Shoulder

Procedure

The CuffMend system provides an efficient, simplified approach for augmenting partial- and full-thickness rotator cuff tears. The system employs the benefits of a thick ArthroFlex dermal allograft, which provides mechanical strength and supports healing.1,2&nbsp;Introduce the graft using the graft spreader and use the FiberStitch™ RC implant for medial soft-tissue fixation to the rotator cuff tendon. Use self-punching PushLock®&nbsp;anchors, spanning the graft over the tuberosity footprint, for lateral bony fixation. Implantation of the CuffMend system is designed to be completed in less than 10 minutes. Scientific literature supports the use of acellular dermal grafts as a safe and effective solution for rotator cuff augmentation.3
References
1. Ely EE, Figueroa NM, Gilot GJ. Biomechanical analysis of rotator cuff repairs with extracellular matrix graft augmentation. Orthopedics. 2014;37(9):608-614. doi:10.3928/01477447-20140825-05
2. Smith MJ, Bozynski cc, Kuroki K, Cook CR, Stoker AM, Cook JL. Comparison of biologic scaffolds for augmentation of partial rotator cuff tears in a canine model. J Shoulder Elbow Surg. 2020;29(8):1573-1583. doi:10.1016/j.jse.2019.11.028
3. Gilot GJ, Alvarez-Pinzon AM, Barcksdale L, Westerdahl D, Krill M, Peck E. Outcome of large to massive rotator cuff tears repaired with and without extracellular matrix augmentation: a prospective comparative study. Arthroscopy. 2015;31(8):1459-1465. doi:10.1016/j.arthro.2015.02.032

Rotator Cuff Healing Index (RoHI) Risk Factors

Human

This animation demonstrates the features and benefits of the CuffMend™ rotator cuff augmentation system.

Not Hidden

English  - en

video

CuffMend™ Rotator Cuff Augmentation System Features and Benefits

Misty Suri, MD (New Orleans, LA), presents a second-look surgery 6 weeks after CuffMend™ augmentation, showing incorporation and vascularization of ArthroFlex® human dermal allograft.
ArthroFlex is a registered trademark of LifeNet Health.

CuffMend™ Rotator Cuff Augmentation: Second-Look Surgery at 6 Weeks

Hi, my name is Misty Surrey from New Orleans, Louisiana, and I'd like to share with you a cuff mend second look case. So our patients, a 40 year old male, he's a military recruiter and he's a recreational bodybuilder. He came in with left shoulder pain after an incident at the gym. Basically he was lifting. He had a pop in his biceps three weeks prior to presentation and he came in. So at this point on physical exam, he had pain in his biceps. He had pretty good range of motion. He was just a hair weak in his rotator cuff and a positive near positive. Hawkins and O'Brien signs on x ray. Nothing significant. No significant arthritis or dislocation or any bony changes. Now an MRI. What we see here is a small ten by ten millimeter partial thickness under surface. Tearing to the rotator cuff did have an upper border sub scap tear with a slap as well. So at this point I decided with the patient that we would proceed with a biceps tenodesis a slap repair, and to address that rotator cuff damage cuff mend augmentation of the partial thickness tearing. So in the operating room, what I found was a type eight slap. There was no evidence of any damage, and the partial thickness rotator cuff damage was confirmed. That we saw in the MRI was about 30%. On the articular side of that rotator cuff, I proceeded with an upper border subscapular repair and a decompression and a repair of that slab. Type eight to address the partial thickness articular sided cuff damage. I proceeded with a cuff mend augmentation of the rotator cuff. So here's a clip of the cuff augmentation part of the procedure. I attached the graph medially with fiber stitch RC anchors both anteriorly and posteriorly with a mattress stitch. I do prefer to use the nanoscope with this part of the case, so I can see the implants deploy on the undersurface of the rotator cuff. I used the two fiber stitches medially, and then two push locks laterally to fix the cuff bin graft. Here's what the final augmentation looked like with the graft nicely tensioned and not over tensioned. So unfortunately, five weeks after surgery, the patient fell and then fell again and had a Popeye deformity that he noticed after the second fall with a significant increase in pain. So he came in and on physical exam. At this point, he had a positive Popeye deformity with a positive speeds and positive Jurgensen signs, as well as a little bit of weakness and decreased range of motion. So an MRI was obtained at this point showing complete disruption of the proximal biceps with about three centimeters of retraction, as we can see here. And the superior aspect of the subscapular was torn as well. So at this point, the plan was to do an open subpectinata thesis with a revision repair of the superior aspect of the subscapularis. So the intraoperative finding confirmed the MRI findings of the torn biceps and the upper subscapularis tear. So I proceeded with an upper subscapular revision repair as well as an open subpectinata thesis. With the second look, I was able to see the great incorporation of the kerfman graft into the rotator cuff tissue. So to probing here you can see the the continuity of the graph to the native tissue, as well as the vascularity of the graft already at the six week time point. Now there is no inflammatory reaction at all. There was no bursitis. This is what it looked like when I put the scope in to the shoulder. So this was this is a very, very convincing second look that shows us great incorporation of this graft at this time point of six weeks. So what happens on the undersurface of the rotator cuff? You can see the complete synovial ization of the implants on the undersurface of the cuff, with no reaction whatsoever. So at the six month time point, he's doing very well. He's quite happy. He has a sane score of 90, he has zero out of ten pain and he's back to weightlifting. His motion is very good and he's got great strength in terms of cuff testing. So this was not an isolated case. I had another patient that also had a subsequent trauma after surgery that we got histology on as they went on to a shoulder arthroplasty after their massive rotator cuff repair that was augmented with cuff meant. And we can see here that there's significant revascularization, active tissue remodeling and decellularization of the graft. This was another patient, also seven months out of surgery that had an AC joint trauma that I got a second look on. That also shows excellent incorporation of the Kauffman graft. To conclude, Kauffman has been a game changer in my practice. With my experience of over 300 cases, I have found Arthur Fleck's to be the perfect combination of mechanics and biology. It's been a paradigm shift for my patients, giving my patients the best chance of healing of their rotator cuff tissue. Thank you.

Patrick J. Denard, MD (Medford, OR), demonstrates a CuffMend™ rotator cuff augmentation procedure. Dr. Denard uses FiberStitch™ RC 1.5 implants for medial fixation of the ArthroFlex dermal allograft and self-punching PushLock® anchors for lateral fixation. View the video for graft preparation <a href="https://www.arthrex.com/resources/VID1-002384-en-US/graft-preparation-for-cu%EF%AC%80mend-rotator-cu%EF%AC%80-augmentation-system">here</a>.&nbsp;
ArthroFLEX® is a trademark of LifeNet Health.

CuffMend™ Surgical Technique Featuring FiberStitch™ RC

I'm Patrick Denard from Medford, Oregon. I'm going to give you my pearls on using CuffMend augmentation, using FiberStitch for medial fixation in the soft tissue. So this is the left shoulder. I've first done a FiberTak bridge knotless repair with 32.6 FiberTak RC anchors medially and two SwiveLock anchors laterally. I like to determine the need for CuffMend augmentation preoperatively using the row index. I think that's the best indicator you have of the chance of healing of the rotator cuff. So there's a couple of pearls for doing CuffMend augmentation after rotator cuff repair. One of those is the lateral portal placement. So we look at the outside view. This would be the placement that I use for my middle anchor just off the corner of the acromion. And for perspective, my lateral cannula is down about four centimeters from the lateral aspect of the acromion. This will again make it easier to insert my graft spreader just above the rotator cuff, parallel to the rotator cuff, prior to inserting the graft spreader. I like to confirm that my angle of approach is going to be to be adequate for my medial FiberStitch anchors. So in this case, again I've already put in. Medial anchors along the greater tuberosity. And I'll just first confirm if those portals are going to be adequate. These are typically going to come right off the corner of the acromion. So this is my middle anchor placement. We can see on the outside and on the inside. We can see that I'm going to be able to get a good angle of approach. Probably this one's going to allow me to get both the anterior and posterior aspects of the graft. But if I feel, especially in the back that I'm going to come off, I'll assess slightly more posterior placement. So in this case I placed a posterior medial anchor and I'll check. And here we have a nice angle approach. So here we have the graft spreader inserted in the standard fashion. I like to confirm that I'm over into the Musculotendinous junction. So here is the lateral aspect of my sutures. So I want to be just over medial beyond that because I want to avoid hitting those sutures. And again we see that we have a nice parallel approach to the rotator cuff because we place that low lateral portal for our rotator cuff repair. So I'll hold this against the rotator cuff. Once the graft is deployed to the graft spreader, I'll insert the skid off the lateral edge of the acromion. Again, for my anterior FiberStitch arc, I'm going to use the middle anchor placement right here. We have a good angle of approach to the graft. I like to use this skid for insertion of the arc because this avoids any soft tissue tangles. Once I have the FiberStitch arc in place, I can back the skid out slightly and then I can use a variety of suture configurations. One option is to use a mattress configuration from anterior to posterior. However, I typically find that a one on and one off approach helps really bring down the corners of the graft. So pass the FiberStitch arc through the graft. So there we deploy our first anchor. And then again I like to go a one off one on. So I'll go slightly more medial into the soft tissue. I'll pull back on the wheel. And then advance. So there are two passes. Once I've deployed both anchors, I'll then take all three suture limbs on the outside and gently pull up to remove slack. Next, I'll grab the loop and gently tension down the first anchor. Once I have my final tensioning, then I will cut the free limb with the tensioner cutter. I can remove any additional slack if necessary. And I like to leave just a very small tail at the edge here. And again I'm going to do a one off one on configuration. First through the graft. Pull the wheel back advance it forward. I'll come out of the graft. Then I'll come back through the soft tissue. Slightly more medial. We'll grab all three limbs and gently remove the slack. Once I do that, that will help set the FiberStitch anchor. Then I can pull on the loop to first advance down, and then pull on the final free limb to get final fixation here. So we have nice fixation in the soft tissue. Immediately the graft spreader is removed I can then obtain my lateral fixation. My two self-punching PushLock anchors. Once I picked my location for my lateral PushLock anchor, I'm going to make sure that I have a little bit of extra slack in the system, because with this self-punching anchor, the slack will be pulled up as it's inserted. We'll insert to the point where the anchor is at the level of the bone, and then remove the orange tab on the outside and deliver the remainder of the anchor into the bone. Finally, we're going to place our anterolateral PushLock anchor. Here from our lateral view you can again see medial fixation extending from medial to lateral with the corners brought down by the PushLock.

Orthobiologics

Professor Eugene Ek (Melbourne, Australia), describes performing CuffMend™ rotator cuff augmentation with an autologous biceps tendon graft using the Autograft Tissue Compression System.

CuffMend™ Rotator Cuff Augmentation Using the Autograft Tissue Compression System With a Biceps Tendon Autograft

Hi, my name is Eugene Eck. I'm an orthopedic surgeon from Melbourne, Australia. I specialise in shoulder, elbow and hand surgery. And today I'm going to talk about the cuff and autograph rotator cuff augmentation system. Our case presentation today involves a 46 year old male who works predominantly in office based jobs, and he is a recreational tennis player. He presented to me with right shoulder pain, with no specific traumatic event preceding this, and had progressively worsening pain, particularly in overhead activities and movements, and also associated weakness on his examination. He had essentially full active range of motion of his shoulder, but he did have some degree of weakness, particularly in abduction, with four out of five power external rotation. Four out of five internal rotation, however, was five out of five. He had associated impingement, pain and tenderness over the long head of biceps tendon with a positive O'Brien sign, but had no AC joint tenderness. As you can see from his X-rays, there was no evidence of any glenohumeral arthritis, but he did have a prominent lateral acromial spur, as you can see on the x ray on the right. As you can see from the coronal PD images, there is a retracted degenerate tear of the supraspinatus tendon. And on the sagittal T1 weighted images on the left, you can see that the rotator cuff muscles itself are relatively well preserved, with no signs of any fatty infiltration or muscle atrophy. The axial image in the middle, you can see the subscapularis tendon is intact and the axial image on the right you can see the AP dimensions of the supraspinatus tendon tear. So what are our treatment options that are nonoperative and operative management options in this patient we elected to do an arthroscopic rotator cuff tendon repair given the patient's age, level of activity, and also his failure of prior nonoperative management with rotator cuff repairs. We have the option of doing a patch augmentation with either autograft allograft or xenograft tissue. Muscle advancement is also an option. We decided in this patient to do an autologous biceps tendon autograft augmentation. The reasons for doing so is that it's a cost effective option for structural and biological augmentation, which has been recently shown in a paper by John Turkish and his colleagues. Given that it's autologous tissue, there's relatively low risk of rejection or foreign body reactions by the patient. It provides structural augmentation to the rotator cuff tendon repair, particularly for tendons that are relatively poor in quality and have a high risk of retear. It's an easily applied graft, and the fixation of the tendon graft itself is actually quite straightforward. So in terms of the procedure itself, I've started by doing a standard shoulder arthroscopy, and I assess the joint. I perform any debridement of the joint itself as necessary and then perform the biceps tenotomy for the biceps tenodesis I performed my biceps tenodesis using a five attack button. I then cut the redundant biceps tendon and pass it to the back table for the autograft tissue compression or the so-called biceps smash. I then re-entered the shoulder joint and then performed my rotator cuff repair as required. And my standard technique is using a five attack speed bridge technique using a two meter row and two lateral row construct. After the biceps tendon graft has been prepared on the back table, it is then delivered to me on the application device, which I then place over the repaired rotator cuff tendon. We fixed the graft medially using two fibre stitch RC anchors in a mattress configuration and laterally with two push lock anchors. We conducted a four month follow up MRI, and this demonstrated that the rotator cuff repair had healed and there was integration of the autograft with the supraspinatus tendon. Here we present patient reported outcomes at six months, which demonstrates significant improvement in function and pain across the ASCs Warwick and the Oxford shoulder scores. So this is an example of a 70 year old active female who has a score of eight. You can see from her MRI scans she has a retracted degenerate tear of the supraspinatus tendon, and the MRI scan shows the AP width of the tear. The right T1 weighted image shows the muscle belly is relatively well preserved, with low degree of fat infiltration and atrophy. So with a score of eight, this equates to approximately 38% healing rate. So in this case, an autologous biceps tendon autograft would be ideal. You can see from this intraoperative image the retracted degenerate tear involving supraspinatus tendon. The middle image shows the repaired rotator cuff tear, and the right image shows the autologous biceps tendon overlaid over the repair. So at four months, you can see that the MRI scans showed that the rotator cuff tendon repair had healed. You can see the preoperative and postoperative MRI scans showing the healed tendon. So today I've done ten cases using the autologous biceps tendon autograft. All these cases had Roae scores of six and above, and had performed MRI scans at four months to assess tendon healing, and in all patients the tendon repairs had all healed. So in terms of rehab, I manage these patients similar to any large rotator cuff repair protocol. I place them in an abduction pillow sling for six weeks, and during this time they start gentle passive range of motion only, and then they progress onto active assisted range of motion after six weeks and then strengthening exercises after three months. So in summary, the Biceps Tendon autograft Augmentation System is an effective technique to augment my rotator cuff repairs, especially in situations where the concern of rotator cuff healing is potentially compromised. From previous studies, we know that the tenocytes are viable post compression, and the graft itself is cost effective and the tissue itself is readily available.

Stephen Brockmeier, MD (Charlottesville, VA), demonstrates the CuffMend™ rotator cuff repair augmentation technique with ArthroFlex® dermal allograft using FiberStitch™ RC anchors for medial fixation and Knotless SwiveLock® anchors for lateral fixation during a FiberTak® SpeedBridge™ repair.

CuffMend™ Rotator Cuff Augmentation Using Knotless SwiveLock® Anchors for Lateral Fixation

Steve Brockmeier here. Coming to you from studio X in Naples, Florida. Today we're going to demonstrate CuffMend dermal graft augmentation of a rotator cuff repair, both from a medial fixation standpoint, but to also highlight lateral fixation utilizing the knotless mechanism and the preexisting lateral row anchors, you can match your graft size to what you need, and you make those measurements once you've completed your cuff repair. A couple of things to highlight. So we've used just standard sutures for the medial fixation here. And then for the lateral fixation we've placed 20.9 FiberLink sutures. And you can see we've got them kind of here to demo how they're placed. So we basically we pass the the non looped end from inferior to superior. And so that has the loop positioned inferiorly for we'll use that to shuttle our sutures and complete our lateral fixation. All right. So we got our graph loaded up. Everything's tensioned the way I typically like it. And you can see it's loaded on the spreader for introduction. You can see the spreader can close and open quite nicely. And this is how we're going to get it into the space. Now to orient you in the subacromial space. This is a standard trans osseous repair. Highlight the fact that the medial row is going to be the knotless FiberTak RC anchors. And so you can see medial fixation brought over to lateral fixation. So standard supraspinatus repair with some extension into the infra our lateral anchors have been placed. So these are our swivel locks. And you can see that the preloaded knotless mechanisms have been externalized. So you've got one going out the direct anterior portal here. So we've kind of docked that here. And then the posterior one is coming out the direct posterior portal here. From a portal standpoint we have our large passport. So our ten millimeter passport placed in our in our repair area. And then I always like to use this accessory portal which you can see I'll put a switching stick in posterolateral portal. So I use this for viewing. I use this sometimes for placement of implants, but this is a nice portal to have that where you have a bunch of different options for suture management and for angles of approach. And then the final portal you're going to see here is kind of a more superior direct portal. We use this for placements of our medial row anchors prior to the rotator cuff repair, and we're going to use this for placement as well of our medial fixation for our CuffMend. Now I'm going to move my camera over to this posterolateral portal and get positioned for placement of our graft. So we'll go ahead and take our graft. And it's folded up for introduction into the joint. And you can see here I'm going to place it through the cannula. Laterally you'll see it kind of emanate into the joint here. And you can see plenty of space. I do take my time with prep for these. So you want to prep down into the recess here. You want to make sure you have good access both anteriorly and posteriorly, so that when you deploy your graft, it deploys nice and easily into the space. So over this I'll place a skid down into the space. And now we're going to place our implant over the skid and into position. And then go ahead and remove the skid. You can see this kind of smaller needle. I'm going to have them tension the graft nicely here. First one will go in. You can see the angle of approach is nice and perfect. And we go in without any issue into the joint. So we're going to deploy our first FiberStitch implant. So all the way back all the way forward to get you positioned. And then we'll carefully slide back so you can do these in a vertical mattress configuration. You can do these in a sandwich configuration. You can do this on and off. So you can see here I'm actually going to put one on and one off here in more of an oblique fashion to try to pull this graph down and tension it. And we'll deploy our second one. And here we go sliding it back carefully, making sure everything stays in place. So this is what you're left with coming out here. So you can see here we've deployed our anchor and you have a loop and you have a straight stitch. And you can look inside the joint there and the split screen. All right. So you stabilize in both hands. You can pull this and see which way the loop pulls. It's that way. So you're going to go the other way. And then we'll start to deploy the rest. So you can see how that's bringing that loop down one final tensioning with the loop and then final tensioning here. And then we have a knot pusher cutter device. So right here. So this goes into the space. And you can use this to tension your implant down. And then we'll cut it. So for this fixation you have options. And you know sometimes the angles of approach are different depending on where you're putting your graft and how you're tensioning it, etc.. So here for example, we've got a pretty good shot from there. But sometimes in this case I'll find that the angle of approach for me, I feel better about coming in from one of your posterior portals so you can see you also have a pretty decent shot right there as well. So we'll have our skin in place. Now our FiberStitch is in place, and this is a reverse curve and a reverse cutting implant. So you can see the bevel is set up to kind of cut through the tissue nicely. And you see how it makes your angle of approach even better here. So we're going to go through the tissue and then we'll deploy and we'll pull it off. And then we'll kind of look and say right how do we want attention. This one. So we're going to come off or we're going to stay on the implant. And again, just to show you the different options, this one will do a horizontal mattress on the tissue itself and the same exact thing. So you can see here we have a loop and we have a stitch. Pull this down. So you have different options as far as stitch configuration depending on what your preference is. Seeing the front one, I tried to pull it anteriorly by doing one on and one off. This one we have a standard horizontal mattress and so you can tension it down quite nicely. Then you want to back off just a little bit and cut it, and leave just a little bit of tail for your final suture fixation here. The next step is to remove the graft spreader from the joint, which is fairly straightforward. So you unhook your sutures. So now we're going to carefully remove our instrument here. And you can see our graft stays in place. Our lateral sutures are still placed okay. So we'll close up our spreader. You don't want to pinch the sutures in your spreader. So you want to just be watching to make sure you don't have anything stuck. Which in this case, we do not. And now our spreader is out and we're ready for our lateral fixation. So for suture management, sometimes I'll go ahead and pull these sutures, the posterior ones out the back. Just so we're not going to get these mixed up in the cannula. So you can see I'm going to grab these. And I'm going to carefully pull those out the back. So now we've got our graph ready for our lateral fixation. And so we're going to go ahead and pull out our locking mechanism here back out into our working cannula. So now we have these externalized through our working portal. All right I'm going to shorten my my Pre-placed FiberLink here. So you can see that this is the FiberLink we placed through our graft. All right. And then we're going to pull through our working stitch. So basically two steps here. Step one shuttle this through the graft. Step two shuttle it through itself to lock it into place. You can see right now we're highlighting this coming through the graft. All right same thing. Now I'll typically floss that a little bit. So we'll shorten this some. But we'll leave this parked. So I'm going to tuck that down like that. And then we'll bring this back out the front and we'll move to our back anchor and we'll bring out our link. And then repeat those steps. So now what we'll do is we'll do our final tensioning while viewing from the direct portal here. So you can see medial fixation lateral fixation. We'll pull these out laterally so we can tension them individually. All right. So this comes out here. All right. And then we can dial our tension into place how we want it. So if we want attention more in the back we can do that. Now if we want attention more in the front, which we definitely need to do, we can do that now. Pretty happy with that final product. Cuffmend with medial fixation utilizing FiberStitch RC and then lateral fixation using the lateral row rotator cuff anchors with the preexisting knotless mechanism. Sutures.

application/pdf

CuffMend™ Rotator Cuff Augmentation System

A list of scientific articles pertaining to a product or procedure.

Eine Liste wissenschaftlicher Artikel zu einem Produkt oder Verfahren.

Wissenschaftsupdate

Lista de artigos científicos referentes a um produto ou procedimento.

Atualizações científicas

Lista de artículos científicos relacionados con un producto o procedimiento.

Actualizaciones científicas

Scientific Updates

Dermal Allograft Augmentation of Rotator Cuff Repair Scientific Update

CuffMend™ Rotator Cuff Augmentation Technique

Child (D)

The Autograft Tissue Compression System is designed to create a graft using autologous tissue, such as biceps tendon. The graft can be used in various procedures, including rotator cuff augmentation and subscapularis repair.

John M. Tokish, MD (Phoenix, AZ), discusses his early experience and rationale for using the Autograft Tissue Compression System to augment rotator cuff repairs with a compressed autograft biceps patch. He also presents the results of his 55-patient case series that demonstrate tenocyte viability of the smashed biceps graft and augmented healing potential.1
1. &nbsp;Brinkman JC, Makovicka JL, Denard PJ, Colbath GP, Mercuri J, Tokish JM. Compression of an autograft biceps into an augmentation patch does not cause mechanical damage to the tenocyte. Arthroscopy. Published online September 26, 2024. doi:10.1016/j.arthro.2024.09.029

Histological Analysis of Compressed Biceps Autograft for Augmentation of Arthroscopic Rotator Cuff Repair

My name is J.T. Turkish from the Mayo Clinic in Arizona, and I'm delighted to share our early experience today with you on our biceps. Autograph patch augmentation for rotator cuff repair. Well, anyone that does rotator cuff surgery knows that this is a battle that we sometimes don't win. We know that based upon many factors, patients can oftentimes have a higher retear rate or failure to heal rate than we would like to see it as surgeons. We know that the cuff at risk has these risk factors to include age and size of tear. And many of these are non-modifiable from this paper on the ROI or the Rotator Cuff Healing Index. We can interpret from the paper a score or a failure rate by ROI score. And you can see that even low numbers such as a five would give you a failure to heal. Expected rate around 30%. Way too high for most of us as surgeons for our comfort level. Well, this, therefore, with failure rates at 25 to 75%, augmentation has become a recognized necessity. Autograft, allograft and xenograft sources have therefore gained popularity to augment healing. Recently, our group has described the use of an autograft biceps graft adapted from tendon normally discarded after tenodesis. This paper that we released used autograft biceps and a skin graft measure, and we were able to expand the anatomized biceps into a reproducible patch. It did preserve some significant tenocytes viability, and the biceps patch was shown to induce differentiation of stem cells to the tenocytes phenotype. There are biologic advantages to the autograft tenocytes as a graft. First, it does initiate mesenchymal stromal cell differentiation into tenocytes like cells, and tenocytes support the proliferation, migration, and antigenic differentiation of tendon derived stem cells. But there are some advantages and of course, disadvantages of autograft biceps patches. The first advantage is it's readily available Most do Bio-Tenodesis when they're doing rotator cuff repair and discard the proximal biceps. This is no cost. The patient already has it in them. You have everything you need right there at the time and point of care. With the Autograft you get the cell, you're trying to get everything else to turn into. So we think this is a significant advantage. Now, the original description was through a commercial skin graft measure and it did expand the area. But we did note that the structural integrity of the patch was sometimes questionable. And we did note in that study that site viability was reduced by about 44%. A newer technique has been developed that we refer to as the biceps smash. This takes a biceps and puts it into a commercially available plate. We then apply uniform compression and it turns it into a very reproducible, uniform patch. It has better structural integrity and it's certainly easier to insert surgically. But there are several questions that must be answered with this. The first is does the compression process damage the Damaged the Tina site at time zero. Does the patch incorporate with the tendon and does it improve healing? Well, with question number one, does the smash damage the tenocytes? We took a look at this and have recently presented a consecutive series of 55 patients undergoing biceps tenodesis as part of our surgical intervention. Generally, when you do a biceps tenodesis the way we do it in the pec fashion, you get about 40mm of biceps that is taken out and normally discarded. Now 27mm of this is usually used for patch represented by the inferior portion of the biceps shown here, and 13mm of the remnant was used in testing for this study. The remnant was split longitudinally, divided it into two regionally identical biceps samples of the tendon. We took one sample of the tendon here, and the second sample one was smashed and one wasn't. One remnant sample was placed back into the autograph compression device and compressed into a patch. The corresponding remnant sample was not compressed and sent to pathology. Both samples were sent to evaluate for Tina site viability and our pathologists were blinded to which sample was which. We had a discussion with the pathologist to say if we could determine under cross examination with H.a staining, and they felt that was the most appropriate way to evaluate whether there was mechanical damage to the Tina sites at time zero. Our results showed that 93% of smashed samples and 96% of non smashed samples showed no evidence of Tina site damage during the process. This difference in Tina site damage was non-significant and essentially equal. So the answer to question one is that the biceps smash preparation does not damage Tina sites at time zero, and therefore allows us to put the Tina site into the surgical field that we want to at time zero. The second question is what happens to the patch on MRI over time? And we've had a number of variable time frames. We've had 30 augmentations of rotator cuffs, and we've been able to obtain 22 of the of the 30 that have reached maturity, and we've gotten MRIs on them post-op at six weeks. The patch is still visible, but there's lots of inflammation still in the cuff. At three months, the patch is visible and the cuff is less inflamed, but still edematous. And what we found is that between four and a half and six months, the patch is no longer visible and cuff healing is more uniform. This represents MRI progression of three different patients, one at six weeks, showing the clearly visible patch but a pretty inflamed cuff, the second at 12 weeks, showing that the patch is a little less visible and the cuff is starting to mature. And by six months you can see a mature cuff repair with no sign of the patch on the MRI anymore. So question three and of course, the most important question for all of us is does this patch augment healing? The answer is we don't know yet. However, we do have some early results. We've had 18 patches performed that we've been able to get post op MRIs on in the setting of full thickness rotator cuff repair. And what we found is we found one MRI retear in those 18 cuffs for retear rate, or a failure to heal rate of 6%. Certainly there's no control group, but compared to the literature, this is very promising in terms of that. What about partial thickness tears? Does the patch augment healing? This is a little tricky to evaluate, but most studies in the past have taken a look at pre versus post tendon thickness. And what we found is we've had six partial thickness rotator cuff augmentations with post op MRIs. And what we found is that all show increase in thickness of the tendon pre to post, as is shown here from left to right. And the average increase in thickness is somewhere between 20 and 40%. The final question that we have right now is can the biceps smash augment SpeedScap repair after total shoulder arthroplasty? We know that after an anatomic total shoulder SpeedScap repairs when evaluated by ultrasound often show discontinuity in up to 50% of tendons. Well, if you could add a patch to augment that and decrease that amount, it might solve an issue that's present in anatomic total shoulder arthroplasty. So we now have done 20 stemless total shoulder arthroplasty. We've had no cases of clinical failure. But the ultrasound evaluations are ongoing. And so a little too early to tell with regard to that. But again promising data. So early conclusions with this. Well, the biceps autograft appears to be a locally available and cost effective option for rotator cuff augmentation. Compression of the autograph can result in a reproducible and robust graft for insertion that does not compromise site viability. Augmentation may decrease retear rates and may increase tendon thickness in the setting of cuff, tear or cuff repair. However, I should caution that this is early results and further study is warranted to determine if this augmentation technique results in improved healing rates and improved patient outcomes. Thank you very much for your attention.

John M. Tokish, MD (Scottsdale, AZ), demonstrates the CuffMend™ technique using a biceps tendon autograft prepared with the Autograft Tissue Compression System and fixated with FiberStitch™ RC and Self-Punching PushLock® anchors. View the graft preparation video <a href="https://www.arthrex.com/resources/VID1-006270-en-US/graft-preparation-for-auto-cuffmend-augmented-rotator-cuff-repair">here</a>.

CuffMend™ Augmentation Technique Using a Biceps Tendon Autograft

My name is J.T. Tokich from the Mayo Clinic in Scottsdale, Arizona. And today we're going to be demonstrating for you an augmentation technique using the patient's own autograft biceps smash using the Arthrex autograph compression device. So you can see that we've been able to harvest about 40mm of tendon. This gives us plenty of length for our biceps to smash, because what we want is about 27mm of tendon for the patch. Once that you're happy that the graft is nicely centered within the tissue plate, we simply cover it. And then we're going to load it on top of the biceps smash press. Once that's done, then we will start with putting the tension down. We're then going to leave that at the max point for four minutes, and the graph then will stay compressed. Once we've given it that four minutes, we're going to loosen it up and the patch is ready to go. The patch is beautifully formed. Now we have to just load it onto the introducer with the graph now prepared and we're back inside, you can easily see the repair that we did viewing from the From the back side portal. One of the things we've learned is that it's better to come in fairly low and parallel. So for the standard placement of the biceps smash autographed patch, we will generally make in addition to this standard lateral working portal, one additional anterolateral portal that you can see is placed by the passport cannula here. This will allow the graft spreader with the patch to sit on top, so viewing from the outside you can see the graft and the graft spreader is prepared nicely. And then all we have to do to insert it is simply slide the wheel back. And this allows us then to enter into the passport. Once it's inside the shoulder, we're going to bring it directly into the top and center it upon the place that we want to be. We can then open the graft here and set it exactly where we want the graph to go. So oftentimes the medial row can be fixed by using standard anterior cannula which we're demonstrating here. I prefer to use simple stitches so that it puts a little bit of tension on the graft. So my first stitch is going to be to come inside of the purple line. I'm going to come in and cheat just inside that, and then we're going to insert the FiberStitch RC until it goes down to the depth stop. Once it's there, I will rotate backwards outside. You can see this until I get a very satisfying click. I then simply go forward and then my second arm of this is ready to be deployed. I back this out. I'm going to come and use this guy over the top of the front side. That guy drops in and I send my FiberStitch wheel back again. And this deploys the second pledget and then we all we have to do is remove the FiberStitch. This gives us a loop and a double mattress. I'll turn my attention to the free end of the suture as shown here on the outside. I then simply have to pull this guy down. It's the second limb of our mattress stitch, and it will allow us to come in and compress. This gives us an excellent first anchor stitch medially on the patch. We then bring the tensioner cutter and this will give us a FlushCut down against the patch. We're now going to repeat that step for our second FiberStitch I back this guy out, I'm going to just simply come over the top of the patch again. Again, coming just over the top so I can secure with a medial stitch right over the top on the other end of this. Once I feel like I've got that patch down, I simply bring the other limb of the mattress suture in place and it will cinch that down completely. Once I've gotten that, we're going to cut the excess edge. Additional stitching is quite easy. One could remove the tissue passer, which is what I generally do now. We can bring the spreader completely out and now we have our patch in place. Two stitches we found is plenty to do this, but if you want to really spread out the graft or if you want additional fixation, we found that this technique of throwing in some of the extra stitches has been an excellent way to really spread out the graft over the top. Now I've got a fourth stitch, one on the outside corner. There's our third stitch symmetrically on the anterolateral aspect for the lateral row. We want to be able to be just slightly distal and lateral to where the patch will naturally step down. You're now getting into pretty hard cortical bone. So we felt that that was best done through the traditional lateral portal. And so I'm going to have to retrieve our stitch through this passport. We're now simply going to load it on our PushLock. You can see we have the Self-punching PushLock for our lateral row. Now one thing that's important is that we leave some slack in this lateral row so as not to over tension it on the patch. So what we like to do is pass point quite a ways to leave this slack in place and then come back. And we can always take up slack. Then this guy can be punched in directly. This nicely restores the patch directly on top of the tendon. We then cut the excess suture off the graft and our posterior lateral row is complete. The self-punching PushLock can then again be introduced into the portal. We then decide where we want this PushLock to go, and then we're going to just tap it in. And then an open cutter comes in and finishes up the edge of this. This completes the patch laterally and medially. And you can see that we have now SpeedBridge repair. And it is now augmented by an autographed biceps tendon. It has my favorite configuration of two stitches medial that are simple to spread the patch out one suture anteromedial and one suture posteromedial again, which does a beautiful job of spreading the graft out. And then we've got the critical portion of the rotator cuff repair covered. This is where the tenocytes need to be. And so we want to be in that position. And we've got our posterior lateral PushLock in place and our anterior lateral PushLock in place as well. And this completes the construct and the repair.

This video demonstrates the use of the Autograft Tissue Compression System to prepare an autograft biceps graft for use with the CuffMend™ rotator cuff augmentation system.

Graft Preparation for Auto CuffMend™ Augmented Rotator Cuff Repair

We are going to demonstrate the recommended technique for graft preparation for the Autograft tissue compression system, or biceps smash, for use in the CuffMend rotator cuff augmentation procedure. To prepare the graft, you will need the compression plates. The MGS press for sutures, a FiberLoop suture, a zero FiberWire, a TigerLink SutureTape, and a FiberLink SutureTape and a graft spreader. Additionally, a mega loader can be helpful for the loading of the graft spreader. For the graft, harvest the biceps tendon through either a super pec or subpac approach. It is recommended to harvest at least 40mm of tendon. Once the graft is harvested, remove and discard approximately one centimeter from the labral attachment point. Since the tissue in that region tends to not smash well, then cut the graft to 27mm in length. The cut tendon can then be placed into the bottom well of the compression plates. Place the cover plate on top and load the plates into the press. Rotating a quarter turn until the plates are locked into place. Rotate the handle to provide compression until the indicator line is at max. After a minimum of four minutes, the plates can be removed from the press. The graft will be approximately 22mm by 27mm. If the graft is stuck to the top plate, move it to the bottom well to allow for easier suturing. The plates have four holes for suture passage. For the medial sutures, a FiberLoop can be used. Cut the thick part of the FiberLoop off and use the Keith needle to pass one end of the suture through the corner of the graft. Remove the needle and thread it onto the opposite end of the suture. Pass the other end of the suture through the graft, creating a mattress stitch. Both passes of the mattress stitch will go through the same hole in the compression plate. Repeat on the opposite medial corner of the graft with the same Keith needle, but now with the zero FiberWire suture. Using the same Keith needle, the FiberLink SutureTape is passed through the corner of the graft in a mattress configuration. Repeat on the opposite corner with a TigerLink SutureTape. If the surgeon is not yet ready for the graft, it is recommended to place the graft in the plates and place under some compression to help keep the graft shape. Additionally, some saline can be added to keep the graft hydrated. When the graft is ready to be loaded into the graft spreader, remove the top plate. The FiberLink SutureTape can be cinched into the plates. Remove the medial stitches from the plates. And pass the sutures through the distal ends of the graft spreader. Cleat the sutures into the handle of the graft spreader in a crisscross configuration. Remove the lateral stitches from the plates and cleat straight down into the handle on the graft spreader. The graft is now ready for insertion.

Autograft Tissue Compression System

SuturePatch is a trimmable all-polyester, nonabsorbable suture construct, designed to reinforce soft tissue.&nbsp;
SuturePatch tissue reinforcement is indicated for managing and protecting soft-tissue injuries and reinforcing tendon repairs. It supports repairs performed with sutures or suture anchors, including rotator cuff, patellar, Achilles, biceps, quadriceps, and other tendons. Sutures and anchors provide biomechanical strength, while SuturePatch reinforces and protects healing tissues.

SuturePatch Tissue Reinforcement Technique

Biologic tuberoplasty harnesses the power of the ArthroFlex dermal allograft to provide a biologic cushion between the acromion and the tuberosity that can prevent bone-on-bone contact due to an irreparable rotator cuff tear.&nbsp;&nbsp;Self-punching tensionable knotless anchor technology allows the ArthroFlex graft to be placed in a quick, effective, and reproducible technique preventing shoulder impingement syndrome, often associated with shoulder pain.&nbsp;
ArthroFLEX® is a trademark of LifeNet Health.

Christopher Adams, MD (Naples, FL), and Misty Suri, MD (New Orleans, LA), demonstrate the technique and order of operations for combining a rotator cable reconstruction with a biologic tuberoplasty to treat massive irreparable rotator cuff tears. They briefly review the demographics of a surgical candidate for this combined procedure.

Posterosuperior Rotator Cuff Tears: Rotator Cable Reconstruction With Biologic Tuberoplasty

This animation demonstrates how to perform the tensionable knotless biologic tuberoplasty procedure for an irreparable rotator cuff tear. The ArthroFlex dermal allograft is used to provide a protective biologic cushion between the acromion and the tuberosity.
ArthroFLEX® is a trademark of LifeNet Health.

Tensionable Knotless Biologic Tuberoplasty With ArthroFLEX® Dermal Allograft

Tensionloc Knotless biologic Tuberoplasty harnesses the power of the ArthroFLEX dermal allograft to provide a biologic cushion between the acromion and the tuberosity that can prevent bone on bone contact due to an irreparable rotator cuff tear. Prepare the greater tuberosity by mildly decorticating the surface using an arthroscopic burr or PoweRasp using an arthroscopic ruler. Measure the anterior to posterior footprint. Measure the medial lateral dimensions of the footprint. Note to undersize the graft by 15 to 20% using a Scorpion suture passer. Prepare the anterolateral corner of the ArthroFlex graft with a 1.3 FiberLink SutureTape in a luggage tag configuration. Repeat for the posterolateral corner. Prepare the graft on the anteromedial corner with a FiberLink in a simple pass, noting the loop to be under the graft. This loop will later be used to shuttle the repair suture from the anteromedial anchor through the graft. Repeat for the posteromedial corner. Through a percutaneous portal, place a 2.6 FiberTak guide onto the anteromedial position of the footprint and insert a self-punching Knotless 2.6 FiberTak soft anchor. Repeat for the posteromedial corner. A passport divider may be used for suture management. Retrieve the number five. Repair suture and round shuttle link from the anteromedial anchor through the lateral portal. Repeat for the posteromedial anchor. Use the FiberLink to shuttle the anteromedial. Repair suture through the anteromedial corner of the graft. Repeat the steps for the posteromedial anchor. Load the number five. Repair suture into the loop of the shuttle stitch and fold it over at the purple mark. Pull the tape end of the shuttle link from the percutaneous portal to convert the knotless mechanism. Repeat the steps for the other medial corner. Remove the passport divider holding counter tension on the lateral luggage sutures. Sequentially pull tension on the anteromedial and posteromedial. Repair sutures to shuttle the graft through the 12mm passport and onto the prepared greater tuberosity. Load the luggage tagged FiberLink SutureTape into the eyelet of the self-punching SwiveLock anchor. Apply tension to the FiberLink SutureTape to achieve the desired fixation and insert the SwiveLock anchor. Repeat for the posterolateral corner of the graft to complete the tension. Double Knotless biologic Tuberoplasty. A partial repair can also be incorporated with a biologic tuberoplasty construct.

This animation demonstrates the features and benefits of the tensionable knotless biologic tuberoplasty technique for the treatment of massive irreparable rotator cuff tears.

Tensionable Knotless Biologic Tuberoplasty for Treating Massive, Irreparable Rotator Cuff
Tears

Raffy Mirzayan, MD (Los Angeles, CA), shares his experience using ArthroFlex dermal allograft to perform a biologic tuberoplasty technique for patients with massive irreparable rotator cuff tears. ArthroFLEX® is a registered trademark of LifeNet Health.

Biologic Tuberoplasty Technique: Why, When, and How

Justin W. Griffin, MD (Virginia Beach, VA), demonstrates a new innovative technique, biologic tuberoplasty, for irreparable rotator cuff tears. He uses this simple technique to fixate the ArthroFlex dermal allograft to the tuberosity, providing a protective covering that may prevent humeral-acromial contact for pain relief in low-demand patients.&nbsp; 

 
ArthroFLEX® is a registered trademark of LifeNet Health.

Tensionable Knotless Biologic Tuberoplasty Technique

Today we're going to be demonstrating biologic tuberoplasty, which is a new technique for management of irreparable rotator cuff tears. Here we have everything we need for performing the procedure in a fast and efficient way. We're going to be using two medial row self-punching knotless FiberTaks. And then laterally we'll use 4.75 SwiveLock for our graft. We have a three millimeter dermal allograft. So here we have a right shoulder. We have several different portals that are important for doing the procedure. I always start from my posterior portal when I'm doing my intra-articular work. We'll be working from a more lateral viewing portal, and then our anterior superior portal is going to be our working portal for placement of the graft. Our suture anchors will be placed percutaneously just off the acromial edge. And then finally we have our anterior portal, which can be helpful for suture management. So this represents our typical appearance of a massive irreparable tear. You can see in the back there's some preserved infraspinatus that we can use to repair to our graft at the end. With side to side sutures. You can see the tuberosity is bare and in the front are subscapularis is intact. So we have two options for how to measure for our graph. So once we get a sense of where the graft is supposed to be, typically I will be decorticating just a little bit on the tuberosity for graft healing. In many cases I'll medialis the footprint just slightly to allow for maximal graft coverage. So we're going to go ahead and measure for our graft. We can place our measuring device here. And we can see that we're measuring approximately 30. Because we know the graft is going to stretch when we place it. We're going to undersize this and cut our graph to 25. So then we're going to get a sense for what our lateral to medial coverage needs to be. For the tuberosity you can see that it's around 20 to 25. We're going to undersize this to 20 which is very typical for this procedure. So while I'm working on placing my medial row anchors, my assistant can prepare the prepare the graft on the back table. Here I'm going to place two luggage tag sutures through the lateral aspect of the graft. Medially we're going to utilize links for passing our repair sutures. This allows us to do all of our suture management more on the back table, as opposed to having to do this up at the side of the patient. So this is really all the preparation that's needed for your graft. So next we'll place our anchors percutaneously. So first we're going to place our Anteromedial anchor. This is our Self-punching Knotless FiberTak. So we can just set this and then leave it. Percutaneously placed there and move on to placement of our posterior anchor. So you can see we have a nice distance between our anchors to get maximum tuberosity coverage. So next I'll retrieve the repair suture as well as the shuttle suture from our anterior anchor. It's important to make sure that we keep these separated more anteriorly in the passport. And then the more posterior. I'm going to stay towards the back side of my passport when I retrieve that. So we've brought our graph to the patient. Next I'll take my anterior repair suture. Just making sure that I'm not twisting anything here. And we'll place this very easily through the link. So our anterior repair sutures through our graft. We'll do the same thing posteriorly. So next we'll convert our anterior knotless FiberTak repair suture. We're going to pull it up to the line. So we'll provisionally tension these. We've got both of our repair sutures out our percutaneous portals so that we're not putting a lot of tension on these. So while we're placing this tension and bringing our graft in, your assistant is placing tension on these lateral cinches so that the graph naturally folds on itself, which allows for easy insertion. So we can progressively tension this in anteriorly and posteriorly. Sometimes you just need to take a little grasper to get this through your your 12 passport here. But it slides in pretty easily. We have very nice coverage of that medial tuberosity. So our next step is to place our lateral row anchors. So typically for placing my anterior anchor I find the biceps groove. And then I move just posterior to that. And that's going to be a good spot for our anterior anchor. Alright. So we're going to punch for our anterior anchor. And this will be our final anchor. So we have our final tuberosity coverage here. This is our tuberoplasty. You can see we have very nice anterior coverage. We've covered all the way up to the remaining infraspinatus. So we can place our side to side sutures. And we've retained our medial repair sutures so we can final tension these. Now as you can see there's very nice coverage here. So we're going to do some final tensioning just to make sure that everything's nice and solid medially. But we really don't have much that we need to take out here. I think everything's tensioned really well. As a final step, we have the option of placing a few side to side sutures through not only our infraspinatus, but also the subscapularis if possible. With the tuberoplasty, I'll keep my patients in a sling for approximately six weeks with passive range of motion, and let them begin active range of motion after coming out of the sling, and begin strengthening at eight weeks. Postoperatively.