Arthroscopic Biologic Interpositional Tuberosity Graft for the Treatment of Irreparable Rotator Cuff Tears

Editorial Commentary: Bursal Acromial Resurfacing Offers Improved Biomechanics in Laboratory Studies but There Is No Consensus on Indications, Technique, or Graft Type, and Clinical Results Are Lacking

Bursal acromial reconstruction/resurfacing, acromiograft, and biologic tuberoplasty are all terms used to describe the concept of fixing a graft (human dermal allograft or fascia lata) to the undersurface of the acromion or onto the greater tuberosity with the aim of achieving pain relief and improved function in patients with massive irreparable cuff tears. The rationale for these procedures is based on the biomechanical concept that an interpositional spacer can reverse superior migration of the humeral head, increase acromiohumeral distance, reduce subacromial contact pressure, and limit painful bone-on-bone contact. These types of procedures are postulated to offer potential advantages (cost savings related to use of implants, long-term biologic solution, technical ease of surgery, and short surgical time) over other options for massive irreparable cuff tears, particularly superior capsule reconstruction and in some respects the subacromial balloon. However, these advantages remain unproven because published clinical studies are sparse. Furthermore, there is no current consensus on indications, technique, or optimum graft choice.

Superior Capsule Reconstruction Using an Acellular Dermal Matrix Allograft Combined With Remnant Tendon Augmentation for Irreparable Rotator Cuff Tear

Graft fixation sites on the greater tuberosity and the superior glenoid for superior capsule reconstruction (SCR) are prone to graft failure. The graft fixation procedure on the superior glenoid is challenging due to the limited working space, narrow graft attachment site, and difficulties in suture management. This technical note introduces the surgical technique of SCR using an acellular dermal matrix allograft combined with remnant tendon augmentation to enhance graft healing and the suture management technique to prevent suture tangling for the treatment of irreparable rotator cuff tear.

Treatment options for massive irreparable rotator cuff tears: a review of arthroscopic surgical options

While functional reconstruction of massive irreparable rotator cuff tears remains a challenge, current techniques aimed at recentering and preventing superior migration of the humeral head allow for clinical and biomechanical improvements in shoulder pain and function. Recentering of the glenohumeral joint reduces the moment arm and helps the deltoid to recruit more fibers, which compensates for insufficient rotator cuff function and reduces joint pressure. In the past, the concept of a superior capsular reconstruction with a patch secured by suture anchors has been used. However, several innovative arthroscopic treatment options have also been developed. The purpose of this article is to present an overview of new strategies and surgical techniques and if existing present initial clinical results. Techniques that will be covered include rerouting the long head of the biceps tendon, utilization of the biceps tendon as an autograft to reconstruct the superior capsule, utilization of a semitendinosus tendon allograft to reconstruct the superior capsule, superior capsular reconstruction with dermal allografts, and subacromial spacers.

Preliminary Outcomes of Arthroscopic Biologic Tuberoplasty in the Treatment of Massive Irreparable Rotator Cuff Tears

INTRODUCTION

Several treatment options exist for the treatment of massive, irreparable rotator cuff tears. A novel technique has been described whereby an acellular dermal allograft is secured to the greater tuberosity which acts as an interpositional tissue preventing bone-to-bone contact between the greater tuberosity and acromion. The preliminary results of this arthroscopic procedure are being presented.

METHODS

Patients who underwent a biologic tuberoplasty procedure between 2015 and 2022, by a single surgeon, were included in this study. Pre- and postoperative American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and visual analogue pain scores (VAS) were prospectively recorded and retrospectively reviewed. Postoperative MRI was obtained in some cases. Paired t-test was used to calculate significance set at <0.05.

RESULTS

Ten patients met the inclusion criteria. The mean age was 70.4+4.7 years (range 65-78). There were five males. The mean length of follow-up was 21+27 months (range six to 95 months). There was significant improvement in ASES (24.3+4 to 91.5+10.3, P<0.00001), SANE (22.5+10.3 to 88+11.6, P<0.00001), and VAS (8.8+0.6 to 1.1+2.5, P<0.00001). MRI was obtained in seven patients at a mean of 5.3+2.9 months and showed a healed graft to the tuberosity in all cases.

CONCLUSION

Biologic tuberoplasty is an effective procedure in improving pain and functional outcomes in patients with massive, irreparable rotator cuff tears.

Dermal Tuberoplasty for Irreparable Supraspinatus Tears Using Self-Punching, Knotless Fixation

Superior capsular reconstruction has become an accepted treatment option for the irreparable rotator cuff tear in the nonarthritic shoulder. Widespread adoption of this technique has been limited, however, because of the technical difficulty of performing this procedure. Recently, allograft interpositional grafting of the greater tuberosity has gained popularity as a simpler alternative to superior capsular reconstruction and provides similar joint preservation advantages. We describe a technique for allograft interpositional tuberoplasty that simplifies graft delivery, graft fixation, and suture management by using a graft inserter and self-punching, knotless soft anchors.

Arthroscopic Biologic Tuberoplasty for Irreparable Rotator Cuff Tears: An Expedited Technique

Massive irreparable rotator cuff tears in patients for whom arthroplasty is not an option can be a challenging clinical scenario for shoulder surgeons to manage. To achieve the best patient outcomes, a myriad of options has been presented in the literature, including debridement with biceps tenotomy or tenodesis, various tendon transfer procedures, superior capsular reconstruction, biceps tendon rerouting, bursal acromion resurfacing, balloon spacers, and tuberoplasty. While debridement with biceps tenotomy and superior capsular reconstruction have historically provided improvements in patient-reported outcomes, high rates of arthritis progression and failure of graft healing have been noted with these techniques, respectively. The superior capsular reconstruction has also proven to be technically challenging. The biologic tuberoplasty procedure was developed after several studies noted a lack of correlation between graft healing and improvement in patient-reported outcomes in superior capsular reconstructions, as long as the tuberosity remained covered with the graft. We present a technically efficient and expedited technique using an acellular human dermal allograft.

Early Treatment of Shoulder Pathology Is Necessary but Not Enough Is Being Performed

Delayed treatment of shoulder instability results in bone loss requiring more-complicated surgery, in turn resulting in less-optimal outcomes. Similarly, delayed treatment of repairable rotator cuff tears results in irreparable tears requiring more-complicated surgery and resulting in less-optimal outcomes. Delayed treatment of shoulder pathology is a problem. Solutions include education and research investigation.