Use of Graft Jacket as an Augmentation for Massive Rotator Cuff Tears

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Tendon healing and improved strength in the face of massive rotator cuff tear repair remains a daunting challenge. Seventeen consecutive patients with massive rotator cuff tears were treated with a standardized open repair technique and the repair augmented with Graft Jacket (Wright Medical, Memphis, Tennessee). Mean follow-up was 1.2 years (438 days). Pain scores improved with 11 patients (64%) reporting no pain or occasional and slight pain. Functional status improved with 12 patients (70%) reporting normal function or slight restriction only. Active forward flexion improved with 10 patients (59%) having greater than 150°. UCLA scores improved significantly from a mean 9.06 preoperatively to 26.12 (P value < 0.001). Three recurrent tears were observed on 11 available postoperative MRI scans and one CT arthrogram. The recurrent tears were smaller than preop MRI scans and 2 of 3 patients were satisfied with surgery. There was no change in muscle trophicity. No other complications were observed, including no infections or sterile inflammatory reactions. Open repair of massive rotator cuff tears with Graft Jacket augmentation appears to be an effective and safe treatment option. Our surgical technique is described as well as the early results.

Section snippets

Indications/Contraindications

Use of Graft Jacket augmentation with standard open rotator cuff repairs is indicated for massive rotator cuff tears, involving two or more tendons. Tear size, amount of retraction, and poor tendon tissue quality all play a role in the decision to use augmentation. Revision of a previous failed repair is also an indication for tissue augmentation. Tissue grafts are indicated to augment a repair and should not be used if the tendon is irreparable to substitute for stable repair. Use of tissue

Preoperative Planning

As with any repair technique for the rotator cuff, preoperative evaluation generally includes magnetic resonance imaging (MRI) or a magnetic resonance (MR) arthrogram. The degree of retraction and trophicity of the involved rotator cuff musculature should be determined before undertaking repair. In the case of revision surgery, preoperative workup should include a workup to rule out infection. Patients must be educated about the use of allograft tissue and informed consent must be obtained. The

Surgical Technique

We utilize general endotracheal anesthesia for rotator cuff repair. Patients are positioned in a modified beach chair position, with use of an articulated arm holder (McConnell Orthopaedics, Greenville, TX).

After the extremity is prepped and draped, we proceed with a diagnostic arthroscopic evaluation of the shoulder. This is important to visualize concurrent pathology such as biceps tendonosis, labral lesions, or glenohumeral arthritis. Concurrent pathology may be treated at this time. The

Postoperative Care

Postoperative immobilization consists of an abduction pillow 45° with no motion for 3 weeks, followed by passive motion above the pillow for an additional 3 weeks or conversion to an Ultra sling (Smith Nephew Don Joy, Carlsbad, CA) with gentle passive range of motion for 3 weeks depending on the degree of tension on the repair at the time of surgery. Active assisted range of motion is initiated at 6 weeks and slowly progressed. Strengthening is delayed until at least 12 weeks. In revision cases

Results

Seventeen consecutive patients underwent open rotator cuff repair with Graft Jacket augmentation at our institution from May 2003 to June 2005 by a single surgeon using a previously described technique. There were 12 males and 5 females with an average age of 56.9 years. The dominant arm was involved in 9 patients (52.9%). Primary diagnosis was primary massive rotator cuff tear (11 patients; 64.7%) or recurrent massive rotator cuff tear (6 patients; 35.3%). Preoperative MRI scans were reviewed

Complications

There were no other complications observed in this series. Specifically, we did not observe any infections or sterile inflammatory reactions in these patients. Subsequent to this series the senior author has had two cases with infections, neither one of which could be linked to the graft. The company was contacted and careful review of the lot numbers from which the grafts were taken revealed no reported infections in other hosts who received tissue from that specific donor.

Discussion

Treatment of massive rotator cuff tears remains a difficult problem, with variable rates of healing reported in the literature. The use of tissue augmentation has been described to enhance healing after rotator cuff repair.6, 7, 8, 9, 10, 11, 12 A number of different tissue grafts are available for use in augmentation, including both xenograft and human allograft tissue. There is limited information in the literature regarding outcomes with the use of tissue augmentation for rotator cuff

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