evidenced based use of biologics with the shoulder• the benefit of synthesc versus biological...
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Evidenced Based Use of Biologics
with the Shoulder
ChristopherDoumas,MD
ClinicalAssistantProfessorOrthopaedicSurgery
Rutgers:RWJMedicalSchool
ChiefofHandSurgeryJerseyShoreUniversityMedical
Center
Discolsure – Ihavenorelevantdisclosurestodiscuss.
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Questions???
• Whatdobiologicsoffertoshouldersurgery?
• IsthereanyevidencethatbiologicsmakeshouldersurgerybeIer?
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Why Biologics? • Rotatorcuffre-tearrates=22-94%!
• Timing• LocaSon• Size• Age• Chronicity
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BrianJ.ColeMD,MBA,L.PearceMcCartyMD,RichardW.KangMD,MS,WinslowAlfordMD,PaulB.LewisMD,MSandJenniferK.HaydenMSN,RN.JournalofShoulderandElbowSurgery,2007-09-01,Volume16,Issue5,Pages579-585
Early Failed Repair = Poor Construct
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Late Failed Repair = Poor Biology
Chronic Rotator Cuff tears
• Typicallyretract• Maybelarge• Reliablyprogresswithatrophytothemusclebelly
• Doesitreallyma-eriftheRTCheals?
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Patients prefer a strong shoulder
StructuralIntegrityAaerRotatorCuffRepairDoesNotCorrelatewithPaSentFuncSonandPain:AMeta-Analysis.Russell,RobertDMD;Knight,JusSnRMD;Mulligan,EdwardDPT;Khazzam,MichaelSMD.JournalofBone&JointSurgery-AmericanVolume.96(4):265-271,February2014.
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14studieswith861paSentsMeta-analysis
78.3%Healedand21.7%Re-tearHealedpa(entshadgreaterstrengthandsa(sfac(on
Can we improve the tendon bone interface?
• PatchespromotematerialproperSes
• GrowthfactorspromotestructuralproperSes
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Patches
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SyntheScs
Xenograas
Allograas
Preclinical For Patches Rotatorcuffrepairusinganacellulardermalmatrixgraa:aninvivostudyinacaninemodel.AdamsJE1,ZobitzME,ReachJSJr,AnKN,SteinmannSP.Arthroscopy.2006Jul;22(7):700-9.
RotatorCuffRepairUsinganAcellularDermalMatrixGraa:AnInVivoStudyinaCanineModel.JulieE.Adams,M.D.a,MarkE.Zobitz,M.S.b,JohnS.ReachJr,M.D.a,Kai-NanAn,Ph.D.b,ScoIP.Steinmann,M.D.Arthroscopy.Volume22,Issue7,July2006,Pages700–709
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BiomechanicalanalysisofgapformaSonandfailuremechanicsofaxenograa-reinforcedrotatorcuffrepairinacadavericmodel.KevinP.SheaMD,ElimoObopilweMS,JohnW.SperlingMD,MBAandJosephP.IannonMD,PhD.JournalofShoulderandElbowSurgery,2012-08-01,Volume21,Issue8,Pages1072-1079
ReconstrucSonoflargerotator-cufftearswithacellulardermalmatrixgraasinrats.JunjiIdeMD,KenshiKikukawaMD,JunHiroseMD,Ken-ichiIyamaMD,HidetoshiSakamotoDrEngandHiroshiMizutaMD.JournalofShoulderandElbowSurgery,2009-03-01,Volume18,Issue2,Pages288-295
Patch Augmentation Indications
• Young• Failuresoratriskforfailure• Massivetears• Chronicchanges• Salvagecases
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Relative Contraindications
• Rotatorcuffarthropathy• Pseudoparalysis• Irreparabletears• UnrealisScexpectaSons
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Patch Interposition Outcomes Level of Evidence 4
Long-termsuccessfularthroscopicrepairoflargeandmassiverotatorcufftearswithafunc(onalanddegradablereinforcementdevice.ChristopherS.ProctorMDJournalofShoulderandElbowSurgery,2014-10-01,Volume23,Issue10,Pages1508-1513
• Thepoly-l-lacScacidbioabsorbablepatchdesignedspecificallytoreinforcethesurgicalrepairoftendonssupportedsuccessfulrepairoflargetomassiverotatorcufftearsin83%ofpa(entsat12monthsaOersurgeryand78%ofpa(entsat42monthsaOersurgery,withsubstanSalfuncSonalimprovement.
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Patch Interposition Outcomes Level of Evidence 4
Long-termsuccessfularthroscopicrepairoflargeandmassiverotatorcufftearswithafunc(onalanddegradablereinforcementdevice.ChristopherS.ProctorMDJournalofShoulderandElbowSurgery,2014-10-01,Volume23,Issue10,Pages1508-1513
• Thepoly-l-lacScacidbioabsorbablepatchdesignedspecificallytoreinforcethesurgicalrepairoftendonssupportedsuccessfulrepairoflargetomassiverotatorcufftearsin83%ofpa(entsat12monthsaOersurgeryand78%ofpa(entsat42monthsaOersurgery,withsubstanSalfuncSonalimprovement.
Rotatorcuffrepairaugmenta(onusinganovelpolycarbonatepolyurethanepatch:preliminaryresultsat12months'follow-up.IvanEncalada-DiazMD,BrianJ.ColeMD,MBA,JohnD.MacGillivrayMD,MichellRuiz-SuarezMD,MS,JamesS.KercherMD,NicoleA.FrielMSandFernandoValero-GonzalezMDJournalofShoulderandElbowSurgery,2011-07-01,Volume20,Issue5,Pages788-794
• ThepolycarbonatepolyurethanepatchwasdesignedtosupportSssueingrowthandenhancehealingasshownbypreclinicalanimalstudies.Clinically,thepatchiswelltoleratedandshowspromisingefficacy,witha10%retearrateatthe12-month(mepoint.
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Patch Extension Outcomes Level of Evidence 4
Aprospec(ve,mul(centerstudytoevaluateclinicalandradiographicoutcomesinprimaryrotatorcuffrepairreinforcedwithaxenograOdermalmatrix.EvanS.LedermanMD,AlisonP.TothMD,GregoryP.NicholsonMD,RobertJ.NowinskiDO,GeorgeK.BalMD,GeraldR.WilliamsMDandJosephP.IannobMD,PhD.JShoulderElbowSurg.2016Apr26Epubaheadofprint
• RepairoflargerotatorcufftearsstructurallyreinforcedwithxenograOECMresultedinimprovedfunc(onaloutcomesscoresandstrength.Adverseeventswereuncommon,andtherateofrevisionsurgerywaslow.
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Patch Extension Outcomes Level of Evidence 4
Aprospec(ve,mul(centerstudytoevaluateclinicalandradiographicoutcomesinprimaryrotatorcuffrepairreinforcedwithaxenograOdermalmatrix.EvanS.LedermanMD,AlisonP.TothMD,GregoryP.NicholsonMD,RobertJ.NowinskiDO,GeorgeK.BalMD,GeraldR.WilliamsMDandJosephP.IannobMD,PhD.JShoulderElbowSurg.2016Apr26Epubaheadofprint
• RepairoflargerotatorcufftearsstructurallyreinforcedwithxenograOECMresultedinimprovedfunc(onaloutcomesscoresandstrength.Adverseeventswereuncommon,andtherateofrevisionsurgerywaslow.
Dermal(ssueallograOfortherepairofmassiveirreparablerotatorcufftears.AnilK.Gupta,KevinHug,DavidJ.Berkoff,BlakeR.Boggess,MollyGavigan,PaulC.MalleyandAlisonP.TothAmJSportsMed.2012Jan;40(1):141-7
• Inourseriesofcarefullyselectedcandidates,allpa(entsdemonstratedasignificantimprovementinpain,rangeofmo(on,andstrength.SubjecSveoutcomemeasures,includingmeanASESandSF-12scores,alsodemonstratedsignificantimprovementatanaverage3-yearfollow-up.
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Patch Extension Outcomes Level of Evidence 3
• ThebenefitofsyntheScversusbiologicalpatchaugmentaSonintherepairofposterosuperiormassiverotatorcufftears:a3-yearfollow-upstudy.
PietroCiampi,CelesteScon,AlessandroNonis,MaIeoVitali,CleliaDiSerio,GiuseppeM.PerenandGianfrancoFraschini.AmJSportsMed.2014May;42(5):1169-75
• CONCLUSION:• Polypropylenepatchaugmenta(onofrotatorcuffrepairwas
demonstratedtosignificantlyimprovethe36-monthoutcomeintermsoffunc(on,strength,andretearrate.
• Re-tearRates:Control41% CollagenPatch51% Polypropelyne17%
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Growth Factors
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PRPincludesmanygrowthfactorsidenSfiedascrucialinnormalbone-to-tendonhealing:TGF-β,bFGF,PDGF,vascularendothelialgrowthfactor,connecSveSssuegrowthfactor,andepidermalgrowthfactor.HighPlateletConcentraSon
butalsolowWBCconcentra(onimportant
Growth Factors Tenocytesofchronicrotatorcufftendontearscanbes(mulatedbyplatelet-releasedgrowthfactors.HoppeS,AliniM,BennekerLM,MilzS,BoileauP,ZumsteinMA.JShoulderElbowSurg.2013Mar;22(3):340-9
• CLINICALRELEVANCE:• Biologicaugmenta(onof
repairedrotatorcuffswithPRGFmayenhancetheproper(esoftherepair(ssue.However,furtherstudiesareneededtodetermineifapplicaSonofPRGFremainssafeandeffecSveinlong-termclinicalstudies.
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TGF-B2minutesBMP-2<16minutesPDGFA-Chain2.4hoursFGF-2<14hours
GrowthFactorHalfLife
Where does the GF go?
• Ontopofthetendon– LiquidPRP
• GFgonein7-12hours
• Betweentendonandbone– Fibrinconstruct
• GFreleasedoverapprox.7days
• Nexttothetendon– CrimsonDuvet
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PRPFM (PRP with fibrin matrix)
Theeffectofplatelet-richfibrinmatrixonrotatorcufftendonhealing:aprospec(ve,randomizedclinicalstudy.RodeoSA,DelosD,WilliamsRJ,AdlerRS,PearleA,WarrenRF.AmJSportsMed.2012Jun;40(6):1234-41
• LevelofEvidence2
• Platelet-richfibrinmatrixappliedtothetendon-boneinterfaceattheSmeofrotatorcuffrepairhadnodemonstrableeffectontendonhealing,tendonvascularity,manualmusclestrength,orclinicalra(ngscales.Infact,theregressionanalysissuggeststhatPRFMmayhaveanega(veeffectonhealing.FurtherstudyisrequiredtoevaluatetheroleofPRFMinrotatorcuffrepair.
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PRPFM (PRP with fibrin matrix)
Theeffectofplatelet-richfibrinmatrixonrotatorcufftendonhealing:aprospec(ve,randomizedclinicalstudy.RodeoSA,DelosD,WilliamsRJ,AdlerRS,PearleA,WarrenRF.AmJSportsMed.2012Jun;40(6):1234-41
• LevelofEvidence2
• Platelet-richfibrinmatrixappliedtothetendon-boneinterfaceattheSmeofrotatorcuffrepairhadnodemonstrableeffectontendonhealing,tendonvascularity,manualmusclestrength,orclinicalra(ngscales.Infact,theregressionanalysissuggeststhatPRFMmayhaveanega(veeffectonhealing.FurtherstudyisrequiredtoevaluatetheroleofPRFMinrotatorcuffrepair.
Platelet-richplasmaaugmenta(onforarthroscopicrotatorcuffrepair:arandomizedcontrolledtrial.CastriciniR,LongoUG,DeBenedejoM,PanfoliN,PiraniP,ZiniR,MaffulliN,DenaroV.AmJSportsMed.2011Feb;39(2):258-65
• LevelofEvidence1
• OurstudydoesnotsupporttheuseofautologousPRFMforaugmenta(onofadouble-rowrepairofasmallormediumrotatorcuffteartoimprovethehealingoftherotatorcuff.Ourresultsareapplicabletosmallandmediumrotatorcufftears;itispossiblethatPRFMmaybebeneficialforlargeandmassiverotatorcufftears.Also,giventheheterogeneityofPRFMpreparaSonproductsavailableonthemarket,itispossiblethatotherprepara(onsmaybemoreeffec(ve.
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Review of GFs
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• RESULTS:• Regularbone-to-tendonhealingformsafibrousjuncSonbetween
tendonandbonethatisdisSnctfromtheoriginalbone-to-tendonjuncSon.TendonaugmentaSonwithcellularcomponentsservesasscaffoldingforfibroblasSccellsandapossiblesourceofgrowthfactorsandfibroblasSccells.ExtracellularmatricesprovideascaffoldforincomingfibroblasSccells,althoughcurrentresearchdoesnotconclusivelyconfirmwhichifanyofthesescaffoldsenhancerepairowinginparttointer-manufacturervaria(onsandthelimitedhumanresearch.Growthfactorsandplatelet-rich-plasmaareestablishedinotherfieldsofresearchandmayenhancerepairbuthavenotbeenrigorouslytested.
• CONCLUSIONS:• ThereispotenSalapplicaSonofbiologic
augmentaSontoimprovehealingaaerrotatorcuffrepair.However,researchinthisfieldiss(llinconclusiveandhasnotbeensufficientlydemonstratedtomeritregularclinicaluse.FuturehumantrialscanelucidatetheuseofbiologicaugmentaSoninrotatorcuffrepairs.
Strategiesinbiologicaugmenta(onofrotatorcuffrepair:areview.CheungEV,SilverioL,SperlingJW.ClinOrthopRelatRes.2010Jun;468(6):1476-84
Liquid vs. Solid PRP
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Crimson Duvet
Mul(plechannelingimprovesthestructuralintegrityofrotatorcuffrepair.JoCH,ShinJS,ParkIW,KimH,LeeSY.AmJSportsMed.2013Nov;41(11):2650-7.
• CONCLUSION:• Thefindingsofthestudyshowedthat
mul(plechannelingsignificantlydecreasedthere-tearrateaOerarthroscopicrotatorcuffrepair,probablyviatherecruitmentofendogenousMSCsfromtheproximalhumerus.Althoughtheresultsdidnotshowsignificantdifferencesintheclinicaloutcomesbetweenthe2groups,bejerclinicaloutcomesmightbean(cipatedinthemulSplechannelinggroupviaimprovedstructuralintegrityinalong-termfollow-up.
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Crimson Duvet
Mul(plechannelingimprovesthestructuralintegrityofrotatorcuffrepair.JoCH,ShinJS,ParkIW,KimH,LeeSY.AmJSportsMed.2013Nov;41(11):2650-7.
• CONCLUSION:• Thefindingsofthestudyshowedthat
mul(plechannelingsignificantlydecreasedthere-tearrateaOerarthroscopicrotatorcuffrepair,probablyviatherecruitmentofendogenousMSCsfromtheproximalhumerus.Althoughtheresultsdidnotshowsignificantdifferencesintheclinicaloutcomesbetweenthe2groups,bejerclinicaloutcomesmightbean(cipatedinthemulSplechannelinggroupviaimprovedstructuralintegrityinalong-termfollow-up.
Bonemarrows(mula(onatthefootprintofarthroscopicsurface-holdingrepairadvancescuffrepairintegrity.TaniguchiN,SuenagaN,OizumiN,MiyoshiN,YamaguchiH,InoueK,ChosaE.JShoulderElbowSurg.2015Jun;24(6):860-6.
• CONCLUSIONS:• Thesefindingsdemonstrate
thatapplyingBMStothefootprintduringASHrepairresultsinimprovedcuffrepairintegrity,par(cularlyinlarge-massivetears,andsuggesttheimportanceofbiologictreatmentforrotatorcuffhealingaaerarthroscopicrotatorcuffrepair.
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Outcomes of Combined Bone Marrow Stimulation and Patch Augmentation for Massive Rotator Cuff Tears.
YoonJP,ChungSW,KimJY,LeeBJ,KimHS,KimJE,ChoJH.AmJSportsMed.2016Apr;44(4):963-71.
• LevelofEvidence3 • CONCLUSION:• Concomitantbonemarrow
s(mula(onandpatchaugmenta(onsignificantlyreducedre-tearandmedial-rowfailureratesinthearthroscopicrepairofmassiverotatorcufftears.
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Role of Acromioplasty ReleaseofgrowthfactorsaOerarthroscopicacromioplasty.RandelliP,Margheri(niF,CabitzaP,DogliobG,CorsiMM.KneeSurgSportsTraumatolArthrosc.2009Jan;17(1):98-101.
• ConcentraSonshigherofTGF-beta1,PDGF-AB,andbFGF.
• Therearehighconcentra(onsofseveralgrowthfactorsinthesubacromialspaceaOeracromioplasty.
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Stem Cells Effectoftheadipose-derivedstemcellfortheimprovementoffajydegenera(onandrotatorcuffhealinginrabbitmodel.OhJH,ChungSW,KimSH,ChungJY,KimJY.JShoulderElbowSurg.2014Apr;23(4):445-55
• RESULTS:
• ThedegreeoffatstainingincreasedfromtheADSC+repairgroup(unclearorweak)tothesaline-onlygroup(stronglypresent).
• CONCLUSION:
• Localadministra(onofADSCsmighthavethepossibilitytoimprovemusclefunc(onandtendonhealinganddecreasefajyinfiltra(onaOercuffrepair.
Adiposederivedstemcells
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Take Home Messages
• Preclinicaltrialsdonotalwaystranslatetogoodresults.
• PatcheshavebeengainingtracSonbuttechniques,costandreimbursementareproblems.Synthe'candpermanent…thefuture?
• LiquidPRPmaybeeffecSvebutsolidPRPappearstogivebeIerhealing.
• MarrowSSmulaSontechniquesarelowcostandcanbeeffecSve
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Take Home Messages
• BonemarrowaspiratesshowveryliIleevidenceatthispoint.
• StemCells???• Minimalevidencepresentasfarasdosage,Smingandfrequency.
• Mostclinicaltrialsforgrowthfactorscost30-50milliondollars,sotheseareverydifficultproductstodevelopforthehopethatitworks!
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Thank You!
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References • 1.BrianJ.ColeMD,MBA,L.PearceMcCartyMD,RichardW.KangMD,MS,WinslowAlfordMD,PaulB.LewisMD,MSandJenniferK.HaydenMSN,RN.JournalofShoulderandElbowSurgery,
2007-09-01,Volume16,Issue5,Pages579-585• 2.GalatzL.M.,BallC.M.,TeefeyS.A.,MiddletonW.D.,andYamaguchiK.Theoutcomeandrepairintegrityofcompletelyarthroscopicallyrepairedlargeandmassiverotatorcufftears.JBoneJoint
SurgAm2004;86:pp.219-224• 3.StructuralIntegrityAaerRotatorCuffRepairDoesNotCorrelatewithPaSentFuncSonandPain:AMeta-Analysis.Russell,RobertDMD;Knight,JusSnRMD;Mulligan,EdwardDPT;Khazzam,
MichaelSMD.JournalofBone&JointSurgery-AmericanVolume.96(4):265-271,February2014.• 4.BiomechanicalanalysisofgapformaSonandfailuremechanicsofaxenograa-reinforcedrotatorcuffrepairinacadavericmodel.KevinP.SheaMD,ElimoObopilweMS,JohnW.SperlingMD,MBA
andJosephP.IannonMD,PhD.JournalofShoulderandElbowSurgery,2012-08-01,Volume21,Issue8,Pages1072-1079• 5.ReconstrucSonoflargerotator-cufftearswithacellulardermalmatrixgraasinrats.JunjiIdeMD,KenshiKikukawaMD,JunHiroseMD,Ken-ichiIyamaMD,HidetoshiSakamotoDrEngandHiroshi
MizutaMD.JournalofShoulderandElbowSurgery,2009-03-01,Volume18,Issue2,Pages288-295• 6.Rotatorcuffrepairusinganacellulardermalmatrixgraa:aninvivostudyinacaninemodel.AdamsJE1,ZobitzME,ReachJSJr,AnKN,SteinmannSP.Arthroscopy.2006Jul;22(7):700-9.• 7.RotatorCuffRepairUsinganAcellularDermalMatrixGraa:AnInVivoStudyinaCanineModel.JulieE.Adams,M.D.a,MarkE.Zobitz,M.S.b,JohnS.ReachJr,M.D.a,Kai-NanAn,Ph.D.b,ScoIP.
Steinmann,M.D.Arthroscopy.Volume22,Issue7,July2006,Pages700–709• 8.Long-termsuccessfularthroscopicrepairoflargeandmassiverotatorcufftearswithafuncSonalanddegradablereinforcementdevice.ChristopherS.ProctorMD.JournalofShoulderandElbow
Surgery,2014-10-01,Volume23,Issue10,Pages1508-15139.• 9.RotatorcuffrepairaugmentaSonusinganovelpolycarbonatepolyurethanepatch:preliminaryresultsat12months'follow-up.IvanEncalada-DiazMD,BrianJ.ColeMD,MBA,JohnD.MacGillivray
MD,MichellRuiz-SuarezMD,MS,JamesS.KercherMD,NicoleA.FrielMSandFernandoValero-GonzalezMD.JournalofShoulderandElbowSurgery,2011-07-01,Volume20,Issue5,Pages788-794• 10.AprospecSve,mulScenterstudytoevaluateclinicalandradiographicoutcomesinprimaryrotatorcuffrepairreinforcedwithaxenograadermalmatrix.EvanS.LedermanMD,AlisonP.TothMD,
GregoryP.NicholsonMD,RobertJ.NowinskiDO,GeorgeK.BalMD,GeraldR.WilliamsMDandJosephP.IannonMD,PhD.JShoulderElbowSurg.2016Apr26Epubaheadofprint• 11.DermalSssueallograafortherepairofmassiveirreparablerotatorcufftears.AnilK.Gupta,KevinHug,DavidJ.Berkoff,BlakeR.Boggess,MollyGavigan,PaulC.MalleyandAlisonP.TothAmJ
SportsMed.2012Jan;40(1):141-7• 12.ThebenefitofsyntheScversusbiologicalpatchaugmentaSonintherepairofposterosuperiormassiverotatorcufftears:a3-yearfollow-upstudy.PietroCiampi,CelesteScon,AlessandroNonis,
MaIeoVitali,CleliaDiSerio,GiuseppeM.PerenandGianfrancoFraschini.AmJSportsMed.2014May;42(5):1169-75• 13.TenocytesofchronicrotatorcufftendontearscanbesSmulatedbyplatelet-releasedgrowthfactors.HoppeS,AliniM,BennekerLM,MilzS,BoileauP,ZumsteinMA.JShoulderElbowSurg.2013
Mar;22(3):340-9• 14.StrategiesinbiologicaugmentaSonofrotatorcuffrepair:areview.CheungEV,SilverioL,SperlingJW.ClinOrthopRelatRes.2010Jun;468(6):1476-84• 15.Theeffectofplatelet-richfibrinmatrixonrotatorcufftendonhealing:aprospecSve,randomizedclinicalstudy.RodeoSA,DelosD,WilliamsRJ,AdlerRS,PearleA,WarrenRF.AmJSportsMed.
2012Jun;40(6):1234-41• 16.Platelet-richplasmaaugmentaSonforarthroscopicrotatorcuffrepair:arandomizedcontrolledtrial.CastriciniR,LongoUG,DeBenedeIoM,PanfoliN,PiraniP,ZiniR,MaffulliN,DenaroV.AmJ
SportsMed.2011Feb;39(2):258-65• 17.MulSplechannelingimprovesthestructuralintegrityofrotatorcuffrepair.JoCH,ShinJS,ParkIW,KimH,LeeSY.AmJSportsMed.2013Nov;41(11):2650-7.• 18.BonemarrowsSmulaSonatthefootprintofarthroscopicsurface-holdingrepairadvancescuffrepairintegrity.TaniguchiN,SuenagaN,OizumiN,MiyoshiN,YamaguchiH,InoueK,ChosaE.J
ShoulderElbowSurg.2015Jun;24(6):860-6.• 19.OutcomesofCombinedBoneMarrowSSmulaSonandPatchAugmentaSonforMassiveRotatorCuffTears.YoonJP,ChungSW,KimJY,LeeBJ,KimHS,KimJE,ChoJH.AmJSportsMed.2016Apr;
44(4):963-71.• 20.Releaseofgrowthfactorsaaerarthroscopicacromioplasty.RandelliP,MargheriSniF,CabitzaP,DoglionG,CorsiMM.KneeSurgSportsTraumatolArthrosc.2009Jan;17(1):98-101.• 21.Effectoftheadipose-derivedstemcellfortheimprovementoffaIydegeneraSonandrotatorcuffhealinginrabbitmodel.OhJH,ChungSW,KimSH,ChungJY,KimJY.JShoulderElbowSurg.
2014Apr;23(4):445-55
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