Name: My Approach to Rotator Cuff Repair
Uploaded: 2014-02-24T00:00:00Z
Channel: Arthrex

<p>Neal ElAttrache, MD, (Los Angeles, CA) presents his principles to achieve successful outcomes for arthroscopic rotator cuff repair. Dr. ElAttrache describes the natural history of cuff tears, biological and biomechanical elements that affect the success or contribute to the failure of cuff repair, a summary of the published biomedical testing, and his practical techniques and tips to achieve the best rotator cuff repair possible.</p>

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VPT1-00101-EN | A | My Approach to Rotator Cuff Repair

Neal ElAttrache

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My Approach to Rotator Cuff Repair

Going to talk briefly. Just setting the stage for what I do and why I do it with regard to the cuff. And these are what I call the rotator cuff repair facts of life. There traditionally was high persistent tear rates with our traditional repairs. And this had been shown no matter who the author. And and this was it was questionable as to if we really were going to be able to approach the results that were being reported with open repairs. We found that healed cuffs definitely have better function, but the cuff is slow to heal and the tendon is relatively avascular for a long period of time after a repair. The vascular response for healing comes from the bone, so the biologic factors come from bone marrow elements that then creep into the repair interface. Face, and these biologic factors for healing are impeded by the synovial environment. The repaired tendon has to sit still for a long period of time over as large an area of. The healing zone the anatomic area of healing on the greater tuberosity. In the face of motion. And it's in that face of motion that that even in the addition, the initial biomechanical studies, we didn't consider we just looked at tension and, and what the cuff would do. But in real life, this cuff has to sit still for a long time while the shoulder is moving. We know that tissue compression, as was mentioned earlier this morning, does enhance healing. We've seen that in soft tissue to bone healing areas of in the, elsewhere in the body. And a lot of this stuff was done with regard to ACL surgery. When we look at screws put in against the semitendinosus or soft tissue grafts in bony tunnels, and compression does enhance this healing. So therefore you want a strong, broad, GAP resistant repair that has some compression element in the repair that contains and protects the industrial healing factors. And we felt that the modified double row repairs that then evolved into the osseous equivalent SutureBridge type repairs would perform significantly better both mechanically and providing the biologic factors for healing. Let's take a look at why then. We were failing with our our other repairs. And quite frankly, if we look critically at the open repairs some of the same failures existed with open rotator cuff surgery as well. These causes of failure I think we can divide up into technical failures. I'd like to think those are mainly historical but inadequate technique, inadequate implants. Then we failed to reproduce the normal anatomy and we would, over tension tissue, put tissue where it wasn't supposed to be. Mechanical failure of our repairs. We were doing repairs that couldn't hold up to the strength necessary and the stresses necessary that, that they'd be exposed to. And the failure of biology you know, just to go back to the mechanical failure Steve was the first one to really show what kind of stresses a repair would be exposed to just by by extrapolating data that would tell us how how much force a supraspinatus tendon would apply to a repair zone. And if you look at, you know, his work, you know, there's a lot of hidden pearls in what he what he does. But if you looked at that data, it was about 275 to 300 newtons would be generated by the supraspinatus. Well, if you looked at our repairs that we were doing, our repairs were holding up to about 275 newtons of of strength. And so one, one pull of the supraspinatus would tax the repair almost maximally. Mentioned briefly, tension overload over reduction of the tendon on the tuberosity can be a problem. Malposition of the tendon on tuberosity. This is probably the biggest part of the learning curve of doing arthroscopic rotator cuff surgery. If you did open surgery, you open up the shoulder, you could grab the rotator cuff and you could yank it and pull it wherever it wanted. And so that led to a lot of failures in probably in the recovery room. Well, the same thing holds true for for arthroscopic management. Now, now we have we have better instruments. We can grab that tissue and put put it where we want it. The biggest part of the learning curve is deciding and learning where it's supposed to go. And so this malposition of the sutures and the most, most dangerous part to where to put sutures is medial to the rotator cuff cable, all those what they call type two failures, where where you end up with a failure at the Musculotendinous junction, that is almost an unrecoverable problem, is because of bad positioning of, of sutures through or medial to the rotator cuff cable. This is the study I was I was telling you about, that really taught me a lot about how strong these repairs need to be and where to reinforce the repairs. You see, the 302 newtons applied by the supraspinatus infraspinatus forces can exceed 600 newtons, and our single row repairs were holding up to about 275 Newtons is barely sufficient in that situation. What wasn't considered that at that time was that there was differential strain within the rotator cuff with rotation. This was our initial comparison. And what spurred me on to look at this was I was at a meeting in in Dublin, Ireland, with Steve Burkhart and Joe de beer, and de beer was telling Steve and I was standing like a fly on the wall, listening to Joe talk to Steve about what he was doing with with double row repairs. And we had a brief conversation about it, and I came home and started to study it. Well, certainly it makes sense. Biomechanically it improved the strength by about 48% compared to single row repairs. Stiffness by 46%, it decreased gap formation by 42% and the strain over the footprint by two thirds. But what about healing? Double row footprint repairs was superior in the lab and in the early clinical studies, but you also wanted a construct that would enhance the healing to a greater degree. So our goal was to develop a construct with that would provide increase in contact and compression over the entire footprint. And that was then the birth of the interlinked double row repair that came to be known as the SutureBridge. When we failed biologically, we were failing because we primarily were not being able to take advantage of where these healing healing factors were coming from. We weren't able to contain them, we weren't able to protect them, and we weren't able to improve the mechanics of compression. And these elderly patients that sometimes we deal with have a questionable biologic wherewithal for healing anyway. And so what that was what I considered something that we needed to try to pay attention to when we were deciding on what technique to to do. We already talked about the pressure effect and this footprint compression. We knew that there were open techniques that were able to do it by passing suture through bone and then tying suture over the top of the tendon. But could this be reproduced? Arthroscopically. And that's what then we set out to do with the bridging repairs. This was our first study that Steve had mentioned. This looked at this was a pressurized film study to see how much of the footprint we could compress in contact with the bridging repairs and the Fujifilm that you see on your on the far left is with the double crossing repair that it looks very familiar as the typical SutureBridge. The Fujifilm in the in the middle is a V shaped linked repair, and then the one on the far right is the double row repair. And what you see there is just simple spot welding of the tendon down onto the bone, so you can contact and compress much more with the simple bridging type of repair. But can these be maintained? So what was the biomechanics of this. And what we saw was that the double row repair, as I showed you before, was very strong compared to single row repairs. And the and we were able to reproduce that strength with just interlinking the bridges. But I'll show you how that the by interlinking the the anchor points is even more beneficial. This is one of the things I learned in doing these studies. And this was a cadaveric study where we just simply looked at where are the strains in the cuff when you move the cuff. And we found something that now looking at it, you see, says, well, that should have been intuitive, but it really wasn't. And what we saw was that the anterior part of the supraspinatus, where that Steve has coined the anterior rotator cuff cable that is under enormously larger forces, under motion and with external rotation. All of the stress and strain goes right to that part of the rotator cuff. So that deserves a lot of attention when that part of the cuff is torn. So how did we account for that? We looked at how the bridging type repairs would hold up to motion, especially with tears in that location compared to our single and double row repairs. And we found that the bridging repairs had a higher yield load than the double row repair when allowing for external rotation. So you see when when the shoulder would rotate if you had unlinked double row repairs, whatever anchor it was that was getting rotated into the axis of of pull was left to fend for itself. It was like you had done a single row repair at that ankle anchor point. And so by interlinking and self-reinforcing. That's another term that Steve coined, the self-reinforcing repairs. You were able to protect that anchor point under motion. Likewise, in abduction, when you abduct the shoulder, the entire medial footprint of the tendon peels off. And so the double row, and especially the linked double row repair will will limit that gapping away and allow the tendon to stay on the bone to promote healing. So what are the advantages of the osseous equivalent technique. They are improved footprint contact improved strength which provides a more favorable tension angle. Minimal gap formation. The tissue can only settle under cycling. It doesn't pull off. It simply slides on on the footprint of a millimeter or even less, rather than actually separating away. It doesn't rely on the most lateral tissue. The interconnectivity is very important because of these repairs being exposed to motion. It facilitates revision repairs. So when your entire tuberosity is filled with shrapnel from previous operations, where do you go? What you do is you bridge over that and you apply the tendon down onto the onto the area for healing. The medial row provides a barrier between the synovial environment and the healing zone. It contains healing factors and allows for biologic manipulation in the future. Potentially. So what does this look like? This is a this is a very sneaky tear. This is one where the entire enter cable is off. If you can see the bicep with no tissue posterior to the bicep tendon, your anterior rotator cuff cable is off. So this is a video that I did maybe four years ago using the the you'll note the anchors that we're using. These are not biocomposite. This is a SwiveLock that was put And so that's the medial row. And what I've done is I've passed the sutures together in a mattress fashion. Now, because the anchor cable is off, I thought that that deserved individual fixation. So I went ahead and put a biocomposite Corkscrew anchor right there and fixed the cable directly with simple sutures. That reduces the repair nicely. And then simply then tie one knot per anchor medially. For large tears. I would, even though it's attractive to do knotless technique for for large tears, I would still suggest that you might want to consider tying one knot per anchor. So that was that was basically the First or second generation of of the bridging repair in that type of tear. That is sort of a lazy crescent. A lazy crescent, meaning that the anchor cable is off, the biceps is exposed, and so that that deserves a bit more reinforcement. This is a more recent technique. We're looking we're intra-articular right now looking at the bicep. Full thickness, large rotator cuff tear that you'll see in a second. Now we're in the bursal space. So the initial thing is once again, determine your orientation of the tear. See what goes where. The initial step here is to fix the biceps. So I pass a FiberTape suture through the bicep tendon. Then I my technique then is I take a the FiberTape pass it over the top, reach underneath. So now I'm through and around the bicep. I punch this is a nice flat rasp that is very good, not only for the acromion, but for the tuberosity. Then you can pull up on your stitches and get underneath the bicep so you get a bleeding bed. Then we punch a hole there in the in the top of the groove. Fix the free ends of the. See what I did? I already estimated the depth of my tunnel, so I slid the eyelet on the sutures about a centimeter and a half. Gave myself a little slack, then applied the anchor into the bony socket. We cut those sutures, then reset the intra-articular portion of the biceps tendon. Don't forget to do that. Then we go ahead and fix our our tear as we did previously. Steve, this is the that technique where I mentioned to bring the sutures through in a horizontal mattress fashion. Then then tying the tying the FiberWire sutures first and then passing the FiberTape from medial to that horizontal mattress over to give what you call the the rip stop. So I'll move forward on this. This is you've seen the steps for that on the previous video. And don't forget what we've been taught about broad based U-shaped tiers and L-shaped tiers. So we want to turn those tears into crescent shaped tiers. And then you can do your interlinking, bridging type repairs that that we just showed. Let's talk very briefly about the results, because I want to talk about some of the misinformation that's being put out right now about whether it's worth it to do these or not. This is a busy slide, but I'm in press right now is a study for jbj's that is an invited review that looks at it's a big meta analysis of of the current literature. And what we see is these level one and two studies all have a they all show a statistical tendency, statistical tendency towards better performance of the bridging double row repairs. But these studies are that are in the literature currently are all underpowered. It was shown by De Haan that in in JSM that in order to show a reduction in complete tear rate by half, you have to have 247 patients needed per comparison group to show a reduction in tear rate by a quarter, you need over a thousand. And the current published studies don't even come close to this. But still, even in the current published studies, you see a statistical tendency to better performance of the repairs that that we're doing with the linking repairs. But that's not what's being presented on the podium. This this slide is it summarizes something else very important. If that blue triangle there crosses the vertical bar, that means that there's there's no statistical significance. What we see is the relative risk of all returns was statistically higher in single row returns than double row returns. If you look at full thickness returns, you didn't see any statistical difference. But if you look at the deep partial thickness returns, you see again a statistically higher rate in the single row returns. Now, if you look at the follow up length of time of the studies in the meta analysis across the worldwide literature, it's little less than two years. These returns, these partial thickness returns are occurring in less than two years. And we know from the current literature that these tears get bigger over time and that once they develop a full thickness tear or retear, they perform significantly more poorly. So the reason that I think that the double row and the linked double row repairs are performing better, and we clinicians know it. It's just that these guys on the podium aren't. It's a problem with the with the way they're doing the studies. They're not they're not following them out long enough because this will reflect itself in poor outcomes. This is a study that Steve has since published since I put this slide in my talk. And it shows the long term outcome of arthroscopic repair of massive tears. And certainly the patients do better. They're stronger and they're much more satisfied considering to have a good an excellent outcome with the repairs. So when do I use the double row repair? Whenever I can and when I can't do anything else. And this is one of those cases that I told you about with the whole tuberosity was filled with shrapnel. So my observations and I'm going to close here shortly. Most tears benefit from and are amenable to footprint compression constructs as part or all of the repair include margin convergence for large U-shaped and L-shaped tears, as necessary for large tears where the head can't be covered. Consider interval slides as described by by Steve, and my personal preference is to either do interval slides or balanced partial repairs. Tears involving the rotator interval usually mobilize adequately by releasing the coracohumeral ligament and the order of repair of torn subscapularis from intra-articular aspect. First anterior cable attachment. Next, post your cable attachment if it's torn. Third margin convergence if necessary. So we're gradually closing this down to a crescent shape. And then a central SutureBridge grafts to bridge gaps are of questionable benefit over balanced partial repairs or interval slides, in my opinion. So why did we fail? We didn't restore anatomy. We provided suboptimal biomechanics and we couldn't optimize the biology for healing. Thank you.

My Approach to Rotator Cuff Repair

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