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Kantanavar R, Lee IE, Rhee SM, Rhee YG. Outcomes of arthroscopic single-row repair alone vs. repair with human dermal allograft patch augmentation in patients with large to massive, posterosuperior rotator cuff tears: a retrospective comparative study. J Shoulder Elbow Surg 2024; 33:823-831. [PMID: 37689106 DOI: 10.1016/j.jse.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Large to massive rotator cuff tears (RCTs) affect shoulder functions profoundly with unmanageable disability without intervention. The retear rates with arthroscopic rotator cuff repair (ARCR) in these patients are abysmal. Patch augmentation has been credited for preventing retears, improving functions by increasing the strength, and acting as a bioconductive scaffold. This study aimed to assess the retear rates and compare the clinical and radiological outcomes between the ARCR with and without acellular human dermal allograft (HDA) augmentation. METHODS This is a retrospective comparative study among patients diagnosed with large to massive, posterosuperior RCTs, operated between January 2020 and December 2021, including 36 patients (group I) with and 131 patients (group II) without HDA augmentation, with a mean follow-up of 20 (range, 12-35) months. The average age was 64 (range, 49-80) and 66 (range, 41-81) years in groups I and II, respectively. In group I, there were 16 male and 20 female patients, whereas in group II, there were 58 male and 73 female patients. RESULTS The visual analog scale score improved to 1.1 ± 1.7 in group I and 2.1 ± 1.7 in group II (P = .005). There was a greater improvement in the University of California, Los Angeles shoulder score to 30.1 ± 4.2 in group I compared with 23.2 ± 3.9 in group II (P = .046). Forward flexion (degrees) improved from a mean of 103.2 ± 18.6 to 138.9 ± 23.5 in group I and from 106.4 ± 21.3 to 127.0 ± 19.5 in group II (P = .004). The acromiohumeral interval (mm) measured in anteroposterior radiographs increased to 8.4 ± 1.8 in group I and 8.2 ± 2.0 in group II (P = .006). The satisfaction after the procedure was 4.4 ± 0.6 in group I and 3.1 ± 1.1 in group II (P = .044). The retear rate in the HDA-augmented group was 5.6% as compared with 29.1% in the nonaugmented group, which was statistically significant (P = .007). There were no complications or adverse tissue reactions against HDA seen in any patients. CONCLUSION In patients with large to massive, posterosuperior RCTs, patch augmentation with acellular HDA significantly averted the retears after ARCR without any graft-related complications. The augmentation also resulted in improved shoulder function and greater range of motion compared with the nonaugmented group.
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Affiliation(s)
- Radhakrishna Kantanavar
- Department of Orthopaedic Surgery, Shoulder & Elbow Clinic, Myongji Hospital, Goyang-si, Kyunggi Gyeonggi-do, Republic of Korea
| | - In El Lee
- Department of Orthopaedic Surgery, Shoulder & Elbow Clinic, Myongji Hospital, Goyang-si, Kyunggi Gyeonggi-do, Republic of Korea
| | - Sung Min Rhee
- Department of Orthopaedic Surgery, Shoulder & Elbow Clinic, College of Medicine, KyungHee University Hospital, Seoul, Republic of Korea
| | - Yong Girl Rhee
- Department of Orthopaedic Surgery, Shoulder & Elbow Clinic, Myongji Hospital, Goyang-si, Kyunggi Gyeonggi-do, Republic of Korea.
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Kim SH, Shin SJ. No Difference In Clinical Outcomes Following Repair of Large Retracted Anterior Rotator Cuff Tears Using Patch Augmentation With Human Dermal Allograft Versus Anterior Cable Reconstruction With Biceps Tendon Autograft. Arthroscopy 2024; 40:294-302. [PMID: 37716630 DOI: 10.1016/j.arthro.2023.08.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Revised: 08/17/2023] [Accepted: 08/20/2023] [Indexed: 09/18/2023]
Abstract
PURPOSE To compare the clinical outcomes and tendon integrity after rotator cuff repair combined with anterior cable reconstruction (ACR) using the proximal biceps tendon and patch augmentation (PA) using a human dermal allograft (HDA) in a large retracted anterior rotator cuff tear. METHODS Patients who underwent arthroscopic rotator cuff repair with 2 different augmentation procedures between January 2017 and December 2020 were enrolled. The inclusion criteria were patients who were treated by arthroscopic rotator cuff repair with ACR using the proximal biceps tendon (ACR group) or patch augmentation using a an HDA (PA group) and follow-up for at least 2 years. Clinical outcomes were assessed using American Shoulder and Elbow Surgeons (ASES) score, Constant score, and the number of patients who achieved minimal clinically important differences (MCID). Magnetic resonance imaging was performed to evaluate tendon integrity after surgery. RESULTS A total of 92 patients were enrolled (ACR group = 55 patients and PA group = 37 patients). The mean ASES and Constant scores significantly improved in the ACR group (68.8 ± 15.3 and 58.4 ± 16.9 before surgery vs 91.4 ± 6.3 and 87.8 ± 6.0 after surgery, P < .001) and in the PA group (63.7 ± 16.7 and 57.9 ± 15.4 before surgery vs 93.1 ± 6.3 and 88.3 ± 6.2 after surgery, P < .001). Overall, 78 patients (84.8%) achieved the MCID with 81.8% in the ACR group and 89.2% in the PA group, with no significant differences between the 2 groups (P = .638). Ten patients (18.2%) had retear in the ACR group, and three patients (8.1%) had retear in the PA group (P = .174). CONCLUSIONS In large retracted anterior rotator cuff tears, both augmentation techniques using biceps tendon autograft and HDA provided satisfactory clinical outcomes that achieved the MCID in 84.8%, range of motion restoration, and lower retear rates with no significant differences between the two groups. LEVEL OF EVIDENCE Level III, retrospective case-control study.
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Affiliation(s)
- Seong Hun Kim
- Department of Orthopedic Surgery, National Health Insurance Service Ilsan Hospital, Gyeonggi, Republic of Korea
| | - Sang-Jin Shin
- Department of Orthopedic Surgery, College of Medicine, Ewha Womans University Seoul Hospital, Seoul, Republic of Korea.
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Bi AS, Anil U, Colasanti CA, Kwon YW, Virk MS, Zuckerman JD, Rokito AS. Comparison of Multiple Surgical Treatments for Massive Irreparable Rotator Cuff Tears in Patients Younger Than 70 Years of Age: A Systematic Review and Network Meta-analysis. Am J Sports Med 2024:3635465231204623. [PMID: 38291995 DOI: 10.1177/03635465231204623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Massive irreparable rotator cuff tears (MIRCTs) remain a challenging treatment paradigm, particularly for nonelderly patients without pseudoparalysis or arthritis. PURPOSE To use a network meta-analysis to analyze comparative studies of surgical treatment options for MIRCTs in patients <70 years of age for several patient-reported outcomes, range of motion (ROM), and acromiohumeral distance (AHD). STUDY DESIGN Network meta-analysis of comparative studies; Level of evidence, 3. METHODS A systematic review of the literature, using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, of the MEDLINE, Embase, and Cochrane Library databases was conducted from 2017 to 2022. Inclusion criteria were (1) clinical comparative studies of MIRCTs (with several study-specific criteria); (2) ≥1 outcome of interest reported on, with standard deviations; (3) minimum 1-year follow-up; and (4) mean age of <70 years for both cohorts, without arthritis or pseudoparalysis. There were 8 treatment arms compared. Outcomes of interest were the American Shoulder and Elbow Surgeons (ASES) score, Constant-Murley score, visual analog scale for pain, AHD, and forward flexion and external rotation ROM. A frequentist approach to network meta-analysis with a random-effects model was performed using the netmeta package Version 0.9-6 in R. RESULTS A total of 23 studies met the inclusion criteria, with 1178 patients included in the network meta-analysis. There was a mean weighted age of 62.8 years, 568 (48.2%) men, with a mean follow-up of 28.9 months. There were no significant differences between groups in regard to sex (P = .732) or age (P = .469). For the ASES score, InSpace balloon arthroplasty (mean difference [MD], 12.34; 95% CI, 2.18 to 22.50; P = .017), arthroscopic bridging graft (aBG) (MD, 7.07; 95% CI, 0.28 to 13.85; P = .041), and long head of biceps augmented superior capsular reconstruction (BSCR) (MD, 5.16; 95% CI, 1.10 to 9.22; P = .013) resulted in the highest P-scores. For the Constant-Murley score, debridement (MD, 21.03; 95% CI, 8.98 to 33.08; P < .001) and aBG (MD, 6.97; 95% CI, 1.88 to 12.05; P = .007) resulted in the highest P-scores. For AHD, BSCR resulted in the highest P-score (MD, 1.46; 95% CI, 0.45 to 2.48; P = .005). For forward flexion ROM, debridement (MD, 45.77; 95% CI, 25.41 to 66.13; P < .001) resulted in the highest P-score, while RSA resulted in the lowest P-score (MD, -16.70; 95% CI, -31.20 to -2.20; P = .024). CONCLUSION For patients <70 years with MIRCT without significant arthritis or pseudoparalysis, it appears that graft interposition repair techniques, superior capsular reconstruction using the long head of the biceps tendon, arthroscopic debridement, and balloon arthroplasty provide superiority in various outcome domains, while RSA provides the least benefit in forward flexion.
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Affiliation(s)
- Andrew S Bi
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Utkarsh Anil
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Christopher A Colasanti
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Young W Kwon
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Mandeep S Virk
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Joseph D Zuckerman
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
| | - Andrew S Rokito
- Department of Orthopedic Surgery, Division of Shoulder and Elbow Surgery, NYU Langone Health, New York, New York, USA
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Mazy D, Chung-Tze-Cheong C, Ma Z, Huo R, Lamer S, Li J, Nault ML. Tough gel adhesive is an effective method for meniscal repair in a bovine cadaveric study. J Exp Orthop 2023; 10:139. [PMID: 38095758 PMCID: PMC10721589 DOI: 10.1186/s40634-023-00691-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 11/13/2023] [Indexed: 12/17/2023] Open
Abstract
PURPOSE To test tough gel adhesives to repair meniscus tears under relevant loading conditions and determine if they have adequate biomechanical properties to repair meniscus tears in a bovine cadaveric study. METHODS Cyclic compression tests on 24 dissected bovine knees were performed. The tough gel adhesive was used either as an adhesive patch or as a coating bonded onto commercially available surgical sutures. Forty-eight menisci were tested in this study; 24 complete radial tears and 24 bucket-handle tears. After preconditioning, the specimens underwent 100 cycles of compression, (800 N/0.5 Hz) on an Instron© machine and the size of the gaps measured. One third of the menisci were repaired with pristine sutures, one third with adhesive patches, and one third with sutures coated in adhesive gel. The size of the gaps was compared after 100 and 500 cycles of compression. RESULTS The mean gap measured at the tear site without treatment was 6.46 mm (± 1.41 mm) for radial tears and 1.92 mm (± 0.65 mm) for bucket-handle tears. After treatment and 500 cycles of compression, the mean gap was 1.63 mm (± 1.41 mm) for pristine sutures, 1.50 mm (± 1.16 mm) for adhesive sutures and 2.06 mm (± 1.53 mm) for adhesive gel patches. There was no significant difference between treatments regardless of the type of tear. Also, the gaps for radial tears increased significantly with the number of compression cycles applied (p > 0.001). CONCLUSION From a biomechanical standpoint, the tough adhesive gel patch is as effective as suturing. In addition, it would allow the repair of non-suturable tears and thus broaden the indications for meniscus repair. LEVEL OF EVIDENCE Controlled laboratory study.
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Affiliation(s)
- David Mazy
- University of Montreal, 2900 Boul. Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada
- CHU Sainte-Justine, 3175 Chemin de La Côte-Sainte-Catherine, Montréal, QC, H3T 1C5, Canada
| | - Christopher Chung-Tze-Cheong
- Department of Mechanical Engineering, McGill University, 817 Sherbrooke Street West Montreal, Quebec, H3A 0C3, Canada
| | - Zhenwei Ma
- Department of Mechanical Engineering, McGill University, 817 Sherbrooke Street West Montreal, Quebec, H3A 0C3, Canada
| | - Ran Huo
- Department of Mechanical Engineering, McGill University, 817 Sherbrooke Street West Montreal, Quebec, H3A 0C3, Canada
| | - Stephanie Lamer
- University of Montreal, 2900 Boul. Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada
| | - Jianyu Li
- Department of Mechanical Engineering, McGill University, 817 Sherbrooke Street West Montreal, Quebec, H3A 0C3, Canada.
- Department of Biomedical Engineering, McGill University, 3775 Rue University Montréal, Montreal, QC, H3A 2B4, Canada.
- Department of Surgery, McGill University, 1650 Cedar Ave, Montreal, QC, H3G 1A4, Canada.
| | - Marie-Lyne Nault
- University of Montreal, 2900 Boul. Edouard-Montpetit, Montréal, QC, H3T 1J4, Canada.
- CHU Sainte-Justine, 3175 Chemin de La Côte-Sainte-Catherine, Montréal, QC, H3T 1C5, Canada.
- Department of Orthopedic Surgery, CIUSSS Hôpital du Sacré-Coeur de Montréal (HSCM), 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada.
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Dommer LM, Chlasta A, Rojas JT, Hayoz A, Schär M, Zumstein MA. Massive rotator cuff tears with short tendon length can be successfully repaired using synthetic patch augmentation. J Shoulder Elbow Surg 2023; 32:2089-2096. [PMID: 37178963 DOI: 10.1016/j.jse.2023.03.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Revised: 03/24/2023] [Accepted: 03/30/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Choosing the optimal treatment for massive rotator cuff tears (MRCTs) still poses a surgical problem. In MRCTs with good muscle quality, but short tendon length, nonaugmented repairs lead to high failure rates of up to 90%. The aim of the study was to evaluate midterm clinical and radiologic outcomes of massive rotator cuff tears with good muscle quality, but short tendon length, which were repaired with synthetic patch augmentation. METHODS A retrospective study of patients who underwent arthroscopic or open rotator cuff repairs with patch augmentation between 2016 and 2019 was performed. We included patients older than 18 years, who presented with an MRCT confirmed by an magnetic resonance imaging (MRI) arthrogram showing good muscle quality (Goutallier ≤ II) and short tendon length (length <15 mm). Constant-Murley score (CS), Subjective Shoulder Value (SSV), and range of motion (ROM) were compared pre- and postoperatively. We excluded patients older than 75 years or with presence of rotator cuff arthropathy Hamada stage ≥2a. Patients were followed up for 2 years minimum. Clinical failures were defined by reoperation, forward flexion <120° or a relative CS < 70. Structural integrity of the repair was assessed using an MRI scan. Comparison between different variables and outcomes was performed using Wilcoxon-Mann-Whitney and χ2 tests. RESULTS Fifteen patients (mean age 57 years, 13 [86.7%] male, 9 [60%] right shoulders) were reevaluated with a mean follow-up of 43.8 months (27-55 months). There was a significant improvement in the absolute CS (from 33 to 81 points, P = .03), the relative CS (from 41% to 88%, P = .04), the SSV (from 31% to 93%, P = .007), and forward flexion (from 111° to 163°, P = .004) but not in external rotation (from 37° to 38°, P = .5). There were 3 clinical failures (1 atraumatic, 2 traumatic) with reoperations (2 reverse total shoulder arthroplasties and 1 refixation). Structurally, there were 3 Sugaya grade 4 and 5 Sugaya grade 5 reruptures resulting in a retear rate of 53%. The presence of a complete or partial rerupture was not associated with inferior outcomes compared with intact cuff repairs. There were no correlations between the grade of retraction, muscle quality, or rotator cuff tear configuration and rerupture or functional outcomes. CONCLUSION Patch augmented cuff repair leads to a significant improvement of functional and structural outcomes. Partial reruptures were not associated with inferior functional outcomes. Prospective randomized trials are needed to confirm the results found in our study.
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Affiliation(s)
- Lukas M Dommer
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland
| | - Adrian Chlasta
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland
| | - J Tomás Rojas
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland; Department of Orthopaedics and Trauma Surgery, Hospital San José - Clínica Santa María, Santiago, Chile
| | - Annabel Hayoz
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland
| | - Michael Schär
- Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Matthias A Zumstein
- Shoulder, Elbow and Orthopaedic Sports Medicine, Sonnenhof Orthopaedics, Bern, Switzerland; Shoulder, Elbow and Orthopaedic Sports Medicine, Department of Orthopaedic Surgery and Traumatology, Inselspital, Bern University Hospital, Bern, Switzerland; Campus Stiftung Lindenhof Bern, Swiss Institute for Translational and Entrepreneurial Medicine, Bern, Switzerland.
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Mandalia K, Mousad A, Welborn B, Bono O, Le Breton S, MacAskill M, Forlizzi J, Ives K, Ross G, Shah S. Scaffold- and graft-based biological augmentation of rotator cuff repair: an updated systematic review and meta-analysis of preclinical and clinical studies for 2010-2022. J Shoulder Elbow Surg 2023; 32:1784-1800. [PMID: 37178960 DOI: 10.1016/j.jse.2023.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 03/05/2023] [Accepted: 03/22/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND Despite advancements in the surgical techniques of rotator cuff repair (RCR), there remains a high retear rate. Biological augmentation of repairs with overlaying grafts and scaffolds may enhance healing and strengthen the repair construct. This study aimed to investigate the efficacy and safety of scaffold-based (nonstructural) and overlay graft-based (structural) biological augmentation in RCR (excluding superior capsule reconstruction and bridging techniques) in both preclinical and clinical studies. METHODS This systematic review was performed in adherence to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, as well as guidelines outlined by The Cochrane Collaboration. A search of the PubMed, Embase, and Cochrane Library databases from 2010 until 2022 was conducted to identify studies reporting the clinical, functional, and/or patient-reported outcomes of ≥1 biological augmentation method in either animal models or humans. The methodologic quality of included primary studies was appraised using the Checklist to Evaluate a Report of a Non-pharmacological Trial (CLEAR-NPT) for randomized controlled trials and using the Methodological Index for Non-randomized Studies (MINORS) for nonrandomized studies. RESULTS A total of 62 studies (Level I-IV evidence) were included, comprising 47 studies reporting outcomes in animal models and 15 clinical studies. Of the 47 animal-model studies, 41 (87.2%) demonstrated biomechanical and histologic enhancement with improved RCR load to failure, stiffness, and strength. Of the 15 clinical studies, 10 (66.7%) illustrated improvement in postoperative clinical, functional, and patient-reported outcomes (eg, retear rate, radiographic thickness and footprint, and patient functional scores). No study reported a significant detriment to repair with augmentation, and all studies endorsed low complication rates. A meta-analysis of pooled retear rates demonstrated significantly lower odds of retear after treatment with biological augmentation of RCR compared with treatment with non-augmented RCR (odds ratio, 0.28; P < .00001), with low heterogeneity (I2 = 0.11). CONCLUSIONS Graft and scaffold augmentations have shown favorable results in both preclinical and clinical studies. Of the investigated clinical grafts and scaffolds, acellular human dermal allograft and bovine collagen demonstrate the most promising preliminary evidence in the graft and scaffold categories, respectively. With a low risk of bias, meta-analysis revealed that biological augmentation significantly lowered the odds of retear. Although further investigation is warranted, these findings suggest graft and scaffold biological augmentation of RCR to be safe.
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Affiliation(s)
- Krishna Mandalia
- Tufts University School of Medicine, Boston, MA, USA; New England Shoulder and Elbow Center, Boston, MA, USA.
| | - Albert Mousad
- Tufts University School of Medicine, Boston, MA, USA
| | | | | | | | | | | | | | - Glen Ross
- New England Baptist Hospital, Boston, MA, USA
| | - Sarav Shah
- New England Baptist Hospital, Boston, MA, USA
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