Arthroscopic Rotator Cuff Repair With Graft Augmentation of 3-Dimensional Biological Collagen for Moderate to Large Tears: A Randomized Controlled Study

Compression of an Autograft Biceps into an Augmentation Patch does not Cause Mechanical Damage to the Tenocyte

PURPOSE

A compression plate has recently been reported as a point of care processor for adapting the long head of the biceps into an autograft patch for rotator cuff augmentation. The purpose of this study was to evaluate the effects of this graft preparation technique on histological evidence of tenocyte mechanical damage.

METHODS

A consecutive series of patients undergoing biceps tenodesis for shoulder pathology were evaluated. After supra-pectoral tenodesis, 27 mm of the long head of the biceps was secured for compression into the patch. The remaining length of residual tendon was longitudinally split, resulting in two equal lengths of remnant tendon from the same zone. One sample was sent to pathology with no preparation, and the other was prepared as a compressed biceps autograft patch according to the manufacturer's recommendations. Both grafts were sent to pathology for evaluation of tenocyte morphology. Records were reviewed to determine if compression resulted in mechanical damage to the tenocytes at the time of biceps augmentation.

RESULTS

55 shoulder procedures and 110 samples were sent for pathology analysis. 42 of the 55 (76%) specimens demonstrated morphologically normal tenocytes in both the compressed and non-compressed groups, and 7 (13%) cases showed evidence of tenocyte necrosis or mechanical damage in both groups. The difference abnormal tenocyte morphology between the compressed group and the native group was not statistically significant (p=0.625).

CONCLUSION

Autograft biceps compression into a point of care patch did not result in mechanical damage to tenocyte morphology at the time of insertion for augmentation of rotator cuff pathology.

CLINICAL RELEVANCE

Free proximal biceps tendon compression can result in a patch that does not mechanically damage the tenocyte. The patch can be used as a biologic autograft to enhance shoulder rotator cuff repair, as well as subscapularis repair in the setting of shoulder arthroplasty.

Patch Augmentation in Arthroscopic Rotator Cuff Surgery-Review of Current Evidence and Newest Trends

Background: Rotator cuff tears are a common and debilitating condition requiring surgical intervention. Arthroscopic rotator cuff repair is essential for restoring shoulder function and alleviating pain. Tear classification by size and tendon retraction, along with the grade for fatty infiltration, influence postoperative outcomes, with large tears and higher fatty infiltration grades linked to higher retear rates. Managing complex tears is challenging, with failure rates ranging from 20 to 94%. Patch augmentation has emerged as a promising strategy, using biological or synthetic materials to reinforce tendon repairs, enhancing structural integrity and reducing retear risk. Methods: A review of the recent literature from January 2018 to March 2024 was conducted using PubMed/MEDLINE, Embase, and Web of Science. Keywords included "rotator cuff tear", "rotator cuff augmentation", "rotator cuff patch", "tendon augmentation", "massive rotator cuff tear", "patch augmentation", and "grafts". Relevant articles were selected based on their abstracts for a comprehensive review. Results: Initial methods used autograft tissues, but advances in biomaterials have led to standardized, biocompatible synthetic patches. Studies show reduced retear rates with patch augmentation, ranging from 17 to 45%. Conclusions: Patch augmentation reduces the retear rates and improves tendon repair, but complications like immune responses and infections persist. Cost-effectiveness analyses indicate that while initial costs are higher, long-term savings from reduced rehabilitation, revision surgeries, and increased productivity can make patch augmentation economically beneficial.

Partial-Thickness Rotator Cuff Tears: Current Concepts

» Partial-thickness rotator cuff tears (PTRCTs) are a common pathology with a likely high asymptomatic incidence rate, particularly in the overhead athlete.» The anatomy, 5-layer histology, and relationship to Ellman's classification of PTRCTs have been well studied, with recent interest in radiographic predictors such as the critical shoulder angle and acromial index.» Depending on the definition of tear progression, rates of PTRCT progression range from 4% to 44% and appear related to symptomatology and work/activity level.» Nearly all PTRCTs should be managed conservatively initially, particularly in overhead athletes, with those that fail nonoperative management undergoing arthroscopic debridement ± acromioplasty if <50% thickness or arthroscopic conversion repair or in situ repair if >50% thickness.» Augmentation of PTRCTs is promising, with leukocyte-poor platelet-rich plasma having the most robust body of supportive data. Mesenchymal signaling cell biologics and the variety of scaffold onlay augments require more rigorous studies before regular usage.

Nanofiber Graft Therapy to Prevent Shoulder Stiffness and Adhesions after Rotator Cuff Tendon Repair: A Comprehensive Review

Stiffness and adhesions following rotator cuff tears (RCTs) are common complications that negatively affect surgical outcomes and impede healing, thereby increasing the risk of morbidity and failure of surgical interventions. Tissue engineering, particularly through the use of nanofiber scaffolds, has emerged as a promising regenerative medicine strategy to address these complications. This review critically assesses the efficacy and limitations of nanofiber-based methods in promoting rotator cuff (RC) regeneration and managing postrepair stiffness and adhesions. It also discusses the need for a multidisciplinary approach to advance this field and highlights important considerations for future clinical trials.

3-Dimensional Bioprinting of a Tendon Stem Cell-Derived Exosomes Loaded Scaffold to Bridge the Unrepairable Massive Rotator Cuff Tear

BACKGROUND

Unrepairable massive rotator cuff tears (UMRCTs) are challenging to surgeons owing to the severely retracted rotator cuff musculotendinous tissues and extreme defects in the rotator cuff tendinous tissues.

PURPOSE

To fabricate a tendon stem cell-derived exosomes loaded scaffold (TSC-Exos-S) and investigate its effects on cellular bioactivity in vitro and repair in a rabbit UMRCT model in vivo.

STUDY DESIGN

Controlled laboratory study.

METHODS

TSC-Exos-S was fabricated by loading TSC-Exos and type 1 collagen (COL-I) into a 3-dimensional bioprinted and polycaprolactone (PCL)-based scaffold. The proliferation, migration, and tenogenic differentiation activities of rabbit bone marrow stem cells (BMSCs) were evaluated in vitro by culturing them in saline, PCL-based scaffold (S), COL-I loaded scaffold (COL-I-S), and TSC-Exos-S. In vivo studies were conducted on a rabbit UMRCT model, where bridging was repaired with S, COL-I-S, TSC-Exos-S, and autologous fascia lata (FL). Histological and biomechanical analyses were performed at 8 and 16 weeks postoperatively.

RESULTS

TSC-Exos-S exhibited reliable mechanical strength and subcutaneous degradation, which did not occur before tissue regeneration. TSC-Exos-S significantly promoted the proliferation, migration, and tenogenic differentiation of rabbit BMSCs in vitro. In vivo studies showed that UMRCT repaired with TSC-Exos-S exhibited significant signs of tendinous tissue regeneration at the bridging site with regard to specific collagen staining. Moreover, no significant differences were observed in the histological and biomechanical properties compared with those repaired with autologous FL.

CONCLUSION

TSC-Exos-S achieved tendinous tissue regeneration in UMRCT by providing mechanical support and promoting the trend toward tenogenic differentiation.

CLINICAL RELEVANCE

The present study proposes a potential strategy for repairing UMRCT with severely retracted musculotendinous tissues and large tendinous tissue defects.

Biomechanical comparison of suture bridge rotator cuff repair with and without dermal allograft pledgets

BACKGROUND

One method to augment rotator cuff repair is to pass dermal allograft pledgets along the sutures that bridge from the medial to the lateral row. It remains unclear whether this augmentation method alters repair biomechanics.

METHODS

This was a controlled laboratory study. After an a priori power analysis, 9 pairs of rotator cuffs underwent double-row suture bridge rotator cuff repair, half randomized to augmentation with dermal allograft pledgets passed along the suture bridge sutures. Repairs were then mounted on a material testing system and loaded cyclically 500 cycles to measure applied force and displacement. Repairs then underwent ultimate failure testing, and stiffness, ultimate failure force, and ultimate failure displacement were measured. Paired t tests were performed to compare between groups.

RESULTS

There were no differences between groups in construct gapping with cyclic loading after 500 cycles (P = .885). There were no differences between the augmented and control groups in yield force (103.5 ± 5.0 vs. 101.4 ± 5.9 N, respectively, P = .183), stiffness (94.2 ± 13.9 vs. 90.9 ± 13.8, P = .585), or ultimate failure force (255.3 ± 65.8 vs. 285.3 ± 83.2, P = .315). There were no differences between groups in failure modes, with most specimens failing by cuff tissue tearing within or medial to the construct.

CONCLUSION

The addition of dermal allograft pledgets does not positively or negatively influence the time-zero biomechanical characteristics of double-row suture bridge rotator cuff repair.

Interposition of acellular amniotic membrane at the tendon to bone interface would be better for healing than overlaying above the tendon to bone junction in the repair of rotator cuff injury

PURPOSE

The retear rate of rotator cuff (RC) after surgery is high, and the rapid and functional enthesis regeneration remains a challenge. Whether acellular amniotic membrane (AAM) helps to promote the healing of tendon to bone and which treatment is better are both unclear. The study aims to investigate the effect of AAM on the healing of RC and the best treatment for RC repair.

METHODS

Thirty-three Sprague Dawley rats underwent RC transection and repair using microsurgical techniques and were randomly divided into the suturing repair only (SRO) group (n = 11), the AAM overlaying (AOL) group (n = 11), and the AAM interposition (AIP) group (n = 11), respectively. Rats were sacrificed at 4 weeks, then examined by subsequent micro-CT, and evaluated by histologic and biomechanical tests. The statistical analyses of one-way ANOVA or Kruskal-Wallis test were performed using with SPSS 23.0. A p < 0.05 was considered a significant difference.

RESULTS

AAM being intervened between tendon and bone (AIP group) or overlaid over tendon to bone junction (AOL group) in a rat model, promoted enthesis regeneration, increased new bone and cartilage generation, and improved collagen arrangement and biomechanical properties in comparison with suturing repair only (SRO group) (AOL vs. SRO, p < 0.001, p = 0.004, p = 0.003; AIP vs. SRO, p < 0.001, p < 0.001, p < 0.001). Compared with the AOL group, the AIP group had better results in micro-CT evaluation, histological score, and biomechanical testing (p = 0 0.039, p = 0.011, p = 0.003, respectively).

CONCLUSION

In the RC repair model, AAM enhanced regeneration of the tendon to bone junction. This regeneration was more effective when the AAM was intervened at the tendon to bone interface than overlaid above the tendon to bone junction.

Rotator Cuff Repair With Patch Augmentation Is Associated With Lower Retear Rates for Large Tears: A Systematic Review of Randomized Controlled Trials

PURPOSE

To perform a systematic review of randomized controlled trials comparing clinical outcomes of rotator cuff repair with and without patch augmentation.

METHODS

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines by searching PubMed, the Cochrane Library, and Embase to identify randomized controlled trials that directly compared outcomes between rotator cuff repair (RCR) with versus without patch augmentation. Patients were evaluated based on retear rate, histological outcomes, radiological outcomes, and patient-reported outcomes (Constant score; American Shoulder and Elbow Surgeons [ASES] score; University of California-Los Angeles shoulder scale; Simple Shoulder Test; EuroQol-visual analog scale; Disabilities of the Arm, Shoulder and Hand score; and PENN shoulder score questionnaire).

RESULTS

Six studies (1 level I, 5 level II) met inclusion criteria, including 188 patients undergoing RCR alone (Control) and 193 patients undergoing RCR with patch augmentation (Patch). Patient age ranged from 56.0 to 68.0 years. The mean follow-up time ranged from 14.0 to 68.4 months. The average body mass index ranged from 24.4 to 29.4, and the overall percentage of males ranged from 32.5% to 82.3%. Three studies found significantly decreased retear rates with patch augmentation. The retear rate ranged from 34.0% to 65.4% in the Control group and 9.1% to 52.9% in the Patch group. One study found a significant difference for the Constant score favoring the Patch group. Two studies found a significant difference for the ASES score favoring the Patch group. One study found significantly better results with patch augmentation in terms of repaired tendon thickness and footprint coverage, based on magnetic resonance imaging.

CONCLUSIONS

Patch augmentation of rotator cuff repairs may be associated with lower retear rates for large tears. There is limited evidence to suggest that patch augmentation is associated with improved patient-reported outcomes.

LEVEL OF EVIDENCE

Level II, systematic review of level I and II studies.

Dermal Allograft Augmentation for Large and Massive Rotator Cuff Tears and Revisions: A Case Series

Introduction Arthroscopic advancements have notably improved rotator cuff repair, yet the healing of tendons and retear risks still pose significant challenges, especially with massive and large tears. These larger tears have shown a quadruple increase in retear rate when the tear size grows from 1-3 cm. The prevalent cause of failure, particularly in tears with fatty degeneration, is suture tearing. As such, techniques that enhance tendon healing are pivotal due to their correlation with improved functional outcomes. Dermal allograft augmentation (DAA) is one method that has demonstrated improvements in rotator cuff repair biomechanics, as well as the promotion of vascularization and neotendon formation. This study evaluates the efficacy of DAA in the postoperative healing of large and massive rotator cuff tears, assessed through patient-reported outcomes and functional range of motion. Methods This retrospective study reviewed a single surgeon's database, selecting patients who underwent arthroscopic surgery for full-thickness rotator cuff tears measuring at least 3 cm, or those with maximum stage II fatty infiltration of the supraspinatus or infraspinatus muscle on MRI. We used three validated patient-reported outcome (PRO) measures, American Shoulder and Elbow Surgeon Score (ASES), Single Assessment Numeric Evaluation (SANE), and Simple Shoulder Test (SST), alongside a range of motion metrics, external rotation (ER), and forward flexion (FF). These were recorded pre-operatively and, at minimum, one year post-operatively, with a standard student t-test employed for comparative analysis. Results Out of 18 total patients, the average age was 61 years, and 83% were male. The cause of injury was mostly traumatic in nature (n=11), with the remainder being chronic (n=7). All three PROs (n=11) demonstrated a statistically significant increase in score including ASES (p=0.003), SANE (p=0.004), and SST (p=0.039). External rotation also significantly improved pre- to post-operative function (46 vs 58, p=0.049). Three patients (17%) suffered from a retear within three months of their rotator cuff repair. Two patients (11%) required a reverse shoulder arthroplasty within a year. Conclusion Our study demonstrated that DAA in rotator cuff repair yielded notable functional and clinical advancements, with a moderately low retear rate as confirmed by ultrasound. These outcomes suggest that DAA is a promising intervention for large and historically difficult rotator cuff tears, offering significant implications for future treatment protocols.

Acellular Collagen Matrix Patch Augmentation of Arthroscopic Rotator Cuff Repair Reduces Re-Tear Rates: A Meta-analysis of Randomized Control Trials

PURPOSE

To perform a meta-analysis of randomized controlled trials (RCTs) to compare the outcomes of arthroscopic rotator cuff repair (ARCR) with and without acellular collagen matrix patch (ACMP) augmentation.

METHODS

A literature search of 3 databases was performed based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RCTs comparing ACMP augmentation and a control for ARCR were included. Clinical outcomes were compared using Revman, and a P value < .05 was considered to be statistically significant.

RESULTS

Five RCTs with 307 patients were included. Overall, 11% of patients treated with ACMP augmentation and 34% of patients in the control group had a re-tear (P = .0006). The mean Constant score was 90.1 with ACMP augmentation, and 87.3 in controls (P = .02). Additionally, there was a significant higher American Shoulder and Elbow Surgeons score with ACMP augmentation (87.7 vs 82.1, P = .01).

CONCLUSIONS

The RCTs in the literature support the use of ACMP augment as a modality to reduce re-tear rates and improve outcomes after ARCR.

LEVEL OF EVIDENCE

Level II, Meta-Analysis of Level II Studies meta-analysis of Level II studies.

Editorial Commentary: Acellular Collagen Matrix Patch Augmentation of Large Rotator Cuff Tear Repair Results in Improved Healing

Despite a high retear rate, repair of large rotator cuff tendon tear repairs shows good clinical outcomes. Unfortunately, these results often deteriorate with time, and large tears, not to mention progressively symptomatic retears, especially in compromised rotator cuff tissue, remain a problem. The solution could include augmenting repair with a patch such as an acellular collagen matrix. Proper patient selection is needed to achieve a benefit justifying the added expense and operative time associated with adding a patch. Biomechanically, such patches are strong and increase suture retention, as well as repair construct strength and stiffness. Patches provide a significant healing effect. Recent research and meta-analysis support the use of patches on rotator cuff tendon tears 3 cm or larger, whereas smaller tears (1-2 cm in length) appear to heal without the need for a patch.

Outcomes of Superior Capsular Reconstruction Using the Long Head of the Biceps Tendon in Large to Massive Rotator Cuff Tears: A Meta-Analysis and Systematic Review

(1) Background: Addressing large to massive rotator cuff tears (LMRCTs) poses complex challenges. This systematic review investigated outcomes of superior capsular reconstruction (SCR) with the long head of the biceps tendon (LHBT) compared to conventional rotator cuff repair (RCR) for LMRCTs. (2) Methods: A systematic search across the MEDLINE/PubMed, EMBASE, Cochrane Library, and Scopus databases until 1 October 2023 identified studies that directly compared SCR with LHBT with conventional RCR in patients with LMRCTs and included a minimum of a 12-month follow-up period. The assessed outcome measures encompassed retear rates, functional outcomes, range of motion (ROM), and acromiohumeral interval (AHI). Risk of bias assessment was conducted via the Robins-I tool. (3) Results: In six studies with 456 cases (210 SCR using LHBT and 246 using RCR), SCR with LHBT significantly reduced retear rates (OR = 0.21; 95% CI, 0.12-0.36; p < 0.01; I2 = 0%). Furthermore, SCR with LHBT showed significant improvement in range of forward flexion (SMD 0.32, 95% CI: 0.09-0.55, p < 0.01, I2 = 39%) and AHI (SMD 0.61, 95% CI: 0.31-0.92, p < 0.01, I2 = 0%) postoperatively. (4) Conclusion: SCR with LHBT is a safe and effective treatment for LMRCTs, reducing retear rates, maintaining greater postoperative AHI, and improving ROM compared to conventional RCR. Additional high-quality interventional studies are needed to confirm these results.

Decellularized biological matrices for the repair of rotator cuff lesions: a systematic review of preclinical in vivo studies

Background: Rotator cuff tears (RCTs), resulting from degeneration or trauma of the shoulder tendons, are one of the main causes of shoulder pain. In particular, massive RCTs represent 40% of all injuries, require surgical treatment, and are characterized by poor clinical outcomes and a high rate of failure. In recent years, the use of biological decellularized patches for augmentation procedures has received great interest owing to their excellent self-integration properties, improving healing and, thus, presenting an innovative therapeutic option. However, the findings from clinical studies have emerged with conflicting viewpoints regarding the benefits of this procedure, as an excessive tension load might compromise the integrity of the tendon-to-bone connection when the patch exhibits low elasticity or insufficient strength. This could prevent the healing process, leading to unpredictable results in clinical practice. Methods: This systematic review was conducted following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines across three databases (PubMed, Scopus, and Web of Knowledge) to underline the results obtained in preclinical studies involving animal models of RCT surgeries that utilized the biological decellularized matrix augmentation technique in the last 5 years. Results: Thirteen articles were included after the screening, and the SYRCLE tools were applied to assess the risk of bias in in vivo studies. Open-surgery techniques were conducted to create tendon defects or detachment in different animal models: rat (31%), rabbit (46%), dog (15%), and sheep (8%). Patches decellularized with non-standardized protocols were used in 77% of studies, while commercially available matrices were used in 15%. Of the studies, 31% used allogenic patches, 61% used xenogenic patches, and 8% utilized both xenogenic and autologous patches. Conclusion: Overall, this review provides a comprehensive overview of the use of acellular patches and their effective therapeutic potential in rotator cuff (RC) repair at the preclinical level with the aim of expanding the strategies and matrices available for surgeons. Systematic review registration: https://www.crd.york.ac.uk/prospero/, identifier CRD42023468716.

Augmentation of Rotator Cuff Repair Using Umbilical Cord Graft: A Preliminary Observational Study

Due to the high rate of rotator cuff re-tear there is an extensive research on augmentation of rotator cuff repairs. The purpose of this single center, prospective study was to evaluate the results of augmentation of the rotator cuff repair with an umbilical cord allograft. The graft group in which the rotator cuff repair was augmented with the graft as an on-lay patch was consisted of 14 patients, while the control group was consisted of 10 patients. The primary outcome of the study was incidence of rotator cuff retears, while secondary outcomes included functional and pain scores. At 6 mo there was a significantly higher incidence of retears in the control group (30%) compared to the graft group (0%; P = 0.028), while at 12 mo the retear rates were statistically similar for the two groups (P = 0.46). The Constant-Murley scores, the ASES scores and the VAS score were similar (P > 0.05) for the two groups at all study times. The results of the study indicated that augmentation of the cuff repair with human umbilical cord graft can result in similar patient reported outcomes compared to a cuff repair without augmentation, but with a lower re-tear rate at 6 mo.

Augmentation of Massive Rotator Cuff Repairs Using Biceps Transposition Without Tenotomy Improves Clinical and Patient-Reported Outcomes: The Biological Superior Capsular Reconstruction Technique

PURPOSE

To evaluate the outcomes of a consecutive series of patients after transposition of the biceps without tenotomy (biological superior capsular reconstruction [bio-SCR] technique) to augment massive rotator cuff repairs.

METHODS

Thirty massive rotator cuff tears repaired and augmented using the bio-SCR technique between June 2018 and July 2021 were identified and retrospectively reviewed. American Shoulder and Elbow Surgeons (ASES) scores, visual analog scale pain scores, supraspinatus and infraspinatus strength, and range of motion were collected preoperatively and postoperatively.

RESULTS

The average age of patients undergoing bio-SCR augmentation was 67.0 years (range, 28.4-81.9 years), and the mean clinical follow-up period was 2.9 years (range, 1.8-4.5 years). The average ASES score improved from 33.2 preoperatively to 80.8 at 6 months postoperatively, 92.0 at 1 year, and 87.0 at 2 years (P < .001). The minimal clinically important difference for the ASES score was exceeded at all postoperative intervals. Active forward flexion improved from 120.6° to 156.8° (P < .001). The pain score improved from 7.1 to 0.9 (P < .001). Postoperatively, 1 complication (3.3%) occurred: a proximal biceps rupture.

CONCLUSIONS

Incorporating a transposed biceps tendon into the repair of a massive rotator cuff tear using the bio-SCR technique resulted in significant clinical improvements with a low complication rate.

LEVEL OF EVIDENCE

Level IV, case series.

Application of Nondegradable Synthetic Materials for Tendon and Ligament Injury

Tendon and ligament injuries, prevalent requiring surgical intervention, significantly impact joint stability and function. Owing to excellent mechanical properties and biochemical stability, Nondegradable synthetic materials, including polyethylene terephthalate (PET) and polytetrafluoroethylene (PTFE), have demonstrated significant potential in the treatment of tendon and ligament injuries. These above materials offer substantial mechanical support, joint mobility, and tissue healing promotion of the shoulder, knee, and ankle joint. This review conclude the latest development and application of nondegradable materials such as artificial patches and ligaments in tendon and ligament injuries including rotator cuff tears (RCTs), anterior cruciate ligament (ACL) injuries, and Achilles tendon ruptures.

Rotator Cuff Repair and Overlay Augmentation by Direct Interlocking of a Nonwoven Polyethylene Terephthalate Patch Into the Tendon: Evaluation in an Ovine Model

BACKGROUND

Arthroscopic repair of large rotator cuff tendon tears is associated with high rates of retear. Construct failure often occurs at the suture-tendon interface. Patch augmentation can improve mechanical strength and healing at this interface.

PURPOSE

To introduce a novel technique for suture-free attachment of an overlaid patch and evaluate its biomechanical strength and biological performance.

STUDY DESIGN

Descriptive and controlled laboratory studies.

METHODS

An established ovine model of partial infraspinatus tendon resection and immediate repair was used. After a nonwoven polyethylene terephthalate patch was overlaid to the resected tendon, a barbed microblade was used to draw fibers of the patch directly into the underlying tissue. In vivo histological assessment of healing was performed at 6 and 13 weeks after implantation. Ex vivo models were used to characterize primary repair strength of the suture-free patch fixation to tendon. Additional ex vivo testing assessed the potential of the technique for patch overlay augmentation of suture-based repair.

RESULTS

The in vivo study revealed no macroscopic evidence of adverse tissue reactions to the interlocked patch fibers. Histological testing indicated a normal host healing response with minimal fibrosis. Uniform and aligned tissue ingrowth to the core of the patch was observed from both the tendon and the bone interfaces to the patch. There was no evident retraction of the infraspinatus muscle, lengthening of the tendon, or tendon gap formation over 13 weeks. Ex vivo testing revealed that direct patch interlocking yielded tendon purchase equivalent to a Mason-Allen suture (150 ± 58 vs 154 ± 49 N, respectively; P = .25). In an overlay configuration, fiber interlocked patch augmentation increased Mason-Allen suture retention strength by 88% (from 221 ± 43 N to 417 ± 86 N; P < .01) with no detectable difference in repair stiffness.

CONCLUSION

Testing in an ovine model of rotator cuff tendon repair suggested that surgical interlocking of a nonwoven medical textile can provide effective biomechanical performance, support functional tissue ingrowth, and help avoid musculotendinous retraction after surgical tendon repair.

CLINICAL RELEVANCE

The novel technique may facilitate patch augmentation of rotator cuff repairs.

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

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.

Two-year outcomes with a bioinductive collagen implant used in augmentation of arthroscopic repair of full-thickness rotator cuff tears: final results of a prospective multicenter study

BACKGROUND

Full-thickness rotator cuff tears (FTRCTs) represent a common shoulder injury that, if untreated, can progress in size, become increasingly painful, and inhibit function. These lesions are often surgically repaired, with double-row arthroscopic repair often preferred for larger tears. Biological augmentation technologies have been developed to improve rates of postoperative radiographic retear and enhance patient-reported outcomes after surgical FTRCT repair. This study sought to confirm that augmented repair with a bioinductive bovine collagen implant results in favorable retear rates and patient outcomes with follow-up to 2 years.

METHODS

A prospective multicenter cohort study was undertaken to determine the efficacy and safety of augmenting single- or double-row arthroscopic repair of FTRCTs with a bioinductive bovine collagen implant. Of 115 adult patients participating, 66 (57.4%) had medium (1-3-cm) tears and 49 (42.6%) had large (3-5-cm) tears. Magnetic resonance imaging and patient-reported outcomes (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES] and Constant-Murley Score [CMS]) were performed and recorded at baseline, 3 months, 1 year, and 2 years.

RESULTS

Mean duration of follow-up was 2.1 years (range, 1.5-2.9 years). Between baseline and 2-year follow-up, mean total thickness of the supraspinatus tendon increased by 12.5% for medium tears and by 17.1% for large tears. Radiographic retear was noted in 7 of 61 available patients (11.5%) with medium tears, and in 14 of 40 patients (35.0%) with large tears. In both groups, these tears primarily occurred before the 3-month follow-up visit (13 of 21 [61.9%]). Radiographic retear with the supplemented double-row (DR) repair technique was 13.2% overall (12 of 91 DR patients; 11.3% for medium tears and 15.8% for large tears). The minimal clinically important difference was achieved by >90% of patients with both medium and large tears for both ASES and CMS. There were 2 serious adverse events classified by the treating surgeon as being possibly related to the device and/or procedure (1 case of swelling/drainage and 1 case of intermittent pain). Nine patients (7.8%; 4 medium tears and 5 large tears) required reoperation of the index rotator cuff surgery.

CONCLUSION

Final 2-year data from this study confirm that using this implant in augmentation of arthroscopic double-row repair of FTRCTs provides favorable rates of radiographic retear and substantial functional recovery. The relative safety of the device is also further supported.

Double-Row Rotator Cuff Repair Technique With Dermal Allograft Augmentation

Rotator cuff tears are common and debilitating injuries in the orthopaedic patient population. Although arthroscopic repair of the rotator cuff generally leads to satisfactory outcomes, some tears would benefit from augmentation with allograft to supplement the native tissue. This biological augmentation has been shown to decrease retear rates and can be beneficial in certain cases based on the size of the tear, amount of retraction, age of the patient, and chronicity. In this technical note, we describe a simple and effective technique for arthroscopic rotator cuff repair with biological augmentation.

Compressed Biceps Autograft Augmentation of Arthroscopic Rotator Cuff Repair

Rotator cuff repair failure rates continue to be a challenging problem. Various methods of biological and structural augmentation of the rotator cuff have been explored to improve tendon healing after repair. We describe a technique in which biceps tendon autograft is harvested after tenodesis. The biceps tendon is then compressed into a patch that is placed over the repaired rotator cuff tendon. Repurposing the portion of the tendon that is otherwise discarded offers several advantages over other augmentations that have been used, including the biological potential of live autograft tenocytes in the patch, lower cost, and no donor-site morbidity.

Loading Mesenchymal Stem Cell-Derived Exosomes Into a Traditionally Designed Rotator Cuff Patch: A Potential Strategy to Enhance the Repair of Chronic Rotator Cuff Tear Associated With Degenerative Changes

BACKGROUND

Retraction and degenerative changes of chronic rotator cuff tears limit the healing capacity after routine surgical repair.

PURPOSE

To fabricate a mesenchymal stem cell-derived exosome (MSC-Exos) loaded patch and evaluate the effect of this patch on the activity of rabbit tenocytes in vitro and on the repair of chronic rotator cuff tears associated with degenerative changes in vivo.

STUDY DESIGN

Controlled laboratory study.

METHODS

The MSC-Exos loaded patch was fabricated using a dynamic wet-spinning system. In the in vitro studies, the proliferation and migration activities of tenocytes were evaluated by culturing tenocytes with saline, a fiber-aligned patch, or an MSC-Exos loaded patch. In the in vivo studies, a rabbit model of chronic rotator cuff tear was established and directly repaired, repaired with fiber-aligned patch augmentation (RFPA group), and repaired with MSC-Exos loaded patch augmentation (REPA group). Histological and biomechanical analyses were performed at 4, 8, and 12 weeks after surgery.

RESULTS

An MSC-Exos loaded patch with inner aligned fibers, a loose microstructure, and reliable initial strength was fabricated using a dynamic wet-spinning system. The MSC-Exos loaded patch significantly promoted tenocyte proliferation and migration activities in vitro. In vivo, the REPA group exhibited significantly higher tendon maturing scores at 8 and 12 weeks after surgery compared with both the control and the RFPA groups. Fatty infiltration was significantly reduced in the REPA group at 4, 8, and 12 weeks compared with both the control and the RFPA groups. Biomechanical properties, including load to failure and stress, were also significantly improved at 12 weeks in the REPA group compared with both the control and the RFPA groups.

CONCLUSION

Results in the present study suggested that an MSC-Exos loaded patch was able to enhance the repair of a chronic rotator cuff tear by providing mechanical support and minimizing degeneration.

CLINICAL RELEVANCE

This work supported the idea that loading bioactive MSC-Exos into a traditionally designed rotator cuff patch might exert a better effect on the repair of chronic rotator cuff tears than augmented patch repair alone.

Changes From Baseline in Patient- Reported Outcomes at 1 Year Versus 2 Years After Rotator Cuff Repair: A Systematic Review and Meta-analysis

BACKGROUND

Most orthopaedic journals currently require reporting outcomes of surgical interventions for at least 2 postoperative years, but there have been no rigorous studies on this matter. Various patient-reported outcome (PRO) measures (PROMs) have been used to assess the status of the shoulder after rotator cuff repair (RCR).

HYPOTHESIS

We hypothesized that the mean shoulder-specific PROMs at 1 year improve substantially over baseline but that there is no clinically meaningful difference between the mean 1- and 2-year PROMs after RCR.

STUDY DESIGN

Meta-analysis; Level of evidence, 2.

METHODS

We conducted a systematic review of published randomized controlled trials (RCTs) and prospective cohort studies (level of evidence 1 and 2) reporting the shoulder-specific American Shoulder and Elbow Surgeons (ASES), the Constant, or the Western Ontario Rotator Cuff (WORC) Index scores at baseline, 1 year, and 2 years after RCR. The methodologic quality of studies was assessed. Also, the random effects meta-analyses of changes in PROMs for each of the first and second postoperative years were conducted.

RESULTS

Fifteen studies (n = 11 RCTs; n = 4 cohort studies) with a total of 1371 patients were included. Studies were highly heterogeneous, but no visual evidence of major publication bias was observed. The weighted means of the baseline PROMs were 46.2 points for the ASES score, 46.4 points for the Constant score, and 38.8 points for the WORC Index. The first-year summary increments were 41.1 (95% CI, 36.0-46.2) points for the ASES score, 34.2 (95% CI, 28.8-39.6) points for the Constant score, and 42.9 (95% CI, 37.3-48.4) points for the WORC Index. In contrast, the second-year summary increments were 2.3 (95% CI, 1-3.6) points for the ASES score, 3.2 (95% CI, 1.9-4.4) points for the Constant score, and 2 (95% CI, -0.1 to 4) points for the WORC Index.

CONCLUSION

All PROMs improved considerably from baseline to 1 year, but only very small gains that were below the minimal clinically important differences were observed between 1 year and 2 years after RCR. This study did not find any evidence for requiring a minimum of 2 years of follow-up for publication of PROs after RCR. Our results suggest that focusing on 1-year PROMs after RCR would foster more timely reporting, better control of selection bias, and better allocation of research resources.

Benefits of Patch Augmentation on Rotator Cuff Repair: A Systematic Review and Meta-analysis

Background:

Despite technological advances, the overall retear rate on rotator cuff repair is still high. Patches have shown significant reduction in retear rate and pain scores; however, this is not a universal finding and conflicting results have been shown among functional shoulder scales.

Purpose:

To analyze previous controlled trials of the literature to bring a consensus about the effectiveness of patch use on rotator cuff repair.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

The search was conducted in PubMed, Web of Science, EMBASE, Scopus, and Cochrane in April 2020. The results of rotator cuff repair with patch augmentation versus without augmentation (control) were compared through odds ratio (OR), raw mean difference (RMD), and standardized mean difference (SMD) of retear rate; functional shoulder scales; strength; and range of motion (ROM).

Results:

Of 733 initial studies, 7 of them met the criteria to be included in the analysis. Compared with the control group, the patch augmentation group had a significantly lower retear rate (OR, 0.32 [95% CI, 0.18 to 0.55]; P < .001), lower pain (SMD, –0.42 [–0.71 to –0.12]; P < .01), a higher University of California Los Angeles Shoulder Rating Scale (RMD, 0.87 [0.15 to 1.60], P = .017), and a trend toward higher strength (SMD, 0.95 [–0.03 to 1.94], P = .05) and lower forward elevation ROM (RMD, –10.50 [–21.86 to 0.67]; P = .06), while no changes were noted for other functional scales or for internal and external rotation ROM.

Conclusion:

The results point to benefits of patch augmentation in rotator cuff repair, particularly a reduction in retear rate. More interventional studies with better methodological quality should be conducted to confirm the results of this initial review.

Augmentation of Rotator Cuff Healing With Orthobiologics

The limited regenerative capacity of the tendon-bone enthesis after surgical repair poses a significant challenge to achieving desired clinical outcomes. Biologic augmentation of the repair site has the potential to enhance the biomechanical and histological integrity of the enthesis, leading to lower retear rates and greater patient satisfaction. Platelet-rich plasma, stem cells and bone marrow aspirate concentrate, growth factors, biodegradable or biomimetic scaffolds, and amniotic products have been investigated in preclinical and, in some cases, clinical studies aimed at augmenting tendon-bone healing. Although many of these therapies have achieved some degree of success in improving structural, histological, and clinical outcomes after surgical tendon-bone enthesis repair, none have reliably and consistently lead to clinical improvement. High-quality randomized controlled clinical studies are needed to definitively evaluate the efficacy of these biologic therapies and ultimately determine which, if any, are capable of achieving a tendon-bone repair that is structurally noninferior to the native enthesis before injury.

Editorial Commentary: Long Head Biceps Tendon Can Be Used Like a Split Skin Graft: Mesh It and Augment Rotator Cuff Repairs

Full-thickness tears of the rotator cuff are common, and surgical treatment is indicated in most cases. Arthroscopic repair has become the standard technique, but despite improved surgical techniques, instrumentations, and implants, failure rates continue to be high and can reach 40% and more. Augmented repairs with allograft patches or autograft tissue, such as long head biceps tendon or fascia lata, have been used with mixed results. However, autograft augmentation seems to be resulting in superior outcomes and higher healing rates. Treating skin defects with split-skin grafts is the gold standard in burns and soft-tissue surgery. Given the limited supply of autograft, meshing autograft tendon and using it similar to a split-skin graft is a novel idea. When using a 2:1 expansion ratio, the long head biceps tendon can be formed into a porous scaffold with the in situ tenocytes, producing cytokines and promoting tenogenic differentiation. However, the scaffolds exhibited reduced tensile properties. The results are encouraging, and it will be interesting whether the clinical trials will demonstrate higher healing rates and better functional outcomes when compared to primary repair and allograft patch augmentation.

Management of Acute Rotator Cuff Tears

Acute, traumatic rotator cuff tears typically occur in younger patients with a fall on an outstretched hand, grabbing an object to catch oneself when falling, or a glenohumeral dislocation. These tears are best evaluated with MRI. Partial-thickness tears may be managed nonoperatively with physical therapy, NSAIDs, and injections. Full-thickness tears in most patients should be managed with surgical repair as soon as possible, with better outcomes shown when repaired within 4 months of injury.

Full-Thickness Rotator Cuff Tears Can Be Safely Treated With a Resorbable Bioinductive Bovine Collagen Implant: One-Year Results of a Prospective, Multicenter Registry

Purpose

The purpose of this study was to prospectively collect safety and efficacy data in a large group of patients undergoing arthroscopic repair of full-thickness rotator cuff tears augmented with a resorbable bioinductive bovine collagen implant designed to promote healing.

Methods

Seventeen centers across the United States enrolled patients in an institutional review board-approved registry to collect outcomes data on the implant. Patients undergoing surgical management of full-thickness rotator cuff tears augmented with the implant were enrolled. Inclusion criteria were age of ≥21 years, willingness to participate and the ability to read and speak English. Exclusion criteria included hypersensitivity to bovine-derived products. Patients were assessed before and after surgery at up to 1 year with outcomes including the single-assessment numeric evaluation (SANE), Veterans RAND 12-Item (VR-12) mental components and physical components (VR-12 PCS), American Shoulder and Elbow Surgeons (ASES), and Western Ontario Rotator Cuff (WORC) outcome measures. Ad hoc analyses were performed to compare these outcomes at all time points depending on tear size (small/medium vs large/massive). Serious complications were collected.

Results

Of 210 patients enrolled, 192 had 1-year follow-up data available. The patients experienced statistically significant improvement between baseline and 1 year for mean SANE, VR-12 PCS, ASES, and WORC scores (40.0-82.0, 33.5-47.3, 46.2-87.8, and 36.2-81.0, respectively; P < .001 for all results). Ad-hoc analysis demonstrated that similar results were obtained at 1 year regardless of tear size. Twenty patients (10.4%) experienced serious complications (10.4%), including revision surgery (n = 18), proximal humerus fracture/partial subscapularis tear resulting from multiple falls (n = 1), and adhesive capsulitis (n = 1).

Conclusions

The safety and efficacy of a bioinductive implant in the surgical management of full-thickness rotator cuff tears at 1 year was shown in this study. Implant efficacy appears to be comparable regardless of the underlying tear size.

Level of Evidence

Level IV, therapeutic case series.

A Historical Analysis of Randomized Controlled Trials in the Management of Pain in Rotator Cuff Tears

The aim of this analysis was to assess the quality of reporting of randomized controlled trials (RCTs) relating to pain management in rotator cuff (RC) tears. This review evaluated the quality of the studies in the literature regarding this topic through the use of some factors and trends. The online databases used to search all RCTs on the topic of RC surgery were Medline, Scopus, CINAHL, EMBASE, and CENTRAL. This research was completed in September 2020. To assess the quality of reports, the Consolidated Standards of Reporting Trials (CONSORT) and the modified Coleman methodology score (MCMS) were used. From the research, 262 articles emerged. Finally, 79 studies were included in this historical analysis. There were no statistically significant changes in MCMS across trials that included or did not include a CONSORT diagram (p = 0.10). A statistically significant difference in MCMS was discovered between papers produced prior to 2009 and publications produced after 2015 (p = 0.03). There was no association between the number of checklist items for each article and the Coleman score. During the years there has been a significant increase in both quantity and quality of RCTs relating to pain in RC tears.

Retear rates after rotator cuff surgery: a systematic review and meta-analysis

Background

Rotator cuff retear (RCR) is one of the main postoperative drawbacks. RCR can be considered a multifactorial issue, which causes are related either to biological than biomechanical factors. The aim of this study was to define the incidence of RCR after surgical treatment at different time points and to identify the main factors influencing the postoperative rotator cuff (RC) healing.

Methods

A systematic review and meta-analysis were performed following the PRISMA guidelines. A comprehensive search of the literature was carried out in July 2020, using PubMed and Cochrane Library databases. Only level 1 and 2 clinical evidence studies were included. Studies were included if patients with preoperative repairable full-thickness RC tears were treated surgically, and if studies reported postoperative RCR confirmed by imaging diagnostic. The association between timing of retear and follow-up time points were investigated using an inverse-variance method of pooling data. A subgroup meta-analysis was performed using the DerSimonian and Laird method for the estimation of the between-study variance, i.e., τ². The association between retear rate after surgery and patients’ age, preoperative tear size, fatty infiltration, postoperative rehabilitation protocol, surgical techniques, and RC repairs was determined by expressing the effect measure in terms of odds ratio (OR) with 95% confidence interval (CI). The Mantel-Haenszel method with 95% CIs was used.

Results

Thirty-one articles were included in this study. The percentage of RCR after surgery was 15% at 3 months follow-up, 21% at 3–6 months follow-up, 16% at 6–12 months follow-up, 21% at 12–24 months follow-up, 16% at follow-up longer than 24 months. The main factors influencing RC healing are both patient-related (i.e., age, larger tear size, fatty infiltration) and not patient-related (i.e., postoperative rehabilitation protocol, surgical techniques, and procedures).

Conclusions

Postoperative RC healing is influenced by patient-related and non-patient-related factors. Further high-level clinical studies are needed to provide highly relevant clinical results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04634-6.

Use of biologics in rotator cuff disorders: Current concept review

Poor tendon to bone healing following rotator cuff repair has led to the continued interest and investigation into biological augmentation. The biology of tendinopathy is not fully understood and consequently the availability of disease modifying therapeutic targets is limited. A ceiling of benefit has been reached by mechanical optimisation of rotator cuff repair and thus, in order to improve healing rates, a biological solution is required. This review focuses on the strategies to biologically augment rotator cuff disorders with an emphasis on rotator cuff repair. Leucocyte rich platelet rich plasma has been shown to improve healing rates without clinically relevant improvements in outcome scores. Similarly, improved healing rates have also been reported with bone marrow stimulation and in long-term follow-up with bone marrow concentrate. Extracellular matrix (ECM) and synthetic scaffolds can increase healing through mechanical and or biological augmentation. A potential third category of scaffold is bio-inductive and has no mechanical support. Studies involving various scaffolds have shown promising results for augmentation of large to massive tears and is likely to be most beneficial when tendon quality is poor, however level I evidence is limited.

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 Historical Analysis of Randomized Controlled Trials in Rotator Cuff Tears

Background and objectives: Our research aimed to evaluate the quality of reporting of randomized controlled trials (RCTs) linked to rotator cuff (RC) tears. The present study analyzed factors connected to the quality of the RCTs and trends in the quality of reporting through time. Materials and Methods: The online databases used to search all RCTs on the topic of RC surgery completed until March 2020 were PubMed and Ovid (MEDLINE). The quality of reporting was evaluated using the modified Coleman methodology score (MCMS) and the consolidated standards of reporting trials (CONSORT). Results: The online search found 957 articles. Finally, 183 studies were included in the quantitative synthesis. A total of 97 (53%) of 183 studies had a level of evidence I and 86 (47%) of 183 studies had a level of evidence II, according to the Oxford Center of Evidence Based Medicine (EBM). A statistically significant difference in MCMS between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had, on average, the highest Coleman score. The average number of CONSORT checklist items for each article across all analyzed RCTs was 21.67. The 37 studies completed up to 2010 averaged a number of checklist items of 19.97 and the studies completed between 2011 and 2019 averaged a number of checklist items of 22.10. A statistically significant difference in the number of checklist items between articles written before 2010 and articles written after 2010 was found. Articles written after 2010 had on average more checklist items. However, low correlation (0.26) between the number of checklist items for each article and the respective Coleman score was found. On the other hand, articles with the CONSORT diagram had a significantly high Coleman score. Conclusions: An improvement in the quantity and quality of RCTs relating to RC surgery over the analyzed period was found.

Patch Augmentation in Rotator Cuff Repair

PURPOSE OF THE REVIEW

Rotator cuff repair has excellent outcomes for many patients but continues to be suboptimal for large, retracted tears, and revision procedures. In these situations, patch augmentation may be considered in order to improve healing. The purpose of this article is to review the history, graft options, indications, surgical technique, outcomes, and complications associated with arthroscopic patch augmentation for rotator cuff repair.

RECENT FINDINGS

Patch augmentation has been shown in several studies to improve healing rates. After multiple investigations into different materials available for patch augmentation, acellular dermal allograft seems to be the graft with the best scientific support. While multiple techniques have been presented, few studies have compared their performance. While the arthroscopic technique for patch augmentation can be challenging, we present a systematic approach to this procedure with the potential to reliably and predictably perform patch augmentation. This technique is a valuable tool for surgeons that treat rotator cuff pathology.

No healing improvement after rotator cuff reconstruction augmented with an autologous periosteal flap

PURPOSE

To show descriptive clinical and magnetic resonance (MR) imaging results after an additional periosteal flap augmentation in mini-open rotator cuff reconstruction and to evaluate potential healing improvement at long-term follow-up.

METHODS

Twenty-three patients with degenerative rotator cuff tears were followed after receiving a mini-open single-row repair with a subtendinous periosteal flap augmentation. Data were collected preoperatively, after 12 months and after 11 years. Clinical examination, simple shoulder test (SST), Constant-Murley Score (CS), ultrasonography examination and 3T MR imaging were performed.

RESULTS

Out of 23 patients, 20 were available for short-term and 19 for final follow-up at a median of 11.5 years (range 10.4-13.0). Questions answered with "yes" in SST improved from baseline 5.0 (range 1.0-8.0) to short 10.5 (range 8.0-12.0) and final follow-up 12.0 (range 7.0-12.0). CS improved from 53.5 (range 25.0-66.0) to 80.8 (range 75.9-89.3) and finally to 79.8 points (range 42.3-95.4). Improvement was highly significant (p < 0.05). Severe retears were found in 9/19 patients. Ossifications along the refixed tendon were noticed in 8/19 cases. Ossifications did not correlate with clinical outcome. At final follow-up, patients with retears seemed likely to have lower strength values in CS (mean ± SD) than patients without retears (7.3 ± 4.1 vs. 12.8 ± 5.3; p < 0.05).

CONCLUSION

No positive effect on improving healing response in rotator cuff refixation with a periosteal flap augmentation could be found. Retear rate is comparable to that of conventional rotator cuff refixation in the published literature. Ossifications along the tendon, without negatively affecting the clinical outcome, were seen. This invasive technique cannot be advised and should not be used anymore.

LEVEL OF EVIDENCE

IV.

Patient-Reported Outcomes After Use of a Bioabsorbable Collagen Implant to Treat Partial and Full-Thickness Rotator Cuff Tears

PURPOSE

To collect outcomes data on patients treated with a bioinductive collagen implant designed to induce rotator cuff healing in partial- and full-thickness cuff tears and to assess the safety and efficacy of the device.

METHODS

Fifteen surgeons in 15 centers in the United States enrolled patients between April 2016 and August 2017 and collected standardized outcomes data. Patients 21 years of age and older, able to read and speak English, and with partial- or full-thickness tears of the rotator cuff documented by magnetic resonance imaging were included in the study. Patients were assessed preoperatively with visual analogue scale (VAS), single-assessment numeric evaluation (SANE), Veterans RAND 12-Item (VR-12), American Shoulder and Elbow Surgeons (ASES), and Western Ontario Rotator Cuff (WORC) outcomes measures. Postoperative assessment was made at 2, 6, and 12 weeks, 6 months, and 1 year. Patients underwent a standardized operative procedure with the implant. Patient demographics, comorbidities, tear types, and concomitant operative procedures were recorded.

RESULTS

Patients in both groups experienced statistically significant improvement in VAS, SANE, VR-12 PCS, ASES, and WORC scores (mean values 1.1, P < .001; 86.0, P < .001; 49.7, P < .001; 85.6, P < .001; and 84.4, P < .001 for partial tears and 1.2, P < .001; 80.7, P < .001; 45.7, P < .001; 83.8, P < .0001; and 80.1, P < .001 for full-thickness tears, respectively). For the partial tear group, average times for return to driving, work, and nonoverhead athletic activity were 14.6, 37.3, and 65.6 days, and for the full-thickness group, 24.5, 50.7, and 119.2 days, respectively. In the partial-thickness group, 84% and 83% of patients reported improvement in their VAS pain and ASES scores, respectively, that met or exceeded each measure's minimal clinically important difference. In the full-thickness group, 72% and 77% of the patients met or exceeded the minimal clinically important differences for VAS pain and ASES, respectively.

CONCLUSION

Outcomes after repair of partial- and full-thickness rotator cuff tears using a bioinductive implant show safety and efficacy at 1-year follow-up.

LEVEL OF EVIDENCE

Retrospective case series, level IV evidence.

Does Arthroscopic Suture-Spanning Augmentation of Single-Row Repair Reduce the Retear Rate of Massive Rotator Cuff Tear?

BACKGROUND

Several surgical techniques have been proposed for massive rotator cuff tears (MRCTs), but the failure rates remain high. The suture-spanning augmentation technique of single-row (SSA-SR) repair was shown to reduce failure rates in cadaveric studies, but the outcome in vivo remains unclear.

PURPOSE

To determine if adding spanning sutures to SR repair during MRCT repairs can improve functional outcome and reduce failure rates.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

The study included 71 patients with a diagnosed MRCT. The study group (n = 35) received SSA-SR repair. The control (n = 36) received SR repair. The American Shoulder and Elbow Surgeons (ASES) score, Constant score, UCLA (University of California, Los Angeles) score, and visual analog scale for pain were assessed preoperatively and 24 months postoperatively. Magnetic resonance imaging was arranged at 6 months postoperatively to evaluate the rotator cuff.

RESULTS

At 6 months postoperatively, the overall retear rate was 31.0%. The retear rate was lower in the SSA-SR group (14.3%) than in the SR group (47.2%, P = .002). At 24 months, the SSA-SR group had markedly improved ASES, Constant, and UCLA scores in comparison with the SR group ( P < .05). Within both groups, all scores had significant improvement as compared with the preoperative status ( P < .05).

CONCLUSION

The SSA-SR repair technique showed improved functional and radiologic results. Based on the superior postoperative outcome of this technique, the SSA-SR repair technique can be a potential treatment option for MRCT repair.

REGISTRATION

NCT03609164 (ClinicalTrials.gov identifier).

Editorial Commentary: "Rotator-Metrics": Understanding Risk Factors for Rotator Cuff Repair Failure May Lead to Better Outcomes

Retear following rotator cuff repair is a significant risk and is associated with worse patient-reported outcomes. Tear size, fatty infiltration, age, and chronicity have all been reported as independent risk factors. Understanding risk factors for rotator cuff repair failure may allow surgeons to optimize outcomes by addressing certain tears, such as tears involving the anterior rotator cuff cable and subscapularis, more acutely and incorporating patch augmentation in tears that are at high risk for failure.

Options for Failed Rotator Cuff Repair

Failed rotator cuff repairs can pose a clinical challenge to the treating orthopedic surgeon. There are many nonsurgical and surgical options available to address the failed rotator cuff repair. Surgical options include revising the primary repair, partial or nonanatomic repair, tendon transfer, biological augmentation or use of tissue-engineered grafts for reconstruction, or total joint arthroplasty (typically with a modern reverse total shoulder arthroplasty system). The treating surgeon must assess the patient's functional status, health status, and expectations in order to customize the appropriate treatment plan for addressing the failed rotator cuff repair. With the abundance of treatment options available, there is typically an adequate solution to help the patient regain function and experience less pain.