“Human Dermal Allograft Interposition for Reconstruction of Massive Irreparable Rotator Cuff Tears,” by Venouzioua Kokkalis, ZT, and Sotereanos, DG, American Journal of Orthopaedics, February 2013, pages 63-70.
This is a small retrospective study involving 14 patients in the average of 54-1/2 years old who underwent either primary or revision repair of massive rotator cuff defects with an average defect of 1.8 cm and a maximum of 2.5 cm that need to be bridged with a dermal allograft. Most of the patients either had a revision or primary acromioplasty or a lateral clavicle excision and/or a biceps tenodesis or tenotomy at the same time, i.e. most patients had procedures done simultaneously. Results were mostly very good with very good pain relief and improvement in motion and even improvement in external rotation and strength in the majority. The authors made no attempt to establish the rotator cuff interposition material had united or even that the rotator cuff itself had healed. There are no indications of findings on any postoperative x-rays to compare with those in the preop x-rays and MRI scans. They concluded that patients with more than 2 cm tendon gaps had worse pain, range of motion and ASES scores compared with patients with smaller tendon gaps. They did not find an association with sex, duration of symptoms, prominence, i.e. grade of 1, 2, 3 acromion, presence of AC joint arthritis, muscle atrophy or fatty infiltration. There were no inflammatory/graft rejection reactions.
Though the results were mostly good in this very small series and with the multiple procedures performed, it is unclear what effect/role the intercellular matrix graft played other than to increase cost and prolong (they were held immobile for 4-6 weeks and passive motion was begun at 4 weeks with strengthening only begun at 3 months) the recovery in this group. What the study does suggest is that failing nonoperative treatment even in the presence of some rotator cuff atrophy and potential rotator cuff tendon gap, primary or revision rotator cuff surgery may be indicated especially if there is associated AC joint arthritis or biceps tendon abnormality and as long as these and a prominent acromion are dealt with simultaneously, one can expect the patient to benefit. What is not clear is which procedures are essential and whether the graft or any attention to the rotator cuff affects the outcome.
Note, Dr. Ichtertz has been utilizing rotator cuff allograft judiciously on patients with massive rotator cuff defects for 25 years. Very few patients are felt to be candidates in my experience and, in his experience, most of the pain relief is afforded by addressing the other problems present in the shoulder simultaneously such as the acromioclavicular joint arthritis and a prominent acromion. A void in the rotator cuff itself in many patients may be given more credit than is due for pain symptoms. We have to continue to monitor the correlation between rotator cuffs (supraspinatus in particular), muscle atrophy identified on preoperative MRI scans, and the short and long-term outcome of patients undergoing rotator cuff surgery.