A Shoulder Surgeon Explains: How to Maximize Rotator Cuff Healing

I'm Dr. Patrick Denard. I'm an orthopedic shoulder surgeon, so I do 100% shoulder surgery, and I'm going to share with you some details on how I think you can maximize rotator cuff healing. These are really important things to consider if you're having a rotator cuff repair because there's a lot of things that are in your control. So first off, let's just start with the foundation. If you have failure of healing or retear, outcomes worsen over time. People can do well for a couple of years, but generally over time, the data shows that the outcomes or function of somebody deteriorates and arthritis progresses with time. And that's important because for years people have said that, you know, in some ways tearing or retearing doesn't matter, but in fact it really does. Now, how common is retears? Despite a large body of literature, retears are actually quite common. We've published a lot, meaning many people have published on this topic, and yet 25% of rotator cuff tears still fail to heal. So it is a big problem. And it's a common problem. So I wanna talk about 5 factors that determine healing. The tear, your fuel, biologics such as PRP, BMAC, growth factors, and perhaps even peptides, which I won't talk about in this one, but I will talk about in other topics, rehab, and the surgeon. All these 5 things combine to support rotator cuff healing. Let's talk about the tear first. This is something that is a big factor, but is not necessarily in your control. It's really for informational purposes. The risk of retear increases with age. That's because biology decreases, and especially in those situations, we need to think about what we can do to alter that situation. It doesn't mean that if somebody is older, say over 60 or 70, they cannot have a rotator cuff repair. It just means that the potential goes down with time. And then the larger the tear gets, the more healing goes down, which means that if you have a small full thickness tear, you want to intervene early and get a repair so that you have a reliable chance of healing as opposed to letting it get larger over time. That's also a topic I will talk about in another specific discussion. Fatty infiltration, or otherwise known as atrophy. So this is when the muscle decreases, and we typically look at this on a side view of the shoulder, what's called a T1 sagittal view. That's where we're looking at the muscle quality. The muscle is in gray, and if we see white on these sequences, that's where there is fatty infiltration. And surgeons like to grade this 0 through 4. 0 meaning there's no fatty infiltration, 4 meaning there is severe fatty infiltration. And the risk of failure of healing goes up progressively as you develop fatty infiltration. Specifically, as you go from grade 0 to 1 to 2 to 3 to 4 in both the supraspinatus muscle and in the infraspinatus muscle, supraspinatus being on the top, infraspinatus being on the back, you see a progressive decrease in healing. This again gets to why it's important to get to a tear early because as fatty infiltration progresses, and unfortunately it's not reversible, the risk of retear goes up. Now this has been combined in a study that I like to use pretty frequently. This is called the Rotator Cuff Healing Index Study. This is a study performed in Korea. They looked at over 600 individuals, very similar to the data I showed earlier. In this particular study, the retear rate overall was about 24%. And they basically created a scoring system that clinicians such as I will use as a way to determine not only the chance of healing but consideration of should we do something else besides just doing a standard repair. So for instance, they looked at age, tear size, retraction, fatty infiltration, as I discussed, as well as bone mineral density and level of work activity. And essentially what you see is that if you have 4 points or less, your chance of healing is very high. Probably just a standard repair is fine. But as the point system goes up, say from 5 to 7 points especially, you really start to see a progressive decline. And that may even be a discussion of if you have so many points, it's not repairable or worth considering doing anything arthroscopic. You really need a shoulder replacement. But if you're in that mid category and somebody doesn't have arthritis, that's where I'm going to consider doing something else, whether it's biologics or augmentation, to really try to maximize their healing potential. The next thing that's really important to consider is your fuel. Of all the things that somebody can control to really impact their outcome, I think this is the single biggest thing that is in the individual or patient's control. Now, this is not commonly recognized by surgeons, but a study recently out of Japan looked at this and found that first off, about half of individuals have some sort of nutritional risk factor when they undergo rotator cuff repair. Now, that's really important because many people think that they are in good health, and they eat well, quote unquote. But when you actually critically look at what's called a GNRI, which is a function of albumin reflective of protein in your body and body weight, it turns about half of people are at risk. And when they looked at actually things like tear size and age, although many surgeons just focus on those as well as fatty infiltration, actually the biggest risk factor in the study for retear was nutrition. There was a 400 to 600% increased risk of retear as the GNRI decreased. Now, GNR is modifiable, which means that if high protein is consumed before and after surgery, you can alter that albumin level. So that's why I say it's really in somebody's control. Another thing that is controlled from a nutritional standpoint is vitamin D. Prior studies have shown that if somebody has vitamin D deficiency, the retear rate is 3 times higher compared to those individuals who have a normal vitamin D level. Vitamin C supplementation has been shown to also increase rotator cuff healing. So if somebody takes 500 milligrams of vitamin C twice a day, the data suggests that they actually may have a lower retear rate. And that's because vitamin C plays a role in collagen production, which of course relates to tendon healing because tendon has collagen in it. Another one that isn't quite shown clinically, but at least in rat models, is glutamine. Glutamine is an amino acid. It is the most abundant amino acid in the body, and at least a rat study shows that glutamine has an important role in bone. And in this particular study, with glutamine supplementation actually improved tendon healing in a rat model. So glutamine is one that I encourage my patients to do on a daily basis after rotator cuff repair. Now let's move on to the third thing, biologics. There's a lot of interest in this. Now biologics are not covered by insurance, but there's options to consider them with the use of rotator cuff repair. And many surgeons will not use biologics because of this cost factor. And I'll talk about how I address that. So platelet-rich plasma is where you take blood off your own body, you spin it down, you get the growth factor-rich area. And although there was some early adoption of PRP, it kind of fell off. But when you really look at the data critically, actually PRP does reduce failure of healing. It actually reduces that by about 50%. So if you think about that, if somebody has on average a 25% risk of retear, or failure of healing, which was, really should be called, you may be able to reduce that down to about 12%, for instance. It's also been shown to potentially improve pain, that is lower pain after surgery, and improve functional outcomes. Now those differences are really, really small, but that's also probably because most of these studies look at 2-year outcomes. And remember earlier I talked about the fact that really you start to see worsening of outcomes over time. So the idea there is that if you can improve healing, you're trying to, um, set yourself up for a better long-term outcome. And this effect of PRP gets more dramatic the larger the tear gets. So for me personally, as a shoulder surgeon, if I had a rotator cuff repair, I would 100% have PRP, no doubt. And especially if it's a larger tear, I would really encourage somebody to do it. But I offer it to all my patients. Another consideration is BMAC, bone marrow aspirate concentrate. So Very similar idea to PRP here, but instead of taking cells off of your blood peripherally, meaning from your arm, for instance, you take cells from the iliac crest, okay? From your hip. And that's because that's the best source of cells that are stem cells or have higher growth factor concentration. There's not nearly as many studies on BMAC as there are in PRP, but nonetheless, there are a couple of studies that show half the revision rate. In much improved healing with the use of BMAC compared to without. So this is another thing that is something worth considering adding to a rotator cuff repair. And thinking about PRP versus BMAC, I kind of think it like about it like the small-medium tear, that's probably the PRP direction. As the tears get larger, it may be more worthwhile to consider BMAC, although unfortunately the cost is higher in that setting. That just has to do with the tools that are required to harvest the BMAC and what that comes from, from companies. Now, as we get into tears that have even lower chance of healing, that's really where you think about tissue augmentation options, whether it's synthetic dermal allograft or xenograft, meaning it comes from an animal source. And I'll review a little bit of the data here on dermal allograft and xenograft in particular because these are the two most popular topics. I do also use a synthetic patch at times as well, but I'm really in this just going to focus on the dermal allograft and xenograft. So what do we know about this topic? We know that if you add graft augmentation, based on large studies, systematic review here, you have a lower retear rate with the use of augmentation. And at least in this systematic review or meta-analysis, that impact was greater than PRP, which makes sense because you're adding a scaffold, not just cells that can disperse really quickly and go away in a short period of time. Unfortunately, they haven't really been well studied together, but it makes sense to me that these are addressing different factors. So if somebody has a large tear or massive tear, it's worthwhile considering PRP or BMAC cells in addition to tissue augmentation. If you look at the use of tissue augmentation, the mainstay is really dermal allograft augmentation, meaning skin that comes from somebody who's passed away It is sterilized, 95% plus of the DNA is removed, and the back skin is used because back skin is actually very thick. That's placed over the rotator cuff and serves as a collagen scaffold or framework to achieve healing. And you typically see over time that you get neovascularization, the new vessels coming into the graft. And what we do when we look at the studies on this, we see that actually improves healing in large massive tears. This is a randomized controlled trial showing that healing went from about 40% to about 85%, meaning without the use of tissue augmentation in these really large tears that had a low healing rate, there was a poor healing chance. But once dermal allograft augmentation was added, healing essentially doubled. So for me, I use this cutoff of that rotator cuff healing index I mentioned earlier, and when I see a level where healing is around the 30-40%, I do dermal allograft augmentation. And in fact, there may be a consideration to use it in lesser cases, less severe rotator cuff healing index scores. But that's really where it's difficult because you get into the cost considerations of all of this. Other studies have shown the same thing, just showing here that there's other studies showing that dermal allograft improves healing. It's not just that single study. Now, Regenitin is a xenograft. This is a really popular graft technique. It comes from bovine tissue or cow tissue. And of course sterilized and everything. But this graft in particular has become very popular because it's very easy to place. And what they did a very good job of is making it easy for the surgeon to do from a technical standpoint. But when you really look at the data for large and massive tears, it does not improve healing. This study here compared with and without the use of Regenitin and found no difference with the use of a Regenitin patch. There was also a randomized controlled trial sponsored by the company who owns this product, and they canned this trial, but you can find it online because once you start a prospective randomized trial, you have to register it at clinicaltrials.gov. And they terminated it because they found at 6 months there was no difference in healing for large massive tears with or without the use of the graft. And they presumably decided that they didn't wanna keep following patients 2 out to 2 years where you need— usually need to go to clinical outcomes for publication because that was going to cost more money. The next thing I want to talk about is the surgeon. So the reality is that technique, volume, and experience matter, and the data prove it. I feel strongly about this as a shoulder specialist, somebody who does 100% shoulder surgery, but the data backs this up. One of the things is a single row or a double row rotator cuff repair. So there's different approaches to rotator cuff tears, and sometimes this is driven by the mobility of the tendon. But nonetheless, if a tendon is mobile, there's an opportunity to do a double row rotator cuff repair, meaning two rows of anchors. And that just makes sense, right? Two rows versus one row, you're going to have better mechanics, and the data shows that leads to better healing. So essentially, it reduces the risk of retear by about half, all things being equal. And you have to be careful about that technically in terms of how you do that, because you don't want to over-tension the rotator cuff. So I do, and do, do single row rotator cuff repairs in certain situations where that is technique possible. But if I can get a double row repair based on mobility, 100%, I'm going to do a double row repair to maximize healing. When we look at volume in shoulder surgeons, you see several interesting findings. First off, with rotator cuff, people who do more do it faster. They have a lower reoperation rate. And when you look at shoulder replacement, there's in fact even a higher rate of mortality, meaning death after surgery, if somebody does a low volume of shoulder surgery. Now this isn't exactly rotator cuff here, this is shoulder arthroplasty, but again, this is a study that I think is interesting because it alludes to or talks about the volume issue. You're talking about over 150,000 patients. You see lower reoperation, lower readmission, and a 40% reduction in complication rates for surgeons that are high volume. Now what's interesting, the interesting about this is especially for shoulder replacement, most surgeries are done by low-volume surgeons. So if you look at 2022, about 35% of shoulder replacements are done by what we would consider high-volume shoulder replacement surgeons. And that's similar to rotator cuff. Rotator cuff's a more common procedure, but nonetheless, a lot of surgery is done by people who do a little bit of it. And so when you're talking to somebody and considering have a rotator cuff repair, It's really important to know who's doing the surgery and how much they do of it because you just get better the more you do. The last thing I want to talk about is rehabilitation. Of course, you go through surgery, you do all these things to try and improve your healing, and then you got to get through it. And this is the hard part that people often don't like about shoulder surgery, but many of these factors are important. So let's look at some of the, the timing evidence. And essentially what it see— what you see here is that It's not necessary to wear a sling for more than 6 weeks, but if people start moving early, that is if they have active motion before about 5 weeks, they have a higher risk of retear. Now that's important because that— what that means is that it's important to follow a rehabilitation protocol. However, I would say that it probably depends on the tear size, or I'm sure it depends on the tear size. In other words, if somebody has a large or massive tear, conservative protocol is absolutely the way to go. You got to get through that period, you know, 6 weeks in a sling and delay your range of motion. But if somebody has a small tear and/or they consider even adding augmentation, it may be you can take that small tear and sort of make it even stronger to move early. Additionally, if somebody has a small tear of the rotator cuff and they could do a double row repair, the evidence shows that they can actually move quite early, perhaps even a sling for just a few weeks or less. So it depends on the tear size, and that's a conversation with your surgeon to really know what situation you sit in, um, and making the best decision to get through that rehab appropriately and maximize healing. So how do I approach this problem for my patients? Well, I try to think about my 3 goals of rotator cuff repair. My first is I want to optimize the biology of the patient because I presented data that says that all these those things are important. Secondly, I got to maximize a repair construct. That's doing double row repairs. I talked about multiple fixation points. And then the third thing I do is augment based on evidence. So my nutrition approach is— what I do is I recommend all my patients get a vitamin D level. I order that in every rotator cuff repair because about a third of people are deficient. If somebody is low, I give them high-dose treatment for 4 to 6 weeks. So that's 50,000 international units a week. Data shows that brings vitamin D level levels up. But if somebody is of a normal level, I still recommend they take 2,000 international units a day. And personally, I think that that is beneficial to begin prior to surgery, about a month prior to surgery at least, and continue for several months afterwards because retear occurs typically in the first 6 to 12 weeks So that 6-12 week period is really, really important. Additionally, I recommend daily protein. Your requirements for protein double after surgery, so it's important to increase your protein and add amino acids like leucine, which improves muscle synthesis, and glutamine, which may improve rotator cuff healing as I discussed earlier. I also advise vitamin C, 500 milligrams twice a day, and then magnesium. I didn't get into that data, but there's some suggestion that magnesium may help with rotator cuff healing. Additionally, a benefit is sleep, and sleep is of course really important for recovery because your body rests. You're going to be able to heal more properly. My augmentation approach after I do my repair, and I have this discussion in advance, is if the Rotator Cuff Healing Index score is 7 or over, I do augmentation and I will do platelet-rich plasma as well. If the score is lower, But somebody wants to do it outside of insurance, I will offer them the option to do that on our own. And I will also offer all my patients the options of doing platelet-rich plasma and BMAC. And that provides an opportunity for us to do something that's not covered by insurance because it's not recognized. Of course, insurance is interested in keeping costs low, but that allows us to provide the opportunity to patients who want it. And I can tell you, that's certainly something I would want as a shoulder surgery patient. So in there and say good luck. And this quote by Einstein is really, I think, poignant here because insanity is the definition of doing something over and over again and expecting the same result. And you can't do that. If we just keep doing the same thing, we're going to get, again, 25% of patients failing to heal on a broad spectrum. So we have to take an individualized approach and try to maximize all these components, including the surgeon, the fuel, the rehab, and biologics in order to obtain healing.