Friday, May 4, 2018

Revision cuff surgery - is dermal matrix allograft of greater value than a smooth and move?

Outcomes of arthroscopic revision rotator cuff repair with acellular human dermal matrix allograft augmentation

These authors studied patient-reported outcomes and failure rate of patients who underwent revision arthroscopic rotator cuff repair augmented with acellular human dermal matrix (AHDM) allograft for repairable retears. 28 patients had minimum 2 year clinical followup but only 13 had postoperative imaging by MRI or ultrasound - four of these had retears. Three patients had another revision surgery.  Only 6 patients had both preoperative and postoperative outcome scores. In these the ASES score improved from 56 to 85 (P = .03) and the SANE score improved from 42 to 76 (P = .03).

The cost of the dermal matrix allograft is not mentioned in this paper.

Comment: The data presented in this paper do not enable the reader to see the value of dermal matrix allograft - the change in scores is available for less that 25% of the cases and less than 50% had post operative imaging of the cuff. 

This paper needs to be viewed in light of the results of a much larger series of patients having irreparable cuff tears treated without attempting to re-establish tendon continuity:

Treatment of irreparable cuff tears with smoothing of the humeroscapular motion interface without acromioplasty

These authors sought to determine whether shoulders with irreparable rotator cuff tears and retained active elevation can be durably improved using a conservative surgical procedure that smoothes the interface between the proximal humeral convexity and the concave undersurface of the coracoacromial arch followed by immediate range of motion exercises.

They reviewed 151 patients with a mean age of 63.4 (range 40–90) years at a mean of 7.3 (range 2–19) years after this surgery.

In 77 shoulders with previously unrepaired irreparable tears, simple shoulder test (SST) scores improved from an average of 4.6 (range 0–12) to 8.5 (range 1–12) (p < 0.001). Fifty-four patients (70%) improved by at least the minimally clinically important difference (MCID) of 2 SST points. For 74 shoulders with irreparable failed prior repairs, SST scores improved from 4.0 (range 0–11) to 7.5 (range 0–12) (p < 0.001). Fifty-four patients (73%) improved by the MCID of 2 SST points.

These authors concluded that smoothing of the humeroscapular interface can improve symptomatic shoulders with irreparable cuff tears and retained active elevation. This conservative procedure offers an alternative to more complex procedures in the management of irreparable rotator cuff tears.
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