Surgical Augmentation of Rotator Cuff Repair
Background: The shoulder joint is the 3rd most common site of musculoskeletal disease, and accounts for 4.5 million chief complaints, with 30-40% being rotator cuff related[1,2,3]. Overall, cadaveric studies estimate RC pathologies in 5-39% of the population at any given time. The gold-standard RC surgery is arthroscopic repair due to its minimally invasive nature in comparison with open surgery. However, there are many risk factors of repair outcomes, with a range of 34-94% of cases failing or retearing. After injury and surgery, the tendon undergoes a three-stage healing process to its original strength: inflammation, proliferation, and remodeling. With such a high and wide range of retear/failure possibilities, this study investigated current literature associated with RC tendon healing through augmentation of the surgical procedure and environment.
Search Methods: PubMed searches including the terms: “rotator cuff augmentation,” “rotator cuff surgery,” and “tendon regeneration.”
Results: There were many results investigating best practices for rotator cuff injury rehabilitation, but specific to surgical techniques, three different interventions showed promise to improve patient outcomes. Each of the augmentations demonstrated increases in shoulder healing, with various improvements throughout. Dermal allografts allow the tendon to gain structural support after surgery, while also creating an environment hypothesized to support cell-seeding and proliferation[5,6]. This promotes improvement of long-term outcomes – in contrast, use of AMLT had no increase in long-term rehabilitation, but supplementing the site with these injections showed marked increases in the short-term “sprint” healing post-op. Interestingly, the use of beige FAPs showed significantly increased healing rates while minimizing adverse outcomes in mice without needing surgery. Each method requires some combination of MRI, histology, or questionnaires to elicit a “snapshot” of the shoulder’s progress. The use of a specific MRI sequence called T1ρ imaging, has been shown to monitor extracellular properties, most specifically through providing quantitative collagen amounts. Given extensive literature regarding tendon regeneration, collagen remains an increasing variable as healing occurs. Exploiting this property could indicate repair quality and ensure proper recovery.
Conclusions: The detrimental outcomes associated with disability of the shoulder joint and the high rates of repair failure indicates a need to increase the efficacy of healing for these patients. Addition of already high-performing dermal allografts shows extreme promise for the field, and investigation of synergistic effects when coupled with AMLT remains unknown. To ensure these augmentations are assisting in the tendon repair, MRI sequences such as T1ρ can accentuate the healing process by providing “quality checks” for patients post-op.
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