Technical Note: Arthroscopic Rotator Cuff Repair with Patch Augmentation with Acellular Dermal Allograft

Abstract

Rotator cuff tears are one of the most common causes of shoulder pain and dysfunction seen by orthopaedic surgeons. Although rotator cuff repair (RCR) has been shown to provide optimal outcomes, retear rates average roughly 60% and have been reported to exceed 90%. Retear after RCR is especially prevalent in patients with large, multitendon tears with poor tissue quality. Allograft augmentation of RCR may reinforce anatomically reparable tears, particularly in patients with poor tissue quality. Although various techniques of patch augmented RCR have been described, the procedure remains challenging. This Technical Note describes RCR augmented with acellular dermal allograft using the CuffMend system (Arthrex Inc, Naples, FL), which significantly decreases surgeon demand and helps avoid the pitfalls common with this procedure.

Fig 1

Outside posterior photo of the right shoulder prepped and draped in the beach chair position with diagnostic arthroscopy portals established. We use 3 portals for access to the subacromial space: lateral viewing portal in line with the back of the clavicle and roughly 3 to 4 cm off the edge of the lateral acromion, posterior working portal, and anterolateral utility portal with screw-in 8.25 mm cannula.

Fig 2

Arthroscopic photo of the right shoulder in the beach chair position viewing posteriorly. Full thickness tears of the supraspinatus and infraspinatus are seen that will be repaired before allograft placement.

Fig 3

Arthroscopic photo of the right shoulder in the beach chair position displaying the final single row rotator cuff repair construct while viewing posteriorly. The anterolateral portal serves as a utility portal with screw-in 8.25 mm cannula. Anterior and lateral anchors are placed to repair the tendon to the footprint.

Fig 4

Intraoperative photo of the premeasured medium (20 mm × 25 mm × 1 mm) or large (25 mm × 30 mm × 1 mm) AFLEX acellular dermal allograft being prepared on the back table. The articular side of the graft is marked, and the graft is loaded articular side up. Two simple stitches are placed on the medial side of the graft using 0 FiberWire sutures or 0 PDS sutures in a simple stick fashion, and two luggage tag stiches are placed on the lateral side of the graft using 0.9 mm SutureTape TigerLink sutures. The medial PDS stiches are loaded onto the Graft Spreader in crisscross fashion, toggled to provide appropriate tension on the AFLEX graft, and secured to the Graft Spreader handle.

Fig 5

Arthroscopic photo of the right shoulder in beach chair position viewing posteriorly of the Graft Spreader device being deployed through a 10 mm × 4 cm PassPort cannula to be placed overlying the rotator cuff repair construct.

Fig 6

Arthroscopic photo of the right shoulder in beach chair position viewing laterally of the medial fixation of the AFLEX graft, including percutaneous poly(lactic-co-glycolic acid) TissueTak soft tissue staples along the medial edge and periphery.

Fig 7

Arthroscopic photograph of the right shoulder in the beach chair position of the lateral fixation of the AFLEX graft, including anterolateral and posterolateral 3.5 mm BioComposite Pushlock Anchors tied with SutureTape.