By Corey G. Solman, Jr., M.D.
Rotator cuff abnormalities are one of the most common disorders encountered by an orthopedic surgeon, especially those who specialize in sports medicine and shoulder surgery. Millions of people suffer from this problem, and unfortunately many require surgery to correct the problem. Over the last few decades, the surgical procedure to repair the rotator cuff has evolved from a large, painful, muscle-splitting incision with a difficult recovery, to, in most cases, an arthroscopic procedure that requires only small incisions through which surgeons use a small camera and work through small plastic tubes. The procedure is essentially identical, with the tendon being sewn back to the bone using combinations of stitches and anchors (small metal or plastic screws that are placed in the bone and have the stitches attached to them). However, with the more minimally invasive arthroscopic procedure, there are no muscle splits, so the patient has less pain, less bleeding, less swelling, less chance of scarring and stiffness, thus potentially making the recovery a bit more “tolerable.”
Rotator cuff repairs performed on healthy individuals with healthy tissue generally yield excellent results, which allows the patient to return to most activities they enjoyed prior to having the shoulder problem. However, inferior results are often the case in patients with advancing age, smoking history, diabetes, and chronic, long-standing tears. These patients generally having poor healing potential, poor tissue quality, and often scarring that can make repairing the tendon very difficult if not impossible. Furthermore, if the tendon can be repaired, the quality of the repair is often sub-optimal, and rates of recurrent tears are much higher, leading to less than favorable results.
More than a decade ago, orthopedic surgeons with expertise in shoulder surgery began devising techniques in an attempt to improve rotator cuff healing and functional outcomes after repairs in patients with less-than-favorable healing potential. These techniques involved “augmenting”, or reinforcing, repairs with tissue “patches” made from either human or porcine (pig) skin. The purpose of this “patch,” is to decrease stress, or “off-load,” the repair of the torn rotator cuff. All rotator cuff repairs are under some tension (or load), and these patches lessen the tension on the repair, which can lead to improvement in healing rates. Of course, repaired tissue is not usually as strong as it was before it tore, and it can certainly tear again with sufficient force. However, the patch incorporates into the normal tissue, making it thicker and stronger, and potentially less susceptible to future tearing.
I was very fortunate in my young career to be involved in the development and use of techniques to reinforce rotator cuff repairs and have been utilizing these patches for almost 10 years. In my practice, I find that the most appropriate patients to use patches on are those with a history of smoking, diabetes, rheumatoid arthritis, and a failure of a previous rotator cuff repair. Also, in younger patients who may have a large rotator cuff tear, I find this technique especially useful to ensure the most optimal result and return these patients to their normal active lifestyle and occupations whenever possible, while lessening the recurrence of their tears.
More recently, a NEW patch has hit the market. It is made of purified bovine (cow) Achilles tendon collagen. Its purpose is to augment the rotator cuff repair, but more excitingly, it is the first patch of its kind to actually “induce” the formation of new collagen fibers within the rotator cuff, which obviously has the benefit of improving healing rates. Recovery times following this surgery, which is also done arthroscopically, are similar to standard rotator cuff repairs.
In addition, this patch can also be used in patients who have been diagnosed with severe tendinitis and partial thickness rotator cuff tears. These are two diagnoses that would normally not be treated with surgery, however, many of these patients do not get better with conservative management, including physical therapy and injections of cortisone, leaving the surgeon puzzled as to what to offer these patients. Now there is a viable option for surgery for these particular diagnoses, and patients can actually enjoy a shorter recovery time as opposed to formal rotator cuff repairs. I have performed several surgeries utilizing this new patch, with excellent early success. I find it very exciting that surgeons can now add a “biologic” augment to rotator cuff repairs, and conditions that were thought previously as “non-operative” conditions that actually improves healing and overall results.
Please do not live with debilitating shoulder pain too long. The results of surgical management are improving dramatically, and rest assured, conservative management is always an option until it no longer provides you with pain relief.
Orthopedic Sports Medicine & Spine Care Institute
Corey G. Solman, Jr., M.D.
1001 S. Kirkwood Road, Ste. 120
St. Louis MO 63122