Bridging Allograft Reconstruction Is Superior to Maximal Repair for the Treatment of Chronic, Massive Rotator Cuff Tears: Results of a Prospective, Randomized Controlled Trial

Abstract

Background: Despite advances in surgical techniques, the use of maximal repair to treat large or massive rotator cuff tears results in a high retear rate postoperatively. Currently, no randomized controlled trials have compared the outcomes of maximal repair with interposition dermal allograft bridging reconstruction.

Hypothesis: We hypothesized that large or massive rotator cuff tendon tears reconstructed using bridging dermal allograft would have better clinical outcomes 2 years postoperatively, as measured using the Western Ontario Rotator Cuff (WORC) index, than would those receiving the current gold standard treatment of debridement and maximal repair alone. We also expected that patients treated via bridging reconstruction using dermal allograft would have fewer postoperative failures as assessed using postoperative magnetic resonance imaging scans.

Study design: Randomized controlled trial; Level of evidence 1.

Methods: A sample size of 30 patients (determined using a priori sample size calculation) with massive, retracted rotator cuff tears were randomly allocated to 1 of 2 groups: maximal repair or bridging reconstruction using dermal allograft. All patients completed questionnaires (WORC and Disabilities of the Arm, Shoulder and Hand [DASH]) preoperatively and postoperatively at 3 months, 6 months, 1 year, and 2 years. The primary outcome of this study was the WORC index at 2 years. Secondary outcomes included healing rate, progression of rotator cuff arthropathy, and postoperative acromiohumeral distance in both groups.

Results: Patients treated via bridging reconstruction using dermal allograft had better postoperative WORC and DASH scores (23.93 ± 24.55 and 15.77 ± 19.27, respectively) compared with patients who received maximal repair alone (53.36 ± 31.93 and 34.32 ± 23.31, respectively). We also noted increased progression to rotator cuff arthropathy in the maximal repair group with an increased retear rate when compared with the reconstruction group (87% and 21%, respectively; P < .001). The acromiohumeral distance was maintained in the reconstruction group but significantly decreased in the maximal repair group.

Conclusion: Rotator cuff bridging reconstruction using a dermal allograft demonstrated improved patient-reported outcomes as measured using the WORC index 2 years postoperatively. This technique also showed favorable structural healing rates and decreased progression to arthropathy compared with maximal repair.

Trial registration: ClinicalTrials.gov (NCT01987973).

Keywords: bridging reconstruction; dermal allograft; interposition graft; massive rotator cuff tear; maximal repair; patient-reported outcome.

Conflict of interest statement

The authors declared that they have no conflicts of interest in the authorship and publication of this contribution. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.

Figures

Figure 1.

Intraoperative images showing final construction after maximal repair of a left shoulder. (A) View from the lateral portal showing repair to the anterior anchor. The defect is shown between the anterior and posterior anchors, with margin convergence sutures in between. (B) View from the same portal; microfracture site of the greater tuberosity is visible and was used to create a crimson duvet. The defect is also visible from this view.

Figure 2.

Intraoperative images of final bridging reconstruction using dermal allograft. (A) View of lateral attachment of graft. (B) View of middle graft. (C) View of graft attachment to remaining cuff. All views are from the posterolateral portal.

Figure 3.

Preoperative computed tomography arthrogram demonstrating a 2-tendon tear of the supraspinatus and infraspinatus tendons with retraction to the level of the glenoid: (A) coronal view; (B) sagittal view; and (C) sagittal view, showing 50% atrophy of the supraspinatus tendon. Postoperative magnetic resonance imaging scan taken 2 years after maximal repair: (D) coronal view, (E) sagittal view, and (F) sagittal view. There is a complete retear of the supraspinatus and infraspinatus tendons from the anchor attachments on the greater tuberosity. Coronal view (D) shows increased arthritis in the glenohumeral joint. Sagittal Y view (F) shows increased atrophy with marked fatty infiltration of supraspinatus and infraspinatus muscles.

Figure 4.

Preoperative magnetic resonance imaging (MRI) scan demonstrating a tear of the supraspinatus and infraspinatus tendons with retraction to the level of the glenoid rim: (A) coronal view and (B) sagittal view. Postoperative MRI scan after bridging reconstruction using dermal allograft showing that the graft is intact, connecting the remnant cuff to the greater tuberosity: (C) coronal view and (D) sagittal view.

Figure 5.

Preoperative (A) anteroposterior, (B) axillary, and (C) lateral radiographs of the left shoulder, showing minimal glenohumeral arthritis and no bony pathologies. Postoperative (D) anteroposterior and (E) lateral radiographs of left shoulder 2 years after surgery, showing superior migration of the humeral head.

Figure 6.

Preoperative (A) anteroposterior, (B) axillary, (C) and lateral radiographs of the right shoulder, showing minimal glenohumeral arthritis and no bony pathologies. Postoperative (D) anteroposterior and (E) lateral radiographs of right shoulder 2 years after bridging reconstruction surgery, showing maintenance of acromiohumeral distance with no osteoarthritic changes.

Figure 7.

Postoperative (A) anteroposterior and (B) lateral radiographs of the left shoulder, showing extensive glenohumeral arthritis with obliteration of the glenohumeral space.