All right, this is Dr. Arroyo here again. I'm a sports medicine doctor from El Paso, Texas. Now we will continue our previous talk about rotator cuff repair, now with rotator cuff augmentation. We will talk about some of the most common techniques for cuff augmentation, and hopefully we can practice some of them in the lab. These are my disclosures. So the repair of massive rotator cuff tear is very difficult. These tears are, for the most part, very retracted. The tendon is very poor. There is a fat infiltration, making the surgery very challenging with very variable outcomes. When we look at the literature, we can see that the rotator cuff re-tears can be present up to 94% of the time based on what literature are you reading. So our purpose as a surgeon is to restore the anatomy and improve the function. In the best attempt to achieve this goal, we have gone into rotator cuff augmentation. This is when the augmentation comes into play because they can provide improved mechanics and enhance healing of this massive rotator cuff tears. So my indication for augmentation is almost every revision, cuff repair, any massive cuff tear with a lot of retraction, tissue deficiency, such as chronic tears or some of them with fat infiltration. What I'm showing here on top left, there is a failed double row repair, most likely from over-tensioning. We can see where the two suture bridge passes were on the rotator cuff. They have this linear tear on the rotator cuff. On the bottom left, we can see a massive and retracted rotator cuff tear. So these are indications for rotator cuff augmentation. On the right, we have a patient who had two prior rotator cuff surgeries, both failed and a bunch of anchors in the proximal humerus. So what are the biomechanics of this patch? As well, they enhance tissue growth, they improve mechanics of the repair, they reduce tension over their repair, and increase the load to failure by providing an environment for healing. The most common grafts that we see out there are Xenograft, Allograft, and Synthetic. I'm gonna talk about each one of them with what we have currently in the market and with what has been used recently. So the Xenograft, some studies by Gupta and his group, they have this study where they had 27 shoulders, they did an open patch augmentation, and they show improvement in function and outcome scores. And 73% of them were intact at two years. Another study, they have 50 patients, they found a repair rate of 34% compared to a 90-something percent that we previously discussed. One of the most common Xenografts out there is the Regenitin. This one is made by Smith and Nephew, it's a bioinductive implant that is made of bovine Achilles tendon, it's mainly type one collagen. So what I'm showing here on the top left is a very massive retracted rotator cuff tear with very thin tissue. So after a single row repair and doing our bone marrow events, we can then deploy this implant. The implant comes already on a handle that you just put it through the lateral portal, deploy the implants, and then you have these PDS staples that you can put through a percutaneous portal to secure the implant to the rotator cuff. So the next one is the Cuffman, it's made by R-TREX, this one uses dermal allograft. The good thing about this one is that you can use different thickness, you can go from one millimeter up to three millimeters, you have to prepare the graft and load it into this device in a very similar fashion, you can load it to the lateral portal, and it also has some PDS staples that you use to secure the graft immediately. They also have a new technique where you can use the patient's bicep tendon and make it like a dermal allograft and use the same deployment mechanism. What I'm showing here on the top left, the same big rotator cuff tear, thin tissue, after a single row repair and bone marrow events, we deploy the implant to the lateral portal, get secure with a PDS staple like so, and use a lateral anchor for lateral fixation of this bio-inductive implant. So this one is from DPU MyTech, it's called the Dermis On Demand, it got released not so long ago. So this one is human dermal allograft, what I like, they come in like small sticks, so you can determine how many of them you will need based on the size of the tear. They are less expensive and they're very easy to use. So top left, rotator cuff tear, everything is being prepared. Top right, all sutures passed, so once you complete your repair, like I'm showing you on this picture on the bottom left, what I do, I call it like a parachute stitches that I pass just medial to my repair. So I have this length of suture coming out to the lateral portal and I can load my DODs and with a knob pusher, I just push them down. This is kind of like how they will look at the end, so once I have all the graft in place, I put a knotless anchor lateral to secure the implant. Like I said, you can choose how many you want based on the size of the rotator cuff tear. So this one is called the BioBrace, it's made by CumMed, this one is a synthetic graft. It's made of collagen membrane with PLLA, it's a very strong material, it's very absorbent, so if you like to inject PRP, bone marrow, things like that, this graft is probably great because it will absorb all that fluid into the graft. So what I do on this one, I keep my camera in the posterior portal, I use the lateral portal to deliver the implant and again, just like with the other implant, I put two shuttle stitches, just medial, to the repair that I use to deploy and position this implant on top of the rotator cuff and again, I use a lateral anchor to secure the graft. But this is a massive retracted degenerative rotator cuff and after doing a repair, I have my implant ready, it gets deployed, I switch it to graft medial and lateral, I use a knotless anchor for graft security. So this video right here, what I wanna show you is kind of like how I pass the implant, so these are my two like shuttle or parachute stitches, so what I do, I pass them to the graft and as I pull them through the portals, you bring the graft into the subacroma space. So once you have the graft part where you want, you start doing stitching, I mean, I'm just fast forwarding a little bit so we don't waste time, so what I'm doing right there, I'm just tying the medial side of the graft to the rotator cuff, I use an SMC sliding knot as well and I get good fixation on that side of the graft and I pretty much repeat the same steps on the other side until the graft is completely secure. just repeating the same step on the other side. So in conclusion, just select the best way to augment the repair. Use whatever you're comfortable with. I think they're all good. It's more like which one you like based on positioning, the technique that you use. So just find whatever you think is going to be the best for you. Definitely just always augment the fish and tissue. Try to improve the biology. What I'm showing here now is a kind of like a trend of using the bicep tendon. Just leave it attached to the superior glenoid and mobilize or transpose the bicep to the center of the humeral head. I have done it multiple times and I think it works. Mainly to be used as a scaffold so you can bring that rotator cuff on top of the bicep tendon or you can actually repair the rotator cuff to the bicep tendon. Kind of like bringing that massive tear into a smaller tear and just getting anchors around the bicep to complete the repair. Here at the bottom you can see just you'll see the bicep rotator cuff over so it serves as a scaffold and it's pretty strong. Also in these cases I propose using PRP or bone marrow aspiration. Again it's not without any additional cost but at this point we're doing a revision, we're doing augmentation, we want the best participation and I think the best is to do everything possible that we can to improve biology and have these tendons to heal. So these are my references so thank you very much again and if you guys want to practice any of these almond techniques we can potentially do it in the lab. Thank you.

rotator cuff repair

augmentation techniques

massive tears

Xenograft

Allograft