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Arthroscopic Rotator Cuff Repair – Graft Reinforcement

Arthroscopic Rotator Cuff Repair

Dr. Ernest Amory Codman, widely considered the father of evidence-based medicine, first championed rotator cuff repair in the early 20th  rotator cuff repaircentury.  He is considered to have performed the first reported rotator cuff repair in the English literature in 1909 after observing treatment for rotator cuff disease and studying it in detail as a medical student in Germany.  Many of the techniques and principles of rotator cuff repair remained relatively unchanged for the remainder of the 20th century.

Arthroscopy of the shoulder, starting with arthroscopic acromioplasty, widely credited to Dr. Harvard Ellman who reported his results in 1987, gradually ushered in a sea change of interest and understanding in shoulder injuries and rotator cuff repair.  Coinciding with the introduction of the suture anchor and arthroscopic techniques, Dr. Eugene Wolf performed first arthroscopic rotator cuff repair with suture anchors in 1990.  Since then a flurry of activity has occurred with an explosion in techniques and implants to improve the results of rotator cuff repairs.

Unfortunately, despite the significant advances that have been made in the treatment of rotator cuff tears, the results and healing rates of rotator cuff repair still vary widely with reported failure rates ranging from 11-94%.  Among the many reasons for this, surgeon skill and experience is often cited as one of the most important variables involved.  Many other factors including patient related factors such as smoking history, age, size of tear, quality of tissue and compliance (meaning following the restrictions and directions required after surgery to allow healing of the repaired tissue) can also play a part.

Because the majority of patients with rotator cuff tears we treat here at The Shoulder Center have not had satisfactory results from previous rotator cuff repair elsewhere, we are always looking at ways to improve the results of rotator cuff repair.  Along with our very popular and scientifically based rotator cuff repair protocol , we are also constantly working to improve the results of rotator cuff repair, even in those patients traditionally thought to have no hope of success.  These techniques have allowed us to offer hope to patients with large or massive rotator cuff tears, as well as those with other risk factors that may limit the results with other surgical techniques-diabetes, smoking, prior surgery, obesity, and patients older than 60 years of age.

Our first priority is to provide patients with a comprehensive diagnosis, which can often mean that the patient has another factor alongside the rotator cuff tear that may have contributed to persistent pain, weakness, or failure to heal-such as: a pinched nerve in the shoulder ,a frozen shoulder ,  or an unstable shoulder , as well as many others.  Along with offering a comprehensive approach to arthroscopic management of any associated pathology, we have also been pioneers in providing innovative techniques for rotator cuff repair, not available elsewhere.  A lot of work has been done on increasing the strength of rotator cuff repairs in an effort to improve results.  Unfortunately, without honoring the anatomy of the rotator cuff and recognizing the principles involved in the function of the rotator cuff, many of these techniques that are very strong in the cadaver lab, have resulted in more worrisome clinical patterns of rotator cuff repair failure.

While fully adhering to the anatomic and physiologic principles of rotator cuff repair we originally outlined, we have also worked tirelessly to find ways to improve the strength of the rotator cuff repair to provide patients an extra safety net and also to find ways to reinforce the rotator cuff tissue for those patients with rotator cuff tissue of questionable quality.  For instance, a massive rotator cuff tear in a patient who has had several previously failed rotator cuff repairs typically means the ability of the rotator cuff tendon to heal is questionable.  Ideally, we would like to have the ability to reinforce the patient’s own rotator cuff tissue so that the compromised tissue is supported during the critical healing phase while also creating a template for replacement of the supporting tissue with the patient’s own tissue to create a stronger more normal rotator cuff tendon at the end of the healing cycle.  There are several promising grafts available currently with excellent biocompatibility and certainly others to follow as the age of biologics continues to advance in shoulder surgery.  We have outlined some of these emerging technologies at Failed Rotator Cuff Repair .  The other part that has been considered impossible by many surgeons is a reliable and durable technique to reinforce rotator cuff repairs without an incision meaning an all-arthroscopic approach.

We have been performing an all-arthroscopic approach for graft reinforcement of rotator cuff repair for several years.  While the results in our hands have been very encouraging, the techniques are very difficult for other surgeons to learn and master, severely limiting these techniques to just a few highly specialized destination centers for shoulder surgery around the world.  That may now be changing with a novel technique we recently described which should make it easier for surgeons to offer better results to more patients.  Building on our original tension band anatomic repair described here ( ) we have used recently introduced technology  to allow us to create a novel technique that not only improves the strength of the rotator cuff repair, but also creates an easy and reproducible method to reinforce the repair with a biologic reinforcement graft to improve the healing rates and results for even the most difficult patients.  A detailed video of our technique is here at rotator cuff repair video.  Rotator cuff tears are very common and unfortunately failed rotator cuff repairs are also very common.  Do your homework and find a shoulder specialist that has experience with the most advanced techniques for arthroscopic rotator cuff repair.


  1. James R. Watkins says:

    Would like some info. on this topic of shoulder specialists. I’ve had 4 shoulder repairs 2 on ea. side ; the most recent this past May 2010 on my left shoulder which included a bicep tenodesis which did not take and I am now having problems w/the shoulder again. any info. would be much appreciated. sincerely Jim Watkins

  2. I have recently received a GraftJacket allograph implant to repair my right rotator cuff, April/2010. I had a massive rotator cuff tear whereby my initial tendor repair surgery, failed. My original surgeon said there was nothing he could do after the re-tear and for a full year I accepted this as gospel. Nonetheless, a friend of mine, a doctor in E.R. in Toronto, recommended a shoulder specialist for a 2nd opinion and I went to see him fully expecting that nothing could be done…I’m glad he did because it has been 10 months now following my Graft Jacket surgery which appears to have worked. I still do not have all my strength and likely won’t regain full strength but I’m committed to continue with my program that my physiotherapist developed. I see the surgeon again in a few more months for a follow-up. I’m hoping to have greater strength and even further range-of-motion. To be honest, I went through extreme pain immediately following surgery since my deltoid had to be detached during the procedure, plus there was lots of clean-up to do from the prior surgery.It was worth it. I don’t know if it is acceptable to name my surgeon here, but, he is amazing; I can’t say enough to thank him and his associates for the fantastic care during the entire process, rehab and recovery. Thanks to Dr. E’s innovative approach, approach and knowledge of the latest ground-breaking techniques and his skill, he was successful. My understanding is that my should was so perfectly, imperfect, that the Graft Jacket Allograft procedure was the only solution remaining.

  3. Maria Klufas says:

    I had a rotators cuff surgery in January, 2012. I was doing excellent, no pain, full motion on my left shoulder. In November, 2012 i lift 5 lb while doing my exercises & have a torn(2.2-1.1) at the same place as before. Went for PT for 4 weeks, didn’t help. Doctor who did first surgery moved out of state. I new doctor recommended surgery or live with pain. I agree to surgery, but went for a second opinion, second doctor agree for surgery & possible use of graft.I ask my surgeon his opinion, he said that he doesn’t have experience with graft & told me to find different doctor. What should i do, if i really don’t have idea what is a graft.
    I would like to know what do to?

  4. I have had 4 rotor cuff repair surgeries and I just had an arthogram done and it showed both arms with multiple tears. My doctor suggested the graft jacket as he said my tissues were not healthy and they keep tearing. What do you know about the graft jacket? Is it safe? What about risk for disease? Is there any other options?

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