If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Editorial Commentary: Reflections From a Mature Arthroscopic Shoulder Surgeon on the History and Current Benefits of Augmentation for the Revision of a Massive Rotator Cuff Tear Using Acellular Human Dermal Matrix Allograft
Acellular human dermal matrix allografts are now being used to augment and sometimes replace severely damaged rotator cuff tissue. I have been interested in this important aspect of orthopaedics for 15 years and am pleased to have the opportunity to share my personal reflections of some of the highlights in science and the literature that helped get to the point now where we can expect greater than 80% healing even in these difficult cases of revision after massive failed cuff repair. The field of tissue engineering will certainly be a critical part of our rotator cuff surgical future.
As I read the timely and important article by Petri et al.
and their scientifically prolific team of researchers and surgeons at the Steadman Philippon Research Institute, I cannot help but reflect on the history regarding the use of human dermal allograft to augment the degenerative rotator cuff tendon. The importance of a healed rotator cuff tendon that can stabilize the shoulder, improve function, and decrease pain is indisputable. Who among us (or our patients) would not prefer a biologically repaired cuff rather than a shoulder prosthesis or a large open tendon transfer operation just because the initial repair failed?
Of course, my concern has always been to avoid that initial failure (i.e., protect the blood supply, avoid excessive tension, and most important of all, open the bone marrow space to allow stem cells and growth factors to form a bone marrow clot or crimson duvet). Given the fact that “failures do happen,” we as shoulder surgeons need to evaluate all the facts available to determine what we can offer our patients when the cuff does not heal.
In 1992 Dr. Scott Steinmann introduced me to a product called GraftJacket (Wright Medical Technology, Memphis, TN). This was an early form of the now well-recognized acellular human dermal matrix allograft (AHDMA). The initial product was less than 1.0 mm thick, was very friable, and could not add significant support for tendon repair—much less resist suture cutout. We developed an arthroscopic technique to implant this allograft in a young construction worker in whom a previous open repair had failed and who could not work. It proved to be a difficult 5-hour operation, but it was successful. Since that first case, we have improved our techniques and routinely perform graft augmentation cases in less than 2 hours.
Soon thereafter, it was proved in an animal model and laboratory research that this allograft material had unique favorable properties when compared with xenograft or with other early synthetic materials. AHDMA had the propensity to attract and bind mesenchymal stem cells and also contained important growth factors that facilitated cell recruitment and neo-tendon proliferation. In addition, there was no immunologic rejection.
Of course, “regeneration” of the tendon was the ideal result, but it was often difficult to achieve. It was a challenge for any repair or reconstruction to succeed because the remaining residual cuff stump, muscles, and tuberosity were often extensively degenerative and distorted with scar, residual anchors, and suture debris.
The pioneering work of Richard Steadman, Lanny Johnson, and Hans Uhthoff in the 1980s opened our eyes to the potential of recruiting the nearby bone marrow elements for healing and regeneration. Not only are these critical healing components available for no additional cost, but they can foster an ideal environment for tendon repair when using the allograft augmentation for its structural support.
When bone marrow streams from the microfractures in the tuberosity, a clot forms, covering the bone and allograft, and provides a continuous fibrous meshwork to which the stem cells can adhere. The platelet granules are then present and available to release their essential growth factors in the precise manner and amount that suit nature's exacting requirements, much like a healing and maturing fracture callus.
Over the years, orthopaedic biologic allograft suppliers have “seen the light.” There are now at least 6 AHDMAs available for clinical use. The new offerings are much more robust, with thicknesses of 2.5 to 3.0 mm, thus greatly improving suture retention and initial structural load sharing. The literature now reflects the benefits of using AHDMA for augmenting these weakened, non-repairable tendons. In addition, the human dermal allograft, along with a bone marrow clot, has been shown to have the potential to replace completely absent tendon segments when no other repair is possible. This is being performed with success both as a bridging technique and as a superior capsule reconstruction.
For 13 years, our shoulder team at Southern California Orthopedic Institute has been performing “bridging repairs” and has followed up more than 230 patients with magnetic resonance imaging (Fig 1). We have documented that we can achieve greater than 75% healing of the allograft even when there is a sizable gap between the stump of the tendon and the tuberosity. At our institution, we commonly offer an AHDMA augment in revision rotator cuff cases and have found greater than 80% healing in a series of 13 patients. Of course, our preference is to have some native cuff tissue to repair and then overlay it with the graft, but this is not always possible, especially when there has been a Cho type 2 failure.
This occurs when the rotator cuff is retorn medial to the muscle-tendon junction, leaving very little tissue to reattach to bone when performing a revision operation.
Rotator cuff defect bridging and superior capsule reconstruction are both still considered off-label by the Food and Drug Administration when the gap is greater than 1 cm. Undoubtedly, with continued proven success, I believe AHDMA cuff augmentation and replacement will become a standard treatment for these complex revision cases.
My hope is that the efforts to develop a synthetic product that has similar properties to AHDMA will eventually be successful. I have no doubt that polymer and biologic scientists will someday produce a safe, strong, and cost-effective off-the-shelf biologic augmentation material that will replace the acellular human dermal allograft. Until that happens, AHDMA seems to be the best option.
Outcomes after open revision repair of massive rotator cuff tears with biologic patch augmentation.
To assess minimum 2-year clinical outcomes after open revision biologic patch augmentation in patients with massive rotator cuff retears who had deficient rotator cuff tendons with healthy rotator cuff muscles.