Biologics as the next step in future of rotator cuff surgery

KOLOA, Hawaii — For the repair of rotator cuff tears, healing matters; however, the use of biologics and patches has unanswered questions, according to a speaker here.

“We have probably maximized what we can achieve from a mechanical standpoint. Biology is clearly going to be the next step for the future of rotator cuff surgery,” Nikhil N. Verma, MD, said at Orthopedics Today Hawaii 2015.

The occurrence of structural failure following rotator cuff repair ranges from 10% to 90%, depending on patient comorbidities, tear size, tissue quality, muscle atrophy and the chronicity of the tears. Verma said the majority of published studies indicate better outcomes for intact rotator cuff repair.

Nikhil N. Verma

Questions remain as to what biologics are appropriate to use, as well as what methods of delivery to the repair site should be used and how to keep the biologics there once delivered, according to Verma. Preclinical data are not always translational, he said, and most available studies are of poor quality. Dose, frequency, cost and regulatory issues remain.

“Endpoints for study are difficult, particularly when we want to look at the anatomy with a large number of patients, which is often cost-prohibitive,” he said.

Platelet-rich plasma presents an easy option for orthopedic surgeons to add to their toolbox of available treatment options for rotator cuff repair; however, the clinical benefit remains unclear, according to Verma.

“It is difficult to obtain a cost or payment reimbursement for these expensive products,” he said. “I think the biggest areas where we need to get better is delivery vehicles.”

Indications to use patch augmentation include younger age, failure of previous repairs generally with medial retraction, poor tissue quality, larger size tears and salvage procedures. Verma said there are a number of scaffolds available for the treatment of rotator cuff tears. However, they should be used for augmentation more than as a gap filler.

“There are arthroscopic techniques that are somewhat challenging, but I think they can be mastered with practice,” he said.

There is no stem cell product available for use in rotator cuff repair, Verma said. Future study is needed before routine use can be recommended. – by Kristine Houck, MA, ELS

Reference:

Verma N. Biologics and patches in rotator cuff repair: What you need in your toolbox. Presented at: Orthopedics Today Hawaii 2015; Jan. 18-22, 2015; Koloa, Hawaii.

Disclosure: Verma receives royalties from Smith & Nephew, consulting fees from MinInvasive and Smith & Nephew; has stock options in Cymedica, MinInvasive and Omeros; and receives research support from Athletics, Arthrex, Arthrosurface, ConMed Linvatec, DJ Orthopedics, MioMed, Mitek and Smith & Nephew.