Arthroscopic Anterior Shoulder Capsular Reconstruction Using Human Acellular Dermal Graft in Conjunction With Anatomic Glenoid Reconstruction.

Capsular insufficiency of the shoulder associated with glenoid bone loss poses a major challenge to orthopaedic surgeons in the management of recurrent anterior instability. Multiple surgical techniques have been described in the literature with varying rates of success, and the majority of these are open techniques. We present a complete arthroscopic technique for anterior capsular reconstruction using acellular human dermal allograft patch in conjunction to an anatomic glenoid reconstruction using a distal tibial allograft in the lateral decubitus position. If the capsular insufficiency is determined irreparable after glenoid reconstruction, the acellular human dermal graft patch is prepared, inserted into the shoulder joint, and appropriately fixed using suture anchors on both glenoid and humerus, all through arthroscopic portals.

Arthroscopic anatomic glenoid reconstruction has a lower rate of recurrent instability compared to arthroscopic Bankart repair while otherwise maintaining a similar complication and safety profile.

OBJECTIVES: The primary purpose of this study was to determine the frequency and type of complications, including subluxation, infection, hardware complication, graft/glenoid fracture, chondrolysis, neurovascular deficits and stiffness following an Arthroscopic Bankart Repair (ABR) or an Arthroscopic Anatomic Glenoid Reconstruction (AAGR) using a distal tibia allograft for recurrent anterior shoulder instability. Secondary purposes were to determine the frank dislocation rate and the associations of post-operative complications with demographic patient factors. METHODS: Demographic and clinical data were reviewed using means ± standard deviations or frequencies in patients with recurrent anterior shoulder instability who underwent either an ABR or an AAGR. Post-operative patient records were analysed to identify any post-operative complications. The numerical variables of the two groups were compared using the independent t-test or Mann-Whitney U test. Categorical variables and complications were tested using the chi-square test, Fisher's exact test, or the two-sided Monte Carlo test with a significance level of 0.05. RESULTS: We included 174 patients in this cohort, with 61.5% of patients receiving ABR and 38.5% receiving AAGR. Most of our patients were male (70.1%) with an average age of 23.41 ± 8.26 years in the ABR group and 29.37 ± 13.54 years in the AAGR group (p = 0.001). The two groups were similar with respect to their post-operative complication rates when excluding frank dislocation (ABR: 11%, AAGR: 12%). The AAGR group had statistically significantly higher rates of hardware removal compared to the ABR group (p = 0.004). The ABR group had 25 post-operative frank dislocations, with none reported in the AAGR cohort (p < 0.001). The total complication rate for each procedure was found to be 35% for ABR and 12% for AAGR. CONCLUSION: AAGR has a comparable safety profile to the ABR when assessing post-operative complications such as subluxation, infection, graft/glenoid fracture, chondrolysis, neurovascular deficits and stiffness. AAGR is superior to ABR with respect to rates of recurrent instability and should be considered as a first-line treatment in certain patients with specific risk factors such as younger age, competitive contact sports participation, and higher number of instability events pre-operatively. LEVEL OF EVIDENCE: Level III.

Bridging Allograft Reconstruction Is Superior to Maximal Repair for the Treatment of Chronic, Massive Rotator Cuff Tears: Results of a Prospective, Randomized Controlled Trial.

BACKGROUND: Despite advances in surgical techniques, the use of maximal repair to treat large or massive rotator cuff tears results in a high retear rate postoperatively. Currently, no randomized controlled trials have compared the outcomes of maximal repair with interposition dermal allograft bridging reconstruction. HYPOTHESIS: We hypothesized that large or massive rotator cuff tendon tears reconstructed using bridging dermal allograft would have better clinical outcomes 2 years postoperatively, as measured using the Western Ontario Rotator Cuff (WORC) index, than would those receiving the current gold standard treatment of debridement and maximal repair alone. We also expected that patients treated via bridging reconstruction using dermal allograft would have fewer postoperative failures as assessed using postoperative magnetic resonance imaging scans. STUDY DESIGN: Randomized controlled trial; Level of evidence 1. METHODS: A sample size of 30 patients (determined using a priori sample size calculation) with massive, retracted rotator cuff tears were randomly allocated to 1 of 2 groups: maximal repair or bridging reconstruction using dermal allograft. All patients completed questionnaires (WORC and Disabilities of the Arm, Shoulder and Hand [DASH]) preoperatively and postoperatively at 3 months, 6 months, 1 year, and 2 years. The primary outcome of this study was the WORC index at 2 years. Secondary outcomes included healing rate, progression of rotator cuff arthropathy, and postoperative acromiohumeral distance in both groups. RESULTS: Patients treated via bridging reconstruction using dermal allograft had better postoperative WORC and DASH scores (23.93 ± 24.55 and 15.77 ± 19.27, respectively) compared with patients who received maximal repair alone (53.36 ± 31.93 and 34.32 ± 23.31, respectively). We also noted increased progression to rotator cuff arthropathy in the maximal repair group with an increased retear rate when compared with the reconstruction group (87% and 21%, respectively; P < .001). The acromiohumeral distance was maintained in the reconstruction group but significantly decreased in the maximal repair group. CONCLUSION: Rotator cuff bridging reconstruction using a dermal allograft demonstrated improved patient-reported outcomes as measured using the WORC index 2 years postoperatively. This technique also showed favorable structural healing rates and decreased progression to arthropathy compared with maximal repair. TRIAL REGISTRATION: ClinicalTrials.gov (NCT01987973).

Poor Sensitivity of Magnetic Resonance Arthrography to Detect Hip Chondral Delamination: A Retrospective Follow-Up of 227 FAI-Operated Patients.

OBJECTIVE: The purpose of this study was to retrospectively assess the frequency and characteristics of acetabular cartilage delamination (CD) in femoroacetabular impingement (FAI) patients and to assess the sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) of magnetic resonance arthrography (MRA) in detecting CD based on the radiologist report. DESIGN: This is a single-center retrospective review of consecutive patients operated for symptomatic FAI. All of the patients had a 1.5-T MR-arthrogram within 12 months preoperatively. MRA reports of these patients were compared with operation notes and surgical videos of all patients by two trained assessors. RESULTS: At surgery, CD of the acetabulum was present in 169 patients out of a total of 229 patients (74%). Only 6.5% (11 patients) of CD was described on the MRA reports preoperatively. The mean age of the patients was 37.6 ± 13.3 years. The average extent of delamination was 3.12 ± 1.5 cm2 with a mean coronal × sagittal extent of 0.68 × 4.33 cm. There was a significant difference regarding age (P = 0.002), alpha angle from frog view (P = 0.002), and alpha angle from anteroposterior view (P = 0.012) between the patients with delamination and without delamination. The majority of labral tears and cartilage damage were located in the anterosuperior quadrant. MRA sensitivity was 6%, specificity 98%, NPV 27%, and PPV 91% based on the radiologist report. CONCLUSION: The CD in patients with FAI can be severely underdiagnosed with MRA. There is a need for better standard diagnostic criteria to detect CD in patients with FAI.

Arthroscopic Anatomic Glenoid Reconstruction Using Distal Tibial Allograft for Recurrent Anterior Shoulder Instability: Clinical and Radiographic Outcomes.

BACKGROUND: The all-arthroscopic anatomic glenoid reconstruction technique using a distal tibial allograft avoids damage to the subscapularis muscle and allows repair of the capsulolabral tissue. PURPOSE: To analyze the clinicoradiologic outcomes of patients who underwent this procedure to treat anterior shoulder instability with glenoid bone loss with a minimum 2-year follow-up. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Over 6 years, 73 patients (52 male and 21 female; mean age, 28.8 years) under the care of the same surgeon underwent arthroscopic stabilization with capsulolabral Bankart repair and bony allograft augmentation of the glenoid for recurrent shoulder instability with significant bone loss. Pre- and postoperative patient-reported functional assessment was performed using 2 questionnaires, the Western Ontario Shoulder Instability Index (WOSI) and the Disabilities of the Arm, Shoulder and Hand, and radiological assessment was performed using radiographs and computed tomography scans obtained preoperatively and approximately 1 year later (mean ± SD, 0.9 ± 1.1 years). RESULTS: The mean follow-up was 4.7 ± 1.1 years. The mean pre- and postoperative WOSI scores were 71.1 ± 17.5 and 25.6 ± 21.9, respectively (P < .001). There were no recurrences of dislocation, although 1 patient had symptoms of subluxation; however, 5 patients had hardware complications that required screw removal. There were no cases of nerve injury. Postoperative computed tomography scans were available for 66 patients. Seven patients were lost to follow-up. The graft union rate was 100%. Overall, graft resorption was <50% in 86% of patients (57/66). Eighteen patients (27%) had no resorption (grade 0), 39 (59%) had <50% (grades 1 and 2), and 9 (14%) had ≥50% (grade 3); however, none had symptoms of instability. The mean alpha angle of the screw between the screw shaft axis and the native glenoid axis was 18.3°± 5.7°. Graft positioning was flush with the glenoid in 61 of 66 patients (92.4%), and vertical positioning was excellent in 64 of 66 patients (97.0%) (3- to 5-o'clock position). CONCLUSION: Arthroscopic stabilization using distal tibial allograft augmentation resulted in excellent clinicoradiologic outcomes at a 2-year follow-up. This procedure has the advantages of being an anatomic reconstruction that addresses bony and soft tissue instability. However, long-term follow-up studies are necessary for better assessment of outcomes.

Arthroscopic Decompression and Subsequent Bone-Grafting of Spinoglenoid Cyst.

Spinoglenoid cysts are associated with labral tears; however, little is known about their associated bony pathology. This Technical Note describes an arthroscopic technique to decompress and subsequently graft a spinoglenoid cyst and associated bony defect. Appropriate preoperative imaging is key to understanding the location of the bony defect and therefore crucial to the success of the bone graft. Adequate release of the labrum should be performed to fully visualized the bony lesion. A subchondroplasty cannulated drill is then placed in the bony defect under direct visualization and said defect is then filled with calcium phosphate cement. Care is taken to ensure no cement is allowed to extrude into the shoulder joint. After the cement has cured, labral pathology is repaired and the usual postoperative physiotherapy protocol is initiated.

Rotator Cuff Reconstruction Using Fascia Lata Patch Autograft for the Nonrepairable Rotator Cuff Tear.

A large to massive rotator cuff tear is a common issue that lacks reliable options to return a patient's range of motion and function when conservative treatment has failed. With up to 96% of massive rotator cuff repairs failing within the first 6 months of repair, surgeons have been searching for a reliable treatment option for this difficult subset of patients. Surgical options for massive, retracted rotator cuff tears include re-establishing the counterforce coupling of the rotator cuff with techniques such as a partial repair or superior capsular reconstruction, preventing superior humeral migration as seen with balloon spacer implantation, and eliminating pain generators with techniques such as biceps tenotomy; however, these do not reconstitute dynamic cuff control. More recently, an acellular dermal allograft, as seen in superior capsular reconstruction, has been used to reconstruct the remaining rotator cuff. We describe a technique using a fascia lata autograft to reconstruct the rotator cuff in the setting of a massive cuff tear. This is of particular importance in centers that lack the funding or institutional approval to use acellular dermal allografts that have been popularized to date.

Arthroscopic Treatment of Medial Femoral Knee Osteochondral Defect Using Subchondroplasty and Chitosan-Based Scaffold.

Osteochondral defects of the knee are highly common, cause significant pain, and reduce function. Standard articular cartilage repair treatments include microfracture alone or in conjunction with subchondroplasty or CarGel (chitosan-based scaffold) application (Piramal Life Sciences). Combining such cartilage regenerative techniques with microfracture yields better long-term outcomes than microfracture alone. The purpose of this Technical Note was to describe the surgical technique of applying CarGel after subchondroplasty and microfracture to repair a medial femoral knee osteochondral defect.

Arthroscopic Revision with Autologous Iliac Crest Bone Graft for Failed Anatomic Glenoid Reconstruction Using Distal Tibia Allograft.

Recurrent instability after anterior shoulder stabilization surgery is not an uncommon complication, with variable rates of recurrences associated with different surgical procedures. The Latarjet procedure continues to be the gold standard in the management of anterior instability with significant glenoid bone loss, although a recent trend toward arthroscopic anatomic glenoid reconstruction (AAGR) with distal tibial allograft has been noted, with excellent short-term results and minimal complication rates. Arthroscopic revision stabilization for failed stabilization procedures is increasingly being performed, although it is technically more challenging than the primary stabilization procedure because of the anatomic rearrangements of the index surgery. In this article, we describe a revision arthroscopic technique for anatomic glenoid reconstruction using iliac crest autograft for a previous failed AAGR procedure secondary to nonunion of the graft. The graft is passed through the Halifax far-medial portal without splitting the subscapularis. Arthroscopic revision in the setting of a failed AAGR procedure is technically easier than after a Latarjet procedure, as the anatomy is relatively undisturbed in the former, facilitating easier identification of anatomic landmarks, accurate graft positioning, and decreased risk of neurovascular injuries. A Bankart capsulolabral repair is performed after graft fixation, making the graft extra-articular and providing additional stability.

Revision of a Failed Latissimus Dorsi Transfer for a Massive Rotator Cuff Tear With Arthroscopic Anatomic Bridging Reconstruction Using an Acellular Human Dermal Matrix Allograft.

Latissimus dorsi tendon transfer is a nonanatomic tendon transfer that is often considered a salvage procedure for failed repairs of massive rotator cuff tears. A rupture of the transferred latissimus tendon is an uncommon complication and there is limited literature on its management, especially in the young, active population without cuff arthropathy. In this article, we present a technique of managing a failed latissimus dorsi tendon transfer for a massive rotator cuff tear with an arthroscopic, anatomic bridging reconstruction using an acellular human dermal matrix allograft.

Anterior Glenohumeral Capsular Reconstruction Using a Human Acellular Dermal Allograft.

Anterior capsular reconstruction needs to be done for most cases of anterior shoulder instability. Several surgical techniques using tendinous allografts and autografts have been used for the treatment of anterior glenohumeral capsular reconstruction. However, the outcomes of these procedures are not satisfactory. This study describes a comparatively new technique of using human acellular dermal allograft (GraftJacket: Wright Medical Group, Memphis, TN) in the reconstruction of the anterior capsule to restore anterior glenohumeral stability.

Arthroscopic Anatomic Glenoid Reconstruction: Analysis of the Learning Curve.

BACKGROUND: Anatomic glenoid reconstruction involves the use of distal tibial allograft for bony augmentation of the glenoid surface. An all-arthroscopic approach was recently described to avoid damage to the subscapularis tendon and preserve the capsule and labrum. PURPOSE: To explore and compare change in surgical time between 2 proposed methods used for the treatment of anterior shoulder instability-arthroscopic anatomic glenoid reconstruction (AAGR) and arthroscopic Latarjet (AL)-over successive procedures. We also compared graft positioning on the anterior glenoid surface between the 2 methods. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: This was a single-surgeon retrospective review of 54 cases of surgically treated recurrent anterior shoulder instability: 27 had AAGR with distal tibial allograft, while the other 27 had AL. AAGR with the distal tibial allograft was the primary choice for the treatment of anterior shoulder instability; however, AL was performed when tibial allograft was not available from the bone bank. Thus, there was an overlapping period for those 2 procedures. Procedure start and end times were recorded, and duration was calculated. Postoperative 3-dimensional computed tomography scans were reviewed, and graft position was judged to be in the lower third (desired position), middle third, or upper third of the anterior glenoid surface. To assess learning, these data were organized in chronological order of surgery, and each surgical cohort was divided into 3 chronological clusters of 9 patients each. Learning was assessed through change in operative time over successive clusters, change in variability of operative time among clusters, and change in graft positioning among clusters. Statistical analysis comprised a 2-tailed independent-sample t test and the Levene test for equality of variance. RESULTS: Our study found that AAGR was significantly faster to perform than AL in the early (P = .001), middle (P = .001), and late (P = .05) clusters of each cohort. Duration of surgery did not significantly improve across clusters within each cohort (P = .15-.79). There were no significant changes in the variability of surgical time in the AAGR group (P = .09) or the AL group (P = .13). Desired positioning of the bone graft on the anterior glenoid surface (lower third) was identified more commonly in the AAGR cohort. CONCLUSION: AAGR is faster to learn and perform than AL for the treatment of recurrent anterior shoulder instability with significant glenoid bone loss. The current study found higher rates of desired graft positioning for AAGR clusters.

Radiographic Analysis of Glenoid Size and Shape After Arthroscopic Coracoid Autograft Versus Distal Tibial Allograft in the Treatment of Anterior Shoulder Instability.

BACKGROUND: The Latarjet procedure for autograft transposition of the coracoid to the anterior rim of the glenoid remains the most common procedure for reconstruction of the glenoid after shoulder instability. The anatomic glenoid reconstruction using distal tibial allograft has gained popularity and is suggested to better match the normal glenoid size and shape. However, concerns about decreased healing and increased resorption arise when an allograft bone is used. PURPOSE: To use radiological findings to evaluate the arthroscopic reconstruction of the glenoid with respect to the size, shape, healing, and resorption of coracoid autograft versus distal tibial allograft. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: A retrospective review was performed of 48 consecutive patients who had an arthroscopic bony reconstruction of the glenoid (12 coracoid autograft, 36 distal tibial allograft), diagnosed anterior shoulder instability, and computed tomography (CT)-confirmed glenoid bone loss more than 20%. Coracoid autograft was performed only when tibial allograft was not accessible from a bone bank. Two fellowship-trained musculoskeletal radiologists reviewed pre- and postoperative CT scans at a minimum follow-up of 6 months for the following: graft position, glenoid concavity, cross-sectional area, width, version, total area, osseous union, and graft resorption. Clinical outcome was noted in terms of instability, subluxation, and dislocation at a minimum follow-up of 2 years. Simple logistic regression, 2-tailed independent-sample t tests, paired t tests, and Fisher exact tests were performed. RESULTS: Graft union was seen in 9 of the 12 patients (75%) who had coracoid autograft and 34 of the 36 patients (94%) who had tibial allograft (odds ratio, 5.66; 95% CI, 0.81-39.20; P = .08). The odds ratio comparing allograft to coracoid for overall resorption was 7.00 (95% CI, 1.65-29.66; P = .008). Graft resorption ≥50% was seen in 3 (8%) of the patients who had tibial allograft and none of the patients who had coracoid autograft. Graft resorption less than 50% was seen in the majority of patients in both groups: 27 (73%) patients with tibial allograft and 5 (42%) patients with coracoid autograft. No statistically significant difference was found between the 2 procedures regarding anteroposterior diameter of graft ( P = .81) or graft cross-sectional area ( P = .93). However, a significant difference was observed in step formation between the 2 procedures ( P < .001). Two patients experienced subluxations in the coracoid group (16%) as well as 2 patients in the tibial allograft group (6%) with a P value of .25. CONCLUSION: Arthroscopic anatomic glenoid reconstruction via distal tibial allograft showed similar bony union but higher resorption compared with coracoid autograft. Even so, no statistically significant difference was found between the 2 procedures regarding final graft surface area, the size of grafts, and the anteroposterior dimensions of the reconstructed glenoids. These short-term results suggest that distal tibial allografts can be used as an alternative to coracoid autograft in the recreation of glenoid bony morphologic features.

Posterior Glenohumeral Capsular Reconstruction Using an Acellular Dermal Allograft.

Posterior shoulder instability is an uncommon and challenging cause of shoulder pain and dysfunction. Surgical management has less reliable results and higher failure rates compared with techniques for anterior shoulder instability. The presence of generalized ligamentous laxity further complicates options for surgical management. If primary capsulolabral repair fails, controversy exists as to the optimal revision procedure. This technical description and video present an arthroscopic technique for reconstruction of the posterior glenohumeral capsule with an acellular dermal allograft to treat posterior instability in a patient with Ehlers-Danlos syndrome and a previously failed posterior capsular plication.

Arthroscopic Anterior and Posterior Glenoid Bone Augmentation With Capsular Plication for Ehlers-Danlos Syndrome With Multidirectional Instability.

Recurrent multidirectional shoulder instability is a difficult clinical problem. This can be compounded in patients with connective tissue diseases such as Ehlers-Danlos syndrome. We present an all-arthroscopic technique involving extra-articular anterior and posterior glenoid bone grafting to augment a capsular repair in a patient with Ehlers-Danlos syndrome and recurrent multidirectional shoulder instability. Graft options include either distal tibial allograft or iliac crest autograft. Anterior graft placement uses a dilated far medial portal using an inside-out technique. The posterior graft is placed through a dilated posterior portal. A 1-mm edge of anterior and posterior glenoid rim is denuded of cartilage for later capsular repair, and grafts are secured flush to the osseous surface. A capsular plication is then completed and repaired to the prepared native glenoid surface, using the grafts as extra-articular osseous bumpers.

Arthroscopic Treatment of Shoulder Instability With Glenoid Bone Loss Using Distal Tibial Allograft Augmentation: Safety Profile and Short-Term Radiological Outcomes.

BACKGROUND: The results of arthroscopic anterior labral repair have demonstrated high failure rates in patients with significant glenoid bone loss. Several reconstruction procedures using a bone graft have been developed to overcome bone loss. PURPOSE: The primary objective of this study was to generate a safety profile for arthroscopic anatomic glenoid reconstruction using a distal tibial allograft. The secondary objective was to evaluate the radiological outcomes of patients who underwent this procedure. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: This retrospective review included the medical charts and diagnostic images of 42 consecutive patients who underwent arthroscopic shoulder stabilization by means of capsule-labral reattachment and bony augmentation with a distal tibial allograft. The safety profile was measured by detecting intraoperative or postoperative complications, including neurovascular (nerves and blood vessels) injuries, bleeding, infections, and dislocations. A radiological evaluation was conducted by assessing computed tomography (CT) scans obtained preoperatively and at approximately 6 months postoperatively. RESULTS: A total of 42 patients (29 male, 13 female) with a mean age of 26.73 ± 9.01 years were included. An excellent safety profile was observed, with no intraoperative complications, neurovascular injuries, adverse events, bleeding, or infections. CT bone scans were obtained for 31 patients, and the mean follow-up for CT scanning (to measure resorption and union) was 6.31 ± 1.20 months (range, 6-7.5 months). There were no cases of nonunion or partial union. Thirteen patients (42%) had no resorption, whereas 13 (42%) and 5 (16%) patents had <50% and ≥50% resorption, respectively. CONCLUSION: Arthroscopic shoulder stabilization with distal tibial allograft reconstruction is a safe operative procedure with a minimal risk to neurovascular structures. Most patients had a healed allograft, but 16% of patients had ≥50% resorption on CT at 6 months. Studies with a longer follow-up are recommended for better assessment of the safety profile.

Labral Gracilis Tendon Allograft Reconstruction and Cartilage Regeneration Scaffold for an Uncontained Acetabular Cartilage Defect of the Hip.

Hip cartilage injuries are very common, with rates as high as 50% having been reported in some series; abnormal femoral acetabular contact can result in a full-thickness cartilage defect or labral lesion. The prevalence of labral lesions can be as high as 55%. This Technical Note describes an arthroscopic technique to reconstruct an uncontained, full-thickness, focal cartilage defect of the acetabulum, with reconstruction of the missing labrum using a gracilis allograft and use of a biological liquid scaffold for cartilage reconstruction. Capsulotomy, acetabuloplasty, and microfracture with marrow bleeding should be performed simultaneously with the gracilis allograft preparation. The graft is inserted and anchored to reconstruct the missing labrum and to re-create a contained defect. Suction and drying of the joint surfaces are performed while the mixture of BST-CarGel (Piramal Healthcare, Laval, Quebec, Canada) and blood is prepared. A drop-by-drop technique is then used to reconstruct the cartilage defect.

Graft Utilization in the Bridging Reconstruction of Irreparable Rotator Cuff Tears: A Systematic Review.

BACKGROUND: Rotator cuff tears are one of the most common conditions affecting the shoulder. Because of the difficulty in managing massive rotator cuff tears and the inability of standard techniques to prevent arthropathy, surgeons have developed several novel techniques to improve outcomes and ideally alter the natural history. PURPOSE: To systematically review the existing literature and analyze reported outcomes to evaluate the effectiveness of using a bridging graft reconstruction technique to treat large to massive irreparable rotator cuff tears. STUDY DESIGN: Systematic review. METHODS: A systematic search of PubMed, EMBASE, CINAHL, and CENTRAL was employed with the key terms "tear," "allograft," and "rotator cuff." Eligibility was determined by a 3-phase screening process according to the outlined inclusion/exclusion criteria. Data in relation to the primary and secondary outcomes were summarized. The results were synthesized according to the origin of the graft and the level of evidence. RESULTS: Fifteen studies in total were included in this review: 2 comparative studies and 13 observational case series. Both the biceps tendon and the fascia lata autograft groups had significantly superior structural integrity rates on magnetic resonance imaging at 12-month minimum follow-up when compared with their partial primary repair counterparts (58% vs 26%, P = .036; 79% vs 58%, P < .05), respectively. Multiple noncomparative case series investigating allografts, xenografts, and synthetic materials for bridging reconstruction of large to massive rotator cuff tears demonstrated high structural healing rates (74%-90%, 73%-100%, and 60%-90%, respectively). Additionally, both comparative studies and case series demonstrated a general improvement of patients' functional outcome scores. CONCLUSION: Using a graft for an anatomic bridging rotator cuff repair results in improved function on objective testing and may be functionally better than nonanatomic or partial repair of large to massive rotator cuff tears. Allograft or xenograft techniques appear to be favorable options, given demonstrated functional improvement, imaging-supported graft survival, and lack of harvest complication risk. More high-quality randomized controlled studies are needed to further assess this technique.

Revision of Failed Rotator Cuff Reconstruction With a Large Humeral Head Cyst.

A revision rotator cuff repair is a technically challenging surgical procedure. This can be further complicated by the presence of poor quality of the cuff tissue, as well as a large greater tuberosity cyst, typically located at the rotator cuff footprint. This Technical Note discusses the surgical approach to deal with a revision rotator cuff tear with a large humeral head cyst. This described arthroscopic technique is performed in a single-stage procedure using a human dermal allograft (GraftJacket) for augmentation. This technique was specifically designed to (1) address the limited area for anchor placement, (2) use a bone graft, demineralized bone matrix, for repairing the bone cyst, and (3) optimize the biology for healing by augmenting the reconstruction with GraftJacket.