10 Rotator Cuff Reconstruction

Ankit Bansal and Uma Srikumaran

Summary

Prolonged rotator cuff failure, persistent pain and dysfunction, may necessitate reconstructive operations. This chapter outlines various surgical options available for treatment of massive rotator cuff tears. If reparable, then primary tissue healing to bone is ideal. However, if not amenable to repair, then tendon augmentation, reconstruction, or tendon transfers offer reasonable alternatives to reverse shoulder arthroplasty.

Massive rotator cuff tears – irreparable – augmentation – reconstruction – tendon-transfer

10 Rotator Cuff Reconstruction

I. Overview

Functional improvement is better if the repaired tendon heals to bone
Lower overhead strength reported if rotator cuff (RTC) tendon retears, even though pain level and functional scores remain favorable
Biologic augmentation options have been described:
1. Allograft
2. Extracellular matrices (ECMs)
3. Platelet-rich plasma (PRP)
4. Growth factors
5. Stem cells
6. Gene therapy.
Risk factors for failure:
1. Size of tear
2. Degree of fatty infiltration, muscle atrophy
3. Patient’s age
4. Prolonged tear chronicity
5. Fixed or dynamic anterosuperior humeral escape.

II. Relative indications

Indicated when diminished potential for tendon healing is suspected
Controversial
Massive RTC tear >5 cm, or involving more than two tendons
Revision surgery for failed previous repair.

III. Contraindications

Active infection
Substantial glenohumeral arthritis.

IV. Reconstructive options for massive RTC tears

Partial repair, margin convergence
Primary repair with biologic augmentation
Primary repair with structural augmentation
RTC reconstruction with structural bridge repair:
1. Allograft, xenograft, nanofiber technology.
Superior capsular reconstruction
Tendon transfers:
1. Latissimus dorsi
2. Pectoralis major.

V. Partial repair with margin convergence

Side-to-side closure of massive, U-shaped RTC tear
Combine this with end-on tendon-to-bone repair of the free tendon edge
U-shaped tears begin as L-shaped tear, but assume a U shape due to elasticity of the muscle-tendon unit
Margin convergence of two-thirds of U-shaped tear reduces free edge strain to one-sixth of initial strain
Partial repair of at least half of the infraspinatus is the goal, if complete tendon coverage is not possible.

VI. Biologic augmentation options

PRP—Derived from platelets:
1. Randomized prospective double-blind controlled study did not find significant differences in clinical outcomes on magnetic resonance imaging (MRI) with use of PRP
2. Randomized study with autologous platelet-rich fibrin matrix did not yield substantial differences in tendon healing.
Mesenchymal stem cells (MSCs):
1. Showed favorable tendon enthesis healing in rat model using anterior cruciate ligament and flexor hallucis longus tendon
2. No clear evidence supporting use of RTC tears:
  1. Unclear whether molecular or cellular signals for appropriate differentiation are present.
Growth factors:
1. Fibroblast growth factors (FGF)
2. Cartilage oligomatrix protein (COMP)
3. Platelet-derived growth factor (PDGF)
4. Transforming growth factor beta-1 (TGF-B1)
5. Bone morphogenic proteins 12,13, and 14
6. Further research required to yield appropriate use and indications.