A presentation on different techniques for shoulder joint preservation in regards to the advances in technology for rotator cuff pathology, from tendonitis to cuff tear arthropathy.
1. My Techniques for Shoulder Joint
Preservation
Alan M. Hirahara, M.D., FRCS(C)
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine
Specializing in arthroscopic shoulder & knee surgery
7. Goals of Treatment
• Decrease pain & inflammation
• Create vascular channels
• Promote stem cell migration
• Achieve healing of tissue
B
A
B
1.5
1
0.5
0
CONTROL ACP HA
LOG HAS-2 FOLD
CHANGE OVER
CONTROL
HA IN SYNOVIOCYTES
20
10
MMP 13-IN
SYNOVIOCYTES
A
B
A
0
-1
-2
CONTROL ACP HA
LOG MMP-13 FOLD
CHANGE OVER
CONTROL
A
B B
0
CONTROL ACP HA
TNF-Α (PG/ML)
TNF- Α
Fortier et al, AJSM, 2014
8. Stem Cells
Proliferation & Migration Significantly Increased with PRP
– Kakudo et al, Plast Recontr Surg 2008
– Zaky et al, J Tissue Eng Regen Med 2008
– Drengk et al, Cells Tissues Organs 2009
– Mishra et al, Tissue Eng Part C Methods
2009
– Kruger et al, J Orthop Res 2012
– Moreira Teixeira et al, Biomaterials 2012
– Murphy et al, Biomaterials 2012
– Hildner et al, J Tissue Eng Regen Med 2013
9. Platelet-Rich Plasma vs. Cortisone Injections
for the Non-surgical Treatment of Shoulder Pain
PRP > Cortisone
• Inflammatory & calcific
processes
– Tendonopathy
• Partial tears & degenerative
processes
– Tendon, ligament, muscle
• Pain relief
PRP = Cortisone
• Full thickness tears
– Rotator cuff, SLAP, instability
• Adhesive capsulitis
• Advanced DJD of shoulder
• 740 patients with injection of cortisone or PRP (ACP) under ultrasound guidance
• 208 Study (PRP) patients / 532 Control (cortisone) patients
10. Type of Tendonopathy
Will Determine Mode of Treatment
• Inflammatory (Tendonitis)
• Degenerative
• Partial tear
– Acute traumatic
– Semi-acute non-traumatic
– Chronic
• Full tear
• Peri-tendon / One
• Intra-tendon / One+
– Intra-tendon / One
– Intra-tendon / One+
– Intra-tendon / 2 or 3
• Peri-tendon / One
11. Other Considerations
• h/o Cortisone
• In season
• Out of season
• Multiple injections
• Peri-tendon / Pain control
• Attempt to heal
12. Injecting to Heal
• Degenerative tendons
– Lat / Med epicondylitis
– Patellar / Quad tendonitis
– Achilles tendonitis
• Partial tears of ligaments
– UCL
– MCL
– NOT Intra-articular ligaments
or tendons
• Calcific tendons
– Rotator cuff
– Patellar
– Achilles
20. FlexiGraft DBM Sponge
• DBM produced significantly
more fibrocartilage &
mineralized fibrocartilage at 12-
week post-op, showing a more
mature, organized tendon-bone
interface
Sundar et al., J Biomed Mater Res. 2009; 88B: 115-
122
Sundar et al., J Bone Joint Surg Br. 2009;91;(9)1257-
62
21. FlexiGRAFT with RC Repair
James Cook, DVM, PhD
• Chronic infraspinatus model
– n = 10 dogs
– Bilateral shoulders, release tendon
– Repair after 4 wks
• FlexiGRAFT / PRP vs. Direct Repair
– Modified SpeedFix configuration
• SutureTak medially
• 12 week sacrifice, outcome
measures
– MRI, Histo, and Biomechanical testing
22. FlexiGRAFT Strip with RC Repair
Standard FlexiGRAFT
T = Tendon; I = Interface; A = Anchor
Standard has more fibrous tissue at interface and is more edematous
34. ECM Patches
• Justification
– Failure rates: 20 57% reported for RC repairs
– In vivo animal studies: Support use of acellular dermal grafts for
augmentation
– Biomechanical studies: Dermal grafts superior suture retention over SIS or
BM patches
• But
– acellular significant DNA
• GraftJacket, Restore, TissueMend
Adams et al, Arthroscopy 2006.
Aurura et al, J Shoulder Elbow Surg 2007.
Coons et al, Sports Med Arthrosc Rev 2006.
35. RC Repair Augmentation
• Peer reviewed clinical studies do not support SIS grafts
• Iannotti et al, (JBJS 2006) - Randomized prospective controlled trial using (Restore) augmentation for
massive tears showing no benefit using SIS. Discontinued study early!
• Walton et al. (JBJS 2007) - 19 pts. 4 of which had severe early inflammatory rxn. 2 yr. MRI shows no
difference in failure rate vs non-augmented, abandoned study early! Porcine graft (Level 3)
• Schlamberg et al. (J Shoulder Elbow Surg 2004) All patients re-tore
• Zheng et al. (J Biomed Mater Res B Appl Biomater 2005) Adverse outcomes related to retained
cellular elements
• Dermis grafts show potential
• Burkhead et al. (Semin Arthroplasty 2007) 17 pts, GJA augmentation, 1.2 yrs F/U, improved UCLA
scores but 3 retears per MRI & no reversal of atrophy or fatty infiltration. No Control group
Iannotti et al, JBJS 2006
Walton et al, JBJS 2007
Schlamberg et al, JSES 2004
Zheng et al, J Biomed Mater Res B Appl Biomater 2005
Burkhead et al, Semin Arthroplasty 2007
36. ArthroFlex
• Ready to use
• Hydrated
• Room temperature storage
• Sterile (10-6 SAL)
• 3 year shelf life
• Biocompatible
– > 97% DNA removal
• Excellent suture retention
strength
• Intact framework
38. DNA Residuals
273
135
16
300
250
200
150
100
50
0
Alloderm GraftJacket ArthroFlex
The DNA content for the three materials averaged: Alloderm1 272.8±168.8 ng/mg; GraftJacket2 134.6 ±
44.0 ng/mg dry weight; ArthroFlex 15.97±4.8 ng/mg dry weight.3
Choe et al. J Urol. 2001.
Derwin et al. JBJS-A. 2006.
Data on file, LifeNet Health.
39. In vivo Study
Devitalized Human Dermis
• Preserved with 15% glycerol and
gamma irradiated at delivered
dose 12.8 - 17.8 kGy
• Implanted subcutaneously in
athymic mice
– In-life period was 4 weeks
• H&E Staining
Post Implantation
Arrows pointing to new blood vessels with
red blood cells in them
Lifenet. Data on file.
Capito et al, Ann Plast Surg. 2012.
40. Placement
• Dermal side
– Shiny, smooth, absorbs blood
– Applied in the down position
against the wound or most
vascularized tissue
• Basement membrane
– Dull and rough in appearance
– Repels blood
– Place in up position
– Packaged in view
45. Options for Irreparable RC Tears
Traditional
• Debridement
• Partial repair
• Biceps tenotomy
• Latissimus dorsi transfer
•
• Reverse arthroplasty
Advanced Technology
• Superior Capsular Reconstruction
46. Disadvantages to Reverse Total Shoulder
• Subject to overuse
• Too easily seen as a solution for all previously untreatable shoulder
pathologies
• Challenging surgical technique
• Requires extensive training and experience limits availability
• Arthroplasty
• Limited life span
• Wide range of complication rates
47. Intercalary Placement
• Biomechanical studies
showing equivalent load-to-failure
and mechanical
properties, but few articles
show success clinically
Snyder et al, IJSS 2007
Schlamberg et al, JSES 2004
48. Bridging vs. SCR
Conventional Patch Graft Superior Capsular Reconstruction
Courtesy of Dr. Teruhisa Mihata
50. Arthroscopic Superior Capsule Reconstruction
Teruhisa Mihata, MD
• Methods:
• 24 shoulders over 2 years
• Autograft fascia lata used to reconstruct superior capsule
• Results:
• A-H distance: 4.6 2.2 mm to 8.7 2.6 mm (p < 0.0001)
• ASES Score: 23.5 to 92.9 points (p < 0.0001)
• Twenty patients (83.3%) had no graft tear or tendon re-tear
Mihata et al, Arthroscopy 2013
53. ArthroFlex Sizes Available
• AFLEX100 3.5 cm x 3.5 cm x 1.5 mm $2,225
• AFLEX101 4.0 cm x 7.0 cm x 1.5 mm $2,650
• AFLEX103 5.0 cm x 9.0 cm x 1.5 mm $3,600
• AFLEX150 1.5 cm x 14.0 cm x 1.5 mm $2,000
• AFLEX200 3.5 cm x 3.5 cm x 2.0 mm $2,975
• AFLEX201 4.0 cm x 7.0 cm x 2.0 mm $3,600
• AFLEX301 4.0 cm x 7.0 cm x 3.5 mm $3,850
• AFLEX400 4.0 cm x 4.0 cm x 1.0 mm $2,050
• AFLEX401 4.0 cm x 7.0 cm x 1.0 mm $2,500
• AFLEX500 3.0 cm x 4.0 cm x .5 mm $1,150
73. Summary
Mihata
• Fascia lata autograft
– 180 N
• A-H distance
– 4.6 mm to 8.7 mm
• ASES Scores
– 23.5 to 92.9
• 83.3% - No graft or re-tear
Hirahara
• ArthroFlex allograft
– 550 N
• A-H distance
– 4.5 mm to 8.8 mm
• ASES Scores
– 45.3 to 82.0
• No complications yet
n = 24 patients / Follow up 24-51 mos n = 3 patients / Follow up 2-4 mos
74. for my patients?
• NO Bone Loss!
• NO Large Incisions!
• NO Prolonged
Rehabiliation
• NO Burned Bridges!
• NO Reverse Prosthesis!
• Less pain!
• Better Function!!