1 Arthroscopy Dec 2015 Included all Meta-analyses before 2015 7 - - PDF document

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Use of Biologics in Rotator Cuff Repair

Jason L. Dragoo, MD Associate Professor Department of Orthopaedic S urgery

Biologics in RTC Repair

• Much attention has been given to optimizing:

 Implant design  S uture configuration  S uture material

• Biological augmentation may enhance local healing
• Biologics can be divided into the following groups:
• Autologous Growth factors (PRP)
• Cellular agents (S

tem cell therapy)

• Tissue therapy (S

caffolds)

PRP: Rotator Cuff Repairs

32 Studie s

PRP did not: Improve clinical outcome lower re-tear rate

✗ ✗

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• Included all Meta-analyses before 2015
• 7 meta-analyses with 3,193 patients
• S

ubgroup analysis: some evidence of outcomes:

• S

maller and medium-sized tears

• Double-row fixation techniques
• PRP clot inj ected at bone-tendon interface

Arthroscopy Dec 2015

Fundamental Question?

• Are cells necessary to

improve RTC healing?

• Why?
• Atrophic cuff tendon
• Displaced local MS

Cs

• Direct repair process

Insertion Site Preparation

• Methods to improve

local environment

 Bed abrasion  Crimson Vail  Microfracture

• Think Biology!

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• Patients with tear had

lower levels of MS Cs

• Patients with local bone

marrow edema

Tear= 214 ±128 No tear= 564 ±216 MS Cs

Marrow Stimulation

MS 78% Control 55%

Taniguchi et al, JSES 2 0 1 3

MS > Control MS > Control

S lide Courtesy of Brian Cole

Stem Cell Therapy

• Only 3 clinical studies have been published
• Mesenchymal stem cell (MS

Cs) therapy may improve healing by:

• S

ecreting growth factors

• Providing cellularity
• Local paracrine activity

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RTC Repair: S tem Cells

• 45 patients BMAC + RCR
• 45 matched control RCR
• 10 year follow-up
• MS

Cs drawn from AS IS and placed at tendon interface

• 87%

healing (BM-MS C) vs. 44 % (Non BM-MS C)

• Control group 4x as likely to have “ poor outcome”

Where should stem cells be harvested?

Proximal Humerus Iliac Crest

• 125 patients with tear

75 w/ o cuff tear

• Marrow aspirated from

greater tuberosity

• Patients with tear had

significantly lower levels

• f MS

Cs

Tear= 214 ±128 No tear= 564 ±216 MS Cs

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Stem Cell Summary

• Clinical evidence to support the use of cells to

augment RTC repair is promising

• More RCTs will be necessary to verify

Hernigou’ s findings

RTC Scaffolds RTC Scaffolds

• Difficult to evaluate
• Many types

 Allograft  Xenograft (Bovine)  S ynthetic

 Many uses…

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RTC Scaffold Uses

Augment repair

• Improve mechanics
• Improve biology

Interposition

• Lengthen tendon
• S

uperior capsular reconstruction

Scaffold Augmentation

N=42, Human Allograft 85% * (augmentation) vs 40% repair N=30, Xenograft 27% (augmentation) vs 60% repair Erythema and/ or drainage seen in 3 of 15 cases of augmentation *statistically significant Level of Evidence II

Scaffold Interposition

N=68 58% * Interposition vs 26% tensioned repair N=48 Re-tear rate: 8% * Interposition vs 42% tensioned repair

*statistically significant Level of Evidence III

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Scaffolds Summary

• May be useful in clinically tough scenarios
• Routine use may be questioned due to

 Cost  Lack of consistent literature  Unclear biologic benefit

Summary

• Give biology the same attention as you give

implant and repair techniques

• Think about the local biological environment

and optimize it when possible

• This may lead to improved healing rates and

clinical outcomes