Rotator cuff Repair - New Techniques and Challenges

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This presentation reviews the current challenges and advances in state of the art rotator cuff repair. Learn more at

This presentation reviews the current challenges and advances in state of the art rotator cuff repair. Learn more at

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  • 1. Rotator Cuff Repair: NewTechniques and ResultsVivek Agrawal, MDThe Shoulder CenterCarmel, IN
  • 2. Rotator Cuff Repair: NewTechniques and Results• Provide anoverview ofadvances in thetreatment of rotatorcuff tears.• Complications• Results
  • 3. Rotator Cuff• “If we are looking at the tendons we repair, the cost pertendon overall is $55,000. That includes sick leave,medical care and rehabilitation.” –Christian Gerber 2010AANA meeting• “With nearly 250,000 rotator cuff repairs performedannually in the United States, the potential for significantexpansion of this market as the baby boomers age istruly impressive.” –PearlDiver 2008• “Independent risk factors for revision RCR includedincreasing age, increased comorbidity, and lowersurgeon volume.” Sherman et al, CORR 2008
  • 4. Shoulder Arthroscopy• Ability to diagnose andtreat a greater spectrumof concurrent shoulderpathology• Much lower risk ofinfection and stiffness• Earlier functionalrecovery• Avoid injury to normaltissues• Minimal scar
  • 5. Disadvantages• Technically difficult – “long learning curve”– Many different techniques- no single standard.– Complications and poor outcomes increaseas more surgeons adopt and learn newtechniques.– Limited availability.
  • 6. Tuberosity Osteolysis Resorbable Anchor
  • 7. Rotator Cuff Repair• Failure ratesreported 11-94%• Multiple Factors– Surgeon– Patient– Implant/Technique
  • 8. The Surgeon• The surgeon is themethod• Steep LearningCurve forarthroscopicrepairs• Widely variabletechniques
  • 9. The Patient• Smoking• Age of Patient• Age of Tear• Size of Tear• Quality of Tissue• Quality of Footprint• Comorbidities• Compliance
  • 10. The Patient: Comorbidities• Associated factors• Advanced age• Smoking• Nicotine• Diabetes• Obesity• Inflammatorydisorder• ConcurrentPathology
  • 11. The Patient: Tissue Factors• Muscle atrophy andfatty infiltration– Changes the materialproperties of themuscle tendon unit– May contribute to hightensile loads at therepair site
  • 12. The Patient: Tissue Factors• Tendons tearthrough diseasedtissues– Poor blood supply– Inferior materialproperties of thetissue– Degenerativetissue
  • 13. The Patient: Footprint• Compromisedbony bed at rotatorcuff footprint• Cysts• Hardware• Osteoporosis
  • 14. The Patient• Compliance• Accidents
  • 15. The Implant/Technique• Knots vs. Knotless• Single Row vs.Dual Row• Suture Bridge?• Multiple competingtechniques• Suture # determinesStrength (Jost, JBJS 2012)
  • 16. The Implant/TechniqueSingle Row-Traditional Dual Row-Suture Bridge19/84 Retear per MRI 27/96 Retear per MRICho et al. AJSM 2010
  • 17. The Implant/TechniqueCho et al. AJSM 2010Type II Tear Suture Bridge“the possibility of direct retear at thefootprint of the rotator cuff increasedwith the severity of fatty degenerationor muscle atrophy in cases with asuture bridge technique”
  • 18. The Implant/TechniqueMitek Versalok- Suture Bridge Arthrex- Suture BridgeBarber et al. Arthroscopy 2010“single row constructs were more resistantto stretching to a 5 mm gap than thedouble row groups”
  • 19. The Implant/Technique• “a larger footprint may be overcompressed by crossing sutures”-Barber et al. Arthroscopy 2010• “after a double row rotator cuffrepair, the medial row becomesthe tension bearing row”• “retrograde suture passinginstruments generally also createa relatively larger hole in therotator cuff”• “oblique path of suture passagethrough the rotator cuff maycontribute to the formation ofmedial cuff failure by potentiallyover-tensioning the medial repair”Trantalis et al. Arthroscopy 2008
  • 20. Tendon Healing• Healing begins by formationof fibro vascular tissueinterface between tendonand bone (Rodeo JBJS 1993,St. Pierre JBJS 1995)• Bone grows into theinterface tissue (Aoki JSES2001)• Collagen fiber continuity isgradually created betweentendon and bone (OgumaJOR 2001)
  • 21. JBJS:2007; 89A(Suppl 3): 127-36• Review of arthroscopic and mini-openrotator cuff repair among the best reportedstudies.– More complications for mini-open repair• 6.6% vs. 3%• Arthrofibrosis (stiffness)• Impingement• Retear rates/ Healing rates not evaluated
  • 22. Outcomes in Work Comp Patients• Misamore et al. (J Bone Joint Surg Am,77(9): 1335-9, 1995.)– 42% able to return to unrestricted duty ataverage of 6.1 months• Self (J Shoulder Elbow Surg, 6: 228,1997.) 18 year study of injured workers.– 54% able to return to unrestricted duty ataverage of 6.8 months
  • 23. Our Results• 71 work comp patients (primary RCR)-August 2001-2005• 81.7% able to resume regular unrestrictedwork at average 110.5 days (3.7 months)• 18.3% required permanent restrictions ataverage of 154.2 days (5.1 months)• Retear Rate: 4% (3/71)• Presented at Indiana Orthopedic Society4/19/2008 and Published IOJ 2008.
  • 24. The Implant/Technique• How do weimprove themechanicalstrength andbiologicenvironment of therepair to promotebetter healing inthis challengingenvironment?
  • 25. Circle Concept
  • 26. Suprascapular Nerve
  • 27. Suprascapular NerveArthroscopic Decompression of a BonySuprascapular Foramen. Arthroscopy2009
  • 28. Unstable Shoulder
  • 29. Biceps/SLAP37% Revision Rate Reported for Type II SLAP. Provencher. AAOS 2012
  • 30. Frozen ShoulderUnrecognized Capsular Tightness Increases Stress at RCR
  • 31. Subscapularis RepairPresent in 27-35% of cases. Frequently missed.
  • 32. Healed Rotator Cuff Repair
  • 33. Emerging Technology/Trends• Arthroscopic Tran Osseous Tension Band RCR with Reinforcement Graft
  • 34. Reinforcement Grafts• Biocompatible and Biologically active– Low immunogenic response– Improves the rate and quality of healing• Material properties– Similar to rotator cuff tendon• Mechanically augment repair– Appropriate construct properties– High suture retention• Reduce AdhesionsReduction of Adhesions with Composite AlloDerm/Polypropylene Mesh Implants for Abdominal Wall ReconstructionButler et al. Plastic & Reconstructive Surgery:August 2004 - Volume 114 - Issue 2 - pp 464-473
  • 35. Biologic Role• Bring host cells into the scaffold and newtissue to the healing site over the first 6weeks after repair• Biocompatible (varies among the grafts)• Potential regenerative role• Prevent formation of adhesions to repair site
  • 36. Mechanical PropertiesSingle Row Repair273 +/- 116N (254N Median)Graft Jacket MaxForce Extreme325 +/- 74N (309N Median)Barber et al.Arthroscopy 2008Patch Evaluations
  • 37. Pre-implant:Initial dermis collagen pattern7 mos. post-implant:Remodeled to tendon collagen patternCompare to normal humantendon collagen patternHistology Supports Biologic Scaffold Theory
  • 38. Literature• Porcine subintestinal mucosa(SIS)• Poor results• Example of “negativerecognition• Rejection of “non-self”-xenograft• Inflammatory response“…unsatisfactorily high proportion ofpatients with a severe inflammatoryreaction to the xenograft, we do notrecommend use of the RestoreOrthobiologic Implant in its presentform.”
  • 39. • Barber et al, Arthroscopy: The Journalof Arthroscopic and Related Surgery,Vol 28, No 1 (January), 2012: pp 8-15• 22 Patients in GRAFTJACKET arm– 30-60 minutes additional operative time• 20 Patients in Control arm• 24 month mean follow-up• MRIs at 12 months minimum• 85% healing in GRAFTJACKET• 40% healing in Control• Dr. Barber-"This multi-center clinicalstudy supported the hypothesisthat augmentation withGRAFTJACKET® Matrix resulted inimproved repair healing for largerotator cuff tears and providedstatistically better functional outcomescores."FIGURE 5. Once in place, the augmenting graft issecured by tying each short-tailed interference knot tothe corresponding suture. © Dr. F. Alan Barber.
  • 40. • 14 patients• MRI at 16.8 months avg.• 86% intact (12/14)• 14% < 1cm discontinuity(2/14)• Strength:1.73 kg to 7.52 kg(p=0.006)
  • 41. Personal TechniqueLateral DecubitusArthroscopic Tunnels for“Trans-Osseous Repair”“Tension Band Repair”Anchors placed distal to footprint.Correct Pattern RestoredApprox. 15 minutes added for Graft
  • 42. Arthroscopic Technique
  • 43. ArthroscopicTechnique
  • 44. Arthroscopic Technique
  • 45. Arthroscopic Technique
  • 46. Arthroscopic Technique
  • 47. • Complex andSalvage Cases• The sameprinciples ofrestoring balancehold
  • 48. Bridging Graft (Salvage)
  • 49. Bridging Graft (Salvage)Fig. 4-A MRI (coronal view) of the shoulder at one-year post-surgery shows the supraspinatus tendon at thelevel of the humeral head with the bridging graft (arrows). Fig. 4-B MRI (sagittal view) of the shoulder at one-year post-surgery shows the intact bridging graft (arrows).
  • 50. Postoperative Pain• Brachial PlexusCatheterProtocol• Allowssignificantreduction in painfor initial 48-72hours aftersurgery
  • 51. Summary• Multiple optionsavailable for RCR.• A comprehensiveapproach combinedwith advancedarthroscopictechniques cansignificantly improveoutcomes.
  • 52. Thank Youwww.TheShoulderCenter.comDr. Vivek Agrawal M.D.