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Soft tissue interposition arthroplasty of the shoulder
Soft tissue interposition arthroplasty of the shoulder Julie E. Adams, MD, and Scott P. Steinmann, MD, Rochester, MN
Soft tissue interposition arthroplasty for treatment of shoulder arthritis is an emerging technique that has received increasing attention recently. Although currently available data are insufficient to advocate routine use of this procedure, the technique is presented as a possible option to treat shoulder arthritis. Further work is required to determine the role of soft tissue interposition arthroplasty in this setting. (J Shoulder Elbow Surg 2007;16:254S-260S.)
C urrently, there is little information on the use of soft
tissue interposition arthroplasty for treatment of shoulder arthritis. Much of the existing data are from Burkhead and others on use of allograft meniscus interposition in the glenoid combined with hemiarthroplasty of the shoulder and more recently, DeBeer’s group.9,20,35,41 To date, no studies have specifically examined interposition or resurfacing without hemiarthroplasty of the shoulder. However, some surgeons have proposed the use of soft tissue interposition arthroplasty alone as a treatment of glenohumeral arthritis, an attractive proposition to avoid or delay traditional hemi or total shoulder arthroplasty, particularly in young active patients who might otherwise require revision of an implant placed at an early age. Many materials are available and represent a variety of processed and unprocessed xenografts, allografts, and synthetic materials. Xenograft and human dermal grafts can both now be processed to yield an acellular collagen scaffold that can be used as an interposition tissue.8 GraftJacket (Wright Medical Technology, Arlington, TN) acellular dermal matrix is 1 such commercially available material that we have clinical and laboratory experience with. Donated cadaveric dermal tissue is processed to remove cellular components while the extracellular matrix is preserved.8 Because the material is rendered acellular during processing, it lacks many of the disadvanFrom the Orthopedic Department, Mayo Clinic. Reprint requests: Scott P. Steinmann, MD, Mayo Clinic, 200 First St, SW, Rochester MN 55905 (E-mail: Steinmann.scott@mayo. edu). Copyright © 2007 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2007/$32.00 doi:10.1016/j.jse.2007.05.001
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tages attendant to the use of standard allograft tissue. This material has been used as skin grafts, in soft tissue reconstruction, dental implantation, and as a periosteal replacement to aid healing in segmental bone defects.3,7,8,30 Previous in vivo studies have demonstrated rapid infiltration of native cellular agents, including fibroblasts and vascular tissue, with minimal host inflammatory response.3,4,8 Because little data exist on outcomes of soft tissue glenoid resurfacing, this report will focus mainly on the techniques of interposition and our clinical and laboratory experience with this material. It should be noted that our limited clinical experience with this material in the setting of resurfacing shoulder arthritis is insufficient to provide support for routine use; however, the technique is presented as possible option for treatment of shoulder arthritis. Further work is indicated to define the role of this procedure. FIRST CARPOMETACARPAL JOINT ARTHROPLASTY We have previously reported on a series of patients with first carpometacarpal (CMC) joint arthritis treated by interposition arthroplasty of the thumb CMC joint with this acellular dermal matrix graft.2 Thumb CMC joint arthritis is a common condition encountered by hand surgeons. Traditional surgical approaches have included arthrodesis, trapeziectomy, or reconstructive arthroplasty techniques; however, a minimally invasive arthroscopic technique can be used to preserve the ligaments and resurface the CMC joint while bone stock is preserved. Débridement with or without interposition of material is possible arthroscopically. Arthroscopy allows for resection of the painful, arthritic joint, whereas interposition arthroplasty prevents bony impingement and further buttresses the first metacarpal. By performing interposition arthroscopically rather than with an open procedure, the integrity of the joint capsule is maintained.28,46 Recontouring the first CMC joint allows the surgeon to perform a partial trapeziectomy and, consequently, preserve bone stock.28,36 Because more bone is maintained by recontouring the joint, a wider range of surgical options are available should a future procedure be needed.36 After adequate arthroscopic débridement, interposition arthroplasty may be performed with a variety of materials.
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For arthroscopic débridement and interposition arthroplasty of the CMC joint, we used the 2 standard 1-R and 1-U portals and a 2.7-mm wrist arthroscope.1 The joint is débrided with cautery or radiofrequency ablation probe, followed by a small joint shaver (3.5 mm). Bony débridement of the typical arthritic biconcave trapezium is performed with the 3.5-mm arthroscopic burr. Typically, 3 to 4 mm of the distal trapezium is removed, leaving a smooth bony surface. The GraftJacket graft material is then passed into the joint through one of the portals and manipulated from the second portal. It is spread out into the joint, and appropriate positioning to cover the cancellous trapezium surface may be confirmed by the arthroscope. The portals are then closed, and the thumb maintained in an abducted position as the traction is removed and a sterile thumb spica abduction splint applied. Immobilization is continued for 6 weeks postoperatively. In our series, 17 consecutive patients (12 women, 5 men) with significant first CMC joint arthritis of 17 thumbs, all Eaton stages II or III and recalcitrant to conservative management, underwent the procedure.15 The average age was 61.7 years (range, 47-86 years). No patient who underwent the procedure was excluded from clinical analysis. Postoperative follow-up averaged 17 months. All patients reported symptomatic relief, and 94% stated that they were partially or completely satisfied. No pain or only occasional pain on activities was reported by 88% of patients; the average pain score was 1.125 on a scale of 0 to 10 (where 0 ⫽ no pain and 10 ⫽ maximal pain). More than 70% of patients reported no-to-mild difficulty in performing activities of daily living; the average grip strength was 18.5 kg, and pinch strength was 3.9 kg. Complications were minimal. Only 2 patients had limited range of motion as assessed by the “palm flat” test and ability to oppose the thumb to the base of the small finger. The outcomes in our series compare favorably with well-established historical controls reported in the literature10-12,18,24,27,43,44 and suggest that arthroscopic débridement and interposition arthroplasty using this acellular dermal matrix graft is a feasible surgical option for management of Eaton stages II or III symptomatic first CMC joint arthritis. No adverse events were associated with the use of this interposition material, and results seem to be durable, at least in the follow-up available in this series. ANIMAL DATA The in vivo behavior of this acellular dermal matrix graft as an interposition or resurfacing material has been studied in a rabbit model for CMC interposition arthroplasty.4 In a rabbit model for interposition arthroplasty for basal joint arthritis of the thumb,
débridement was performed of the lunate bone and adjacent cartilaginous surfaces, followed by interposition of the human acellular dermal matrix graft into the subsequent defect. On each side, the extensor digitorum and extensor carpi radialis tendons were identified and removed. To serve as a control, the contralateral side was treated by interposition of a “tendon ball” made up of the extensor digitorum and extensor carpi radialis tendons. This was sized to fit the defect created by lunate excision. Animals were euthanized at 4 and 8 weeks postoperatively. Vascular, radiographic, and histologic studies were performed. At both the 4-week and 8-week marks, a connective tissue attachment was noted between the graft and the adjacent carpal bones in both specimen groups. Fibroblast-like cells were noted lining the surface and infiltrating into the specimens. No foreign body or immune cell infiltrate was noted in either specimen group. Over time, a trend towards infiltration of fibroblast like cells was noted in the dermal graft and the autologous tendon interposition groups. The autologous tendon specimens appeared to have much greater cellular infiltration at each time period, with nearly uniform and complete infiltration by the 8-week time point. In contrast, cellular infiltration was noted in the acellular dermal matrix group specimens, with increasing cellularity at the 8-week mark. High-resolution radiographs were obtained to evaluate for maintenance or subsidence of the interposition space and shifting of the remaining carpal bones; no overt shifting or collapse was seen, and all specimens in the control and experimental interposition groups demonstrated a preserved clear space representing the interposition site. Vascular studies were suggestive of neovascularity in both specimen groups. USE OF ACELLULAR DERMAL MATRIX GRAFTS IN THE SHOULDER Results from our work in CMC interposition arthroplasty provide support for use of such soft tissue grafts in the shoulder. In addition, we have studied this material as a patch graft in full-thickness rotator cuff defects, with favorable clinical and animal study results.3 Full-thickness cuff defects in the setting of large or massive irreparable rotator cuff tears present a therapeutic challenge.* Because tissue may be insufficient or of inadequate quality to repair, a variety of materials have been used as an adjunct.† In a canine model of a full-thickness infraspinatus tendon tear,3 tendon was excised from the bony * †
References 16,19,21,25,26,29,31,34,37,39,42,45. References 5,6,13,14,16,17,21-23,26,29,32,33,38-40,42,45.
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interface to the myotendinous junction, and human acellular dermal matrix graft (experimental) or the autologous excised tendon (control) was used to bridge the defect. Shoulders were evaluated histologically and biomechanically at time points from time 0 to 6 months. The initial strength of the control and experimental repairs was similar. At 6 weeks, the strength of the experimental side was half that of the control side. Strength of the control specimens remained the same at 6 and 12 weeks, but by 12 weeks, the strength of the experimental repair was equal to the control. Initial ultimate stress was higher in the experimental group but was not significantly different between the graft and control groups during the remaining survival time points. There was a consistent increase in ultimate stress from 6 weeks to 3 months to 6 months, suggestive of tissue proliferation and maturation with time. Histologic evaluation showed cells had infiltrated the grafts by 6 weeks. Light microscopy demonstrated tenocyte-like cells and collagen bundles in a regular and parallel orientation similar to normal tendon structure in both control and experimental specimens. All animals were ambulatory and full-weightbearing immediately after surgery. No evidence of infection or rejection was noted. Although this study does not replicate human pathology with chronic retracted cuff defects and possible multiple comorbidities and impaired healing responses in the human host,6,40 it does appear that the acellular dermal matrix material was well tolerated and rapidly and readily incorporated in this canine model. Information on load to failure indicates that the regenerated tendon is sufficiently robust to withstand physiologic loads in vivo.3 TECHNIQUE OF INTERPOSITION ARTHROPLASTY The technique of resurfacing of the glenoid can be performed arthroscopically. The basic idea of the technique is to recontour the glenoid if it is a biconcave surface to a concave surface and then to resurface the glenoid. This is very similar to the procedure that has worked well in the CMC joint of the thumb where the trapezium is partially resected, and a resurfacing or interposition of the trapezium is performed. The procedure itself is somewhat technically demanding and requires reasonable experience with shoulder arthroscopy. The procedure begins with the patient placed in the lateral decubitus position. It is possible to perform this in the beach chair position; however, it is helpful to have the arm abducted in traction, which allows greater access from the posterior shoulder. The first part of the procedure is to establish a posterior portal
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Figure 1 Computed tomography scan demonstrates biconcave glenoid with posterior subluxation.
to the shoulder joint; and through this, the arthroscope is placed and visualization of the glenohumeral joint is confirmed. An anterior superior portal is then established; and through this, a shaver and burr can be passed into the joint. If the glenoid surface appears to be biconcave (Figure 1), then a glenoidplasty can be performed in which a round or oval arthroscopic burr is used to reform the normal appearance of the glenoid (Figure 2). This is usually performed by identifying the central ridge of the glenoid and the posterior portion of the biconcave glenoid (Figure 3). The high side of the glenoid, typically the anterior aspect, can then be burred, and the biconcave nature of the arthritic glenoid can be restored to a single concave surface. This is a similar to the ream-and-run type of procedure, where a reamer is placed on the glenoid to reshape and realign the articular surface during open surgery. If the glenoid is concentric with only central wear, then a burr can be used to lightly decorticate the glenoid surface to allow for bleeding of the underlying bone. A microfracture technique can be performed also to bring potential healing from the deeper aspect of the glenoid surface. After the glenoid is addressed and any labral tears resected, preparation can be made for the interposition itself. The glenoid is measured, typically off of the computed tomography scan, and this is used to measure the size of the GraftJacket tissue. The thickest type of GraftJacket is used for this procedure, and
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Figure 3 Arthroscopic view before the burr is used to recontour a biconcave glenoid. Arrows show the central ridge of the biconcave glenoid.
Figure 2 A, Drawing shows biconcave glenoid and posterior subluxation. B, An arthroscopic burr is used to recontour the glenoid surface.
because the GraftJacket tends to expand when hydrated, the graft that is cut is typically undersized about 20%. It is somewhat easier to cut the GraftJacket before it is hydrated. The GraftJacket is then rehydrated.
While the GraftJacket is being rehydrated, the Arthrex PushLock system (Naples, FL) is used to make 6 holes using the PushLock drill at the anterosuperior, anteormiddle, and anteroinferior, in addition to the posterosuperior, posteromiddle, and posteroinferior areas. These are then drilled for placement of the PushLock anchors. The reason for drilling all the holes before placement of the graft is the greater visualization of the glenoid before the graft is placed in the joint. After the 6 holes have been drilled for the PushLock anchors, the graft is prepared on the back table. Six sutures are placed in the graft to coincide with the 6 PushLock anchor holes that have been drilled; these are simple square knots that are tied down with No. 2 FiberWire (Arthrex). One limb of the 6 knots is cut, leaving 6 FiberWire strands from each of the 6 sutures. At this point, the graft is rolled up in a tube very similar to rolling up a carpet. The 3 anterior sutures are segregated from the 3 posterior sutures, and preparation is made for passage into the joint (Figure 4, A). The bladder of the posterior cannula will need to be removed, and this is easiest done with a No. 11 blade to cut out the rubber bladder to allow passage of the rolled up graft into the joint. The graft is passed into the joint by first placing the 3 anterior sutures into the joint and retrieving them out anteriorly. Once the 3 sutures are passed out anteriorly, the graft is pushed and pulled through the posterior cannula into the joint (Figure 5). Once the graft is in the joint, it is spread out to cover the surface of the glenoid. Then the sutures are retrieved in sequential fashion beginning with the anterior sutures, and PushLock anchors are placed from anterorsuperior to anterorinferior. Once the anterior aspect of the graft jacket is secured to the glenoid, then viewing is switched from anterior to posterior and the posterior
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Figure 4 A, The patient is placed in the lateral decubitus position with establishment of a posterior portal and 2 anterior portals. The glenoid graft can be seen with suture placed before graft passage. B, Drawing of the graft ready for passage into the glenohumeral joint.
PushLocks are placed, securing the graft in position over the glenoid. A suture cutter is used to cut the strand from each of the PushLock anchors flush with the glenoid surface. The cannulas are removed, the portals are closed with sutures, a sterile dressing is applied, and the arm is placed into a sling. Postoperatively, a sling is used for the first 4 to 6 weeks, and the patients are told to refrain from doing any work activity with the shoulder. After 1 month in the sling, patients are gradually allowed to return to normal activities. Currently, outcomes data after this procedure are limited and do not provide support to recommend routine use of this procedure. The purpose of this manuscript is however, to present this technique as 1
Figure 5 A, Drawing of graft. B, Graft being passed into the glenohumeral joint. C, Final fixation of graft performed with PushLock anchors (Athrex, Naples, FL).
possible option for treatment of shoulder arthritis. Further study with long-term follow-up is required to determine the role of this technique in treatment of the arthritic shoulder.15
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REFERENCES
1. Adams JE, Berger RA, Steinmann SP. Arthroscopic partial trapeziectomy and interposition arthroplasty of the thumb carpometacarpal joint. JASSH 2005;5:115-22. 2. Adams JE, Merten S, Steinmann SP. Arthroscopic interposition arthroplasty of the first carpometacarpal joint. J Hand Surg [Br] 2007;32:268-74. 3. Adams JE, Reach JS, Zobitz ME, An KN, Steinmann SP. Rotator cuff repair using an acellular dermal matrix graft: an in vivo study in a canine model. Arthroscopy 2006;22:700-9. 4. Adams JE, Steinmann SP. Interposition arthroplasty using an acellular dermal matrix: a histological, vascular, and radiographic study in rabbits. Poster presentation: AAOS 2006, Chicago, IL, March 22-26. 5. Aoki M, Uchiyama E, Ohtera K, Ishii S, Ohtani S, Yamakoshi K. Restoration of tensile properties at tendon insertion to bone by a patellar tendon-tibia autograft: an experimental study with canine infraspinatus. J Shoulder Elbow Surg 1999;8:628-33. 6. Baleani M, Schrader S, Veronesi CA, Rotini R, Giardino R, Toni A. Surgical repair of the rotator cuff: a biomechanical evaluation of different tendon grasping and bone suture fixation techniques. Clin Biomech 2001;18:721-9. 7. Belcher HJ, Zic R. Adverse effect of porcine collagen interposition after trapeziectomy: a comparative study. J Hand Surg [Br] 2001;26:159-64. 8. Beniker D, McQuillan D, Livesey S, Urban RM, Turner TM, Blum B, et al. The use of aceullar dermal matrix as a scaffold for periosteum replacement. Orthopedics 2003;26(5 suppl):s591-6. 9. Bhatia DN, van Rooyen KS, du Toit DF, de Beer JF. Arthroscopic technique of interposition arthroplasty of the glenohumeral joint. Arthroscopy 2006;22:570, e1-5. 10. Braun RM, Neill Cage DJ, Mack GR, Perlman RD, Fowler L, et al. Arthroscopically assisted tendon interposition arthroplasty at the base of the thumb. Tech Hand Up Extrem Surg 2001;5:42-8. 11. Culp RW, Rekant MS. The role of arthroscopy in evaluating and treating trapeziometacarpal disease. Hand Clin. 200;17:3159, x-xi. 12. Davis TR, Brady O, Dias JJ. Excision of the trapezium for osteoarthritis of hte trapeziometacarpal joint: a study of the benefit of ligament reconstruction or tendon interposition. J Hand Surg [Am] 2004;29:1069-977. 13. Dejardin LM, Arnoczky SP, Clarke RB. Use of small intestinal submucosal implants for regeneration of large fascial defects: an experimental study in dogs. J Biomed Mat Res 1999;46:203-11. 14. Dejardin LM, Arnoczky SP, Ewers BJ, Haut RC, Clarke RB. Tissue-engineered rotator cuff tendon using porcine small intestine submucosa. Histologic and mechanical evaluation in dogs. Am J Sports Med 2001;29:175-84. 15. Eaton RG, Glickel SZ, Littler JW. Tendon interposition arthroplasty for degenerative arthritis of the trapeziometcarpal joint of the thumb. J Hand Surg [Am] 1985;10:645-54. 16. Gartsman GM. Massive, irreparable tears of the rotator cuff. Results of operative debridement and subacromial decompression. J Bone Joint Surg Am 1997;79:715-21. 17. Guven O, Bezer M, Guven Z, Gokkus K, Tetik C. Surgical technique and functional results of irreparable cuff tears reconstructed with the long head of the biceps tendon. Bull Hosp Joint Dis 2001;60:13-7. 18. Hartigan BJ, Stern PJ, Kiefhaber TR. Thumb carpometacarpal osteoarthritis: arthrodesis compared with ligament reconstruction and tendon interposition. J Bone Joint Surg Am 2001;83:1470-8. 19. Hawkins RJ, Misamore GW, Hobeika PE. Surgery for fullthickness rotator-cuff tears. J Bone Joint Surg Am 1985;67: 1349-55. 20. Humphrey CS, Johnson DAL, Norris TR. Meniscal allograft interposition arthroplasty for shoulder osteoarthritis: two year follow-up results. Presented at: ASES Closed Meeting: Biologics in Shoulder Surgery. Chicago, IL; Sept 16, 2006.
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21. Iannotti JP. Full-thickness rotator cuff tears: factors affecting surgical outcome. J Am Acad Orthop Surg 1994;2:87-95. 22. Kimura A, Aoki M, Fukushima S, Ishii S, Yamakoshi K. Reconstruction of a defect of the rotator cuff with polytetrafluoroethylene felt graft. Recovery of tensile strength and histocompatibility in an animal model. J Bone Joint Surg Br 2003;85:282-7. 23. Koh JL, Szomor Z, Murrell GA, Warren RF. Supplementation of rotator cuff repair with a bioresorbable scaffold. Am J Sports Med 2002;30:410-3. 24. Kuhns CA, Emerson ET, Meals RA. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: a prospective single-surgeon study including outcomes measures. J Hand Surg [Am] 2003;28:381-9. 25. Luopajarvi T, Kuorinka I, Virolainen M, Holmberg M. Prevalence of tenosynovitis and other injuries of the upper extremities in repetitive work. Scand J Work Environ Health 1979;5(suppl 3): 48-55. 26. Malkani AL, Sundine MJ, Tillett ED, Baker DL, Rogers RA, Morton TA. Transfer of the long head of the triceps tendon for irreparable rotator cuff tears. Clin Orthop 2004;428:228-36. 27. Menon J. Arthroscopic management of trapeziometacarpal joint arthritis of the thumb. Arthroscopy 1996;12:581-7. 28. Menon J. Arthroscopic evaluation f the first carpometacarpal joint. J Hand Surg [Am] 1997;22:1077-80. 29. Mura N, O’Driscoll SW, Zobitz ME, Heers G, An KN. Biomechanical effect of patch graft for large rotator cuff tears: a cadaver study. Clin Orthop 2003:131-8. 30. Neel M: The use of a periosteal replacement membrane for bone graft containment at allograft-host junctions after tumor resection and reconstruction with bulk allograft. Orthopedics 2003; 26(5S):s587-s589. 31. Neer CS 2nd, Craig EV, Fukuda H. Cuff-tear arthropathy. J Bone Joint Surg Am 1983;65:1232-44. 32. Neviaser JS, Neviaser RJ, Neviaser TJ. The repair of chronic massive ruptures of the rotator cuff of the shoulder by use of a freeze-dried rotator cuff. J Bone Joint Surg Am 1978;60:681-4. 33. Neviaser JS. Ruptures of the rotator cuff of the shoulder. New concepts in the diagnosis and operative treatment of chronic ruptures. Arch Surg 1971;102:483-5. 34. Neviaser RJ. Tears of the rotator cuff. Orthop Clin North Am 1980;11:295-306. 35. Nicholson GP, Goldstein J, Romeo AA, McCarty LP, Hayden JK, Cole BJ, et al. Lateral meniscus allograft biologic glenoid arthroplasty in total shoulder arthroplasty for young shoulders with degenerative joint disease. Presented at: ASES Closed Meeting: Biologics in Shoulder Surgery. Chicago, IL; Sept 16, 2006. 36. Pellegrini VD Jr, Burton RI. Surgical management of basal joint arthritis of the thumb. Part I. Long-term results of silicone implant arthroplasty. J Hand Surg [Am] 1986;11:309-24. 37. Romeo AA, Hang DW, Bach BR Jr, Shott S. Repair of full thickness rotator cuff tears. Gender, age, and other factors affecting outcome. Clin Orthop 1999:243-55. 38. Sano H, Kumagai J, Sawai T. Experimental fascial autografting for the supraspinatus tendon defect: remodeling process of the grafted fascia and the insertion into bone. J Shoulder Elbow Surg 2002;11:166-73. 39. Schlepckow P, Sigg A. In-vitro reconstruction of massive rotator cuff ruptures with triceps tendon or coracoacromial ligament. Arch Orthop Trauma Surg 2001;121:286-90. 40. Sener M, Altay MA, Baki C, Turhan AU, Cobanoglu U. The comparison of patellar tendon bone autografting and free flexortendon autografting in infraspinatus defect of the shoulder: biomechanical and histological evaluation in a sheep model. Knee Surg Sports Traumatol Arthrosc 2004;12:235-40. 41. Sperling JW, Steinmann SP, Cordasco FA, Henshaw DR, Coons DA, Burkhead WZ. Shoulder arthritis in the young adult: arthroscopy to arthroplasty. Instr Course Lect. 2006;55:67-74. 42. Sundine MJ, Malkani AL. The use of the long head of triceps
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interposition muscle flap for treatment of massive rotator cuff tears. Plastic Reconstruct Surg 2002;110:1266-72; discussion 1273-4. 43. Swafford AR. Arthroscopic resurfacing of the basilar joint of the thumb. Podium presentation: 24th Annual Meeting of the Arthroscopic Association of North America. Vancouver, BC, Canada; May 14-17, 2005. 44. Trumble TE, Rafijah G, Gilbert M, Allan CH, North E, McCallister WV. Thumb trapeziometacarpal joint arthritis: partial trapeziec-
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tomy with ligament reconstruction and interposition costochondral allograft. J Hand Surg [Am] 2000;25:61-76. 45. Warner JJ. Management of massive irreparable rotator cuff tears: the role of tendon transfer. Instr Course Lect 2001;50:63-71. 46. Yang SS, Weiland AJ. First metacarpal subsidence during pinch after ligament reconstruction and tendon interposition basal joint arthroplasty of the thumb. J Hand Surg Am 1998;23:879-83.
Soft tissue interposition arthroplasty for treatment of shoulder arthritis is an emerging technique that has received increasing attention recently. Although currently available data are insufficient to advocate routine use of this procedure, the technique is presented as a possible option to treat shoulder arthritis. Further work is required to determine the role of soft tissue interposition arthroplasty in this setting. (J Shoulder Elbow Surg 2007;16:254S-260S.)
C urrently, there is little information on the use of soft
tissue interposition arthroplasty for treatment of shoulder arthritis. Much of the existing data are from Burkhead and others on use of allograft meniscus interposition in the glenoid combined with hemiarthroplasty of the shoulder and more recently, DeBeer’s group.9,20,35,41 To date, no studies have specifically examined interposition or resurfacing without hemiarthroplasty of the shoulder. However, some surgeons have proposed the use of soft tissue interposition arthroplasty alone as a treatment of glenohumeral arthritis, an attractive proposition to avoid or delay traditional hemi or total shoulder arthroplasty, particularly in young active patients who might otherwise require revision of an implant placed at an early age. Many materials are available and represent a variety of processed and unprocessed xenografts, allografts, and synthetic materials. Xenograft and human dermal grafts can both now be processed to yield an acellular collagen scaffold that can be used as an interposition tissue.8 GraftJacket (Wright Medical Technology, Arlington, TN) acellular dermal matrix is 1 such commercially available material that we have clinical and laboratory experience with. Donated cadaveric dermal tissue is processed to remove cellular components while the extracellular matrix is preserved.8 Because the material is rendered acellular during processing, it lacks many of the disadvanFrom the Orthopedic Department, Mayo Clinic. Reprint requests: Scott P. Steinmann, MD, Mayo Clinic, 200 First St, SW, Rochester MN 55905 (E-mail: Steinmann.scott@mayo. edu). Copyright © 2007 by Journal of Shoulder and Elbow Surgery Board of Trustees. 1058-2746/2007/$32.00 doi:10.1016/j.jse.2007.05.001
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tages attendant to the use of standard allograft tissue. This material has been used as skin grafts, in soft tissue reconstruction, dental implantation, and as a periosteal replacement to aid healing in segmental bone defects.3,7,8,30 Previous in vivo studies have demonstrated rapid infiltration of native cellular agents, including fibroblasts and vascular tissue, with minimal host inflammatory response.3,4,8 Because little data exist on outcomes of soft tissue glenoid resurfacing, this report will focus mainly on the techniques of interposition and our clinical and laboratory experience with this material. It should be noted that our limited clinical experience with this material in the setting of resurfacing shoulder arthritis is insufficient to provide support for routine use; however, the technique is presented as possible option for treatment of shoulder arthritis. Further work is indicated to define the role of this procedure. FIRST CARPOMETACARPAL JOINT ARTHROPLASTY We have previously reported on a series of patients with first carpometacarpal (CMC) joint arthritis treated by interposition arthroplasty of the thumb CMC joint with this acellular dermal matrix graft.2 Thumb CMC joint arthritis is a common condition encountered by hand surgeons. Traditional surgical approaches have included arthrodesis, trapeziectomy, or reconstructive arthroplasty techniques; however, a minimally invasive arthroscopic technique can be used to preserve the ligaments and resurface the CMC joint while bone stock is preserved. Débridement with or without interposition of material is possible arthroscopically. Arthroscopy allows for resection of the painful, arthritic joint, whereas interposition arthroplasty prevents bony impingement and further buttresses the first metacarpal. By performing interposition arthroscopically rather than with an open procedure, the integrity of the joint capsule is maintained.28,46 Recontouring the first CMC joint allows the surgeon to perform a partial trapeziectomy and, consequently, preserve bone stock.28,36 Because more bone is maintained by recontouring the joint, a wider range of surgical options are available should a future procedure be needed.36 After adequate arthroscopic débridement, interposition arthroplasty may be performed with a variety of materials.
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For arthroscopic débridement and interposition arthroplasty of the CMC joint, we used the 2 standard 1-R and 1-U portals and a 2.7-mm wrist arthroscope.1 The joint is débrided with cautery or radiofrequency ablation probe, followed by a small joint shaver (3.5 mm). Bony débridement of the typical arthritic biconcave trapezium is performed with the 3.5-mm arthroscopic burr. Typically, 3 to 4 mm of the distal trapezium is removed, leaving a smooth bony surface. The GraftJacket graft material is then passed into the joint through one of the portals and manipulated from the second portal. It is spread out into the joint, and appropriate positioning to cover the cancellous trapezium surface may be confirmed by the arthroscope. The portals are then closed, and the thumb maintained in an abducted position as the traction is removed and a sterile thumb spica abduction splint applied. Immobilization is continued for 6 weeks postoperatively. In our series, 17 consecutive patients (12 women, 5 men) with significant first CMC joint arthritis of 17 thumbs, all Eaton stages II or III and recalcitrant to conservative management, underwent the procedure.15 The average age was 61.7 years (range, 47-86 years). No patient who underwent the procedure was excluded from clinical analysis. Postoperative follow-up averaged 17 months. All patients reported symptomatic relief, and 94% stated that they were partially or completely satisfied. No pain or only occasional pain on activities was reported by 88% of patients; the average pain score was 1.125 on a scale of 0 to 10 (where 0 ⫽ no pain and 10 ⫽ maximal pain). More than 70% of patients reported no-to-mild difficulty in performing activities of daily living; the average grip strength was 18.5 kg, and pinch strength was 3.9 kg. Complications were minimal. Only 2 patients had limited range of motion as assessed by the “palm flat” test and ability to oppose the thumb to the base of the small finger. The outcomes in our series compare favorably with well-established historical controls reported in the literature10-12,18,24,27,43,44 and suggest that arthroscopic débridement and interposition arthroplasty using this acellular dermal matrix graft is a feasible surgical option for management of Eaton stages II or III symptomatic first CMC joint arthritis. No adverse events were associated with the use of this interposition material, and results seem to be durable, at least in the follow-up available in this series. ANIMAL DATA The in vivo behavior of this acellular dermal matrix graft as an interposition or resurfacing material has been studied in a rabbit model for CMC interposition arthroplasty.4 In a rabbit model for interposition arthroplasty for basal joint arthritis of the thumb,
débridement was performed of the lunate bone and adjacent cartilaginous surfaces, followed by interposition of the human acellular dermal matrix graft into the subsequent defect. On each side, the extensor digitorum and extensor carpi radialis tendons were identified and removed. To serve as a control, the contralateral side was treated by interposition of a “tendon ball” made up of the extensor digitorum and extensor carpi radialis tendons. This was sized to fit the defect created by lunate excision. Animals were euthanized at 4 and 8 weeks postoperatively. Vascular, radiographic, and histologic studies were performed. At both the 4-week and 8-week marks, a connective tissue attachment was noted between the graft and the adjacent carpal bones in both specimen groups. Fibroblast-like cells were noted lining the surface and infiltrating into the specimens. No foreign body or immune cell infiltrate was noted in either specimen group. Over time, a trend towards infiltration of fibroblast like cells was noted in the dermal graft and the autologous tendon interposition groups. The autologous tendon specimens appeared to have much greater cellular infiltration at each time period, with nearly uniform and complete infiltration by the 8-week time point. In contrast, cellular infiltration was noted in the acellular dermal matrix group specimens, with increasing cellularity at the 8-week mark. High-resolution radiographs were obtained to evaluate for maintenance or subsidence of the interposition space and shifting of the remaining carpal bones; no overt shifting or collapse was seen, and all specimens in the control and experimental interposition groups demonstrated a preserved clear space representing the interposition site. Vascular studies were suggestive of neovascularity in both specimen groups. USE OF ACELLULAR DERMAL MATRIX GRAFTS IN THE SHOULDER Results from our work in CMC interposition arthroplasty provide support for use of such soft tissue grafts in the shoulder. In addition, we have studied this material as a patch graft in full-thickness rotator cuff defects, with favorable clinical and animal study results.3 Full-thickness cuff defects in the setting of large or massive irreparable rotator cuff tears present a therapeutic challenge.* Because tissue may be insufficient or of inadequate quality to repair, a variety of materials have been used as an adjunct.† In a canine model of a full-thickness infraspinatus tendon tear,3 tendon was excised from the bony * †
References 16,19,21,25,26,29,31,34,37,39,42,45. References 5,6,13,14,16,17,21-23,26,29,32,33,38-40,42,45.
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interface to the myotendinous junction, and human acellular dermal matrix graft (experimental) or the autologous excised tendon (control) was used to bridge the defect. Shoulders were evaluated histologically and biomechanically at time points from time 0 to 6 months. The initial strength of the control and experimental repairs was similar. At 6 weeks, the strength of the experimental side was half that of the control side. Strength of the control specimens remained the same at 6 and 12 weeks, but by 12 weeks, the strength of the experimental repair was equal to the control. Initial ultimate stress was higher in the experimental group but was not significantly different between the graft and control groups during the remaining survival time points. There was a consistent increase in ultimate stress from 6 weeks to 3 months to 6 months, suggestive of tissue proliferation and maturation with time. Histologic evaluation showed cells had infiltrated the grafts by 6 weeks. Light microscopy demonstrated tenocyte-like cells and collagen bundles in a regular and parallel orientation similar to normal tendon structure in both control and experimental specimens. All animals were ambulatory and full-weightbearing immediately after surgery. No evidence of infection or rejection was noted. Although this study does not replicate human pathology with chronic retracted cuff defects and possible multiple comorbidities and impaired healing responses in the human host,6,40 it does appear that the acellular dermal matrix material was well tolerated and rapidly and readily incorporated in this canine model. Information on load to failure indicates that the regenerated tendon is sufficiently robust to withstand physiologic loads in vivo.3 TECHNIQUE OF INTERPOSITION ARTHROPLASTY The technique of resurfacing of the glenoid can be performed arthroscopically. The basic idea of the technique is to recontour the glenoid if it is a biconcave surface to a concave surface and then to resurface the glenoid. This is very similar to the procedure that has worked well in the CMC joint of the thumb where the trapezium is partially resected, and a resurfacing or interposition of the trapezium is performed. The procedure itself is somewhat technically demanding and requires reasonable experience with shoulder arthroscopy. The procedure begins with the patient placed in the lateral decubitus position. It is possible to perform this in the beach chair position; however, it is helpful to have the arm abducted in traction, which allows greater access from the posterior shoulder. The first part of the procedure is to establish a posterior portal
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Figure 1 Computed tomography scan demonstrates biconcave glenoid with posterior subluxation.
to the shoulder joint; and through this, the arthroscope is placed and visualization of the glenohumeral joint is confirmed. An anterior superior portal is then established; and through this, a shaver and burr can be passed into the joint. If the glenoid surface appears to be biconcave (Figure 1), then a glenoidplasty can be performed in which a round or oval arthroscopic burr is used to reform the normal appearance of the glenoid (Figure 2). This is usually performed by identifying the central ridge of the glenoid and the posterior portion of the biconcave glenoid (Figure 3). The high side of the glenoid, typically the anterior aspect, can then be burred, and the biconcave nature of the arthritic glenoid can be restored to a single concave surface. This is a similar to the ream-and-run type of procedure, where a reamer is placed on the glenoid to reshape and realign the articular surface during open surgery. If the glenoid is concentric with only central wear, then a burr can be used to lightly decorticate the glenoid surface to allow for bleeding of the underlying bone. A microfracture technique can be performed also to bring potential healing from the deeper aspect of the glenoid surface. After the glenoid is addressed and any labral tears resected, preparation can be made for the interposition itself. The glenoid is measured, typically off of the computed tomography scan, and this is used to measure the size of the GraftJacket tissue. The thickest type of GraftJacket is used for this procedure, and
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Figure 3 Arthroscopic view before the burr is used to recontour a biconcave glenoid. Arrows show the central ridge of the biconcave glenoid.
Figure 2 A, Drawing shows biconcave glenoid and posterior subluxation. B, An arthroscopic burr is used to recontour the glenoid surface.
because the GraftJacket tends to expand when hydrated, the graft that is cut is typically undersized about 20%. It is somewhat easier to cut the GraftJacket before it is hydrated. The GraftJacket is then rehydrated.
While the GraftJacket is being rehydrated, the Arthrex PushLock system (Naples, FL) is used to make 6 holes using the PushLock drill at the anterosuperior, anteormiddle, and anteroinferior, in addition to the posterosuperior, posteromiddle, and posteroinferior areas. These are then drilled for placement of the PushLock anchors. The reason for drilling all the holes before placement of the graft is the greater visualization of the glenoid before the graft is placed in the joint. After the 6 holes have been drilled for the PushLock anchors, the graft is prepared on the back table. Six sutures are placed in the graft to coincide with the 6 PushLock anchor holes that have been drilled; these are simple square knots that are tied down with No. 2 FiberWire (Arthrex). One limb of the 6 knots is cut, leaving 6 FiberWire strands from each of the 6 sutures. At this point, the graft is rolled up in a tube very similar to rolling up a carpet. The 3 anterior sutures are segregated from the 3 posterior sutures, and preparation is made for passage into the joint (Figure 4, A). The bladder of the posterior cannula will need to be removed, and this is easiest done with a No. 11 blade to cut out the rubber bladder to allow passage of the rolled up graft into the joint. The graft is passed into the joint by first placing the 3 anterior sutures into the joint and retrieving them out anteriorly. Once the 3 sutures are passed out anteriorly, the graft is pushed and pulled through the posterior cannula into the joint (Figure 5). Once the graft is in the joint, it is spread out to cover the surface of the glenoid. Then the sutures are retrieved in sequential fashion beginning with the anterior sutures, and PushLock anchors are placed from anterorsuperior to anterorinferior. Once the anterior aspect of the graft jacket is secured to the glenoid, then viewing is switched from anterior to posterior and the posterior
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Figure 4 A, The patient is placed in the lateral decubitus position with establishment of a posterior portal and 2 anterior portals. The glenoid graft can be seen with suture placed before graft passage. B, Drawing of the graft ready for passage into the glenohumeral joint.
PushLocks are placed, securing the graft in position over the glenoid. A suture cutter is used to cut the strand from each of the PushLock anchors flush with the glenoid surface. The cannulas are removed, the portals are closed with sutures, a sterile dressing is applied, and the arm is placed into a sling. Postoperatively, a sling is used for the first 4 to 6 weeks, and the patients are told to refrain from doing any work activity with the shoulder. After 1 month in the sling, patients are gradually allowed to return to normal activities. Currently, outcomes data after this procedure are limited and do not provide support to recommend routine use of this procedure. The purpose of this manuscript is however, to present this technique as 1
Figure 5 A, Drawing of graft. B, Graft being passed into the glenohumeral joint. C, Final fixation of graft performed with PushLock anchors (Athrex, Naples, FL).
possible option for treatment of shoulder arthritis. Further study with long-term follow-up is required to determine the role of this technique in treatment of the arthritic shoulder.15
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