Treatment of Partial-Thickness Rotator Cuff Tears With a Resorbable Bioinductive Bovine Collagen Implant: 1-Year Results From a Prospective Multicenter Registry

Arthroscopic management of isolated partial-thickness rotator cuff tears

PURPOSE

The aim of the present study is to provide a comprehensive review on the surgical outcomes following arthroscopic treatments of partial-thickness rotator cuff tears (PT-RCTs) and to compare the postoperative American Shoulder and Elbow Surgeons (ASES) score following in situ transtendon repair and tear completion, followed by repair.

METHODS

Medline, EMBASE, Scopus, CINAHL and CENTRAL bibliographic databases were searched. Papers including patients with PT-RCTs of any grade who underwent treatment using debridement, in situ transtendon repair, tear completion and repair or bioinductive collagen implants were reviewed. Primary PT-RCTs were the sole indication for surgery. Primary postoperative outcomes assessed included the ASES score, the Absolute Constant-Murley score, the Simple Shoulder Test, the Visual Analogue Scale, the University of California-Los Angeles Shoulder Scale, the Western Ontario Rotator Cuff Score, range of motion, complications and revisions. A meta-analysis of comparative studies compared the postoperative ASES score between patients treated with in situ transtendon repair versus tear completion repair.

RESULTS

Twenty-eight studies were included. The ASES score was reported by four comparative studies with contrasting results. The heterogeneity was high (I2 = 86%), and effect sizes ranged from -0.49 in favour of the tear completion and repair technique to an effect size of +1.07 favouring in situ transtendon repair. The overall effect size of 0.02 suggests an equivalence between the two techniques in terms of the ASES score. Two studies with a total sample size of 111 patients reported on debridement, and four studies with a total sample size of 155 patients reported on bioinductive collagen implants.

CONCLUSION

Debridement alone is suitable for Ellman grades I-II PT-RCTs. In situ transtendon and tear completion repair techniques yield similar postoperative outcomes. Bioinductive collagen implants hold promise but lack long-term efficacy data. High-quality comparative studies are needed to determine the best treatment for PT-RCTs.

LEVEL OF EVIDENCE

Level IV.

Arthroscopic Repair of Retracted Large and Massive Rotator Cuff Tears With and Without Augmentation With a Bio-Inductive Collagen Implant Reveals Substantial and Comparable Clinical Improvement

PURPOSE

To compare clinical and imaging results after repair of retracted large and massive full-thickness rotator cuff tears, including revision repairs, with and without augmentation with a bio-inductive collagen implant.

METHODS

The study group comprised 24 patients (17 male subjects) with retracted 2 or 3 tendon rotator cuff tears undergoing arthroscopic repair followed by onlay augmentation with a bio-inductive collagen implant. The control group comprised 24 patients (19 male subjects) matched by tear size undergoing repair without augmentation. Mean patient age at repair in both groups was 61 years. Active range of motion and patient-reported outcomes were recorded before and after surgery. Noncontrast high-field magnetic resonance imaging was obtained in 20 of 24 collagen implant patients and 17 of 24 control patients at minimum 6 months' follow-up to assess tendon healing.

RESULTS

American Shoulder and Elbow Surgeons and Simple Shoulder Test scores improved from 35 to 86 and 3.6 to 9.3, respectively, in the collagen implant group and from 39 to 87 and 3.9 to 9.7 in the control group. The visual analog score-pain improved from 6.0 to 0.9 and from 5.9 to 0.9 in the collagen implant and control groups, respectively (P < .001 for all). Overall improvements in range of motion and patient-reported outcomes were similar in both groups. Magnetic resonance imaging revealed intact repairs in 11 of 20 (55%) patients in the patch group and 9 of 17 (53%) in the control group. Two patients in each group were revised to reverse shoulder arthroplasty.

CONCLUSIONS

Arthroscopic repair of retracted large and massive rotator cuff tears, including revision repairs, with and without augmentation using a bio-inductive collagen implant results in substantial and comparable early clinical improvement, although predictable healing remains elusive. Further work is needed to optimize patient selection for massive rotator cuff repair and define more precisely the indications for augmentation of these repairs using the collagen implant.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Economic Evaluation of a Bioinductive Implant for the Repair of Rotator Cuff Tears Compared with Standard Surgery in Italy

INTRODUCTION

Rotator cuff tear (RCT) is a painful, progressive condition resulting from damage to the rotator cuff tendons and is the leading cause of shoulder-related disability. Surgical repair of rotator cuff is an established standard of care (SOC); however, failure of the procedure can occur. In this context, the use of collagen-based bioinductive implant REGENETEN showed long-term improvements in clinical scores. The aim of the study was to assess the cost-effectiveness of REGENETEN combined with SOC (SOC + REGENETEN) compared to SOC alone from both National Healthcare Service (NHS) and societal perspectives in Italy.

METHODS

A decision analytic model was developed to estimate the number of tears healed and costs for the two considered treatment strategies over 1 year. Clinical data were retrieved from the literature, and the clinical pathways for the management of patients with RCTs were retrieved from four key opinion leaders in Italy.

RESULTS

Over a 1-year time horizon, healed lesions were 90.70% and 72.90% for surgical repair of RCTs with and without REGENETEN, respectively. Considering the NHS perspective, mean costs per patient were €7828 and €4650 for the two strategies, respectively, leading to an incremental cost-effectiveness ratio (ICER) of €17,857 per healed tear. From the societal perspective, the mean costs per patient were €12,659 for SOC and €11,784 for REGENETEN, thus showing savings of €4918 per healed tear when the bioinductive implant is used. The sensitivity analyses confirmed the robustness of the model results.

CONCLUSION

In the context of paucity of cost-effectiveness studies, our findings provide additional evidence for clinicians and payers regarding the value of a new treatment option that supports a tailored approach for the management of patients with RCTs.

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.

Arthroscopic Autologous Coracoacromial Ligament Augment Technique for Particle Thickness of Rotator Cuff with at Least Two Years Follow-Up

OBJECTIVE

Patch technology has been the new technique in the treatment of partial thickness of the rotator cuff tear (PTRCTs) to address the limitation of traditional techniques. Compared with allogeneic patches and artificial materials, coracoacromial ligament is obviously closer to their own biology. The purpose of the study was to evaluate the functional and radiographic outcomes following arthroscopic autologous coracoacromial ligament augment technique for treatment of PTRCTs.

METHOD

This study included three female patients with PTRCTs who underwent arthroscopy operation in 2017 with an average age of 51 years (range from 50 to 52 years). The coracoacromial ligament implant was attached to the bursal side surface of the tendon. The clinical results were evaluated by American Shoulder and Elbow Surgeons (ASES) score, Simple Shoulder Test (SST), acromiohumeral distance (AHD) and muscle strength before and 12 months after operation. Magnetic resonance imaging (MRI) was performed 24 months after operation to assess the integrity of the anatomical structure of the original tear site.

RESULT

The average ASES score improved significantly from 57.3 preoperatively to 95.0 at 1-year follow-up. The strength improved significantly from grade 3 preoperatively to grade 5 at 1 year. Two of three patients underwent the MRI at 2-year follow-up. Radiographic released the complete healing of rotator cuff tear. No implant-related serious adverse events were reported.

CONCLUSION

The new technique of using autogenous coracoacromial ligament patch augment provides good clinical results on patients with PTRCTs.

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.

Human Dermal Allograft Patch Augmentation of Degenerate Rotator Cuff Tendon Using a Single Lateral-Row Technique

The role of biological augmentation in arthroscopic rotator cuff repair surgery has increased over the years. It has shown favorable healing rates and functional outcomes. Patch augmentation is commonly applied in repairs of massively retracted cuff tears, full-thickness tears, revision repair, or open cuff surgery. There is a paucity of literature on the use of patch augmentation when dealing with a chronic degenerate tendon associated with small-sized cuff tears. In recent years, the resorbable bioinductive bovine collagen implant has gained popularity for its application in partial-thickness tears via an isolated bioinductive repair fashion, without traditional rotator cuff repair. These bioinductive implants, albeit promising in their biological properties for tendon repair, lack structural strength and do not confer similar biomechanical advantages as human dermal allograft. We share our surgical technique for an arthroscopic patch augmentation involving human dermal allograft, using a single-lateral row surgical fixation, to address a degenerate cuff tendon with small-sized rotator cuff tear. We believe that our use of a human dermal patch augmentation conferred increased biomechanical advantage and reduced costs while delivering favorable outcomes for patients in our value-driven care.

Bioinductive collagen implants facilitate tendon regeneration in rotator cuff tears

Purpose

To evaluate the clinical outcomes, MRI imaging and histological characteristics of biopsy samples of the tendon from patients in whom rotator cuff repair was previously performed with a bioinductive type I bovine collagen implants.

Methods

Prospective study of 30 patients with partial or complete rotator cuff tears who underwent arthroscopic repair and augmentation with a resorbable type I bovine collagen implant. Preoperatively and at 6 and 12 months after surgery, the VAS, ASES and Constant-Murley scores were evaluated and an MRI study was performed. At 6 months, biopsies of the resulting tissue were obtained and examined histologically.

Results

Patients experienced statistically significant and sustained improvement from baseline for all scores and the mean tendon thickness increased by 1.84 mm. Magnetic resonance imaging evidence of complete healing was found in 27 patients and a considerable reduction in defect size, greater than 50%, was shown in 3. In all samples obtained, the new tissue generated had the histological appearance of a tendon, and was indistinguishable from the native tendon. There was no evidence of any remaining collagen implant.

Conclusions

Biopsies of tissue formed from bioinductive type I bovine collagen implants showed, six months after surgery, the generation of a neotendon indistinguishable from the native one. Histology and MRI imaging, revealed complete integration of the implant and absence of inflammatory or foreign body reactions. The clinical parameters, thickness and MRI signal of the tendon improved significantly at 6 months, regardless of the type and size of the tear, and remained unchanged until 12 months.

Level of evidence

Level IV, case series.