Efficacy of an Amniotic Fluid Derived Allograft, (FlōGraft®) in Rotator Cuff Repairs: A Prospective Study

Patients will be given a written explanation of the study and screened for inclusion and exclusion criteria. Included patients will have a repairable, full thickness rotator cuff tear limited to the supraspinatus and infraspinatus, confirmed by MRI. Patients with concomitant biceps tenotomy, tenodesis, arthroscopic subacromial decompression, and distal clavicle excision will be included. Patients with prior operations on the shoulder, partial thickness tears, subscapularis tears or labral tears requiring repair, irreparable supraspinatus tears, staged bilateral rotator cuff repairs, or concomitant suprascapular nerve decompression will be excluded. We will also exclude patients with co-morbid conditions requiring the use of corticosteroids. Patients who cannot have an MRI for medical reasons will also be excluded.

All participants will volunteer to enroll in the study by signing informed consent (Attachment B). All potential subjects will be over 18 years of age and capable of providing their own informed consent. Patients will be recruited from the patient populations of Dr. Edwards, Dr. Elkousy, Dr. Morris, Dr. Gombera and Dr Brown. The informed consent process will be conducted by the investigators, their staff, or their research associates (e.g., orthopedic surgery fellows), who will explain the purpose and methods of the study, the risks and benefits, and requirements of participation. Randomization to groups will occur following informed consent; patients will not know to which group they are assigned.

1. Arthroscopic transosseous equivalent rotator cuff (TOE) repair will be performed; this is our standard procedure, using suture anchors in the medial and lateral rows for a TOE technique. The medial row will be 4.5 mm Polyether ether ketone (PEEK) anchors and the lateral row will be a 5.5 mm PEEK knotless anchor. Medial row anchor sutures will be tied.
2. FlōGraft® details: 4cc of FlōGraft® will be used in each treated patient, provided in a single peel pouch containing two 2cc vials. In FlōGraft® treated patients, FlōGraft® will be applied, following repair as detailed below.
3. FlōGraft® Preparation Protocol 3.1 Store FlōGraft® at -65◦C or colder until immediately prior to use. 3.2 Remove box from cold storage, open exterior box and remove interior package containing vials.

3.3 Neither the interior dust cover nor the outside of the vial are sterile. Do not place either the interior package or the vial in sterile field.

3.4 Remove vials from packaging, place on non-sterile, secure, flat surface, or hold vial firmly in one hand allowing contents to thaw (3-7 minutes.) Hold vial upright to aspirate contents. Note: Allograft should be implanted immediately post-thaw, but not later than eight (8) minutes post-thaw.

3.5 Pierce the vial cap and draw thawed solution into syringe. Do not pressurize vial with air prior to extracting thawed FlōGraft® solution.

3.6 If needed, change needle size based on surgeon preference (18g to 23g.)
4. FlōGraft® Implantation 4.1 After the rotator cuff repair is completed, shut off water-flow to joint. Excess water in joint is drained through the skin incisions, creating a "dry" sub-acromial space.

4.2 Insert needle through skin incision or percutaneously. Under direct visualization, inject FlōGraft® directly into rotator cuff tissue at repair site in approximately 0.50 cc aliquots. Cover entire repair site.

4.3 Implant allograft into the cuff muscle more medially to the repair in 0.25-0.5 cc aliquots, as appropriate.
5. Postoperative management: 4 weeks immobilization in abduction sling; passive range of motion will be initiated at the discretion of the surgeon based on tear size. Active range of motion will begin at 8 weeks to 16 weeks.
6. Diagnostic MRI will be performed at one and two years postoperatively.

• Superiority of augmented repairs (Biological), also known as FlōGraft®, Human amniotic fluid-derived allograft: 4cc of FlōGraft® injected into repair subject tissue divided evenly between repair site and muscle body
• Fat degeneration of supraspinatus muscle (Biological), also known as FlōGraft®, Human amniotic fluid-derived allograft: 4cc of FlōGraft® injected into repair subject tissue divided evenly between repair site and muscle body

Primary outcomes

• Structural healing integrity [1 year post-operation]: Improved structural healing is the best indication of long-term surgery success. The Sugaya grading system is a method to account for structural integrity of the rotator cuff following surgery with five possible classifications. Sugaya scale: type I indicating sufficient thickness with homogeneously low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, the presence of a minor discontinuity; and type V, the presence of a major discontinuity. Types I-III indicate different levels of healing. The classification of each shoulder must be assessed using MRIs (grade determined by a blinded musculoskeletal radiologist).

Secondary outcomes

• Fatty degeneration [1 year post-operation]: Musculoskeletal radiologists will also evaluate fatty degeneration of the rotator cuff at 1 year post-operatively from the MRI using the Global Fatty Degeneration Index (GFDI).
• Structural healing integrity (2) [2 years post-operation]: Improved structural healing is the best indication of long-term surgery success. The Sugaya grading system is a method to account for structural integrity of the rotator cuff following surgery with five possible classifications. Sugaya scale: type I indicating sufficient thickness with homogeneously low intensity; type II, sufficient thickness with partial high intensity; type III, insufficient thickness without discontinuity; type IV, the presence of a minor discontinuity; and type V, the presence of a major discontinuity. Types I-III indicate different levels of healing. The classification of each shoulder must be assessed using MRIs (grade determined by a blinded musculoskeletal radiologist).
• Fatty degeneration (2) [2 years post-operation]: Musculoskeletal radiologists will also evaluate fatty degeneration of the rotator cuff at 2 years post-operatively from the MRI using the Global Fatty Degeneration Index (GFDI).
• Functional outcome [Baseline]: Functional outcomes will be assessed using the American Shoulder and Elbow Surgeons Score.
• Functional outcome (2) [3 months post-operation]: Functional outcomes will be assessed using the American Shoulder and Elbow Surgeons Score.
• Functional outcome (3) [6 months post-operation]: Functional outcomes will be assessed using the American Shoulder and Elbow Surgeons Score.
• Clinically Assessed Re-tear [3 months post-operation]: Any incidence of clinically assessed re-tear will be documented by the treating surgeon during routine postoperative follow-up clinic visits and examinations.
• Clinically Assessed Re-tear (2) [6 months post-operation]: Any incidence of clinically assessed re-tear will be documented by the treating surgeon during routine postoperative follow-up clinic visits and examinations.

Sex: All, accepts healthy volunteers

Inclusion Criteria:

* Included patients will have a repairable, full thickness rotator cuff tear limited to the supraspinatus and infraspinatus, confirmed by MRI. Patients with concomitant biceps tenotomy, tenodesis, arthroscopic subacromial decompression, and distal clavicle excision will be included.

Exclusion Criteria:

* Patients with prior operations on the shoulder, partial thickness tears, subscapularis tears or labral tears requiring repair, irreparable supraspinatus tears, staged bilateral rotator cuff repairs, or concomitant suprascapular nerve decompression will be excluded. We will also exclude patients with co-morbid conditions requiring the use of corticosteroids. Patients who cannot have an MRI for medical reasons will also be excluded.

• Gregory Stocks, MD, Study chair, Texas Orthopedic Hospital