1 Single-Row Rotator Cuff Repair Using Graft Augmentation and Bone Marrow Aspirate Concentrate Augmentation

Anand Murthi and Manesha Lankachandra

Summary

Large rotator cuff tears with poor tissue quality are a difficult surgical problem. Various biologic options are available that can reinforce the native tissue in a repair and potentially improve healing rates. The video describes our technique for use of a biofiber graft at the repair site and harvesting and use of bone marrow aspirate concentrate over the repair. This chapter highlights the available literature on the use of biologics in rotator cuff repair.

Keywords: biofiber graft, bone marrow aspirate concentrate (BMAC), rotator cuff tear, single row

1.1 Patient Positioning

? The patient is positioned in the beach chair, with care taken to support the medial edge of the scapula while still allowing for unencumbered shoulder extension. It often helps to make sure the patient?s hips are moved far enough over toward the operative side to allow the arm to hang freely.

? We use a pneumatic arm holder on the operative side, which helps with glenohumeral distraction and arm positioning in general.

? Prior to placement in the arm holder, an examination under anesthesia is performed to evaluate for any stiffness.

? After the last drape is placed, strips of incise drapes are used to secure the edges of the drape to the patient circumferentially around the shoulder. Even with a sticky extremity drape, this step helps to keep the drapes from shifting intraoperatively.

1.2 Portal Placement

? The bony landmarks of the acromion, scapular spine, clavicle, and coracoid are palpated and drawn out.

? A standard posterior viewing portal is made 2?3 cm inferior and 1?2 cm medial to the posterolateral edge of the acromion. Entry into the glenohumeral joint can be made easier by palpating the bony edge of the glenoid with the tip of the trocar, ?rolling over? the rounded edge to find the joint space. Gentle lateral traction on the humerus can also help to expand this space, making it easier to find. Aiming the trocar toward the previously marked coracoid is also helpful because it allows the trocar to fall over the posterior lip of the glenoid rim.

? Once the viewing portal is established, an anterior viewing portal is made with an outside-in technique. A spinal needle is placed lateral and superior to the coracoid, aiming for the rotator interval. After the needle is positioned appropriately superior to the subscapularis tendon and inferior to the long head of the biceps tendon, a portal is made and a cannula is placed. A common mistake is to direct the needle too laterally and superiorly. Instead, aim the needle toward the glenoid face and keep this trajectory in mind when placing the cannula.

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Fig. 1.1 Lateral arthroscopic view of massive rotator cuff tear.

? For subacromial work, an anterolateral portal is made, again using an outside-in technique with a spinal needle. For this portal, remember to consider the location and type of rotator cuff tear (? Fig. 1.1). Instruments should be able to access the most anterior and posterior parts of the tear as well as the footprint. It is helpful to think about placing this portal at a point equidistant to the anterior and posterior edges of the tear, but each tear is different.

1.3 Surgical Technique

? After a diagnostic glenohumeral shoulder arthroscopy is performed, a subacromial decompression is done. The same posterior portal is used, sliding the trocar under the inferior surface of the acromion until it reaches the coracoacromial ligament, which can be palpated with the tip of the trocar as an irregular surface just inferior to the anterior acromion.

? After the decompression, attention is turned to the rotator cuff. With large, chronic tears, the rotator cuff tendons are sometimes scarred down in a retracted position to the undersurface of the acromion and the underlying capsule. Releasing these adhesions allows the tendons to be mobilized back to the tuberosity more easily, facilitating a tension-free repair. However, there is a balance between performing adequate releases and damaging the already attenuated rotator cuff tissue.

? Any remaining soft tissue on the tuberosity is removed with electrocautery, and the tuberosity surface is prepared with a bur up to the edge of the articular cartilage. Preparing the footprint up to the edge of the articular surface allows placement of anchors as medially as possible, avoiding lateralization and unnecessary tension on the repair.

? At this point, the bone marrow aspirate is harvested from the humeral head. Using this site allows for relatively minimal donor site morbidity and saves the time and expense of prepping and draping a distant site. The amount of bone marrow aspirate and the equipment needed vary with the system used, but in general a Jamshidi needle is used to extract the required material, which is handed off the field for concentration.

? Turning to the rotator cuff repair, the goal in these larger tears is a tension-free repair with multiple sutures passing through the repair construct. Therefore, triple loaded anchors are generally chosen and are passed through the lateral portal. Remember that this portal must be large enough to allow for passage of multiple suture limbs and the graft, so an appropriately sized cannula must be chosen.

? First, one limb from the anterior anchor is passed through the anterior-most cuff, and its corresponding loop strand is parked outside of the anterior portal. Similarly, the posterior-most suture from the posterior anchor is passed through the posterior cuff and its loop strand is parked outside of the posterior portal. The middle four suture limbs are then passed through the middle portion of the tear, and these four suture ?post? strands are brought outside the body and passed through the biofiber graft under direct visualization.

? The two graft sutures are tied and cut to begin reducing the tear, and the graft is then shuttled down the cannula into the subacromial space. The graft is placed on the edge of the rotator cuff using graspers and a probe. It is useful here to have assistance keeping the graft in position while the sutures are tied, sandwiching the rotator cuff tendon between the tuberosity and the graft. The graft acts as a scaffold at the tendon?bone interface.

? After the repair is complete, the fluid is suctioned out of the subacromial space and the bone marrow aspirate concentrate (BMAC) is injected over the repair and into the graft using a spinal needle.

? The portals are closed in standard fashion and the patient is placed in a sling and bolster.

1.4 Rehabilitation

? We do not change our rehabilitation protocol when using a graft or BMAC as an adjunct to rotator cuff repair.

? The patient is immobilized for 6 weeks (phase 1), coming out of the sling for non-weight-bearing waist-level activity (typing, writing, hygiene) and elbow and wrist range of motion.

? At 6 weeks, range of motion is started, focusing on supine overhead stretching (phase 2).

? At 12 weeks, a strengthening program can begin (phase 3).

? This program should be customized based on the abilities and motivation of the patient as well as the robustness of the repair.

1.5 Rationale and Evidence for Approach

? The use of biologics in orthopedics, and in shoulder surgery and rotator cuff repair, in particular, is relatively new. There is a paucity of human studies, and even fewer studies assess clinical outcomes even in the short term. However, there are some products and techniques that have come into widespread and accepted use.

? Neviaser initially described the use of graft material in rotator cuff repair in 1978.1 In this report, freeze-dried graft of a rotator cuff was used to bridge an irreparable repair. In our practice, graft material is more commonly used to reinforce a repair with poor-quality tissue.

? There are multiple options for graft material, although allograft and synthetic materials are most commonly used.2 In ? Video 1.1, we used a synthetic graft at the repair site. No studies directly compare different types of grafts with each other, so the choice of type of graft is generally surgeon-dependent.

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Video 1.1 Single-row rotator cuff repair using graft augmentation and bone marrow aspirate concentrate augmentation.

? Biomechanically, graft augmentation attempts to decrease rates of gap formation, facilitating better healing at the repair site. Biomechanical studies in cadavers using allografts and xenografts have shown decreased tendon gapping and load-to-failure.3,4 In vivo studies are lacking.

? Histologic studies show evidence of increased cell adhesion and proliferation, depending on the graft type.5

? Clinical outcome studies for the GRAFTJACKET (Wright, Memphis, TN) showed higher American Shoulder and Elbow Surgeons scores at 2 years.6

? Mesenchymal stem cells from bone marrow have the potential to differentiate into tendon cells. However, the clinical significance of this application for rotator cuff repair is not clear. In animal studies, there is some evidence for increased cell differentiation into tenocytes, but it is unclear whether this improves rotator cuff healing.7

? Human studies are few, but the few available studies using BMAC, using a centrifuge to concentrate the mesenchymal stem cells in bone marrow aspirate, showed increased healing rate of the repaired rotator cuff.8,9 The clinical relevance of these findings is unclear.

References

[1] Neviaser JS, Neviaser RJ, Neviaser TJ. The repair of chronic massive ruptures of the rotator cuff of the shoulder by use of a freeze-dried rotator cuff. J Bone Joint Surg Am. 1978; 60(5):681?684

[2] Gillespie RJ, Knapik DM, Akkus O. Biologic and synthetic grafts in the reconstruction of large to massive rotator cuff tears. J Am Acad Orthop Surg. 2016; 24(12):823?828

[3] Mc Carron JA, Milks RA, Mesiha M, et al. Reinforced fascia patch limits cyclic gapping of rotator cuff repairs in a human cadaveric model. J Shoulder Elbow Surg. 2012; 21(12):1680?1686

[4] Shea KP, Obopilwe E, Sperling JW, Iannotti JP. A biomechanical analysis of gap formation and failure mechanics of a xenograft-reinforced rotator cuff repair in a cadaveric model. J Shoulder Elbow Surg. 2012; 21(8):1072?1079

[5] Ricchetti ET, Aurora A, Iannotti JP, Derwin KA. Scaffold devices for rotator cuff repair. J Shoulder Elbow Surg. 2012; 21(2):251?265

[6] Barber FA, Burns JP, Deutsch A, Labb� MR, Litchfield RB. A prospective, randomized evaluation of acellular human dermal matrix augmentation for arthroscopic rotator cuff repair. Arthroscopy. 2012; 28(1):8?15

[7] Gulotta LV, Kovacevic D, Ehteshami JR, Dagher E, Packer JD, Rodeo SA. Application of bone marrow-derived mesenchymal stem cells in a rotator cuff repair model. Am J Sports Med. 2009; 37(11):2126?2133

[8] Hernigou P, FlouzatLachaniette CH, Delambre J, et al. Biologic augmentation of rotator cuff repair with mesenchymal stem cells during arthroscopy improves healing and prevents further tears: A case-controlled study. Int Orthop. 2014; 38(9):1811?1818

[9] Depr�s-Tremblay G, Chevrier A, Snow M, Hurtig MB, Rodeo S, Buschmann MD. Rotator cuff repair: A review of surgical techniques, animal models, and new technologies under development. J Shoulder Elbow Surg. 2016; 25(12):2078?2085

Suggested Readings

Greenspoon JA, Petri M, Warth RJ, Millett PJ. Massive rotator cuff tears: Pathomechanics, current treatment options, and clinical outcomes. J Shoulder Elbow Surg. 2015; 24(9):1493?1505

Smith RD, Carr A, Dakin SG, Snelling SJ, Yapp C, Hakimi O. The response of tenocytes to commercial scaffolds used for rotator cuff repair. Eur Cell Mater. 2016; 31:107?118