Welcome to Orthosports Question for Physiotherapists, May 2023. This month Dr Doron Sher discusses the use of a patch in Rotator Cuff Repairs.
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QUESTION | HOW DO YOU DECIDE WHEN TO ADD A PATCH WHEN PERFORMING A ROTATOR CUFF REPAIR?
ANSWER | This is a very good question because despite major advances in technology the retear rate of the rotator cuff following repair is higher than we would like it to be. Interestingly the clinical outcome in these cases remains very good.
As patients age the quality of their rotator cuff declines. These days people are staying active to an older age and many patients remain dissatisfied with their shoulder function despite having had an excellent physiotherapy programme and perhaps several subacromial corticosteroid injections for the treatment of their rotator cuff tear.
As a surgeon, repairing older, poorer quality tissue is challenging and so we have been searching for solutions to make the healing of the repair more reliable. There have been many patches tried over the years with conflicting results as to retear rate and pain scores. The materials that the patches were made of have varied widely with some designed to be structural and others just to increase blood flow and healing with no structural support at all.
A recent metanalysis (Orthop J Sports Med. 2022 Mar; 10(3): 23259671211071146.
Published online 2022 Mar 24. doi: 10.1177/23259671211071146) concluded that adding a patch to a repair led to a significantly reduced retear rate and pain score and an improved UCLA shoulder functional score. There was no improvement in range of motion, strength, Constant score or SST score which shows you that shoulder scores are not as useful as we would like them to be. There were trends which were not significant such as the range of motion being worse in the patch group (perhaps it fills the subacromial space too much?) These studies varied widely in the type of tear repaired and the materials used so we need to be careful not to read too much into the results.
Just to mention a few of the available patches: porcine small intestine submucosa; acellular porcine dermis patch; fascia lata autograft patch; 3-dimensional type 1 collagen matrix; scaffold derived from submucosal and basilar mucosal layers of small intestine submucosa; acellular human dermal matrix; porcine dermal patch etc……….
The operative time is certainly longer adding the patch but in situations where the rotator cuff quality is already poor this seems like a very reasonable trade off if the retear rate will be lower.
Of course, the best outcome is still a robust repair of the patient’s own tendon where that is possible and the patch is just one of the many techniques used to try to improve outcomes for the patient.