10 Revision Rotator Cuff Repair: Patch Augmentation
Abstract
During revision rotator cuff repair tissue compromize is common. This chapter will discuss indications, operative technique, and challenges when utilizing a patch for rotator cuff structural and biologic augmentation.
10.1 Goals of Procedure
Improve the outcome of revision rotator cuff repair (RCR) by utilizing extracellular matrix (ECM) tissue to structurally and biologically augment rotator cuff repair procedures.
Recurrent rotator cuff tears after large RCR are still reported to be 34 to 94%. In an effort to improve the healing rates of large tears, the use of ECM grafts derived from human or animal tissues can be used to surgically augment the repaired rotator cuff by reinforcing the repair. Augmentation of RCR may increase mechanical strength at initial fixation. RCR reinforced with ECM grafts have been shown to decrease gap formation by up to 40% and increase ultimate load to failure by 35% in a human cadaveric model that was tensioned over the repair. 1 Onlay reinforcement has also been validated biomechanically to decrease gap formation and increase load to failure. 2 The best technique for reinforcement has not been defined.
10.2 Advantages
Augmentation of RCR can improve initial fixation of the rotator cuff. Graft procedures can be performed arthroscopically or by open techniques.
10.3 Indications
Augmentation of RCR is generally considered for revision cases or in large to massive tears with tissue compromise.
10.4 Contraindications
Contraindications to revision RCR include advanced fatty infiltration, glenohumeral joint degenerative change or humeral greater tuberosity deformity, advanced age, medical comorbidity, or significant tobacco use. Augmentation would be contraindicated if the patient has sensitivity or allergy to any part of the particular product chosen. Please review manufacturer information regarding possible sensitivity or allergy. The suspicion or presence of past or current infection would be considered a contraindication.
10.5 Preoperative Preparation
Preoperative evaluation should emphasize an understanding of the patient’s history with regard to the original diagnosis, review of operative report and photos, circumstances of the re-tear, and pertinent medical comorbidities. Physical examination should assess motion, strength deficiencies, cervical disease, and neurologic status. The clinician should always consider infection as a cause of re-tear. Imaging is recommended to include plain X-ray and advanced imaging. MRI is the imaging of choice. In the presence of metallic hardware or when MRI is contraindicated, a CT arthrogram is indicated. The rotator cuff should be assessed for atrophy, fatty infiltration, and the location of re-tear (specifically a re-tear medial to the prior repair or type II failure) as this may influence the indication for repair. The clinician should consider that many patients can function well even when the rotator cuff is deficient and avoid surgery in functional pain-free shoulders.
10.5.1 Positioning
Anesthesia: general, interscalene block, or combination.
The patient is positioned in the lateral decubitus or the beach-chair position.
10.6 Operative Technique
An examination under anesthesia is important as many of the patients have contractures or adhesions and releases are frequently necessary. In cases of revision rotator cuff tears, the author prefers to insert the arthroscope directly into the subacromial space to avoid any iatrogenic injury to the residual posterior cuff. Standard posterior, lateral, and anterior portals are established. Additional portals are commonly used for anchor insertion, suture management, and graft passage including anterolateral, posterolateral, and the Neviaser portals. Use disposable working cannulas to minimize fluid extravasation. There is usually significant bursal hypertrophy, and a complete bursectomy will aid visualization and proper assessment of the tear pattern and reparability. The remainder of the shoulder pathology is addressed and additional procedures completed as needed. Loose sutures are removed and anchors are removed if needed. Anchors are only removed if loose or prominent, as the residual defects may require bone grafting and repair can be compromised.
Localizing the scapular spine and coracoid process can assist in identifying the rotator cuff tendons, and mobilization techniques to include interval slides, interval slide in continuity, and release of the articular side capsular contractions can help restore muscle tendon excursion. At this stage, reparability is assessed. For a successful ECM augmentation, the rotator must be reparable by a single- or double-row technique with or without margin convergence or side-to-side repair with minimal tension. If the rotator cuff cannot be primarily repaired, the clinician can consider debridement only, partial repair, interposition, or superior capsular reconstruction.
10.6.1 Repair
Many techniques have been described for rotator cuff augmentation. The author prefers a technique that tensions the graft independent of the RCR to assist in load sharing. 3 The greater tuberosity is debrided preserving subchondral bone. The graft will be attached medial to the repair and these sutures are placed prior to initiating the RCR. Mattress sutures (no. 2 nonabsorbable) are placed in the tendons to be repaired 5 mm lateral to the musculotendinous junction and spaced 1 cm apart. It is far simpler to place these sutures at this stage than after the cuff is repaired. The repair can be performed all arthroscopically or open. The arthroscopic technique is described below; however, the technical steps are the same for open repair.
The steps involved in repairing the rotator cuff and attaching the ECM graft depend on the type of repair the surgeon chooses. Anchors are inserted (or alternatively bone tunnels) and sutures are passed through the rotator cuff tendons for standard RCR by the surgeon’s choice of method. In many cases, the bone is soft or compromised, frequently requiring larger diameter anchors. If the repair is a single-row or transosseous tunnel repair, then all sutures can be tied or secured at this time. When utilizing a double-row or transosseous equivalent (TOE) technique, all sutures should be passed but not secured laterally. Multiple accessory portals are frequently required for anchor placement and suture management.
The size of the desired graft is measured. The graft should extend beyond the defect by at least 5 mm medial, anterior, and posterior, and extend laterally 1 cm over the greater tuberosity. The ECM graft of surgeon’s choice should be handled based on manufacturer’s recommendation, thoroughly irrigated, and trimmed to the appropriate size. The author recommends a graft 1.5 to 2.0 mm in thickness.
The graft is brought to the patient and placed on a towel near the lateral portal. The lateral portal is exchanged for a 1-cm-diameter portal to aid in graft passage. The sutures that were previously placed for graft attachment are identified individually and one limb from each pair in placed in Mason–Allen technique and spaced equally on the medial side of the graft. If a TOE repair is utilized, the medial row sutures are also passed through the ECM graft at the appropriate spacing. Care is taken to pass all sutures individually and have an assistant maintain tension on all passed sutures to avoid tangling. The author prefers to pass no. 2 sutures with a commercial arthroscopic suture passer and punch the graft with a 2-mm skin biopsy punch for larger sutures that allow the graft to glide over the sutures for easier insertion. Once all suture passes are complete, an additional no. 2 suture is placed in the graft medially and then shuttled into the shoulder and retrieved through a Neviaser portal. This suture allows the surgeon to pull the graft into the shoulder with tensioning any of the repair sutures to avoid anchor or tissue pullout. Two additional no. 2 sutures are passed at the anterolateral and posterolateral corners. These are utilized for final tensioning during lateral fixation. The graft is then rolled anterior to posterior and a tissue grasper is used to push the graft into the shoulder. The push/pull technique minimizes the risk of tissue or anchor failure. The medial row sutures are tied completing the medial repair.
Lateral Fixation in Single-Row Technique or Transosseous Tunnels
Standard suture anchors can be utilized and the incorporated suture passed through the lateral edge of the patch by a suture passer. If tunnels are used, they need to be placed about 1 cm distal on the greater tuberosity.
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