What Factors Can Enhance Rotator Cuff Healing? 2019

F. Alan Barber MD, FACS

Plano Orthopedic Sports Medicine & Spine Center

Disclosures

◼ The following relationships exist:

◼ Royalties: DePuy-Mitek

◼ Consulting: DePuy-Mitek

◼ Research and educational support: DePuy-Mitek

◼ Others: Lippincott Wilkins and Williams, Sports Medicine and Arthroscopy Review, Arthroscopy Journal

Goal of Rotator Cuff Repair

◼ Reattach the tendon to the bone

◼ Achieve complete tendon healing

Goal: Replicate normal biology

Ide et al. Arthroscopy 2009

Normal fibrocartilage transition

Surgery: Fibrovascular scar

Healing Challenges? (Tashjian 2010)

◼ Older patients, chronic tears

◼ Tears >5 cm length (2 tendons)

◼ Retraction >2.5 cm (at or medial to glenoid on MRI)

◼ >50% fatty infiltration

◼ Diabetics, smokers

◼ Non-compliance with rehab

How to improve cuff healing?

1. Patient selection

2. Biological augmentation

3. Mechanical factors: reinforcement

1. Patients

◼ Age: < 55 y/o: 95% healing

55-64 y/o: 75% healing

> 65 y/o: 43% healing

◼ Tear size (# tendons, massive tear)

◼ Smoking/nicotine (Baumgarten CORR 2010; Kane

Orthopedics 2006; Mallon JSES 2004; Galatz JBJS 2006)

◼ Fluoroquinolones: inhibits tenocytes growth, increased cell death (Fox AJSM 2014,

Tsai Eur J Pharmacol 2009)

(Boileau JBJS 2005)

1. Patients

◼ Hypercholesterolemia (Beason et al J Orthop Res

2010; Abboud and Kim CORR 2010)

◼ Diabetes (Abate BMC Musculoskelet Disord. 2010; Bedi et

al 2009, Roquelaure Scand J Work Environ Health. 2011)

1. Patients: Acute or Chronic?

◼ Non-operative conservative!

◼ 47% of symptomatic tears progressed over 19 months

◼ 1 cm-2 cm tears progressed most

◼ Risk factors: medium-sized (1-2 cm) full-thickness tears in a smoker

Yamamoto et al. AJSM 2017

1. Patients: Acute or Chronic

◼ Muscle atrophy & fatty degeneration progressed fastest in medium-sized tears (AAOS 2017)

◼ Yamamoto et al. AAOS 2019

◼ 56% of the tears progressing did so in the first 6 months

◼ 46% progressed in Length & Width

1. Patient Selection

◼ Steroids prevent collagen, granulation

tissue, and extracellular matrix production.

◼ Preoperative steroid injections increased revision RCR up to 150% in first 6 -12 mo postop. (Agarwalla et al. Arthroscopy 2019)

◼ Steroid injections within 6 months before RCR increases revisions in next 3 yrs (Traven et al

Arthroscopy 2019; Weber Arthroscopy 2019; Werner Arthroscopy 2018; Desai Arthroscopy 2018)

1. Patient Selection

◼ COX-2 inhibitors prevent healing

◼ RCT (level 1) 180 patients

◼ Compared celecoxib, ibuprofen, tramadol

◼ Celecoxib: 37% retears

◼ Ibuprofen: 7% retears

◼ Tramadol:4% retears Oh et al. AJSM 2018

1. Patient Selection

COX-2 inhibitors prevent healing

◼ Cohen et al AJSM 2006

◼ Burns et al. AAOS 2019

◼ Insulin Resistance may be a risk factor for rotator cuff tears (Park et al AAOS 2019)

1. Testosterone Levels?

◼ PearlDiver database search

◼ Males <70: compared rotator cuff repair revision rates to preop Testosterone

◼ Low testosterone (233): 8.6% revisions

◼ Normal testosterone (202): 3% revision

(p=0.007)

◼ Testosterone replacement??

Cancienne et al. AAOS 2019

2. Biological Augmentation

◼ Doxycycline: inhibits matrix metalloproteinases

◼ Improves rotator cuff healing after repair in rats: 130mg/kg (Bedi et al. AJSM 2010)

◼ Protects against Propionibacterium acnes, which may inhibit cuff healing

◼ 100 mg BID x 14 days

2. Biological Augmentation

◼ Atelocollagen (Suh et al. AJSM 2017)

◼ Rabbit supraspinatus tendon

◼ Atelocollagen patch implanted between bone and tendon

◼ Histology significantly better than control group @12 wks

◼ Load to failure higher (p=0.001)

2. Biological Augmentation

◼ Atelocollagen injections (type 1) in

PAINT lesions (US guided)

◼ RCT (level 1), MRI at 6 mo follow up

◼ Gp 1: 1 ml atelocollagen (30)

◼ Gp 2: 0.5 ml atelocollagen (32)

◼ Gp 3: no injection (32)

Kim YS et al. AAOS 2019

2. Biological Augmentation

◼ Atelocollagen injection PAINT lesions

◼ Gp 1: 37% decreased tear (p=0.003)

◼ Gp 2: 28% decreased tear (p=0.02)

◼ Gp 3: 6% decreased tear size

Kim YS et al. AAOS 2019

2. Biological Augmentation

Statins enhance rotator cuff healing

◼ Atorvastatin found to stimulate tenocyte proliferation, migration, and adhesion via increased COX2 activity and autocrine/paracrine PGE2 signaling.

Dolkart O, et al. AJSM 2014

2. Biological Augmentation

◼ Recombinant human parathyroid hormone improves cuff tendon-to-bone healing (rat model)

◼ Post repair injections: subcut daily (rat model)

◼ Showed increased failure loadsDuchman KR, et al. JSES 2016

Hettrich et al. J Ortho Res 2012

2. Biological Augmentation

Recombinant human parathyroid hormone (Teriparatide)

Prospective Level 3 study of >2cm tears

◼ Gp1: 20 μg QD subcut x 3 mo post op

◼ Gp2: no Rx

◼ Gp1: 16.1% (5 of 31) failed (MRI)

◼ Gp2: 33.9% (42 of 124) failed (p=0.037)

Oh JH, et al. Arthroscopy 2019

Marrow stem cells (Crimson Duvet)

◼ Steve Snyder: Crimson Duvet (2003)

◼ Bone Marrow elements are key for healing and may be inhibited by covering the bone and blocking the Crimson Duvet.

Crimson Duvet

◼ Microfracture of the greater tuberosity lateral to the attached tendon results in “streaming bone marrow elements”

Crimson Duvet: 8 weeks

◼ Extension of the cuff “neo-tendon” over the greater tuberosity

Crimson Duvet: Clinical Data

◼ Lower retear rates with Crimson Duvet

◼ 124 full-thickness rotator cuff tears

◼ 36.8 mo f/u; MRI (min 9 mo post op)

◼ Healed Marrow vents: 77.8%

Control group: 54.8% (P =.023)

Jo et al. AJSM 2013

Crimson Duvet: Clinical Data

◼ 40 Marrow vents, 40 Controls

◼ MRI healing: Marrow vents 65.7% Control 52.6% (p=0.2)

◼ Better 2 tendon tear healing

Marrow vents: 60%

Control group 12.5% (p=0.04)

◼ Milano et al. Arthroscopy 2013

Crimson Duvet: Clinical Data

Other positive reports

◼ Bonnevialle et al. JSES 2015

◼ Taniguchi et al. JSES 2015

◼ Osti et al. Int Ortho 2013

◼ Jo et al. KSSTA 2011

3. Mechanical Factors

3. Anchor … Suture Tension

Hooke’s Law: F= X(k)Force = Distance (spring constant)

Over Tension = Failure!

3. Suture Abrasion

◼ Abrasion may occur during cycling

◼ Influence early gap formation

◼ Prevent rotator cuff repair healing

3. Suture Abrasion

◼ FiberWire & FiberTape was significantly more abrasive than OrthoCord

◼ FiberWire most abrasive of 9 sutures (OrthoCord, Maxbraid, Force Fiber,

Ultrabraid, Ticron…) Williams et al. JSES 2016

Deranlot et al. Arthroscopy 2014 Lambrechts et al. Int J Should Surg 2014

Failure Type Matters!

◼ Type 1 tear No remaining foot print

◼ Type 2 tear: tissue remained at footprint

SR Suture Bridge

Cho AJSM 2010

Type 2

Type 1

Suture Bridge Concerns

◼ Single Row: 75% type 1; 25% type 2

◼ DR-SB: 26% type 1; 74% type 2; also increased fatty atrophy

SR Suture Bridge

Cho AJSM April 2010Cho AJSM Oct 2011

Type 1

Type 2

3. Mechanical Factors (Reinforcement)

◼ Graft augmentation

◼ What material?

Graft Options

◼ Autografts

◼ Allografts

◼ Xenografts

◼ Synthetic grafts

Ideal Augmentation Graft

◼ Provide structural strength

◼ Improve the biological environment

◼ Matrix for cellular in-growth

◼ Incorporate into cuff during healing

◼ Bridging defects <1cm “On-label” (FDA)

Autografts: Fascia Lata

◼ Fascia lata: 6-8mm thick; 6cmx3cm (harvested near hip)

Mihata Arthroscopy 2013

Autografts: ITB + bone blockMihara et al. Arthroscopy 2014Mihara et al. JSES 2016

Allografts: Dermal or Tendon

Acellular Dermal Matrix (ADM)

◼ Allopatch HD (Musculoskeletal Tissue Foundation)

◼ ArthroFlex (LifeNet Health)

◼ GraftJacket (Wright Medical Technology)

◼ RC Allograft Patch: human freeze dried rotator cuff (Arthrex)

Xenografts: cow, pig, horse

◼ Bovine fetal skin: TissueMend (Stryker)

◼ Porcine small intestine submucosa -SIS: CuffPatch (Biomet) & Restore (DePuy):

◼ Porcine skin: Zimmer Collagen Repair patch (Zimmer) Conexa (Tornier):

◼ Equine pericardium: OrthAdapt (Synovis-

Baxter): (may not be available)

Xenografts: Ono OJSM 2016

◼ Systematic Review/ rotator cuff grafts

◼ Large to massive rotator cuff tears

◼ MRI or US proven healing

◼ Grafts offered superior tendon healing and clinical outcomes

◼ Concerns about: porcine small intestine submucosa, bovine grafts

Xenografts: Not Effective

◼ Bryant et al. JSES 2016

◼ RCT moderate & large cuff tears

◼ With/without SIS augmentation

◼ MRA @ no retear difference (p=.3)

Others: Iannotti JBJS 2006, Sclamberg JSES 2004, Walton JBJS 2007

Synthetic substitutes

◼ SportMesh: Polyurethane urea (Biomet)

◼ X-Repair: Poly-L-lactide (Synthasome)

◼ RCR Patch: Polycarbonate poly(urethane urea) (Biomerix)

Bovine Collagen Implant

◼ Augments biomaterial properties

◼ Not a structural graft!

◼ 13 pts partial thickness tears

◼ Complete healing (7/13) @ 12 months

◼ 92% (12/13) G/E results

◼ No tear progression @ 24 mo (MRI)

Bokor et al. 2016

Biologic Reinforcement

◼ Bovine collagen implant

◼ Schlegel et al. 2018 (33 patients)

◼ McIntyre et al. AANA 2018

Biologic Reinforcement

10 month post implant re-look

65 y/o WM w/ symptomatic 40% bursal tear

Biologic Reinforcement

◼ Ryu (2019) 25 pts MRI evidence

Preop 6 weeks 4 months 30 months

3. Mechanical Reinforcement

◼ Cuff ADM Onlay Graft

◼ Tears: 3cm; 2 tendons

◼ Small defect left after repair

◼ Exclusion: tears > 5 cm; smokers, subscap tears

Barber et al. Arthroscopy 2012

Acellular Dermal Matrix Allograft Outcomes: Onlay

◼ Prospective, randomized cuff repair

◼ Augmentation: 85% intact

◼ Controls: 40% intact(p<0.01)

◼ No adverse events related to the augmentation device.

Barber et al. Arthroscopy 2012

Grafts in Massive Cuff Repair

◼ Systematic review 10 studies, 316 pts

◼ Large-massive cuff tears + grafts

◼ Allograft augmentation: functionally & structurally superior to primary repair

◼ Augmentation 85% intact

◼ Controls 40% intact (P<.01)

Ferguson AJSM 2016

Acellular Dermal Matrix Allografts Onlay Massive Cuff Repairs

◼ Prospective comparative study

◼ F/U 25 mo; ultrasound

◼ Retears: Control 26%

ADM augmentation 10% (P=.0483)

◼ More pain reduction with ADM; higher ASES, SF-12, WORC scores

Gilot Arthroscopy 2015

BB: 57 y/o WF MRI Tech

◼ R Shoulder Pain: FOOSH on wet sidewalk in New Orleans during Mardi Gras

◼ FF: 30 active, 90 passive

◼ AB: 30 active, 70 passive

◼ Strength: 3/5, 3/5, and 5/5

BB: 57 y/o WF MRI Results

◼ 4cm x 4.5cm SS and IS retracted tear

◼ No significant atrophy

Onlay Technique

4 year follow up

◼ FF: 180 active

◼ AB: 180 active

◼ ER: 90 active

◼ IR: 70 active

◼ Strength: 5-/5, 5/5, and 5/5

How to improve outcomes?

1. Patient selection: age, tear size, smokers, diabetics

2. Biological: PRP membrane, improved blood flow (marrow vents)

3. Mechanical: acellular dermal Onlay allografts for tears >3cm

How to Improve Outcomes?

◼ What else?

◼ Slow rehab

◼ Doxycycline

◼ Recombinant Parathyroid hormone?

◼ Revisions

◼ Larger tears with atrophy

◼ Low humeral bone density

Thank You

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