Rotator cuff Repair - New Techniques and Challenges
Rotator Cuff Repair: NewTechniques and ResultsVivek Agrawal, MDThe Shoulder CenterCarmel, IN
Rotator Cuff Repair: NewTechniques and Results• Provide anoverview ofadvances in thetreatment of rotatorcuff tears.• Complications• Results
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
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
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.
The Implant/Technique• Knots vs. Knotless• Single Row vs.Dual Row• Suture Bridge?• Multiple competingtechniques• Suture # determinesStrength (Jost, JBJS 2012)
The Implant/TechniqueSingle Row-Traditional Dual Row-Suture Bridge19/84 Retear per MRI 27/96 Retear per MRICho et al. AJSM 2010
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”
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”
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
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)
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
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
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.
The Implant/Technique• How do weimprove themechanicalstrength andbiologicenvironment of therepair to promotebetter healing inthis challengingenvironment?
Emerging Technology/Trends• Arthroscopic Tran Osseous Tension Band RCR with Reinforcement Graft
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
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
Pre-implant:Initial dermis collagen pattern7 mos. post-implant:Remodeled to tendon collagen patternCompare to normal humantendon collagen patternHistology Supports Biologic Scaffold Theory
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.”
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).