How to Improve the Biology of Rotator Cuff Healing
Authors: MA Zumstein, P Boileau
References: Presented at SECEC 2009
Currently, the expected rate of structural failure of the muscle-tendon-bone unit after full thickness rotator cuff tendon repair ranges between 70 and 94%1-4. The majority of the failures occur in cases lacking sufficient primary tendon-to-bone restoration within the first few months postoperatively3. Therefore, every attempt should be made to optimize tendon to bone healing after rotator cuff repair. Repair techniques have evolved and eliminated primary tendon to bone fixation by improving suture and anchor material, tendon grasping techniques and tendon mobilization. Although biomechanical studies have shown
stronger repairs with more anchors and sutures, the success of current techniques is more dependent on the biology of
the healing tissue: The healing potential of rotator cuff repair decreases with age: the rate of tendon healing drops down
to 50% after 55 years of age1. This goes along with the established increase in prevalence of tears with age5. The
distal rotator cuff tendons have lower levels of cellular activity6 and large tears have degenerative changes7. Furthermore, osteopenia of the greater tuberosity may affect primary fixation strength and healing biology8. Thus, it appears that new biologic treatment strategies are necessary to support the biological environment to restore the functional unit, specifically in the elderly patients.
Experimental studies have shown that healing after rotator cuff repair comes from the underlying bone9 and the bursal epitenon10, but not from the tenocytes themselves. The repaired insertion is characterized histologically by disorganized tissue with poorer mechanical properties11 and differs from the normal development of the tendon-to-bone insertion12, 13. The formation of a natural four-zone tendonto-bone-insertion14, 15 requires cells, a fibrocartilagenous extracellular matrix (ECM) with collagens I, II, and X and proteoglycans12, different growth factors16, and a 3-dimensional matrix which is conductive17. Although experimental studies with various techniques of biologic augmentation have shown improved healing with inductive
growth factors18-21, it is rather unlike that any one single factor will have the important effect when used in isolation. Autologous thrombocyte concentrates are newly emerging centrifugation techniques to promote tissue healing. The rationale behind their clinical application is based on the recognition of the key role of thrombocytes in the initiation of tissue healing. Thrombocytes adhere, aggregate, form a fibrin mesh and subsequently release a large variety of autologous growth factors and have raised the hope of a safe and easily accessible source. The most common is platelet-rich plasma (PRP), which is made of anticoagulated blood in a two-step procedure using calcium or bovine thrombin to activate and form a fibrin structure secondarily.
PRP has been analyzed experimentally22-28 and employed clinically29-31 with early promising results. However, aside from the lack of clear evidence32 it has the following disadvantages: (1) it time consuming; (2) it is cost effective; (3) it has low-density unstable three-dimensional matrix; and (4) there is a possibility of inducing coagulopathies and cross infection33.
A recent further development of autologous platelet preparations is platelet-rich fibrin (PRF)34, 35. In addition to the favorable PRP-properties, PRF has several advantages: (1) Other than the initial cost of a centrifuge, the preparation of PRF is free; (2) It is a very simple one-step 20 minutes procedure, and is feasible to parallel the surgical intervention in the operating room; (3) it maintains the properties of fibrin adhesives, and the slow polymerization during PRF preparation generates a high density fibrin network with a conductive quality (scaffold) which does not dissolve after application35; this may lead to more efficient cell migration, proliferation and cicatrisation17, 36; (4) the fibrin network directly entraps activated cells, and leads to slow and efficient local delivery of growth factors and cytokines37; (5) platelets and leucocytes are collected with high efficiency, and are activated and preserved in a healthy state.
In summary, PRF may be a potentially advantageous source of local applied growth factors in rotator cuff tendon repair. However, any questions remain unanswered and let open a huge field for future researches. Are chronically degenerated rotator cuff tenocytes able to proliferate and produce the collagens and proteoglycans of a natural tendon to bone insertion? Are they able to reverse potential adverse effects of previous steroid injections? Is PRF able to store and release growth factors over time? What is the role of leucocytes and which is the best protocol to get the highest growth factor release over time? Is the application of PRF feasible and reproducible during rotator cuff repair? Do we get an earlier and higher vascularization response subsequent to PRF application? Do we get an increased watertight restoration of the rotator cuff insertion using PRF as a local growth factor delivery system? It is our hope to bring some answers in the closed future.
1. Boileau P, Brassart N, Watkinson DJ, Carles M, Hatzidakis AM, Krishnan SG. Arthroscopic repair of fullthickness tears of the supraspinatus: does the tendon really heal? J Bone Joint Surg Am. Jun 2005;87(6):1229-1240.
2. Galatz LM, Ball CM, Teefey SA, Middleton WD, Yamaguchi K. The Outcome and Repair Integrity of Completely Arthroscopically Repaired Large and Massive Rotator Cuff Tears. J Bone Joint Surg Am. February 1, 2004 2004;86(2):219-224.
3. Gerber C, Fuchs B, Hodler J. The results of repair of massive tears of the rotator cuff. J Bone Joint Surg Am. Apr 2000;82(4):505-515.
4. Zumstein MA, Jost B, Hempel J, Hodler J, Gerber C. The Clinical and Structural Long-Term Results of Open Repair of Massive Tears of the Rotator Cuff. J Bone Joint Surg Am. November 1, 2008 2008;90(11):2423-2431.
5. Yamaguchi K, Ditsios K, Middleton WD, Hildebolt CF, Galatz LM, Teefey SA. The demographic and morphological features of rotator cuff disease. A comparison of asymptomatic and symptomatic shoulders. J Bone Joint Surg Am. Aug 2006;88(8):1699-1704.
6. Matthews TJ, Smith SR, Peach CA, Rees JL, Urban JP, Carr AJ. In vivo measurement of tissue metabolism in tendons of the rotator cuff: IMPLICATIONS FOR SURGICAL MANAGEMENT. J Bone Joint Surg Br. May 2007;89(5):633-638.
7. Matthews TJ, Hand GC, Rees JL, Athanasou NA, Carr AJ. Pathology of the torn rotator cuff tendon. Reduction in potential for repair as tear size increases. J Bone Joint Surg Br. Apr 2006;88(4):489-495.
8. Meyer DC, Fucentese SF, Koller B, Gerber C. Association of osteopenia of the humeral head with full-thickness rotator cuff tears. J Shoulder Elbow Surg. May-Jun 2004;13(3):333-337.
9. Uhthoff HK, Sano H, Trudel G, Ishii H. Early reactions after reimplantation of the tendon of supraspinatus into bone. A study in rabbits. J Bone Joint Surg Br. Sep 2000;82(7):1072-1076.
10. Hirose K, Kondo S, Choi HR, Mishima S, Iwata H, Ishiguro N. Spontaneous healing process of a supraspinatus tendon tear in rabbits. Arch Orthop Trauma Surg. Jul 2004;124(6):374-377.
11. Thomopoulos S, Williams GR, Soslowsky LJ. Tendon to bone healing: differences in biomechanical, structural, and compositional properties due to a range of activity levels. J Biomech Eng. Feb 2003;125(1):106-113.
12. Galatz L, Rothermich, S., VanderPloeg, K., Petersen, B., Sandell, L., Thomopoulos, S. Development of the supraspinatus tendon-to-bone insertion: Localized expression of extracellular matrix and growth factor genes. Journal of Orthopaedic Research. 2007;25(12):1621-1628.
13. Gerber C, Schneeberger AG, Perren SM, Nyffeler RW. Experimental rotator cuff repair. A preliminary study. J Bone Joint Surg Am. 1999;81(9):1281-1290.
14. Thomopoulos S, Hattersley G, Mertens L RM, Galatz L, Williams G, Soslowsky L. The localized expression of extracellular matrix components in healing tendon insertion sites: an in situ hybridization study. Journal of Orthopaedic Research. 2002;20(3):454-463.
15. Woo SL, Hildebrand K, Watanabe N, Fenwick JA, Papageorgiou CD, Wang JH. Tissue engineering of ligament and tendon healing. Clin Orthop Relat Res. Oct 1999(367 Suppl):S312-323.
16. Wurgler-Hauri CC, Dourte LM, Baradet TC, Williams GR, Soslowsky LJ. Temporal expression of 8 growth factors in tendon-to-bone healing in a rat supraspinatus model. Journal of Shoulder and Elbow Surgery. 2007;16(5, Supplement 1):S198.
17. Laurens N, Koolwijk P, de Maat MP. Fibrin structure and wound healing. J Thromb Haemost. May 2006;4(5):932-939.
18. Forslund C, Aspenberg P. Improved healing of transected rabbit Achilles tendon after a single injection of cartilage-derived morphogenetic protein-2. Am J Sports Med. Jul-Aug 2003;31(4):555-559.
19. Lou J, Tu Y, Burns M, Silva MJ, Manske P. BMP-12 gene transfer augmentation of lacerated tendon repair. J Orthop Res. Nov 2001;19(6):1199-1202.
20. Rodeo S, Potter H, Kawamura S, Turner A, Kim H, Atkinson B. Biologic Augmentation of Rotator Cuff Tendon-Healing with Use of a Mixture of Osteoinductive Growth Factors. The Journal of Bone and Joint Surgery. Nov 1 2007;89(11):2485-2497.
21. Murray DH, Kubiak EN, Jazrawi LM, et al. The effect of cartilage-derived morphogenetic protein 2 on initial healing of a rotator cuff defect in a rat model. J Shoulder Elbow Surg. Mar-Apr 2007;16(2):251-254.
22. Moojen DJ, Everts PA, Schure RM, et al. Antimicrobial activity of platelet-leukocyte gel against Staphylococcus aureus. J Orthop Res. Mar 2008;26(3):404-410.
23. Schnabel LV, Mohammed HO, Miller BJ, et al. Platelet rich plasma (PRP) enhances anabolic gene expression patterns in flexor digitorum superficialis tendons. J Orthop Res. Feb 2007;25(2):230-240.
24. Murray M, Spindler KP, Ballard P, Welch TP, Zurakowski D, Nanney LB. Enhanced histologic repair in a central wound in the anterior cruciate ligament with a collagenplatelet-rich plasma scaffold. Journal of Orthopaedic Research. 2007;25(8):1007-1017.
25. Kajikawa Y, Morihara T, Sakamoto H, et al. PRP (Platelet Rich Plasma) enhances the initial Tendon Healing of Circulation derived Mesenchymal Cells: Experimental study using Bone Marrow Chimeric Model. Paper presented at: 53rd Annual Meeting of the Orthopaedic Research Society, 2007; San Diego, Ca.
26. Virchenko O, Aspenberg P. How can one platelet injection after tendon injury lead to a stronger tendon after 4 weeks? Interplay between early regeneration and mechanical stimulation. Acta Orthop. Oct 2006;77(5):806-812.
27. Smith JJ, Ross MW, Smith RK. Anabolic effects of acellular bone marrow, platelet rich plasma, and serum on equine suspensory ligament fibroblasts in vitro. Vet Comp Orthop Traumatol. 2006;19(1):43-47.
28. Zhang Y, Zeng B, Zhang C, Yuan T. [Effects of platelet-rich plasma on proliferation and osteogenetic activity of marrow mesenchymal stem cells in vitro]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. Feb 2005;19(2):109-113.
29. Everts PA, Devilee RJ, Brown Mahoney C, et al. Exogenous application of platelet-leukocyte gel during open subacromial decompression contributes to improved patient outcome. A prospective randomized double-blind study. Eur Surg Res. 2008;40(2):203-210.
30. Marx RE, Carlson ER, Eichstaedt RM, Schimmele SR, Strauss JE, Georgeff KR. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Jun 1998;85(6):638-646.
31. Randelli PS, Arrigoni P, Cabitza P, Volpi P, Maffulli N. Autologous platelet rich plasma for arthroscopic rotator cuff repair. A pilot study. Disability & Rehabilitation. 2008;99999(1):1 - 6.
32. Sanchez AR, Sheridan PJ, Kupp LI. Is platelet-rich plasma the perfect enhancement factor? A current review. Int J Oral Maxillofac Implants. Jan-Feb 2003;18(1):93-103.
33. Landesberg R, Moses M, Karpatkin M. Risks of using platelet rich plasma gel. J Oral Maxillofac Surg. Sep 1998;56(9):1116-1117.
34. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part II: platelet-related biologic features. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Mar 2006;101(3):e45-50.
35. Dohan DM, Choukroun J, Diss A, et al. Platelet-rich fibrin (PRF): a second-generation platelet concentrate. Part I: technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. Mar 2006;101(3):e37-44.
36. Bensaid W, Triffitt JT, Blanchat C, Oudina K, Sedel L, Petite H. A biodegradable fibrin scaffold for mesenchymal stem cell transplantation. Biomaterials. Jun 2003;24(14):2497-2502.
37. Dohan Ehrenfest DM, de Peppo GM, Doglioli P, Sammartino G. Slow release of growth factors and thrombospondin-1 in Choukroun's platelet-rich fibrin (PRF): a gold standard to achieve for all surgical platelet concentrates technologies. Growth Factors. Feb 2009;27(1):63-69.