So, we're going to move on to onlay dermis grafts with Patrick Naird. All right. Thanks to Scott and Mike for the ability to be up here. And I'm going to talk about onlay dermal graft, why, when, and how. I do have some disclosures that are relevant to this topic. So, when should we augment, why, and then how should we do this? So, if you look at this paper right here, I think this is a really nice evaluation that Mattson put together. And if you look at the outcomes over the last 20 years, we have not improved that much. We've gotten slightly better. The re-tear rates have gotten slightly lower, but overall, we still have failures in about 25% of cases despite a large proliferation of articles. And we know that biology is going to be the solution. So, how do you predict? This is what I use most commonly, the rotator cuff healing index. 600 patients, I think it's the best tool that we have right now. As they identified, as many have also shown, there's several factors that are associated with healing, retraction, age, infraspinatus, fatty infiltration, as we all know. But what they did is they took it one step further and put it into this Rohy index, divided it into points, as you can see here, 94% healing, dropping down to 14% healing over 10 points. But there's a big gap that's occurring there. So, if you break this down a little bit further, you really see that after about six points, you drop off this cliff. Why is that? Because if you have a tear size over three centimeters with fatty infiltration of the infraspinatus of over two, you have seven points. So, if you remember nothing else, in that setting, you really want to think about your healing rate being very low, about 30%. And you should consider doing something different. Others have, of course, argued that you could do this even lower. But in my view, I think this is the greatest chance to really modify your outcomes. Ashish and I, therefore, put together this paper here where we looked at tears that were repairable, and here we recommended when the Rohy was over seven, you should really consider augmentation. Why is that important? Because then you can choose preoperatively, and then it can facilitate the speed of your surgery, because you don't want to be having to put these things together afterwards. So, why dermal allograft? We have dermal allograft, we have xenograft options. I think if you look at some of the basic science evidence, such as this study by Matt Smith and Jimmy Cook, that evidence tends to favor dermal allograft because you see less inflammatory reactions. That said, Buddy, as was mentioned, has shown that he had high healing rate with a bovine onlay patch. I think there is some concern for stiffness with the scapula dyskinesis, and it's also been suggested by Mike Kissenberth in his evaluation of partial tears. We know that dermal allograft has a long history of usage. We know that way back from Alan Barber's study, where they took healing from 40% to 85%, echoing those patients that probably would have had that Rohy index of seven or greater. Others have shown the same in a non-randomized trial here. So, how do we do this? I'll show you my surgical technique. This is right shoulder. This is a massive tear, two tendon, infraspinatus, and supraspinatus. There's mobility, but there's some fatty infiltration. So, I've preoperatively determined that I'm going to use an onlay dermal allograft to augment. I get a double rotary repair here, reinforcing. I had three anchors immediately. Then I'll prep my graft on the back table. This will be occurring while I'm doing my repair. So, I'll put a couple of sutures on the end of the graft, and then I can load this onto what's called a graft spreader. That will allow me to introduce the graft. So, this is ready to go. This is a one millimeter dermal allograft. There is opportunity, though, to use a two millimeter dermal allograft in some cases. The graft can be introduced, and I'll flip back to the arthroscopic view and show you how I get fixation immediately using a soft anchor. This is going to go right off the corner of the acromion. I'll push through the graft. I usually like to put one off and one on. This is a device that's commonly used for meniscal repair. And, of course, there are other technologies out there as well. But I think something like this is much easier than having pre-placed sutures because it allows you to hold the graft. You want to put it over the musculotinnitus junction. And here you'll see I get a mattress knotless fixation. Now, in the back one, you'll also see the anchor kind of sit on top because sometimes it's hard to get that angle at the back, but I think that's quite fine. It'll actually nicely compress the graft down. So you'll see what that anchor looks like on the top. So now we have medial fixation. I remove the graft spreader, and then I can simply go laterally with two self-punching three five millimeter anchors. So there's our final onlay dermal allograft on top of our double row repair. And we were able to do that in about five minutes after the repair. Now, if you look here, I think this is really what is the big question. Biomechanics, it probably favors interposition. That is passing sutures through the tendon. Maybe onlay will integrate, and you'll get some biomechanics later if you're not moving the patients very easily. But certainly the technical ease and the healing is where we really have to look at long term because the technical ease is on the onlay aspect. Healing, we're currently designing a randomized controlled trial to evaluate this further. In conclusion, there's a high risk of failure in patients with rotator cuff tears, but you can try to predict this preoperatively. I think augmentation can improve healing based on the literature. And onlay technical, onlay grafts are technically easy, but we require further evaluation to assess healing. Thank you.

Patrick Naird

onlay dermis grafts

rotator cuff tears

rotator cuff healing index

dermal allograft augmentation