Rotator Cuff Matrix Augmentation and Interposition: A Systematic Review and Meta-analysis

Patch augmentation surgery for rotator cuff repair: the PARCS mixed-methods feasibility study

BACKGROUND

A rotator cuff tear is a common, disabling shoulder problem. Symptoms may include pain, weakness, lack of shoulder mobility and sleep disturbance. Many patients require surgery to repair the tear; however, there is a high failure rate. There is a need to improve the outcome of rotator cuff surgery, and the use of patch augmentation (on-lay or bridging) to provide support to the healing process and improve patient outcomes holds promise. Patches have been made using different materials (e.g. human/animal skin or tissue and synthetic materials) and processes (e.g. woven or mesh).

OBJECTIVES

The aim of the Patch Augmented Rotator Cuff Surgery (PARCS) feasibility study was to determine the design of a definitive randomised controlled trial assessing the clinical effectiveness and cost-effectiveness of a patch to augment surgical repair of the rotator cuff that is both acceptable to stakeholders and feasible.

DESIGN

A mixed-methods feasibility study of a randomised controlled trial.

DATA SOURCES

MEDLINE, EMBASE and the Cochrane Library databases were searched between April 2006 and August 2018.

METHODS

The project involved six stages: a systematic review of clinical evidence, a survey of the British Elbow and Shoulder Society's surgical membership, a survey of surgeon triallists, focus groups and interviews with stakeholders, a two-round Delphi study administered via online questionnaires and a 2-day consensus meeting. The various stakeholders (including patients, surgeons and industry representatives) were involved in stages 2-6.

RESULTS

The systematic review comprised 52 studies; only 15 were comparative and, of these, 11 were observational (search conducted in August 2018). These studies were typically small (median number of participants 26, range 5-152 participants). There was some evidence to support the use of patches, although most comparative studies were at a serious risk of bias. Little to no published clinical evidence was available for a number of patches in clinical use. The membership survey of British Elbow and Shoulder surgeons [105 (21%) responses received] identified a variety of patches in use. Twenty-four surgeons (77%) completed the triallist survey relating to trial design. Four focus groups were conducted, involving 24 stakeholders. Differing views were held on a number of aspects of trial design, including the appropriate patient population (e.g. patient age) to participate. Agreement on the key research questions and the outline of two potential randomised controlled trials were achieved through the Delphi study [29 (67%)] and the consensus meeting that 22 participants attended.

LIMITATIONS

The main limitation was that the findings were influenced by the participants, who are not necessarily representative of the views of the relevant stakeholder groups.

CONCLUSION

The need for further clinical studies was clear, particularly given the range and number of different patches available.

FUTURE WORK

Randomised comparisons of on-lay patch use for completed rotator cuff repairs and bridging patch use for partial rotator cuff repairs were identified as areas for further research. The value of an observational study to assess safety concerns of patch use was also highlighted. These elements are included in the trial designs proposed in this study.

STUDY REGISTRATION

The systematic review is registered as PROSPERO CRD42017057908.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 13. See the NIHR Journals Library website for further project information.

Holding on by a thread: the continuing story of rotator cuff tears

Rotator cuff tears are a common cause of shoulder pain. The incidence of these tears has increased significantly over the years, with the demands of an increasingly active elderly population. Therefore, a detailed understanding of rotator cuff tears will help doctors manage their patients' condition. This field has rapidly advanced over the past decade and this review provided an insight into the latest developments.

Use of implantable meshes for augmented rotator cuff repair: a systematic review and meta-analysis

OBJECTIVE

To appraise studies reporting on clinical effectiveness and safety of surgical meshes used to augment rotator cuff repairs (RCRs).

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase and Cochrane databases were searched between April 2006 and April 2020.

ELIGIBILITY CRITERIA

All studies evaluating adults (≥18 years) undergoing RCR were considered. There were no language restrictions.

DATA EXTRACTION AND SYNTHESIS

Screening, data extraction and quality appraisal were conducted by two independent reviewers. Meta-analysis was conducted using a random-effects models if ≥2 comparative studies reported the same outcome measure. Risk of bias assessment was undertaken for randomised (RoB2, Cochrane) and comparative studies (ROBINS-I, Cochrane).

RESULTS

We included 60 studies, consisting of 7 randomised controlled trials, 13 observational comparative studies and 40 observational case series. All comparative studies reported on shoulder-specific functional outcome scores, 18 on the radiographic occurrence of re-tear and 14 on pain score metrics. All studies contained some risk of bias.Compared with non-augmented repair, a small improvement in shoulder-specific function or pain scores was observed for synthetic patches with a mean improvement of 6.7 points on the University of California Los Angles (UCLA) shoulder score (95% CI 0.1 to 13.4) and 0.46 point reduction on the Visual Analogue Scale (95% CI -0.74 to -0.17), respectively. A reduced likelihood of radiologically observed re-tear was observed for synthetic (risk ratio (RR) 0.41, 95% CI 0.27 to 0.61) and allograft (RR 0.34, 95% CI 0.18 to 0.65) patches. A total of 49 studies reported on the occurrence of complications. Slightly higher crude complication rates were observed following patch-augmented repair (2.1%) than standard repair (1.6%).

CONCLUSIONS

While several studies suggest a decreased failure rate and small improvements in shoulder function and pain following augmented RCR, a paucity of rigorous clinical evaluation, for both effectiveness and safety, prevents firm recommendations.

PROSPERO REGISTRATION NUMBER

CRD42017057908.

A new decellularized tendon scaffold for rotator cuff tears - evaluation in rabbits

Background

Scaffolds have considerably advanced in recent years. In orthopaedic surgery, scaffolds have been used as grafts in procedures involving tendon and ligament reconstruction. This paper aimed to produce and evaluate decellularized tendon scaffolds (DTSs) from biomechanical, microscopic, macroscopic and in vivo perspectives.

Methods

Bilateral gastrocnemius muscle tendons from 18 adult New Zealand rabbits were collected. Of these 36 tendons, 11 were used as controls (Group A - control), and 25 were used in the decellularization protocol (Group B - DTS). The groups were subjected to histological, biomechanical and macroscopic analyses, and Group B - DTS was subjected to an additional in vivo evaluation. In the decellularization protocol, we used a combination of aprotinin, ethylenediamine tetraacetic acid (EDTA), sodium dodecyl sulfate (SDS) and t-octyl-phenoxypolyethoxyethanol (Triton X-100) for six days. During this period, the scaffolds were kept at room temperature on an orbital shaker with constant motion.

Results

The DTSs showed an increased cross-sectional area and inter-fascicular distance and no change in parallelism or matrix organization. The nuclear material was not organized in the DTSs as it was in the control. In the biomechanical analysis, no significant differences were found between the groups after analysing the ultimate tensile load, stiffness, and elongation at the ultimate tensile load. During the in vivo evaluation, mononuclear cell infiltration was noted.

Conclusions

The evaluated decellularization protocol generated a tendon scaffold, maintained the most important biomechanical characteristics and permitted cell infiltration.

Factors Related to Pain in Patients With Retorn Rotator Cuffs: Early Postoperative Pain Predicts Pain at 12 Months Postoperatively

Background:

Retearing of a repaired rotator cuff leads to diverse symptoms, including pain, regardless of the degree of the tear, but the relationship between pain and retears is poorly understood.

Purpose:

To determine which factors are correlated with shoulder pain in retears of a repaired rotator cuff.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

We retrospectively reviewed a cohort of patients who were diagnosed as having a retear on magnetic resonance imaging after primary rotator cuff repair. The primary outcome variable of interest was the visual analog scale (VAS) for pain score at 12-month and final follow-up (mean, 25.2 months). We evaluated the relationship of pain at 12-month and final follow-up with preoperative patient factors (age, sex, and underlying conditions), preoperative range of motion, and preoperative pain; postoperative pain at 3 and 6 months; and perioperative conditions (tear extent, tear size, accompanying lesions, and procedures other than rotator cuff repair).

Results:

A total of 48 patients were reviewed. The VAS score at 3 months postoperatively showed a positive correlation with the VAS score at 12 months postoperatively (ρ = 0.537; P < .001) and at final follow-up (ρ = 0.537; P < .001). Univariate and multivariate regression analyses revealed that the VAS score at 3 months postoperatively (P = .0001 and P = .0017, respectively), hypertension (P = .0108 and P = .0073, respectively), and late detection of the retear (P = .0091 and P = .0208, respectively) were significant predictors of pain at 12 months postoperatively.

Conclusion:

The presence of pain in the early postoperative period, underlying hypertension, and late detection of the retear were related to pain severity in patients 12 months after rotator cuff surgery.

Clinical Outcomes Following Biologically Enhanced Patch Augmentation Repair as a Salvage Procedure for Revision Massive Rotator Cuff Tears

PURPOSE

To evaluate the clinical outcomes of patients who underwent biologically enhanced patch augmentation repair for the treatment of revision massive rotator cuff tears.

METHODS

Twenty-two patients who underwent arthroscopic and mini-open rotator cuff repair using a patch augmented with platelet-rich plasma and concentrated bone marrow aspirate (cBMA) for revision massive (≥2 tendons) rotator cuff tears from 2009 to 2014, with a minimum 1-year follow-up, were included in the study. In this procedure the medial side of the graft is secured to the rotator cuff tendon remaining medially. American Shoulder and Elbow Surgeons (ASES), Simple Shoulder Test, and postoperative Single Assessment Numerical Evaluation scores were evaluated. To determine the clinical relevance of ASES scores, the minimal clinically important difference, substantial clinical benefit (SCB), and the patient-acceptable symptomatic state (PASS) thresholds were used. Clinical success or failure was defined based on whether the patient reached the SCB threshold. In the laboratory, cellular counting along with the concentration of connective tissue progenitor cells were performed on patch samples from the day of surgery. Scaffolds were processed histologically at days 0, 7,14, and 21 of culture.

RESULTS

Patients had significant improvement in the Simple Shoulder Test (2.6 ± 3.0_pre vs 5.2 ± 4.2_post, P = .01), whereas improvement in pain scores was found to be nonsignificant (5.6 ± 2.5_pre vs 4.2 ± 3.4_post,P = .11) at final follow-up. Mean ASES improved by Δ14.6 ± 33.4 points; however, this did not reach statistical significance (40.2 ± 21.6_pre vs 53.9 ± 31.4_post,P = .10). With regards to ASES score, 45% of patients achieved the minimal clinically important difference, 41% the SCB, and 32% reached or exceeded the PASS criteria. At 21 days, there was a significantly greater cell count in scaffolds from patients who had clinical success than those who were failures (P = .02).

CONCLUSIONS

Only 41% of patients undergoing biologically enhanced patch augmentation repair reached substantial clinical benefit, whereas 32% reached or exceeded the PASS criteria.

LEVEL OF EVIDENCE

Case Series: Level IV.

Editorial Commentary: Biologically-Enhanced Patch Augmentation: The Perfect Marriage of Mechanical Stability and Biology for Rotator Cuff Healing? Unfortunately, Not Yet

Recurrent rotator cuff tears are a frequent cause of shoulder disability. To repair a rotator cuff, the surgeon faces both mechanical and biological challenges. Patch use as a scaffold for rotator cuff repair is well-described, as is biological augmentation, with clinical indications and efficacy being the subjects of ongoing study. However, a clinical report of dermal allograft patch augmentation combined with attempts at supercharging the biology is novel. This technique would benefit from controlled, prospective studies, with tight inclusion criteria.

Epidemiological Analysis of Changes in Clinical Practice for Full-Thickness Rotator Cuff Tears From 2010 to 2015

Background:

Rotator cuff injuries are a leading cause of shoulder disability among adults. Surgical intervention is a common treatment modality; however, conservative management has been described for the treatment of rotator cuff tears. As the cost of health care increases, the industry has shifted to optimizing patient outcomes, reducing readmissions, and reducing expenditure. In 2010, the American Academy of Orthopaedic Surgeons created clinical practice guidelines (CPGs) to guide the management of rotator cuff injuries. Since their publication, there have been several randomized controlled trials assessing the management of rotator cuff injuries.

Purpose:

To quantitatively describe changes in the management of full-thickness rotator cuff tears over time with regard to the publication of the CPGs and prospective clinical trials.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included in the study were Humana-insured patients in the PearlDiver database with the diagnosis of a full-thickness rotator cuff tear from 2010 to 2015. Patients undergoing rotator cuff repair (CPT-29827, CPT-23410, CPT-23412, CPT-23420) and patients undergoing nonoperative management in the queried years were identified. The incidence of physical therapy (PT), nonsteroidal anti-inflammatory drugs (NSAIDs), and corticosteroid injections was assessed.

Results:

In 2015, patients with full-thickness rotator cuff tears were less likely to receive a corticosteroid injection (16.5% vs 23.9%, respectively; odds ratio [OR], 0.6; P < .001) or undergo PT (7.8% vs 12.1%, respectively; OR, 0.6; P < .001) before rotator cuff repair in comparison with 2010. Additionally, patients were no more likely to be prescribed NSAIDs before rotator cuff repair in 2015 in comparison with 2010 (OR, 1.0; P = .6). Patients with full-thickness rotator cuff tears were less likely to undergo acromioplasty in 2015 in comparison with 2010 (48.2% vs 76.9%, respectively; OR, 0.4; P < .001); however, the rate of concomitant biceps tenodesis slightly increased (14.8% vs 14.6%, respectively; OR, 1.1; P = .01).

Conclusion:

From 2010 to 2015, there were changes in the management of full-thickness rotator cuff tears, including decreased preoperative utilization of corticosteroid injections and PT as well as a decrease in concomitant acromioplasty, and the rate of biceps tenodesis slightly increased. As CPGs and prospective investigations continue to proliferate, management practices of patients with full-thickness rotator cuff tears continue to evolve.

Arthroscopic Rotator Cuff Repair With Allograft Augmentation: Making It Simple

Rotator cuff tears are increasing in frequency in the aging population and are a common issue seen by orthopaedic surgeons. In patients with large, multi-tendon rotator cuff tears or retears, treatment can be challenging. Failure rates of up to 90% have been reported for rotator cuff repair (RCR) of large, multi-tendon tears. Biological augmentation has been an area of interest because of the distinctly different biology of the repaired tendon compared with the native tendon. These biological differences affect the ultimate tensile properties of the repair and may contribute to gap formation and the high failure rate of repairs. RCR with allograft augmentation is a technique that shows potential benefit to healing and preventing retears. Arthroscopic augmentation of RCRs can be challenging. The technique described in this Technical Note illustrates a simple and easily reproducible method for augmenting RCRs with human acellular dermal allograft.