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Arthroscopic Rotator Cuff Repair – Graft Reinforcement

Dr. Ernest Amory Codman, widely considered the father of evidence-based medicine, first championed rotator cuff repair in the early 20th century. 

He is considered to have performed the first reported rotator cuff repair in the English literature in 1909 after observing treatment for rotator cuff disease and studying it in detail as a medical student in Germany. Many of the techniques and principles of rotator cuff repair remained relatively unchanged for the remainder of the 20th century.

Developments in Rotor Cuff Repair

Arthroscopy of the shoulder, starting with arthroscopic acromioplasty, widely credited to Dr. Harvard Ellman who reported his results in 1987, gradually ushered in a sea change of interest and understanding in shoulder injuries and rotator cuff repair. Coinciding with the introduction of the suture anchor and arthroscopic techniques, Dr. Eugene Wolf performed first arthroscopic rotator cuff repair with suture anchors in 1990. Since then a flurry of activity has occurred with an explosion in techniques and implants to improve the results of rotator cuff repairs.

Advancements in Rotator Cuff Surgery

Unfortunately, despite the significant advances that have been made in the treatment of rotator cuff tears, the results and healing rates of rotator cuff repair still vary widely with reported failure rates ranging from 11-94%. Among the many reasons for this, surgeon skill and experience is often cited as one of the most important variables involved. Many other factors including patient related factors such as smoking history, age, size of tear, quality of tissue and compliance (meaning following the restrictions and directions required after surgery to allow healing of the repaired tissue) can also play a part.

Improvements in Rotator Cuff Treatment

Because the majority of patients with rotator cuff tears we treat here at Arizona Center for Hand to Shoulder Surgery have not had satisfactory results from previous rotator cuff repair elsewhere, we are always looking at ways to improve the results of rotator cuff repair. Along with our very popular and scientifically based rotator cuff repair protocol , we are also constantly working to improve the results of rotator cuff repair, even in those patients traditionally thought to have no hope of success. These techniques have allowed us to offer hope to patients with large or massive rotator cuff tears, as well as those with other risk factors that may limit the results with other surgical techniques-diabetes, smoking, prior surgery, obesity, and patients older than 60 years of age.

Start with a Comprehensive Diagnosis

Our first priority is to provide patients with a comprehensive diagnosis, which can often mean that the patient has another factor alongside the rotator cuff tear that may have contributed to persistent pain, weakness, or failure to heal-such as: a pinched nerve in the shoulder ,a frozen shoulder , or an unstable shoulder , as well as many others. Along with offering a comprehensive approach to arthroscopic management of any associated pathology, we have also been pioneers in providing innovative techniques for rotator cuff repair, not available elsewhere. A lot of work has been done on increasing the strength of rotator cuff repairs in an effort to improve results. Unfortunately, without honoring the anatomy of the rotator cuff and recognizing the principles involved in the function of the rotator cuff, many of these techniques that are very strong in the cadaver lab, have resulted in more worrisome clinical patterns of rotator cuff repair failure.

Reinforcing Rotator Cuff Tissue

While fully adhering to the anatomic and physiologic principles of rotator cuff repair we originally outlined, we have also worked tirelessly to find ways to improve the strength of the rotator cuff repair to provide patients an extra safety net and also to find ways to reinforce the rotator cuff tissue for those patients with rotator cuff tissue of questionable quality. For instance, a massive rotator cuff tear in a patient who has had several previously failed rotator cuff repairs typically means the ability of the rotator cuff tendon to heal is questionable. Ideally, we would like to have the ability to reinforce the patient’s own rotator cuff tissue so that the compromised tissue is supported during the critical healing phase while also creating a template for replacement of the supporting tissue with the patient’s own tissue to create a stronger more normal rotator cuff tendon at the end of the healing cycle. There are several promising grafts available currently with excellent biocompatibility and certainly others to follow as the age of biologics continues to advance in shoulder surgery. We have outlined some of these emerging technologies at Failed Rotator Cuff Repair. The other part that has been considered impossible by many surgeons is a reliable and durable technique to reinforce rotator cuff repairs without an incision meaning an all-arthroscopic approach.

Arthroscopic Graft Reinforcement

We have been performing an all-arthroscopic approach for graft reinforcement of rotator cuff repair for several years. While the results in our hands have been very encouraging, the techniques are very difficult for other surgeons to learn and master, severely limiting these techniques to just a few highly specialized destination centers for shoulder surgery around the world. That may now be changing with a novel technique we recently described which should make it easier for surgeons to offer better results to more patients. Building on our original tension band anatomic repair described here we have used recently introduced technology to allow us to create a novel technique that not only improves the strength of the rotator cuff repair, but also creates an easy and reproducible method to reinforce the repair with a biologic reinforcement graft to improve the healing rates and results for even the most difficult patients. A detailed video of our technique is here at rotator cuff repair video. Rotator cuff tears are very common and unfortunately failed rotator cuff repairs are also very common. Do your homework and find a shoulder specialist that has experience with the most advanced techniques for arthroscopic rotator cuff repair.

Vivek Agrawal, MD

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