Clinical Sports Medicine Update
Biomechanical and Biologic Augmentation for the Treatment of Massive Rotator Cuff Tears
Shane J. Nho,*† MD, MS, Demetris Delos,‡ MD, Hemang Yadav,‡ MBBS, Michael Pensak,‡ † ‡ ‡ Anthony A. Romeo, MD, Russell F. Warren, MD, and John D. MacGillivray, MD † From the Section of Shoulderand Elbow Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush University Medical Center, Rush Medical ‡ College of Rush University, Chicago, Illinois, and the Sports Medicine and Shoulder Service, Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
Recent studies have reported that massiverotator cuff tears do not heal as predictably as, and may have diminished clinical outcomes compared with, smaller rotator cuff tears. An improved understanding of the biologic degeneration and the biomechanical alterations of massive rotator cuff tears should provide better strategies to optimize outcomes. The approach to patients with massive rotator cuff tears requires careful assessment of thepatient and the extent of rotator cuff degeneration to determine the appropriate treatment. For a rotator cuff tear that is repairable, the goal is to produce a tension-free, anatomical repair that restores the footprint using soft tissue releases and various suturing techniques, including double-row, transosseous-equivalent suture bridges or the rip-stop stitch. For irreparable cuff tears, thesurgeon may elect to proceed with 1 of 2 approaches: (1) palliative surgical treatment—that is, rotator cuff debridement, synovectomy, biceps tenotomy, tuberoplasty and/or nonanatomical repair with partial repair; or (2) salvage treatment with various tendon transfers. Even though the biomechanical constructs for rotator cuff repairs have been improved, the integrity of the repair still depends onbiologic healing at the tendon-to-bone junction. There has been much interest in the development of a scaffold to bridge massive rotator cuff tears and adjuvant biologic modalities including growth factors and tenocyte-seeded scaffolds to augment tendon-to-bone healing. The treatment of rotator cuff disease has improved considerably, but massive rotator cuff tears continue to pose a challenging problemfor orthopaedic surgeons. Keywords: rotator cuff; massive; tear; repair; biologics
DeOrio and Cofield25 defined massive rotator cuff tears as those in which the length of the greatest diameter of the tear measured more than 5 cm; other authors have defined massive cuff tears as those that involve at least 2 tendons.38 The literature on both open and arthroscopic approaches reports improvedresults in shoulder function and pain relief with rotator cuff repair, although the size of the tear has a direct effect on clinical outcome and tendon healing.4,6,16,17,25 Galatz et al32 published one of the early series of arthroscopic rotator cuff repair for massive tears
*Address correspondence to Shane J. Nho, MD, MS, Rush University Medical Center, 1725 West Harrison Street, Suite 1063,Chicago, IL 60612 (e-mail: firstname.lastname@example.org). One or more authors has indicated a potential conflict of interest: Russell F. Warren has received royalties from Smith & Nephew and Biomet, and is a consultant for Bionx; Anthony A. Romeo has received royalties, stock, and research support from Arthrex; and John D. MacGillivray is a consultant for Arthrex. The American Journal of Sports Medicine, Vol. X,No. X DOI: 10.1177/0363546509343199 © 2009 The Author(s)
and determined that 17 of 18 (94%) resulted in repeated tears. Recent series of arthroscopic rotator cuff repair have demonstrated that postoperative healing occurs between 71% and 89% for the entire cohort, but tendon healing drops considerably to 47% to 50% for the subset of massive rotator cuff tears.1,6,31,40,41,67,73 In addition,...