31 Biological Augmentation of Rotator Cuff Repair with Platelet-Rich Plasma and Multiple Channeling

Paul Shinil Kim and Chris Hyunchul Jo

Summary

Several augmentation strategies have been described to enhance rotator cuff tendon healing after surgical repair. We discuss two techniques: 1) platelet-rich plasma augmentation and 2) multiple channeling (bone marrow stimulation) to improve structural integrity after repair.

Keywords: rotator cuff, platelet-rich plasma, biological augmentation

31.1 Patient Positioning

? Lateral decubitus position.

? Maintain stability with the beanbag.

? Shoulder traction with the Spider Limb Positioner (Tenet Medical Products, Smith & Nephew, Andover, MA).

? Tilting the table ~20?30� posteriorly.

31.2 Portal Placement

31.2.1 Posterior Portal

? 2 cm medial and 3 cm distal to the posterolateral tip of the acromion.

? Soft spot in the triangular region between the acromion, glenoid, and humeral head.

31.2.2 Anterior Portal

? Halfway between the acromioclavicular (AC) joint and the lateral aspect of the coracoids.

? Intraarticular space border: superolaterally by the biceps tendon, inferiorly by the subscapularis tendon, and medially by the anterosuperior portion of the glenoid.

31.2.3 Lateral Portal (50-Yard Line View)

? 3 cm lateral to lateral border of the acromion, in line with the posterior edge of the AC joint.

? Used for subacromial decompression, and ultimately provides a working portal for rotator cuff repair.

31.2.4 Posterolateral Portal (Grand Canyon View)

? Just lateral to the posterolateral edge of the acromion.

? Better visualization of rotator cuff pathology.

31.3 Surgical Technique (Step-by-Step Approach)

31.3.1 Exploration for the Glenohumeral Joint

? Biceps tendon and superior labrum.

? The biceps tendon anchor at the superior glenoid serves as an obvious anatomic landmark for orientation in the joint.

? Posterior labrum.

? Glenoid surface and humeral head cartilage.

? Inferior capsule and axillary recess.

? For evidence of loose bodies or synovitis.

? Supraspinatus tendon articular side.

? Superior glenohumeral ligament (SGHL) and middle glenohumeral ligament (MGHL).

? Draped obliquely over the deep surface of the subscapularis tendon and becomes taut with external rotation.

? In most cases, the MGHL can be identified at its origin from the anterosuperior labrum.

? Subscapularis tendon.

? Insertion of the subscapularis tendon can be inspected during internal rotation and posteriorly translation of the humeral head.

31.3.2 Management of the Biceps Tendon1

? Depending on the patient?s age, activity level, symptoms, rehabilitation, and degree of subscapularis tear.

? Biceps tenotomy should be considered if the patients are more than ~55?60 years old, female, low demand for physical activity, within repairing the torn cuff tendon, and not doing passive range of motion (ROM) exercise for postoperative rehabilitation.

? Biceps tenodesis are preferred for male and younger patients (< 50 years) or the patients of any age involved in heavy labor.

31.3.3 Preparation for the Tendon Repair2

? Debride the bursal tissue, subacromial, and distal clavicle osteophytes minimally.

? Extensive acromioplasty to flatten the hooked or curved acromion are rarely performed.

? Debride the frayed and atrophied tendons of torn end minimally so the structural fibers of the tendon are preserved.

? Evaluation of the rotator cuff tear: anteroposterior dimension, mediolateral retraction, and the numbers of involved tendons.

? Tendon mobility is evaluated by grasping the tendon and gently pulling it laterally. This determines the position of the tendon edge relative to the repair site on the greater tuberosity.

? Excursion can be increased, when necessary, with superior capsulotomy, release of the coracohumeral ligament, and medialization of the greater tuberosity.

? The footprint of the greater tuberosity is debrided to achieve complete clearance of the remnant soft tissue with preservation of the calcified fibrocartilage of the insertion.

31.3.4 Arthroscopic Repair

? Insert the medial anchors at the medial border of the rotator cuff footprint.

? Placing sutures through the torn end of the rotator cuff.

? The medial row sutures are tied using the slippage-proof knot3,4 if necessary.

? The lateral row is secured using suture anchors, and the sutures are cut.

31.4 Surgeon Tips and Tricks (Use of Specific Instrumentation)

31.4.1 Platelet-Rich Plasma Augmentation5,6,7,8,9,10

? Especially for the large to massive tears, biological augmentation with platelet-rich plasma (PRP) could enhance the quality of the structural integrity after repair.

? PRP is prepared using a platelet pheresis system with a leuko-reduction set and a standard collection program 1 day before surgery.

? To produce a gel from PRP, 0.3 mL of 10% calcium gluconate is added to 3 mL of PRP.

? Threading No. 1 polydioxanone (PDS II) suture to the posterior rotator cuff using a suture hook near the footprint. Opposite end of the PDS suture is retrieved through the lateral portal and then PRP gels are threaded consecutively to the PDS suture.

? The PRP gels are introduced into the 5.5 mm cannula and a knot pusher pushed the gels to reach to the repair site.

? While blocking the outer opening of the cannula with a finger, a suture retriever passes through the anterior rotator cuff and brings PDS suture back out to the anterior portal.

? With the PRP gels in place, medial row sutures are tied and the lateral row is secured using suture anchors, and the sutures are cut.

31.4.2 Multiple Channeling11,12,13,14,15

? The multiple channeling procedure is a kind of bone marrow stimulation technique.

? A bone punch with a thin and long tip is preferred to create channels.

? Make multiple channels from immediately adjacent to the articular cartilage of the humeral head to the lateral ridge of the greater tuberosity.

? By internally and externally rotating the arm, holes are made over the greater tuberosity. Usually, the holes are 4 to 5 mm apart and 10 mm deep. This procedure usually takes10 min for any tear size.

? After multiple channeling, suture anchors are placed in the usual manner. See accompanying ? Video 31.1.

image

Video 31.1 Video of rotator cuff repair with microchanneling and PRP augmentation.

31.5 Pitfalls/Complications

? In the application of PRP, there are several techniques are introduced and it is important to choose the proper technique of arthroscopic application of PRP before the surgery and practices should be needed.

? Create the multiple channels with a thinner and longer bone punch rather than a thicker and shorter awl for microfracturing, which might cause the fracture of greater tuberosity and may not be enough to reach the bone marrow.

31.6 Rehabilitation

? Same as the conventional arthroscopic rotator cuff repair in both procedures.

? The shoulders are immobilized for 4?6 weeks using an abduction brace.

? Shrugging, protraction, and retraction of shoulder girdles and intermittent exercise of the elbow, wrist, and hand are encouraged immediately after surgery as tolerated.

? However, no passive motion is allowed for patients with a massive tear until6 weeks after surgery.

? Passive ROM exercise is allowed after gradual weaning off the abduction brace from 4 to 6 weeks after surgery.

? Beginning strengthening exercise after 3 months.

? Full return to sports is allowed after 6 months according to the individual recovery.

References

[1] Hsu AR, Ghodadra NS, Provencher MT, Lewis PB, Bach BR. Biceps tenotomy versus tenodesis: a review of clinical outcomes and biomechanical results. J Shoulder Elbow Surg. 2011; 20(2):326?332

[2] Jo CH, Kim JE, Yoon KS, et al. Does platelet-rich plasma accelerate recovery after rotator cuff repair? A prospective cohort study. Am J Sports Med. 2011; 39(10):2082?2090

[3] Jo CH, Lee J-H, Kang S-B, et al. Optimal configuration of arthroscopic sliding knots backed up with multiple half-hitches. Knee Surg Sports Traumatol Arthrosc. 2008; 16(8):787?793

[4] Clark RR, Dierckman B, Sampatacos N, Snyder S. Biomechanical performance of traditional arthroscopic knots versus slippage-proof knots. Arthroscopy. 2013; 29(7):1175?1181

[5] Jo CH. Arthroscopic rotator cuff repair with platelet-rich plasma (PRP) gel: a technical note. Acta Orthop Belg. 2011; 77(5):676?679

[6] Jo CH, Shin JS, Shin WH, Lee SY, Yoon KS, Shin S. Platelet-rich plasma for arthroscopic repair of medium to large rotator cuff tears: a randomized controlled trial. Am J Sports Med. 2015; 43(9):2102?2110

[7] Charousset C, Zaoui A, Bella�che L, Piterman M. Does autologous leukocyte-platelet-rich plasma improve tendon healing in arthroscopic repair of large or massive rotator cuff tears? Arthroscopy. 2014; 30(4): 428?435

[8] McCarrel T, Fortier L. Temporal growth factor release from platelet-rich plasma, trehalose lyophilized platelets, and bone marrow aspirate and their effect on tendon and ligament gene expression. J Orthop Res. 2009; 27(8):1033?1042

[9] Zargar Baboldashti N, Poulsen RC, Franklin SL, Thompson MS, Hulley PA. Platelet-rich plasma protects tenocytes from adverse side effects of dexamethasone and ciprofloxacin. Am J Sports Med. 2011; 39(9): 1929?1935

[10] Jo CH, Lee SY, Yoon KS, Shin S. Effects of Platelet-rich plasma with concomitant use of a corticosteroid on tenocytes from degenerative rotator cuff tears in interleukin 1?-induced tendinopathic conditions. Am J Sports Med. 2017; 45(5):1141?1150

[11] Jo CH, Shin JS, Park IW, Kim H, Lee SY. Multiple channeling improves the structural integrity of rotator cuff repair. Am J Sports Med. 2013; 41(11):2650?2657

[12] Jo CH, Yoon KS, Lee JH, et al. The effect of multiple channeling on the structural integrity of repaired rotator cuff. Knee Surg Sports Traumatol Arthrosc. 2011; 19(12):2098?2107

[13] Kida Y, Morihara T, Matsuda K, et al. Bone marrow-derived cells from the footprint infiltrate into the repaired rotator cuff. J Shoulder Elbow Surg. 2013; 22(2):197?205

[14] Milano G, Saccomanno MF, Careri S, Taccardo G, De Vitis R, Fabbriciani C. Efficacy of marrow-stimulating technique in arthroscopic rotator cuff repair: a prospective randomized study. Arthroscopy. 2013; 29(5): 802?810

[15] Taniguchi N, Suenaga N, Oizumi N, et al. Bone marrow stimulation at the footprint of arthroscopic surface-holding repair advances cuff repair integrity. J Shoulder Elbow Surg. 2015; 24(6):860?866