Healing and Functional Results of Dermal Allograft Augmentation of Complex and Revision Rotator Cuff Repairs

Bioaugmentation demonstrates similar outcomes and failure rates for arthroscopic revision rotator cuff repair compared to revision without bioaugmentation

Background

Arthroscopic revision rotator cuff repairs (RCRs) exhibit lower healing rates and inferior outcomes compared to primary repairs. There is limited evidence regarding the use of bioaugmentation in the setting of revision RCRs. Autologous conditioned plasma (ACP) is a promising adjunct that has been shown to improve healing rates and patient-reported outcomes (PROs) in the primary setting. In addition, bioinductive patches such as collagen bovine patches have become a popular adjunct for stimulating healing in the primary setting. The aim of this study is to assess the outcomes after use of ACP and collagen bovine patch augmentation for revision arthroscopic RCR. We hypothesized improved PROs and higher healing rates would be observed with bioaugmentation for revision repair compared to without.

Methods

This was an institutional review board-approved, retrospective case-control study from 2 fellowship-trained surgeons that included all consecutive patients undergoing arthroscopic revision RCR from 2010 to 2021. Reconstruction such as superior capsular reconstruction, partial revision repair, and less than 1-year follow-up were excluded. The bioaugmentation cohort received ACP and/or collagen bovine patch at the time of revision repair. PROs were collected from all patients including American Shoulder and Elbow Surgeons Standardized Assessment Form (ASES), visual analog scale for pain (VAS), Brophy score, and Patient-Reported Outcomes Measurement Information System (PROMIS) mental and physical scores. Failure of revision RCR was defined as an ASES postoperative total score less than 60 or a symptomatic retear confirmed on magnetic resonance imaging. Student's t-test was used for all comparisons of continuous variables. Chi-squared test used for comparison of all categorical variables. Statistical significance was set at <0.05.

Results

Thirty-eight patients met inclusion criteria with average follow-up of 3.5 ± 1.7 years. There was no significant difference in follow-up between patients with and without bioaugmentation. Of the 38 patients, 14 patients met failure criteria. There was no significant difference in the rate of failure between the bioaugmentation cohort (6/19, 31.6%) vs. patients who did not receive bioaugmentation (8/19, 42.1%) (P = .74). In addition, no significant differences were identified for ASES (64.6 ± 20.1 vs. 57.5 ± 17.2, P = .32), Brophy (6.4 ± 5.2 vs. 6.0 ± 4.1, P = .84), PROMIS Mental (13.4 ± 3.9 vs. 11.7 ± 3.2), or PROMIS Physical (12.8 ± 3.1 vs. 11.9 ± 3.2) scores between the bioaugmentation vs. no bioaugmentation groups.

Conclusion

Bioaugmentation with a bioinductive collagen patch or ACP demonstrated similar failure and PROs compared to without bioaugmentation in the setting of revision RCR.

Biologics in rotator cuff repair

Rotator cuff tears are common in middle-aged and elderly patients. Despite advances in the surgical repair of rotator cuff tears, the rates of recurrent tear remain high. This may be due to the complexity of the tendons of the rotator cuff, which contributes to an inherently hostile healing environment. During the past 20 years, there has been an increased interest in the use of biologics to complement the healing environment in the shoulder, in order to improve rotator cuff healing and reduce the rate of recurrent tears. The aim of this review is to provide a summary of the current evidence for the use of forms of biological augmentation when repairing rotator cuff tears.

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.

Bridging repair reinforced with artificial ligament as an internal brace for irreparable massive rotator cuff tears

BACKGROUND

The irreparable massive rotator cuff tear (IMRCT) is challenging to manage. Although various surgical options have been proposed to treat IMRCTs, the optimal surgical technique remains controversial. Arthroscopic bridging patch repair is clinically used for treating IMRCTs, but the healing rate of the patch graft is negatively affected by superior shift of the humeral head. This study aimed to evaluate the clinical efficacy of artificial ligament as an internal brace (IB) reinforcing fascia lata autograft bridging repair (ABR) in the treatment of IMRCTs.

METHODS

The data of 50 patients with IMRCTs who underwent ABR reinforced with artificial ligament as an IB (ABR + IB) (internal brace group) or ABR alone (control group) were retrospectively evaluated preoperatively and at 2-year follow-up. Clinical outcomes were assessed based on the shoulder activity, of which the strength was measured using a 0-10 points manual muscle test scale, American Shoulder and Elbow Surgeons score, and visual analog scale for pain. Imaging outcomes were evaluated based on acromiohumeral distance (AHD), Hamada grade, Goutallier grade, and the status of fascia lata grafts as per radiographs or magnetic resonance imaging findings.

RESULTS

Both groups showed significantly better results in shoulder activity, American Shoulder and Elbow Surgeons score, visual analog scale score, and AHD at 2-year follow-up compared with preoperative levels (P < .001). Compared with the control group (n = 24), the internal brace group (n = 26) had better mean AHD (7.0 ± 1.4 mm vs. 5.9 ± 1.0 mm, P = .002), mean improvement in AHD (3.3 ± 1.5 mm vs. 2.0 ± 0.6 mm, P < .001), healing rate of autografts (92.3% vs. 54.2%, P = .002), and improvement rate of Hamada grade (73.1% vs. 41.7%, P = .025) at 2-year follow-up. No significant differences were found in active elevation, active external rotation, active internal rotation, abduction strength, external rotation strength, internal rotation strength, American Shoulder and Elbow Surgeons score, or visual analog scale between the 2 groups at 2-year follow-up.

CONCLUSION

Both the ABR + IB and ABR improved the postoperative short-term clinical and imaging outcomes in managing IMRCTs, the ABR + IB is statistically superior to ABR alone in terms of healing rate of the bridging graft, AHD, and Hamada grade at 2-year follow-up, while further clinical investigations with larger sample size and longer follow-ups are required to validate the clinical significance of this novel technique for IMRCTs.

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

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.

Indications and Technique: Rotator Cuff Repair Augmentation

Rotator cuff repair (RCR) augmentation is often considered for patients with large-to-massive rotator cuff tears or chronic tears with poor tissue quality. Augmentation can provide mechanical stability and improved biology to improve the likelihood of a successful repair. This article discusses the indications, diagnosis, surgical techniques, and outcomes for RCR augmentation using an acellular dermal allograft, partially demineralized cancellous allograft, dermal xenograft, bone marrow aspirate concentrate, and platelet-rich plasma.

Arthroscopic Incomplete Rotator Cuff Repair With Patch Augmentation Using Acellular Dermal Matrix Allograft

Arthroscopic rotator cuff repair has been shown promising clinical outcomes. However, large to massive rotator cuff tears are difficult to completely repair with appropriate tension because of their size or poor tissue quality. An incomplete repair using the "hybrid technique" is one of way to solve this problem by maximizing the contact area between the tendon and the footprint of greater tuberosity. Additionally, the acellular dermal matrix patch augmentation has emerged as an adjuvant technique to enhance the biomechanical properties to promote healing of the repaired construct. This Technical Note describes arthroscopic incomplete rotator cuff repair using the "hybrid technique" with acellular dermal matrix patch augmentation.

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.

Unsuccessful Osteochondral Allograft Cap to Prevent Overgrowth in a Pediatric Patient with Previous Transtibial Amputation: A Case Report

CASE

This case demonstrates the attempted utilization of an osteochondral allograft for the prevention of bony overgrowth in a patient with fibular hemimelia and previous transtibial amputation with failure of Teflon capping. Additionally, we describe a novel technique to provide additional padding and increase the width of the residual limb using a dermal allograft.

CONCLUSIONS

Bony overgrowth after pediatric amputations is common and often necessitates revision procedures secondary to infection, ulceration, pain, and discomfort with prosthesis use. Our use of an osteochondral allograft cap to prevent bony overgrowth ultimately failed 13 months following the procedure, and further research on various graft options and other treatment modalities is warranted, especially if the proximal fibula is unavailable or there is concern for donor site morbidity associated with harvesting autologous grafts.

Arthroscopic Superior Capsule Reconstruction with Combined Fascia Lata Autograft and Synthetic Scaffold Patch Graft for the Treatment of Irreparable Rotator Cuff Tears Yields Favorable Clinical and Radiographic Outcomes at Minimum Two-Year Follow-Up

PURPOSE

To report the results of the arthroscopic superior capsule reconstruction (ASCR) technique with a combined fascia lata autograft and synthetic scaffold patch graft for irreparable massive rotator cuff tears (RCTs).

METHODS

The period for this retrospective study was between December 2016 and December 2020. The criteria for inclusion were patients treated arthroscopically for an incompletely reparable massive RCT (dimension > 5 cm and two tendons fully torn, intact or reparable subscapularis tendons and teres minor tendon with or without irreparable infraspinatus, a radiological Hamada classification between grade 0 and 4, and a minimum 24-month postoperative follow-up).. Clinical outcomes were evaluated pre-operatively and at a final follow-up by a visual analog scale (VAS) for pain and range of motion along with the American Shoulder and Elbow Surgeons score (ASES), the University of California Los Angeles score (UCLA), and the Constant-Murley score (CMS). Radiological outcomes were assessed according to the rotator cuff arthropathy (RCA) and the acromiohumeral distance (AHD) stages. Graft integrity and muscle fatty infiltration were evaluated by magnetic resonance imaging (MRI).

RESULTS

A total of 43 patients were enrolled in the study with a mean follow-up duration of 45.6 months (range 24 to 64). All clinical scores also improved at the two-year follow-up (mean VAS 0.7 [SD 0.7] vs. 5.4 [SD 1.1], P < 0.001; mean ASES 92.6 [SD 8.0] vs. 34.8 [SD 13.4], P < 0.001; mean UCLA 31.5 [SD 3.9] vs. 11.0 [SD 3.2], P < 0.001; and mean CMS 86.6 [SD 7.2] vs. 40.0 [SD 11.6], P < 0.001), and 39 of 43 fascia lata grafts were fully intact on MRI (91%).

CONCLUSIONS

ASCR with a combined fascia lata autograft and synthetic scaffold patch graft resulted in good functional outcomes, with a high rate of graft healing at the two-year follow-up. All patients achieved clinically relevant improvement (met minimal clinically important differences (MCID)) on ASES, UCLA, and VAS with improved abduction strength restoration.

Can the Single Assessment Numeric Evaluation be used as a stand-alone subjective outcome instrument in patients undergoing rotator cuff repair?

BACKGROUND/HYPOTHESIS

There is no consensus to which patient-determined shoulder outcome scores should be considered when analyzing patient outcomes. Use of multiple patient-determined outcomes may be redundant and cause increased responder burden. The Single Assessment Numeric (SANE) has not been widely accepted as a stand-alone shoulder-specific outcome measure. The hypothesis was that SANE will correlate with and be comparable in responsiveness to other subjective outcome measures that have been used in a stand-alone fashion in patients undergoing rotator cuff repair (American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form [ASES], Western Ontario Rotator Cuff Index [WORC], and the Simple Shoulder Test [SST]). In addition, the SANE will be more relevant to each patient compared to the ASES, further supporting its use as a stand-alone shoulder-specific outcomes measure.

METHODS

A retrospective review of a database of patients undergoing rotator cuff repair was reviewed where the SANE was recorded with the ASES, WORC, and/or SST. Correlations were determined using the Pearson coefficient. Subgroup analysis was performed to determine if correlations differed in (1) preoperative and (2) postoperative outcome determinations. Responsiveness was determined by calculating the standardized response mean (SRM) and the effect size (ES) of all scores. Relevance and precision of the SANE and ASES were examined using 150 consecutive patients to determine the number of questions in each score that were not answered.

RESULTS

Correlation was excellent for the SANE and the ASES (n = 1838, r = 0.81, P < .0001), the WORC (n = 1793, r = 0.82, P < .0001), and the SST (n = 1836, r = 0.76, P < .0001). Correlation of preoperative scores was moderate and postoperative scores were excellent when comparing the SANE with all 3 scores. All scores were highly responsive, with the SRM of the SANE = 2.1, ASES = 2.2, WORC = 2.4, and the SST = 1.8. The ES of the SANE = 2.4, ASES = 2.7, WORC = 3.0, and the SST = 2.1. One hundred percent of the SANE scores were answered completely compared with 57% (P < .0001) of the ASES, with significant variability found in the answers to the "work" and "score" questions.

CONCLUSION

In patients undergoing rotator cuff repair, the SANE highly correlated and has equivalent responsiveness with the WORC, ASES, and SST, which have been used as stand-alone shoulder-specific outcomes measures. The SANE may provide the same information as the WORC, ASES, and SST regarding outcome with significant reduction in responder burden. This study supports that the SANE can be used as a subjective, stand-alone instrument for patients undergoing rotator cuff repair.

Augmentation of Arthroscopic Rotator Cuff Repair With Cannulated Dermal Allograft Implant

Arthroscopic rotator cuff repair (RCR) is a popular treatment for rotator cuff tears. Retear after RCR remains a significant concern even with modern techniques. Augmentation of RCR has been described using multiple different grafts, one option including a cannulated dermal allograft implant (DePuy Mitek). The utilization of this implant avoids significantly increased surgical time, allows for augmentation at the weakest area of repair, and does not lead to any wasted allograft material.

Management of Failed Rotator Cuff Repairs: A Review

Failed rotator cuff repairs present a complex issue for treating surgeons. Many methods of management exist for this pathology including revision repair with biologic augmentation, repairs with allograft, tendon transfers, superior capsular reconstruction, balloon arthroplasty, bursal acromial reconstruction, and reverse total shoulder arthroplasty. This review discusses the current literature associated with these management options.

Graft Augmentation of Repairable Rotator Cuff Tears: An Algorithmic Approach Based on Healing Rates

We provide our algorithm for tissue augmentation of rotator cuff repairs based on the current available evidence regarding rotator cuff healing. A variety of factors are associated with healing following rotator cuff repair. Increasing tear size and retraction as well as severe fatty degeneration have been associated with worsening rates of tendon healing. Given the correlation between tendon healing and postoperative outcomes, it is important to identify patients at high risk for failure and to modify their treatment accordingly to minimize the risk of early biomechanical failure and maximize the potential for structural healing. One approach that may be used to improve healing is tissue augmentation. Tissue augmentation is the use of tissue patches and scaffolds to provide rotator cuff reinforcement. Surgical management for rotator cuff tears (RCTs) continues to be a challenging task in orthopaedic surgery today. Appropriate treatment measures require an in depth understanding and consideration of the patient's prognostic factors such as age, fatty infiltration of the rotator cuff muscles, bone mineral density, rotator cuff retraction, anteroposterior tear size, work activity, and degenerative changes of the joint. Using these factors within the Rotator Cuff Healing Index, we can determine a patient's surgical treatment that will yield the maximum healing rate. For nonarthritic RCTs, joint-preserving strategies should be first-line treatment options. For young, active patients with a reparable RCT and minimal fatty infiltration, a complete repair can be effective. For young patients with irreparable RCTs, superior capsular reconstructions, and tendon transfers are viable options. For elderly patients with low work activity, an irreparable RCT and significant fatty infiltration, a partial repair with or without graft augmentation can be attempted if minimal to no arthritic changes are seen. LEVEL OF EVIDENCE: Level V, expert opinion.