are also discussed.