What is Patch Augmentation for Rotator Cuff Repair?
Patch augmentation for rotator cuff repair is a shoulder surgery technique in which processed dermal allograft is used to treat large and massive rotator cuff tears.
The rotator cuff is a group of four tendons that joins the head of the humerus to the deeper muscles and provides stability and mobility to the shoulder joint. A major injury to any of these tendons may result in a tear. This can occur with repeated overhead use of the arm, while playing sports, or due to age-related wear and tear. A rotator cuff tear is one of the most common causes of shoulder pain in athletes and middle-aged adults and older individuals, and results in weakness of the arm and restricted range of motion.
Rotator cuff repair using a rotator cuff graft/patch augmentation involves fixing a biological scaffold (patch) to improve the strength of the repair and/or induce the healing of the torn rotator cuff tendon. The tissue graft materials that may be utilized for scaffold or patch augmentation are derived in the form of:
- Autograft – graft obtained from the same patient
- Allograft – graft obtained from a human donor, deceased donor, or tissue bank
- Xenograft – graft obtained from animals, most commonly cow (bovine) or pig (porcine)
- Synthetic - man-made material
After studying different materials available for patch augmentation, acellular dermal allograft (soft tissue allograft derived from donated human skin) appears to be the graft with the best scientific support. Unlike other biological scaffolds, no adverse host tissue response has been reported. These also have better mechanical properties than other biological scaffolds.
Anatomy of the Shoulder
The shoulder joint, also called the glenohumeral joint, is a ball-and-socket joint made up of three bones: the humerus (upper arm bone), scapula (shoulder blade), and clavicle. The head of the humerus articulates with the socket of the scapula called the glenoid cavity. The clavicle bone or collarbone is an S-shaped bone that connects the scapula to the sternum or breastbone. Tendons and ligaments around the shoulder joint provide strength and stability to the joint.
Indications for Patch Augmentation for Rotator Cuff Repair
Traditional rotator cuff repair surgery for a torn rotator cuff tendon may offer extremely good results for many patients but it continues to be suboptimal for large, retracted tears, and revision procedures. In such situations, patch augmentation may be an ideal option to improve tendon strength and healing and functional outcomes of the shoulder, especially in patients with poor tissue quality.
In general, your physician may recommend patch augmentation for repairing your rotator cuff tear in the following scenarios:
- You have a large rotator cuff tear of 3 to 5 cm
- Prior failed rotator cuff repair
- Chronic tears with poor tissue quality
- Your symptoms have lasted for 6 to 12 months
- You have a significant loss of function and weakness in your shoulder
- You are an athlete and wish to return to sports soon
- Conservative treatments have failed to heal the tear or alleviate symptoms
Preparation for Patch Augmentation for Rotator Cuff Repair
Preparation for patch augmentation for rotator cuff repair may involve the following steps:
- A review of your medical history and a physical examination is performed by your doctor to check for any medical issues that need to be addressed prior to surgery.
- Diagnostic tests such as routine blood work to help detect any abnormalities that could compromise the safety of the procedure and imaging such as an MRI scan is also performed to assess the size of the tear, retraction of the tendons, and degenerative status of the muscles and tendons supporting the shoulder joint.
- You will be asked if you have allergies to medications, anesthesia, or latex.
- You should disclose your current medications or supplements you are taking or any current illnesses or conditions you have such as heart or lung disease.
- You may be asked to stop taking certain medications, such as blood thinners, anti-inflammatories, aspirin, or other supplements for a week or two.
- You should refrain from alcohol and tobacco at least a few days prior to surgery and several weeks after, as it can hinder the healing process.
- You should not consume any solids or liquids at least 8 hours prior to surgery.
- You should arrange for someone to drive you home after surgery.
- A signed informed consent form will be obtained from you after the pros and cons of the surgery have been explained.
Procedure for Patch Augmentation for Rotator Cuff Repair
Rotator cuff repair with patch augmentation is usually performed using a minimally invasive arthroscopic approach under general or regional anesthesia and involves the following steps:
- You will be placed on the procedure table in a beach chair or lateral decubitus position.
- The skin around the shoulder joint is cleaned with an antiseptic solution, and two to three small incisions (arthroscopic portals), about a half-inch in length, are made over your shoulder joint.
- An arthroscope, a slender tubular device fitted with a light and small video camera, is inserted through one of the incisions into your shoulder joint.
- The video camera transmits the image of the inside of your shoulder joint onto a monitor for your surgeon to determine the gravity of rotator cuff damage.
- Miniature surgical instruments are inserted through the other incisions to remove the damaged part of the rotator cuff tendon and injured surrounding tissue.
- A processed premeasured medium or large-sized acellular dermal allograft is obtained and secured to the ends of the trimmed rotator cuff tendon with stitches.
- The bones of the shoulder joint are then prepared for placement of the graft.
- Multiple types of suture anchors are used to reattach the torn rotator cuff tendon along with dermal allograft patch augmentation to the prepared shoulder bone.
- Patch augmentation can improve the mechanical strength of the repair, has the capacity to integrate into the tendon, and improve healing and functional outcomes of the shoulder.
- A final shoulder assessment is performed to confirm satisfactory repair and graft placement.
- Finally, the scope and the instruments are withdrawn, and the skin incisions are closed and bandaged.
Post-Operative Care and Recovery
In general, postoperative care and recovery after patch augmentation for rotator cuff repair will involve the following steps:
- You will be transferred to the recovery area where your nurse will closely observe you for any allergic/anesthetic reactions and monitor your vital signs.
- Following the surgery, your arm will be placed in a shoulder sling for 2 to 4 weeks to rest the shoulder and promote healing.
- You may experience pain, swelling, and discomfort in the shoulder area. Pain and anti-inflammatory medications are provided as needed to address these.
- Antibiotics are also prescribed to address the risk of surgery-related infection.
- You may also apply ice packs on the shoulder area to help reduce swelling and pain.
- You are encouraged to move around in bed and walk as frequently as possible to prevent the risk of blood clots.
- Instructions on incision site care and bathing will be provided to keep the wound clean and dry.
- Refrain from strenuous activities and lifting heavy weights for at least a couple of months. A gradual increase in activities is recommended.
- An individualized physical therapy protocol will be designed to help strengthen your shoulder muscles and optimize shoulder function once you are off the sling.
- You should be able to resume your normal daily activities in 3 to 4 weeks but with certain activity restrictions. Return to sports may take 6 months or longer.
- Refrain from driving until you are fully fit and receive your doctor’s consent.
- A periodic follow-up appointment will be scheduled to monitor your progress.
Risks and Complications
Patch augmentation for rotator cuff repair is a relatively safe procedure; however, as with any surgery, some risks and complications may occur, such as the following:
- Infection
- Re-tear
- Postoperative pain
- Bleeding or hematoma
- Damage to surrounding structures
- Shoulder stiffness or restricted motion
- Thromboembolism or blood clots
- Shoulder instability
- Adverse reactions to anesthesia/allergic reactions
