---
title: 'Rotator Cuff Repair with Biobrace augmentation and Bone marrow concentrate'
type: 'lecture'
url: 'https://doc.social/lectures/rotator-cuff-repair-with-biobrace-augmentation-and-bone-marrow-concentrate'
published: '2023-07-09'
author: 'Don Buford, MD, RMSK'
specialty: 'Orthopaedic Surgery'
topics: 'Rotator Cuff, Rotator Cuff Tear'
transcript: 'yes'
---

# Rotator Cuff Repair with Biobrace augmentation and Bone marrow concentrate

Take a look at how to increase your success rate for healing a torn rotator cuff!

## Summary

Many rotator cuff tears are at risk of non-healing despite our current best repair techniques. Augmenting the rotator cuff repair with a graft/implant can improve the success rate. Recently a new graft, Biobrace, has become increasingly popular because of its combination of collagen to stimulate biology and PLLA fibers to provide initial strength. The Biobrace graft is strong and suturable during surgery and yet reabsorbs over several years so the native soft tissues heal without being stress shielded!

## Transcript

3,011 words · 18 min · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:03] Hi, thank you for taking the time to have a look at this presentation.
[0:06] In this presentation, I'm going to talk about Rotator Cuff augmentation using the latest Biorace implant in an onlay technique. I'm also going to add some Bone Marrow Concentrate at the end of the surgical procedure to try and maximize the healing potential.
[0:21] This is a technique talk. It's about 20 minutes long, and, and I appreciate you having a look.
[0:28] This page highlights my disclosures of note, I am a longstanding consultant for ConMed, which is the company that manufactures the Biobrace implant.
[0:40] The QR code in the middle of the screen is a link to the handout for this talk. You can also find it by going to any web browser and punching in Buford.info/ Bioracebiologics.
[0:55] These are our Social Media contact points. I do house a lot of lectures and videos on one of our two YouTube channels.
[1:03] Also active on LinkedIn, Facebook, and Instagram.
[1:08] So, let's get right into the H&P. This is a 62-year-old who presented status post fall 4 months prior. He now has Ongoing right Shoulder Pain, weakness, and dysfunction. He had a normal Shoulder prior to the fall, so this sounds like a relatively acute Rotator Cuff injury. He has already tried NSAIDs and Physical therapy. By the time he comes to see us, he's not had much improvement with either one of those uh treatment modalities.
[1:34] On physical exam, he has no visible muscle atrophy. He has some non-specific tenderness over the lateral Shoulder and bursal area.
[1:43] His forward flexion is 135 degrees. His abduction is also 135 degrees.
[1:49] He externally rotates to about 80 degrees.
[1:52] His internal rotation is a bit limited. He can only go to the posterior Hip.
[1:57] There's no appreciable Shoulder instability on exam.
[2:01] In terms of his muscle testing, all of his cuff muscles are 4 out of 5 or 5 out of 5, and of note, his subscapularis uh muscle tendon uh testing appeared normal.
[2:15] So an initial evaluation of the X-rays.
[2:18] On the AP on the far left.
[2:22] He does not appear to have a high riding humeral head. He does have some AC joint arthrosis, like most in their 60s will have. He does not really have any Other significant bony Pathology of note on that image. On the axial image in the middle of the screen, again, we can see pretty well preserved glenohumeral joint space. I don't see significant osteophytes or changes in the humeral head morphology. It does not appear to be subluxated.
[2:50] So, this appears to be a reasonable axillary view. And then finally, on the outlet view on the right, you get a sense of his acromial morphology. He is trending towards having a type 3 acromion, I guess maybe that's the most diplomatic way to say it. Uh, certainly, it's not a type 1 acromion. So, somewhere between 2 and 3 on his acromial morphology, and the thickness appears to be, uh,
[3:11] Somewhere right around 1 centimeter.
[3:15] These are his MRI scans, which really make the diagnosis in terms of the tendon Pathology. He's got a full thickness supraspinatus tear. It clearly extends into the infraspinatus, as you can see in the bottom right-hand corner.
[3:29] He does have some muscle atrophy as noted in the uh MRI image in the bottom, in the middle of the screen. So, he's got changes not only in the infraspinatus, but also in the supraspinatus. Of note, his subscapularis appears essentially normal.
[3:44] So, at this point, putting this all together, we can now start to have some discussion with the patient about the actual diagnosis and have some Informed Consent discussion.
[3:55] So, this appears to be a 3 to 4 centimeter tear that involves the supraspinatus and infraspinatus uh Rotator Cuff tendons. He does have retraction at least to the level of the glenoid. He does have some measurable muscle atrophy. If we were going to use the Gellier classification, probably a G2.
[4:12] It's likely a a relatively acute Rotator Cuff injury based on his history and on the imaging.
[4:18] His Roy score is at least a 6. I didn't do a bone density test, but, uh, based on his retraction and his age, and the muscle changes, he's probably got a 60+% chance of non-healing with a Primary Rotator cuff repair where nothing else is done. And for those reasons, we discussed adding an implant like Biorace, and also adding autologous biologics like Platelet-rich plasma, Bone Marrow Concentrate, or adipose.
[4:47] Of note, the Surgery center was not reimbursed for the cost of the Biobrace implant from this patient's insurance company. That is not uncommon for these types of uh implants. There are some companies that will carve out implants and pay the facility. You just have to take it on a case by case basis based on where you're doing these procedures.
[5:07] A lot of the dermal graphs that are truly considered graphs are, are typically not reimbursed, but again, you have to take it on a case by case basis and do your own Research.
[5:17] Nonetheless, we all agree that the cost of Revision surgery is significant.
[5:23] Papers have tried to quantify the cost. It's north of $50,000 when you include time lost from work, second Surgery, sometimes hospitalization, uh, and additional implants and, and surgical procedures.
[5:38] This patient opted to pay cash for the Bone Marrow Concentrate procedure after understanding the risks and benefits and going over the published data with me on using Bone Marrow Concentrate for Rotator Cuff augmentation.
[5:53] So this is how the day starts. The patient comes into the operating room, the anesthesiologist puts the patient under general endotracheal anesthesia, and I turn the patient prone because the posterior iliac crest is thicker than the anterior crest. It's therefore more accessible, and there's a larger safety margin in getting Bone Marrow posteriorly compared to anteriorly.
[6:14] In addition, we have more room, especially in this technique, if we're going to get 120 cc's, there is much more room along the posterior iliac crest, in my experience.
[6:24] This is also a less painful place in my experience, uh, from, from which to get the Bone Marrow. Patients really don't have much complaints from that little band-aid.
[6:36] And so what is the next step?
[6:39] The next step is to do your best Rotator cuff repair.
[6:43] Whether it's lateral decubitus or beach chair position, whether it's single row, double row, triple row, whatever your best Rotator cuff repair for that patient, that's what you do.
[6:54] One technical pearl, if you can't get the humeral head covered by the Rotator cuff repair, then you've got to consider something else. You've got to consider a dermograft or a tendon transfer, subacromial balloon, or some Other option, because this onlay technique that I'm describing is really best used when, even though it's a large or even a massive tear, we're able to get this tendon reapproximated back to the bone.
[7:19] I use an 8 millimeter cannula, and in the ConMed portfolio, that's a yellow dry dock cannula that you see here on the screen.
[7:27] One tip is when it's time to pass that implant down into the subacromial space, we use an 11 blade scalpel to, to cut multiple little um uh slices into the inner diaphragms, and that makes graft passage a non-issue.
[7:45] This highly technical schematic on the left is how we organize our sutures in the Biobrace implant. The lateral aspect is at the bottom of the screen, medial is at the top, anteriors to the right, posteriors to the left. So, the first step, uh, marked by the number one in green, is we pass these inverted mattress sutures through the lateral edge of the Biorace. We use mattress sutures because they're about twice as strong as just doing a simple suture through the Biorace.
[8:15] And with this inverted mattress suture, those will ultimately be secured with a knotless anchor in the lateral aspect of the tuberosity.
[8:24] Mdially, we're going to have to pass sutures through the BioBrace, and then tie what's called an interference knot or a stick knot, because the medial sutures are the ones that we use to pull the graft into the subacromial space.
[8:40] I like to actually pass those sutures in the subacromial space first, before passing the limb through the Biobrace. You can do it either way. I just have a particular way I do it, and I'm sure all of you will develop your own technique um for this.
[8:57] Once you pass those sutures through the medial muscle, both anterior and posterior, you've now got two different colored suture limbs coming out of the anteriorlateral cannula, and that is what you're going to pass through the Biorace, again, leaving about a 5 millimeter gap.
[9:12] The stick knots are illustrated by the, by the video on the right, where you're just taking the suture through the BioBrace, and then you're passing 4 or 5 quick throws in a row to create a large knot that sits on top of the BioBrace. And now when you pull that knot, it'll pull the BioBrace into position.
[9:33] This is what it looks like. We always use a surgical towel or something to keep the graft off the skin.
[9:40] Here you can see the medial stick knots.
[9:43] They're different colors just to make uh planning easy. And then here are our lateral inverted mattress sutures. The one step that you can see in this picture that we haven't talked about yet is we're pre-soaking the BioBrace with a little bit of Bone Marrow Concentrate. But this is what the preparation on the BioBrace, in terms of suture preparation, this is what it looks like.
[10:06] And now it's time to bring that BioBrace into the subacromial space. After we've already nicked the inner diaphragm with that 11 blade scalpel, this becomes very easy. We just have to pull on the posterior and pull on the anterior sutures. Those are each coming out of the respective cannulas, and as we pull those sutures this way, the Biobrace goes down through the cannula. We can chase it with a grasper or some Other device, uh, using a traumatic kind of hands-off technique on the graft.
[10:35] And so now let's go through an abbreviated surgical video. All of the things that we do to place this bower brace in an onlay fashion are listed on the right. The first step in this lateral decubitus position is to evaluate the biceps tendon and decide if we're going to be doing a biceps tenodesis or leaving it alone. And so here we've decided to do a supra pectoral biceps tenodesis. That means taking a spinal needle, passing it right through the tendon. We use a shuttle relay to bring suture back through the biceps.
[11:03] And then, when we do this a second time and retrieve that suture from the posterior aspect, that gives me a purse string kind of mattress suture around the biceps tendon, and we can later fix that biceps tendon in the, in the subacromial space using a knotless suture anchor.
[11:19] And so, there you can see we're passing and retrieving the second suture. It goes around the biceps and through it. It's a very strong way to secure the biceps in less than a couple of minutes here. And then we'll go ahead and use a pair of scissors to do the tenotomy at its insertion into the superior labrum. And so, once we have the biceps cut, there, you can see it cut there.
[11:38] We evaluate the rest of the joint, and now we're into the subacromial space. And so, we can see that this is indeed a large tear. We've got a little bit of bursal tissue, um, blocking the true extent of the tear. We're gonna worry about that in a minute. The next step is to make more space for us to operate. So, we're going to take off some of the anterior and some of the lateral acromion.
[11:59] We don't want to have our anterior cannula kind of restricted, because if, if that bone is pushing on that blue cannula, you can believe it's going to push on the repaired Rotator Cuff. So, we get that out of the way. We can move the blue cannula, make sure we have plenty of space. That, that is encouraging that our repaired cuff will have plenty of space. Once we take away the bursal tissue, we can really identify the tear pattern here and the amount of retraction. We can also make a pretty good assessment of the cuff tissue.
[12:25] And confirm the fact that we want to graft or or or use an implant as an augmentation for this repair. So, how to repair this with minimal tension.
[12:34] Well, we know that if we just take every torn edge of this cuff back to the bone, there's going to be a lot of excess tension. The repair probably won't make it overnight. And so, we use our margin convergence techniques that we were taught by Dr. Burkhart probably 15 years ago now as a way to start the repair with minimal tension. The side to side sutures, as they're also called, are a key suturing technique.
[13:00] For these large and massive tears. Here's our spectrum handle coming in from posterior. We'll go through both delaminated portions of the cuff.
[13:09] In this case, because of the size of the tear, we're going to do this in 2 passes.
[13:14] That's our first pass through the posterior leaf. We do a second pass through the anterior leaf, and these are sutures that are not attached to anchors.
[13:22] After we pass 4 of these side to side sutures, in this case, the cuffs come together actually quite nicely with minimal tension. So, this is advanced the infraspinatus.
[13:32] Anteriorly. Here you can see these sutures are tied. They're alternating colors. And look, we've almost got that tendon completely covering the humeral head just from four side to side sutures, but we're far from done. We've got to put in some anchors and some sutures to hold the tendon down to the bone, because we have to have this healed to the bone as well. And so, this is our most posterior triple loaded suture anchor. This is a single row technique for me. All three sutures are passed and tied really through the infraspinatus there.
[14:01] We're going to place a 2nd anterior triple loaded all suture anchor, and once we tie those, we now have 6 sutures holding this tendon back down to the bone. You can see the exposed footprint. You can even see our biceps tenodesis suture over there to the right. And so now, that's our best cuff repair for this. We've got the humeral head completely covered, 4 side to sides, 2 triple loaded anchors.
[14:23] But now we have to place our Biobrace implant.
[14:28] We're going to measure the BioBrace is 30 millimeters in the mediallateral direction, and so we'd like to leave about 1 centimeter to cover the lateral aspect of that repair. And so I'm measuring to see about how far.
[14:41] 20 millimeters is immediately on this repair. And we're going to center the BioBrace directly over that margin convergencet suture line right down the middle of the Rotator Cuff. And so that gives me a good idea in terms of our anterior and posterior sutures, we know the BioBrace is 23 millimeters wide, so we want to place one suture posterior and the Other suture anterior, and there needs to be more than 23 millimeters of space between those two, so that when we tie those knots, the BioBrace is not bunched up. And so, here's our posterior.
[15:10] Pass. This is done through a posterior cannula.
[15:14] We're using the spectrum two set. There's a shuttle relay, that's retrieved out of the anterolateral cannula. We repeat the process anteriorly, we make the stick knots, and then when we pull on those, it brings the BioBrace down just like you see here into the subacromial space. OK? So we have the stick knot on top, underneath the BioBrace, that suture is going through the muscle.
[15:38] And now from posterior, all we have to do is retrieve the stick knots and tie these medial sutures to secure the medial aspect of the BioBrace. So here we are from the medial cannula, retrieving that, we cut off the stick knot and then go ahead and tie. There it is tied. Same thing anteriorly, retrieve the stick knot, notice our margins on the graph, and then we tie it medially.
[16:01] The inverted mattress sutures are then locked down through a knotless anchor. In the convent portfolio. I'm using these 3.5 millimeter pop lock anchors in this example. You can use Other anchors like an Argo anchor, for example, from the convent portfolio.
[16:16] The final coup de grace for me is to break the cortex with a 2 millimeter punch, and then take an 18 gauge spinal needle as deeply as I can put it into the tuberosity to start to inject our Bone Marrow Concentrate. We'll turn off the water. I did this just for demonstration purposes. We do the rest of it with the water off. We dry out the area, and we put the rest of the Bone Marrow Concentrate into the subacromial space. And so that's what the finished onlay looks like, and I'm happy with, with uh that appearance there.
[16:48] So in summary, I truly believe that we can help improve Rotator cuff repair outcomes with a Biorace implant augmentation at the index procedure when we have our best chance to affect healing and biology. We do this for repairs that are at risk, whether you're using the Rohi scoring system or some Other mechanism to determine what you think the at-risk tears are.
[17:10] I also add Bone Marrow Concentrate or another orthobiologic because it's safe, and we have mounting evidence that it may help with the healing and decrease revisions, as well as increasing tissue quality. So thank you for your attention.
[17:24] Here is the QR code for the handout once again.
[17:28] And these are our Social Media contact points. So best wishes and good luck with these augments.