Clinical outcomes and structural integrity rate of arthroscopic augmented rotator cuff repairs using extracellular porcine matrix patch.

Background: Structural failure rate in rotator cuff repairs is still high. The purpose of the study is to assess the structural integrity of a series of augmented rotator cuff repairs with porcine matrix patch and report the functional outcomes. Methods: Between 2014 and 2017, 44 consecutive patients underwent arthroscopic double-row repair of medium to massive rotator cuff tears with extracellular porcine dermal matrix augmentation. At one-year follow-up, magnetic resonance imaging scan was performed to assess the integrity of the repair. Oxford Shoulder Score (OSS), Constant Score (CS) and Visual Analogue Scale pain score, together with range of motion were used to assess patients. Results: Patients mean age was 68 (53-82); mean follow-up was 17.2 (12-24) months. On magnetic resonance imaging scans, seven rotator cuff repair failures (15.9%) were observed: tear size was an independent predictor of re-rupture at one-year follow-up. Clinical scores showed a statistically significant improvement at three months and until final follow-up (p< 0.001). No complications occurred. Conclusion: Observed structural failure rate of 15.9% is lower than those reported in the literature for standard rotator cuff repair of medium to massive tears in similar cohorts to ours. Extracellular matrix augmentation for rotator cuff repair was shown to be a safe and reliable support to the repairs and patients recovered good shoulder function.Level of Evidence: Level IV.

Arthroscopic Allograft Bone Block Procedure with Remplissage for Bipolar Lesions.

Anterior shoulder instability with bone loss is a challenging condition. The two most performed procedures, Bankart repair & Latarjet, are not without issues. We describe a technique where arthroscopic free bone grafting was performed in conjunction with remplissage. We feel that this combined arthroscopic procedure offers advantages that include reduced risk of conventional Latarjet complications, including neurological deficits and metal hardware complications while preserving subscapularis and coracoid. Furthermore, these advantages may not come at the cost of compromised outcomes, particularly recurrence rate, as the remplissage may compensate for the possible lack of "sling effect" with free bone graft reconstruction.

Rotator Cuff Repair With Patch Augmentation: What Do We Know?

Background: Repair of massive rotator cuff tears remains a challenging process with mixed success. There is a growing interest in the use of patches to augment the repair construct and the potential to enhance the strength, healing, and associated clinical outcomes. Such patches may be synthetic, xenograft, or autograft/allograft, and a variety of techniques have been tried to biologically enhance their integration and performance. The materials used are rapidly advancing, as is our understanding of their effects on rotator cuff tissue. This article aims to evaluate what we currently know about patch augmentation through a comprehensive review of the available literature. Methods: We explore the results of existing clinical trials for each graft type, new manufacturing methods, novel techniques for biological enhancement, and the histological and biomechanical impact of patch augmentation. Results: There are promising results in short-term studies, which suggest that patch augmentation has great potential to improve the success rate. In particular, this appears to be true for human dermal allograft, while porcine dermal grafts and some synthetic grafts have also had promising results. Conclusion: However, there remains a need for high-quality, prospective clinical trials directly comparing each type of graft and the effect that they have on the clinical and radiological outcomes of rotator cuff repair.

Bony increased-offset reverse shoulder arthroplasty: A meta-analysis of the available evidence.

BACKGROUND: Reverse shoulder arthroplasty (RSA) has revolutionized the management of many shoulder pathologies. Lateralization has become favourable to combat complications (e.g. notching, compromised external rotation), using a metallic, or autogenous bone-graft baseplates - bony increased-offset reverse shoulder arthroplasty (BIO-RSA). We systematically reviewed the literature to determine: Does BIO-RSA improve range of motion and outcome scores?Are notching rates decreased?Does the graft heal? METHODS: All available prospective studies, trials and case series reporting on BIO-RSA were included. Outcomes were grouped into outcome scores, range of motion and radiographic outcomes. Data were pooled and statistical analysis performed. RESULTS: Eight studies reported on 385 RSA - 235 BIO-RSA and 150 standard-RSA (STD-RSA). Follow-up was 20-36 months; average age 74 years. Outcome scores: Constant-Murley and SSV scores showed statistically significant post-operative benefit of BIO-RSA (mean-difference 4.0 (95% confidence interval (CI): 0.79,7.1) and 6.8 (95% CI: 3.8, 9.9)). No Minimal Clinically Importance Difference was surpassed. Range of motion: No difference was found in any direction. Notching: Notching was less likely with BIO-RSA (odds ratio 0.19 (95% CI: 0.10, 0.38)). Healing and loosening: 92% grafts fully healed/incorporated. Loosening rate was 2.4%. CONCLUSIONS: Literature on BIO-RSA is limited with only one randomised controlled trial (RCT). Weak evidence exists for improved outcome scores. Range of motion is equivocal. Notching rates are significantly lower in BIO-RSA. The graft usually heals.

Clinical and Radiological Outcomes of Rotator Cuff Repairs Using All-Suture Anchors as Medial Row Anchors.

BACKGROUND: The aim of our study is to report the clinical and radiological outcomes of a series of prospectively enrolled patients who have had double-row transosseous equivalent rotator cuff repairs, where all-suture anchors were used as medial-row anchors, with a minimum follow-up of 1 year. METHODS: Twenty-two consecutive patients underwent arthroscopic transosseous equivalent double-row rotator cuff repair using all-suture anchors as medial-row anchors. Oxford Shoulder Score, Constant Score and Visual Analogue Scale pain score, together with shoulder range of motion, were used preoperatively and at 3 months, 6 months and final follow-up. Radiological evaluation was performed with magnetic resonance imaging at one-year post surgery to assess the structural integrity of the repair and the rate of cyst formation in greater tuberosity. RESULTS: The patient mean age was 61 years (range 46-75). Minimum follow-up was 1 year, and the mean final follow-up was 15 months (range 12-24). Healing failure in our patients was less than 5% (1/22 patients). There were significant improvements in shoulder function outcome scores at final follow-up. The Constant and Oxford scores were 78 and 44 at final follow-up respectively. There were similar magnitudes of improvement in range of motion (combined abduction and rotation), pain score and supraspinatus strength at final follow up. The improvements in outcome scores were already statistically significant at 3 months (P<.001). Using Kim's classification for cyst formation on T2-weighted MRI images, we observed no fluid or minimal fluid collection in 85% of the patients (17/22 patients). There were no correlations between the grade of bone changes and the clinical outcomes. CONCLUSION: It is safe to use all-suture anchors as medial-row anchors when performing double-row anchor transosseous equivalent rotator cuff repairs. The purported advantages of all-suture anchors may outweigh their perceived disadvantages in rotator cuff repair surgery.

Posterior Shoulder Instability: The Augmented McLaughlin Procedure.

Posterior shoulder dislocation, whilst uncommon, is frequently missed and often associated with a significant defect on the antero-medial aspect of the humeral head (the reverse Hill-Sachs lesion). Several techniques for stabilisation have been described, depending on the size of the lesion. We describe an additional technique for stabilising the shoulder following posterior dislocation by augmenting the reverse Hill-Sachs lesion with layers of extracellular matrix, thus further filling the defect.

Hamburger Technique: Augmented Rotator Cuff Repair With Biological Superior Capsular Reconstruction.

Despite profound advancements in arthroscopic rotator cuff repair (RCR) techniques, radiologic failure rates may be in excess of 60% with repairs of large and massive tears in the elderly population. One of the strategies to improve these healing rates has been "patch" augmentation of the cuff repair. At the same time, superior capsular reconstruction (SCR) has gained significant popularity as an option for irreparable rotator cuff (RC) tears. Some have also advocated performing SCR in addition to arthroscopic RCR to reinforce the repair and improve healing rates. Techniques involving the use of fascia lata, ECM patches, and long head of the biceps (LHB) for SCR to reinforce the cuff repair have all been elegantly described. In this article, we propose a technique that enables a combination of the aforementioned procedures and involves performing RCR with patch augmentation, as well as SCR using LHB. In doing so, the repaired RC is bordered by the patch over its bursal surface and the LHB on the articular surface (functioning as the superior capsule), thus giving us the name "Hamburger technique" (a 3-layered construct).

Superior Capsule Reconstruction: What Do We Know?

The management of irreparable rotator cuff tears remains challenging. Since its introduction by Mihata in 2012, superior capsule reconstruction (SCR) has grown in popularity at an astonishingly rapid rate. The aim of this article is to provide a comprehensive review of the available literature, in order to highlight what has so far been published on SCR, covering all aspects including biomechanical, clinical and radiological studies as well as descriptions of the various techniques for performing the procedure. The short-term clinical results of SCR are promising, but there is need for further long-term studies, as well as randomised controlled trials comparing SCR to other treatment modalities for irreparable rotator cuff tears. Further imaging studies looking at graft healing rates are also required as the healing rates published so far are variable. Additionally, the mechanism of action by which SCR delivers good short-term functional outcomes needs further clarification, as does the importance of the choice of graft type and thickness.

Distal Triceps Rupture Repair: The Triceps Pulley-Pullover Technique.

Distal triceps rupture is an uncommon but debilitating injury, and surgical fixation is almost invariably warranted. A number of techniques have been described in the literature in which combinations of transosseous tunnels and bone anchors have been used. We describe a modification to existing techniques-the triceps pulley-pullover technique with all-suture anchors. This technique minimizes bone loss, while maximizing the bone-tendon contact area and creating a double-row repair to optimize strength and healing.

Compensating for loss: running on one tibialis anterior.

Rupture of the tibialis anterior (TA) tendon is rare and may be either traumatic or spontaneous. TA is the main ankle dorsiflexor, providing 80% of the power, as well as contributing to inversion of the foot. We describe a case of an 84-year-old male who was incidentally diagnosed with absence of his left TA at age 46 while preparing for his first-ever marathon. There was no history of specific injury to this tendon. He subsequently went on to lead an active sporting life, completing over 20 marathons with a best time of 3 hours 12 min.