Name: Rotator Cuff Allograft: Augmentation and Bridging Technique
Uploaded: 2009-11-06T00:00:00Z
Channel: Arthrex

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VID1-003552-en-US | A | Rotator Cuff Allograft: Augmentation and Bridging Technique

Bryan Hanypsiak

Human

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Rotator Cuff Allograft: Augmentation and Bridging Technique

Maximizes its ability to heal and the particular characteristics of the rotator cuff allograft patch, which Arthrex will be offering, which I think maximize its healing potential. A Quick History of Rotator cuff allografts. The Cliff notes version. There's a lot of studies out there. Some have good results. Some have satisfactory results. Some have poor results. My take on it is that in the right setting, with the right patient, the right graft material, and maybe the right combination of orthobiologics, you can achieve a satisfactory result that you may not be able to otherwise get in the massive cuff tear. We have two allograft patch products which will be coming out very shortly. The first is a rotator cuff allograft, which is a human rotator cuff taken from near the Musculotendinous junction. It is available at the greater tuberosity insertion, which is thicker, probably best used the thicker version for bridging constructs and a thinner version for augmentation. We also offer a devitalized dermis patch, which, as you'll see, is the only sterile human dermis patch available. This is a look at some of the patches that are currently available on the market. A number of them are xenografts and a few of them are human skin. So speaking specifically about the Arthrex rotator cuff allograft, I don't have a picture because I implanted all of them over the last few weeks working on this technique, but it is sterile processed. We use aloe wash to reduce or eliminate bacteria, lipid and marrow. It's donor tested according to AaBb and FDA guidelines, and it receives a low dose gamma radiation. It is also lyophilized, which makes it 97% devoid of DNA, which serves as an antigen. In contrast, if you look at a another patch currently on the market, the restore patch that has roughly 50% of its DNA still intact at the time of implantation. The Lyophilization enhances the Enhances the wicking characteristics of the material, which allows it to easily. Soak up and bring ACP into the joint. Furthermore, it allows it to be stored at room temperature on the shelf for approximately five years. With other advantages. The characteristics of the rotator cuff allograft is very stiff. It's stiffer than all other conventional grafts on the market, and even after processing, still closely approximates the stiffness of native rotator cuff. Its suture retention abilities are excellent, with suture pull out strength roughly equivalent to native cuff. Its human allograft not a xenograft, and it's also cheaper than competitive grafts. The RC allograft and the vitalized dermis will be priced around $1,500, whereas the graft jacket typically costs around 2500. As far as in vitro testing, and I know Gus had to go, but he still continues to present even when he's not here. He did all of this work for us, so I'd just like to like to show what he's done. The patch, the rotator cuff allograft is very highly porous and then allows easy cell infiltration during healing. That's not true of all grafts. If you look at the Pegasus graft, which is equine pericardium, it's not very porous at all. And cells have difficulty gaining access to the patch. Cell culture studies that were done on all patches show varying amounts of site adhesion and proliferation across the spectrum of available grafts. Rc allograft had high amounts of initial adhesion and proliferation, which I think are two characteristics that are vital for patch incorporation. Cells are easily able to get into the patch, and then they're able to begin growing very quickly. What we're going to see here is the 24 hour adhesion characteristics. Tcp is a positive control. On the left you see the restore patch and the rotator allograft are the best at allowing Tenocytes to enter the patch at 24 hours at 48 hours. We looked at proliferation of those cells that entered the patch. And this is where restore falls off. But RC. Allograft continues to accelerate. So when you look at the two properties in combination. The rotator cuff allograft very quickly allows cells to get in and begin proliferating. We also looked at the suture retention strength of rotator cuff allograft. And we found it was at. Least equivalent to all other patch materials. The linear stiffness is where the rotator cuff. Allograft excelled. The stiffness refers to the patches ability to transfer and maintain load. And measures elongation of the graft. This is another area where I think graphs that have not been successful fail is when you cyclically load them after implanting, they stretch and eventually fail with suture pull out through the weakened tendon. The rotator cuff allograft is exceptionally stiff and does not stretch. Looking at this again, this is the suture retention strength of the allograft. And this is equivalent on suture pull out testing to all other graphs. There is no statistical difference between those two as far as linear stiffness of the graft, which is the. Elongation rotator cuff graft is easily superior. Looking at some in vivo testing, rotator cuff allografts were implanted into dogs as spanning grafts for surgically created defects. All the grafts were processed identically at 12 weeks. Radiographs and ultrasound showed good tendon to bone healing, and the histology confirmed that if you look at the histologic slides, the rotator cuff allograft is on the left. The control group, which is canine autograft is on the right. And here you see excellent tendon to bone and tendon to muscle healing, which is not different from the control group. We also offer very quickly decellularized dermis graft. Big advantage to this. This size RC allograft typically tops out at about three by three. The dermis is available in much larger sizes. It is again the only sterile human dermis allograft which is available. That's done using aloe wash and it's Preservon treated which again allows storage at room temperature. And as we discussed earlier price point is a significant advantage. There's multiple indications for the dermis in addition to rotator cuff augmentation. It's been used for Achilles grafts wound barriers ankle stabilization procedures. And it's an excellent carrier of ACP. So very quickly, this is a one of my cadaveric patients with a simulated massive terror of the cuff. What we were looking for in a technique is something that's simple and easily reproducible. I like the SpeedBridge technique, which I had not had the opportunity to use for a patch in practice, particularly because, as Doctor Burkhart pointed out, the FiberTape have a 20% greater ability to not pull through tissue, and I think that's an important property to have, particularly when you're trying to keep your sutures in the in the patch while it's resorbed and incorporated. First thing we do when we get in there is go ahead and measure the size of the defect. I insert this measuring probe and there's a two millimeter gap between each line. Measure the defect in the tendon in both planes, both horizontally and vertically, to measure the depth of the footprint. And that tells me how big a patch I need. So the first step of this is to just like any SpeedBridge technique, insert 2 or 3 SwiveLock of medial row and pass these through the tendon. You can pass these as I do in a single step using a FiberLink, or you can pass these individually to spread your sutures across. Now what I'm doing here is you can see I've got my SwiveLock already implanted and they're out the anterior portal scoping the posterior lateral. We're going to use a ten millimeter passport cannula, which is probably the best for getting the graft in. And Grafton, and I'm just passing shuttle sutures through two stab incisions I've made, anterior and posterior. I'm going to use those to control the graft and to control its orientation as it comes into the joint. This is just a quick video to show how easy it is to manipulate and cut the graft. And here I am trimming it down to size. Next thing we do is once we have the graft size properly, we place two FiberLink cinch stitches at the lateral corners. This allows us to control the back end of the graph. And then I pass these out, those stab incisions which I just showed you that allows me to pull the graft down lateral side first, standing straight up and pull it out of the way and then push down from the medial side. We go ahead and pass the fiber tapes and the safety suture included on the SwiveLock through in one shot, and we have a quick video of video of that. This is just using the FiberLoop to go ahead and create a cinch stitch on the corner, and we'll cut that short for time purposes. Here we are. Going ahead and passing the SwiveLock just made a small poke hole. I found the easiest way to do this was with a Penetrator. Grab them and pass them through the through the graft. And at this point, we have all our sutures passed through the graft. So once you have that done, the next step is to go ahead and tie the limbs one limb from each of your anchors together to create this medial bridging effect. And you use this to shuttle the patch down on top of the existing rotator cuff. And this works very well. And then you can tie this to seal the medial side. And that really holds Your patch and in place. I keep traction, just gentle traction on these to orient the patch appropriately and keep that from folding up on itself. So what we're going to see here, we're going to insert a just a round object, something to tie our loop over up on top of the patch. We'll go ahead and tie the knots and we'll pull this down. And we're ready to go ahead and move the patch into the joint. Now we're going to go ahead and take each limb, each remaining limb from the SwiveLock so that safety stitch. And we can use this as a suture pulley to slide through the SwiveLock and pull the graph down. So now take a a probe. I use the FiberTape grasper here and And just dunk the graft down through that short passport cannula. This will look from inside the joint. And this is what I like to call the flying carpet effect. Here I am just demonstrating that you have complete control of the back end of this graft. We're pulling it all the way forward and we're going to pull it all the way back. You see, you have your your SwiveLock FiberTape pass through the medial aspect of the graft. Now, what we're going to do is use our tension slide with the medial suture to reduce that on top of the cuff. And then we're going to come in and push that down and take out the tension in the FiberTape. And that has essentially reduced the graft over the area we'd like. Next step is to go ahead and tie that medial row together, cut those and get rid of those sutures. Alternatively, they can be tied after fixation and lateral. I just prefer to do that first. It gets those out of the way for me. And then at standard SpeedBridge technique, crossed the sutures and dunk them in. And what that does is it tightly compresses the patch down to the bleeding bony bed that you've created. We'll skip that because we've seen a number of those. One thing I will show you quickly is that passport offers a tremendous advantage, particularly when you do a SwiveLock or PushLock. That's my tap in there. I use the plastic or the peek tips because the sutures slide a little bit easier through them, and I'm able to keep my tap in there and not lose my hole. And so I don't take that tap out. I have both instruments through the passport simultaneously until I'm ready to just pop that over and dunk it in the hole. And that is a quick look at the finish construct. And I just threw that in there to you know, I dreaded massive cuff tears in practice. I just threw that in there to remind me how shockingly easy this procedure was the first time I did it. Thank you.

Rotator Cuff Allograft: Augmentation and Bridging Technique

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