Reconstruction of Massive Rotator Cuff Tear Using Embroidered Polyester Cuff Reinforcement

Nottingham Shoulder and Elbow UnitNottingham Shoulder and Elbow Unit

I-H Jeon, WI-H Jeon, WAA Wallace, L Neumann, Wallace, L Neumann,

J Ellis, A McLeodJ Ellis, A McLeod

Introduction

Treatment of rotator cuff tear has been Treatment of rotator cuff tear has been

evolved. However, there are no definite evolved. However, there are no definite

solution for massive rotator cuff tear.solution for massive rotator cuff tear.

Conservative treatmentConservative treatment

DebridementDebridement

Muscle transferMuscle transfer

Introduction

Modes of failure in bone tunnel methodModes of failure in bone tunnel method

suture migration through bonesuture migration through bone Modes of failure in Modes of failure in

Mode of failure in suture anchor techniqueMode of failure in suture anchor technique

Loosening and backing out of anchor screws Loosening and backing out of anchor screws

(different behaviour of (different behaviour of humeral anchors humeral anchors thanthan glenoid glenoid

anchorsanchors) )

Augmentation deviceAugmentation device

Treatment of rotator cuff tear has been Treatment of rotator cuff tear has been

evolved. However, there are no definite evolved. However, there are no definite

solution for massive rotator cuff tear.solution for massive rotator cuff tear.

Conservative treatmentConservative treatment

DebridementDebridement

Muscle transferMuscle transfer

Introduction

Augmentation deviceAugmentation device

Gerber C, Schneeberger AG, Perren SM, Nyffeler RW.Experimental rotator cuff repair. A preliminary study.J Bone Joint Surg Am. 1999 Sep;81(9):1281-90.

Introduction

Polyester has been proposed for ligament Polyester has been proposed for ligament

augmentation device and substitute in the augmentation device and substitute in the

knee.Literature demonstrated thatknee.Literature demonstrated that

Scaffold for soft tissue ingrowthScaffold for soft tissue ingrowth

Mechanical support: Mechanical support: appropriate initial strength appropriate initial strength

to meet the biomechanical demands of the injured to meet the biomechanical demands of the injured

area, area,

Less foreign body reactionLess foreign body reaction

Introduction

The purpose of this study was to

evaluate the application of

Polyester Embroidery

Reinforcement (Nottingham

augmentation device) and

investigate the outcome in massive

full thickness RCTs previously

considered irreparable using this

method.

Materials and Methods

Patients were added to the study if they had clinical Patients were added to the study if they had clinical

weakness and pain and if magnetic resonance weakness and pain and if magnetic resonance

imaging confirmed a imaging confirmed a massive massive rotator cuff tear. rotator cuff tear.

2222 patients ( patients (1313 men men/ 9 women/ 9 women) )

13 patients followed up > 10 months13 patients followed up > 10 months

MeanMean age of age of 6060 years (range 4 years (range 466-78) -78)

Patients with combined glenohumeral Patients with combined glenohumeral

arthritis have been excluded.arthritis have been excluded.

F.UF.U 1010--2323 months (mean months (mean 1212 months). months).

DDuration of symptoms uration of symptoms : : 19 (4-36) months. 19 (4-36) months.

Pre-op symptoms were moderate to severe Pre-op symptoms were moderate to severe

shoulder pain on lifting and shoulder shoulder pain on lifting and shoulder

weakness. weakness.

Materials and Methods

Pre-op MRI scans in 8 cases revealed FT large Pre-op MRI scans in 8 cases revealed FT large

or massive tears of the RC with Goutallier or massive tears of the RC with Goutallier

grade III-IV fatty degeneration. grade III-IV fatty degeneration.

Materials and Methods

**

Operative Technique

1

2

Identify the retracted distal stump and release adhesion

Operative Technique

3

4

Insertion involves anchoring the device to the undersurface of the retracted RC tendon with 10-12 stitches

Make a bone tunnel under the G.T.

Operative Technique

5

6

PPass the other end of the device ass the other end of the device through a tunnel under the through a tunnel under the greater tuberositygreater tuberosity

AAnchoring the device, under nchoring the device, under tension, to the proximal humerus tension, to the proximal humerus with 1 or 2 large AO screwswith 1 or 2 large AO screws

Operative Technique

The proximal fixation is The proximal fixation is similar to “spot-welding” similar to “spot-welding” The The distal fixation is a distal fixation is a “flexible plate” type of “flexible plate” type of fixation. fixation.

Operative Technique

The device is made of polyester, The device is made of polyester, embroidered for good tissue embroidered for good tissue ingrowth ingrowth and provides good initial and provides good initial mechanical strength, mechanical strength, thus fixing the thus fixing the cuff to the headcuff to the head during the healing during the healing processprocess

Clinical Results-Constant score

Pain score

0

2

4

6

8

10

12

14

1 2 3 4 5 6 7 8 9 10 11 12 13 14No of cases

Pain

Sco

re

Pain(Pre)Pain(Post)

10.3

7.6

0

2

4

6

8

10

12

14

Preop Postop

ADL Score

0

2

4

6

8

10

1 2 3 4 5 6 7 8 9 10 11 12 13No of cases

AD

L Sco

re

ADL (Pre)ADL(Post)

4.7

6.7

0

2

4

6

8

10

Preop Postop

Clinical Results-Constant score

Range of motion

0

5

10

15

20

25

30

35

40

1 2 3 4 5 6 7 8 9 10 11 12 13

ROM(Pre)ROM(Post)

Clinical Results-Constant score

0

5

10

15

20

25

30

35

40

preop postop

Power at abduction 90

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10 11 12 13

Power(Pre)Power(Post)

Clinical Results-Constant score

Abuction Power

5.5 6.1

0

5

10

15

20

25

preop postop

Overall Constant Score:

0

20

40

60

80

100

1 2 3 4 5 6 7 8 9 10 11 12 13

PreCSPostCS

Clinical Results-Constant score

59 59

44.2

61

0

10

20

30

40

50

60

70

80

preop postop

AA

A*A*

N-AN-A

N-A*N-A*

TenTen reported a marked improvement in the reported a marked improvement in the

early post-operative period. early post-operative period.

Results

Radiographic Results

Case-1

F/69 Postop 12 moCS: 3578

Case-1

Preop Preop

Elevation 90Elevation 90ER 50ER 50Constant score:Constant score:87/34 (R/L)87/34 (R/L)

PostopPostop

Elevation 180Elevation 180ER 90ER 90Constant score:Constant score:90/67 (R/L)90/67 (R/L)

Case- 3

CS 64 CS 64 25256161

M/62 postop 6mo

Case-2

Postop 4 mo F/46 Preop

Case-2

Postop 4 mo CS:38/85

Severe fatty degeneration at supra+infra

Re-rupture of tendon at 10 months postop

Re-rupture of RC: 2 Re-rupture of RC: 2

Stiff Stiff shouldershoulder: 1 (MUA+ arthro debriment) : 1 (MUA+ arthro debriment)

Deep infection: 0 (No foreign body reaction)Deep infection: 0 (No foreign body reaction)

Complications

M/46 re-rupture of supraspinatus at 12 monthsM/46 re-rupture of supraspinatus at 12 months

Biomechanical property of Biomechanical property of

Nottingham Augmentation Device (in vitro)Nottingham Augmentation Device (in vitro)

Discussion

Fatigue test in saline Fatigue test in saline at 200 and 300N, maximum elongation of 0.38mm. at 200 and 300N, maximum elongation of 0.38mm.

Reaction of Polyester

Discussion

Polyester fibres

Fibrin

Fascia-likeCollagen

HPF: Patient 4 (at 14 years)

P Durani, I-H Jeon, TA McCulloch, A McLeod, WA Wallace The Histological In-growth of soft tissue into the Nottingham hood prosthesis, British Orthop Research Society 2003

Treatment of massive RC tears is Treatment of massive RC tears is

still controversial.still controversial.

This polyester augmentation device This polyester augmentation device

provides initial mechanical strength, provides initial mechanical strength,

prevent tendon stripping, &prevent tendon stripping, &

provides scaffold for soft tissue ingrowth with provides scaffold for soft tissue ingrowth with

less foreign body reaction.less foreign body reaction.

Conclusion

Biomechanical study of polyester Biomechanical study of polyester

augmentation deviceaugmentation device

What happens to tendon-device interfaceWhat happens to tendon-device interface

How to adjust proper tensionHow to adjust proper tension

Future Study

Randomized comparative Randomized comparative

study between repair and study between repair and

debridementdebridement

Thank YouThank You