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Can we improve rotator cuff tendon biology and is augmentation helpful?
Mr Adnan Saithna, Consultant Sports Injury Knee and Shoulder Surgeon based at Southport, Ormskirk and Renacres Hospitals
The role for improving biology..
• High failure rates, particularly for massive tears
• Widely reported figures of 20-90%
• How can we optimise the biology:
Avoid treatments that impair biology
Optimise the repair
Optimise patient factors
Augmentation
PRP
Stem Cells
Patches
SR:Effect of glucocorticoidsMechanical properties of tendon, Dean et al
Effect of glucocorticoids
• significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis
• There is increased collagen disorganisation and necrosis as shown by in vivo studies
• Directly affects microvascularisation of the footprint, Bonneviale et al
• 48 patients
Angiogenesis assessed by CD34 immunostaining from intra-op biopsy at repair
Correlated with success of repair at 1 year
Glucocorticoid injection significantly reduces CD34 staining (and microvascularity of footprint) 10% vs 16%
Microvascularity correlates with success of cuff healing after repair
16%
14%
4%
Association between rate of microvascularisation and Sugaya grade
Footprint preparation: Radiofrequency ablation• Ficklcherer, et al. Arthroscopy 2014
• Supraspinatus repair in 189 rats
Footprint either decorticated, untreated or treated with RFA
• Biomechanics of repair
Mean load to failure significantly reduced in RFA group
No diff decorticated/untreated
• Histological
Significantly reduced type II collagen in RFA group compared to others
Crimson duvet Snyder et al, TSES, 2009
RCT, Microfracture, Milano et al, Arthroscopy 2013
40 patients in each arm
Significantly improved healing rate in large tears (65 vs
52 %)
No difference in small tears
No difference in constant score
Similar findings Jo et al , AJSM 2013
Optimising patient factors:Smoking and cuff repairSystematic Review, Santiago-Torres, AJSM 2014
• Nicotine delays tendon to bone healing in rat model with lower load to failure at 10 and 28 days
• Clinical outcomes
3 studies
Balyk et al and Mallon et al show significantly worse clinical scores (ASES, UCLA) in smokers at 6 months and 1 year post-op
In contrast Prasad showed no difference
• structural integrity (MRI/USS)
4 studies
Neyton significantly reduced healing on MRI at 16 months
Thashijan et al and Dhanjari et al showed trend to inferior outcomes in smokers on USS
Nho et al, no difference on USS
Diabetic control• Cho et al, AJSM 2015
• Cohort study
• Diabetic patients with post-operative Hba1c more than 7% greater than pre-op value classified as poor control
• Cuff re-tear rate defined by MRI significantly higher (43%) in poorly controlled diabetics than in good control (26%) p<0.001
Vitamin DRyu, AJSM 2015
• Cohort study
• 91 patients
• No association between Vitamin D levels, clinical scores and structural outcomes
PRP: Systematic Review of Meta AnalysesSaltzman et al, Arthroscopy 2016
• The current highest level of evidence suggests that PRP use at the time of arthroscopic rotator cuff repair does not universally improve re-tear rates or affect clinical outcome scores.
• However, the effects of PRP use on re-tear rates trend toward beneficial outcomes if evaluated in the context of the following specific variables:
use of a solid PRP matrix
application of PRP at the tendon-bone interface
in double-row repairs
and with small- and/or medium-sized rotator cuff tears.
Stem cells in tendon disordersSystematic Review: Pas et al BJSM 2017
• No high quality evidence found for the therapeutic use of stem cells for tendon disorders (including cuff repair).
• The use of stem cell therapy for tendon disorders in clinical practice is currently not advised.
• Kim et al AJSM 2017
MSCs loaded in fibrin glue
Cohort study
No clinical differences at 28 months
MRI retear rate 28% vs 14% p<0.001
Human Dermal Matrix AugmentationRCT, Barber et al, Arthroscopy 2012
Augmentation associated with better scores at mean f/up 24 months
• The ASES score improved from 48.5 to 98.9 in group 1 and from 46.0 to 94.8 in group 2. (P = .035).
• The Constant score improved from 41.0 to 91.9 in group 1 and from 45.8 to 85.3 in group 2. (P = .008).
• No difference in UCLA score
Outcomes after patch useSR: Steinhaus, Arthroscopy 2016• 24 included studies (19 level IV)
• When categorized by graft type, the rates of complete re-tears were synthetic: 15.0% (33 of 220), xenograft: 42.0% (50 of 119), and allograft: 9.9% (7 of 71)
• Overall, the complication rate was 3.5% (12 of 340) including 1 severe inflamm reaction, 2 x cystic change HH, 1 deep infection
• Failure rates seem low compared to previously reported rates for large tears but broad inclusion criteria and predominantly cohort series
Some studies included smaller tears
Differing lengths of follow up
Broad inclusion criteria
Weak evidence
Future directions• MSC/biomolecule (BMP-7) loaded hydrogels and synthetic scaffolds have
shown promise in animal studies
• However, a cautious approach must be adopted as animal models have limitations. Eg. Rat model – much higher healing rates, limited fatty degeneration, different morphology and loading
Summary• Avoid steroid injections
• Counsel diabetics and smokers
• Some evidence for footprint preparation but avoid compromising fixation
• PRP/MSCs insufficient evidence to currently support a role
• Patch augmentation – some evidence but mainly Level IV only. More comparative studies required
• Animal studies should be interpreted with caution (as learned from PRP)