When and How to Use Patches

Introduction

Symptomatic large and massive rotator cuff tears are common with advancing age. Among those who undergo rotator cuff repair surgery, reasonable clinical outcomes have been reported in the majority of patients; however, complete tendon-to-bone healing is uncommon, with retear rates ranging from 40% to over 90%. In order to improve healing rates, various scaffolds have been investigated to augment these tears at high risk of retearing. In addition, some tears are not fully repairable, and grafts have been used to bridge the defect in the cuff tendon. In this chapter, we describe the use of human dermal allograft as both an augmented graft and an interposition graft because of its favorable biologic and mechanical properties.

Brief Description of Procedure

A dermal allograft patch can be used either to bridge a defect greater than 1 cm in size (interposition) or to augment a complete repair (augmentation). We prefer to use an arthroscopic technique over an open technique, largely owing to improved visualization and preservation of the deltoid attachment. Sutures are passed through the graft outside the shoulder, and knots are tied on one end of the suture; the other end of the suture is shuttled into the joint through the native cuff tissue and out another cannula. These medial ends are then slowly pulled, which draws the graft into the joint. The suture ends are then tied together, firmly fixing the graft to the native tissue.

Patient History

• Night pain is common.

• Chronic limiting activity–related shoulder pain.

• Physiologically “young,” typically 50- to 70-year-old age range.

• Note prior surgery, and obtain operative reports if possible.

Patient Examination

• Inspection: Note prior incisions; deformity (such as scapular winging); and muscle atrophy, including the deltoid and supraspinatus/infraspinatus fossae.

• Palpation: Tenderness to palpation of the periscapular musculature, acromion, subacromial bursa, acromioclavicular (AC) joint, clavicle, and biceps tendon can identify concomitant pathology.

• Range of motion (ROM): Active forward flexion is often painful, typically above 130 degrees. Passive ROM is variable but often normal. Supine internal/external rotation testing with the arm abducted 90 degrees can assist in identifying concomitant adhesive capsulitis.

• Strength: Weakness during supraspinatus testing is a clinical hallmark. Testing is performed with the arm abducted in the scapular plane, internally rotated, and with the hand slightly below shoulder height. Assess external rotation strength with the elbow adducted to the side; this will identify involvement of the infraspinatus/teres minor. Belly press/lift-off/bear-hug testing can assist in identifying subscapularis pathology.

• Special testing: Results of provocative impingement and biceps testing are often positive secondary to bursal inflammation and bicipital degeneration in large rotator cuff tears.

Imaging

• We routinely get four standard views of the shoulder for all new patients: a true anteroposterior (AP) view (Grashey), a supraspinatus outlet or “arch view,” an axillary lateral view, and an AC joint (Zanca) view.

• Joint space narrowing and other signs of osteoarthritis are noted on axillary lateral and true AP views. Rotator cuff arthropathy is a contraindication to allograft repair.

• We use mostly noncontrast magnetic resonance imaging (MRI). Intraarticular gadolinium contrast is useful to assess the integrity of prior rotator cuff repair but is rarely needed to assess the need for use of dermal allograft. Other pathologies, such as AC joint arthropathy, biceps tendinopathy, and subscapularis tendon tears, are assessed and planned for accordingly. The articular surface is carefully evaluated; minor articular defects are not considered a contraindication, whereas larger full-thickness defects are.

• The presence of an “S-wave” is favorable for primary cuff repair. This is present when cuff tissue has a recoiled appearance on coronal MRI images ( Fig. 23.1 ).

  

• Dermal allograft augmentation should be considered when an MRI shows an “at-risk” tendon that has a thin diminutive appearance but likely can be reapproximated to bone ( Fig. 23.2 ).

  

• Interposition grafting is considered in cases where MRI shows a segmental tendon defect that likely will not allow reduction to the tuberosity. This is occasionally observed in Cho type II failures near the musculotendinous junction after double-row rotator cuff tendon repair ( Fig. 23.3 ).

  

• We do not routinely order electromyography with nerve conduction studies to evaluate the suprascapular nerve. Suprascapular nerve decompression at the time of surgery is controversial and of uncertain clinical benefit. Rotator cuff tendon reduction near its anatomic footprint presents the best option for “untethering” the suprascapular nerve. However, in cases where interposition grafting is used and the cuff remains in a more retracted position, decompression of the suprascapular nerve at the time of repair may have a theoretical benefit. More investigation is warranted before recommending for or against nerve decompression in these instances.

Treatment Options

• Conservative treatment: Nonoperative treatment of rotator cuff tears consists of physical therapy, nonsteroidal antiinflammatory drugs (NSAIDs), and steroid injections. An initial course of physical therapy with NSAIDs is appropriate for those with more minor rotator cuff tears and for patients apprehensive about undergoing surgery. We typically limit patients to one or two steroid injections total.

• Partial rotator cuff tendon repair: There are instances where patients cannot have dermal allograft repairs despite being ideal candidates (e.g., financial, cultural). Partial repairs that address concomitant pathology will often give them some relief but with guarded expectations about shoulder function and pain alleviation.

• Reverse total shoulder arthroplasty: Ideal for patients with rotator cuff arthropathy that precludes rotator cuff repair. Although repair of the tendon is often feasible, a frank discussion must address whether a cuff repair will alleviate the patient’s symptoms, because complaints related to osteoarthritis may be unchanged or become worse.

• Latissimus dorsi tendon transfer: Data in the literature regarding improvement after latissimus dorsi tendon transfer have shown favorable results. No currently existing studies compare dermal allograft interposition with tendon transfer, and thus more investigation is required.

• Superior capsular reconstruction: This emerging technique is currently being investigated. We have noted on rare occasions that medial rotator cuff tissue is inadequate even for dermal allograft interposition. In these cases, superior capsular reconstruction may present a viable option.

Surgical Anatomy

• Scapular spine: Visualization of scapular spine serves as a reference for the “midpoint” of the tendon while placing medial sutures ( Fig. 23.4 ).

  

• Humeral footprint anatomy: Anchors are ideally placed at the medial supraspinatus/infraspinatus footprint 5 mm from the articular cartilage at a 45-degree “tent peg” angle ( Fig. 23.5 ).

  

• Suprascapular nerve: Overly aggressive medial debridement will place the suprascapular nerve at risk ( Fig. 23.6 ).

  

• Tear classification: Rotator cuff tears are described by pattern (e.g., L-shaped or reverse L-shaped, stellate, “monk’s hood”) and classified using the system described by Snyder ( Table 23.1 ). When complete lesions are found, which is often the case with larger tears considered for dermal allograft, the size of the complete tear follows the “C” designation scheme:

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    CI: A small complete tear, such as a puncture wound, would be rated CI.

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    CII: A moderate tear that still encompasses only one of the rotator cuff tendons with no retraction of the torn ends would be rated as a CII lesion.

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    CIII: A CIII lesion involves an entire tendon with minimal retraction of the torn edge, usually 3 cm in size.

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    CIV: A massive rotator cuff tear (CIV) involves two or more rotator cuff tendons, frequently with associated retraction and scarring of the remaining ends of the tendon and often an L-shaped tear. When a CIV cuff tear cannot possibly undergo direct repair to the greater tuberosity, it is termed “irreparable.”

  TABLE 23.1

  Rotator cuff tear classification as described by snyder

  From Snyder SJ. Evaluation and treatment of the rotator cuff . Orthop Clin North Am. 1993;24:173–192 .

  Classification of Rotator Cuff Tears

  Location of tear A Articular surface B Bursal surface C Complete tear, connecting A and B sides Severity of tear 0 Normal cuff, with smooth coverings of synovium and bursa I Minimal superficial bursal or synovial irritation or slight capsular fraying in a small localized area, usually <1 cm II Actual fraying or failure of some rotator cuff fibers in addition to synovial, bursal, or capsular injury, usually <2 cm in size III More severe rotator cuff injury, including fraying and fragmentation of tendon fibers, often involving the whole surface of a cuff tendon (most often the supraspinatus), usually <3 cm in size IV Very severe partial rotator cuff tear that usually contains, in addition to fraying and fragmentation of tendon tissue, a sizable flap tear, usually larger in size than grades I–III and often encompassing more than a single tendon

Surgical Indications

• Persistent activity-related shoulder pain and failure of other conservative measures are common indications for operative rotator cuff repair. Symptomatic full-thickness rotator cuff tears with retraction are generally treated surgically because the risk of progression to an irreparable tear is significant.

• Once a patient elects to undergo rotator cuff repair, the first decision a surgeon must make is whether the rotator cuff tear is likely to be repairable using standard techniques based on clinical exam and imaging.

• Ideal candidates for dermal allograft use include the following:

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    Failed prior repairs

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    Fatty infiltration

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    Muscle atrophy

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    Thin, degenerative tendon

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    Large tears (>2 cm)

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    Significant retraction (beyond humeral apex)

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    Chronic traumatic tears

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    History of failed repair on contralateral shoulder

• Patients are advised that the final decision on whether to use the graft, augment, or perform an interposition procedure is made intraoperatively.

One or more of the above risk factors warrants preparation for the use of dermal allograft. There are few absolute contraindications to using a graft, but patient bias against using an allograft must be respected. Cost, additional time requirement, and surgeon’s comfort level are relative contraindications.

Note: Use of patches is approved by the U.S. Food and Drug Administration (FDA) only as an augmentation with less than 1-cm defect; therefore interposition is currently an “off-label” use, and patients should be informed of the FDA status.

Surgical Technique Setup

Establishing Surgical Portals