Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
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
Kings Peak, Utah
13,528 ft #44