37 Dermal Augmentation for Challenging Large and Massive Rotator Cuff Tears

Devon T. Brameier and Paul M. Sethi

Summary

Repairs of small and medium-sized repairs provide successful long-term functional outcomes; however, massive rotator cuff tears continue to be challenging to manage, with traditional repairs failing in 37%?94% of cases. Dermal allografts have the potential to improve these massive repairs by providing biological and mechanical support to the repair, encouraging organized recruitment of the desired tissue types while off-loading stress from the repair site. Repairs augmented with dermal allografts may exhibit superior functional outcomes and reduced repair re-tear rates, suggesting this augmented approach may be a viable option for managing massive tears. This chapter provides a modern arthroscopic surgical technique for using dermal allografts as onlay augmentations in repairing massive rotator cuff repairs and highlights relevant literature in support of dermal augmentation in challenging rotator cuff repair.

Keywords: dermal allograft, dermal augmentation, massive rotator cuff tear, onlay augmentation, rotator cuff repair, rotator cuff tear

37.1 Patient Positioning

? Patient may be positioned in beach chair or lateral position for rotator cuff repair as per surgeon preference and training.

37.2 Portal Placement

? Standard posterior, posterolateral, anterolateral, and anterior portals are traditionally used with percutaneous anchor placement portals as indicated.

? A large flexible cannula may be beneficial in the midlateral portal for graft introduction.

37.3 Surgical Technique

? Patients are brought to the operating room and a comprehensive diagnostic arthroscopy is completed.

? In the setting of revision rotator cuff surgery, the biceps is routinely treated with tenotomy or tenodesis, depending on the patient demands and expectations.

? The leading edge of the subscapularis is carefully examined with posterior subluxation of the humeral head. The subscapularis is repaired when torn.

? After addressing concomitant pain generators, attention is turned to the rotator cuff.

? The rotator cuff is assessed and mobilized as required.

? Undersurface tissue releases are carried out between capsule and rotator cuff, and up along the coracoid and glenoid.

? We do not routinely use anterior and posterior interval releases.

? The greater tuberosity is denuded of soft tissue and the bone excoriated.

? Preexisting sutures and anchors are often removed.

? When the rotator cuff has poor mobility, the articular margin is medialized by 5 mm to enlarge the available contact area between cuff and bone.

? If the tissue cannot be mobilized, and partial repair is deemed unacceptable, superior capsule reconstruction is considered.

? When the rotator cuff has adequate excursion to the lateral tuberosity, but is significantly thinned, we will perform a dermal onlay with a transosseous equivalent repair (? Fig. 37.1, ? Fig. 37.2, ? Video 37.1).

? After repairing the rotator cuff tear (? Fig. 37.1a?c, ? Fig. 37.2a?b), the area to be grafted is measured. For an onlay graft, the graft size often matches the footprint area of the repair. A suture with knots tied every 10 mm, or a commercially available arthroscopic ruler (? Fig. 37.2c), may be used to measure the area to be patched, adding a rim of 5 mm on all but the lateral margin. These measurements are used to create a template for graft preparation (? Fig. 37.3a).

? The surgical author chooses to use a 20 mm � 20 mm � 1 mm Arthrex ArthroFLEX decellularized dermal allograft; however, any other equivalent decellularized dermal allograft may also be used with equivalent success. The graft is cut to size according to the intraoperative-derived template (? Fig. 37.3).

? Double-loaded suture anchors (from surgeon?s preferred provider) are placed on the medial margin of the articular cartilage, one anterior and one posterior (? Fig. 37.1d).

? The sutures of the two medial double-loaded anchors are passed through the cuff in a mattress fashion.

? The first pair of sutures (one from the anterior anchor and one from the posterior anchor) are tied.

? The second mattress is passed through the graft and the graft is parachuted down the sutures (? Fig. 37.4).

? The medial mattress sutures are tied down. The limbs are then crossed and placed into two lateral anchors, completing the transosseous repair (? Fig. 37.1e, ? Fig. 37.2d?f).

37.4 Surgeon Tips and Tricks

? A free suture, passed through the Nevasier portal and then through the cannula and into the dermal graft, may be used as a shuttled (or pull) switch to help draw the graft into the subacromial space (? Fig. 37.1d).

? As an alternative to a full-sized patch, dermal pledgets such as the Arthrex ArthroFLEX Biowashers may be used to augment the repair (? Fig. 37.5).1 Full-sized dermal allografts may also be cut into smaller dermal pledgets if pre-prepared pledgets are unavailable.

? After the medial row is passed, the dermal pledget is parachuted down the suture limbs and tied into place. Sutures may be tied or bridged into a lateral row of anchors depending on the repair construct.

? Pledgets are relatively easy to use and avoid many of the technical pitfalls associated with suture tangle and graft management.

? Frequently in revision or challenging cases, the rotator cuff will not have the mobility such that a low tension repair to lateral tuberosity is feasible. In this case, single-row repair to the tension-free middle or medial tuberosity with a dermal onlay augment is elected.

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Fig. 37.1 These intraoperative arthroscopic images show the revision repair of a large rotator cuff tear with thin tissue via a single-row repair augmented with a dermal allograft. (a) An arthroscopic view of the tear with deficient tissue and delamination from the medial glenoid to the tuberosity. (b) Placement of the double-loaded anchor used to repair the tear. (c) The completed side-to-side and single-row repair. (d) The sutures from two double-loaded anchors that have not been tied and will be passed through the graft. The sutures of the double-loaded anchors (lighter blue and white/black striped) are used to create the mattress over the graft while the free suture (darker blue) is used as a shuttled stitch passed freely through Nevasier?s portal to draw the graft into the repair site. (e) The completed augmented repair with two mattress stitches. (� Paul M. Sethi, MD.)

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Fig. 37.2 These images show the intraoperative arthroscopic process of a revision repair of a large rotator cuff tear with thin tissue via a single-row repair augmented with a dermal allograft. (a) An arthroscopic view of the tear including preexisting sutures from the previous repair, which were later removed. (b) An arthroscopic view of the completed single-row repair. (c) The use of a commercially available arthroscopic ruler to measure the graft site. (d) The graft introduced to the repair site with the mattress sutures passed through the medial holes. (e) The first mattress being secured with a knotless anchor. (f) The completed augmented repair. (� Paul M. Sethi, MD.)

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Video 37.1 Surgical demonstration of a revision repair of a large rotator cuff tear augmented with a dermal allograft.