Editorial Commentary: Causes of Failure After Arthroscopic Rotator Cuff Repair

Background: Bridging rotator cuff tendon defects with a patch is a reasonable treatment for massive rotator cuff tears (MRCTs). However, the poor outcomes associated with routine patch repair have prompted exploration into superior bridging techniques and graft structures. Purpose: To detect whether dual-suspensory reconstruction using a banded graft would be superior to routine bridging using a patch graft to treat MRCTs and to detect the comparative effectiveness of patellar tendon (PT) and fascia lata (FL) grafts in dual-suspensory reconstruction. Study Design: Controlled laboratory study. Methods: Unilateral chronic MRCTs were created in 72 mature male New Zealand White rabbits, which were randomly divided into 3 groups: (1) patch bridging repair using rectangular FL autograft (PR-FL), (2) dual-suspensory bridging reconstruction using banded FL autograft (DSR-FL), and (3) dual-suspensory bridging reconstruction using banded PT autograft (DSR-PT). In each group, the mean failure load and stiffness of the cuff-graft-humerus (C-G-H) complexes of 6-week and 12-week specimens were recorded, with the failure modes and sites noted. Moreover, cuff-to-graft and graft-to-bone interface healing and graft substance remodeling of the complexes were histologically evaluated (via hematoxylin and eosin, Picrosirius red, Masson trichrome, and Safranin O/fast green staining) at 6 and 12 weeks to assess integrations between the bridging constructs and the native bone or rotator cuff tendons. Results: The DSR-PT group had the greatest mean failure loads and stiffness of the C-G-H complexes at 6 and 12 weeks (41.81 ± 7.00 N, 10.34 ± 2.68 N/mm; 87.62 ± 9.20 N, 17.98 ± 1.57 N/mm, respectively), followed by the DSR-FL group (32.04 ± 5.49 N, 8.20 ± 2.27 N/mm; 75.30 ± 7.31 N, 14.39 ± 3.29 N/mm, respectively). In the DSR-PT and DSR-FL groups, fewer specimens failed at the graft-to-bone junction and more failed at the cuff-to-graft junction, but both groups had higher median failure loads at 6 and 12 weeks (DSR-PT: cuff-to-graft junction, 37.80 and 83.76 N; graft-to-bone junction, 45.46 and 95.86 N) (DSR-FL: cuff-to-graft junction, 28.52 and 67.68 N; graft-to-bone junction, 37.92 and 82.18 N) compared with PR-FL (cuff-to-graft junction, 27.17 and 60.04 N; graft-to-bone junction, 30.12 and 55.95 N). At 12 weeks, the DSR-FL group had higher median failure loads at graft substance (72.26 N) than the PR-FL group (61.27 N). Moreover, the PR-FL group showed more inflammatory responses at the 2 healing interfaces and the graft substance in the 6-week specimens and subsequently displayed poorer interface healing (assessed via collagen organization, collagen maturity, and fibrocartilage regeneration) and graft substance remodeling (assessed via collagen organization and maturity) in 12-week specimens compared with the DSR-PT and DSR-FL groups. Superior interface healing and substance remodeling processes were observed in the DSR-PT group compared with the DSR-FL group. Conclusion: When compared with routine patch repair, the dual-suspensory reconstructions optimized biomechanical properties and improved interface healing and graft substance remodeling for bridging MRCTs. Furthermore, the dual-suspensory technique using the PT graft presented superior histological and biomechanical characteristics than that using FL. Clinical Relevance: The dual-suspensory reconstruction technique using banded tendon grafts may enhance bridging constructs for MRCTs in humans, warranting further investigations of clinical outcomes.

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Biomechanical and Histological Results of Dual-Suspensory Reconstruction Using Banded Tendon Graft to Bridge Massive Rotator Cuff Tears in a Chronic Rabbit Model

Han

et al. 2022

“…1,10,18,36 In contrast, the pulling force in the bone tunnel by whipstitch sutures was parallel to the tensile force in the intratunnel portions of the Plug-Pat, which decreased the tension at the graft-suture interface. 23,24,38 Furthermore, these specially designed bone fixation constructs in the Plug-Pat resulted in superior contact characteristics when compared with the conventional Rect-Pat. The increased graft-bone refreshed contact area has been reported to optimize the pressurized contact distributions at time zero and have less propensity for gap formation, which may also contribute to the superior initial fixation strength in the Plug-Pat.…”

Section: Discussionmentioning

confidence: 99%

The Plug-Type Patch Results in Immediate and Postoperative Advantages in Graft-to-Bone Integration for Bridging Massive Rotator Cuff Tears in a Chronic Rabbit Model

Huang

Han

et al. 2022

Background: Various patches have been used to bridge massive rotator cuff tears (MRCTs) by reconnecting the cuff tendons to the humeral head, but the outcomes continue to be suboptimal. Notably, the graft-bone junction is a vulnerable site for failure, which requires optimization in patch design and techniques to enhance initial and postoperative fixation strength at the graft-bone interface. Hypothesis: The plug-type patch (Plug-Pat) through intratunnel fixation would optimize mechanical characteristics in initial graft-to-bone fixation and subsequently improve postoperative biomechanical and histological properties in graft-to-bone healing when compared with the routine rectangular patch (Rect-Pat). Study Design: Controlled laboratory study. Methods: A total of 60 mature male New Zealand White rabbits underwent acute rotator cuff defects to create chronic models with MRCTs. The fascia lata autograft was then harvested to prepare a Plug-Pat, which was distally rooted in the bone tunnel and proximally sutured to native tendons in a horizontal mattress fashion to reconnect the humeral head and cuff tendons. The control group was repaired with a routine Rect-Pat that was secured onto the bone surface for graft-bone fixation. After surgery, the cuff-graft-bone complexes of rabbits in both groups were harvested immediately (0 weeks) for time-zero initial fixation strength and refreshed contact area assessment, and at 6 or 12 weeks for postoperative biomechanical and histological evaluation. Results: The Plug-Pat significantly enhanced initial fixation strength in comparison with the Rect -Pat (mean ± SD; failure load, 36.79 ± 4.53 N vs 24.15 ± 2.76 N; P < .001) and decreased failure at the graft-bone interface of the construct at 0 weeks, with a significantly increased refreshed bone bed contact area (52.63 ± 2.97 mm2 vs 18.28 ± 1.60 mm2; P < .001) between the graft and bone. At 6 and 12 weeks postoperatively, the Plug-Pat similarly resulted in greater failure load (43.15 ± 4.53 N vs 33.74 ± 2.58 N at 6 weeks; P = .001; 76.65 ± 5.04 N vs 58.17 ± 5.06 N at 12 weeks; P < .001) and stiffness (10.77 ± 2.67 N/mm vs 8.43 ± 0.86 N/mm at 6 weeks; P = .066; 16.98 ± 2.47 N/mm vs 13.21 ± 1.66 N/mm at 12 weeks; P = .011), with less specimen failure at the graft-bone interface than the Rect-Pat. In histological analyses, the Plug-Pat had a higher postoperative graft-bone integration score than the Rect-Pat, showing a more mature intratunnel healing interface with fibrocartilage tidemark formation, improved collagen properties, and more oriented cells when compared with those at the surface healing interface in the Rect-Pat. Conclusion: The Plug-Pat enhanced initial fixation strength and enlarged the refreshed contact area for graft-bone connection at time zero and subsequently improved postoperative biomechanical properties and graft-bone integration at the graft-bone healing interface when compared with the Rect-Pat. Clinical Relevance: The Plug-Pat using intratunnel fixation may be a promising strategy for patch design to optimize its initial and postoperative graft-bone connection for bridging reconstruction of MRCTs.

“…14 The factors that bring about the high failure rate of RCR have multiple aspects; 14,21 namely, patient factors, tear factors, and surgical factors. 22,24 Among them, surgical factors have a critical effect on tendon-bone healing after RCR. 27 Surgical factors can be subdivided into the repair technique, suture anchors, preparation of the greater tuberosity, and structural augmentation.…”

mentioning

confidence: 99%

Comparison of 3 Different Surgical Techniques for Rotator Cuff Repair in a Rabbit Model: Direct Suture, Inlay Suture, and Polyether Ether Ketone (PEEK) Suture Anchor

Du,

Chen,

Fang

et al. 2024

Background: Rotator cuff tears have been repaired using the transosseous method for decades. The direct suture (DS) technique has been widely used for rotator cuff tears; however, the retear rate is relatively high. Suture anchors are now used frequently for rotator cuff repair (RCR) in accordance with recent developments in materials. However, polyether ether ketone (PEEK) may still cause complications such as the formation of cysts and osteophytes. Some studies have developed the inlay suture (IS) technique for RCR. Purpose/Hypothesis: To compare how 3 different surgical techniques—namely, the DS, IS, and PEEK suture anchor (PSA)—affect tendon-bone healing after RCR. We hypothesized that the IS technique would lead to better tendon-to-bone healing and that the repaired structure would be similar to the normal enthesis. Study Design: Controlled laboratory study. Methods: Acute infraspinatus tendon tears were created in 36 six-month-old male rabbits, which were divided into 3 groups based on the technique used for RCR: DS, IS, and PSA. Animals were euthanized at 6 and 12 weeks postoperatively and underwent a histological assessment and imaging. The expression of related proteins was demonstrated by immunohistochemistry and immunofluorescence staining. Mechanical properties were evaluated by biomechanical testing. Results: At 12 weeks, regeneration of the enthesis was observed in the 3 groups. However, the DS group showed a lower type I collagen content than the PSA and IS groups, which was similar to the results for scleraxis. The DS group displayed a significantly inferior type II collagen expression and proteoglycan deposition after safranin O/fast green and sirius red staining. With regard to runt-related transcription factor 2 and alkaline phosphatase, the IS group showed upregulated expression levels compared with the other 2 groups. Conclusion: Compared with the DS technique, the PSA and IS techniques contributed to the improved maturation of tendons and fibrocartilage regeneration, while the IS technique particularly promoted osteogenesis at the enthesis. Clinical Relevance: The IS and PSA techniques may be more beneficial for tendon-bone healing after RCR.