Thank you. My name is Mark Edelman and I'm the co-director of the Sports Medicine Fellowship at the Southern California Orthopedic Institute and also the current president of ANNA. Thank you for being here. My topic today is rotator cuff repair with dermal matrix augmentation or bridge grafting for patch graft extension. My disclosures are available on the AAOS website and in your program but I must also disclose that the use of a cellular human dermal matrix allograft is on label for augmentation and bridging less than one centimeter. If there's bridging greater than one centimeter those are considered off-label uses. We're going to begin with a case example today. A 71 year old active woman who I see all day long in my clinic in Los Angeles. She's had some vague shoulder pain for years and then suffered a tennis accident six months prior to presentation with severe pain and weakness. She's pseudoparetic with 120 degrees of active forward elevation and abduction. External rotation is 60 degrees and internal rotation is to L1. She has positive impingement signs but no real external rotation lag but does demonstrate weakness with forward elevation and external rotation testing. She's had no response to physical therapy and therapy. She doesn't tolerate exercise and continues to have night pain. She's basically miserable. Here's her x-rays and there's no surprises or tricks here. What you see here is her glenohumeral joint looks to be well maintained. Perhaps maybe a hemata too. A little bit of a prominent acromion but no significant proximal humeral migration. Her MRI though shows a different story. What we can see is a largely retracted tear of the supraspinatus with the supraspinatus at the level of the glenoid here in this position here and significant atrophy looking at this on the sagittal oblique with the cotelliate probably a 3. So here's the problem. We have a big tear which is likely acute on chronic with a potentially high retear rate after repair or is it really a retear or does she just never heal in the first place? What we're dealing with is multifactorial risk factors. There's chronicity, you have stiff atrophic tissue with limited blood supply, poor biology, she's over 70, fortunately she's not a smoker but all this together leads to poor healing. When you think about small versus large tears, larger tears have fewer fibroblasts, fewer blood vessels and inflammatory cells. The larger tears undergo this metaplasia and are harder to get healed. The smaller tear is going to be more likely to heal and if you get to those early you're going to have a better opportunity for healing as well. In this case we have a large tear at least acute on chronic if not chronic but she's an active individual who's really unhappy. So the question really is is augmentation going to be beneficial and can we improve outcomes and healing using biological and biomechanical augmentation in this case? If we look at the biologic graphs available you've got dermal matrix allograft and then you also have the xenograft products with bovine collagen implant which is bioinductive but doesn't offer strength. You can use the IT band autograph like Mahada and use it as an SCR and there are several synthetics in development. These all have different properties and handling characteristics and costs and you need to understand them. When we look at the augmentation goal we want to improve not only healing but biomechanical repair strength. We want to close the residual defect and use this scaffold for ingrowth to try to avoid over tensioning the repair. If we look at some of the biomechanics on this Alan Barber has shown us that when you add a human dermal allograft you are significantly stronger to both cyclical loading and ultimate load to failure with greater than a hundred newtons of strength added. We also know from study also done by a Dr. Alan Barber and my partner Dr. Burns at SCOE that you can double the healing rate when you augment these large tears greater than three centimeters done with a good quality level 2 study. If you look at the systematic reviews Ivan Wong has shown that there is superior functional and structural outcomes when compared to a primary repair in a conventional fashion for large to massive rotator cuff tears. So for me the augmentation indications are pretty clear. I use for revision repairs massive tears usually greater than four centimeters that I think can be repairable and what we call at-risk tears those retracted more than two centimeters and greater than three centimeters in size. If they're chronic push traumatic and they have grade 3 Goutelier changes with atrophy of at least 50%. So here's what we're looking at and we'll just look at this video. So this is the tear the biceps is intact and you can see we can pull on it but I can't really get it out in position. In this case we can use a margin convergence approach and get the rotator cuff reattached but I'm concerned about her inability to heal and so in this case I'm going to use a dermal matrix allograft and we'll pull it in from the lateral portal sew it in circumferentially and then go ahead and fix it laterally. When we look inside the joint we can see we've got that rotator cuff repaired and by adding the dermal graft on top we can increase our chance for healing by double according to Alan Barber's work. If we move on and look at what about truly irreparable tears that same 71 year old who has an irreparable cuff. A revision situation with grade 4 fatty infiltration. To me that's a hundred percent chance she's not going to heal and in those cases if they're not in a place where they want to consider reverse arthroplasty which is really not the topic of this talk then a bridging graft may be beneficial. You can contain the joint reattach the muscle unit to the bone and use the scaffold for regeneration and we have probably the world's largest experience using dermal matrix allograft for this. When Dr. Snyder and I looked at a group of our patients 109 patients with an average age of 54 with truly irreparable tears they had any level of fatty degeneration or atrophy most of them had prior surgery. We did not do pseudo paralytics so they had to be able to get to at least 90 degrees of active forward elevation and what we found is we were able to get 65% healed on MRI their UCLA score doubled their simple shoulder test doubled and their visual pain scale decreased dramatically and only two went on to reverse arthroplasty. Well how does it work? Well I don't think we're exactly sure what we're trying to do is reestablish the force couple between any remaining anterior and posterior rotator cuff elements to give the deltoid better biomechanical advantage and we may be keeping the head down similar to what an SCR is doing so called reducing the boutonniere deformity to allow the arm to work more effectively. The other option is is what happens when we look at the muscle by connecting the graft to the remaining muscle tendon unit we may be able to salvage the remaining muscle and prevent more atrophy. In this patient if you look two years later certainly the muscle has remained while it's not going to get better as we know from Christian Gerber in this case it has not gotten worse. Similarly if we look at systematic reviews looking at bridging the graft utilization for these does also appear to be beneficial and they have improved function when you look at objective testing and may be functionally better than a non-anatomic or a partial repair so it does appear that they have a role and so if we look at this case so now in this case even with a margin convergence I'm not going to be able to fill that defect the tissue is more a trophic and can barely move past the margin of the glenoid. So in this case we're similarly going to use a dermal graft from the lateral portal I pass all my sutures first and we unfold this like a parachute and once you have it unfolded it becomes just like a standard rotator cuff repair. We'll go ahead and sew it anteriorly medially and posteriorly and then once you're done you fix the graft to the humeral head just like the native rotator cuff. You want to have a little of this trampoline effect and we'll fix it back down to bone in a similar fashion. So how do I decide what to do? Well, if there's a repairable large retracted cuff, I repair it and I'll add a dermal matrix allograft on top for a high-risk patient. If it's not repairable and there's decent quality rotator cuff tissue to sew to, then I'll do the off-label interposition and try to get some dynamic control and function and preserve any muscle that remains. If the native rotator cuff is medial to the glenoid or poor quality, I do an SCR and repair the anterior and posterior cuff to the graft tissue to complete my repair. So in conclusion, today it's unclear which use of dermal matrix allograft is best. Whichever technique is used, it does not burn any bridges. It's a viable option for very difficult group of patients. Thank you very much and I appreciate the opportunity to participate.

Mark Edelman

Sports Medicine Fellowship

Southern California Orthopedic Institute

dermal matrix augmentation

rotator cuff repair