When and How to Use Patches


Chapter 23

When and How to Use Patches



Kent P. Sheridan, Brian D. Dierckman, Joseph P. Burns, and Stephen J. Snyder

Introduction


Symptomatic large and massive rotator cuff tears are common with advancing age. Among those who undergo rotator cuff repair surgery, reasonable clinical outcomes have been reported in the majority of patients; however, complete tendon-to-bone healing is uncommon, with retear rates ranging from 40% to over 90%. In order to improve healing rates, various scaffolds have been investigated to augment these tears at high risk of retearing. In addition, some tears are not fully repairable, and grafts have been used to bridge the defect in the cuff tendon. In this chapter, we describe the use of human dermal allograft as both an augmented graft and an interposition graft because of its favorable biologic and mechanical properties.

Brief Description of Procedure


A dermal allograft patch can be used either to bridge a defect greater than 1 cm in size (interposition) or to augment a complete repair (augmentation). We prefer to use an arthroscopic technique over an open technique, largely owing to improved visualization and preservation of the deltoid attachment. Sutures are passed through the graft outside the shoulder, and knots are tied on one end of the suture; the other end of the suture is shuttled into the joint through the native cuff tissue and out another cannula. These medial ends are then slowly pulled, which draws the graft into the joint. The suture ends are then tied together, firmly fixing the graft to the native tissue.

Patient History



Patient Examination



Imaging





  1. • We routinely get four standard views of the shoulder for all new patients: a true anteroposterior (AP) view (Grashey), a supraspinatus outlet or “arch view,” an axillary lateral view, and an AC joint (Zanca) view.
  2. • Joint space narrowing and other signs of osteoarthritis are noted on axillary lateral and true AP views. Rotator cuff arthropathy is a contraindication to allograft repair.
  3. • We use mostly noncontrast magnetic resonance imaging (MRI). Intraarticular gadolinium contrast is useful to assess the integrity of prior rotator cuff repair but is rarely needed to assess the need for use of dermal allograft. Other pathologies, such as AC joint arthropathy, biceps tendinopathy, and subscapularis tendon tears, are assessed and planned for accordingly. The articular surface is carefully evaluated; minor articular defects are not considered a contraindication, whereas larger full-thickness defects are.

  5. • The presence of an “S-wave” is favorable for primary cuff repair. This is present when cuff tissue has a recoiled appearance on coronal MRI images (Fig. 23.1).
  6. • Dermal allograft augmentation should be considered when an MRI shows an “at-risk” tendon that has a thin diminutive appearance but likely can be reapproximated to bone (Fig. 23.2).
  7. • Interposition grafting is considered in cases where MRI shows a segmental tendon defect that likely will not allow reduction to the tuberosity. This is occasionally observed in Cho type II failures near the musculotendinous junction after double-row rotator cuff tendon repair (Fig. 23.3).
  8. • We do not routinely order electromyography with nerve conduction studies to evaluate the suprascapular nerve. Suprascapular nerve decompression at the time of surgery is controversial and of uncertain clinical benefit. Rotator cuff tendon reduction near its anatomic footprint presents the best option for “untethering” the suprascapular nerve. However, in cases where interposition grafting is used and the cuff remains in a more retracted position, decompression of the suprascapular nerve at the time of repair may have a theoretical benefit. More investigation is warranted before recommending for or against nerve decompression in these instances.

image
FIG. 23.1 The “S-wave” is viewed on a coronal MRI of the supraspinatus tendon. The recoiled tendon has an undulating appearance, which is favorable for primary repair of tendon to bone. 
Shoulder Arthroscopy Third Edition, Wolters Kluwer Health, Page 249.

image
FIG. 23.2 Coronal MRI of an “at-risk” tendon considered for augmentation. This patient has a large retear after prior repair. Although the remaining tendon can likely be reapproximated back to bone, the risk of nonhealing is high because of poor tissue quality. 
Shoulder Arthroscopy Third Edition, Wolters Kluwer Health, Page 324.

image
FIG. 23.3 Coronal MRI of a failure following a double-row repair. A segment of nonfunctional tendon remains attached to the greater tuberosity while the medial tendon is shortened and retracted with the supraspinatus muscle. It is unlikely that the remaining tendon will be reducible to the tuberosity without excessive tension, and therefore this patient will likely need an interposition dermal allograft. 
Shoulder Arthroscopy Third Edition, Wolters Kluwer Health, Page 336.


Treatment Options





  1. • Conservative treatment: Nonoperative treatment of rotator cuff tears consists of physical therapy, nonsteroidal antiinflammatory drugs (NSAIDs), and steroid injections. An initial course of physical therapy with NSAIDs is appropriate for those with more minor rotator cuff tears and for patients apprehensive about undergoing surgery. We typically limit patients to one or two steroid injections total.
  2. • Partial rotator cuff tendon repair: There are instances where patients cannot have dermal allograft repairs despite being ideal candidates (e.g., financial, cultural). Partial repairs that address concomitant pathology will often give them some relief but with guarded expectations about shoulder function and pain alleviation.
  3. • Reverse total shoulder arthroplasty: Ideal for patients with rotator cuff arthropathy that precludes rotator cuff repair. Although repair of the tendon is often feasible, a frank discussion must address whether a cuff repair will alleviate the patient’s symptoms, because complaints related to osteoarthritis may be unchanged or become worse.
  4. • Latissimus dorsi tendon transfer: Data in the literature regarding improvement after latissimus dorsi tendon transfer have shown favorable results. No currently existing studies compare dermal allograft interposition with tendon transfer, and thus more investigation is required.
  5. • Superior capsular reconstruction: This emerging technique is currently being investigated. We have noted on rare occasions that medial rotator cuff tissue is inadequate even for dermal allograft interposition. In these cases, superior capsular reconstruction may present a viable option.

Surgical Anatomy





  1. • Scapular spine: Visualization of scapular spine serves as a reference for the “midpoint” of the tendon while placing medial sutures (Fig. 23.4).
  2. • Humeral footprint anatomy: Anchors are ideally placed at the medial supraspinatus/infraspinatus footprint 5 mm from the articular cartilage at a 45-degree “tent peg” angle (Fig. 23.5).

  3. image
    FIG. 23.4 Viewing from the lateral portal on a left shoulder, the rotator cuff footprint is visualized with cystic changes and prior implants from failed repairs. The articular edge is visualized on the horizon with the scapular spine in the background. The scapular spine serves as a reference to the native tendon midpoint and will be used while passing sutures.


  4. image
    FIG. 23.5 The suture anchors are inserted 5 mm lateral to the articular cartilage at a 45-degree “tent peg” angle. 
    Shoulder Arthroscopy Third Edition, Wolters Kluwer Health, Page 287.



  6. image
    FIG. 23.6 The suprascapular nerve travels through the fibro-osseous tunnel of the suprascapular notch and suprascapular ligament to innervate the supraspinatus. The nerve then passes around the spinoglenoid notch to innervate the infraspinatus. 
    Shoulder Arthroscopy Third Edition, Wolters Kluwer Health, Page 361.

  7. • Suprascapular nerve: Overly aggressive medial debridement will place the suprascapular nerve at risk (Fig. 23.6).
  8. • Tear classification: Rotator cuff tears are described by pattern (e.g., L-shaped or reverse L-shaped, stellate, “monk’s hood”) and classified using the system described by Snyder (Table 23.1). When complete lesions are found, which is often the case with larger tears considered for dermal allograft, the size of the complete tear follows the “C” designation scheme:


    1. – CI: A small complete tear, such as a puncture wound, would be rated CI.
    2. – CII: A moderate tear that still encompasses only one of the rotator cuff tendons with no retraction of the torn ends would be rated as a CII lesion.
    3. – CIII: A CIII lesion involves an entire tendon with minimal retraction of the torn edge, usually 3 cm in size.
    4. – CIV: A massive rotator cuff tear (CIV) involves two or more rotator cuff tendons, frequently with associated retraction and scarring of the remaining ends of the tendon and often an L-shaped tear. When a CIV cuff tear cannot possibly undergo direct repair to the greater tuberosity, it is termed “irreparable.”


  10.  


    TABLE 23.1









    Rotator cuff tear classification as described by snyder
    Classification of Rotator Cuff Tears
    Location of tear


    A Articular surface



    B Bursal surface



    C Complete tear, connecting A and B sides

    Severity of tear


    0 Normal cuff, with smooth coverings of synovium and bursa



    I Minimal superficial bursal or synovial irritation or slight capsular fraying in a small localized area, usually <1 cm



    II Actual fraying or failure of some rotator cuff fibers in addition to synovial, bursal, or capsular injury, usually <2 cm in size



    III More severe rotator cuff injury, including fraying and fragmentation of tendon fibers, often involving the whole surface of a cuff tendon (most often the supraspinatus), usually <3 cm in size



    IV Very severe partial rotator cuff tear that usually contains, in addition to fraying and fragmentation of tendon tissue, a sizable flap tear, usually larger in size than grades I–III and often encompassing more than a single tendon


    From Snyder SJ. Evaluation and treatment of the rotator cuff. Orthop Clin North Am. 1993;24:173–192.


Surgical Indications





  1. • Persistent activity-related shoulder pain and failure of other conservative measures are common indications for operative rotator cuff repair. Symptomatic full-thickness rotator cuff tears with retraction are generally treated surgically because the risk of progression to an irreparable tear is significant.
  2. • Once a patient elects to undergo rotator cuff repair, the first decision a surgeon must make is whether the rotator cuff tear is likely to be repairable using standard techniques based on clinical exam and imaging.
  3. • Ideal candidates for dermal allograft use include the following:


    1. – Failed prior repairs
    2. – Fatty infiltration
    3. – Muscle atrophy
    4. – Thin, degenerative tendon
    5. – Large tears (>2 cm)
    6. – Significant retraction (beyond humeral apex)
    7. – Chronic traumatic tears
    8. – History of failed repair on contralateral shoulder

  5. • Patients are advised that the final decision on whether to use the graft, augment, or perform an interposition procedure is made intraoperatively.

One or more of the above risk factors warrants preparation for the use of dermal allograft. There are few absolute contraindications to using a graft, but patient bias against using an allograft must be respected. Cost, additional time requirement, and surgeon’s comfort level are relative contraindications.

image
FIG. 23.7 Preparation and draping for shoulder arthroscopy. A towel is folded into a pouch (B) and wrapped in Coban to keep basic instruments (grasper, switching sticks) close at hand. 
Shoulder Arthroscopy Third Edition, Wolters Kluwer Health, Page 12.

Note: Use of patches is approved by the U.S. Food and Drug Administration (FDA) only as an augmentation with less than 1-cm defect; therefore interposition is currently an “off-label” use, and patients should be informed of the FDA status.

Surgical Technique Setup


Positioning



Equipment



Establishing Surgical Portals


Brief Description of Surgical Portals and Optimizing Visualization



Procedure





  1. • Draw the exterior bony anatomy (clavicle, AC joint, acromion, scapular spine, midacromial orientation line).
  2. • Create a standard PMGP and AMGP. The AMGP is most efficiently made by placing the scope in the rotator interval, placing a switching stick through the scope sheath to pierce the rotator interval, and then making a small incision to pass the switching stick “through and through” out of the skin. A Crystal cannula can then be placed over the switching stick, followed by introduction of the arthroscope.
  3. • Perform a complete 15-point arthroscopic glenohumeral evaluation, viewing from both the posterior and anterior portals. Document the condition of the cartilage surface, labrum, biceps, subscapularis, synovium, and articular portion of the rotator cuff.
  4. • Prepare the shoulder joint by debriding frayed and loose tissue.


    1. – If suture material is present within the degenerative cuff edges, it can be removed, and the cuff edges can gently be debrided. Debriding the tendon edge may aid in healing by removing proapoptotic factors detrimental to tissue regeneration.
    2. – Releases of the rotator cuff are initially performed from within the glenohumeral joint space. The shaver at this stage can be used to bluntly dissect, release adhesions, and mobilize any scar tissue that has formed.
    3. – The medial stump of the rotator cuff can be carefully released by mobilizing scar and capsule just above the glenoid.

  6. • Repair any significant subscapularis or labral pathology as needed.
  7. • Remove the arthroscope and anterior portal and perform subacromial bursoscopy.


    1. – Prior to reinsertion of the arthroscope, the arm is placed into the “bursal position” to allow better visualization of the subacromial space. Traction is generally increased to 15 pounds.

    2. image
      FIG. 23.8 Arthroscopic view from the midlateral subacromial portal. The bursa, greater tuberosity footprint, and rotator cuff have been adequately debrided and are ready for a dermal allograft. In this case, an interposition graft was used because of stiff, thin rotator cuff tissue.

    3. – With the arm in adduction, the bursal space is entered, and a full evaluation of the anatomy is performed.

  9. • Thoroughly debride bursal tissue, viewing from the anterior and posterior portals to visualize the entire rotator cuff. Keep the deltoid fascia intact when possible to minimize fluid extravasation. Hemostasis is obtained with electrocautery.


    1. – Previously placed anchors are left in place if possible but removed if they are obstructing the bone needed for graft attachment near the articular edge of the humerus.
    2. – If there are cysts or large bony defects that will likely compromise fixation stability of the new anchors, they should be filled with a suitable bone graft material.

  11. • Create an MLSAP using a spinal needle to localize over the midpoint of the cuff tear. This will be used as a working portal and also for graft passage. The entry of the spinal needle is generally 3–4 cm distal to the lateral acromion and near the midacromial orientation line.


    1. – When the MLSAP is centered over the cuff defect, it may not be centered on the acromion in the sagittal plane.

  13. • Perform subacromial decompression, AC joint resection, or biceps procedure as necessary. Debride all soft tissues off the greater tuberosity to cortical bone. This will create a better surface for regrowth of the footprint (Fig. 23.8).
  14. • Insert 7-mm Dry-Doc arthroscopic cannulas in the AMGP and PMGP. An 8.5-mm Dry-Doc cannula is placed in the MLSAP.

  15. image
    FIG. 23.9 Portal and cannula placement on a left shoulder for rotator cuff augmentation or interposition. The arthroscope is placed in the optional posterolateral viewing portal. The blue 7-mm cannulas are placed in the anterior midglenoid portal (right) and posterior midglenoid portal (left). The larger yellow 8-mm lateral cannula will be used for graft passage and anchor placement. When using a posterolateral portal, the yellow cannula is placed slightly anterior to the midpoint of the lateral acromion to allow adequate spacing between the viewing and working portals. 
    Shoulder Arthroscopy Third Edition, Wolters Kluwer Health, Page 325.



    1. – If the cuff defect is very large (over 3.5 cm in either dimension), a 10-mm-diameter cannula with an external rubber diaphragm is recommended to allow passage of the graft in the cannula.

  17. • A final check on visualization with debridement of soft tissues and hemostasis is quickly performed prior to starting repair procedures.
  18. • Using a ring forceps, we perform a trial reduction of the rotator cuff, which represents a key branching point in our decision process. After grasping the apex of the cuff, if it can be easily reduced to the medial footprint, we perform a standard “SCOI row” repair (so named for the Southern California Orthopedic Institute, where it was first developed) in patients without previously mentioned risk factors for failure. If a reduction is feasible but with a moderate amount of tension, we perform a repair with augmentation. If reduction requires great effort or is impossible, we perform a graft interposition.
  19. • Optional portal: A PLP can be created for visualization during suture and graft passage. This portal should be placed just posterior to the middle of the tear such that it will have complete visualization throughout the case, including the entire tear, the greater tuberosity, and the MLSAP as it enters the subacromial space. Visualization of the aperture of the MLSAP cannula is particularly important because introduction of the grasper can be directly visualized when retrieving sutures, thereby assuring that entanglement has not occurred. The disadvantage of this portal is that it creates an additional incision. The benefit is that work in the AMGP and PMGP can continue without switching the camera between them. For illustrative purposes, an accessory PLP is used in the section of this chapter describing augmentation.

Pearls



Pitfalls



Step-By-Step Guide to Surgical Technique: Rotator Cuff Augmentation Using Dermal Allograft


Step 1: Back Table Preparation



Step 2: Rotator Cuff Tendon Repair





  1. • Create standard portals (PMGP, AMGP, and MLSAP) and prepare the shoulder for rotator cuff tendon repair as previously outlined in this chapter.
  2. • Once augmentation is deemed appropriate, the cuff tear is evaluated, and feathered edges are debrided.

  3. image
    FIG. 23.10 Short-tailed interference knot sutures (STIKs) are demonstrated in different colors to allow easy differentiation during management. The 4-mm switching rod is placed near the handle of a sterilization tray to hold it suspended. With use of a No. 2 braided suture, three throws of alternating triple-surgeon knots are placed around the guide rod for bulk. The “STIK suture” refers to the free end, and the “STIK knot” refers to the knotted end. 
    Shoulder Arthroscopy Third Edition, Wolters Kluwer Health, Page 340.

    Related posts:

    Patient Positioning and Anesthesia for Rotator Cuff Surgery Arthroscopic Trillat Procedure for Recurrent Anterior Shoulder Instability With Associated Irreparable Rotator Cuff Tear Nonoperative Care of Rotator Cuff Disorders: Physical Therapy, Modalities, and Injectables What Type of Rotator Cuff Tear Is This? Tear Pattern Recognition and Soft-Tissue Releases Subscapularis Tendon Tears: Arthroscopic Management Arthroscopic Rotator Cuff Repair: Double Row

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Mar 28, 2020 | Posted by in ORTHOPEDIC | Comments Off on When and How to Use Patches

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