Chapter 38

With the advent of magnetic resonance imaging (MRI) and our better understanding of the clinical evaluation and natural history of rotator cuff problems, orthopedic surgeons now have the tools to reduce the number of misdiagnosed and thus mismanaged rotator cuff tears. In addition, with modern shoulder arthroscopy techniques we have the ability to repair serious rotator cuff tears and thereby reduce the incidence and severity of the common sequela of chronic disability that often follows the failure to perform such repairs.

Unfortunately, there are still numerous patients in whom the initial injury is missed or in whom the pathology is so severe, with advanced tendon disease, that even an appropriate repair fails. In these situations the patient has a weak painful shoulder and very few acceptable surgical options. Current reports indicate failure rates of 41% to 94% for treatment of massive cuff tears.1–4

When the pain and disability from severe, nonrepairable rotator cuff disease are unacceptable, the only available choices for treatment include radical open surgery for a latissimus dorsi muscle transfer to replace the cuff, or some type of constrained total shoulder joint replacement, such as a reverse total shoulder. Both of these options offer some benefit but are considered, at best, unpredictable, especially in younger patients without arthritis.

The obvious solution to this serious quandary is to replace or reinforce the severely damaged cuff tendon with a substitute grafting material. In the past, grafts such as Teflon, fascia lata, biceps tendon, and freeze-dried cuff tendon have been tested, but none of these materials has been consistently successful. Although new materials are now available, orthopedists are understandably cautious when presented with any sort of graft material to replace this important tendon.

Currently there is resurgence in interest in biologically assisting the healing of the damaged rotator cuff either by augmentation of a weak tendon after direct repair or, in very difficult situations, by replacement of the deficient tendon with biologic materials. These new biologic materials are called extracellular matrix (ECM) grafts. Numerous classes of biologic matrices are available, including dermal allografts, dermal xenografts, resorbable and nonresorbable fabrics, and many other collagen and man-made products. Each material has unique properties that must be understood before its use in a patient is considered.2,5–11

With the advent of modern tissue banks offering safe, reliable, and readily available allograft tissue with proven success in reconstructing multiple other areas of the body, surgeons are now comfortable investigating the potential for replacing damaged rotator cuff tissue with a regenerative biologic matrix. Numerous animal laboratory studies support the concept that certain acellular dermal graft materials are successful for restoring deficient rotator cuff tendons.12,13 Short-term to midterm results in humans are promising and have shown reliable improvement in shoulder function and pain scores. Rotator cuff reconstruction with a biologic matrix can now readily be performed arthroscopically in the outpatient surgical center with minimal morbidity to surrounding tissue.^14–16

Characteristics of the ideal rotator cuff graft are presented in Box 38-1.

Our graft choice for this group of patients with chronic massive nonrepairable rotator cuff damage over the past 6.5 years has been a human acellular dermal matrix allograft, GraftJacket (Wright Medical Technology, Arlington, VA).14,16,17

Use of an acellular human dermal allograft material as a “patch” graft is considered an off-label use by the U.S. Food and Drug Administration (FDA). When GraftJacket is used to augment a deficient tendon or bridge a cuff defect less than 1 cm, its use is considered “on label.”

Surgical Technique for Complete Replacement of a Massive Nonrepairable Rotator Cuff Tendon Defect

The specific steps of the procedure are outlined in Box 38-2.

Box 38-2   Surgical Steps

1. Complete initial preparation of the STIK sutures.

2. Perform shoulder evaluation, debridement, decompression, and preparation.

3. Insert the first suture anchor.

4. Measure the defect in the rotator cuff.

5. Prepare the graft.

6. Insert the anterior anchor and perform biceps tenodesis with an “Italian loop” stitch.

7. Attach the graft to the posterior and medial cuff.

8. Attach the graft to the anterior cuff and biceps tendon.

9. Deliver the graft into the shoulder.

10. Tie the STIK sutures.

11. Tie the anchored sutures.

12. Suture the lateral graft to bone.

13. Insert the third and fourth anchors.

14. Tie the anchored sutures.

15. Evaluate the repair.

STIK, Short-tail interference knot.

Preparing the Graft

On the back table, tie 12 short-tail interference knots (STIK) sutures with three different-colored No. 2 braided polyester suture material. Form the STIK sutures by looping a suture around a 2-mm metal rod and tying a loop with a bulky knot below it. Test the strength of the knot by pulling firmly on the free end of the STIK suture while the loop is still on the post.

Make a knotted suture measuring device by tying a loop on one end of a No. 0 braided suture and forming simple half-hitch knots along the suture at 1-cm intervals for 5 cm, beginning 1 cm from the loop end. Load the nonloop end of the suture onto a single-eye knot pusher and pull it up to the loop knot. The loop end of the suture will be passed into the shoulder with the knot pusher so that it can be grasped with a small clamp via another portal, and the knotted suture can thus be laid along the edges of the cuff defect and measured by counting the knots.

Hydrate or otherwise prepare the graft in room temperature sterile saline if needed.

Shoulder Evaluation, Debridement, Decompression, and Preparation

The scope is positioned in any appropriate portal.

Begin by creating standard posterior midglenoid (PMG) and anterior midglenoid (AMG) portals, and place a 7-mm operating cannula in each one. Create the midlateral subacromial (MLSA) portal carefully. Use a spinal needle to select a location 4 cm lateral to the midpoint of the cuff defect. Insert an 8-mm docking cannula in this portal. All three cannulas are left in these portals for the entire procedure, and all stitching and knot-tying tools and the scope can be moved among these portals without need to remove the cannula.

Perform a 15-point evaluation of the shoulder, and document the condition of the cartilage surface, labrum, biceps subscapularis, synovium, and rotator cuff.

Prepare the shoulder joint by debriding the degenerative cuff edges and bursal scar. Repair any significant subscapularis or labral tissues as needed. Mobilize the medial stump of the rotator cuff by carefully releasing the scar and capsule just above the glenoid.

Prepare the bursa by smoothing the underside of the acromion and acromioclavicular joint if needed. Remove any suture anchors that are blocking the area of graft attachment in the area 3 cm lateral to the articular cartilage edge. Debride all soft tissue and lightly decorticate the greater tuberosity to expose the cancellous bone, including the area of the biceps groove. This will create a better surface for healing the biceps tenodesis.

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