Doing a Little Something Extra:

For Life and Rotator Cuff Repair

By: R. Judd Robins, M.D. Member, AANA Communications and Technology Committee

 

As we reach the end of what hopefully has been another productive, growth-filled year as Orthopaedic Surgeons, it is worth taking the time and energy to celebrate along with acknowledge the accomplishments and contributions of the people around us that make it happen. Certainly, we want to recognize our teammates at work – physician assistants, OR and nursing staff, surgical technicians, medical assistants and clinical staff. How successful would we really be without our fellow physician colleagues and partners – both in and out of orthopaedic surgery? As researchers we recognize collaboration with research assistants, statisticians, data scientists, review boards and many more is the only way we find success in these endeavors. For those of us engaged in team coverage, “team sports medicine” relies heavily on the professionalism of athletic trainers, physical therapists, nutritionists, strength and conditioning coaches, sports psychologists and a whole host of professionals optimizing athlete care – week in and week out – during the pre-, in- and post-seasons. Many of us are grateful for the support of our industry and equipment “reps” that are integral to the care we provide to our patients in and out of the operating room. And most important, no continued success occurs in the workplace without the love and support of our families and close friends.

 

This is the time of year that we try to do ‘a little something extra’ to show our gratitude and support for the great work and contributions of those around us. That can come in the form of monetary bonuses, department or company holiday parties, the giving of gifts and maybe ‘a little something extra’ for meals and holiday traditions for our families and the ones we love. The concept of doing ‘a little something extra’ has also found its way into our professional endeavors as Orthopaedic Surgeons in the last few years, whether that be the addition of a lateral extra-articular tenodesis to an ACL reconstruction or a remplissage to an arthroscopic shoulder stabilization surgery. Another area of treatment in which ‘a little something extra’ has had increased focus is in our efforts to improve outcomes and healing rates for rotator cuff repair surgery. 

 

Rotator cuff tears are biologically and physiologically challenged tendon injuries that are difficult to reliably get to heal with surgical repair.  As the tendons of the rotator cuff age, blood supply becomes tenuous, the tendon cuff is exposed to constant load through a wide arc of motion and shear forces and contact with surrounding bone and structures can lead to impingement, abrasion and retear. Retear rates after rotator cuff repair have traditionally been reported to vary between 13-90%, with more recent meta-analysis demonstrating retear rates at 16% beyond 24 months of follow-up.1-3

 

Shoulder surgeons have attempted to manipulate many variables to optimize and improve healing rates throughout the years. Over time, we have learned a few things that work and things that do not make a difference on healing rates. The concept of reducing risk for impingement by performing acromioplasty made sense to many. However, multiple studies and meta-analyses have continued to demonstrate the addition of acromioplasty to rotator cuff repair surgery does not influence outcomes or retear rates.4-5 In the early 2000’s to 2010’s, a lot of effort and research evaluated the effects of rotator cuff repair technique, often dubbed the “single row vs. double row (vs suture bridge) controversy.” With all the time, energy and effort trying to identify the ‘optimal’ repair construct, it is now recognized that single row vs. double row technique does not necessarily affect retear rates, pain or outcomes, with even a recent meta-analysis suggesting concern suture bridge may have higher retear rates compared to the other two techniques; rather, multiple inherent factors related to rotator cuff tear pathology – such as amount of tendon retraction and fatty atrophy of the muscle – have a bigger influence on outcomes and risk for retear.3,6,7  

 

What about adding ‘a little something extra’ to our rotator cuff repairs? Specifically, is there anything we can do as surgeons to improve the biological or mechanical environment of the rotator cuff repair site? Advocated by Dr. Stephen J. Snyder and others, bone marrow stimulation of the greater tuberosity (aka “crimson duvet”) initially was supported by data demonstrating improved healing rates when added to rotator cuff repairs.8 As bone marrow stimulation has been further studied, the benefits have become less clear: three recent meta-analyses showing improved healing rates but two other meta-analyses demonstrated no difference in retear rates.9-13 Another option has been to inject molecular signals in the form of platelet rich plasma (PRP) to the rotator cuff repair site. As data has been published over the last 15 years, results have varied from PRP being effective at reducing retear rates, having no effect and in a few cases making retear rates worse. The most recent three-arm randomized control trial demonstrated no benefit from leukocyte rich or leukocyte poor PRP, while one of two meta-analyses published last year demonstrated no benefit with the other study finding lower retear rates when adding PRP to rotator cuff repair compared to adding bone marrow stimulation.14-16 

 

Another effort to add ‘a little something extra’ has come in the form of augmenting the repair site with a “patch” to increase the mechanical strength of the repair construct in the setting of a potential biomechanically challenged rotator cuff tear, or to augment the biological environment of the repaired tendon (i.e. biological scaffold). Structural allograft has emerged as a promising ‘something extra’ to re-enforce rotator cuff repairs and lower retear rates.3 In 2008, Barber and colleagues published biomechanical data that demonstrated human dermal allograft significantly increased the strength of rotator cuff repair.17 Since that time, many comparative studies and randomized control trials have been accomplished evaluating the clinical effects of augmenting rotator cuff repair with allograft, autograft, xenograft and synthetic material, with allograft and certain types of xenograft demonstrating positive results in regard to lower retear rates and variable results on patient reported outcomes.3,18-20 The most recent and comprehensive meta-analysis demonstrated that both acellular human dermal allograft and bovine collagen patches have the most promising clinical data at lowering retear rates; moreover, the use of these two types of patches were found to be safe with low risk of complications.21 The most recent comparative study utilizing human dermal allograft augmentation demonstrated improved outcomes and a drop in retear rates from 29.1% to 5.6% (p=0.007) during short term follow-up in the setting of large to massive rotator cuff repair when compared to no augmentation.22 These results support the most recent randomized control trial comparing dermal allograft augmentation to controls with 5.7 year follow-up which demonstrated a drop in retear rates from 38.1% to 9.1% (p=0.034).23 Subset analysis of the augmentation group demonstrated that when complete coverage of the greater tuberosity footprint was achieved no retears occurred at final follow-up. 

 

What about when the rotator cuff tendon is retracted so far medially it cannot be reduced to the greater tuberosity without undue tension? Bailey and colleagues reported on utilizing dermal allograft as an “interposition” graft to bridge the distance between retracted cuff and the footprint vs. rotator cuff repair with augmentation vs. standard repair, finding that interposition and augmentation both outperformed standard repair alone.24 Finally, a comparative study in large retracted rotator cuff tears found no difference in outcomes or retear rates when utilizing the biceps tendon for autograft cable reconstruction vs. human dermal autograft augmentation (18.2 vs 8.1% p=0.174) indicating that when a patient does not have a proximal biceps tendon available, human dermal allograft augmentation has at least equivocal improved outcomes and protection of the surgical repair site.25   

 

Augmenting the strength of the repair is not the only way to add ‘a little something extra’ to rotator cuff repair. Utilization of a ‘biological scaffold’ patch to a repair site has been adopted to induce a better healing response and promote more normalized tissue growth at the repair site. Various methods have been attempted throughout the last two decades with best results supporting the use of a thin, specially prepared patch made from highly purified and reconstituted collagen bovine tendon fibers originating from a specific breed from New Zealand. This patch provides no structural improvement at the repair site but instead is resorbed by six months and stimulates tissue growth to reduce risk of retear. A unique use of this graft has been in the setting of symptomatic partial-thickness rotator cuff tears where the biological scaffold is applied to the partial tear site without performing a sutured repair of the partially torn rotator cuff tendon. Initial case control studies have been supportive: use of the bovine biological scaffold has demonstrated improved outcomes, increased tendon thickness on MRI and ultrasound, with a very low rate of retear.26 Another case series evaluated the use of this same patch in the setting of full thickness rotator cuff tears, finding improved outcomes, increased tendon thickness on MRI and ultrasound, a healing rate of 96% and reoperation rate of 9%  with no adverse reactions.27 Additionally, a case series published this year specifically looked at revision rotator cuff repair surgery augmented with the bovine collagen patch and found that over 70% of repairs remained intact at one year.28 However, the most recent meta-analysis of this particular patch notes that while current data supports that this patch increased tendon thickness in rotator cuff repair surgery, improved outcomes and documented a good safety profile, there is a lack of case-control and comparative studies evaluating adding this biological scaffold versus performing standard rotator cuff suture repair.29 The good news is the first double-blinded randomized control trial comparing application of the bovine collagen scaffold vs. takedown and suture repair of  full thickness rotator cuff repairs was just published this past year. The authors also obtained tissue biopsy of the repair sites at the six-month point. They found the bovine scaffold group had superior tendon quality and quantity based upon imaging and biopsy results, improved patient outcomes, higher satisfaction, a 100% fill-in rate of the tendon defect at one year and earlier return to work compared to the traditional-suture repair group.30 At this point in time, the data supports utilizing  this particular patch in the setting of partial thickness rotator cuff tear with anticipated good outcomes and healing rates.   

 

What about doing ‘a little something extra’ from both a biological and structural augmentation approach? This has also been reported on by Yoon and colleagues in combining human dermal allograft and bone marrow stimulation of the greater tuberosity vs. standard repair alone. They demonstrated no difference in patient-reported outcomes, but retear rate significantly improved (19% vs 46.3% p=0.036) with the biological and mechanical augmentation approach. When retear did occur, augmentation prevented a worse retear pattern (medial-row tear: 0% vs 72% p = 0.014).26

 

Doing ‘a little something extra’ to celebrate and appreciate the ones around us who helped make for a successful year is appropriate, recommended and highly encouraged. Along those same lines, doing ‘a little something extra’ to help improve rotator cuff repair outcomes and lower retear rates also has some foundational data to help guide Orthopaedic Surgeons on which ‘a little something extra’ interventions are appropriate to add to our care of rotator cuff pathology through surgical intervention. As we conclude this calendar year celebrating and recognizing the growth and successes that have occurred, let us commit to do ‘a little something extra’ in the new year to recognize those who support us as well as push ourselves to improve the care we provide to our patients suffering from rotator cuff pathology.          

 

References

  1. Bellumore, Y., Mansat, M., Assoun, J. Results of the Surgical Repair of the Rotator Cuff: Radio-Clinical Correlation. Revue de Chirurgie Orthopédique et Réparatrice de l'Appareil Moteur. 1994; 80(7): 582–594.
  2. 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. The Journal of Bone and Joint Surgery – American Volume. 2004; 86(2): 219–224.
  3. Longo, U.G., Carnevale, A., Piergentili, I., Berton, A., Candela, V., Schena, E., Denaro, V. Retear Rates After Rotator Cuff Surgery: A Systematic Review and Meta-Analysis. BMC Musculoskeletal Disorders. 2021; 22(1): 749.
  4. Waterman, B.R., Newgren, J., Gowd, A.K., Cabarcas, B., Lansdown, D., Bach, B.R., Cole, B.J., Romeo, A.A., Verma, N.N. Randomized Trial of Arthroscopic Rotator Cuff With or Without Acromioplasty: No Difference in Patient-Reported Outcomes at Long-Term Follow-Up. Arthroscopy. 2021; 37(10): 3072–3078.
  5. Abrams, G.D., Gupta, A.K., Hussey, K.E., Tetteh, E.S., Karas, V., Bach, B.R. Jr., Cole, B.J., Romeo, A.A., Verma, N.N. Arthroscopic Repair of Full-Thickness Rotator Cuff Tears With and Without Acromioplasty: Randomized Prospective Trial With Two-Year Follow-Up. The American Journal of Sports Medicine. 2014; 42(6): 1296–1303.
  6. Tashjian, R.Z., Hung, M., Burks, R.T., Greis, P.E. Influence of Preoperative Musculotendinous Junction Position on Rotator Cuff Healing Using Single-Row Technique. Arthroscopy. 2013; 29(11): 1748–1754.
  7. Tashjian, R.Z., Erickson, G.A., Robins, R.J., Zhang, Y., Burks, R.T., Greis, P.E. Influence of Preoperative Musculotendinous Junction Position on Rotator Cuff Healing After Double-Row Repair. Arthroscopy. 2017; 33(6): 1159–1166.
  8. Arroyo, W., Getelman, M.H., Snyder, S.J. Single Row Rotator Cuff Repair With Triple Loaded Suture Anchors: The SCOI Row Technique. Arthroscopy. 2021; 37(8): 2397–2398.
  9. Ajrawat, P., Dwyer, T., Almasri, M., Veillette, C., Romeo, A., Leroux, T., Theodoropoulos, J., Nauth, A., Henry, P., Chahal, J. Bone Marrow Stimulation Decreases Retear Rates After Primary Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-Analysis. The Journal of Shoulder and Elbow Surgery. 2019; 28(4): 782–791.
  10. Yang, G., Li, S., Jiang, C., Zhang, H., Lu, Y. The Role of Bone Marrow Stimulation in Rotator Cuff Repair: A Systematic Review and Meta-Analysis. Journal of Experimental Orthopaedics. 2023; 10(1): 27.
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  12. Shin, K.H., Kim, J.U., Jang, I.T., Han, S.B. Effect of Bone Marrow Stimulation on Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-Analysis. The Orthopaedic Journal of Sports Medicine. 2024; 12(1): 23259671231224482.
  13. Fairley, J.A., Pollock, J.W., McIlquham, K., Lapner, P. Bone Channeling in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-Analysis of Level I Studies. The Journal of Shoulder and Elbow Surgery. 2024; 33(1): 210–222.
  14. Yao, L., Pang, L., Zhang, C., Yang, S., Wang, J., Li, Y., Li, T., Xiong, Y., Li, J., Tang, X. Platelet-Rich Plasma for Arthroscopic Rotator Cuff Repair: A Three-Arm Randomized Controlled Trial. The American Journal of Sports Medicine. 2024; 52(14): 3495–3504.
  15. Sánchez-Losilla, C., Ferré-Aniorte, A., Álvarez-Díaz, P., Barastegui-Fernández, D., Cugat, R., Alentorn-Geli, E. Efficacy of Platelet-Rich Plasma in Rotator Cuff Repair: Systematic Review and Meta-Analysis. Revista Española de Cirugía Ortopédica y Traumatología. 2024; 68(3): 296–305.
  16. Lim, J.J., McCarty, C., Belk, J.W., Keeter, C., Frank, R.M., Bravman, J.T., Seidl, A.J., McCarty, E.C. Rotator Cuff Repair With Platelet-Rich Plasma Is Associated With Lower Retear Rates When Compared With Rotator Cuff Repair With Patch Augmentation: A Systematic Review. The Orthopaedic Journal of Sports Medicine. 2025; 13(7): 23259671251358398.
  17. Barber, F.A., Herbert, M.A., Boothby, M.H. Ultimate Tensile Failure Loads of a Human Dermal Allograft Rotator Cuff Augmentation. Arthroscopy. 2008; 24(1): 20–24.
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  19. Hurley, E.T., Crook, B.S., Danilkowicz, R.M., Buldo-Licciardi, M., Anakwenze, O., Mirzayan, R., Klifto, C.S., Jazrawi, L.M. Acellular Collagen Matrix Patch Augmentation of Arthroscopic Rotator Cuff Repair Reduces Retear Rates: A Meta-Analysis of Randomized Controlled Trials. Arthroscopy. 2024; 40(3): 941–946.
  20. Orozco, E., Dhillon, J., Keeter, C., Brown, T.D., Kraeutler, M.J. Rotator Cuff Repair With Patch Augmentation Is Associated With Lower Retear Rates for Large Tears: A Systematic Review of Randomized Controlled Trials. Arthroscopy. 2024; 40(4): 1300–1308.
  21. Mandalia, K., Mousad, A., Welborn, B., Bono, O., Le Breton, S., MacAskill, M., Forlizzi, J., Ives, K., Ross, G., Shah, S. Scaffold- and Graft-Based Biological Augmentation of Rotator Cuff Repair: An Updated Systematic Review and Meta-Analysis of Preclinical and Clinical Studies for 2010–2022. The Journal of Shoulder and Elbow Surgery. 2023; 32(9): 1784–1800.
  22. Kantanavar, R., Lee, I.E., Rhee, S.M., Rhee, Y.G. Outcomes of Arthroscopic Single-Row Repair Alone vs. Repair With Human Dermal Allograft Patch Augmentation in Patients With Large to Massive, Posterosuperior Rotator Cuff Tears: A Retrospective Comparative Study. The Journal of Shoulder and Elbow Surgery. 2024; 33(4): 823–831.
  23. Lee, G.W., Kim, J.Y., Lee, H.W., Yoon, J.H., Noh, K.C. Clinical and Anatomical Outcomes of Arthroscopic Repair of Large Rotator Cuff Tears With Allograft Patch Augmentation: A Prospective, Single-Blinded, Randomized Controlled Trial With a Long-Term Follow-Up. Clinical Orthopaedic Surgery. 2022; 14(2): 263–271.
  24. Bailey, J.R., Kim, C., Alentorn-Geli, E., Kirkendall, D.T., Ledbetter, L., Taylor, D.C., Toth, A.P., Garrigues, G.E. Rotator Cuff Matrix Augmentation and Interposition: A Systematic Review and Meta-Analysis. The American Journal of Sports Medicine. 2019; 47(6): 1496–1506.
  25. Kim, S.H., Shin, S.J. No Difference in Clinical Outcomes Following Repair of Large Retracted Anterior Rotator Cuff Tears Using Patch Augmentation With Human Dermal Allograft Versus Anterior Cable Reconstruction With Biceps Tendon Autograft. Arthroscopy. 2024; 40(2): 294–302.
  26. Yoon, J.P., Chung, S.W., Kim, J.Y., Lee, B.J., Kim, H.S., Kim, J.E., Cho, J.H. Outcomes of Combined Bone Marrow Stimulation and Patch Augmentation for Massive Rotator Cuff Tears. The American Journal of Sports Medicine. 2016; 44(4): 963–971.
  27. Thon, S.G., O’Malley, L., O’Brien, M.J., Savoie, F.H. Evaluation of Healing Rates and Safety With a Bioinductive Collagen Patch for Large and Massive Rotator Cuff Tears: Two-Year Safety and Clinical Outcomes. The American Journal of Sports Medicine. 2019; 47(8): 1901–1908.
  28. Delgado, C., Rodríguez, G., Ortega, C., López, V., Ardévol, J., Calvo, E. Biological Augmentation in Revision Surgery: Effect of a Bioinductive Collagen Patch (REGENETEN) in Patients With Rotator Cuff Retear and a Previous Arthroscopic Rotator Cuff Repair. The Journal of Shoulder and Elbow Surgery. 2025.
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  30. Camacho Chacón, J.A., Roda Rojo, V., Martin Martinez, A., Cuenca Espierrez, J., Garcia Calvo, V., Calderón Meza, J.M., Martin Hernandez, C. An Isolated Bioinductive Repair vs. Sutured Repair for Full-Thickness Rotator Cuff Tears: Two-Year Results of a Double-Blinded, Randomized Controlled Trial. The Journal of Shoulder and Elbow Surgery. 2024; 33(9): 1894–1904.

 

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