Graft augmentation of rotator cuff repair

OVERVIEW

Chapter synopsis

Advances in biologic and structural augmentation of full-thickness rotator cuff tear repairs will be necessary to solve the problem of non-healing of large and/or revision tears. This chapter will outline a technique for biologically and structurally augmenting rotator cuff repairs using a human dermal allograft. While many different types of augmentation are currently being investigated, the specific technique described in this chapter has been carefully selected and developed through a combination of biomechanical and clinical peer-reviewed published research, expert opinion and extensive personal experience.

Important points

Fixation technique matters. Multiple studies have shown that a graft which covers or spans the rotator cuff repair is far superior to one that is incorporated into the repair.
The ideal type of “graft” for augmenting the rotator cuff has not been clearly defined: allograft acellular dermis, xenograft collagen, autograft tendon, synthetics, mesenchymal cells, platelet-rich plasma, and drug therapy are all amongst those being investigated. However, based upon current data, allograft has had more promising results than xenograft (see Table 28.1 ).
This chapter will focus on the use of acellular human dermal allograft (AHDA) as a biologic augment for full-thickness tears. AHDA has several potential benefits: (1) A relatively long and successful clinical history of safe and effective use in the shoulder and other parts of the body, (2) improved biomechanical strength of rotator cuff repair, (3) a microstructure amenable to biologic regeneration, and (4) a reliable technique for arthroscopic implantation.
Expectation management, for both patients and surgeons, is essential: The goals of the procedure should be limited to improving symptoms with minimal risk, maximizing function to the degree the patient can achieve, and delaying or avoiding reverse shoulder arthroplasty.

Clinical/surgical pearls

Patient selection is crucial: The patient should not have significant glenohumeral osteoarthritis or stiffness. Ideal patients have intact active motion with isolated complaints of pain. Ideal age for healing is generally younger than 55.
Plan to use four arthroscopic portals, with an anterolateral cannula large enough to allow passage of a graft: 8.5 mm or larger diameter.
Work quickly with low arthroscopic pump pressure and aggressive hemostasis to minimize swelling and maximize visibility. Consder adding epinepherine to the arthroscopy fluid bags to improve visualization.
Graft sizing and suturing: Understand the size the graft needs to be. Matching suture placement within the shoulder to the graft size will lead to a well-placed, balanced graft.

Clinical/surgical pitfalls

Technique: All grafts and all construct types are not the same. Be aware that the graft type and technique described in this chapter are based upon the best data available at the time of publication. Alternative grafts and different techniques can be expected to have different results.
Visualization: As with all surgical procedures, visualization is essential. Poor visualization will lead to compromised results.
Suture management: Precise, error-free suture management is essential. With basic attention to detail, suture entanglement should never occur.
Graft Passage: Ensure the cannula for the graft is large enough and/or flexible enough to allow passage: 8.5 mm diameter or greater. Silicon cannulas with flexible diameters can work well.
Proficiency requires practice: This procedure can be easily performed on a dry model and/or in a cadaver. Failure to become competent in a lab setting usually leads to struggle if not outright failure in the operating room.

Video available

: Arthroscopic Augmentation of a Rotator Cuff Repair Using Human Dermal Allograft

Introduction

Symptomatic non-healing and retearing of supraspinatus rotator cuff tears continues to be a problem for shoulder specialists. As a result, many different ways to augment the repair are being investigated. Acellular human dermal allografts (AHDAs), xenograft collagen, autograft tendon, mesenchymal cells, platelet-rich plasma (PRP), and drug therapy are all being investigated in the hopes of finding a better solution. To date, high-level peer reviewed research is limited on all of these graft options, and most surgeons are well aware that a new procedure or implant’s popularity often outpaces the proven research of its benefits. This chapter will present the rationale and technique for arthroscopic augmentation of full-thickness supraspinatus tear repairs using an AHDA in a precise manner. The technique presented represents a combination of the best available research to date with the most reliable surgical techniques.

Pre-operative considerations

History

Patient histories are variable and can be unique in the cases of complex rotator cuff tears: trauma, degenerative origin, prior surgeries, prior infection, biceps pathology, adhesive capsulitis/stiffness, smoking history, diabetes, and alcohol intake are all factors that affect treatment. It is important to gather all these historical elements, in addition to any prior operative notes and photos that may be available.

Signs, symptoms, physical examination

Signs and symptoms are typically the same as those for a supraspinatus rotator cuff tear: anterolateral shoulder pain, radiating toward the deltoid insertion, night pain, pain with overhead activities, shoulder weakness, potential muscle atrophy.
Presence of impingement signs: positive Neer and Hawkins tests.
Weakness in forward elevation, scaption, external rotation, positive Jobe Empty Can test, positive Hornblower’s sign in severe cases of infraspinatus and teres minor involvement.

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