This presentation reviews the current challenges and advances in state of the art rotator cuff repair. Learn more at https://www.theshouldercenter.com/

1. Rotator Cuff Repair: New
Techniques and Results
Vivek Agrawal, MD
The Shoulder Center
Carmel, IN

2. Rotator Cuff Repair: New
Techniques and Results
• Provide an
overview of
advances in the
treatment of rotator
cuff tears.
• Complications
• Results

3. Rotator Cuff
• “If we are looking at the tendons we repair, the cost per
tendon overall is $55,000. That includes sick leave,
medical care and rehabilitation.” –Christian Gerber 2010
AANA meeting
• “With nearly 250,000 rotator cuff repairs performed
annually in the United States, the potential for significant
expansion of this market as the baby boomers age is
truly impressive.” –PearlDiver 2008
• “Independent risk factors for revision RCR included
increasing age, increased comorbidity, and lower
surgeon volume.” Sherman et al, CORR 2008

4. Shoulder Arthroscopy
• Ability to diagnose and
treat a greater spectrum
of concurrent shoulder
pathology
• Much lower risk of
infection and stiffness
• Earlier functional
recovery
• Avoid injury to normal
tissues
• Minimal scar

5. Disadvantages
• Technically difficult – “long learning curve”
– Many different techniques- no single standard.
– Complications and poor outcomes increase
as more surgeons adopt and learn new
techniques.
– Limited availability.

6. Tuberosity Osteolysis Resorbable Anchor

7. Rotator Cuff Repair
• Failure rates
reported 11-94%
• Multiple Factors
– Surgeon
– Patient
– Implant/Technique

8. The Surgeon
• The surgeon is the
method
• Steep Learning
Curve for
arthroscopic
repairs
• Widely variable
techniques

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
• Inflammatory
disorder
• Concurrent
Pathology

11. The Patient: Tissue Factors
• Muscle atrophy and
fatty infiltration
– Changes the material
properties of the
muscle tendon unit
– May contribute to high
tensile loads at the
repair site

12. The Patient: Tissue Factors
• Tendons tear
through diseased
tissues
– Poor blood supply
– Inferior material
properties of the
tissue
– Degenerative
tissue

13. The Patient: Footprint
• Compromised
bony bed at rotator
cuff footprint
• Cysts
• Hardware
• Osteoporosis

14. The Patient
• Compliance
• Accidents

15. The Implant/Technique
• Knots vs. Knotless
• Single Row vs.
Dual Row
• Suture Bridge?
• Multiple competing
techniques
• Suture # determines
Strength (Jost, JBJS 2012)

16. The Implant/Technique
Single Row-Traditional Dual Row-Suture Bridge
19/84 Retear per MRI 27/96 Retear per MRI
Cho et al. AJSM 2010

17. The Implant/Technique
Cho et al. AJSM 2010
Type II Tear Suture Bridge
“the possibility of direct retear at the
footprint of the rotator cuff increased
with the severity of fatty degeneration
or muscle atrophy in cases with a
suture bridge technique”

18. The Implant/Technique
Mitek Versalok- Suture Bridge Arthrex- Suture Bridge
Barber et al. Arthroscopy 2010
“single row constructs were more resistant
to stretching to a 5 mm gap than the
double row groups”

19. The Implant/Technique
• “a larger footprint may be over
compressed by crossing sutures”-
Barber et al. Arthroscopy 2010
• “after a double row rotator cuff
repair, the medial row becomes
the tension bearing row”
• “retrograde suture passing
instruments generally also create
a relatively larger hole in the
rotator cuff”
• “oblique path of suture passage
through the rotator cuff may
contribute to the formation of
medial cuff failure by potentially
over-tensioning the medial repair”
Trantalis et al. Arthroscopy 2008

20. Tendon Healing
• Healing begins by formation
of fibro vascular tissue
interface between tendon
and bone (Rodeo JBJS 1993,
St. Pierre JBJS 1995)
• Bone grows into the
interface tissue (Aoki JSES
2001)
• Collagen fiber continuity is
gradually created between
tendon and bone (Oguma
JOR 2001)

21. JBJS:2007; 89A(Suppl 3): 127-36
• Review of arthroscopic and mini-open
rotator cuff repair among the best reported
studies.
– 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 at
average 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 at
average of 6.8 months

23. Our Results
• 71 work comp patients (primary RCR)-
August 2001-2005
• 81.7% able to resume regular unrestricted
work at average 110.5 days (3.7 months)
• 18.3% required permanent restrictions at
average of 154.2 days (5.1 months)
• Retear Rate: 4% (3/71)
• Presented at Indiana Orthopedic Society
4/19/2008 and Published IOJ 2008.

24. The Implant/Technique
• How do we
improve the
mechanical
strength and
biologic
environment of the
repair to promote
better healing in
this challenging
environment?

25. Circle Concept

26. Suprascapular Nerve

27. Suprascapular Nerve
Arthroscopic Decompression of a Bony
Suprascapular Foramen. Arthroscopy
2009

28. Unstable Shoulder

29. Biceps/SLAP
37% Revision Rate Reported for Type II SLAP. Provencher. AAOS 2012

30. Frozen Shoulder
Unrecognized Capsular Tightness Increases Stress at RCR

31. Subscapularis Repair
Present 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 Adhesions
Reduction of Adhesions with Composite AlloDerm/Polypropylene Mesh Implants for Abdominal Wall Reconstruction
Butler et al. Plastic & Reconstructive Surgery:
August 2004 - Volume 114 - Issue 2 - pp 464-473

35. Biologic Role
• Bring host cells into the scaffold and new
tissue to the healing site over the first 6
weeks after repair
• Biocompatible (varies among the grafts)
• Potential regenerative role
• Prevent formation of adhesions to repair site

36. Mechanical Properties
Single Row Repair
273 +/- 116N (254N Median)
Graft Jacket MaxForce Extreme
325 +/- 74N (309N Median)
Barber et al.
Arthroscopy 2008
Patch Evaluations

37. Pre-implant:
Initial dermis collagen pattern
7 mos. post-implant:
Remodeled to tendon collagen pattern
Compare to normal human
tendon collagen pattern
Histology Supports Biologic Scaffold Theory

38. Literature
• Porcine subintestinal mucosa
(SIS)
• Poor results
• Example of “negative
recognition
• Rejection of “non-self”-
xenograft
• Inflammatory response
“…unsatisfactorily high proportion of
patients with a severe inflammatory
reaction to the xenograft, we do not
recommend use of the Restore
Orthobiologic Implant in its present
form.”

39. • Barber et al, Arthroscopy: The Journal
of 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 clinical
study supported the hypothesis
that augmentation with
GRAFTJACKET® Matrix resulted in
improved repair healing for large
rotator cuff tears and provided
statistically better functional outcome
scores."
FIGURE 5. Once in place, the augmenting graft is
secured by tying each short-tailed interference knot to
the 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 Technique
Lateral Decubitus
Arthroscopic Tunnels for
“Trans-Osseous Repair”
“Tension Band Repair”
Anchors placed distal to footprint.
Correct Pattern Restored
Approx. 15 minutes added for Graft

42. Arthroscopic Technique

43. Arthroscopic
Technique

44. Arthroscopic Technique

45. Arthroscopic Technique

46. Arthroscopic Technique

47. • Complex and
Salvage Cases
• The same
principles of
restoring balance
hold

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 the
level 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 Plexus
Catheter
Protocol
• Allows
significant
reduction in pain
for initial 48-72
hours after
surgery

51. Summary
• Multiple options
available for RCR.
• A comprehensive
approach combined
with advanced
arthroscopic
techniques can
significantly improve
outcomes.

52. Thank You
www.TheShoulderCenter.com
Dr. Vivek Agrawal M.D.