Abstract
Rotator cuff tendinopathy is a common and important source of shoulder pain. Symptoms tend to worsen over time and can progress to partial- or full-thickness rotator cuff tears. This can lead to increased pain and a further decrease in function. The use of orthobiologics for surgical augmentation has been a subject of much interest and discussion regarding its potential adjuvant assistance in rotator cuff reconstruction. We describe a transtendinous repair of large interstitial rotator cuff tears augmented by injecting platelet-rich plasma and autologous bursal tissue into the interstitial defect prior to reconstruction.
Technique Video
Understanding the rotator cuff anatomy is important in determining the process of an anatomic rotator cuff repair (RCR). Each of the 4 rotator cuff tendons has a distinct footprint, and understanding this allows for its restoration with a transtendinous reconstruction.1,2 The rotator cuff inserts on the greater tuberosity and extends anterior to posterior for about 2.1 cm, approximately 1 mm from the articular margin and with a transverse dimension of 14.7 mm. The average area of insertion is 1.55 cm2 for the supraspinatus and 1.76 cm2 for the infraspinatus, but the footprint shape has individual variations.3,4
An increased prevalence of asymptomatic rotator cuff tears occurs with age and also has been seen in athletes.5,6 Magnetic resonance imaging (MRI) and ultrasound are integral in determining rotator cuff tear pathology and helping determine repairability.7,8 Although interstitial tears are readily identifiable on imaging, arthroscopic visualization is a much better predictor of interstitial partial-thickness rotator cuff tears (PTRCTs) than MRI alone.9 Although many PTRCTs can improve with arthroscopic subacromial decompression, some will progress to full-thickness tears over time.10
The literature has suggested that PTRCTs should be treated if the tear is greater than 50% of the thickness of the tendon.11 Acromioplasty has been shown to be less effective in the treatment of PTRCTs.12,13 Bollier and Shea14 found that no single treatment for PTRCTs showed definitively better outcomes than other common surgical treatments, whereas Shin15 found that a transtendinous repair of articular-sided PTRCTs helped reduce over-tensioning of the reconstruction. Cadaveric models have suggested the biomechanical superiority of in situ transtendon repair as opposed to tear completion and double-row repair.16 Increasing age is associated with the risk of retear in repairs that were completed prior to reconstruction.17 Shin argued that tendon integrity may be higher with a transtendinous repair. Wang et al.18 did not find any significant difference in pain or function when comparing arthroscopic debridement with tear completion and subsequent repair. Double-row and single-row transtendinous repairs showed similar pain and clinical outcomes, although retear rates were higher in the single-row group.19 Numerous arthroscopic strategies have been suggested for PTRCTs.20 Arthroscopic repair of interstitial tears by first completing the tear yielded improved clinical outcomes including pain and function but showed a retear rate of 10.7% at 2 years.21 Patients with interstitial cuff tears have also shown improvement in pain and function with a double- or single-row transtendinous repair.22,23 Owing to varying results, it is difficult to advocate one type of surgical repair over another when treating PTRCTs.20
There have been a number of studies in recent years evaluating the efficacy of platelet-rich plasma (PRP) and other orthobiologics for PTRCTs. The mechanism of action of PRP is complex but appears to be partially due to a large inflammatory reaction that triggers a subsequent regenerative response.24 The literature has described various orthobiologic treatment protocols including PRP alone, PRP with bone marrow aspirate concentrate, hyaluronic acid plus PRP, and uncultured, autologous, fresh, unmodified, adipose-derived regenerative cells (UA-ADRCs), which have all shown potential for the treatment of PTRCTs.25, 26, 27, 28 Poff et al.29 stated that PRP injection into the tear site and surgical reconstruction were both effective in the treatment of high-grade interstitial PTRCTs. A systematic review showed that PRP was beneficial in decreasing pain in patients with PTRCTs.30 Li et al.,31 in a meta-analysis, found that the use of PRP in conjunction with an arthroscopic reconstruction improved functional outcome scores and reduced retear rates. This improvement in retear rates using PRP was also reported by Ryan et al.32 Mesenchymal stem cells from autologous subacromial bursal tissue have been shown to differentiate into bone, tendon-like tissue, chondrocytes, and adipocytes, making it a potential source for orthobiologic augmentation in repairs.33, 34, 35 Bursal tissue has been used to augment repairs alone, as well as in combination with PRP.36,37 Bursal tissue harvested at the time of RCR has the potential to be used in conjunction with other biological therapies and assist in regeneration and healing after RCR surgery.38
The purpose of this article is to describe our technique for a biologically enhanced repair of an interstitial rotator cuff tear with an intralesional PRP and bursal tissue injection. Institutional review board approval was obtained.
Surgical Technique
Preoperative Evaluation
A thorough evaluation, including clinical findings and imaging, is necessary in determining the necessity of the intralesional injection. Radiographs (anteroposterior, Grashey, supraspinatus outlet, and axillary views) are obtained routinely. The MRI findings should show a large interstitial rotator cuff tear (Fig 1). The size of the interstitial defect is important in determining the utility of our technique. Small interstitial defects are likely not amenable to this procedure. The larger the interstitial defect, the greater need and the greater the ease of using this technique of injecting PRP and collected autologous bursal tissue into the intratendinous defect.
Fig 1.
Magnetic resonance imaging (MRI) scans of left shoulder: T2_blade_coronal_fs (A) and T2_blade_sagital_fs (B) T2-weighted scans using BLADE sequence with fat saturation. The MRI scans show a significant interstitial rotator cuff tear (arrow) involving the supraspinatus.
Transtendinous Repair
We describe a transtendinous repair of interstitial rotator cuff tears augmented by injecting PRP and autologous bursal tissue into the interstitial defect prior to reconstruction (Video 1). The patient is given a general anesthetic with endotracheal intubation and positioned in the lateral decubitus position on the operating room table. The patient’s operative upper extremity is then prepared and draped in the usual sterile fashion. The patient’s shoulder is suspended with the Arthrex Shoulder Distraction System (AR-1600M 9; Naples, FL). A 30° arthroscope (Arthrex Synergy Video System) is inserted into the patient’s glenohumeral joint, and a diagnostic arthroscopy is performed.
A complete and thorough evaluation of the glenohumeral joint is performed to ensure that there is no significant intra-articular pathology that would preclude this procedure. It is during this time that the patient’s blood is drawn and the PRP (Arthrex ACP [Autologous Conditioned Plasma] Double-Syringe System) is prepared.
The arthroscope is then repositioned in the subacromial space. A lateral portal is created, and a thorough bursectomy is performed with a full-radius shaver (Arthrex Synergy Resection, 4.0-mm Double Cut). The bursal tissue is collected with a GraftNet (Arthrex) and will be used later with the PRP (Fig 2). An acromioplasty with a gentle lateral bevel is performed with a burr (5.0-mm ClearCut Burr, 12 flute; Arthrex). The rotator cuff is palpated with a probe to assess normal tendinous integrity. The surgeon should ensure that the lack of normal tendinous quality corresponds with the interstitial tear that is seen on the preoperative MRI scan. Testing for the “bubble sign” is performed to confirm that there is a significant interstitial defect.39 The location of anchor insertion is determined preoperatively using the MRI scans (Fig 3). It is important to know the exact insertion site of the anchors. The coronal MRI scan provides the surgeon with an understanding of the volume and length of the tear. The sagittal MRI scan shows the width of the tear. Knowing the width is key and provides the surgeon with the knowledge of where to insert the anchors to ensure that the reconstruction spans the defect. Two 2.6-mm knotless FiberTak anchors (Arthrex) are inserted into the greater tuberosity in a transtendinous fashion. These anchors span the interstitial defect (Fig 4). A small puncture hole is created with a Penetrator device (Arthrex) through the bursal side of the rotator cuff, into which a Touhy needle (Arthrex) can be inserted. The Penetrator should be “painted” with a skin marker to ensure the entry hole remains visible throughout the reconstruction. A knotless interlocking double-pulley repair technique is initiated. This reconstruction technique is performed when the repair suture of the anterior anchor is passed through the passing suture of the posterior anchor. This is repeated by passing the repair suture of the posterior anchor through the passing suture of the anterior anchor. When this is completed, it results in a spanning reconstruction that firmly compresses the tendon back to its footprint.
Fig 2.
(A) Bursal tissue collected with GraftNet. (B) Platelet-rich plasma collected with ACP (Autologous Conditioned Plasma) Double-Syringe System. (C) Completed mixture of platelet-rich plasma and autologous bursal tissue that will be injected into interstitial defect.
Fig 3.
Preoperative planning with sagittal magnetic resonance imaging scan of left shoulder to determine placement of suture anchors (arrows) that will span defect from anterior to posterior.
Fig 4.
Transtendinous suture anchor placement anterior and posterior to defect, spanning interstitial tear (posterior viewing portal).
Prior to completing the reconstruction, the Touhy needle is inserted into the hole in the cuff and the interstitial defect is filled with a combination of PRP (ACP [Autologous Conditioned Plasma] Double-Syringe System) and bursal tissue. After the injection is completed, the knotless interlocking double-pulley repair is completed (Fig 5). As the reconstruction is completed, the surgeon should make sure to keep the puncture hole lateral to the reconstruction. This may require some traction with a grasper as the repair is finalized. The rotator cuff is reconstructed firmly to the greater tuberosity. The PRP and collected bursal tissue are trapped within the interstitial defect, leaving a residual bubble sign (Fig 6) within the tendon. A second syringe of PRP is injected into the subacromial space. The arthroscopic equipment is then removed from the patient’s shoulder (Table 1).
Fig 5.
The interlocking double-pulley reconstruction is completed after injecting and filling the interstitial defect with platelet-rich plasma and autologous bursal tissue (posterior viewing portal).
Fig 6.
The reconstruction is palpated to ensure the integrity of the repair and to confirm the biological “bubble” (posterior viewing portal).
Table 1.
Pearls and Pitfalls of Biologically Enhanced Repair of Interstitial Rotator Cuff Tears With Intralesional Platelet-Rich Plasma and Bursal Tissue Injection
| Pearls |
| Evaluate the interstitial tear thoroughly on MRI. |
| Determine the anchor location using sagittal MRI. |
| Perform testing for the bubble sign to confirm the interstitial tear. |
| Make a small puncture hole with a “painted” penetrator. |
| Insert the 2.6-mm Knotless FiberTak anchors in a transtendinous fashion. |
| Perform an interlocking double-pulley reconstruction. |
| Prior to completing the repair, inject the PRP and autologous bursal tissue into the interstitial defect. |
| Make sure to keep the puncture hole positioned lateral to the reconstruction. |
| Pitfalls |
| Inadequate preoperative evaluation of MRI scans |
| Anchor placement too lateral in greater tuberosity |
| Failing to paint penetrator prior to creating puncture hole |
| Failing to keep puncture hole lateral to reconstruction as it is secured |
MRI, magnetic resonance imaging; PRP, platelet-rich plasma.
Postoperative Rehabilitation
The patient is placed in a sling (SlingShot 2; Breg, Carlsbad, CA) for 6 weeks. Our standard postoperative protocol is as follows: 6 weeks in a sling; 6 weeks of home stretching exercises (table-top slide, wall walking, pulley, and passive external rotation to the side); and 6 weeks of strengthening exercises with a red TheraBand (TheraBand, Akron, OH), comprising internal rotation, external rotation, rowing, and biceps curl. At 18 weeks postoperatively, the patient initiates formal physical therapy.
Discussion
The key for all surgical procedures is to ensure healing that results in an excellent outcome. The advantage of augmenting a biological interface within a large interstitial tear is to stimulate healing by providing a robust environment in which this can occur. Ensuring that the healing variables are accounted for should improve the outcome of the procedure. In cases of extensive interstitial rotator cuff tears, completion and reconstruction do not seem reasonable given the significant chance of retear.21 Given that interstitial rotator cuff repairs have shown improved outcomes with a double- or single-row transtendinous repair, a less invasive reconstruction should be advantageous in this situation.22,23 Along with a less invasive approach, the addition of autologous bursal tissue in combination with PRP seems to be a wise and reasonable addition to the repair.29, 30, 31, 32, 33,36,37 By introducing both PRP and collected bursal tissue into the defect before completing the reconstruction, a more profound healing response should occur. An enhanced repair, that is, biological intralesional tendon repair, provides a safe and biological technique to address large interstitial PTRCTs. The main advantage of approaching this type of tear with orthobiolobics is that this technique is minimally invasive with great healing potential (Table 2). This particular technique has the advantage of using all-suture anchors, in addition to being a knotless repair. Another advantage of this technique is that it uses an interlocking double-pulley reconstruction. This specific construct connects the anterior and posterior anchors in a manner that anatomically and firmly repairs the tendon to the greater tuberosity with excellent tissue indentation and compression.
Table 2.
Advantages and Disadvantages
| Advantages |
| Biological interface within large interstitial tear to stimulate healing |
| Minimally invasive technique |
| All-suture anchors |
| Knotless technique |
| Interlocking double pulley for increased fixation strength |
| Disadvantages |
| Failure of delaminated layers to heal |
| Failure of reconstruction due to decreased healing |
| More extensive revision rotator cuff repair |
A disadvantage of augmenting such large interstitial tears in this manner is the chance that the expected healing of the delaminated layers does not occur. This risk may lead to failure of the reconstruction and, ultimately, revision rotator cuff repair. Given the minimally invasive nature of this technique, the risks are minimal if performed correctly. The greatest error or pitfall comes with anchor insertion. The surgeon needs to accurately insert the anchors in a transtendinous position. This allows the reconstruction to span the interstitial defect from anterior to posterior. As the autologous fluid mixture is introduced into the tear, the puncture hole must be held lateral to the reconstruction. If this is not achieved, the injected PRP and collected bursal tissue will not be retained in the defect as a biological bubble. This will result in failure to capture the biological healing properties of the injection within the tear, which could ultimately lead to its failure.25, 26, 27, 28, 29, 30, 31, 32
Disclosures
The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: D.P.R. reports that administrative support and article publishing charges were provided by West Virginia University; reports a consulting or advisory relationship with Arthrex; receives speaking and lecture fees from Arthrex; and receives travel reimbursement from Arthrex. The other author (T.M.G.) declares that he has no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Supplementary Data
Enhanced repair of partial-thickness rotator cuff tear (biological intralesional tendon repair) using platelet-rich plasma and collected bursal tissue (posterior viewing portal).
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Associated Data
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Supplementary Materials
Enhanced repair of partial-thickness rotator cuff tear (biological intralesional tendon repair) using platelet-rich plasma and collected bursal tissue (posterior viewing portal).