Abstract:Rotator cuff repairs are associated with suboptimal outcomes and possibly greater incidence of retears if the biological healing environment is compromised. Strategies to optimize tendon–bone healing include the use of bioinductive scaffolds and regenerative stem cell therapy. The subacromial bursa has been shown to have significant pluripotent stem cell potency for tendon healing and has the advantage of easy accessibility and no added cost. However, a reproducible surgical technique for bursal mobilization, … Show more
“…Subsequent sutures (3rd anchor) are passed via tendon and bursal tissue in a single pass, or further posterolateral via separate passes. 9 The bursal passage points are predetermined using mobility assessment with traction as described above (Fig 5).…”
Section: Step 5: Tuberosity Preparation and Suture Anchor Insertionmentioning
confidence: 99%
“…The vascularity of the bursal layer is derived from the suprascapular vessels medially, and the deltoid vasculature posteriorly and laterally; bursal continuity should, therefore, be maintained at its medial (acromial, scapular spine, and musculotendinous) and lateral (deltoid) attachments for preserving vascular connections. 9 The goal is to harvest a previously described “vascular bursal duvet” that is sufficiently mobile to cover the bursal surface of the repaired rotator cuff. Fig 3 Subacromial bursa (B) harvest technique is demonstrated (right shoulder, high posterolateral High posterolateral portal viewing, lateral working portal).…”
Section: Surgical Techniquementioning
confidence: 99%
“…[2][3][4][5][6] The use of subacromial bursa as a biological augmentation tissue has been evaluated in basic science studies, and arthroscopic techniques for bursaaugmented repairs have been described recently. [7][8][9][10][11] The purpose of this report is to present an arthroscopic technique for biologically augmented repair of massive retracted rotator cuff tears. The technique involves using the long tendon of the biceps and subacromial bursa as autografts for deep and superficial tendon augmentation, and the repair is performed as a biceps-cuff-bursa composite unit.…”
Section: Introductionmentioning
confidence: 99%
“…2 , 3 , 4 , 5 , 6 The use of subacromial bursa as a biological augmentation tissue has been evaluated in basic science studies, and arthroscopic techniques for bursa-augmented repairs have been described recently. 7 , 8 , 9 , 10 , 11 …”
Surgical repair of massive and chronic rotator cuff tears is difficult due to tendon retraction and severe atrophy, and the resultant retear rate in the structurally weak tendons is high. Commercially available patches and bioinductive scaffolds have been used to provide strength and superior healing environment in partial and complete rotator cuff tears. Biological biceps autograft has been used for superior capsular reconstruction, and the subacromial bursa has been shown to have significant pluripotent stem cell potency for tendon healing. We describe our technique for combined use of the long biceps tendon (LBT) and vasculature-preserved subacromial bursa as autografts in rotator cuff repair augmentation. The technique involves obtaining a LBT graft of sufficient length using a "traction and tenodesis" technique. The subacromial bursa is mobilized as a continuous layer (vascular bursal duvet) by maintaining its medial and lateral vascularity. All-suture anchors are used to minimize the insertion apertures (3 mm) in tuberosity. The bursa is advanced laterally, and the mobilized cuff is repaired together as a biceps-cuff-bursa composite unit. Combined use of the biceps and bursa as biological autografts has the advantage of structural and regenerative augmentation, and the autografts are easily accessible without added cost.
“…Subsequent sutures (3rd anchor) are passed via tendon and bursal tissue in a single pass, or further posterolateral via separate passes. 9 The bursal passage points are predetermined using mobility assessment with traction as described above (Fig 5).…”
Section: Step 5: Tuberosity Preparation and Suture Anchor Insertionmentioning
confidence: 99%
“…The vascularity of the bursal layer is derived from the suprascapular vessels medially, and the deltoid vasculature posteriorly and laterally; bursal continuity should, therefore, be maintained at its medial (acromial, scapular spine, and musculotendinous) and lateral (deltoid) attachments for preserving vascular connections. 9 The goal is to harvest a previously described “vascular bursal duvet” that is sufficiently mobile to cover the bursal surface of the repaired rotator cuff. Fig 3 Subacromial bursa (B) harvest technique is demonstrated (right shoulder, high posterolateral High posterolateral portal viewing, lateral working portal).…”
Section: Surgical Techniquementioning
confidence: 99%
“…[2][3][4][5][6] The use of subacromial bursa as a biological augmentation tissue has been evaluated in basic science studies, and arthroscopic techniques for bursaaugmented repairs have been described recently. [7][8][9][10][11] The purpose of this report is to present an arthroscopic technique for biologically augmented repair of massive retracted rotator cuff tears. The technique involves using the long tendon of the biceps and subacromial bursa as autografts for deep and superficial tendon augmentation, and the repair is performed as a biceps-cuff-bursa composite unit.…”
Section: Introductionmentioning
confidence: 99%
“…2 , 3 , 4 , 5 , 6 The use of subacromial bursa as a biological augmentation tissue has been evaluated in basic science studies, and arthroscopic techniques for bursa-augmented repairs have been described recently. 7 , 8 , 9 , 10 , 11 …”
Surgical repair of massive and chronic rotator cuff tears is difficult due to tendon retraction and severe atrophy, and the resultant retear rate in the structurally weak tendons is high. Commercially available patches and bioinductive scaffolds have been used to provide strength and superior healing environment in partial and complete rotator cuff tears. Biological biceps autograft has been used for superior capsular reconstruction, and the subacromial bursa has been shown to have significant pluripotent stem cell potency for tendon healing. We describe our technique for combined use of the long biceps tendon (LBT) and vasculature-preserved subacromial bursa as autografts in rotator cuff repair augmentation. The technique involves obtaining a LBT graft of sufficient length using a "traction and tenodesis" technique. The subacromial bursa is mobilized as a continuous layer (vascular bursal duvet) by maintaining its medial and lateral vascularity. All-suture anchors are used to minimize the insertion apertures (3 mm) in tuberosity. The bursa is advanced laterally, and the mobilized cuff is repaired together as a biceps-cuff-bursa composite unit. Combined use of the biceps and bursa as biological autografts has the advantage of structural and regenerative augmentation, and the autografts are easily accessible without added cost.
“…Due to the potentially beneficial cellular composition as well as growth factor content, we speculate that the bursa may serve as a supportive structure to augment tendon healing after RC repair. An easy and reliable arthroscopic surgical technique has already been described in which the RC tendons are covered with the subacromial bursa, using the highly vascularized bursa to augment RC repair [ 14 , 15 ]. Additionally, a recent technical note has reported on a method for re-implanting autologous minced bursa tissue obtained from bursectomy to the RC surface with the aim of supporting RC repair [ 16 ].…”
Background
The role of the subacromial bursa in the development or healing of shoulder pathologies is unclear. Due to this limited knowledge, we aimed to understand specific reactions of the subacromial bursa according to rotator cuff (RC) pathologies compared to non-tendon defects of the shoulder. We hypothesized that the tissue composition and inflammatory status of the bursa are likely to vary between shoulder pathologies depending on the presence and the extent of RC lesion.
Method
Bursa samples from patients with either 1) shoulder instability with intact RC (healthy bursa, control), 2) osteochondral pathology with intact RC, 3) partial supraspinatus (SSP) tendon tear, or 4) full-thickness SSP tear were investigated histologically and on gene expression level.
Result
Bursae from SSP tears differed from non-tendon pathologies by exhibiting increased chondral metaplasia and TGFβ1 expression. MMP1 was not expressed in healthy bursa controls, but strongly increased with full-thickness SSP tears. Additionally, the expression of the inflammatory mediators IL1β, IL6, and COX2 increased with the extent of SSP tear as shown by correlation analysis. In contrast, increased angiogenesis and nerve fibers as well as significantly upregulated IL6 and COX2 expression were features of bursae from patients with osteochondral pathology. Using immunohistochemistry, CD45+ leukocytes were observed in all examined groups, which were identified in particular as CD68+ monocytes/macrophages.
Conclusion
In summary, besides the strong increase in MMP1 expression with SSP tear, molecular changes were minor between the investigated groups. However, expression of pro-inflammatory cytokines correlated with the severity of the SSP tear. Most pronounced tissue alterations occurred for the osteochondral pathology and full-thickness SSP tear group, which demonstrates that the bursal reaction is not exclusively dependent on the occurrence of an SSP tear rather than longstanding degenerative changes. The present bursa characterization contributes to the understanding of specific tissue alterations related to RC tears or non-tendon shoulder pathologies. This pilot study provides the basis for future studies elucidating the role of the subacromial bursa in the development or healing of shoulder pathologies.
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