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Arthroscopic revision rotator cuff repair of large and massive retears using an interpositional bridging dermal allograft

Open AccessPublished:March 19, 2022DOI:https://doi.org/10.1016/j.jseint.2022.02.010

      Background

      The purpose of this study was to report the clinical outcomes and retear rate following arthroscopic interpositional bridging dermal allograft for revision rotator cuff repair of large and massive retears.

      Methods

      Twenty-three patients were retrospectively reviewed at a minimum follow-up of 24 (mean, 47; range, 24-77) months after revision rotator cuff repair using an interpositional bridging dermal allograft. There were 17 males and 6 females with a mean age of 56 (range, 40-74) years. Clinical outcomes were assessed using range of motion, the American Shoulder and Elbow Surgeons score and Western Ontario Rotator Cuff Index. Graft integrity was assessed at 12-months using magnetic resonance imaging.

      Results

      The interval between the primary rotator cuff repair and interpositional bridging graft was a mean of 82 (range, 7-192) months. Forward flexion improved from a mean of 145° (range, 60-180°) preoperatively to 152° (range, 135-170°) postoperatively (P = .3561). There was a decrease in external rotation from a mean of 50° (range, 20-80°) preoperatively to 37° (range, 0-45°) postoperatively (P = .0021). The American Shoulder and Elbow Surgeons score improved (P = .0196) from a mean of 50 (range, 10-88) to 69 (range, 22-97), and the Western Ontario Rotator Cuff index improved (P = .0008) from a mean of 34 (range, 3-90) to 57 (range, 14-93). The graft was intact in 39% of patients. No patients underwent further surgery.

      Conclusion

      Interpositional bridging grafting for revision rotator cuff repair of large and massive retears leads to a significant improvement in functional outcome but is associated with a high retear rate.

      Level of evidence

      Keywords

      The incidence of primary rotator cuff repair has been consistently rising over the last 2 decades.
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      Revision surgery is indicated for symptomatic retears with shoulder dysfunction. The results are favorable and characterized by an improvement in range of motion and functional outcome. However, these though are accompanied by complication and reoperation rates of 12% and 5%, respectively.
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      Independent risk factors for a poor clinical outcome after a rotator cuff retear include smoking, female sex, and retears of the same or larger size than the initial tear.
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      When dealing with a large and massive rotator cuff retear after a previous repair, direct tendon-bone repair is not often possible because of a combination of tissue loss, poor tendon quality, and limited tendon mobility. The use of an interpositional graft here may be advantageous because by bridging the gap between the torn rotator cuff tendon and the humerus, it may create an environment conducive to healing by permitting a tension-free repair, complete footprint coverage, and sealing the joint from the subacromial space. Types of graft include autografts (biceps tendon and fascia lata), allografts (human dermal matrix), xenograft (porcine dermal matrix), and synthetic materials derived from a number of polymers such as polytetrafluoroethylene.
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      • Murrell G.A.C.
      Interposition graft repair of irreparable rotator cuff tears: a review of biomechanics and clinical outcomes.
      Studies examining the use of interpositional bridging grafting in primary rotator cuff repair have demonstrated an improvement in range of motion and functional outcome.
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      Evaluating the outcomes of rotator cuff repairs with polytetrafluoroethylene patches for massive and irreparable rotator cuff tears with a minimum 2-year follow-up.
      Patient selection is crucial with those who are younger and more active identified as being the most suitable candidates provided they have good residual tendon quality and no arthritis.
      • Sunwoo J.Y.
      • Murrell G.A.C.
      Interposition graft repair of irreparable rotator cuff tears: a review of biomechanics and clinical outcomes.
      However, the results of interpositional bridging grafts have not been specifically studied in the revision setting.
      The purpose of this study was to report the clinical outcomes and retear rate following arthroscopic interpositional bridging dermal allograft for revision rotator cuff repair of large and massive retears.

      Materials and methods

      We performed a retrospective review of consecutive patients who underwent arthroscopic revision rotator cuff repair using an interpositional bridging dermal allograft. Institutional review board approval was obtained before the commencement of the study. Eligible subjects included those with persistent pain and limited function after previous rotator cuff repair with documented failure of healing or a retear (as determined on the basis of ultrasonography [US] or magnetic resonance imaging [MRI]). All recurrent tears involved the posterosuperior rotator cuff (supraspinatus and infraspinatus) and were categorized as large (3-5 cm) or massive (>5cm and/or involving at least 2 tendons) as described by DeOrio and Cofield and Gerber et al.
      • DeOrio J.K.
      • Cofield R.H.
      Results of a second attempt at surgical repair of a failed initial rotator-cuff repair.
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      • Gerber C.
      • Maquieira G.
      • Espinosa N.
      Latissimus dorsi transfer for the treatment of irreparable rotator cuff tears.
      All subscapularis tears were also included.
      Inclusion criteria were a consecutive group of patients who had failed nonoperative treatment (physiotherapy and analgesia) and had persistent pain and limited function that required a revision rotator cuff repair of a large or massive retear using an interpositional bridging graft (ArthroFlex; LifeNet Health, Richmond, VA, USA). Minimum follow-up was 2 years. Exclusion criteria comprised the presence of arthritis on plain radiographs, Workers' compensation patients, and those who did not give their consent for participation in research. Medical records and operative reports were analyzed by an orthopedic surgeon who had not been involved in the surgical procedures.

      Participants

      From September 2014 to July 2019, 23 patients were eligible for the study. There were 17 males and 6 females with a mean age of 56 (range, 40-74) years at the time of surgery. The number of diabetics and smokers in the cohort was recorded because these factors can lead to structural failure after a rotator cuff repair.
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      ,
      • Park J.H.
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      • Kim T.M.
      • Kim J.
      • Yoon J.P.
      • Kim J.Y.
      • et al.
      Effect of smoking on healing failure after rotator cuff repair.
      Surgery was performed on the dominant shoulder in 16 cases. The mean duration of symptoms before revision repair was 33 (range, 3-156) months. The interval between primary rotator cuff repair and revision surgery was 82 (range, 3-192) months. Two patients had 2 previous rotator cuff repairs, but the remaining patients had all undergone 1 previous surgery.

      Clinical and radiological assessment

      Preoperative evaluation was undertaken by assessing pain, range of motion (forward flexion and external rotation), patient-reported outcome measures (PROMs), and integrity of the initial repair using US or MRI. Postoperative evaluation was undertaken by assessing PROMs, range of motion (forward flexion and external rotation), and graft integrity on MRI at 12 months. PROMs comprised the American Shoulder and Elbow Surgeons (ASES) score and the Western Ontario Rotator Cuff (WORC) Index.
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      • Griffin S.
      The development and evaluation of a disease-specific quality-of-life questionnaire for disorders of the rotator cuff: the Western Ontario Rotator Cuff Index.
      ,
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      American Shoulder and Elbow Surgeons Standardized Shoulder Assessment form, patient self-report section: reliability, validity, and responsiveness.
      The WORC index relies on patient self-reporting and consists of 21 questions grouped into 5 categories: physical symptoms, sports/recreation, work, lifestyle, and emotions. Each question uses a visual analog scale to provide a final rating from 0% (lowest functional status) to 100% (the highest functional status).
      All PROMs were collected and managed using Research Electronic Data Capture electronic data capture tools hosted at the University of Calgary.
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      This is a secure, web-based software platform designed to support data collection for research studies.

      Surgical technique

      All operations were performed by the senior author (I.K.L.). Preoperative assessment specifically focused on determining the precise details of all prior surgeries (Table I). Under general anesthesia, the patient was positioned in the lateral decubitus position. The arm was held in place with the SPIDER Arm positioner (TENET Medical Products, Smith & Nephew, Andover, MA, USA) to allow traction with simultaneous rotation. A diagnostic arthroscopy was performed with an arthroscopic pump maintaining pressure at 30 mm Hg.
      Table IDetails of previous rotator cuff repair surgery that were evaluated.
      Tear size
      Tear retraction (cm)
      Tendon quality (thick vs. thin)
      Tendon mobility
      Tendons involved
      Concurrent shoulder pathology
      Biceps tenotomy/tenodesis
      Acromioplasty
      Distal clavicle excision
      Single or double row repair
      In cases where the long head of biceps tendon was grossly tendinopathic or unstable, a tenotomy or a tenodesis was done. For the latter, a 7.0 mm Biotenodesis screw (Arthrex, Inc., North Naples, FL, USA) was inserted at the inferior aspect of the biceps groove for interference fixation of the biceps tendon within the bone. Upper and full-thickness subscapularis tears were repaired in all cases. In those with retraction, a 3-sided release (anterior, posterior, and superior) was performed before reattaching it to the lesser tuberosity. Attention was then turned to the posterosuperior rotator cuff (supraspinatus and infraspinatus tendons). Acromioplasty was not routinely performed and nor was resection of the coracoacromial ligament, so as to prevent anterosuperior escape of the humeral head.
      • Hockman D.E.
      • Lucas G.L.
      • Roth C.A.
      Role of the coracoacromial ligament as restraint after shoulder hemiarthroplasty.
      Retraction, mobility, and thickness of the remaining tendon tissue were assessed (Fig. 1). Sutures from previous surgery were débrided to leave a smooth tendon capable of retaining sutures. Existing suture anchors were removed if possible. All tears were extensively mobilized, and after preparing the footprint to achieve a bleeding bone bed, a partial repair was carried out when possible. Interpositional bridging grafting was performed when a residual gap remained between a good quality tendon edge and the footprint (Fig. 2).
      Figure thumbnail gr1
      Figure 1Left shoulder viewing through the lateral portal. Massive, retracted rotator cuff tear with sutures from a previous repair ().
      Figure thumbnail gr2
      Figure 2Left shoulder viewing through the posterior portal demonstrating insufficient tendon mobility to achieve a tension-free repair without the use of a graft.
      Two 4.75-mm medial row double-loaded suture anchors (Healicoil Regenesorb; Smith & Nephew, Andover, MA, USA) were placed anteriorly and posteriorly at the articular margin (Fig. 3). Simple sutures from these were passed into the anterolateral and posterolateral portions of the rotator cuff. Multiple simple sutures using #2 FiberWire (Arthrex, North Naples, FL, USA) were placed into the medial, anterior, and posterior leaves of the tendon to serve as multiple attachment points for the graft. The size of the defect was determined using a dedicated measuring device (SCR Guide, Arthrex, Inc.). Human dermal allograft (Arthroflex 301; Arthrex, Inc.) was then appropriately cut and contoured with a 5 mm overlap medially, anteriorly, and posteriorly and a 1 cm overlap laterally on the humeral footprint to facilitate a double-row repair. The previously placed sutures were subsequently passed through the graft extra-corporeally and arranged around a 10 mL syringe using a previously described technique (Fig. 4).
      • Rashid M.S.
      • Novak M.
      • Lo A.
      • Lo I.K.Y.
      A technique using an easy-to-fabricate cannula to manage sutures and aid graft passage in arthroscopic superior capsular reconstruction.
      The graft was then shuttled through the syringe to cover the residual rotator cuff defect. The lateral sutures were tied first, followed by the medial ones. The side-to-side sutures were then passed through the anterior and posterior portions of the graft and tied (Fig. 5). The repair was completed by securing the lateral aspect of the graft with 2 further lateral row anchors (4.75 m Biocomposite SwiveLock; Arthrex, Inc., Naples, FL, USA), thus creating a double-row construct with good tendon-bone compression.
      Figure thumbnail gr3
      Figure 3Left shoulder viewing through the posterior portal illustrating 2 medial row suture anchors ().
      Figure thumbnail gr4
      Figure 4Graft being prepared for delivery into the shoulder having had sutures passed through it.
      Figure thumbnail gr5
      Figure 5Left shoulder viewing through the posterior portal. Graft secured to the remaining rotator cuff tissue and covering the defect.
      During the first 6 weeks, hand, wrist, and elbow range of motion was allowed. Passive external rotation was allowed as tolerated unless there was a concomitant subscapularis repair, whereby external rotation was limited to 0°. Sling immobilization was discontinued after 6 weeks. Beginning in the seventh postoperative week and progressing through the 12th postoperative week, patients performed passive overhead stretches and progressive active assisted to active range of motion. Strengthening was delayed until 16 weeks postoperatively. Full return to activity was not allowed until 1 year postoperatively. Return to work was individualized based on the specific demands of each patient.

      Statistical analysis

      Data were summarized with routine descriptive statistics. Paired t tests were used to evaluate differences between preoperative and postoperative range of motion, ASES scores, and WORC index. A P value <.05 was considered to be statistically significant. The SPSS software package, version 22 (IBM, Armonk, NY, USA), was used to analyze data.

      Results

      The mean duration of follow-up was 47 (range, 24-77) months after revision rotator cuff repair using an interpositional bridging dermal allograft. The cohort consisted of 2 smokers and 7 diabetics. Dimensions of the grafts were 4.7 (range, 1.5-4.3) cm anteriorly, 4.8 (range, 1.5-4) cm posteriorly, 2.5 (range, 1.5-3.4) cm medially, and 2.3 (range, 1.5-3.2) cm laterally. At revision surgery, all retears were large and massive, and the mean tendon retraction was 3 (range, 1.3-5) cm. Associated procedures performed at the time of surgery included 5 subscapularis repairs, 8 partial infraspinatus repairs, 3 capsular releases, 2 biceps tenodeses, and 4 biceps tenotomies. No perioperative complications were noted, and no further surgery was carried out. There were no cases of any excessive inflammatory reactions, infections, or tissue rejection identified.

      Clinical and radiological assessment

      All patients were available for the evaluation of range of motion, although complete pre- and post-operative PROMs were available for 15 patients. Forward flexion improved from a mean of 145° (range, 60°-180°) preoperatively to 152° (range, 135°-170°) postoperatively but was not significantly different (P = .3561). There was a decrease in external rotation from a mean of 50° (range, 20°-80°) preoperatively to 37° (range, 0°-45°) postoperatively (P = .0021). The ASES score improved from a mean of 50 (range, 10-88) to 69 (range, 22-97; P = .0196), and the WORC index improved from a mean of 34 (range, 3-90) to 57 (range, 14-93; P = .0008). Eighteen patients underwent MRI at a minimum of 12 months after surgery. Of those 18 patients, 7 (39%) had intact grafts, and of the 11 retears, no patients underwent further surgery.

      Outcomes in intact and ruptured grafts

      Complete pre- and postoperative outcome scores were available for 10 of 18 patients who underwent an MRI to evaluate graft integrity. The entire cohort though (18 patients with MRIs) did have range of motion assessment. Because of the small numbers, comparative statistics between groups with an intact and ruptured graft were not carried out.
      In the group with intact grafts, forward flexion improved from a mean of 146° (range, 115°-150°) preoperatively to 156° (range, 140°-170°) postoperatively (P = .2778). There was a decrease in external rotation from a mean of 46° (range, 20°-90°) preoperatively to 43° (range, 30°-50°) postoperatively (P = .6842). In the subset of 10 patients with complete functional outcomes scores, the ASES score improved from a mean of 45 (range, 10-92) to 60 (range, 43-95; P = .2327), and the WORC index improved from a mean of 32 (range, 12-47) to 69 (range, 32-93; P = .0755).
      In the retear group, forward flexion improved from a mean of 153° (range, 135°-180°) preoperatively to 159° (range, 145°-180°) postoperatively (P = .5183). There was a decrease in external rotation from a mean of 56° (range, 20°-90°) preoperatively to 34° (range, 0°-45°) postoperatively (P = .2015). In the subset of 10 patients with complete functional outcomes scores, the ASES score improved (P = .1412) from a mean of 46 (range, 16-88) to 63 (range, 22-91), and the WORC index improved (P = .0706) from a mean of 32 (range, 3-55) to 46 (range, 14-75).

      Discussion

      The available surgical options for managing structural failure after a rotator cuff repair are limited. A recent systematic review examining revision repair reported that of the 804 patients studied, only 12% had augmentation with a graft.
      • Brochin R.L.
      • Zastrow R.
      • Hussey-Andersen L.
      • Parsons B.O.
      • Cagle P.J.
      Revision rotator cuff repair: a systematic review.
      Although the clinical results were characterized by an improvement in range of motion (forward flexion and internal/external rotation) and functional outcome, the complication (12%) and reoperation (5%) rates were relatively high. The highest complication rate of 17% was associated with the use of grafts and most frequently involved failure (88%). Poorer outcomes were demonstrated in large or massive tears and in cases where there had been more than one previous surgery. As RTSA is arguably the “end stage” procedure in a patient with a failed rotator cuff repair, this should be borne into consideration early in the surgical decision-making process.
      To our knowledge, this is the first study to report the clinical outcomes and retear rates after arthroscopic interpositional bridging grafting for revision rotator cuff repair using acellular dermal matrix in a cohort of large and massive tears. At a mean follow-up of 47 months, there was a significant improvement in PROMs, but this was accompanied by a reduction in external rotation and a rerupture rate of 61%. Subgroup analysis of the retear group illustrated a trend toward improved forward flexion and PROMs but a reduction in external rotation.
      In this study exclusively focusing on the revision of large/massive retears after a previous rotator cuff repair, limited tendon mobility and tear retraction precluded direct tendon-bone reattachment necessitating in graft application. The outcomes of this study are characterized by a significant gain in functional outcome accompanied by a reduction in external rotation and a graft rerupture rate of 61%. This can be attributed to the sole inclusion of revision procedures, as these are associated with a higher retear rate than primary repairs.
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      • Murrell G.A.
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      Potential reasons for this include reduced circulation in regions of degenerative tendon and dense fibrous tissue resulting in less neovascularization and limited tendon healing.
      • Shamsudin A.
      • Lam P.H.
      • Peters K.
      • Rubenis I.
      • Hackett L.
      • Murrell G.A.
      Revision versus primary arthroscopic rotator cuff repair: a 2-year analysis of outcomes in 360 patients.
      Similarly, the sole inclusion of large and massive tears in this study may be responsible for the high retear rate observed because larger tears result in higher failure rates.
      • Chung S.W.
      • Kim J.Y.
      • Kim M.H.
      • Kim S.H.
      • Oh J.H.
      Arthroscopic repair of massive rotator cuff tears: outcome and analysis of factors associated with healing failure or poor postoperative function.
      ,
      • Galatz L.M.
      • Ball C.M.
      • Teefey S.A.
      • Middleton W.D.
      • Yamaguchi K.
      The outcome and repair integrity of completely arthroscopically repaired large and massive rotator cuff tears.
      ,
      • Harryman 2nd, D.T.
      • Mack L.A.
      • Wang K.Y.
      • Jackins S.E.
      • Richardson M.L.
      • Matsen 3rd, F.A.
      Repairs of the rotator cuff. Correlation of functional results with integrity of the cuff.
      In a systematic review of revision rotator cuff repair, Brochin et al
      • Brochin R.L.
      • Zastrow R.
      • Hussey-Andersen L.
      • Parsons B.O.
      • Cagle P.J.
      Revision rotator cuff repair: a systematic review.
      demonstrated that large and massive tears were independent predictors of a poor outcome. Djurasovic et al
      • Djurasovic M.
      • Marra G.
      • Arroyo J.S.
      • Pollock R.G.
      • Flatow E.L.
      • Bigliani L.U.
      Revision rotator cuff repair: factors influencing results.
      reported on 80 revision rotator cuff repairs, of which 51 were large or massive. At 49-month follow-up, outcomes were satisfactory (excellent, good, or fair) in 55 patients (69%) and unsatisfactory (poor) in 25 (31%). Compared with those with larger tears, patients with a medium or small tear at the initial procedure had a significantly better functional outcome after revision.
      Interpositional bridging grafts are appealing because they preserve native tendon tissue without being associated with some of the serious complications that can occur after RTSA.
      • Boileau P.
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      Neumann et al
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      • Zgonis M.H.
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      • Kremen T.J.
      • Boggess B.R.
      • et al.
      Interposition dermal matrix xenografts: a successful alternative to traditional treatment of massive rotator cuff tears.
      reviewed 61 patients after repair of a massive rotator cuff tear with porcine acellular dermal matrix as an interpositional graft. At a mean of 50.3-month follow-up, 92% of repairs were fully intact on ultrasonography, and there was an improvement in pain, range of motion (external rotation and forward flexion), and muscle strength. Rupture of the graft occurred in 5/61 patients. In some of these cases though, an improvement in pain and ROM was still observed, and only one patient required further surgery. In a further study evaluating the results of human dermal allograft as a bridging construct for massive rotator cuff tears, Gupta et al
      • Gupta A.K.
      • Hug K.
      • Berkoff D.J.
      • Boggess B.R.
      • Gavigan M.
      • Malley P.C.
      • et al.
      Dermal tissue allograft for the repair of massive irreparable rotator cuff tears.
      found it improved pain, range of motion (external rotation and forward flexion), and strength at an average of 3-year follow-up. Using ultrasonography, completely intact repairs were noted in 73% of patients, and partially intact repairs were observed in 22%. On dynamic ultrasonography, all completely/partially intact repairs moved as a single unit. Subgroup analysis comparing intact and ruptured grafts was not performed; however, further surgery was required in 2 cases of rerupture, with one of these patients (a partially intact repair) still exhibiting an improvement in pain, ROM, and subjective outcomes. In this study exclusively focusing on revision rotator cuff repair, despite a graft rupture rate of 61%, no further surgery was required, and an improvement was demonstrated in flexion and PROMs. This suggests that integrity of the graft may not necessarily be the most important factor determining the results of an interpositional bridging graft and that it may simply represent a temporary spacer that decreases pain so that rehabilitation can continue uninterrupted.
      • Ferrando A.
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      • Delaney R.A.
      Superior capsular reconstruction using a porcine dermal xenograft for irreparable rotator cuff tears: outcomes at minimum two-year follow-up.
      Although interpositional bridging grafting can improve clinical outcomes after rotator cuff repair, no previous study has examined its use in the revision repair of large/massive tears. Specific problems that must be anticipated during the procedure include tendon degeneration, as this may inhibit tendon-bone healing and the difficulty in discerning between the true tear-margin and fibrous tissue overlying the retracted tendon. We postulate that the reduction in external rotation observed in our study may be because of a combination of tightening the posterior rotator cuff tissue when securing the graft, and the double-row construct used, as this has been shown to alter normal glenohumeral kinematics and reduce motion.
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      • et al.
      The effect of supraspinatus tears on glenohumeral translations in passive pitching motion.
      The limitations to this study include the retrospective design, incomplete follow-up data, and short-term follow-up. The absence of a control group prevents the improvement in functional outcome being reliably attributed to the bridging graft rather than another factor such as the natural history of the disease process. Preoperative MRI assessment of all tears would have allowed detailed characterization of fatty infiltration and muscle atrophy, as these may well have contributed to the outcome. All procedures were undertaken by a single surgeon with a high-volume tertiary referral practice dedicated to complex rotator cuff tears, and so this limits the external generalizability.

      Conclusion

      This is the first study to report the outcomes of arthroscopic interpositional bridging grafting of large and massive rotator cuff retears. Despite a reduction in external rotation and limited graft healing, there was still a significant improvement in patient-reported outcome at short-term follow-up. Compared with interpositional bridging grafting used in primary rotator cuff repair, its use as a salvage procedure in the revision setting is associated with worse clinical outcomes and a higher retear rate, and so it does not represent a viable solution at this stage. Future studies should compare bridging grafting for revision rotator cuff repair to other techniques (eg, partial repair and isolated débridement) and evaluate the influence of graft retears on clinical outcomes.

      Acknowledgments

      The authors would like to acknowledge Kristie More and Deanne Meredyk for setting up the database used to analyze the data.

      Disclaimers:

      Funding: No funding was disclosed by the authors.
      Conflicts of interest: The authors, their immediate families, and any research foundation with which they are affiliated have not received any financial payments or other benefits from any commercial entity related to the subject of this article.

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